cp

macs

TABLE 1. Summary of the MACS

MACS Level	Description
I	Handles objects easily and successfully.
II	Handles most objects but with somewhat reduced quality or speed of achievement.
III	Handles objects with difficulty; needs help to prepare or modify activities.
IV	Handles a limited selection of easily managed objects in adapted situations.
V	Does not handle objects and has severely limited ability to perform even simple actions.

house

TABLE 2. House Functional Classification

Grade	Designation	Activity Level
0	Does not use	Does not use
1	Poor passive assist	Uses as stabilizing weight only
2	Fair passive assist	Can hold on to object placed in hand
3	Good passive assist	Can hold on to object and stabilize it for use by the other hand
4	Poor active assist	Can actively grasp object and hold it weakly
5	Fair active assist	Can actively grasp object and stabilize it well
6	Good active assist	Can actively grasp object and then manipulate it against other hand
7	Spontaneous use, partial	Can perform bimanual activities easily and occasionally uses the hand spontaneously
8	Spontaneous use, complete	Uses hand completely independently without reference to the other hand

tetraplegia ue

A group of hand surgeons realized in the 1970s that the level of injury did not predict the number of available muscles in the upper limb very well. Therefore the international classification was established in 1979, at the Edinburgh meeting. It was called “The international classification (IC) of hand surgery in tetraplegic patients” (table 2) and it describes the number of possible transferable muscles. To measure and evaluate hand strength each muscle is tested and all muscles with a BMRC grade of M4 or more are recorded.^[3]
Table 2: International Classification of Hand surgery in Tetraplegic Patients^[3]

	Group	M4 (BMRC) Muscles
	IC 0	No muscle below the elbow
High-level Tetraplegia
	IC 1	m. brachioradialis
	IC 2	m. extensor carpi radialis longus
Mid-level tetraplegia
	IC 3	m. extensor carpi radialis brevis
	IC 4	m. pronator teres
	IC 5	m. flexor carpi radialis
Low-level tetraplegia
	IC 6	finger extensors
	IC 7	thumb extensor
	IC 8	partial digital flexors
	IC 9	lack only intrinsics
	IC X	exceptions

A muscle not included in the International Classification, but of great importance, is the triceps muscle. When assessing a patient pre-operatively the triceps strength must also be recorded. An active triceps means a patient can reach in space, and the elbow can be stabilized against gravity and against other muscles to be transferred. (see further)^[3]

Furthermore, to classify patients it is essential to record sensation in at least the thumb and index pulpa. Patients with a two point discrimination of less than 10mm are classified as cutaneous sensation (OCu) and patients with a two point discrimination of more than 10mm are classified as ocular sensation (O) (meaning that control of the to be operated limb cannot be performed by normal sensation, but is controlled visually).^[28]

Therefore patients are classified as: O or OCu, IC gr(0-X), Triceps + or –

For example: a patient has sensation of 8 mm in thumb and index pulpa, and has a good brachioradialis, extensor carpi radialis longus and brevis and a pronator teres (all of M4) but no Triceps. This patient is classified as OCu 4, Tr -.

The Role of the Upper Extremity Surgeon in the Management ofTetraplegia

• Dan A. Zlotolow, MD

TABLE 1. International Classification for Surgery of the Hand in Tetraplegia (Edinburgh 1978, Modified—Giens, 1984)

Reprinted with permission from Kuz JE, Van Heest AE, House JH. Biceps-to-triceps transfer in tetraplegic patients: report of the medial routing technique and follow-up of three cases. J Hand Surg 1999;24A:161–172.

Grade	Lowest Motor Description	Muscle Function Below the Elbow
0	ElbowFlexion/supination	None
1	Forearmneutralization	BR
2	Weakwristextension	ECRL
3	Strongwristextension	ECRB
4	Forearmpronation	PT
5	Wristflexion	FCR
6	Fingerextension	EDC
7	Thumbextension	EPL
8	Weakdigitalflexion	FDS
9	StrongdigitalFlexion(lacksonlyintrinsics)	FDP
X	Exceptions	Variable

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