Surgical decision making for residual limb deformities following traumatic brain injury.

When neurologic recovery has plateaued following traumatic brain injury, careful assessment is needed prior to making surgical decisions to correct residual limb deformities. Sufficient cognition to follow simple commands, cooperate with postoperative therapy, and benefit from improved function is essential. Sensation must also be intact. Motor control of the extremity can be evaluated by clinical examination supplemented by nerve blocks to relieve spasticity in antagonistic muscle groups. Dynamic electromyography is frequently required for surgical decision making. Hand placement may be deterred by spasticity of the brachioradialis, biceps, and brachialis muscles. Active finger extension may be masked by spastic flexors. In the lower extremity, knee flexion may be blocked during the preswing period by inappropriate firing of one or more components of the quadriceps. The equinovarus deformity of the foot is the result of spasticity of the gastrocsoleus muscles, the toe flexors, and the tibialis anterior.