Functional and/or hygienic surgery of the hypertonic upper limb.

Neuro-orthopedic complications of the upper limb affect all of its joints and lead to a multitude of clinical pictures. The clinical assessment, which should be multidisciplinary, will have to answer basic questions to define the goal(s) and the appropriate surgical strategy. What is the patient's and family's complaint? What is the possible utility of the deformities? What is the type of deformity? Is it reducible or not? What is the contribution of the upper limb deformities versus that of any associated injuries to the discomfort? Several difficulties exist in the clinical assessment: evaluation of the antagonists especially the wrist extensor muscles; the intrinsic deformity component, which can be masked by the extrinsic component when retracted, the muscles responsible for a wrist flexion contracture and the complex shoulder deformities. Many patients have multiple deformities, which creates a problem for the hierarchy of corrections depending on the objectives. The answer to these questions helps to define a clear objective that will be formalized in a contract with the patient and subsequently to define the surgical strategy. Surgery is based on a simple principle: relax the muscles on the side of the deformity, either by selective neurotomy if there is a simple hypertonia, or by a tendon procedure if the muscle is retracted; compensate for the antagonists if they are deficient, and potentially stabilize the joint. Conservative procedures are preferred to preserve the possibility of functional recovery in the future. The wide range of medical and surgical solutions allows the patient's care to be personalized. In the upper limb, the results are better for hygienic, positioning, and analgesic objectives. They remain more difficult to obtain for functional objectives, due to the biomechanical complexity of gripping.