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Pronator Teres Rerouting in Children With Cerebral Palsy

Article in The Journal Of Hand Surgery · April 2006

DOI: 10.1016/j.jhsa.2005.11.009 · Source: PubMed

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 Pronator Teres Rerouting in Children With
Cerebral Palsy
Robert E. Bunata, MD

From the Fort Worth Affiliated Orthopaedic Residency Program, Fort Worth, TX.

Purpose: The forearm in children with cerebral palsy often assumes uncontrolled dynamic
positioning in pronation when the hand is put into use. This hypertonic positioning seems to
be an expression of dystonia rather than spasticity. This article reports the effect of pronator
teres rerouting (PTR) using the technique of tendon Z-lengthening and repair on active motion
and on forearm positioning during use.
Methods: Thirty-one patients who had pronator teres rerouting were observed before and
after surgery for active and passive forearm range of motion, changes in dynamic forearm
positioning, and the performance of 5 functional tasks related to forearm rotation. The
primary indication for surgery was pronation positioning of 25° or greater because that
positioning precludes grasping a glass or cup of water.
Results: The follow-up period averaged 39 months. The average active supination increased
65°, and the average dynamic positioning changed from 26° pronation to 7° pronation. Thirty
of the 31 patients gained the ability to hold a cup of water in the involved hand. Nine children
positioned the hand in supination during grasp.
Conclusions: Pronator teres rerouting improves both active supination and dynamic forearm
positioning in children with cerebral palsy. The use of the technique described in the
literature resulted in slight overcorrection of forearm positioning in the nine children. This
finding is consistent with the concept that positioning disorders are at least partly dystonic
rather than spastic. It is recommended that the transfer be tensioned more loosely in children
who have excessive dynamic hypertonia. (J Hand Surg 2006;31A:474.e1– 474.e11. Copy-
right © 2006 by the American Society for Surgery of the Hand.)
Type of study/level of evidence: Therapeutic, Level IV.
Key words: Cerebral palsy, dystonia, hemiplegia, pronation, pronator teres rerouting.

he affected forearms of children with cerebral erable term for this type of condition is dystonic hyper-

T palsy (CP) hemiplegia commonly assume a dy-

namically pronated position (pronation defor-
mity) during reach and grasp activities.1 The exact
reasons for this posturing are not understood com-
pletely. In the past it has been attributed to spastic-
ity,1–22 but recent appreciation of brain complexity and
development suggest this posturing may instead be an
expression of dystonia.23–27 “Spasticity . . . refers to an
abnormality of muscle tone in which there exists . . .
exaggerated muscle stretch reflexes” and “in its purest
definition . . . does not actually include sustained abnor-
malities in muscle tone (sometimes referred to as ‘spas-
tic dystonia’), which may be more responsible for the
characteristic postures.”23 Another perhaps more pref-
tonia.26 In this article the term dynamic forearm posi-
tioning describes the position of rotation the forearm
assumes when the child is using the hand for a func-
tional task.
Pronation deformity interferes with placing the
hands in opposition for 2-handed activities1,7 such as
for the manipulation of small objects10 and it pre-
vents getting the hand to the mouth and hair.28 In
addition it interferes with using the involved hand in
holding a cup level, shaking hands, holding a tele-
phone, or carrying a tray. Dynamic positioning dur-
ing use is different from active range of motion as
evidenced in reports by Sakellarides et al,3
Strecker et al,6 and Gschwind and Tonkin.28 Even

474.e1 The Journal of Hand Surgery

 Robert E. Bunata / PTR in Children With CP 474.e2

Table 1. Surgical Protocols

Surgical Tendon Tension of Position in
Indication Attachment Repair Surgical Cast Rehabilitation
Tubby19,20 Relief of pronator Bone periosteum “Placed on Forearm Education and training;
spasm plus 1 suture the stretch” supinated 4 active movements at
in bone hole weeks 6 weeks
Denischi15,16 Spastic pronation Bone trough and Sutured in full Supination for Active exercises at 3
Sustained 2 drill holes supination 3 weeks weeks
pronounced so hand
pronation remains in
supination
Sakellarides Pronation Bone drill hole Forearm held 60° Supination, Bivalved removable
et al3 contracture at 45° elbow at 45° cast for 4 weeks;
Pronation supination flexion for 5 night use for 6
deformity weeks months
Gschwind and Pronation Z-lengthened Not stated Cast in full Supination exercises
Tonkin28 deformity tendon supination 5 and supination night
weeks splint until plateau of
function
Strecker et al6 Pronation 1 Drill hole Not stated Cast elbow Long arm splint and
deformity 90°, forearm exercises for 2 weeks
60° changed to night use
supination of splint for 2 weeks
for 4 weeks
Gerwin10 Pronation Bone anchor or Forearm at Cast 45° Removable splint for 4
deformity drill hole 45° supination weeks, night splint
supination for 4 weeks continued if needed

children who can supinate actively beyond neutral
will pronate when attempting a task. The pronation
becomes more pronounced when the patient is anx-
ious or has increased sensory input.2,17,18,26 Dynamic
positioning in pronation is a common reason patients
seek help, and the pronation deformity is the most
common reason given for recommending forearm
surgery (Table 1).1,3–7,10,11,13–16,19,20,28
Several surgical procedures have been used to treat
the forearm pronation deformity of CP including
pronator teres tenotomy,5,6,11 lengthening,2,3 and the
Green (flexor carpi ulnaris to extensor radialis brevis)
tendon transfer,3,5,7,8,12 but there has been dissatis-
faction with their effectiveness.3,15 Pronator teres
rerouting (PTR)3,6,9,15,16,19,20,28 has been explored as
a more effective alternative.3,6
Tubby19,20 described the development of PTR in
his 1906 Hunterian oration and his 1912 text of
orthopedic surgery. Although the procedure has not
been used widely, there have been several publi-
cations about PTR, many of which have included
modifications of the bone reattachment tech-
nique.3,6,9,10,15,16,28 In 1992 Gschwind and
Tonkin28 described a modification of the technique
by Z-lengthening the pronator teres tendon and
wrapping the distal tendon end around the radius,
pulling it through the interosseus membrane and
repairing the tendon to its proximal end rather than
detaching and re-attaching the tendon to bone. (A
more complete history of PTR is available in Ap-
pendix A; this appendix can be viewed at the
Journal’s Web site, www.jhandsurg.org.) Table 1
summarizes important elements in published re-
ports on PTR.
Previous reports of PTR have used the change in
preoperative and postoperative active supination to
evaluate their results,3,6,28 except for 1 investigator
who graded results as good, satisfactory, or fair.15,16
Most reports cite pronation deformity as the indica-
tion for performing the surgery because it is what
interferes with hand use.
Previous researchers have been dissatisfied with
other methods of treating pronation deformity. Sakel-
larides et al3 stated that Green transfer and pronator
tenotomy failed to improve active supination ade-
quately, Strecker et al6 stated that tenotomy im-
proved active supination but only to a limited degree,
and Denischi15,16 reported that pronator tenotomy
did not relieve dynamic pronation positioning. I
agree with Denischi.15,16
This article documents the effect PTR has not only
on active range of motion but also on dynamic fore-
arm positioning and its effect on 5 hand functions
relating to forearm rotation in an effort to establish
that PTR improves dynamic forearm positioning.
474.e3 The Journal of Hand Surgery / Vol. 31A No. 3 March 2006
Figure 1. Preoperative clinical measurements of motion in a patient with less dystonic hypertonia. (A) Active pronation 50°. (B)
Active supination 75°. (C) Dynamic positioning 40° pronation. The patient was unable to hold a cup with water in it.
Materials and Methods
Pronator teres rerouting was recommended for pa-
tients with CP hemiplegia whose hand use was lim-
ited by dynamic positioning in pronation but who
showed spontaneous use of the involved
hand.1,6,7,10,11 Children with quadriplegia and chil-
dren who had a Green tendon transfer were excluded.
Patients were not excluded because of decreased
stereognosis4 –7,10,13,14,21,28 or impaired cognition.
To evaluate spontaneous use of the hand a history
of the child’s use of the hand at home was obtained
and the child was observed. The child was asked to
stack blocks with one hand and then the other and
was watched when asked to write his or her name or
draw a picture to see how he/she removed the marker
top and stabilized the paper. The child also was asked
to remove the lid from a small jar. This last obser-
vation was one of the most revealing. Only if the jar
was secured with the involved hand rather than being
placed between the knees or under the involved arm
was the child considered to have spontaneous use of
the hand.
Preoperative evaluation included stereognosis test-
ing, active and passive range of forearm rotation, and
determination of the forearm position with spontane-
ous use. Tests of general hand function such as
House’s scoring system or Jebson’s hand evaluation
were not used because the object was to identify the
effect of 1 surgery instead of global hand function.
Instead of measuring global hand function 5 func-
tional tests relating to forearm rotation were re-
corded. These were as follows: the ability to hold a
cup level (the child was handed a cup with a small
amount of water in it), to take a drink from the cup,
to hold a telephone to the ipsilateral ear, to use a
keyboard (the patient was asked to type his/her first
name on a keyboard using the involved hand), and to
stabilize a piece of paper with a volar part of the hand
when writing.
Dynamic positioning in pronation that prevented
holding a cup level was the primary indication for
PTR surgery; it was present in all children in this
study. I observed that being unable to hold a cup
level indicated dynamic positioning of 25° pronation
or more (Fig. 1). Some older children with larger
hands could adjust to the task and hold the cup from
the top or manipulate their fingers to accommodate
for the deformity, but it was awkward. Younger
children often put 1 finger inside the cup and pinched
the rim. These compensatory techniques did not
count as being able to hold the cup in a useful
manner.
Stereognosis was tested using 3 objects: a key, a
paperclip, and a coin. Stereognosis was graded as
good if the child identified 3 of 3 options, fair if 2 of
3, and poor if none or 1 was determined accurately.
Active and passive pronation and supination were
measured using a standard hand-held goniometer
placing 1 arm of the goniometer on the dorsum of the
distal radius and aligning the other arm with the
humerus while the child turned the palm up and
down (Fig. 2).
Before January of 2004 the determination of fore-
arm dynamic positioning was based on the observa-
tion that the child could not hold a cup level. I
recorded that those children had forearm positioning
of more than 25° pronation. To calculate averages
and for statistical analysis these patients were con-
sidered to have dynamic positioning of 25°. Since
January of 2004 a hand-held goniometer has been
used to measure dynamic positioning. Specifically
the child was handed a cup by an assistant and asked
to reach for and grasp it with the involved hand. Then
the child was asked to transfer the cup from hand to
hand while the examiner observed and aligned a
goniometer to measure forearm position (Fig. 2C).
The patient was asked to grasp a cup a second time
and this time the forearm was grasped and stabilized
by an assistant in the position of rotation assumed
while performing the task and the measurement was
confirmed. Measurements made from a video record-
ing were attempted but not used because trying to

Figure 2. Motion measurement technique. Goniometer aligned with dorsal distal radius and axis of humerus. (A) Active
pronation 60°. (B) Active supination ⫺10°. (C) Dynamic positioning 30° pronation. This patient had good hand dexterity and
could hold a cup; no surgery was recommended.
capture uninhibited spontaneous positioning on a
camera fixed in space made measurements unreliable
and not reproducible.
The treatment and chart analysis protocols for each
patient were reviewed by the institutional review
board at Cook Children’s Hospital in Fort Worth,
Texas. The PTR was combined with other proce-
dures at the same surgical setting5,13,14,22,28 as listed
in Table 2.
Surgical techniques of PTR have been de-
scribed.1,3,6,7,9 –11,28 Appendix B contains a more
complete description of the surgical technique I used for
these patients. (This appendix may be viewed at the
Journal’s Web site, www.jhandsurg.org.) Specific
points that should be emphasized are as follows: a
volar oblique skin incision provided adequate and
safe exposure to mobilize the tendon and muscle
completely, a Z-lengthening of 5 to 6 cm made it
possible for the distal tendon to be spiraled around
the radius with adequate length for repair, tendon
tension was set by holding the tendon ends side-by-
side under moderate tension with the forearm in
supination, and a locked running nonabsorbable su-
ture joined the top and bottom of the overlapped
tendons. The tension could be adjusted further so that
the forearm assumed a final resting position of
midrotation. The pronator quadratus was not dis-
turbed in any of these patients and the biceps tendon
(a supinator) was not lengthened if elbow flexion
contractures were corrected.20
After surgery a long-arm cast was applied with the
Robert E. Bunata / PTR in Children With CP 474.e4
forearm in 30° of supination. Five weeks after sur-
gery the cast was removed and active range-of-mo-
tion exercises and formal occupational therapy were
initiated. No postoperative splinting of the forearm
was used.
Between March 31, 1999 and June 24, 2004 there
were 39 eligible patients who had PTR; 31 had
adequate data for definitive follow-up evaluation. For
those 31 patients the average age at the time of
surgery was 8 years 3 months, with a range from 4
years to 16 years 7 months old. Sixteen patients had
right and 15 had left involvement; 20 patients were
male and 11 were female.
The 31 patients available for retrospective fol-
low-up evaluation were examined for active and pas-
sive pronation and supination, and dynamic forearm
positioning during hand use was measured as de-
scribed earlier. They also were examined for the
ability to perform the 5 functional tests.
The pronation and supination range-of-motion
data were analyzed using a 2-factor analysis of vari-
ance; the changes in pronation, supination, and grasp
position were analyzed with a 1-factor analysis of
variance. Significance was accepted at a p value of
less than .05.
Results
Results are summarized in Table 2. The average
follow-up time was 39 months, with a range of 8 to
63 months; 23 of the 31 patients were followed up for
more than 2 years. Typical forearm range of motion
 474.e5
Table 2. Patient Information
Active Motion

The Journal of Hand Surgery / Vol. 31A No. 3 March 2006

Patient Age at Stereo- Additional Follow-Up, Before Surgery After Surgery Active Motion Change Dynamic Positioning†
Number Surgery Gender Diagnosis gnosis Procedures* mo Pronation Supination Pronation Supination Pronation Supination Before Surgery After Surgery
1 8 y 6 mo F R hemi Good 1,2,3 52 80 0 70 70 10 lost 70 ⬎25 10
2 4y M R hemi Good 2,3,5 48 70 0 50 90 20 lost 90 30 0
3 10 y 5 mo M R hemi Fair 1,2 8 50 0 65 65 15 65 30 0
4 4 y 8 mo M L hemi Fair 3,5 49 60 20 pronation 55 80 5 lost 100 ⬎25 20 supination
5 10 y 1 mo M R hemi Fair 1,3,5 63 80 0 80 40 0 40 ⬎25 10 supination
6 9 y 2 mo M L hemi Good 1,2,3,4,5,6 12 60 5 pronation 65 10 5 lost 15 ⬎25 10
7 4 y 10 mo F L hemi Fair 3, 48 80 20 pronation 45 40 35 lost 60 ⬎25 0
8 8 y 1 mo F L hemi Fair 1,2,3,4 53 80 10 60 70 20 lost 60 ⬎25 10
9 9 y 3 mo M R hemi Fair 3,4 63 80 10 pronation 30 75 30 lost 85 ⬎25 20 supination
10 4 y 2 mo F L hemi Poor 3,4 16 70 20 pronation 60 0 10 lost 20 ⬎25 10
11 16 y 7 mo M L hemi Poor 1,2,3,4,6 12 60 60 45 55 15 lost 5 lost 25 10
12 9 y 8 mo M R hemi Poor 1,2,3,4 58 80 10 pronation 30 70 50 lost 80 ⬎25 0
13 4 y 4 mo M R hemi Fair 1,2,3,4 25 60 20 pronation 55 80 5 lost 100 ⬎25 0
14 5 y 8 mo M R hemi Poor 3,4 21 80 10 pronation 60 70 20 lost 80 ⬎25 0
15 4y M L hemi Good 3, 60 80 40 pronation 30 65 50 lost 80 ⬎25 10 supination
16 14 y 6 mo M R hemi Poor 1,3,4,8 25 80 10 pronation 30 100 50 lost 110 ⬎25 25 supination
17 13 y 2 mo M R hemi Good 1,2,3,7 12 70 20 55 60 15 lost 40 ⬎25 0
18 4 y 4 mo M R hemi Poor 1,2,3,4,5 17 80 20 pronation 40 75 40 lost 95 ⬎25 15 supination
19 9 y 1 mo F L hemi Fair 1,2,3,4 53 70 10 pronation 30 75 30 lost 95 ⬎25 0
20 12 y 9 mo F R hemi Poor 1,3,4,5 56 80 45 60 70 20 lost 25 ⬎25 0
21 4 y 11 mo M L hemi Good 1,2,3,4 40 60 20 pronation 15 85 45 lost 105 ⬎25 20 supination
22 14 y 2 mo M R hemi Poor 1,2,3,4 37 78 10 40 40 38 lost 30 ⬎25 10
23 8 y 7 mo F R hemi Poor 1,2,3,4,5 60 80 0 45 85 35 lost 85 ⬎25 15
24 9 y 9 mo F L hemi Poor 3,4 19 80 10 pronation 55 70 25 lost 60 30 10
25 9 y 9 mo F L hemi Poor 1,2,3,4,5 40 60 35 pronation 35 80 25 lost 115 ⬎25 20 supination
26 4 y 4 mo M L hemi Poor 2,3 54 80 0 70 60 10 lost 60 ⬎25 10
27 9y F L hemi Poor 1,2,3 52 60 20 pronation 55 25 pronation 5 lost 25 lost ⬎25 55
28 8 y 5 mo F L hemi Poor 1,2,3,4 39 70 30 45 90 25 lost 60 ⬎25 0
29 9 y 10 mo M R hemi Poor 1,2,3,4,5 28 80 20 pronation 70 30 10 lost 50 ⬎25 0
30 4 y 7 mo M R hemi Good 2,3,4 27 80 10 pronation 60 70 20 lost 80 45 0
31 10 y 1 mo M L hemi Poor 1,2,3,4 52 80 0 60 80 20 lost 80 ⬎25 20 supination

Average 8 y 9 mo 20 M 16 R Good 7 39 73 13 50 62 22 lost 65 26 7

11 F 15 L Fair 8
Poor 16

ECU, extensor carpi ulnaris; ECRB, extensor carpi radialis brevis; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; EPL, extensor pollicis longus; FDS, flexor digitorum superficialis.
Motion and positions shown in degrees.
*1, ECU to ECRB; 2, lengthen FCR or FCU; 3, lengthen thumb adductors; 4, EPL re-route; 5, thumb metacarpophalangeal capsulodesis; 6, lengthen elbow flexors; 7, lengthen FDS; 8, lengthen finger intrinsics.
†Dynamic position in pronation unless otherwise stated.

Figure 3. Preoperative clinical measurements of motion in patient with excessive dystonic hypertonia. (A) Active pronation 55°.
(B) Active supination 15°. (C) Dynamic positioning 65° pronation.
and dynamic positioning are shown before surgery in
Figures 2 and 3 and after surgery in Figure 4 (see also
videos 1 and 2, which may be viewed at the Journal’s
web site, www.jhandsurg.org).
The average supination gain for the 31 patients
was 65° (range, 25° supination lost to 115° supina-
tion gained). The preoperative and postoperative
mean supination values were significantly different
from each other (p ⬍ .001). There was an average
loss of 22° of active pronation, with a range of 50°
pronation loss to 15° pronation gain. The preopera-
tive and postoperative mean active pronation values
were significantly different from each other (p ⬍
.001). Twenty-eight patients lost pronation. The av-
erage dynamic positioning changed from 26° prona-
tion (range, 25° to 45°) before surgery to 7° prona-
tion (range, 25° supination to 55° pronation) after
surgery. These values were also significantly differ-
ent from each other (p ⬍ .001). The extremes of
postoperative dynamic positioning were 55° prona-
tion in 1 patient (patient 27) and 25° supination in 1
patient (patient 16). All other patients were within
20° of neutral and 12 had forearm positioning at
neutral. The postoperative positioning during active
use was not as fixed as the preoperative dynamic
deformity and the patients could make subtle adjust-
ments during hand use.
Figure 4. Postoperative motion (patient in Fig. 3). (A) Active pronation 60°. (B) Active supination 90°. (C) Dynamic positioning
neutral. Tension of the transfer repair was made looser than the standard technique. This patient intermittently rested the forearm
in supination when sitting.
Robert E. Bunata / PTR in Children With CP 474.e6
The results of the functional tests are shown in
Table 3. Some items deserve emphasis. Thirty of the
31 patients gained the ability to hold a cup of water
level with the involved hand. (No patient could do so
before surgery.) Twenty-eight patients could use the
hand to take a drink although 9 did so with difficulty.
Twenty-five patients could hold a telephone to the
ear with the involved hand. None lost the ability to
use a keyboard (11 gained that skill) or stabilize a
piece of paper with the palm or volar fingertips while
writing.
The 16 patients with poor stereognosis gained an
average of 61° (range, 25° supination lost to 115°
supination gained) of active supination and their
postoperative dynamic positioning was 2.5° (range,
25° supination lost to 55° supination gained). These
changes in motion were similar to those of the whole
group. Of those 16 patients 15 gained the ability to
hold a cup level. The patients with poor stereognosis
did not do as well with more complex tasks. Only 10
of the 16 patients could take a drink with the in-
volved hand whereas 12 of the 15 with good or fair
sensation could do so. Twelve of the 16 patients with
poor stereognosis could hold a telephone receiver to
the ear whereas 13 of 15 with better sensation could.
Patient 27 requires explanation. Failure of the PTR
in this patient was a result of poor patient selection
474.e7 The Journal of Hand Surgery / Vol. 31A No. 3 March 2006

Table 3. Task Evaluation Before and After Surgery

Patient Hold Cup Level Drink From Cup Hold Telephone to Ear Use Keyboard Stabilize Paper
1 N/Y N/Y N/Y N/Y Y/Y
2 N/Y N/Y N/Y Y/Y Y/Y
3 N/Y N/Y N/Y Y/Y Y/Y
4 N/Y N/Difficult* N/Y Y/Y Y/Y
5 N/Y N/Y N/Y Y/Y Y/Y
6 N/Y N/Y N/Y Y/Y Y/Y
7 N/Y N/Y N/Y Y/Y Y/Y
8 N/Y N/Y N/Y N/Y Y/Y
9 N/Y N/Y N/Y Y/Y Y/Y
10 N/Y N/Y N/Y Y/Y Y/Y
11 N/Y N/Y N/Y Y/Y Y/Y
12 N/Y N/Difficult N/N Y/Y Y/Y
13 N/Y N/Difficult N/Y N/N Y/Y
14 N/Y N/Y N/Y Y/Y Y/Y
15 N/Y N/Y N/Y N/Y Y/Y
16 N/Y N/Difficult N/Y Y/Y Y/Y
17 N/Y N/Y N/Y Y/Y Y/Y
18 N/Y N/Difficult N/Y Y/Y Y/Y
19 N/Y N/N N/Y N/Y Y/Y
20 N/Y N/Difficult N/Y N/Y Y/Y
21 N/Y N/Difficult N/N N/Y Y/Y
22 N/Y N/Y N/Y N/Y Y/Y
23 N/Y N/Y N/Y Y/Y Y/Y
24 N/Y N/Y N/Y Y/Y Y/Y
25 N/Y N/Y N/Y N/Y Y/Y
26 N/Y N/Y N/Y N/Y Y/Y
27 N/N N/N N/N N/N Y/Y
28 N/Y N/Difficult N/N N/Y Y/Y
29 N/Y N/N N/Y N/Y Y/Y
30 N/Y N/Y N/N Y/Y Y/Y
31 N/Y N/Difficult N/N Y/Y Y/Y
Before surgery 31 no 31 no 31 no 18 yes, 13 no 31 yes
After surgery 30 yes, 1 no 28 yes, 3 no 25 yes, 6 no 29 yes, 2 no 31 yes
*Difficult: patient required assistance from other hand, or patient spilled water.

because the patient did not have as good spontaneous Discussion

use of the hand as believed before surgery. She had
poor stereognosis. The wrist and thumb tendon trans-
fers also failed in part because of poor compliance
and cooperation with postoperative splinting and
therapy.
After surgery 5 patients tended to carry their fore-
arms in supination when at rest or walking. All
patients who carried their forearms in supination had
good use except the boy who could grasp a cup but
not take a drink (patient 16 with dynamic positioning
at 25° supination). The appearance of the patient’s
forearm resting in supination was not pleasing.
Nine patients had postoperative dynamic position-
ing in supination. They had less active preoperative
supination (average supination ⫽ 17° pronation;
range, 35° pronation to 0°) when compared with the
22 patients who had postoperative positioning be-
tween 0° and 20° pronation (average ⫽ 1° supina-
tion; range, 15° pronation to 50° supination). These
values are significantly different (p ⫽ .01).
Pronator teres rerouting using the technique of
Gschwind and Tonkin28 is a useful procedure for
treating dynamic pronation deformity in children
with CP. Technically it is easier than the technique of
inserting the tendon directly into bone, it does not
risk fracture of the radius as reported by some inves-
tigators3,15,16 using bone insertion technique, and it
facilitates adjusting the transfer tension.
Changes in active supination and pronation, inci-
dence of the complication of radius fracture, and
length of follow-up evaluation from published re-
ports and the present study are summarized in Table
4. These studies should be compared with care; for
instance, in this study there were no patients who
used a reverse grasp posture,6 who completely lacked
active supination,8 or who were quadriplegic.3,6,28
Dynamic forearm positioning changed from dis-
abling pronation to a more functional position near
neutral position.7,28,29 The preoperative value is un-

Table 4. Results From Published Studies and the Present Study
Number Change in Active Forearm Rotation
of
Patients Supination
Sakellarides 22 Average gain of 46°
et al3
Denischi15,16 10 Not stated
Strecker et al6 39 Average gain of 78°
Gschwind and 6 Not individually recorded;
Tonkin28 group 3 with no active
supination before
surgery had a post-
operative average arc of
supination that reached
97° (65° pronation to
30° supination)
Present study 31 Average gain of 65°
derstated because all patients who had surgery before
January 2004 had a measurement of more than 25°
rather than a precise measurement. Their actual mea-
surement could vary from 25° to 50° or more. After
surgery 29 of 31 patients assumed a position within
20° of neutral (Table 2), thereby achieving the pri-
mary goal of the surgery.
There were 9 patients, however, who had overcor-
rected and had postoperative positioning in supina-
tion. These 9 patients might have been identified
before surgery because they had less preoperative
active supination than the other 22 patients. One
might believe that the patients who were tighter
before surgery would be the most difficult to correct
but these findings seem to indicate that the opposite
is true. Their preoperative passive supination was
similar to that of the whole group.
This overcorrection is consistent with the concept
that positioning disorders in CP are more a reflection
of dystonia (or a mixed disorder) rather than spastic-
ity.23–27 Mayston25 reported that a lack of cortical
control of movement will result in an impairment of
“feed-forward or anticipatory control of both postural
and task related activity.” When the child with CP
attempts a task the extrapyramidal postural control
system increases muscle tone in an unbalanced way
that affects the pronator (and other) muscle. This
unbalanced increase in tone results in the dynamic
pronation positioning or pronation deformity. If this
hypertonic pronator is moved to provide a supination
vector30 the greater tone results in increased supina-
tion positioning.
Because of the overcorrection in 9 patients I re-
cently have loosened the tension of the tendon repair
in children who have preoperative supination of less
than neutral and/or dynamic forearm positioning
Robert E. Bunata / PTR in Children With CP 474.e8
Fracture
of
Pronation Radius Follow-Up Time
Did not state; 2 2–6 y, average not stated
mentioned risk of
loss
Not stated 1 Not stated
Reported no loss of 0 7–44 mo; average, 21 mo
pronation
Not stated; figures 0 6–37 mo; average, 14 mo
show less
pronation after
surgery than
before surgery
Average loss of 22° 0 8–63 mo; average, 39 mo
greater than 45° (excessive dystonic hypertonia)
(Figs. 3, 4). The repair is made with the forearm held
in pronation and the tendon ends are joined without
tension.
Table 3 shows changes in the results of the 5
specific functional tests. The first 3 tests relate to the
ability to supinate and the last 2 relate to the preser-
vation of use dependent on pronation. Patients per-
formed the first 3 tests better after surgery than
before; none lost function in the tests related to
pronation.
The use of the keyboard and stabilizing paper
often involved shoulder abduction both before and
after surgery.31 Before surgery the children used the
keyboard with the forearm held near the position of
the pronation deformity. The improvement by 7 chil-
dren in using a keyboard probably relates to other
procedures or to postoperative therapy.
Slightly more than half (16 of 31) of the patients
had poor stereognosis. Children with poor stereog-
nosis gained motion to the same extent as the whole
group; however, they did not show the same im-
provement in postoperative functional testing. Chil-
dren with poor stereognosis had more difficulty tak-
ing a drink and less ability to hold a telephone
receiver to the ear. This task failure rate in children
with poor stereognosis may reflect reduced sponta-
neous use and less practice using the involved hand.
The major shortcoming of this report is that there
is not better preoperative evaluation and documenta-
tion of hypertonia. Future studies regarding position-
ing abnormalities in children with CP should evalu-
ate reflexes, passive motion tested with and without
muscle stretching,32 and measurement of dynamic
positioning. Validated hand function tests (eg, Jebson
474.e9 The Journal of Hand Surgery / Vol. 31A No. 3 March 2006
hand evaluation, House’s rating scale) also would
improve the study of these problems.
This study confirms previous findings that PTR
improves active supination in patients with CP hemi-
plegia. In addition this study accomplishes the ob-
jective posed in the introduction by showing that
PTR improves dynamic positioning of the forearm in
these children. Although few hemiplegic CP children
consistently use or will use the involved hand spon-
taneously for activities such as taking a drink or
answering the telephone, PTR improves their ability
to position the forearm, giving them the opportunity
to use the involved hand when they so choose.
The author wishes to thank Joel Mitchell, PhD, of Texas Christian
University for help with statistics.
Received for publication February 5, 2004; accepted in revised form
November 15, 2005.
No benefits in any form have been received or will be received from
a commercial party related directly or indirectly to the subject of this
article.
Corresponding author: Robert E. Bunata, MD, Fort Worth Affiliated
Orthopaedic Residency Program, 801 W. Terrell, Forth Worth, TX
76104; e-mail: rebunata@earthlink.net.
Copyright © 2006 by the American Society for Surgery of the Hand
0363-5023/06/31A03-0019$32.00/0
doi:10.1016/j.jhsa.2005.11.009
References
1. Manske PR, Strecker WR. Pronator teres rerouting for spas-
tic rotational forearm deformities in cerebral palsy. Surg
Rounds Orthop 1987;1:39 – 44.
2. Koman LA, Smith BP, Shilt JS. Cerebral palsy. Lancet
2004;363:1619 –1631.
3. Sakellarides HT, Mital MA, Lenzi WD. Treatment of pro-
nation contractures of the forearm in cerebral palsy by
changing the insertion of the pronator radii teres. J Bone
Joint Surg 1981;63A:645– 652.
4. Mital MA, Sakellarides HT. Surgery of the upper extremity
in the retarded individual with spastic cerebral palsy. Orthop
Clin North Am 1981;12:127–141.
5. Zancolli EA, Goldner LJ, Swanson AB. Surgery of the
spastic hand in cerebral palsy: report of the committee on
spastic hand evaluation. J Hand Surg 1983;8:766 –772.
6. Strecker WB, Emanuel JP, Dailey L, Manske PR. Compar-
ison of pronator tenotomy and pronator rerouting in children
with spastic cerebral palsy. J Hand Surg 1988;13A:540 –543.
7. Manske PR. Cerebral palsy of the upper extremity. Hand
Clin 1990;6:697–709.
8. Beach WR, Strecker WB, Coe J, Manske PR, Schoenecker
PL, Dailey L. Use of the Green transfer in treatment of
patients with spastic cerebral palsy: 17-year experience.
J Pediatr Orthop 1991;11:731–736.
9. Matev I. Surgery of the spastic hand. In: Tubiana R, ed. The
hand. Vol IV. Philadelphia: W.B. Saunders, 1991:728 –729.
10. Gerwin M. Cerebral palsy. In: Green DP, Hotchkiss RN,
Pederson WC, eds. Green’s operative hand surgery. 4th ed.
New York: Churchill Livingstone, 1999:259 –286.
11. Gschwind CR. Surgical management of forearm pronation.
Hand Clin 2003;19:649 – 655.
12. Green WT, Banks HH. Flexor carpi ulnaris transplant and its
use in cerebral palsy. J Bone Joint Surg 1962;44A:1343–
1352.
13. Goldner JL. Surgical reconstruction of the upper extremity
in cerebral palsy. Instr Course Lect 1987;36:207–235.
14. Van Heest AE, House JH, Cariello C. Upper extremity
surgical treatment of cerebral palsy. J Hand Surg 1999;24A:
323–330.
15. Denischi A. Die Transplantation des Pronator Teres in der
Behandlung der spastischen Pronation der Hand. Beitr Or-
thop 1965;12:604 – 606.
16. Denischi A. Contribution au traitement chirurgical de la
pronation spastique de la main par la transposition du rond
pronateur. Rev Chir Orthop 1967;53:87–92.
17. Samilson RL. Principles of assessment of the upper limb in
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18. Leclercq C. General assessment of the upper limb. Hand
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19. Tubby AH. Recent surgical methods in the treatment of
certain forms of paralysis. BMJ 1906;3:481– 488.
20. Tubby AH. Deformities including diseases of the bones and
joints. Vol I. London: Macmillan, 1912:731–734.
21. Van Heest AE. Surgical management of wrist and finger
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25. Mayston MJ. People with cerebral palsy: effects of and
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JW, the Task Force on Childhood Motor Disorders. Classi-
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Classification and operative procedures for pronation defor-
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EA. Selection of fusion position during forearm arthrodesis.
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267–272.

Appendix A
History of Pronator Teres Rerouting
Surgery
Tubby1 developed pronator teres transplantation or
rerouting (PTR) in 1899. He reported in his Hunt-
erian Oration published in 1906 that he relieved
“pronator . . . spasm of the forearm by detaching the
tendon of insertion of the pronator radii teres, passing
it through the interosseous membrane and refixing it
to the outer side of the radius so that it may assist in
supination.” A more complete description that in-
cluded suturing the tendon through a drill hole with a
simple silk suture was published in his 1912 text-
book.2 Bradford3 performed the surgery in 3 cases in
1904, reporting good early results but “the ultimate
gain was not as great, perhaps owing to the difficulty
of inserting the end of the pronator muscle in a
proper position.”
Denischi4,5 reported on his experience with the
surgery in 1965 and 1967. For his tendon reattach-
ment he made a trough in the radial cortex and passed
sutures through the bone. It was his opinion that
pronator teres tenotomy did not come close to solv-
ing the problem of pronator spasticity and preferred a
surgery providing a supination force. He reported 10
patients with 6 good results (by subjective evalua-
tion) and 4 patients who required further surgery
before 2 became good and 2 became satisfactory.
One patient fell and fractured the radius.
Sakellarides et al6 reported their experience with
PTR in 1981. In the first cases they used a large drill
hole through both cortices of the radius but had 2
fractures and modified the technique using a large
hole in 1 cortex to insert the tendon into a small hole
in the second cortex to pass a suture around the bone.
They reported on 22 patients who had average active
supination before surgery of ⫺3° (range, ⫺35° to
0°). They recorded 11 excellent (active supination,
⬎65°; pronation, 90°), 7 good (active supination,
35°– 65°; pronation, 60°), and 4 fair results (active
supination, 20°–35°; pronation, 50°).
In 1988 Strecker et al7 modified the technique of
Sakellarides et al6 by tying the tendon to bone with a
suture on only 1 side of the radius. They had no
fractures. They compared 10 patients who had pro-
nator tenotomy (PTT) with 39 PTR patients. The
preoperative PTT active supination was ⫺18.6°
(range, ⫺80° to 0°) and the PTR average active
supination was ⫺41.6° (range, ⫺90° to 30°). The
PTT postoperative active supination was 35.9°
(range, 0°–90°) and the PTR postoperative active
supination was 48.2° (range, ⫺15° to 85°). The PTR
provided a greater gain in active supination than PTT
Robert E. Bunata / PTR in Children With CP 474.e10
(78° vs 54°) and was their procedure of choice for
pronation deformity.
In 1991 Matev8 referred to the techniques of Tub-
by1 and Denischi4,5 in describing his experience with
PTR in Tubiana’s textbook. Although not described
in the text, an illustration that accompanies his chap-
ter indicated that rather than completely detaching
the pronator, he performed a Z-lengthening of the
tendon and reattached the muscle to its own tendon
that had been wrapped around the radius and pulled
through the interosseous membrane. His impression
after 17 cases was that PTR was “the most reliable
operation for pronation forearm deformity.” He
warned against cutting the pronator quadratus be-
cause overcorrection might result (2 of 9 cases).
In 1992 Gschwind and Tonkin9 formally described
the modification of wrapping the Z-lengthened ten-
don end around the radius rather than detaching and
reattaching the tendon to bone. Their results do not
translate easily for comparison with those of other
investigators. They performed 6 PTR procedures in 3
groups classified by the severity of the preoperative
limit on supination. Four patients were in group 3,
which contained a total of 8 patients (no active, free
passive supination). After surgery this group
achieved an average “supination” arc (average active
supination for the group appears to be about 30°
forearm rotation) of 97°. They reported no fractures.
The details of the protocols used by investigators
reporting the use of PTR in treating dynamic forearm
pronation positioning are shown in Table 1.
References for Appendix A
1. Tubby AH. Recent surgical methods in the
treatment of certain forms of paralysis. BMJ 1906;3:
481-488.
2. Tubby AH. Deformities including diseases of
the bones and joints. Vol II. London: Macmillan,
1912:731–734.
3. Bradford EH. The treatment of infantile spastic
paralysis. Am J Orthop Surg 1904;1:375-380.
4. Denischi A. Transplantation des Pronator Teres
in der Behnadlung ser spastischen Pronation der
Hand. Beitr Orthop 1965;12:604-606.
5. Denischi A. Contribution au traitement chirur-
gical de la pronation spastique de la main par la
transposition du rond pronateur. Rev Chir Orthop
1967;53:87-92.
6. Sakellarides HT, Mital MA, Lenzi WD. Treat-
ment of pronation contractures of the forearm in
cerebral palsy by changing the insertion of the pro-
nator radii teres. J Bone Joint Surg 1981;63A:645-
652.
7. Strecker WB, Emanuel JP, Dailey L, Manske
PR. Comparison of pronator tenotomy and pronator
474.e11 The Journal of Hand Surgery / Vol. 31A No. 3 March 2006
rerouting in children with spastic cerebral palsy.
J Hand Surg 1988;13A:540-543.
8. Matev I. Surgery of the spastic hand. In: Tubi-
ana R, ed. The hand. Vol IV. Philadelphia: W.B.
Saunders, 1991:728-729.
9. Gschwind C, Tonkin M. Surgery for cerebral
palsy: part 1 classification and operative procedures for
pronation deformity. J Hand Surg 1992;17B:391-395.
Appendix B
Pronator Teres Rerouting Technique
The surgical technique in this report is a slightly
modified version of Gschwind and Tonkin’s. The
distal two thirds of the pronator teres (PT) muscle
and tendon are exposed through a slightly curved
longitudinal incision over the interval between the
brachioradialis and flexor carpi radialis. The radial
artery and nerve are retracted radialward. The tendon
is Z-lengthened, leaving a 4- to 5-cm length of distal
tendon attached to the radius and taking care to cut
all other tendinous and muscular attachments of pro-
nator teres from the radius extraperiosteally. These
attachments are variable and can be quite extensive
and complete severance is important. A suture is
placed in the distal tendon for control. The flexor
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pollicis longus muscle is elevated from the radius at
the level of the pronator tendon insertion, with care
taken to protect the interosseus artery and nerve. A
2-cm incision is made in the interosseous membrane.
A right-angle clamp is placed through the interosse-
ous membrane from volar to dorsal, passing it around
the radius deep to the extensor indicis proprius mus-
cle dorsally. The clamp is used to pull the distal
tendon from dorsal to volar, thereby placing it on the
volar/ulnar side of the radius. The proximal and
distal PT tendon ends are held side-by-side, with
moderate tension keeping the forearm in slight supi-
nation and sutured with a locked running nonabsorb-
able suture on the top and bottom of the tendon
junction. The tension is adjusted further so that the
forearm assumes a resting position of midrotation.
The pronator quadratus is not disturbed in any of
these patients. After surgery a long-arm cast is ap-
plied with the forearm in 30° of supination.
If the patient has preoperative supination of 0° or
less then the technique is modified to make the repair
tension less. The proximal and distal PT tendon ends
are held side-by-side with no tension while the fore-
arm is in neutral rotation. They are joined by the
same suture technique.