Plastic Surgery Volume 6: Hand and Upper Extremity (4th Edition) – Peter C. Neligan

755
Examples of nerve transfer procedures for specific injury patterns
Hints and tips
Priorities with median nerve injury are to re-establish anterior
interosseous nerve (AIN) function, thumb opposition, index
and long finger flexion, and critical sensation to the first
webspace. A combination of nerve and tendon transfers can
be done. For reconstruction of proximal median nerve injuries,
radial to median nerve transfers are used. For reconstruction
of more distal median nerve or isolated AIN injuries, brachialis
to AIN branch transfers can be done. This transfer is also
useful for patients with lower plexus injuries.
nerves are smaller and sit more superiorly than the sensory
nerves. Often several are required. These are dissected as far
medially as possible and then divided.
These extraplexal donor nerves can be transferred to a
variety of potential recipients, depending on surgical goals.
They can be used to establish shoulder stability and external
rotation (suprascapular and axillary nerves), elbow flexion
(musculocutaneous), or even to recreate elbow extension or
finger flexion by neurotizing one or two free-functioning
gracilis flaps.27 This is often accomplished as a two-stage
procedure.
Discussion of cross C7 transfer, phrenic nerve
transfers (motor)
Contralateral C7 transfer has been described as a safe option
in the literature28,29 and has been met with varying levels of
success and controversy. Approaches include prespinal tun­
neling, and complete and partial root harvest. However, evi­
dence suggests that the degree of function obtained does not
justify the donor complications, even with hemi-contralateral
C7 harvest.30
The phrenic nerve has also been used, with some studies
documenting no significant impact on respiration and others
reporting decreased pulmonary capacity that goes on to
improve. The senior author no longer uses either the phrenic
nerve or the contralateral C7 as a potential nerve donor as
results are, at best, Medical Research Council (MRC) grade 3
of 5 after several years for limited elbow flexion or poor finger
flexion.
Median nerve injury
Specific patient exam findings
The median nerve proper supplies pronator teres (PT), FCR,
palmaris longus, and FDS. The nerve then divides. The ante­
rior interosseous nerve innervates flexor pollicis longus, flexor
digitorum profundus (FDP) to the index finger and sometimes
long finger, and pronator quadratus (PQ). The remainder of
the nerve is largely sensory, with a small motor component
contributing to the recurrent motor branch, which innervates
the thenar muscles (abductor pollicis brevis, opponens pollicis
and the superficial head of flexor pollicis brevis) and the two
radial lumbricals.
Patients presenting with a median nerve injury will have
numbness in the distribution of the median nerve. Depending
on the level of injury, motor deficits will vary.
Reconstruction techniques
Use of radial to median branch nerve transfers (motor)
Branches of the radial nerve may be used to restore median
nerve function in a proximal median nerve injury.17 Transfer
of the extensor carpi radialis brevis branch (ECRB) of the
radial nerve is used to restore PT function. Transfer of the
supinator branch is used to restore anterior interosseous nerve
(AIN) function (Fig. 33.15). A volar forearm incision with step
lengthening of the PT and release of the deep head will facili­
tate visualization. The median nerve is identified and dis­
sected to reveal the PT and AIN recipient branches. The nerve
to supinator is identified on the posterior aspect of the radial
nerve and the ECRB nerve is also identified. There are two
fascicles to the ECRB and use of one branch is sufficient to
restore pronation. Recovery of pronation occurs approxi­
mately 3–4 months postoperatively. If AIN function is
required, the authors recommend using the nerve to brachialis
(described below).
Use of brachialis branch to AIN branch nerve transfer
The brachialis branch of the musculocutaneous nerve may be
used to restore AIN function (or, as noted above, in the setting
of a lower brachial plexus injury) (Fig. 33.16).31 A medial arm
incision is made and the donor nerve to brachialis is then
followed distally into the muscle as far as possible and
divided. It is transposed over to the median nerve to identify
the level for coaptation, and an internal neurolysis of the
median nerve is performed (Fig. 33.17). Knowledge of the
internal topography of the median nerve is crucial to perform­
ing this transfer. The lateral aspect of the median nerve is all
sensory, and the medial aspect is motor. The AIN portion of
the nerve is located at the posterior medial aspect of the nerve.
Those performing this procedure for the first time may prefer
to dissect the AIN out distally and then visually and, intermit­
tently, physically neurolyze to confirm that the correct recipi­
ent fascicles have been identified. These recipient fascicles are
neurotized and divided proximally. Of note, the nerve to the
pronator can be included in this transfer to augment AIN
function.
Sensory nerve transfer to restore critical sensation to the
first webspace is also recommended (see below).
Use of adjunct tendon transfers to augment
nerve transfers
Tendon transfers can be utilized to augment nerve transfers
in median nerve injury. The most commonly performed
tendon transfer would be to restore thumb opposition, as this
is innervated by the most distal branches of the median nerve
and will be slowest to recover. The authors’ preference for
restoration of thumb opposition is transfer of extensor indicis
proprius tendon to abductor pollicis brevis. Another option is
to use extensor digiti minimi.
Ulnar nerve injury
Specific patient exam findings
Patients presenting with an ulnar nerve injury will have
numbness in the small and ulnar side of the ring finger.

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SECTION V
CHAPTER 33 • Nerve transfers
Fig. 33.15  A schematic of radial to median nerve transfers. (A) The radial nerve is visualized superiorly as it branches into three branches, from lateral to medial: posterior
interosseous nerve (PIN), extensor carpi radialis brevis (ECRB), and radial sensory. The donor ECRB nerve is green. The median nerve is visualized inferiorly, with the
non-functioning anterior interosseous nerve (AIN) illustrated branching off the lateral aspect of the nerve (red). Note that the AIN is the only branch to exit radially. (B) The
donor ECRB nerve has been coapted end to end with the distal recipient AIN nerve.
A
B
Median nerve
Median nerve
Radial nerve
Radial nerve
PIN
PIN
AIN
AIN
ECRB
ECRB
Depending on the level of injury, sensation to the dorsum of
the hand and wrist may also be affected. The motor deficits
associated with ulnar nerve injury are particularly devastat­
ing. The deep motor branch of the ulnar nerve innervates all
of the intrinsic muscles of the hand, and injury results in the
inability to pinch, abduct, and adduct the fingers, and impairs
power grasp. More proximal injuries will also further impair
grip, with added losses of the FDP to the small and ring
fingers and FCU.
Hints and tips
Priorities for ulnar nerve injury are to re-establish intrinsic muscle
function, especially pinch, ring, and small finger flexion, and
critical sensation to the ulnar border of the hand. A combination
of nerve and tendon transfers can be done. For reconstruction
of proximal nerve injuries, a direct end-to-end anterior
interosseous nerve (AIN) to deep motor branch of ulnar nerve
transfer is useful. For incomplete, or partial, nerve injuries where
level of recovery is uncertain, reverse end-to-side AIN to deep
motor branch “supercharging” should be considered.

757
Examples of nerve transfer procedures for specific injury patterns
Fig. 33.16  A schematic of the nerve to brachialis to anterior
interosseous nerve transfer. (A) The median nerve (pink) and
musculocutaneous nerve (yellow) are shown in their normal
anatomic position. Note that the branch to brachialis exits
medially approximately 13 cm to the elbow crease. (B) The
brachialis branch of the musculocutaneous nerve (donor) is
coapted end to end with the divided distal end of the anterior
interosseous nerve (recipient), which is located on the posterior
medial aspect of the median nerve in the arm.
A
B
Median nerve
Musculocutaneous nerve
Musculocutaneous nerve
Brachialis branch
Brachialis branch
Posterior fascicle
Anterior
interosseus
nerve
Fig. 33.17  Clinical photos of nerve to brachialis to anterior interosseous nerve. A clinical example of a nerve to brachialis to anterior interosseous nerve (AIN) transfer.
(A) The median nerve is isolated with a vessel loop. Forceps are used to reveal the AIN nerve branching off the radial aspect of the median nerve. (B) A magnified view
illustrating the branch to brachialis (marked with a vessel loop) divided and transposed over, to be coapted end to end with the recipient distal AIN.
A
B
Reconstruction techniques
Use of median to ulnar branch nerve transfers (motor)
The median nerve may be used to restore ulnar nerve func­
tion, especially following very proximal injuries where time
to regenerate to motor end plate becomes an issue. Both
sensory and motor nerve transfers are utilized to restore
optimal function. The sensory nerve transfers are described
later. For restoration of intrinsic muscle function, the distal
AIN nerve is transferred to the deep motor branch of the ulnar
nerve at the distal forearm level (Fig. 33.18).9,32 Release of the
nerve through Guyon’s canal, with particular attention to
adequate release of the deep motor branch, is an essential
component of this transfer.9 Use of a volar forearm incision

758
SECTION V
CHAPTER 33 • Nerve transfers
neurolysis from the deep motor branch decompression at the
leading edge of the hypothenar muscles confirms this. Once
this plane is identified, the recipient motor fascicular group is
isolated proximally and divided to allow for the appropriate
motor nerve transfer.
Sensory nerve transfer to the ulnar border of the hand is
recommended (see below).
Use of adjunct tendon transfers to augment
nerve transfers
Tendon transfers are frequently performed to augment median
to ulnar nerve transfers. The intrinsic muscles are so distal
and are so important for function that these tendon transfers
are often performed at the same time as the nerve transfers,
even though their use might be considered redundant. Teno­
desis of the ulnar nerve-powered ring and small FDP tendons
to the median nerve-powered index and long FDP tendons
is performed. Thumb adduction is also augmented using
and retraction of the flexor tendons radially allow visualiza­
tion of the donor AIN as it enters into the deep surface of the
PQ. The AIN is dissected distally into the mid-substance of
the muscle and divided. It is transposed over to the ulnar
nerve to identify the point where it can be coapted with no
tension (Fig. 33.19). At this point, the neurolysis of the ulnar
nerve is performed. Within the proximal forearm, prior to the
take off the dorsal cutaneous branch, the topography of the
ulnar nerve is sensory–motor–sensory. The medial-most
sensory portion goes on to become the dorsal cutaneous ulnar
branch (DCU) approximately 9 cm proximal to the wrist
crease. As the nerve continues, the lateral sensory portion of
the ulnar nerve is significantly larger than the more medial
motor portion. Microforceps are used to tap along the surface
of the nerve until they plunge into the natural cleavage plane
between the sensory and motor portions of the nerve.32 Visual
Fig. 33.18  Anterior interosseous nerve (AIN) to deep motor branch of ulnar nerve.
A schematic of the distal AIN to deep motor branch transfer. The donor AIN (green)
is seen divided under the pronator quadratus muscle and transposed over to the
recipient deep motor branch of the ulnar nerve. At this level, distal to the take off
the dorsal cutaneous ulnar branch, the motor fascicles are ulnar and the main
sensory component of the nerve is radial. The coaptation is performed in an
end-to-end manner. FDS, Flexor digitorum superficialis; FDP, flexor digitorum
profundus.
Pronator quadratus
Ulnar nerve
Deep motor
branch fascicles
Median nerve
FDS, FDP retracted
radially
AIN
Fig. 33.19  Clinical photos of anterior interosseous nerve (AIN) to deep motor
branch of ulnar nerve. Clinical example of an AIN to deep motor branch nerve
transfer. (A) A vessel loop surrounds the distal AIN. The ulnar nerve is exposed on
a blue background. The dorsal cutaneous ulnar branch is illustrated branching off
ulnarly. (B) The donor AIN is divided distally and transposed over to the ulnar
nerve. The dorsal cutaneous branch of the ulnar nerve is now located beneath the
blue background, and a motor fascicle from the ulnar aspect of the main nerve is
divided as the recipient and coapted end to end to the AIN nerve.
A
B

759
Examples of nerve transfer procedures for specific injury patterns
Hints and tips
Priorities with radial nerve injury are to re-establish wrist, finger,
and thumb extension. Unlike tendon transfers, use of median-
to-radial nerve transfers allows for individual and separate
finger extension in addition to wrist and thumb extension.
extensor indicis proprius to adductor pollicis tendon transfer.
In patients with a prominent Wartenberg’s sign, abductor
digiti minimi is transferred to the extensor digitorum com­
munis tendon of the small finger.32
Radial nerve injury
Specific patient exam findings
The radial nerve is a mixed motor and sensory nerve that
receives contribution from C5, C6, C7, C8, and T1. The radial
nerve proper innervates the three heads of the triceps muscle,
anconeus epitrochlearis, brachioradialis, and extensor carpi
radialis longus (ECRL). The nerve then branches into the
posterior interosseous nerve (PIN) and radial sensory nerve
(RSN). The PIN then innervates the ECRB, supinator, extensor
carpi ulnaris, extensor indicis proprius, extensor digitorum
communis, extensor digiti minimi, abductor pollicis longus,
extensor pollicis longus, and extensor pollicis brevis. Of note,
the ECRB branch can occasionally come off the radial nerve
proper or branch off along with the radial sensory nerve,
meaning that wrist extension can be variably affected in
injuries at this level depending on individual anatomy.
Patients presenting with radial nerve injuries will have
sensory defects in the distribution of the radial nerve. Motor
deficits will depend on the level of injury. Isolated radial nerve
injuries are typically distal to the triceps, so elbow extension
is often preserved.
Reconstruction techniques
Use of median to radial branch nerve transfers
The most commonly performed transfers include using
redundant fascicles to FDS or FCR as donors to provide
innervation to PIN and ECRB (Fig. 33.20).33 An incision is
made at the volar forearm and step lengthening of the PT may
be performed to improve visualization. Knowledge of the
internal topography of the median nerve is essential for this
transfer, as protection of the branches to PT and AIN is man­
datory. The most proximal branches, of which there are
usually two, are to PT. Then, a branch to FCR and PL departs
from the ulnar side of the nerve. The next two branches will
be to the FDS and also depart ulnarly. The AIN departs from
the median nerve on the radial side, and is the only branch to
exit radially. The remaining sensory and thenar branches
continue distally.
The recipient radial nerve branches are identified by
retracting the brachioradialis laterally. The first nerve encoun­
tered will be the radial sensory branch, followed by the
smaller branch to ECRB and the larger PIN located just deep
and radial to the sensory branch. These recipient nerves are
dissected as proximally as possible and then transected.
Mobilization is facilitated by excluding the branch to the
supinator, which comes off posteriorly. The recipient nerves
are then transposed over to the median nerve to determine
the level for neurolysis. The median nerve is dissected and
redundant fascicles to FDS and FCR are divided and trans­
ferred. Motor reinnervation occurs at approximately 9–12
months postoperatively.
Use of adjunct tendon transfers to augment
nerve transfers
The authors suggest augmenting median to radial nerve
transfers with tendon transfer of PT to ECRB during the same
procedure. This transfer provides earlier restoration of wrist
extension, which is then enhanced once the nerve transfer
becomes viable at 9–12 months.
Sensory nerve injury
Restoration of key sensory functions
Restoration of discriminatory sensation in critical areas can be
accomplished using noncritical area donors. One of the newer
developments in nerve transfer surgery is to maintain some
donor territory protective sensation by use of adjunct end-to-
side transfers. A number of studies have demonstrated that
“collateral sprouting” occurs with an end-to-side sensory
repair, and novel axonal regeneration from the donor nerve
occurs into the recipient stump.8 Only sensory axons sprout
de novo without injury, whereas motor nerves require a proxi­
mal nerve injury to do so.8 Making use of this principle, efforts
are made to restore protective sensation to the donor region
with end-to-side coaptation of the distal donor to an intact
sensory nerve.
Use of ulnar to median branch nerve transfers (sensory)
A fourth webspace (ulnar) to first webspace (median) nerve
transfer can be performed to restore critical first webspace
sensation only. Alternatively, a triad of nerve transfers from
the ulnar nerve can restore more extensive sensation and
minimize donor deficits (Fig. 33.21). The DCU is transferred
end to end to the radial portion of the median nerve to restore
critical thumb and radial index sensation. The nerve to the
third webspace is the most ulnar portion grouping of fascicles
at this level (Fig. 33.22). It is coapted end to side to the main
sensory component of the ulnar nerve for restoration of third
webspace protective sensation. The distal end of the transected
donor DCU is coapted end to side to the ulnar nerve to restore
the donor deficit.32
Use of median to ulnar branch nerve transfers (sensory)
A third webspace (median) to ulnar small-finger nerve trans­
fer can be used to restore sensation to the ulnar border of the
hand. Alternatively, restoration of ulnar nerve sensation can
be provided by a triad of nerve transfers from the median
nerve (Fig. 33.23). The third webspace fascicle of the median
nerve is transferred end to end to the main sensory compo­
nent of the ulnar nerve (Fig. 33.24). End-to-side coaptation
of the dorsal cutaneous ulnar branch to the sensory com­
ponent of the median nerve is performed more proximally.
The distal third webspace (median) donor is then coapted
end to side to the remainder of the intact sensory portion
of the median nerve to restore protective sensation to the
donor defect.

760
SECTION V
CHAPTER 33 • Nerve transfers
Fig. 33.20  Median to radial nerve transfers. A schematic diagram of median to radial nerve transfers. The redundant fascicles to flexor carpi radialis (FCR) and flexor
digitorum superficialis (FDS) (donors) are transferred to the extensor carpi radialis brevis (ECRB) and posterior interosseous nerve (PIN) respectively.
A
B
Median nerve
Median nerve
Radial nerve
Radial sensory
Radial nerve
PIN
PIN
FCR
FDS
FCR
FDS
ECRB
ECRB
Use of median and ulnar nerve transfers to restore first
webspace sensation in C5–C6 root level brachial plexus
injury (sensory)
In patients with an isolated upper trunk injury, sensation to
the first and second webspaces will be absent. A combination
of distal transfers at the level of the median and ulnar nerve
proper can be used to reconstruct this deficit (Fig. 33.25).
The third webspace nerve is transected and coapted end
to end to the radial aspect of the median nerve to restore
thumb and first webspace sensation. The distal end of the
transected third webspace is coapted end to side to the ulnar
nerve to restore protective sensation of the donor site. This
effectively transfers intact sensation that originated from the
C7 and C8 roots to the C5 and C6 level at a close-to-target end
organ level.
Use of lateral antebrachial cutaneous nerve to radial
nerve transfers (sensory)
Patients with radial sensory nerve injury have numbness
on the dorsal radial aspect of the hand and wrist. Unfor­
tunately, this injury is also commonly associated with
excruciating phantom pain due to this nerve’s exquisite
sensitivity to denervation. The lateral antebrachial cutane­
ous nerve runs superficial and medial to the brachioradialis
and is in close proximity to the radial sensory nerve. It is
also a close size match. Coaptation of the expendable lateral

761
Postoperative care
Fig. 33.22  Identifying the fascicle to the third webspace. This clinical photograph
demonstrates identifying the third webspace fascicle at the proximal wrist level.
Microforceps were walked along the surface of the nerve until they plunged into the
natural cleavage plane. The division is also marked with a prominent vessel on the
surface of the nerve.
Fig. 33.21  A schematic of the triad of transfers used to restore sensation in a median nerve deficit. (A) The non-functional median (red) and the functioning ulnar nerve
(yellow). (B) The triad of nerve transfers from ulnar to median (inset) is a magnification of the transfers showing the dorsal cutaneous branch of the ulnar nerve (donor)
coapted end to end to the radial side of the median (recipient) to restore first webspace sensation, the distal third webspace (recipient) end to side to the ulnar sensory
(donor), and the distal dorsal cutaneous branch of the ulnar nerve end to side to restore sensation to the donor deficit. The third webspace fascicle is shown in blue.
A
B
Median nerve
Median nerve
1st & 2nd webspace fascicle
of median nerve
3rd webspace fascicle
of median nerve
3rd webspace fascicle
of median nerve
1st & 2nd webspace
fascicle of
median nerve
Dorsal cutaneous branch
of ulnar nerve
Dorsal cutaneous branch of ulnar nerve
Dorsal cutaneous branch of ulnar nerve
Nerve autograft
Nerve autograft
Palmar branch of median nerve
Palmar branch of ulnar nerve
Thenar (motor) branch
of median nerve
Thenar (motor) branch
of median nerve
Thenar (motor)
branch of
median nerve
Deep (motor) branch of ulnar nerve
Superficial (sensory)
branch of ulnar nerve
1st webspace
2nd webspace
3rd webspace
4th webspace
Ulnar nerve
antebrachial cutaneous nerve (LABC) to the denervated radial
sensory nerve territory may not restore completely normal
sensation, but can significantly interrupt the neuropathic
pain cycle.
Use of radial to axillary nerve transfers (sensory)
Patients with axillary nerve injury have numbness on the
lateral aspect of the shoulder. To treat this, the sensory portion
of the axillary nerve can be transferred end to side to a
functioning intact nerve such as the radial. At this level, the
internal topography of the radial nerve is such that the lateral
aspect is sensory.
Postoperative care
Postoperative wound care
Patients are initially placed into a bulky soft dressing for
comfort. Patients are encouraged to move their extremity
early to promote nerve gliding, as all nerve transfers are
performed under no tension.34 Concomitant tendon transfers
may also dictate splinting and therapy regimens and will
supersede the minor restrictions required for post nerve
transfer patients. If the insertion of the pectoralis major muscle
was disinserted to allow access to the medial pectoral nerve,
the tendon is reapproximated and the shoulder is immobilized
for a full 4 weeks.34
Complications
Complications specific to nerve surgery include temporary
pain, paresthesias, or motor neurapraxia secondary to retrac­
tion or manipulation of nerves; neuroma; and inadequate
functional recovery. The complication rate associated with
nerve transfer should be significantly less than that seen with
operating within a scarred and hostile zone of injury. Nerve
transfers are performed remote from the time of injury, thus
ensuring that patients have been stabilized, appropriately
evaluated and educated, serially clinically examined, and
perhaps most importantly, that surgery takes place during
regular, scheduled hours with a staff familiar with the proce­
dure, as opposed to exploratory repair in a trauma or after-
hours situation.

762
SECTION V
CHAPTER 33 • Nerve transfers
Fig. 33.23  Sensory nerve transfers to restore ulnar nerve deficit. A schematic of the triad of nerve transfers used to restore ulnar nerve sensation. (A) The functioning
median nerve is shown in yellow and the non-functioning ulnar nerve is shown in red. (B) The triad of nerve transfers to restore sensation. (Inset) A magnified view of the
nerve transfers illustrating the third webspace fascicle (donor) coapted end to end with the ulnar sensory (recipient), the distal dorsal cutaneous branch of the ulnar nerve
(recipient) coapted end to side to the sensory side of the intact median nerve (donor), and the distal third webspace nerve coapted end to side to the median sensory to
restore donor sensory loss.
Median nerve
Median nerve
3rd webspace fascicle
of median nerve
3rd webspace fascicle
of median nerve
Deep (motor) branch
of ulnar nerve
3rd webspace fascicle
of median nerve
3rd webspace
fascicle of
median nerve
Dorsal cutaneous branch
of ulnar nerve
Dorsal cutaneous branch of ulnar nerve
Sensory component of ulnar nerve
Sensory component
of ulnar nerve
Dorsal cutaneous branch of ulnar nerve
Palmar branch of median nerve
Palmar branch of ulnar nerve
Thenar (motor) branch
of median nerve
Deep (motor) branch of ulnar nerve
Superficial (sensory)
branch of ulnar nerve
1st webspace
2nd webspace
3rd webspace
4th webspace
Ulnar nerve
A
B
Fig. 33.24  Internal topography of the ulnar nerve in the distal forearm. A clinical
photograph illustrating the internal topography of a neurolyzed ulnar nerve at the
wrist. The tenotomy scissors are displacing the dorsal cutaneous branch of the
ulnar nerve ulnarly, the microforceps are separating the deep motor branch fascicles
ulnarly, and the remainder of the radial portion of the nerve is sensory. At this level,
the topography of the ulnar nerve is sensory–motor–sensory in a radial to ulnar
direction.
Rehabilitation
All patients are introduced to our hand therapists prior to
surgery and referrals for therapy are given at the first postop­
erative visit. Patients are instructed about wound and scar
management, the need for protective splinting or sling use,
and pain management. Wrist cock-up splints are used in
patients with radial nerve injuries until reinnervation occurs.
Supportive braces for patients with painful humeral sublux­
ation at the glenohumeral joint due to loss of deltoid function
can also be used. Education about their nerve transfer is
provided, and retraining is discussed in the early postopera­
tive period, long before clinical recovery will have occurred,
to keep the motor cortex prepared for reinnervation.34,35 The
long-term focus of rehabilitation is on re-education, as the
cortical command required to initiate target muscle function
will differ from before. The patient will “relearn” motor
control of the reinnervated target muscle by activating the
nerve to the donor muscle, similar to the re-education required
following tendon transfer. For restoration of sensation, as
patients perceive input stimulus from the reinnervated terri­
tory, cortical remapping occurs. Patients are provided with
written instructions about exercises as well as an anticipated
timeline for recovery.
Prior to reinnervation, the focus is on maintaining full
active and passive range of motion and on prevention of pain
syndromes related to musculoskeletal imbalances associated
with lost or impaired muscle strength. Therapists also work
to optimize strength of uninvolved and donor muscles follow­
ing transfer.
Once reinnervation has occurred, therapy is focused on
strengthening. Maintaining full passive range of motion
throughout is paramount. Patients may start by “strengthen­
ing the donor” and then advance to co-contracture activities
as reinnervation proceeds. For example, this would include
finger and wrist flexion with elbow flexion in double fascicu­
lar nerve transfer patients. Specific strategies involve repeti­
tive motor co-contraction of the donor and recipient muscles,
with and without passive assistance. The incorporation of
resistance into the exercises is progressive as tolerated, start­
ing with gravity completely eliminated and then against

763
Postoperative care
Fig. 33.25  Sensory nerve transfers to restore C5/C6 deficit. A schematic of sensory nerve transfers used to restore sensation to the first webspace following C5/C6 root
injuries of the brachial plexus. (A) The non-functional nerves are visualized in red and the functioning nerves are yellow. (B) The ulnar and median nerves are used to
restore sensation to the first webspace and the radial border of the thumb. (Inset) A magnified view of the nerve transfers illustrating end-to-end coaptation of the third
webspace nerve (donor) to the first webspace nerve (recipient). The distal third webspace nerve is then coapted end to side with the sensory portion of the ulnar nerve to
restore sensation to the donor third webspace.
A
B
Median nerve
1st webspace fascicle
of median nerve
1st webspace fascicle
of median nerve
3rd webspace fascicle of median nerve
3rd webspace fascicle of median nerve
Palmar branch
of median nerve
Thenar (motor)
fascicle of
median nerve
Dorsal cutaneous branch
of ulnar nerve
Palmar branch of median nerve
Palmar branch of ulnar nerve
Thenar (motor) branch
of median nerve
Deep (motor) branch of ulnar nerve
Superficial (sensory)
branch of ulnar nerve
1st webspace
2nd webspace
3rd webspace
4th webspace
Ulnar nerve
Fig. 33.26  (A–D) A 25-year-old right-handed female with a traumatic proximal ulnar nerve laceration. She underwent primary repair of the ulnar nerve transection at the
time of initial injury by another surgeon. For timely restoration of intrinsic function, she underwent a distal nerve transfer procedure at 1 month post-injury. A distal anterior
interosseous nerve (to pronator quadratus) to deep motor branch of ulnar nerve end-to-end coaptation was performed. At nearly 2 years post-injury, she has no significant
clawing, improved strength (pinch of 18 on the right, 12 on the left; grip of 70 on the right, 60 on the left), and reasonable intrinsic function (intact abduction, adduction
with simultaneous lumbrical plus positioning), residual Froment’s sign and inability to cross the fingers. She has resumed all of her baseline work (desk job) and leisure
(weightlifting) activities and is not interested in further surgery. (© 2015 nervesurgery.wustl.edu.)
A
B
C
D

764
SECTION V
CHAPTER 33 • Nerve transfers
33.26A–D). A single patient required a secondary tendon
transfer to improve small-finger adduction.9
Inevitably, the literature contains much controversy regard­
ing the outcomes following nerve transfers, and longer
follow-up is required to assess the success of these novel
procedures. This is particularly true because the continued
effect of cortical remodeling as demonstrated with functional
MRI studies as well as gradual strengthening and incorpora­
tion of the restored function has been shown to continue for
as long as 5 years or more post-transfer surgery. It seems clear,
however, that the exponential increase in publications related
to nerve transfers demonstrates that nerve transfers can no
longer be considered experimental, and are rivaling other
procedures in the treatment of severe brachial plexus and
many other peripheral nerve injuries.
Secondary procedures
Given the devastating nature of brachial plexus and proximal
nerve injuries, it is inevitable that nerve transfers are not suc­
cessful in every circumstance. Where concern exists regarding
the likelihood of functional recovery, adjunct procedures are
performed to augment the nerve transfer.
In the event of a failed nerve transfer and the necessity of
further secondary procedures, there are several important
considerations. When planning nerve transfers, one must
consider the possible salvage procedures required should the
transfer fail. Thus, when deciding on donor nerve, it is prudent
to ensure that options are left for later (for example, avoiding
the harvest of redundant fascicles to both flexor carpi radialis
and FCU). A donor for tendon transfer requires MRC grade 5
of 5 strength because following transfer it will be downgraded
by a minimum of one grade. This becomes especially chal­
lenging in patients with multiple nerve injuries, and illustrates
the importance of an accurate and detailed physical examina­
tion at preoperative assessment.
gravity, and finally against resistance. Place-and-hold exer­
cises facilitate strengthening. Resisted exercises are introduced
much later, after good movement against gravity is obtained,
to avoid overfatiguing the transfer and discouraging the
patient.
In severe injuries, hand therapists can instruct patients in
adaptive strategies for handedness retraining and performing
activities of daily living with their impaired extremity. We
have found that hand therapy is an integral part of the success
of our nerve transfers.
Outcomes and prognosis
The evaluation of outcomes following brachial plexus and
peripheral nerve reconstruction lacks standardization and
objectivity, largely given the extent and variation of nerve
injuries.34 In addition, the expected outcomes vary with the
initial injury, given that nerve transfer for a partial, distal
nerve defect would be anticipated to have near-complete
function following surgery compared to a pan-plexus type of
injury presenting with a flail extremity, where expectations
are significantly lower. Due to these difficulties, it is difficult
to compare different surgical approaches with regard to
patient outcome and prognosis; however, there have been
numerous articles reporting favorable outcomes on an increas­
ing number of nerve transfer options.
We feel shoulder function is best improved by reinnerva­
tion of both suprascapular and axillary nerves, confirmed in
a large meta-analysis of 1088 nerve transfers.21 Variable levels
of transfer and incomplete inclusion of all the branches of the
axillary nerve (to teres minor and the anterior, middle, and
posterior deltoid) may, in part, explain the continued debate
in the literature about the variable conclusions regarding the
superiority of transfer versus direct repair or interposition
grafting.36–38 In a recent study by Garg et al., the use of dual
nerve transfers to restore shoulder and elbow function in C5/
C6-level injuries was superior to the results of traditional
nerve grafting.39 In a clinical series of seven patients undergo­
ing nerve transfer from triceps to axillary nerve, all patients
recovered MRC 4/5 power. Five of the patients had excellent
recoveries and 2 showed good results.40
The double fascicular nerve transfer has been evaluated
with long-term follow-up in more than one study, and all
patients were noted to achieve at least MRC grade 4 of 5
function with no appreciable donor deficit. Innervation was
noted at a mean of 5.5 months postoperatively.22
In medial pectoral to musculocutaneous nerve transfers
with an interpositional lateral antebrachial cutaneous nerve
graft, three of four patients achieved MRC grade 4 of 5 elbow
flexion, and the last, MRC grade 3 of 5. Reinnervation was
first noted at 6–8 months postoperatively.5
Restoration of radial nerve function in the forearm using
expendable branches of the median nerve has demonstrated
predictable results, with MRC grade 4 of 5 wrist and finger
extension by 1 year.41
In another series, eight patients undergoing transfer of the
distal AIN to the deep motor branch of the ulnar nerve were
evaluated. All patients had reinnervation of the ulnar intrinsic
muscles facilitating grip and lateral pinch strength. No patient
required anticlaw procedures. None of the patients had a
deficit in pronation associated with AIN transfer (Fig.
Tendon transfers have the benefit of not being restricted by
time, given that distal motor denervation and fibrosis do not
affect the outcome. For this reason, there is no harm in
attempting a nerve transfer as a primary procedure (as long
as it is completed within the timeframe to achieve motor
reinnervation, which is approximately within 12 months post-
injury), and reserving the tendon transfer for a secondary
procedure if the functional outcome is less than desired.
Nerve transfers should not be attempted if there are
not suitable, redundant, available donors, as in the setting
of a multinerve injury. In this setting, nerve grafting com­
bined with tendon transfer, or even arthrodesis, may be
warranted.
Hints and tips
Avoid using a donor nerve that may be required for a
secondary procedure such as a tendon transfer down the
road. Prior to cutting a donor nerve, make sure the rest of the
nerve performs all essential functions with fastidious
intraoperative nerve stimulation.

765
Future directions
In our experience, secondary procedures are rarely
required following nerve transfer. However, we are
diligent about considering options when planning our initial
procedure.
Future directions
Nerve transfer techniques have proved to be a powerful tool
to restore meaning function. More recent work expands their
application in a variety of directions.
In peripheral nerve and brachial plexus injury, novel com­
binations of sensory and motor transfers42–45 based on the
principles of expendable donor, appropriate recipient and
knowledge of internal topography continue to expand the
literature. Early reports of adaptation to lower extremity
nerve injury patterns,46–49 while more limited by the greater
distances to target, are encouraging. Broadened applications
to pediatrics50,51 and central nervous system disorders such as
spinal cord injury52–59 and transverse myelitis60 will require a
cautious approach and ongoing study to avoid potential
harms in these complicated and vulnerable patients.
8. Hayashi A, Pannucci C, Moradzadeh A, et al. Axotomy or
compression is required for axonal sprouting following end-to-side
neurorrhaphy. Exp Neurol. 2008;211:539–550. This study demonstrated
that sensory nerves would collaterally sprout from a normal nerve into a
distal end-to-side-positioned nerve spontaneously. By contrast it showed
that a motor nerve needed an injury in order to sprout (traumatic
sprouting). This is a significant paper in that it shows that if you want to
get some sensory recovery, then the end-to-side will work, but if you want
motor, you need to injure the motor nerve traumatically in order to get it
to sprout in an end-to-side fashion.
10. Kale SS, Glaus SW, Yee A, et al. Reverse end-to-side nerve transfer:
from animal model to clinical use. J Hand Surg Am. 2011;36:1631–
1639.e2.
16. Kozin SH. Injuries of the brachial plexus. In: Ianotti JP, ed. Disorders
of the Shoulder: Diagnosis and Management. Philadelphia, PA:
Lippincott Williams & Wilkins; 2007:1087–1130.
32. Brown JM, Yee A, Mackinnon SE. Distal median to ulnar nerve
transfers to restore ulnar motor and sensory function within the
hand: technical nuances. Neurosurgery. 2009;65:966–977, discussion
977–8. This is an up-to-date description of the technical nuances of
transfer from the distal anterior interosseous nerve to the motor
component of the ulnar nerve. This anterior interosseous nerve to deep
motor branch of ulnar nerve was first done by the authors in 1991 and is
generally accepted as a procedure of choice for high ulnar nerve problems.
33. Ray WZ, Mackinnon SE. Clinical outcomes following median to
radial nerve transfers. J Hand Surg Am. 2011;36:201–208. This
manuscript describes the outcome of a number of patients undergoing
median to radial nerve transfer and provides the technical nuances and the
pearls and pitfalls of this nerve transfer.
34. Tung TH, Mackinnon SE. Nerve transfers: indications, techniques,
and outcomes. J Hand Surg Am. 2010;35:332–341.
35. Mackinnon SE, Novak CB (eds). Nerve Transfers issue. Hand Clin.
2008;24:319–488. This Hand Clinics is a multiauthored text covering all
aspects of nerve transfers from surgical techniques to physical therapy.
Access the complete reference list online at

765.e1
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that sensory nerves would collaterally sprout from a normal nerve into a
distal end-to-side-positioned nerve spontaneously. By contrast it showed
that a motor nerve needed an injury in order to sprout (traumatic
sprouting). This is a significant paper in that it shows that if you want to
get some sensory recovery, then the end-to-side will work, but if you want
motor, you need to injure the motor nerve traumatically in order to get it
to sprout in an end-to-side fashion.
9. Novak CB, Mackinnon SE. Distal anterior interosseous nerve
transfer to the deep motor branch of the ulnar nerve for
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plexus palsy. Hand (N Y). 2006;1:71–77.
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an end to side neurorrhaphy of the accessory nerve to the
suprascapular nerve: case report. Hand (N Y). 2010;5:313–317.
20. Leechavengvongs S, Witoonchart K, Uerpairojkit C, et al. Nerve
transfer to deltoid muscle using the nerve to the long head of the
triceps, part II: a report of 7 cases. J Hand Surg Am. 2003;28:633–638.
21. Merrell GA, Barrie KA, Katz DL, et al. Results of nerve transfer
techniques for restoration of shoulder and elbow function in the
context of a meta-analysis of the English literature. J Hand Surg Am.
2001;26:303–314.
22. Mackinnon SE, Novak CB, Myckatyn TM, et al. Results of
reinnervation of the biceps and brachialis muscles with a double
fascicular transfer for elbow flexion. J Hand Surg Am. 2005;30:
978–985.
23. Carlsen BT, Kircher MF, Spinner RJ, et al. Comparison of single
versus double nerve transfers for elbow flexion after brachial
plexus injury. Plast Reconstr Surg. 2011;127:269–276.
24. Aszmann OC, Rab M, Kamolz L, et al. The anatomy of the pectoral
nerves and their significance in brachial plexus reconstruction. J
Hand Surg Am. 2000;25:942–947.
25. Garcia-Lopez A, Sebastian P, Martinez F, et al. Transfer of the nerve
to the brachioradialis muscle to the anterior interosseous nerve for
treatment for lower brachial plexus lesions: case report. J Hand Surg
Am. 2011;36:394–397.
26. Bertelli JA, Ghizoni MF. Transfer of supinator motor branches to the
posterior interosseous nerve in C7–T1 brachial plexus palsy. J
Neurosurg. 2010;113:129–132.
27. Doi K, Muramatsu K, Hottori Y, et al. Reconstruction of upper
extremity function in brachial plexopathy using double free gracilis
flaps. Tech Hand Up Extrem Surg. 2000;4:34–43.
28. Terzis JK, Kokkalis ZT. Selective contralateral C7 transfer in
posttraumatic brachial plexus injuries: a report of 56 cases. Plast
Reconstr Surg. 2009;123:927–938.
29. Wang L, Zhao X, Gao K, et al. Reinnervation of thenar muscle after
repair of total brachial plexus avulsion injury with contralateral C7
root transfer: report of five cases. Microsurgery. 2011;31:323–326.
30. Sammer DM, Kircher MF, Bishop AT, et al. Hemi-contralateral C7
transfer in traumatic brachial plexus injuries: outcomes and
complications. J Bone Joint Surg Am. 2012;94:131–137.
31. Zheng XY, Hou CL, Gu YD, et al. Repair of brachial plexus lower
trunk injury by transferring brachialis muscle branch of
musculocutaneous nerve: anatomic feasibility and clinical trials.
Chin Med J. 2008;121:99–104.
32. Brown JM, Yee A, Mackinnon SE. Distal median to ulnar nerve
transfers to restore ulnar motor and sensory function within the
hand: technical nuances. Neurosurgery. 2009;65:966–977, discussion
977–8. This is an up-to-date description of the technical nuances of
transfer from the distal anterior interosseous nerve to the motor
component of the ulnar nerve. This anterior interosseous nerve to deep
motor branch of ulnar nerve was first done by the authors in 1991 and is
generally accepted as a procedure of choice for high ulnar nerve problems.
33. Ray WZ, Mackinnon SE. Clinical outcomes following median to
radial nerve transfers. J Hand Surg Am. 2011;36:201–208. This
manuscript describes the outcome of a number of patients undergoing
median to radial nerve transfer and provides the technical nuances and the
pearls and pitfalls of this nerve transfer.
34. Tung TH, Mackinnon SE. Nerve transfers: indications, techniques,
and outcomes. J Hand Surg Am. 2010;35:332–341.
35. Mackinnon SE, Novak CB (eds). Nerve Transfers issue. Hand Clin.
2008;24:319–488.
This Hand Clinics is a multiauthored text covering all aspects of nerve
transfers from surgical techniques to physical therapy.
36. Yang LJ, Chang KW, Chung KC. A systematic review of nerve
transfer and nerve repair for the treatment of adult upper brachial
plexus injury. Neurosurgery. 2012;71:417–429, discussion 29.
37. Wolfe SW, Johnsen PH, Lee SK, et al. Long-nerve grafts and nerve
transfers demonstrate comparable outcomes for axillary nerve
injuries. J Hand Surg Am. 2014;39:1351–1357.
38. Terzis JK, Barmpitsioti A. Axillary nerve reconstruction in 176
posttraumatic plexopathy patients. Plast Reconstr Surg.
2010;125:233–247.
39. Garg R, Merrell GA, Hillstrom HJ, et al. Comparison of nerve
transfers and nerve grafting for traumatic upper plexus palsy: a
systematic review and analysis. J Bone Joint Surg Am. 2011;93:
819–829.
40. Leechavengvongs S, Witoonchart K, Uerpairojkit C. Thuvasethakul
P. Nerve transfer to deltoid muscle using hte nerve to the long head
of the triceps, part II: a report of 7 cases. J Hand Surg Am.
2003;28(4):633–638.
41. Ray WZ, Mackinnon SE. Clinical outcomes following median to
radial nerve transfers. J Hand Surg Am. 2011;36:201–208.
42. Phillips BZ, Franco MJ, Yee A, et al. Direct radial to ulnar nerve
transfer to restore intrinsic muscle function in combined proximal

765.e2
SECTION V
CHAPTER 33 • Nerve transfers
median and ulnar nerve injury: case report and surgical technique. J
Hand Surg Am. 2014;39:1358–1362.
43. Pet MA, Ray WZ, Yee A, et al. Nerve transfer to the triceps after
brachial plexus injury: report of four cases. J Hand Surg Am.
2011;36:398–405.
44. Malungpaishrope K, Leechavengvongs S, Witoonchart K, et al.
Simultaneous intercostal nerve transfers to deltoid and triceps
muscle through the posterior approach. J Hand Surg Am. 2012;37:
677–682.
45. Garcia-Lopez A, Perea D. Transfer of median and ulnar nerve
fascicles for lesions of the posterior cord in infraclavicular brachial
plexus injury: report of 2 cases. J Hand Surg Am. 2012;37:1986–1989.
46. Tung TH, Chao A, Moore AM. Obturator nerve transfer for femoral
nerve reconstruction: anatomic study and clinical application. Plast
Reconstr Surg. 2012;130:1066–1074.
47. Giuffre JL, Bishop AT, Spinner RJ, et al. Surgical technique of a
partial tibial nerve transfer to the tibialis anterior motor branch for
the treatment of peroneal nerve injury. Ann Plast Surg. 2012;69:
48–53.
48. Giuffre JL, Bishop AT, Spinner RJ, et al. Partial tibial nerve transfer
to the tibialis anterior motor branch to treat peroneal nerve injury
after knee trauma. Clin Orthop Relat Res. 2012;470:779–790.
49. Flores LP, Martins RS, Siqueira MG. Clinical results of transferring a
motor branch of the tibial nerve to the deep peroneal nerve for
treatment of foot drop. Neurosurgery. 2013;73:609–615, discussion
15–6.
50. Zuckerman SL, Eli IM, Shah MN, et al. Radial to axillary nerve
neurotization for brachial plexus injury in children: a combined
case series. J Neurosurg Pediatr. 2014;14:518–526.
51. Chan KM, Olson JL, Morhart M, et al. Outcomes of nerve transfer
versus nerve graft in ulnar nerve laceration. Can J Neurol Sci.
2012;39:242–244.
52. Fox IK, Davidge KM, Novak CB, Hoben G, Kahn LC, Juknis N,
Ruvinskaya R, Mackinnon SE. Nerve Transfers to Restore Upper
Extremity Function in Cervical Spinal Cord Injury: Update and
Preliminary Outcomes. Plast Reconstr SurgI. 2015;136(4):780–792.
53. Fox IK, Davidge KM, Novak CB, et al. Use of peripheral nerve
transfers in tetraplegia: evaluation of feasibility and morbidity.
Hand (N Y). 2015;10:60–67.
54. van Zyl N, Hahn JB, Cooper CA, et al. Upper limb reinnervation in
C6 tetraplegia using a triple nerve transfer: case report. J Hand Surg
Am. 2014;39:1779–1783.
55. Mackinnon SE, Yee A, Ray WZ. Nerve transfers for the restoration
of hand function after spinal cord injury. J Neurosurg. 2012;117:
176–185.
56. Friden J, Gohritz A. Brachialis-to-extensor carpi radialis longus
selective nerve transfer to restore wrist extension in tetraplegia: case
report. J Hand Surg Am. 2012;37:1606–1608.
57. Bertelli JA, Mendes Lehm VL, Tacca CP, et al. Transfer of the distal
terminal motor branch of the extensor carpi radialis brevis to the
nerve of the flexor pollicis longus: an anatomic study and clinical
application in a tetraplegic patient. Neurosurgery. 2012;70:1011–1016.
58. Bertelli JA, Ghizoni MF, Tacca CP. Transfer of the teres minor motor
branch for triceps reinnervation in tetraplegia. J Neurosurg.
2011;114:1457–1460.
59. Bertelli JA, Tacca CP, Ghizoni MF, et al. Transfer of supinator motor
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60. Dorsi MJ, Belzberg AJ. Nerve transfers for restoration of upper
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deficits due to transverse myelitis: case report. Microsurgery.
2012;32:64–67.

SECTION V • Paralytic Disorders
34 
Tendon transfer for reconstruction of the
wrist and hand
Neil F. Jones
SYNOPSIS
■ Tendon transfers in the upper limb are indicated to restore function to
paralyzed muscle and tendon following nerve injury, direct muscle or
tendon injury, and to restore balance to hands affected by neurological
disease.
■ In selecting donor tissue, the surgeon has to consider expendability of
the muscle–tendon unit, the native strength of donor and paralyzed
muscle, and the direction of transfer and integrity of the muscle.
■ The timing of tendon transfers can be classified as early, conventional,
or late.
■ Upper extremity neurological injury can be subdivided into radial nerve
palsy, low and high median nerve palsy, low and high ulnar nerve
palsy, and combined nerve injuries.
Introduction
Tendon transfers are reconstructive techniques that will
restore motion or balance to the hand lost secondary to
impaired or absent function of the extrinsic or intrinsic
muscle–tendon units of the forearm and hand. In a typical
tendon transfer, the tendon of insertion of a functioning
muscle is detached, mobilized, and then reattached to another
tendon or bone to substitute for the action of a non-functioning
muscle–tendon unit. Very occasionally, both the tendon of
origin and the tendon of insertion are detached and then
reattached at different locations. Unlike a tendon graft, the
transferred donor tendon remains attached to its parent
muscle. A tendon transfer also differs from a microsurgical
free muscle transfer in that the neurovascular pedicle to the
muscle of the transferred tendon remains intact.
There are three general indications for tendon transfers in
the upper extremity:
1. To restore function to a paralyzed muscle due to injuries
of the peripheral nerves, the brachial plexus, or the
spinal cord.
2. To restore function following closed tendon ruptures or
open injuries to the tendons or muscles.
3. To restore balance to a deformed hand due to various
neurological diseases.
Tendon transfers are best conceptualized as a means to restore
a lost “function”, rather than a means of substituting for a
specific muscle, i.e., restoring strong pinch as opposed to
restoring function of the flexor pollicis longus. Tendon trans­
fers are performed predominantly following peripheral nerve
injuries and therefore will be discussed according to the
three specific nerve palsies. However, the general principles
described in this chapter apply to all transfers (Table 34.1).
General principles
Bone and soft-tissue healing
Steindler1 first suggested that tendon transfers cannot glide
through edematous or scarred soft tissues, nor can they flex
or extend stiff metacarpophalangeal (MCP) and proximal
interphalangeal (PIP) joints. He therefore advocated that
tendon transfers be delayed until “tissue equilibrium” had
been restored. Before a tendon transfer is performed, all
fractures should be healed or rigidly fixed by internal fixation.
Chronic scarred skin and subcutaneous tissues or skin grafts
in the projected line of pull of a tendon transfer should be
excised and the defect resurfaced with a flap that itself is
allowed to heal and the new scars become mature. If second­
ary tendon transfers are likely to be necessary, initial split-
thickness skin grafting of soft-tissue defects of the hand and
forearm, simply to achieve a healed wound, should be avoided
if possible. Instead, a pliable flap ideally of skin and subcuta­
neous tissues should be considered, either as a delayed
primary coverage using pedicled flaps such as the groin flap
and reverse radial forearm flap or free flaps such as the lateral
arm flap, contralateral radial forearm flap, scapular flap, and
latissimus dorsi flap. Occasionally, silicone rods can be placed

767
General principles
Strength
In selecting the most appropriate donor muscle–tendon, the
surgeon must consider not only the strength of the muscle to
be transferred, but also the native strength of the now para­
lyzed muscle or muscles and the strength of the antagonist
muscle.2 Brand3,4 has emphasized that the maximum potential
force of a muscle is directly proportional to its physiologic
cross-sectional area. It has been calculated that a muscle can
produce a force of 3.65 kg per square centimeter of its cross-
sectional area. This potential force is maximal when the
muscle is at its resting length which is defined as the position
midway between the length when it is fully stretched pas­
sively and when it is fully contracted.
Amplitude
The potential amplitude or excursion of a donor muscle–
tendon unit must also be sufficient to restore the specific lost
function. The finger flexors have an amplitude of 70 mm,
the finger extensors 50 mm and the wrist flexors and exten­
sors 33 mm. The tenodesis effect of wrist flexion or extension
may also increase the effective amplitude of a tendon transfer
by 25 mm (Fig. 34.1). Excursion of a donor muscle may also
be increased by extensive release of its surrounding fascia
and is best exemplified by transfer of the brachioradialis (BR)
muscle. The distal portion and tendon of the brachioradialis
muscle are surrounded by dense fascia. Release of these
fascial attachments will add an additional 2–3 cm of passive
excursion.
Table 34.1  Basic principles of tendon transfers
Soft-tissue “equilibrium”
Full passive range of motion of involved joints
Adequate amplitude of donor muscle
Direct line of pull
Single function for each transferred tendon
Synergy of transfer
Clinical tips
• Full passive range of motion of the MCP and PIP joints
should be achieved before considering any tendon
transfers.
• The selected donor muscle–tendon unit must be
expendable.
• One wrist flexor, one wrist extensor, one extrinsic flexor, and
one extrinsic extensor tendon to each digit should always
be retained.
at the time of flap coverage, either beneath or through the
subcutaneous fat of a transferred flap to create a smooth
tunnel through which a tendon transfer may be later passed.
The span of the thumb–index finger webspace should be
maintained by splinting, especially following median nerve
injuries. If a secondary adduction contracture has developed,
this should be released by a Z-plasty, skin grafting, or trans­
position flap, and release of the adductor pollicis if needed,
prior to any opposition tendon transfer. Full passive range of
motion of the MCP and PIP joints should be achieved by
physical therapy and dynamic splinting prior to any tendon
transfer. Preliminary capsulotomies of the MCP and PIP joints
or tenolysis of adherent flexor or extensor tendons may occa­
sionally be required if dynamic splinting fails to achieve
adequate joint mobility.
Selection of donor muscle–tendon
Expendability
The muscle–tendon unit selected as a potential donor for
transfer must be expendable. Its sacrifice must not create an
important new deficit. For example, the ring finger flexor
digitorum superficialis (FDS) tendon may be used to correct
MCP hyperextension (claw deformity) in patients with a low
ulnar nerve palsy, but it is not expendable in patients with a
high ulnar nerve palsy who have no functioning flexor digi­
torum profundus (FDP) tendon to the ring finger. The selec­
tion of a muscle–tendon unit as a tendon transfer may also be
influenced by the patient’s occupation. For example, the flexor
carpi radialis (FCR) may be a more appropriate transfer to
provide finger extension in a working man rather than the
more conventional flexor carpi ulnaris (FCU) transfer, since
the FCU provides the important function of flexion and ulnar
deviation of the wrist needed in work activities such as ham­
mering. More importantly, if multiple tendon transfers are
required, a minimum of one wrist flexor, one wrist extensor,
and one extrinsic flexor and extensor tendon to each digit
should always be retained.
• Potential amplitude of donor muscle–tendon units:
• Finger flexors – 70 mm;
• Finger extensors – 50 mm;
• Wrist flexors and extensors – 33 mm.
Clinical tips
• The potential amplitude of a donor wrist extensor tendon
may be increased by 20 mm to produce an effective
amplitude by the tenodesis effect of wrist extension.
• The potential amplitude of a donor wrist flexor tendon can
be increased by 20 mm to produce an effective amplitude
by the tenodesis effect of wrist flexion.
Direction of transfer and integrity
A tendon transfer should pass in a direct line from the origin
of the donor muscle to its new insertion. Unless early tendon
transfers are being performed, when there is still a chance of
reinnervation following nerve repair, the recipient tendons
should be divided proximal to the site of the tendon juncture
to create a more direct line of pull (end-to-end) rather than
producing a Y- shaped end-to-side juncture. Tendon transfers
should only act across one joint and only perform one single
function. This maintains the “integrity” of the muscle.
However, a transfer may be inserted into several recipient
tendons as long as they each perform the same function in
adjacent digits. Finally, the donor muscle selected should

768
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
Fig. 34.1  (A) The wrist tenodesis effect: Wrist flexion will increase the potential
amplitude of a tendon transfer to restore finger extension by 20 mm. (B) Similarly,
wrist extension will increase the potential amplitude of a tendon transfer to restore
finger flexion by 20 mm.
A
B
preferably be synergistic with the function of the muscle to be
restored or at least be potentially retrainable.
The surgeon has to determine the specific functions to be
restored, select the appropriate donor muscle–tendon units,
and decide on the timing of the tendon transfer. To make this
selection, every muscle still functioning in the forearm and
hand should be tested by manual muscle testing to document
which ones are functioning and their strength graded. From
this list of functioning muscles, only those that are expendable
are available as donor transfers. The specific functions of the
hand that need to be restored are then listed in order of prior­
ity. The final step is to match the available donor muscles with
the functions that need to be restored, based on the force,
amplitude, and direction of the various muscles available.
Arthrodesis of a more proximal joint such as the wrist may
occasionally need to be considered to release a wrist flexor or
extensor tendon for transfer. Transfers that require postopera­
tive immobilization with the wrist in flexion are usually per­
formed at a first stage. Those transfers requiring postoperative
immobilization with the wrist in extension are performed at
a second stage.
Clinical tips
• Document which muscles are functioning and their
individual strengths.
• Only the expendable muscles in this group of functioning
muscles can be considered as potential donor transfers.
• List the specific hand functions that need to be restored, in
order of priority.
• Match the available expendable donor muscles with the
hand functions to be restored.
Timing of tendon transfers
Timing of tendon transfers may be classified as early, conven­
tional, or late. A conventional tendon transfer is usually per­
formed after reinnervation of the paralyzed muscle fails to
occur by 3 months after the expected time of reinnervation
based on the rate of nerve regeneration of 1 mm/day. Brand,3
Omer,5 and Burkhalter6 have advocated “early” tendon trans­
fers in certain circumstances, in which a tendon transfer is
performed simultaneously with the nerve repair or before the
expected time of reinnervation of the muscle. This “early”
tendon transfer therefore serves as a temporary substitute for
the paralyzed muscle until reinnervation occurs, by acting as
an “internal splint”. If reinnervation is suboptimal, the “early”
tendon transfer acts as a helper to augment the power of the
muscle and if reinnervation fails to occur it then acts as a
permanent substitute.
Surgical techniques
The success of any tendon transfer depends entirely on pre­
venting scarring or adhesions along the path of the transferred
tendon. Incisions should be carefully planned prior to eleva­
tion of the tourniquet so that the final tendon junctures lie
transversely beneath skin flaps rather than lying immediately
beneath and paralleling the incisions. The donor muscle
should be carefully mobilized to prevent damage to its neu­
rovascular bundle which usually enters in the proximal third
of the muscle. The transferred tendon should glide in a tunnel
through the subcutaneous tissues and not cross bone devoid
of uninjured periosteum nor pass through small fascial
windows. Only the distal end of the tendon should be grasped
with surgical instruments and care taken to prevent desicca­
tion of the tendon or the surrounding tissues. Tendon junctures
are performed using a Pulvertaft weave technique when pos­
sible. The donor and recipient tendons are sutured under
normal tension and after one or two non-absorbable sutures
have been inserted, the tension of the transfer is checked by
observing the flexion and extension of the digit during teno­
desis of the wrist. Postoperatively the hand is immobilized in
the desired position for 3–4 weeks, at which time gentle active
range of motion exercises are started, usually under the
supervision of a therapist, but the hand is protected for a
further 3 weeks in a lightweight protective splint.

769
Radial nerve palsy
fracture was very poor, but the prognosis for full recovery of
an intact radial nerve, whether the fracture is open or closed,
was very good. Mayer and Mayfield8 reported 39 cases of
posterior interosseous nerve (PIN) neurorrhaphy with com­
plete recovery in 28 and partial recovery in 11 patients. Young
et al.9 studied 51 patients with PIN palsy and only 11 had
resolved by 3 months. Of the remaining 40 patients, 20 of the
23 who underwent neurolysis and 10 of the 12 who underwent
nerve grafting had excellent or good results. A conflicting
study of radial nerve injuries demonstrated useful function in
65%, but only 38% of patients who underwent nerve grafting
obtained useful motor function.10 These studies demonstrate
that injury and repair of the radial and PIN nerves can provide
significant return of function and should be considered.
With extensive nerve gaps or associated soft-tissue injuries or
in older patients, the chances of successful reinnervation
are much less predictable and it may therefore be more appro­
priate for these patients to undergo the full set of tendon
transfers early.11 In a patient awaiting return of nerve function,
it is important to maintain supple MCP joints capable of full
extension and adequate radial abduction of the thumb with
appropriate splinting and therapy.
Radial nerve palsy
Indications
The functional motor deficit in radial nerve palsy consists of
inability to extend the wrist, inability to extend the fingers at
the MCP joints, and inability to extend and radially abduct
the thumb (Fig. 34.2). However, the most significant disability
is that patients are unable to stabilize their wrist, so that
transmission of flexor power to their fingers is impaired
resulting in marked weakness of grip strength.
Tendon transfers are therefore required to provide wrist
extension, extension of the fingers at the MCP joints, and
extension and radial abduction of the thumb. Unlike the
median and ulnar nerves, sensory loss following radial nerve
injury is not functionally disabling unless the patient develops
a painful neuroma.
Timing
Timing of tendon transfers for radial nerve palsy remains
controversial. The two options are either to perform an “early”
tendon transfer simultaneously with repair of the radial nerve
to act as an “internal splint” to provide immediate restoration
of power grip; or more conventionally, to delay any tendon
transfers until reinnervation of the most proximal muscles,
brachioradialis and extensor carpi radialis longus fails to
occur within the calculated time limit. The more proximal the
nerve injury, the less likely that functional muscle reinnerva­
tion will occur.3,6 If the nerve remains in continuity, most
surgeons would suggests that 3 months of observation are
indicated to await spontaneous recovery in peripheral nerve
palsies.
Ring et al.7 reviewed 24 patients with a complete radial
nerve palsy associated with a high-energy humeral fracture.
Six of 11 open fractures had a transected radial nerve and
none of the five patients who underwent primary repair of
the radial nerve recovered any function. All eight nerves that
were explored and found to be intact and 9 of 10 unexplored
nerves recovered completely, with initial signs of recovery at
an average of 7 weeks and full recovery at an average of 6
months. The authors concluded that primary repair of a
transected radial nerve associated with a high-energy humerus
Clinical tips
• Carefully design the incisions not only to allow dissection of
the donor muscle–tendon unit, but also so that the tendon
junctures lie beneath an elevated skin flap, rather than
immediately beneath the incision, to prevent adhesions that
will restrict gliding of the tendon transfer.
• The recipient tendon should be fully distracted to produce
maximal function of the recipient tendon and the donor
tendon transfer should be sutured at its resting length to
the recipient tendon using a Pulvertaft weave technique.
• Correct tensioning of the tendon transfer is checked by
observing flexion and extension of the digits or abduction
and adduction of the thumb during tenodesis of the wrist.
Fig. 34.2  (A) Typical appearance of a patient with radial nerve palsy with wrist
drop. The fingers extend at the proximal interphalangeal joints through the tenodesis
effect. (B) Even with the wrist supported in extension, the patient is unable to
actively extend the fingers at the metacarpophalangeal joints or extend the thumb.
A
B

770
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
forearm if necessary (see Figs. 34.4 & 34.6). Through the same
distal incision, the palmaris longus (PL) tendon is transected
at the wrist crease and the muscle mobilized into the middle
third of the forearm (see Figs. 34.5 & 34.6). An S-shaped inci­
sion is then made beginning over the volar-radial aspect of
the middle third of the forearm and passing dorsally and
ulnarly over the radial border of the forearm. The tendon of
pronator teres is elevated from the radius in continuity with
a 2–3 cm strip of periosteum (see Fig. 34.3). The ECRB is
transected at its musculotendinous junction if there is no
chance of future reinnervation of the wrist extensors. The
pronator teres is then re-routed around the radial border of
the forearm superficial to the brachioradialis and extensor
carpi radialis longus in a straight direction to its insertion into
ECRB (see Fig. 34.3). The FCU tendon is passed through a
subcutaneous tunnel made with a Kelly clamp from the
Operations
Franke provided one of the earliest descriptions of tendon
transfers for radial nerve palsy using the FCU to extensor
digitorum communis (EDC) transfer through the interosseous
membrane.12 Capellen in 1899 described the FCR to extensor
pollicis longus (EPL) transfer. The pronator teres (PT) to
extensor carpi radialis longus (ECRL) and the extensor carpi
radialis brevis (ECRB) transfer for wrist extension was first
reported in 1906 by Sir Robert Jones. Zachary13 emphasized
the importance of retaining at least one wrist flexor, preferably
the FCR to facilitate wrist control. Other authors have sug­
gested that FCU is not an expendable tendon and therefore
prefer to use the FCR as the donor tendon to restore finger
extension.14 The advantage of using FCR is that it preserves
the important vector of wrist flexion and ulnar deviation
which is so important for power grip in a working man. This
is particularly true in the patient with a posterior interosseous
nerve (PIN) palsy, in which ECRL function is preserved but
extensor carpi ulnaris (ECU) activity is lost. This leads to
radial deviation of the wrist with attempted wrist extension.
Use of the FCU in this setting will therefore increase the radial
deviation of the wrist, since only radially deviating wrist
motors are preserved.
Several different tendon transfers have been reported for
radial nerve palsy but three patterns of transfer have
evolved.15,16 The use of pronator teres (PT) to provide wrist
extension has become universally accepted, the only remain­
ing controversy being whether to insert pronator teres into
extensor carpi radialis brevis (ECRB) alone or into both exten­
sor carpi radialis longus (ECRL) and extensor carpi radialis
brevis. The three patterns of tendon transfer differ therefore
only in the technique of restoring finger extension and thumb
extension and radial abduction (Table 34.2).13,17–19
Standard FCU transfer (Figs. 34.3–34.5)
In the patient with a radial nerve palsy, the FCU transfer is
the author’s preferred technique; in the patient with a PIN
palsy, the FCR transfer is preferred. Through an inverted
J-shaped incision over the ulnar–volar aspect of the distal
forearm, the FCU tendon is transected at the wrist crease and
released extensively from its fascial attachments up into the
proximal third of the forearm, taking care not to damage the
neurovascular pedicle, using a second incision in the proximal
Table 34.2  Tendon transfers for radial nerve palsy
Standard FCU
transfer
FCR transfer
Boyes superficialis
transfer
PT to ECRB
PT to ECRB
PT to ECRB
FCU to EDC
FCR to EDC
FDS of ring finger to EDC
long, ring, and small
fingers
PL to EPL
PL to EPL
FDS long finger to EIP and
EPL (FCR to APL and EPB)
APL, Abductor pollicis longus; ECRB, extensor carpi radialis brevis; EDC,
extensor digitorum communis; EIP, extensor indicis proprius; EPB, extensor
pollicis brevis; EPL, extensor pollicis longus; FCR, flexor carpi radialis; FCU,
flexor carpi ulnaris; FDS, flexor digitorum superficialis; PL, palmaris longus; PT,
pronator teres.
Fig. 34.3  (A) The insertion of pronator teres is released from the radius, if
necessary, extended by a strip of periosteum. (B) The pronator teres is passed
around the radial border of the forearm superficial to brachioradialis and sutured to
the transected tendon of extensor carpi radialis brevis.
A
B
Extensor carpi
radialis brevis
Extensor carpi
radialis longus
Pronator
teres
Brachioradialis

Fig. 34.4  (A) The flexor carpi ulnaris tendon is transected
and passed around the ulnar border of the distal forearm and
(B) woven into the combined extensor digitorum communis
tendons proximal to the extensor retinaculum.
A
B
Flexor carpi
ulnaris
Extensor
digitorum
communis
Fig. 34.5  (A) The extensor pollicis longus tendon is transected at its
musculotendinous junction, (B) re-routed into the anterior aspect of the distal
forearm and attached to the palmaris longus, if present, to provide both thumb
extension and some radial abduction.
A
B
Extensor
pollicis
longus
Palmaris longus
Fig. 34.6  (A) Through a volar incision in the distal third of the forearm, the flexor
carpi ulnaris (FCU) tendon and its distal muscle and the palmaris longus tendon
are isolated. (B) The pronator teres tendon is passed around the radial border of the
forearm and sutured to extensor carpi radialis brevis. The FCU tendon is passed
around the ulnar border of the distal forearm and sutured to the extensor digitorum
communis tendons.
A
B

772
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
Appropriate tension is then evaluated by checking that all
four digits extend synchronously when the wrist is palmar
flexed and most importantly that all four digits can be pas­
sively flexed into a fist when the wrist is extended. Finally,
palmaris longus and extensor pollicis longus are interwoven
over the radiovolar aspect of the wrist with the thumb in
maximal extension and the wrist in neutral with the PL tendon
at its resting tension. The wrist is immobilized in 45° of exten­
sion in a volar splint with the MCP joints positioned in slight
flexion and the thumb in full extension and abduction.
Active flexion and extension of the fingers and thumb are
started at 3 12 to 4 weeks and active exercises of the wrist
begun at 5 weeks. Protective splinting is continued until 6 to
8 weeks postoperatively. Results have been uniformly good
(Fig. 34.7).
FCR transfer (Fig. 34.8)
The skin incision begins from the radiovolar aspect of the
mid-forearm and extends dorsally over the third and fourth
extensor tendon compartments. The pronator teres is trans­
ferred to the extensor carpi radialis brevis and the palmaris
longus is transferred to the extensor pollicis longus exactly as
described in the standard FCU transfer. The FCR tendon is
divided at the wrist crease and mobilized approximately to
the level of the mid-forearm and re-routed around the radial
border of the forearm. The four EDC tendons, and if necessary
the EDM, may be woven through the donor FCR tendon
proximal to the extensor retinaculum, but more usually the
extensor tendons need to be re-routed superficial to the exten­
sor retinaculum to obtain a straighter line of pull (see Fig.
34.8). To prevent a bulky tendon juncture, the small finger
EDC and EDM may be sutured side-to-side to the ring finger
EDC and the index finger EDC sutured side-to-side to the
long finger EDC under appropriate tension. Then only the
two EDC tendons to the long and ring fingers require weaving
through the FCR tendon. As with the standard FCU transfer,
proximal incision used to mobilize FCU, around the ulnar
border of the forearm into the dorsal incision, to lie obliquely
across the EDC tendons proximal to the extensor retinaculum
(see Fig. 34.6). Alternatively, the FCU tendon may be passed
from the palmar incision to the dorsal incision through a
window in the interosseous membrane.20 If no return of EDC
function is to be expected, the EDC tendons can be transected
at their musculotendinous junctions so that a more direct line
of pull can be achieved. Otherwise an end-to-side juncture is
performed. The extensor pollicis longus (EPL) tendon is
divided at its musculotendinous junction, removed from
the third dorsal extensor tendon compartment, and passed
through a subcutaneous tunnel from the base of the thumb
metacarpal to the volar wrist incision (see Fig. 34.5). If the PL
is absent, the EPL tendon is included with the EDC tendons
and the FCU transfer provides both finger and thumb exten­
sion. To prevent a collapse flexion deformity at the carpometa­
carpal joint of the thumb, tenodesis of the abductor pollicis
longus may be necessary. After transection of the APL tendon
in the distal forearm, it is looped around the brachioradialis
proximal to the radial styloid and sutured to itself with the
thumb metacarpal held in extension with the wrist in 30° of
extension.
The proper tension in radial nerve tendon transfers should
be tight enough to provide full extension of the wrist and
digits but without restricting full flexion of the digits when
the wrist is fully extended. The pronator teres at its resting
tension is woven through the ECRB tendon with the wrist in
45° of extension. The distal ends of the four EDC tendons to
the index, long, ring and small fingers are sutured to the FCU
tendon proximal to the extensor retinaculum. The extensor
digiti minimi is usually not included unless there is still an
extensor lag when proximal traction is applied to the EDC
tendon to the small finger. With the wrist in neutral and FCU
under maximal tension, each individual EDC tendon is
sutured to provide full extension at the MCP joint, starting
with the index finger and finishing with the small finger.
Fig. 34.7  (A) The patient 3 years following pronator teres to extensor carpi radialis
brevis transfer showing wrist extension and satisfactory finger flexion; (B) full
extension of the fingers at the metacarpophalangeal joints; and (C) excellent thumb
extension and radial abduction.
A
B
C

773
Radial nerve palsy
Boyes flexor digitorum superficialis transfer
(Fig. 34.9)
Boyes17 was the first to suggest that neither FCU nor FCR have
sufficient amplitude (30 mm) to produce full excursion of the
finger extensor tendons (50 mm) without the potential increase
in amplitude obtained with the tenodesis effect of wrist
flexion. He therefore advocated using the flexor digitorum
superficialis (FDS) tendons to the long and ring fingers, which
have an amplitude of 70 mm, to act as donor tendons to
restore finger extension.17,18 The advantages of the Boyes
transfer are that this transfer will potentially allow simultane­
ous wrist and finger extension; secondly, it may allow inde­
pendent thumb and index finger extension; and finally, it does
not weaken wrist flexion. However, the long and ring fingers
are deprived of superficialis function and this may result in
weak grip. Harvesting of the superficialis tendons may also
lead to the subsequent development of either a “swan neck”
deformity or a flexion contracture at the PIP joint.
The FDS tendons to the long and ring fingers are exposed
between the A1 and A2 pulleys either through one transverse
incision at the base of the fingers or two separate longitudinal
incisions. The FDS tendons are divided just proximal to their
decussation and then withdrawn proximally into a longitudi­
nal incision over the volar aspect of the middle third of the
forearm. The tendon of pronator teres can be transected and
re-routed through this same incision as described previously.
Blunt dissection on either side of the flexor digitorum profun­
dus (FDP) muscles allows a window to be excised in the
these tendon junctures are performed with the wrist in neutral
and the MCP joints in full extension with the FCR tendon
under maximal traction. Postoperative management is similar
to that for the FCU transfer. Chandraprakasam et al.20
described a modification of the modified Jones transfer in
which the pronator teres is transferred to ECRB; the FCR is
transferred to the finger extensors and the palmaris longus
transferred to EPL; all through a single incision along the
radial aspect of the distal third of the forearm curving obliquely
to end at Lister’s tubercle.
Fig. 34.8  Flexor carpi radialis transfer to the combined tendons of extensor
digitorum communis. The tendon juncture may have to lie superficial to the
extensor retinaculum. Tendon transfers of pronator teres to extensor carpi radialis
brevis and palmaris longus to extensor pollicis longus are the same as in the flexor
carpi ulnaris transfers.
Extensor
pollicis longus
Extensor digitorum
communis muscle
Extensor digitorum
communis tendons
Extensor carpi
radialis brevis
Flexor carpi radialis
Pronator teres
Fig. 34.9  In the Boyes tendon transfer, the long and ring finger flexor digitorum
superficialis tendons, FDSL and FDSR are transferred either through a window in the
interosseous membrane (A) or around the radial and ulnar border of the forearm to
restore extension of the extensor digitorum communis tendons to the long, ring,
and small fingers and the extensor indicis proprius and extensor pollicis longus
tendons (B).
Extensor
pollicis
longus
Extensor
indicis
proprius
Flexor digitorum
superficialis
(middle finger)
Flexor
digitorum
superficialis
(ring finger)
A
B

774
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
follow up of 9.5 years revealed 11 excellent, two good, one
fair, and one bad result, with the main problems being loss of
power grip and development of a radial deviation deformity.25
This resulted in an evolution in the author’s technique to use
pronator teres to restore wrist extension, FCR to restore finger
extension, and palmaris longus to restore thumb extension
with tenodesis of the abductor pollicis longus to brachioradia­
lis to restore thumb abduction. Gousheh and Arasteh26 trans­
ferred only the FCU to the finger extensors and EPL in 108
patients. At a mean follow-up of 4 years, wrist extension was
less than the opposite side, but extension of the fingers was
similar to the normal hand and most patients were able to
return to their previous job. According to the authors, there
was no obvious difference between the results using a single
FCU tendon transfer compared to their previous results using
the conventional three tendon transfers for reconstruction of
radial nerve palsy. Altintas et al.27 compared the long-term
results after tendon transfers for radial nerve palsy, using the
FCU in 58 patients and the FCR in 19 patients. Wrist extension
averaged 73% of the opposite side, finger extension 32%, and
thumb extension 80%. Grip strength was reduced to 49% and
pinch strength to 28% of the opposite hand and the mean total
DASH score was 16. Eighty-nine percent of patients remained
employed after tendon transfers for radial nerve palsy.
Chuinard et al.18 studied 21 patients who had undergone
the Boyes FDS transfers with excellent results in 10, good in
six, and only a fair result in five patients. Subjectively, 13
patients felt that they had obtained an excellent result and
eight a good result. Complications requiring a second proce­
dure were reported in five patients and included adhesions,
dehiscence of the transfer, MCP and wrist extension contrac­
tures, and problems with correct tensioning of the transfers.
A report by Fujiwara28 of 13 patients with radial nerve palsy
and five patients with PIN palsy documented generally good
results with the Boyes transfers. No patient in either of these
studies developed postoperative median nerve compression
despite the potential for this complication with this transfer.
Krishnan and Schackert29 evaluated the function of 29 patients
who had undergone a Boyes transfer of the FDS tendons to
the long and ring fingers through the interosseous membrane
for radial nerve palsy. Near-normal wrist extension was
achieved in 22 of 25 patients. Finger extension simultaneously
with wrist extension was achieved in 12 patients, but in 17
patients full finger extension was only possible with the wrist
in neutral. Selective extension of the index finger and thumb
powered by the FDS tendon from the long finger was achieved
in all patients.
All three techniques have been reported to yield good
results, but there are few quantitative studies to substantiate
the reported outcomes, and no prospective comparison of the
three different techniques. The FCU transfer is perhaps the
simplest technique and provides reproducibly good results in
patients with radial nerve palsy.
Low median nerve palsy
Anatomical considerations
The functional deficit following injury to the median nerve
distal to the innervation of the extrinsic forearm flexor muscles
consists primarily of loss of opposition of the thumb and
interosseous membrane just proximal to the pronator quadra­
tus (see Fig. 34.9). This window should be made as large as
possible at least 4 cm long and as wide as the interosseous
space, so that the muscle bellies of the two FDS tendons can
be passed through this window to minimize the development
of adhesions. It is important to pass the FDS tendons of the
ring and long fingers to their respective sides of the median
nerve to prevent scissoring over the nerve and compression.
Thomsen and Rasmussen21 prefer to transfer the two FDS
tendons around the radial and ulnar borders of the forearm
through subcutaneous tunnels. Through a J-shaped incision
passing transversely across the dorsum of the wrist and then
extending proximally along the dorsum of the ulna, the exten­
sor tendons are isolated as well as extensor carpi radialis
brevis. In Boyes’ original description, pronator teres was
sutured to both ECRL and ECRB,17 but in order to prevent
excessive radial deviation, pronator teres should only be
woven end-to-end into ECRB with the wrist in 30° of exten­
sion. The long finger FDS is then passed to the radial side of
the FDP muscles and the ring finger FDS to the ulnar side
through the interosseous window into the dorsal incision.
After transection of the EPL and EIP tendons, they are woven
end-to-end into the long finger FDS tendon. Similarly, the
transected EDC tendons to the index, long, ring, and small
fingers are woven end-to-end into the ring finger FDS tendon,
although this arrangement can be reversed. The tendon junc­
tures are performed proximal to the extensor retinaculum
with resting tension in the donor FDS tendons and full exten­
sion at the MCP joints.
If necessary, abductor pollicis longus (APL) is transected at
its musculotendinous junction and passed through a subcu­
taneous tunnel from the base of the thumb into the volar
forearm incision. Either palmaris longus or flexor carpi radia­
lis are transected at the wrist crease and woven end-to-end
with the APL tendon to provide abduction of the thumb and
prevent a collapse deformity of the thumb metacarpal. The
tourniquet should be deflated prior to the closure of the inci­
sions because of the likelihood of bleeding from the anterior
or posterior interosseous arteries.
Outcomes
Tendon transfers for radial nerve palsy are generally predict­
able. Tsuge22 described the evolution of his technique in 69
patients over a 25 year period. Using the FCU transfer and
insertion of pronator teres into both ECRL and ECRB in the
initial 41 patients, he reported “fairly satisfactory” results, but
felt that there were three problems: development of radial
deviation of the wrist, restriction of wrist flexion, and mar­
ginal thumb abduction. Because of these concerns, pronator
teres was transferred only to ECRB and the FCR was trans­
ferred through the interosseous membrane for finger exten­
sion, leaving the FCU intact leading to good results in 24 of
27 cases. A long-term functional study of the FCU transfer in
six patients by Raskin and Wilgis23 revealed adequate wrist
motion and power to perform daily activities, and a work-
simulation protocol showed patients were able to perform
tasks without significant difficulty. Problems of inadequate
ulnar deviation, grip strength, and wrist instability were not
seen. A subjective outcome study by Riordan24 also revealed
satisfaction with the standard FCU transfer. Long-term evalu­
ation of the FCU transfer for radial nerve palsy at a mean

775
Low median nerve palsy
absent sensation over the thumb, index, long, and radial half
of the ring finger.
Opposition is a composite motion that occurs at all three
joints to position the thumb pad opposite the distal phalanx
of the partially flexed long finger. Abduction, pronation, and
flexion occur at the carpometacarpal joint, abduction and
flexion at the metacarpophalangeal joint, and either flexion or
extension at the interphalangeal joint. Approximately 40° of
abduction of the thumb metacarpal occurs at the carpometa­
carpal joint and 20° of abduction of the proximal phalanx
occurs at the metacarpophalangeal joint. From a starting posi­
tion of full extension and adduction, the thumb pronates
approximately 90° during opposition to the long finger. Exten­
sion of the thumb interphalangeal joint is required for pulp-
to-pulp pinch, whereas slight flexion of the interphalangeal
joint allows tip-to-tip pinch. Of the three intrinsic thenar
muscles, the flexor pollicis brevis (FPB) muscle typically,
although not always, receives a dual innervation from both
the median and ulnar nerves. Because the flexor pollicis brevis
may remain innervated by the ulnar nerve in approximately
70% of median nerve injuries, patients may not notice any
significant functional loss, but careful testing will reveal
decreased strength of abduction and lack of pronation.
Prior to any opposition transfer, patients with median
nerve injuries should be instructed to prevent the develop­
ment of an adduction or supination contracture of the thumb
by a program of passive abduction exercises. A static thumb–
index finger webspace splint may be used at night, but this
usually interferes with the already compromised function of
the hand if used during the day. Care should be taken to
insure that such splints abduct the thumb metacarpal rather
than the proximal phalanx; otherwise the median nerve palsy
will be compounded by attenuation of the ulnar collateral
ligament of the metacarpophalangeal joint. If patients present
with an established adduction or supination contracture of
the thumb, release of the thumb–index finger webspace skin,
fascia over the first dorsal interosseous muscle, or even the
first dorsal interosseous and adductor muscles themselves
may be required prior to any opposition tendon transfer.
Bunnell30 first emphasized that the pull of an opposition
tendon transfer should be in an oblique direction from the
thumb metacarpophalangeal joint to the region of the pisi­
form, and secondly, that in order to produce pronation, the
transfer should be inserted into the dorso-ulnar base of the
proximal phalanx. Opposition transfers that are directed
along the radial aspect of the palm will produce a greater
component of palmar abduction, whereas transfers that pass
from the pisiform will produce both abduction and pronation.
The more distal the transfer passes across the palm, the greater
the power of thumb flexion. Several methods of insertion of
opposition transfers have been advocated including attach­
ment to the dorso-ulnar base of the proximal phalanx
(Bunnell30, Royle-Thompson31,32), insertion into the abductor
pollicis brevis tendon (Littler33), dual insertion into the abduc­
tor pollicis brevis and continuation distally into the MCP joint
capsule and extensor pollicis longus tendon (Riordan24), inser­
tion into the abductor pollicis brevis, dorsal joint capsule and
adductor pollicis (Edgerton and Brand34), and finally utiliza­
tion of a distal-based extensor pollicis brevis tendon (Phalen
and Miller35). However, a biomechanical study has shown that
opposition tendon transfers inserted into the abductor pollicis
brevis (APB) tendon alone will produce full abduction and
pronation.36 Therefore the more complex dual insertions
should probably be reserved for combined median and ulnar
nerve palsies.
Timing
Several factors influence the likelihood of useful motor and
sensory return following median nerve injury including
patient age, level of injury, length of nerve defect and inter­
position nerve graft; and period of preoperative delay. The
best results are realized in distal injuries in young patients
requiring only primary repair. Associated injuries such as
vascular injury, tendon injury, and concomitant ulnar nerve
transection portend a worse prognosis. The chances of rein­
nervation of the thenar muscles following group fascicular
repair of a distal median nerve laceration should be reason­
ably optimistic. Therefore, conventional timing of an opposi­
tion tendon transfer may only be required in those patients
who fail to demonstrate signs of reinnervation within the
usual calculated time interval. For older patients or those
with poor prognostic comorbid factors, early tendon transfers
should be considered.
Careful observation of thumb function following either a
low or high median nerve palsy will reveal whether an “early”
tendon transfer for thumb opposition is necessary. Flexor
pollicis brevis remains innervated by the ulnar nerve in
approximately 70% of median nerve injuries so that thumb
function may not be significantly compromised. Consequently
an “early” opposition transfer may not be necessary. Other
patients, however, will adapt to their loss of opposition and
abduction by substitution of the abductor pollicis longus to
provide thumb abduction, but this can only be achieved with
the hand positioned in pronation. This places the patient at
an even greater disadvantage in that not only do they have
absent sensation in the median nerve distribution, but with
the forearm in pronation they cannot even see the palmar
surface of their hand to compensate for their loss of sensation.
Therefore, if the surgeon or therapist observes the patient
attempting to grasp objects by radial abduction of the thumb
with the forearm in pronation, an “early” opposition tendon
transfer should be strongly considered. If, however, the patient
is able to pick up an object with the forearm in neutral or
grasp an object with the forearm in supination, it is likely that
flexor pollicis brevis remains innervated by the ulnar nerve
and consequently the decision for performing an “early”
opposition tendon transfer can be delayed.
Operations
Burkhalter extensor indicis proprius transfer
(Fig. 34.10)
The extensor indicis proprius (EIP) transfer37 is the author’s
preferred technique, except in elderly patients with thenar
atrophy secondary to severe carpal tunnel syndrome (see Fig.
34.10). The EIP tendon is transected through a small transverse
incision just proximal to the MCP joint of the index finger. The
distal stump of the EIP tendon is then repaired to the extensor
digitorum communis tendon of the index finger to prevent
extensor lag at the metacarpophalangeal joint. The EIP tendon
is mobilized through two small transverse incisions one
proximal and one distal to the extensor retinaculum and the

776
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
is only just long enough to reach the abductor pollicis brevis
tendon. The postoperative results have been very predictable
(Fig. 34.11).
Bunnell ring finger flexor digitorum superficialis
transfer (Fig. 34.12)
In the flexor digitorum superficialis transfer described origi­
nally by Bunnell,30 the ring finger FDS tendon is isolated
through a small transverse incision just distal to the distal
palmar crease. The tendon is transected between the A1 and
A2 pulleys and delivered into a proximal incision made over
the volar aspect of the distal forearm (Fig. 34.13A). The flexor
carpi ulnaris tendon is split longitudinally to create a distal-
based strip of the radial half of the tendon. This is then passed
through a slit in the flexor carpi ulnaris tendon just proximal
to the pisiform and sutured to itself to create a pulley (see Fig.
34.13B,C). The distal end of the ring finger FDS tendon is
passed through this pulley and through an oblique subcuta­
neous tunnel across the palm into an incision over the radial
aspect of the MCP joint of the thumb. All the other incisions
are then closed and the tension on the tendon transfer adjusted
as described previously.
Simple looping of the ring finger FDS around the FCU
tendon rather than using a fixed pulley rapidly becomes inef­
fective and the transfer becomes converted to a flexor of the
muscle belly mobilized through a longitudinal incision over
the ulnar aspect of the dorsum of the mid-forearm (see Fig.
34.10C). A transverse incision is made just proximal to the
pisiform bone and a subcutaneous tunnel developed to
connect this incision to the dorsal forearm incision. The EIP
tendon is then passed subcutaneously around the ulnar
border of the distal forearm superficial to the extensor carpi
ulnaris tendon into the pisiform incision. The abductor pol­
licis brevis tendon is identified through a small incision over
the radial aspect of the MCP joint of the thumb and a subcu­
taneous tunnel made connecting this incision with the pisiform
incision. The tendon transfer is passed obliquely across the
palm (see Fig. 34.10D) and woven into the tendon of abductor
pollicis brevis under maximum tension with the wrist in
neutral position and the thumb in maximal palmar abduction.
The tension of the transfer is then tested by the tenodesis
effect of the wrist. Wrist flexion should allow the thumb to be
passively adducted. If wrist extension produces excessive
flexion or extension of the thumb at the metacarpophalangeal
joint, this indicates that the transfer has been inserted either
too far volarly or too far dorsally and should be adjusted
accordingly. The thumb is immobilized in full abduction with
the wrist in slight palmar flexion for 4 weeks, at which time
active abduction and opposition movements are begun with
protective splinting for a further 3–4 weeks. The only potential
disadvantage with this tendon transfer is that the EIP tendon
Fig. 34.10  (A,B) In the Burkhalter opposition tendon transfer, extensor indicis proprius (EIP) is transected at the level of the metacarpophalangeal (MCP) joint of the index
finger and (C) mobilized through a dorsal-ulnar incision in the distal forearm. The EIP tendon is passed around the ulnar border of the distal forearm and (D) passed
obliquely across the palm from the level of the pisiform to the radial aspect of the MCP joint of the thumb and sutured to the insertion of abductor pollicis brevis.
Extensor digitorum
communis (index finger)
Extensor indicis proprius
Abductor pollicis brevis
A
B
C
D

777
Low median nerve palsy
continuity with the distal palmaris longus tendon through a
standard carpal tunnel incision in the palm extending proxi­
mally into the distal forearm (Fig. 34.16A). A subcutaneous
tunnel is developed from the radial aspect of the distal forearm
incision along the thenar eminence into a mid-axial incision
on the radial aspect of the MCP joint of the thumb (see Fig.
34.16B). The fascial extension of the palmaris longus tendon
is passed through this subcutaneous tunnel and sutured to the
abductor pollicis brevis tendon under maximal tension with
the wrist in neutral position (see Fig. 34.16C).
Other opposition tendon transfers
Huber42 and Nicholaysen43 described transfer of the abductor
digiti minimi (ADM), which may occasionally be indicated in
patients with a combined median and radial nerve palsy
and also in children with congenital anomalies affecting the
thumb. Since the muscle originates at the pisiform, this
MCP joint rather than a true opposition transfer. Other pulleys
for the ring finger FDS transfer include passing the tendon
through Guyon’s canal or through a window in the transverse
carpal ligament (Snow–Fink).
Compared with the EIP transfer, the ring finger FDS is rela­
tively stronger and has greater length. This is perhaps the
strongest of the opposition transfers (Fig. 34.14C,D). However,
the ring finger FDS is not available as a donor tendon in a
high median nerve palsy or in low median nerve injuries in
which there have been associated injuries to the flexor tendons.
The ring finger FDS transfer should also not be selected in
combined low median and high ulnar nerve palsies since the
ring finger FDS is the only remaining flexor tendon in the ring
finger. In low median–low ulnar nerve palsies, the ring finger
FDS may be required for correction of clawing. In addition,
harvesting of the FDS tendon may result in either a flexion
contracture or a “swan neck” deformity of the PIP joint of the
donor finger.
Camitz palmaris longus transfer (Fig. 34.15)
The palmaris longus (PL) donor tendon in the Camitz
transfer38–41 will provide abduction of the thumb but little
pronation or flexion and is particularly indicated in elderly
patients with thenar atrophy due to long-standing carpal
tunnel syndrome. A strip of palmar fascia is dissected in
Fig. 34.11  (A) Postoperative opposition of the right thumb has been restored after
a Burkhalter extensor indicis proprius transfer. (B) Thumb abduction is symmetrical
with the normal thumb.
A
B
Fig. 34.12  Bunnell transfer using the flexor digitorum superficialis of the ring
finger passed through a pulley of the flexor carpi ulnaris tendon to restore
opposition of the thumb.
Pisiform
Abductor pollicis
brevis
Flexor digitorum
superficialis
Flexor digitorum
superficialis
(ring finger)
Flexor carpi
ulnaris pulley

778
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
Fig. 34.13  (A) Harvesting the flexor digitorum superficialis (FDS) tendon from the ring finger. (B,C) A sucker tip is used to create a pulley for the FDS from a distal-based
slip of flexor carpi ulnaris just proximal to the pisiform.
A
B
Pisiform
1 cm
4 cm
Flexor carpi
ulnaris tendon
C
Fig. 34.14  (A) Preoperative appearance of a patient with Charcot–Marie–Tooth disease with severe thenar atrophy and inability to oppose either thumb. (B) Postoperatively
after a Bunnell transfer, the patient is able to oppose their right thumb to the tip of the small finger.
A
B

779
Low median nerve palsy
along the radial aspect of the hypothenar eminence and the
muscle elevated in a distal to proximal direction taking care
to protect the neurovascular bundle which enters the muscle
just beyond the pisiform. A wide subcutaneous tunnel is dis­
sected between the hypothenar incision and the insertion of
transfer provides excellent flexion and pronation of the thumb
but little palmar abduction. The insertion of the abductor
digiti minimi tendon is transected from the ulnar lateral band
through an ulnar midaxial incision along the proximal phalanx
of the small finger. The incision is then extended proximally
Fig. 34.15  Camitz opposition transfer using the palmaris
longus tendon extended with a strip of palmar fascia and
transferred to the insertion of abductor pollicis brevis.
A
B
Palmaris longus
Strip of
palmar
fascia
Insertion
into tendon
abductor
pollicis brevis
Palmaris tendon
extended with a
rolled-up strip of
palmar fascia
Transverse carpal
ligament
Fig. 34.16  (A) In this patient with severe left carpal tunnel syndrome and thenar atrophy, the palmaris longus tendon is extended with a rolled-up sheet of palmar fascia
and (B) transferred subcutaneously to the insertion of the abductor pollicis brevis tendon on the radial aspect of the metacarpophalangeal joint of the thumb. (C) One year
postoperatively, the patient demonstrates excellent palmar abduction of the thumb; but because the vector of transfer is not from the region of the pisiform, the Camitz
transfer does not provide pronation of the thumb.
A
B
C

780
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
High median nerve palsy
Indications
The functional deficit following injury to the median nerve
proximal to its innervation of the extrinsic forearm flexor
muscles consists of inability to flex the index finger at the PIP
and distal interphalangeal (DIP) joints and the thumb at the
interphalangeal joint in addition to loss of opposition (Fig.
34.18). This is due to paralysis of all four flexor digitorum
the abductor pollicis brevis muscle at the MCP joint of the
thumb. Hemostasis is achieved after releasing the tourniquet
and the entire abductor digiti minimi muscle rotated 180°
through the subcutaneous tunnel in the palm and sutured into
the abductor pollicis brevis tendon. This transfer has been
compared to turning the page of a book.42 Cawrse and
Sammut44 described a modification of the Huber transfer in
which the abductor digiti minimi is released both distally and
proximally, so that the muscle is a complete island. This
eliminates any compression of the ulnar nerve by the muscle
transfer.
Phalen and Miller35 advocate the use of the extensor pollicis
brevis (EPB) tendon activated by extensor carpi ulnaris (ECU).
The EPB is divided at its musculotendinous junction in the
distal forearm and retrieved through an incision at the meta­
carpophalangeal joint of the thumb. This distally based tendon
may then be passed through a subcutaneous tunnel obliquely
across the palm to the area of the pisiform. The extensor carpi
ulnaris tendon is transected at the base of the fifth metacarpal
and routed subcutaneously around the ulnar border of the
wrist to be interwoven with the extensor pollicis brevis tendon
(Fig. 34.17).
Taylor described the use of the extensor digiti minimi
(EDM) as an opposition tendon transfer.45 This transfer, which
was also described by Schneider, re-routes the EDM around
the ulnar side of the hand to the thumb MCP joint.46
Fig. 34.17  (A) In the Phalen and Miller opposition tendon transfer, the
ECU is detached from the base of the small finger metacarpal and
transferred around the ulnar border of the forearm and sutured to the
distal-based EPB tendon (B).
Extensor carpi
ulnaris
Extensor
pollicis
longus
Extensor
pollicis brevis
Distal-based extensor
pollicis brevis remains
attached to the base
of the proximal phalanx
Pisiform
Abductor
pollicis brevis
B
A
Fig. 34.18  Typical posture of high median nerve palsy with inability to flex the
interphalangeal joint of the thumb and inability to flex the proximal interphalangeal
and distal interphalangeal joints of the index finger.

781
High median nerve palsy
end-to-side into the flexor pollicis longus tendon, which
remains in continuity. Through the same volar forearm inci­
sion, the FDP tendons to the index and long fingers can be
sutured side-to-side to the ulnar innervated FDP tendons to
the ring and small fingers. The results of these two transfers
are also relatively predictable (Fig. 34.20).
If power flexion of the index and long fingers is required,
then formal transfer of the extensor carpi radialis longus
tendon to the index and long finger FDP tendons may be
performed. The ECRL is transected through a small transverse
incision at the base of the index finger metacarpal and passed
subcutaneously around the radial border of the distal forearm
into the volar incision. The FDP tendons to the index and long
fingers are woven into the ECRL tendon so that with the wrist
in 30–45° of extension, the tips of the index and long fingers
almost touch the palm. Similarly, with the wrist in full palmar
flexion, the fingers will almost assume a fully extended posi­
tion. Adjusting tension on this transfer using the tenodesis
effect of the wrist is absolutely critical, because the donor
ECRL tendon has only 30 mm of amplitude whereas the FDP
tendons normally have 70 mm of excursion. If this transfer is
sutured under too much tension, it will result in flexion con­
tractures of these two fingers.
The timing of tendon transfers in a high median nerve
palsy remains controversial.6 If a good primary or delayed
primary nerve repair can be performed, there is a reasonable
chance of reinnervation of the extrinsic flexor muscles in a
young patient. Consequently “early” brachioradialis to flexor
superficialis muscles, the flexor digitorum profundus tendons
to the index and long fingers, and the flexor pollicis longus
muscle. Patients are often still able to flex the long finger due
to interconnections between the FDP tendons to the long, ring,
and small fingers in the distal forearm. Therefore, the two
functions that need to be restored in patients with a high
median nerve palsy are flexion at the interphalangeal joint of
the thumb and flexion of the PIP and DIP joints of the index
and long fingers, together with a conventional opposition
tendon transfer.
Operations
Flexion of the interphalangeal joint of the thumb may be
restored by transfer of brachioradialis (BR) to flexor pollicis
longus (FPL) and flexion of the DIP joint of the index and long
fingers by side-to-side tenorrhaphy of the FDPs of index and
long fingers to the FDPs of the ring and small fingers16 (Fig.
34.19). The brachioradialis is divided at its insertion on the
radial styloid and extensively mobilized from its investing
fascia up into the proximal third of the forearm so that the
freed muscle can develop approximately 30 mm of excursion.
If reinnervation of the flexor pollicis longus muscle is not
expected to occur following repair or grafting of the median
nerve, the tendon can be divided at its musculotendinous
junction and woven end-to-end into the brachioradialis
tendon. However, if there is any possibility of reinnervation
of FPL, the brachioradialis tendon should be woven
Fig. 34.19  (A) The flexor digitorum profundus (FDP)
tendons of the index and long fingers are sutured to the
FDP tendons of the ring and small fingers, which are still
innervated by the ulnar nerve. (B) The flexor pollicis longus
tendon is sutured to the brachioradialis tendon to restore
flexion of the interphalangeal joint of the thumb.
A
B
Brachioradialis
Flexor
pollicis
longus
Flexor
digitorum profundus
Side to side
tenorrhaphy of
flexor digitorum
profundus tendons
(index and middle to
ring and small)

782
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
Fig. 34.20  (A) Postoperatively after side-to-side tenorrhaphy of the flexor
digitorum profundus tendons, the patient has regained satisfactory flexion at the
proximal interphalangeal and distal interphalangeal joints of the index finger.
(B) After the brachioradialis to flexor pollicis longus transfer, the patient has
satisfactory flexion of the interphalangeal joint of the thumb. The patient also
underwent a Burkhalter opposition transfer using extensor indicis proprius and has
excellent abduction of the thumb.
A
B
pollicis longus or side-to-side repair of the index and long
finger FDP tendons to the ring and small finger FDP tendons
is not necessary. However, if the patient is seen late and
requires secondary nerve grafting of the median nerve, then
tendon transfers for restoration of thumb flexion and index
and long finger flexion should be performed simultaneously
with the nerve graft.
Outcomes
There is no standard measurement of opposition in the litera­
ture. Some authors have developed functional scales to rate
outcome, while others have reported subjective patient satis­
faction.47,48 An anatomic and biomechanical study by Cooney
et al.36 showed that the FDS of the ring finger and the ECU
were the best transfers for replacing thenar muscle strength,
abduction, and pronation. They calculated that the ECU and
FDS transfers restored 60% and 40% respectively of required
thenar muscle strength. The Camitz transfer provided good
abduction, but weak flexion and opposition.
Excellent or good results were obtained in approximately
88% after EIP transfer in patients with nerve deficits second­
ary to leprosy.49 Similar results have been reported by other
authors, but little data exists documenting thumb range of
motion or rigorous functional outcomes. Schwartz and Mac­
Donald50 performed a retrospective review of 156 opposition
tendon transfers primarily using FDS. Objective parameters
were rated as good or excellent in 89% and patient satisfaction
was rated as good or fair in 93%. There are few publications
containing objective data that discuss the long-term functional
outcomes of the Bunnell FDS transfer. Brandsma et al.51
reported 32% excellent and 51% good results. Some of the
other patients in this study underwent FDS transfers for
intrinsic function. Of the 158 donor fingers, swan neck defor­
mities were seen in 15%, DIP joint flexion contractures in 29%,
and PIP joint flexion contractures in 18%. Groves and Goldner52
reported 75% success in 16 patients with high median nerve
or brachial plexus lesions reconstructed with FDS opposition
transfers.
While Phalen and Miller35 reported good results with the
ECU transfer, another study described the development of
significant radial deviation in one-third of cases.53 These
authors cautioned that the FCU must have normal strength to
maintain proper wrist balance after ECU transfer.
Braun40 reported good results in 28 patients who underwent
the Camitz transfer. Foucher et al.41 reported 91% good long-
term results in 73 Camitz transfers performed at the same
time as carpal tunnel release. Terrono et al.54 retrospectively
reviewed their experience with 33 Camitz transfers for severe
median nerve compression in patients with a mean age of 65
years. Ninety-four percent of the patients felt that their thumb
dexterity and speed were improved by the operation; only
two patients were unhappy with the results. No objective
biomechanical data are available for this transfer.
Table 34.3 catalogs some of the clinical studies of opposi­
tion tendon transfers. Success is defined differently in each
study and thus a cohesive evaluation and enlightened recom­
mendation is difficult to make. Data on high median nerve
palsy reconstruction are even more scarce.
Low ulnar nerve palsy
Indications
Injury to the ulnar nerve distal to the innervation of the ring
and small finger FDP and FCU muscles produces a functional
deficit consisting of paralysis of all seven interossei, the ulnar
two lumbricals, the hypothenar and the adductor pollicis
(AP), and part of the flexor pollicis brevis (FPB) muscles. This
results in an imbalance of the flexor and extensor forces at the
MCP, PIP, and DIP joints of the fingers. Since the interossei are
the main flexors of the MCP joints, extension of the proximal
phalanges at the MCP joints by the extrinsic extensor tendons
is unopposed and MCP joint hyperextension occurs to the
extent allowed by the volar plates. Because the extrinsic exten­
sor tendons concentrate their extension at the MCP joints and
the interossei are unable to actively extend at the PIP and DIP
joints, the increased tension in the flexor tendons that occurs
as the MCP joints begin to hyperextend will be unopposed at
the PIP and DIP joints. This therefore results in the typical
claw hand with hyperextension at the MCP joints and recipro­
cal flexion at the PIP and DIP joints (Duchenne’s sign)
(Fig. 34.21).
Imbalance between the extrinsic extensor and flexor tendons
leads to asynchronous flexion of the fingers and weak grip
strength. The MCP joints do not flex until after the interphalan­
geal joints have become completely flexed, resulting in curling
of the tips of the fingers into the palm with loss of ability to

783
Low ulnar nerve palsy
Fig. 34.21  Typical posture of the ulnar claw hand characterized by hyperextension
at the metacarpophalangeal joints, usually the ring and small fingers and reciprocal
flexion at the proximal interphalangeal and distal interphalangeal joints.
Fig. 34.22  A patient with a combined low median–low ulnar nerve palsy
demonstrating asynchronous flexion of the fingers, with flexion at the proximal
interphalangeal and distal interphalangeal joints occurring before flexion at the
metacarpophalangeal joints. Because of severe thenar atrophy, there is also loss of
opposition of the thumb.
Table 34.3  Opposition tendon transfers for low median nerve palsy
Technique
Etiology
Author
Success
Huber
Trauma, neurologic disease
Wissinger et al., 1977*
80%
Camitz
Nerve compression
Terrono et al., 199354
94%
Foucher et al., 199141
91%
EIP
Trauma
Anderson et al., 199149
88%
Burkhalter et al., 197337
88%
Bunnell
Leprosy
Brandsma et al., 199251
83%
Leprosy
Palande 1975†
94%
Trauma
Kirklin and Thomas 194848
85%
Trauma
Groves and Goldner 197552
75%
EDQ
Trauma
Schneider 196946
80%
*Wissinger HA, Singsen EG. Abductor digiti quinti opponensplasty. J Bone Joint Surg Am. 1977;2:22–23.
†Palande DD. Opponensplasty in intrinsic-muscle paralysis of the thumb in leprosy. J Bone Joint Surg Am. 1975;57:489–93.
grasp large objects. In a low ulnar nerve palsy, the clawing and
loss of integrated MCP and interphalangeal joint flexion are
confined to the ring and small fingers and to a lesser extent the
long finger, since the lumbricals to the index and long fingers
remain innervated by the median nerve. However, in a com­
bined median and ulnar nerve palsy, all four fingers are affected
(Fig. 34.22). Fowler55 has shown that the PIP joints can be
extended by the extrinsic extensor tendons provided that the
MCP joints are stabilized against hyperextension. Both the
claw deformity and the asynchronous flexion may therefore be
improved either by static procedures to prevent hyperexten­
sion at the MCP joints or by dynamic tendon transfers to
produce either MCP joint flexion alone or to provide both MCP
joint flexion and interphalangeal joint extension.
The other significant impairment in patients with low ulnar
nerve palsy is weak thumb–index finger pinch, which may be
only 20–25% of normal due to paralysis of the adductor pol­
licis, one half of the FPB, and the first dorsal interosseous
muscles. However, in 58% of ulnar nerve injuries, there is dual
innervation of the flexor pollicis brevis muscle, which can to
some extent provide thumb MP joint flexion and key pinch
to the index finger. Loss of key pinch is usually manifest
by compensatory activation of the flexor pollicis longus
producing excessive flexion at the interphalangeal joint
(Froment’s sign) (Fig. 34.23) and occasionally hyperextension
at the MCP joint (Jeanne’s sign) as the patient attempts force­
ful pinch. In such patients with weak pinch, tendon transfers
will be required to restore adduction of the thumb and abduc­
tion of the index finger.
Patients may also develop an irritating ulnar deviation of
the small finger in addition to clawing at the MCP joint of the
small finger (Wartenberg’s sign) caused by paralysis of the
third palmar interosseous muscle and the unopposed action
of the extensor digiti minimi tendon. Occasionally, a tendon
transfer may be required to correct this ulnar deviation of the
small finger.
Therefore, tendon transfers may be indicated in an ulnar
nerve palsy15,16 (Table 34.4) to correct:
1. Clawing and asynchronous flexion of the fingers
2. Weak thumb–index finger pinch
3. Ulnar deviation deformity of the small finger
4. Weak FDP flexion at the DIP joints of the ring and small
fingers.

784
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
muscle power, grip strength, and sensation for at least 2 years
in high and 3 years in low ulnar nerve repairs. The significant
conclusion from this study was that early tendon transfers
should only be performed in manual laborers who complain
of poor grip or key pinch.
Static procedures to correct clawing of
the fingers
Static procedures to prevent hyperextension of the proximal
phalanges at their MCP joints include A1 pulley release, fas­
ciodermadesis at the MCP joint level, capsulodeses, and
various tenodeses. Capsulodesis of the MCP joint, described
by Zancolli,57 is a very simple technique in which the A1
pulley is first released, the volar plate is incised longitudinally
and detached from the metacarpal to create two distally based
flaps, which are then advanced proximally and attached to
the metacarpal neck to maintain the MCP joint in approxi­
mately 20° of flexion. Omer58,59 described creating a distal-
based flap of the volar plate by making two parallel incisions
on the medial and lateral aspects of the volar plate and excis­
ing Burow’s triangles distally to allow proximal advancement
of the volar plate (Fig. 34.24). The volar plate is anchored to
the metacarpal neck with wire sutures through drill holes or
by using a bone anchor. Recurrence of clawing has been
demonstrated in long-term follow-up studies.60
Parkes61 has described an effective tenodesis both to prevent
hyperextension at the MCP joints and to provide extension at
the interphalangeal joints by using tendon grafts sutured to
the transverse carpal ligament and passed volar to the deep
transverse intermetacarpal (intervolar plate) ligaments to
insert into the radial lateral band of each finger. Omer58 modi­
fied the Parkes tenodesis by attaching one tendon graft to the
ulnar lateral band of the ring finger, passing around the deep
transverse intermetacarpal ligament and suturing it to the
radial lateral band of the small finger, with a second tendon
graft from the ulnar lateral band of the index finger around
the deep transverse intermetacarpal ligament to the radial
lateral band of the long finger. Fowler attached tendon grafts
to the extensor retinaculum, routed them dorsally through the
intermetacarpal spaces and then volar to the deep transverse
intermetacarpal ligaments and attached the grafts to the radial
Fig. 34.23  With absence of the adductor pollicis muscle in a low ulnar nerve
palsy, flexor pollicis longus primarily flexes the interphalangeal joint of the thumb,
which results in hyperflexion of the interphalangeal joint when the patient attempts
to produce key pinch (Froment’s sign) and occasionally hyperextension at the
metacarpophalangeal joint (Jeanne’s sign).
Timing
Timing of tendon transfers for ulnar nerve palsy is primarily
dependent on two factors: the probability of motor recovery
and the severity of the functional deficit. Primary microsurgi­
cal repair of the ulnar nerve at the wrist can be expected to
yield useful results in about 75% of patients. Secondary nerve
grafting has been reported to provide some functional motor
recovery in approximately 40% to 75% of cases, with a some­
what worse prognosis for sensory recovery. As in other
peripheral nerve injuries, younger patients, those with shorter
nerve defects, and those without other significant associated
injuries have a better chance of obtaining useful results from
ulnar nerve repair.
“Early” tendon transfers should be considered for those
with a debilitating claw deformity. While clawing should be
treated proactively using a lumbrical block splint, some
patients may benefit from early static transfers to prevent
MCP hyperextension and clawing. Trevett et al.56 studied the
functional results following both high and low ulnar nerve
repairs to better define the indications for tendon transfers.
They demonstrated continued improvement in intrinsic
Table 34.4  Tendon transfers for ulnar nerve palsy
Function to be restored
Preferred tendon transfer
Clawing of the ring and small fingers
Two slips of ring finger or long finger FDS to the radial lateral bands or proximal phalanges
or A2 or A1 and A2 pulleys of the ring and small fingers
Clawing of all four fingers
EF4T or PL4T transfers to the radial lateral bands of the long, ring and small fingers and the
ulnar lateral band of the index finger; or to the combined interosseous tendon insertion
Thumb adduction
ECRB + tendon graft to adductor pollicis
Index finger abduction
Accessory APL to first dorsal interosseous
Severe thumb MCP joint hyperextension
MCP joint arthrodesis
Fixed thumb IP joint contracture
IP joint arthrodesis
Weak DIP joint flexion ring and small fingers
Side-to-side tenorrhaphy of the ring and small finger FDP tendons to the long finger FDP
tendon
DIP, Distal interphalangeal; ECRB, extensor carpi radialis brevis; EF4T, extensor tendon, flexor route, four-tailed graft; FDP, flexor digitorum profundus; FDS, flexor
digitorum superficialis; IP, interphalangeal; MCP, metacarpophalangeal; PL4T, palmaris four-tailed graft.

785
Low ulnar nerve palsy
DIP joints (Fig. 34.25), the transfer may only need to produce
strong MCP joint flexion by insertion of the transfer either into
the A1 pulley (Zancolli62); the A2 pulley (Brooks–Jones63) (Fig.
34.26C); the A1 and proximal half of the A2 pulley Anderson64;
or through a drill hole in the proximal phalanx (Burkhal­
ter65) (see Fig. 34.26B). However, with longstanding flexion
deformities of the PIP joints, the central slip of the extensor
mechanism may become attenuated. Consequently, even with
passive flexion of the MCP joints, the patient cannot actively
extend the PIP joints using the extrinsic extensor tendons.
In these circumstances, the transfer should be inserted into
one of the lateral bands (see Fig. 34.26A); or into the dorsal
base of the middle phalanx; or into the combined interos­
seous tendons (which Zancolli termed “direct interosseous
lateral bands of the fingers.55 The Riordan tenodesis employs
a similar dorsal route, utilizing two distally based strips of the
ECRL and ECU tendons passed down the lumbrical canals,
volar to the deep transverse intermetacarpal ligaments and
attached to the radial lateral bands.24
The various dynamic tendon transfers that have been
described to correct clawing differ primarily as to whether
they provide only MCP joint flexion or whether they provide
both MCP joint flexion and interphalangeal joint extension.
The surgeon can determine which general type of transfer
is most appropriate by preoperative testing of PIP and DIP
joint extension with the MCP joints held passively flexed – the
Bouvier maneuver. With the MCP joints flexed, if the extrinsic
extensor tendons can produce full extension at the PIP and
Fig. 34.24  Omer modification of the Zancolli capsulodesis: (A) The A1 pulley is released. (B) A distal-based flap of the volar plate is created and (C) advanced proximally
and fixed to the metacarpal neck.
A
B
C
Deep
transverse
intermetacarpal
ligament
A2 pulley
A1 pulley released
Volar plate MCP joint
Fig. 34.25  The Bouvier maneuver: (A) Typical claw hand deformity of the small finger and to a lesser extent the ring finger with hyperextension at the metacarpophalangeal
(MCP) joints and flexion at the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints. (B) In the Bouvier maneuver, the surgeon blocks hyperextension at the
MCP joints and in this patient the extrinsic extensor tendons are able to produce full extension at the PIP and DIP joints.
A
B

786
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
activation”62,66), so that both MCP joint flexion and PIP joint
extension can potentially be restored.
If one of the FDS tendons is used as a donor tendon to
produce either MCP joint flexion alone or both MCP joint
flexion and interphalangeal joint extension, it does not
produce any increase in power grip; whereas adding an extra
muscle–tendon unit from outside the hand to activate these
transfers, such as a wrist flexor (FCR) or extensor tendon
(ECRL, ECRB), will potentially lead to increased grip strength.
Tendon transfers to correct clawing
All of the following have been described as the donor muscle–
tendon unit in tendon transfers to correct asynchronous finger
flexion and clawing in ulnar nerve palsy67 (see Table 34.4):
1. Flexor digitorum superficialis
2. Extensor carpi radialis brevis
3. Extensor indicis proprius and extensor digiti minimi
4. Flexor carpi radialis
5. Extensor carpi radialis longus
6. Palmaris longus.
Stiles and Forrester-Brown68 originally described transfer of
one slip of each FDS tendon into the extensor mechanism and
this was subsequently modified by both Bunnell69 and Littler.33
The Littler modification is referred to as the modified Stiles–
Bunnell technique and involves transfer of the FDS of the ring
finger or long finger or both fingers, splitting the tendon
longitudinally into two slips, passing each slip of the FDS
tendon down the lumbrical canals, and attaching them to the
radial lateral bands of the fingers (Fig. 34.27).
If the Bouvier maneuver confirms that the extrinsic exten­
sor tendons can produce full extension at the PIP and DIP
joints with the MCP joints flexed, alternative insertions of the
modified Stiles–Bunnell transfer into either the pulleys or the
proximal phalanx can be considered in an attempt to prevent
the risk of developing a secondary hyperextension deformity
at the PIP joint. Zancolli originally described dividing the FDS
tendons to the ring and small fingers distal to the A1 pulley
between the A1 and A2 pulleys through a distal palmar crease
incision. Each tendon is withdrawn from the flexor sheath
between the A1 and A2 pulleys, looped around the A1 pulley,
Fig. 34.26  Alternative insertions for tendon transfers to prevent clawing: (A) Into the lateral band. (B) Burkhalter insertion through a drill hole or bone anchor in the
proximal phalanx. (C) “Lasso” insertion into either the A1 pulley (Zancolli); the A2 pulley (Brooks–Jones); or the A1 and proximal half of the A2 pulley (Anderson).
A
B
C
Lateral band
Proximal phalanx
A2 pulley
and sutured back to itself. This has been termed the “lasso”
procedure.62 In patients with a high ulnar palsy, the ring and
small finger superficialis tendons cannot be used and therefore
the long finger FDS tendon is divided into two slips and each
slip is passed under the A1 pulleys of the ring and small
fingers and sutured to itself (see Fig. 34.27). The FDS tendon
slips are sutured with the wrist in neutral, the MCP joints in
60° of flexion and the wrist is then immobilized in 10° of
flexion and the MCP joint is 90° of flexion for 3 weeks, but
allowing motion at the PIP and DIP joints. Omer and Brooks–
Jones63 described looping the FDS tendon around the A2
pulley (see Fig. 34.26C) rather than the A1 pulley, and Ander­
son64 has described an extended pulley insertion (EPI) by
looping the FDS tendon around both the A1 and the proximal
half of the A2 pulleys. Burkhalter65 recommended insertion
of the FDS tendon slips of a modified Stiles–Bunnell transfer
into a radial–ulnar drill hole in the proximal phalanx (see
Fig. 34.26B).
In a combined high median–ulnar nerve palsy, all the FDS
tendons are paralyzed and consequently an “indirect lasso”
procedure is required. After passing the FDS tendons around
the A1 pulleys, the proximal ends of the FDS tendons are
activated either by extensor carpi radialis longus or flexor
carpi radialis. Brooks and Jones63 have described a variant of
this transfer in which the extensor carpi radialis longus or
flexor carpi radialis are elongated with plantaris or toe exten­
sor tendon grafts passed through the carpal tunnel and
inserted more distally into the A2 pulley. Burkhalter and
Strait65 have also used the same donor tendons, the ring finger
FDS and extensor carpi radialis longus but with insertion
through a transverse drill hole in the middle third of the
proximal phalanx. The ring finger FDS is divided at the level
of the PIP joint withdrawn into the palm and divided into two
slips. Each slip is then passed down the lumbrical canal into
a transverse drill hole on the radial aspect of the middle third
of the proximal phalanx of the ring and small fingers.
Modified Stiles–Bunnell transfer
(see Fig. 34.27)
In the modified Stiles–Bunnell transfer33 for patients with an
isolated low ulnar nerve palsy, the ring finger FDS tendon is

787
Low ulnar nerve palsy
divided just proximal to the PIP joint, withdrawn through a
transverse distal palmar crease incision, and split longitudi­
nally into two slips. The radial lateral bands of the ring and
small fingers are exposed through radial midaxial incisions
and each slip of the FDS tendon is passed down the lumbrical
canals of the ring and small fingers. With the wrist in neutral,
each slip is sutured under adequate tension to the radial
lateral bands with the MCP joints in 45–55° of flexion and the
interphalangeal joints fully extended (see Fig. 34.27). Tension
is assessed using the tenodesis effect of the wrist – with wrist
extension, the fingers should assume the “intrinsic-plus” posi­
tion. The hand is immobilized in a dorsal block splint with
the wrist in slight flexion and the MCP joints flexed 70○ for
3 12 to 4 weeks. In a high ulnar nerve palsy, the ring finger FDS
tendon is the only remaining extrinsic flexor tendon in the
ring finger and therefore the long finger FDS tendon is used.
Occasionally, the long or ring finger FDS tendon may be split
into three slips, should the long, ring, and small fingers need
correction. With a total intrinsic palsy, the FDS tendons to both
the long and ring fingers are each divided into two slips and
passed down the lumbrical canals to the radial lateral bands
of the index, long, ring, and small fingers. Brand advocates
insertion of the slip to the index finger into the ulnar lateral
band to provide improved three-point pinch. However, this
may result in scissoring of the index and long fingers. Zan­
colli62 has described insertion of the FDS donor tendon into
the combined interosseous tendons rather the radial lateral
bands and termed this alternative technique of restoring MCP
joint flexion and interphalangeal (IP) joint extension as “direct
interosseous activation”.
One of the disadvantages of the modified Stiles–Bunnell
transfer is that the ring finger superficialis is not expendable
in a high ulnar nerve palsy or in a combined high median–
high ulnar nerve palsy. Secondly, the transfer may result in
progressive overcorrection of the claw deformity eventually
resulting in a “swan neck” hyperextension deformity at the
PIP joints. A “swan neck” hyperextension deformity can be
prevented by utilizing one of the distal slips of FDS as a
tenodesis across the PIP joint. Thirdly, the donor long or ring
finger may develop a flexion contracture at the PIP joint or
loss of extension at the DIP joint. North and Littler70 recom­
mended harvesting the FDS tendon through a Bruner incision
between the A1 and A2 pulleys rather than a midaxial incision
at the level of the PIP joint. The modified Stiles–Bunnell
transfer should therefore only be used in patients with mild
PIP joint flexion contractures or stable fingers without passive
hyperextension at the PIP joints.
Brand EE4T transfer (Fig. 34.28)
Due to his extensive experience of tendon transfers in leprosy
patients, Brand4,71 originally described transfer of the extensor
carpi radialis brevis (ECRB), extended with four tendon grafts,
passed from dorsal to palmar through the intermetacarpal
spaces and then down the lumbrical canals to be attached to
the radial lateral bands of the middle, ring, and small fingers,
and to the ulnar lateral band of the index finger (EE4T: exten­
sor tendon, extensor route, four-tailed graft). However, during
wrist extension, the ECRB and tendon grafts relax, which is a
relative disadvantage of this dorsal routing of the original
Brand transfer. Burkhalter and Strait65 modified the Brand
EE4T transfer by using ECRL instead of ECRB and by only
Fig. 34.27  (A) Modified Stiles–Bunnell transfer to prevent clawing. The flexor
digitorum superficialis (FDS) tendon from the long finger is split into two slips and
inserted into the radial lateral band (ring finger) or the A2 pulley (small finger).
(B) Splitting of the FDS tendon from the long finger into two slips, which are
passed down the lumbrical canals to the radial lateral bands of the ring and small
fingers.
A
Insertion into radial lateral band
(ring finger)
Insertion into A2 pulley
(small finger)
Long finger flexor digitorum
superficialis tendon
split into 2 slips
B

788
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
Fig. 34.28  Brand EE4T (extensor tendon, extensor route, four-tailed graft) transfer:
Extensor carpi radialis brevis is extended by three tendon grafts which are passed
volar to the intermetacarpal ligaments and inserted into the radial lateral bands of
the long, ring, and small fingers.
Deep transverse
intermetacarpal
ligaments
Insertion into radial
lateral bands of long,
ring and small fingers
Palmaris or plantaris
tendon grafts or
fascia lata grafts
Extensor carpi radialis brevis
tendon controls the index and long fingers and the EDM
tendon controls the ring and small fingers. In a modification
of this Fowler transfer, Riordan has described splitting only
the EIP tendon into two slips and passing them from dorsal
to palmar through the third and fourth intermetacarpal spaces
to insert into the radial lateral bands to correct clawing of the
ring and small fingers.72 A relative disadvantage of the Fowler
and Riordan transfers is that the EIP and EDM tendons are
only just long enough to reach the radial lateral bands and
these transfers are rarely used.
Brand EF4T transfer (Fig. 34.29)
Brand71 modified his original dorsal transfer of ECRB by
extending extensor carpi radialis longus (ECRL) with a four-
tailed tendon graft or fascia lata graft through the carpal
tunnel to the radial lateral bands of the long, ring, and small
fingers and the ulnar lateral band of the ring finger (EF4T:
extensor tendon, flexor route, four-tailed graft). In an isolated
ulnar nerve palsy, this transfer is only attached to the radial
correcting the ring and small fingers. The ECRL is lengthened
with two tendon slips which are passed through the third and
fourth intermetacarpal spaces, down the lumbrical canals,
volar to the deep transverse intermetacarpal ligaments and
inserted into a drill hole on the radial aspect of the middle
third of the proximal phalanges. The wrist is immobilized in
40° of extension and the MCP joints in 70° of flexion for 4
weeks. This transfer will only produce MCP joint flexion, but
is an alternative transfer for a combined high median–high
ulnar nerve palsy when the modified Stiles–Bunnell flexor
digitorum superficialis transfer is not available. Riordan24
described a similar transfer using flexor carpi radialis (FCR)
transferred dorsally around the radial border of the forearm
and elongated with tendon grafts passed dorsal-to-palmar
through the intermetacarpal spaces volar to the deep trans­
verse intermetacarpal ligaments and inserted into the radial
lateral bands. This transfer is mutually beneficial if there is an
associated flexion contracture of the wrist.
The dorsal route also forms the basis for the Fowler transfer
using both the EIP and extensor digiti minimi (EDM) tendons.
The two tendons are divided just beyond the MCP joints of
the index and small fingers and each tendon is split longitu­
dinally into two slips. The four slips are tunneled subcutane­
ously to the radial lateral bands of the fingers.55 The EIP
Fig. 34.29  Brand EF4T (extensor tendon, flexor route, four-tailed graft) transfer to
correct clawing of all four fingers: Extensor carpi radialis longus is transferred
around the radial border of the forearm, extended by four tendon grafts, which are
passed through the carpal tunnel and inserted into the radial lateral bands of the
long, ring, and small fingers and the ulnar lateral band of the index finger.
Inserted into ulnar
lateral band of
index finger
Inserted into radial
lateral bands of
long, ring and
small fingers
Fascia lata or plantaris
tendon grafts
Extensor carpi radialis longus

789
Low ulnar nerve palsy
proximal to the PIP joints under equal tension. Tension is
adjusted in the index finger first, then the small finger, and
finally the long and ring fingers. The hand is immobilized
with the wrist in neutral, the MCP joints flexed 90°, and the
IP joints straight for 3 weeks.
Fritschi PF4T transfer
Fritschi73 has described the palmaris longus as an alternative
motor for the Brand EF4T transfer. In the Lennox–Fritschi
PL4T (palmaris four-tail) transfer, the palmaris longus tendon
is lengthened with a tendon graft or fascia lata graft, which
are then passed through the carpal tunnel to the lateral bands
in a similar route to the Brand EF4T procedure. However, the
palmaris longus is obviously a much weaker donor muscle
than the ECRL.
Two alternative insertions have been described for the
Brand EF4T and Lennox–Fritschi PL4T transfers, either the
common interosseous tendon insertion or the A2 pulley.
Zancolli62 originally described looping the tendon graft or
fascia lata grafts around the common interosseous tendon – a
technique described as “direct interosseous activation”. In
addition to restoring MCP joint flexion, this insertion may
potentially provide abduction of the fingers. Palande66 has
also reported using both the ECRL and palmaris longus
tendons extended with tendon grafts, inserting them around
the common interosseous tendons. ECRL or palmaris longus
are elongated with tendon grafts or fascia lata grafts which
are then tunneled through the carpal tunnel to emerge distal
to the superficial palmar arch through an incision just to the
ulnar side of the thenar crease. The first dorsal interosseous
tendon, the palmar and dorsal interosseous tendons in the
second, third, and fourth webspaces and the muscle–tendon
junction of the hypothenar muscles are all identified through
lateral bands of the ring and small fingers (Fig. 34.30). Two
short transverse incisions are made, one over the second
dorsal extensor tendon compartment to allow transection of
the ECRL tendon, which is withdrawn into the second inci­
sion over the radial aspect of the mid-forearm. Either a folded
fascia lata graft or a plantaris tendon graft is sutured to the
distal end of the ECRL tendon projecting through the radial
forearm incision. The elongated ECRL tendon is then passed
around the radial border of the forearm into a transverse volar
forearm incision just proximal to the wrist crease. Through a
3 cm-long incision on the ulnar side of the thenar crease, a
tendon-tunneling forceps is introduced distal to the superficial
palmar arch and passed along the floor of the carpal tunnel
to exit on the radial side of the volar forearm incision and the
tendon grafts or fascia lata graft are then pulled distally
through the carpal tunnel into the palmar incision. The proxi­
mal tendon juncture therefore lies distal to the volar forearm
incision, but proximal to the transverse carpal ligament. Each
of the two plantaris slips are split longitudinally to produce
four slips or the fascia lata graft is split into four slips. Through
radial midaxial incisions over the proximal phalanges of the
long, ring, and small fingers, the tunneling forceps is passed
down each lumbrical canal volar to the deep transverse
intermetacarpal ligaments into the palmar incision and the
three tendon slips are brought out into each midaxial incision.
The tendon slip to the index finger is tunneled to an ulnar
midaxial incision and attached to the ulnar lateral band. This
will produce supination of the index finger and may provide
better three-point pinch. The hand is positioned on a frame
with the wrist flexed 30°, the MCP joints flexed 70° and the
interphalangeal joints fully extended. Proximal traction is
applied to each lateral band to take up any slack in the exten­
sor mechanism. After taking up the slack in all four plantaris
tendon grafts, they are sutured to the lateral bands just
A
B
C
Fig. 34.30  Brand EF4T (extensor tendon, flexor route, four-tailed graft) transfer to
correct clawing of the ring and small fingers in a low ulnar nerve palsy. (A) Extensor
carpi radialis longus (ECRL) is detached from its insertion on the base of the index
finger metacarpal. (B) A palmaris longus tendon graft has been sutured to ECRL and
passed around the radial border of the forearm (or through the interosseous
membrane). The palmaris longus tendon graft is passed through the carpal tunnel
and split into two slips, which are passed down the lumbrical canals to be inserted
into the radial lateral bands of the ring and small fingers. (C) Postoperative
correction of the claw deformity of the ring and small fingers.

790
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
tendon (Fig. 34.31). Other tendon transfers to restore adduc­
tion of the thumb have included either the brachioradialis77
or extensor carpi radialis longus78 elongated with a tendon
graft and passed through the third intermetacarpal space to
the thumb MCP joint, and the extensor indicis proprius passed
through the second intermetacarpal space.79 Combined trans­
fers to provide both thumb adduction and index finger abduc­
tion have been described by splitting the extensor indicis
proprius or extensor digiti minimi tendons.80
If there is a severe collapse Z-deformity of the thumb with
hyperextension at the MCP joint and flexion at the IP joint, or
a transverse incision along the distal palmar crease. The
plantaris tendon grafts or fascia lata grafts are split into four
or five slips. One slip is looped around the muscle–tendon
junction of the first dorsal interosseous; one slip around the
combined first palmar interosseous and second dorsal interos­
seous tendons in the index–long finger webspace; one slip
around the combined third dorsal interosseous and second
palmar interosseous tendons in the long–ring finger webspace;
one slip around the combined fourth dorsal interosseous and
third palmar interosseous tendons in the ring–small finger
webspace; and if necessary the final fifth slip can be looped
around the muscle–tendon junction of the hypothenar
muscles. The hand is positioned with the MCP joints flexed
60° and the interphalangeal joints straight. After slack has
been taken up, each of the four of five slips are sutured back
onto themselves, starting on the radial side with the index
finger, then the slip between the ring and small fingers and
finally the slips between the index and long fingers and
between the long and ring fingers. The correct tension is
confirmed by performing a wrist tenodesis maneuver. The
hand is immobilized for 3 weeks with the wrist neutral, the
MCP joints in 90° of flexion, and the interphalangeal joints
extended.
Brooks and Jones63 described amalgamating the Brand
EF4T transfer with the Zancolli lasso procedure in which the
ECRL or FCR tendons are elongated with plantaris or toe
extensor tendon grafts and passed through the carpal tunnel
and looped around the A2 pulleys of each finger. This variant
of the EF4T transfer will only produce MCP joint flexion.
Tendon transfer to correct ulnar deviation of
the small finger
A variant of the Fowler transfer has been advocated by Blacker
et al.74 to correct the ulnar deviation deformity of the small
finger (Wartenberg’s sign). The ulnar half of extensor digiti
minimi is detached, passed volar to the deep transverse
intermetacarpal ligament and sutured into the insertion of the
radial collateral ligament of the MCP joint at the base of the
proximal phalanx, or if there is associated clawing of the small
finger, it is looped under the A2 pulley and sutured back to
itself (Brooks’ insertion). Chung et al.75 described transferring
EIP to the distal radial aspect of the extensor hood of the small
finger to correct the persistent abduction deformity of the
small finger in an ulnar nerve palsy.
Tendon transfers to provide adduction of
the thumb
The most successful tendon transfers to restore adduction of
the thumb have a transverse direction of pull across the palm
deep to the flexor tendons to insert into the tendon of adduc­
tor pollicis. Littler33 has advocated transfer of the ring finger
FDS tendon deep to the flexor tendons of the index and long
fingers, parallel and superficial to the transverse fibers of
adductor pollicis and inserted into a drill hole just distal to
the adductor insertion, and has been able to document an
increase in pinch strength to 71% of the opposite hand. Smith76
described using extensor carpi radialis brevis extended by a
free tendon graft passed through the second intermetacarpal
space and tunneled deep to the flexor tendons but superficial
to the adductor pollicis to an insertion into the adductor
Fig. 34.31  Smith adduction transfer. A tendon graft is attached to the adductor
tubercle on the ulnar base of the proximal phalanx of the thumb, passed through the
second intermetacarpal space and sutured to extensor carpi radialis brevis.
Tendon graft passed
through the index-long
finger intermetacarpal
space
Tendon graft sutured
to insertion of adductor
pollicis tendon
Extensor carpi radialis brevis

791
High ulnar nerve palsy
an exaggerated Jeanne’s sign when attempting to pinch,
arthrodesis of the MCP joint may be necessary.33,81 The thumb
MCP joint is positioned in 15–20° of flexion and 15° pronation
and arthrodesis achieved using a dorsal plate, interosseous
wiring, or tension band wiring. Arthrodesis of the MCP joint
may be combined with an adductor transfer or the transfer
may be performed secondarily. Occasionally, if there is a
severe fixed flexion deformity of the IP joint, arthrodesis of
the IP joint is indicated82 instead of the MCP joint, combined
with an adductor transfer. IP joint arthrodesis is achieved with
interosseous wiring, K-wires or a combination of each or
headless compression screws.
For mild collapse deformities of the thumb without a fixed
contracture, a split FPL to EPL transfer may be indicated.83
Through a volar Bruner incision, the FPL is split longitudinally
from its insertion proximally to the distal end of the A1 pulley.
The radial half of FPL is transected at its insertion, retracted
back proximal to the oblique pulley, and passed deep to the
radial neurovascular bundle around the radial border of the
proximal phalanx into a longitudinal incision on the dorsum
of the proximal phalanx. The radial slip of FPL is sutured to
the EPL tendon proximal to the IP joint with the MCP joint in
15° of flexion and the IP joint in full extension. The IP joint is
fixed with a K-wire for 4 weeks.
Ring finger flexor digitorum superficialis
adductor transfer
The ring finger FDS tendon is transected between the A1 and
A2 pulleys through a short incision at the base of the ring
finger.33 The FDS tendon is then passed transversely across the
palm deep to the index and long finger flexor tendons to the
ulnar aspect of the thumb MCP joint, through a short incision
just to the ulnar side of the thenar crease. The transfer is either
sutured into the adductor pollicis tendon or passed through
a drill hole in the proximal phalanx just distal to the adductor
insertion and tied over a button. Tension is set with the wrist
in neutral and the thumb adducted against the index finger
with the FDS tendon at its resting length. Appropriate tension
is confirmed by tenodesis of the wrist – with wrist flexion, the
thumb should be able to be passively abducted. Edgerton and
Brand34 have described a variation of this transfer in which
the ring finger FDS is brought through a window in the
palmar fascia and then passed subcutaneously to the abductor
insertion. The vertical septum of palmar fascia arising from
the long finger metacarpal acts as a pulley. Obviously, the ring
finger FDS cannot be used as an adductor transfer in patients
with a high ulnar nerve palsy since this would deprive the
ring finger of its only remaining flexor tendon.
Smith extensor carpi radialis brevis adductor
transfer (see Fig. 34.31)
Extensor carpi radialis brevis is transected through a short
transverse incision over the second dorsal extensor compart­
ment just distal to the extensor retinaculum and withdrawn
through a second transverse incision just proximal to the
extensor retinaculum.76 A small flap is then elevated over the
ulnar aspect of the MCP joint of the thumb and a palmaris or
plantaris tendon graft sutured to the adductor pollicis tendon.
Through a short transverse incision overlying the proximal
third of the second intermetacarpal space, a tendon passer is
used to tunnel the tendon graft deep to the flexor tendons but
superficial to the adductor pollicis, withdrawing it dorsally
through the second intermetacarpal space. After passing the
tendon graft subcutaneously to the most proximal incision, it
is woven into the extensor carpi radialis brevis tendon with
the wrist in neutral and the thumb adducted (see Figs. 34.31
& 34.33). Tension is then checked by tenodesis of the wrist –
with wrist flexion, the thumb should become strongly
adducted, whereas wrist extension should allow easy passive
abduction of the thumb. Postoperatively the thumb is immo­
bilized for 3 weeks midway between full abduction and full
adduction with the wrist in 20–30° of extension.
Tendon transfers to provide index
finger abduction
Restoration of strong abduction of the index finger is the
second component required for powerful pinch. Bunnell69
described the transfer of extensor indicis proprius (EIP)
extended with a short tendon graft and inserted into the first
dorsal interosseous tendon. Bruner84 divided the extensor
pollicis brevis (EPB) tendon over the dorsum of the MCP
joint of the thumb and tunneled it subcutaneously beneath
the extensor pollicis longus tendon into the first dorsal
interosseous tendon. Hirayama85 lengthened the palmaris
longus tendon with a strip of palmar fascia (similar to the
Camitz transfer) and tunneled it subcutaneously around
the radial border of the forearm over the dorsum of the
wrist and hand to insert into the first dorsal interosseous
tendon. Graham and Riordan86 transferred the FDS of the
ring finger in a similar route around the radial border of the
wrist over the dorsum of the hand to either the first dorsal
interosseous tendon or into a drill hole on the radial aspect
of the index finger. However, one of the accessory tendons of
abductor pollicis longus (APL) extended with a free tendon
graft or attached to the re-routed EDC tendon of the index
finger may be the best choice to restore abduction of the
index finger.87
Neviaser accessory abductor pollicis longus
and free tendon graft (Fig. 34.32)
Neviaser et al.87 described an accessory APL tendon elongated
with a palmaris or plantaris tendon graft transferred to the
insertion of the first dorsal interosseous tendon (see Figs.
34.32e and 34.33). A small flap is elevated over the radial
aspect of the proximal phalanx of the index finger and a
tendon graft sutured to the first dorsal interosseous tendon
just distal to the MCP joint. The proximal end of the tendon
graft is then passed subcutaneously to a transverse incision
just distal to the first dorsal extensor compartment. After
opening the compartment, one of the accessory APL tendons
is transected and interwoven with the tendon graft with
the wrist in neutral position and the index finger radially
abducted.
High ulnar nerve palsy
Many surgeons fail to realize the significant functional deficit
in a high ulnar nerve palsy associated with paralysis of the
flexor carpi ulnaris and FDP tendons to the ring and small

792
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
Outcomes
There are very few reports to substantiate the relative effec­
tiveness of the various transfers to restore synchronous MP
flexion and IP extension of the fingers and thumb–index finger
pinch. Hastings and Davidson88 compared four techniques:
Zancolli “lasso”, Stiles–Bunnell, Brand, and Riordan and
Fowler transfers to correct the claw deformity in 12 patients
with high, 14 patients with low, and three patients with mixed
high and low ulnar nerve palsy. Successful outcomes were
seen in the majority of cases. Most failures occurred in the
small finger and transfers utilizing the superficialis tendons
were found to further weaken the hand. Only transfers using
wrist flexors or extensors have been shown to increase grip
strength. A later report examining the effectiveness of the FDS
“lasso” procedure showed similar results, with correction of
clawing in 19 of 23 digits but no significant improvement in
grip strength.89 The extended pulley insertion for a modified
Stiles–Bunnell transfer produced good to excellent correction
of clawing in 92% of fingers.64 Brandsma et al.51 reported good
(57%) or excellent (21%) results using the FDS transfer to
restore intrinsic function. The long or ring finger FDS transfer
resulted in 95% good or excellent correction of clawing in
leprosy patients at an average follow-up of 2 years.64 The
Brand EF4T transfer provided 79–86% good to excellent cor­
rection of clawing at a 10-year follow-up.64 Eighty-five percent
good to excellent results were obtained utilizing the common
interosseous tendon insertion technique.62 PIP hyperextension
occurred in 6.25% when the common interosseous tendon
insertion was utilized in an EF4T transfer, compared with a
13.75% incidence when the EF4T transfer was inserted into
the lateral bands.64 Therefore there is less chance of over­
correction producing a PIP joint hyperextension deformity
by utilizing the common interosseous tendon insertion. An
additional advantage of using ECRL as the motor is that the
palmar arch is restored. Ozkan et al.90 compared the results
of three different tendon transfers to restore grip strength
and correct the claw deformity in 44 patients with ulnar
nerve palsy. Twenty-four patients were reconstructed with a
modified Stiles–Bunnell four-tail procedure, 11 patients with
the Brand EF4T transfer and nine patients with a Zancolli
“lasso” procedure. With a recent paralysis, the Zancolli and
Brand procedures were the most effective in restoring grip
strength, but with long-standing paralysis, the Stiles–Bunnell
four-tail procedure was the most successful in correcting the
claw deformity.
Hastings and Davidson88 showed an approximate dou­
bling of pinch strength in hands treated with the ECRB
adductorplasty transfer, although it is interesting to note
that only 18 of the 34 patients in this study felt that pinch
strength was compromised enough to warrant a tendon
transfer. Robinson et al.80 evaluated the combination of the
ulnar slip of EDM to provide thumb adduction and EIP to
restore index finger abduction in six patients and demon­
strated an average improvement in pinch strength from 5%
to 40–50% of the normal side. Fischer et al.91 evaluated the
results of tendon transfers to restore thumb adduction
(ECRL was transferred to adductor pollicis) and index finger
abduction (APL was transferred to the first dorsal interosse­
ous) at an average of 6 years postoperatively. Key pinch
averaged 73%, pulp-to-pulp pinch averaged 72%, grip
strength was 73%, the force of thumb adduction was 63%,
fingers. The only remaining tendons on the ulnar side of the
hand are the FDS tendon to the ring finger and the usually
diminutive FDS tendon to the small finger. However, paralysis
of the FDP tendons to the ring and small fingers will often be
masked by interconnections between these two tendons and
the long finger FDP tendon at the wrist. If there is significant
weakness of DIP joint flexion of the ring and small fingers
(Pollock’s sign), power grip can be restored by side-to-side
tenorrhaphy of the ring and small finger FDP tendons to the
median-innervated middle finger FDP tendon.58 This should
be performed before tendon transfers to correct clawing are
performed, but patients should be warned that this will
temporarily exaggerate their clawing and that they should use
a lumbrical block splint. To restore independent flexion of the
ring and small fingers, the FDS tendon of the long finger may
be used as a donor tendon to activate the FDP tendons of the
ring and small fingers. Patients requiring strong ulnar devia­
tion and flexion of the wrist may occasionally need to be
considered for transfer of the FCR tendon to FCU.58
Fig. 34.32  Neviaser transfer to restore abduction of the index finger. A palmaris
tendon graft is sutured to the insertion of the first dorsal interosseous muscle on
the radial base of the proximal phalanx of the index finger and sutured to one of the
accessory tendons of abductor pollicis longus.
1st dorsal interosseous
muscle
Tendon graft sutured to
insertion of 1st dorsal
interosseous muscle
Palmaris tendon graft
Accessory tendon of
abductor pollicis longus

793
Tendon transfers for combined nerve injuries
tendon transfers. The choice of tendon transfers and the timing
of the surgery should be well planned, designed, and individu­
alized to address the patient’s specific functional needs. It is
unwise to adopt a “cookbook” approach for reconstruction of
the patient with combined nerve injuries. Basic principles of
tendon transfers such as soft-tissue equilibrium, full passive
range of motion of involved joints, selection of the appropriate
donor muscle, and direction of transfer as outlined earlier
should be carefully considered in preoperative planning.
Before any operation is performed, the patient should be
educated about the goals and risks of the procedure and the
and the force of index finger abduction was 58% of the
normal hand.
Tendon transfers for combined
nerve injuries
It is much more difficult to reconstruct the upper extremity
affected by multiple nerve injuries. The majority of these
patients require multiple reconstructive procedures and
Fig. 34.33  (A) Smith transfer to restore adduction of the thumb and the Neviaser
transfer to restore abduction of the index finger. (B) A tendon graft has been
attached to the adductor pollicis insertion and passed deep to the flexor tendons
and neurovascular bundles through the second intermetacarpal space from palmar to
dorsal. A second tendon graft has been sutured to the tendon of insertion of the first
dorsal interosseous muscle. (C) Traction on these two tendon grafts flexes and
adducts the thumb and abducts the index finger at the metacarpophalangeal joint.
(D) Postoperatively the patient has excellent abduction of the index finger for key
pinch and (E) significant improvement in pinch strength.
Accessory tendon
of abductor
pollicis longus
Palmaris tendon graft
sutured into adductor
pollicis tendon insertion
Palmaris tendon graft sutured into insertion
of 1st dorsal interosseous muscle
Extensor carpi radialis brevis
A
B
C
D
E

794
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
developed a flexion contracture of the wrist, by involuntarily
trying to prevent clawing by flexing their wrist, the FCR
tendon may be used to motor the four tendon grafts.25
If the patient still has poor palmar sensibility despite nerve
repair or nerve grafting, consideration should be given to
transfer of a superficial radial nerve innervated flap to the
thumb or nerve transfer of the superficial radial nerve to the
distal median nerve.
Tendon transfers for high median–high ulnar
nerve palsy
This is a very severe injury in which there is no active flexion
of the fingers and thumb, and loss of thumb opposition and
key pinch, in addition to the loss of palmar sensibility. Initially,
the fingers may be fully extended even at the interphalangeal
joints despite the intrinsic paralysis. However, once tendon
transfers are completed to provide active finger flexion, the
fingers gradually assume a claw posture. Tendon transfers for
reconstruction of a high median–high ulnar nerve palsy have
to be performed in two or three stages. The goals are to restore
finger and thumb flexion, thumb–index finger pinch, abduc­
tion and opposition of the thumb, and correct the later
development of clawing of the fingers.
Thumb adduction and key pinch can be achieved by trans­
fer of extensor carpi radialis brevis with a free tendon graft
through the second intermetacarpal space to the adductor
pollicis insertion.76,98 Finger flexion can be restored by transfer
of extensor carpi radialis longus to the four FDP tendons.58
This can be combined with tenodesis of the DIP joints of the
three ulnar fingers.92 Flexion of the thumb can be restored by
transfer of the brachioradialis to flexor pollicis longus through
the same palmar incision.58 The brachioradialis muscle must
be mobilized and elevated off the radius into the proximal
third of the forearm. A Pulvertaft tendon weave is then per­
formed between the brachioradialis and flexor pollicis longus
in the distal third of the forearm.78,92 As in a low median–low
ulnar nerve palsy, the most reliable procedure for thumb
opposition is transfer of the extensor indicis proprius to the
abductor pollicis brevis insertion.37 If the IP joint of the thumb
tends to assume a flexed position, the EIP transfer should be
inserted both into the APB insertion and then into the EPL
tendon just proximal to the IP joint.25 If thumb pinch remains
unstable with MP extension and IP joint flexion, arthrodesis
of the MP joint should be considered. A useful procedure that
avoids the need to fuse the IP joint of the thumb involves
longitudinal splitting of the FPL tendon, detaching the radial
half from its insertion into the distal phalanx and transfer of
this tendon slip dorsally where it is attached into the EPL
tendon proximal to the IP joint of the thumb.83 This results in
a dynamic stabilization of the IP joint when the transfer pulls
through the FPL.
If after finger flexion has been restored the fingers begin to
adopt a claw position, there are no expendable wrist extensors
(ECRL and ECRB) remaining to provide integration of MP
flexion and IP joint extension, static tenodesis techniques may
be necessary. Free tendon grafts can be placed from the deep
transverse metacarpal ligaments to the lateral bands61 or from
the dorsal carpal ligament to the lateral bands.25 Alternatively,
hyperextension can be prevented by Zancolli capsulodeses or
arthrodeses of the PIP joints. Finally, abduction of the index
finger for pinch can be restored using an accessory abductor
fact that the injured extremity will never be normal. As a
general rule, the results of tendon transfers for combined
nerve injuries are inferior to those for a single nerve injury.92,93
Adding to the complexity of these problems, the number
of donor tendons is limited, more joints need to be mobilized,
there is a more profound sensory loss, and the soft tissues may
be more scarred in this patient population. Multiple nerve
repairs or nerve grafting should be done as soon as clinically
appropriate but return of motor function rarely extends
beyond two major joints distal to the injury.94 Reinnervated
muscles, however, should not be used or only used with great
caution as a donor for tendon transfers.
Dynamic tenodesis is an important concept in reconstruc­
tion of these combined nerve injuries. Wrist flexion or exten­
sion can be used to augment the excursion of any tendon
transfer that crosses the wrist. For example, if a wrist flexor
such as FCR is used to activate flexor digitorum profundus,
flexion of the fingers will be enhanced if the patient extends
their wrist using the ECRL or ECRB simultaneously with
contraction of the FCR transfer. Therefore, if the excursion of
a tendon transfer is less than optimal to produce a specific
function, increased range of motion can be achieved through
wrist tenodesis.95
Tendon transfers for low median–low ulnar
nerve palsy
A low median and low ulnar nerve palsy is the most common
combined nerve injury in the upper extremity and is usually
the result of a “spaghetti-wrist” laceration.92 This leads to
complete loss of sensation on the palmar surface of the hand
and a complete intrinsic motor paralysis that results in a claw
hand deformity. A flat transverse metacarpal arch with hyper­
extension at the MCP joints and hyperflexion at the PIP joints
(see Fig. 34.22) accompanied by an abducted small finger are
the hallmark of this injury. It is especially important to prevent
an adduction contracture of the thumb–index webspace.95 The
surgeon should repair or graft the median and ulnar nerves
before any tendon transfers are performed in order to restore
some protective sensibility to the hand. The goals of recon­
struction in a low median–low ulnar nerve palsy are to restore
thumb adduction, thumb abduction and opposition, abduc­
tion of the index finger, and improved extension of the PIP
joints of the fingers.
Thumb adduction for key pinch can be restored by transfer
of the extensor carpi radialis brevis extended by a tendon
graft through the second intermetacarpal space and inserted
into the adductor tubercle of the thumb metacarpal76 or alter­
natively by transfer of the ring finger FDS tendon to the
adductor insertion.33 The best option for reconstruction of
thumb opposition is the extensor indicis proprius transfer
re-routed around the ulnar border of the hand and inserted
into the abductor pollicis brevis tendon.37,96 This transfer can
be combined with arthrodesis of the MCP joint of the thumb
to allow for maximum stability.97 Index finger abduction for
strong pinch can be restored by transfer of one of the acces­
sory slips of the abductor pollicis longus tendon extended by
a tendon graft to the first dorsal interosseous insertion.87
Finally, clawing of the fingers can be corrected by using ECRL
or palmaris longus71,73 extended by four tendon grafts and
inserted either into the radial lateral bands or the A2 pulleys
as previously discussed. Alternatively, if the patient has

795
Tendon transfers for combined nerve injuries
pollicis longus tendon extended with a free tendon graft to
the first dorsal interosseous87 or alternatively by using exten­
sor pollicis brevis.84
The importance of restoring sensibility to the radial side of
the hand in a high median–high ulnar nerve palsy cannot be
overstated, either by secondary nerve repair or nerve grafting.
A sensate hand is the prerequisite for performing the tendon
transfers mentioned above. If sensation cannot be restored,
Omer has advocated a fillet flap of the index finger to resurface
the thumb–long finger webspace with dorsal skin innervated
by the superficial radial nerve.92 Alternatively, a first dorsal
metacarpal artery flap innervated by the superficial branch of
the radial nerve can be transferred to the palmar surface of
the thumb; or the superficial branch of the radial nerve itself
can be transferred to the distal median nerve as a nerve
transfer.
Tendon transfers for reconstruction
after trauma
Tendon transfers are an excellent method of restoring active
motion to the hand and wrist following traumatic injuries of
the muscles and tendons of the forearm, wrist, and hand. If
there has been segmental loss of tendon, a tendon graft is
often used instead of a tendon transfer. With more severe
trauma (industrial or motor vehicle accidents, blast, missile,
and explosion injuries), associated damage to the soft tissues
Fig. 34.34  (A) This patient demonstrates inability to extend the
interphalangeal joint of the thumb due to a rupture of the extensor
pollicis longus (EPL) tendon caused by a minimally displaced Colles
fracture of the distal radius. (B) The extensor indicis proprius tendon is
transected at the metacarpophalangeal joint of the index finger and
passed subcutaneously to be sutured to the ruptured end of the EPL
tendon. (C) Postoperatively the patient demonstrates excellent extension
and (D) flexion of the interphalangeal joint of the thumb.
A
B
C
D
will leave a scarred bed which is unsuitable for tendon grafts,
since a tendon graft is more likely to become adherent to the
scarred surrounding tissue than a tendon transfer. If a forearm
muscle itself has been badly damaged, a tendon graft will be
unable to restore active motion and a tendon transfer will be
necessary.
Time is another important consideration in reconstruction
of the post-traumatic upper extremity. Myostatic contracture
and atrophy are the unavoidable fate of injured muscle if there
has been a long delay between the traumatic event and the
reconstructive procedure, again making a tendon transfer a
more suitable option for reconstruction.
Tendon transfers to restore thumb extension
Rupture of the EPL tendon occurs in approximately 1 in 200
distal radius fractures, classically at Lister’s tubercle, and may
happen at any time from several weeks to several months
after the fracture. Ischemia of the tendon due to swelling and
edema of the tenosynovium and attrition over the roughened
dorsal radial cortex have been postulated as the etiology for
this tendon rupture.99–102 Patients present with weak or loss of
extension at the interphalangeal joint (Fig. 34.34A) or para­
doxically with incomplete extension at the MCP joint as well
as inability to raise the thumb dorsal to the plane of the hand.
The optimal choice for restoration of thumb extension is the
EIP to EPL transfer, which can be performed under local

796
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
used for an additional 3–4 weeks and there is usually no need
for retraining (see Fig. 34.34C,D).
Tendon transfers to restore finger extension
Restoration of finger extension after trauma can be accom­
plished by tendon transfers similar to those used for radial
nerve palsy. Those transfers were discussed in detail earlier
in this chapter and include transfer of either of the wrist
flexors FCU or FCR to the EDC or the Boyes transfer of the
FDS of the long and ring fingers to the EDC.
Tendon transfers to restore thumb flexion
Acute lacerations or ruptures of the flexor pollicis longus
tendon can be treated by primary or delayed primary repair
or tendon grafting. However, with a missed diagnosis, the
muscle fibers undergo significant shortening, atrophy, and
fibrosis within 6 months to a year from injury. In these situa­
tions it is preferable to restore thumb flexion using a tendon
anesthesia (see Fig. 34.34B). The EIP tendon is harvested
through a short transverse incision just proximal to the index
finger MCP joint and its distal stump is then sutured end-to-
side to the EDC tendon of the index finger to prevent extensor
lag of this finger. The EIP is retrieved through a second trans­
verse incision just distal to the extensor retinaculum. A third
incision is made over the distal third of the thumb metacarpal
and the EIP is tunneled subcutaneously to this incision. The
distal end of the EIP is sutured to the distal end of the EPL with
the wrist held in neutral and the thumb fully extended and
parallel or just volar to the plane of the palm.103 The tension of
the transfer can be checked by tenodesis of the wrist. With wrist
flexion, the thumb should move dorsal to the plane of the palm
and with wrist extension the thumb should be able to be placed
in full passive abduction and opposition. The patient is even
able to use the EIP transfer immediately and extend the thumb
on the operating table if the surgery is performed under local
anesthesia as “wide-awake” surgery.104 Postoperatively, the
wrist is immobilized in 40° of extension with the thumb in
abduction and extension for 3–4 weeks. A removable splint is
Fig. 34.35  (A) Loss of flexion at the interphalangeal joint of the thumb due to a missed laceration of the flexor pollicis longus (FPL) tendon. (B) The flexor digitorum
superficialis of the ring finger is harvested and (C) transferred through the tendon sheath of FPL. (D) Postoperatively the patient demonstrates excellent flexion of the
interphalangeal joint and (E) satisfactory extension.
A
B
C
D
E

797
Summary
(Fig. 34.36) or a functioning free gracilis muscle transfer. The
ECRL is transected at the base of the index finger metacarpal
and mobilized through a longitudinal incision on the dorsum
of the forearm (Fig. 34.37). It is then tunneled subcutaneously
around the radial border of the forearm to a palmar incision
over the distal forearm. Great care has to be exercised in
adjusting the tension when suturing the ECRL to all four FDP
tendons, since the ECRL only has 30 mm amplitude and the
FDP tendons require 70 mm of excursion for full finger flexion.
Inserting the transfer too tightly will prevent full finger exten­
sion. The wrist tenodesis effect is vitally important in this
transfer – wrist extension should cause the fingers to flex
down to the palm, whereas wrist flexion should allow the
fingers to come out to full extension. If the flexor pollicis
longus is also non-functioning, thumb flexion can be restored
by transferring brachioradialis to FPL through the same
palmar incision (see Fig. 34.19B).
Summary
Tendon transfers, if carefully selected and performed meticu­
lously, will provide a gratifying functional improvement to
the hand affected by radial, median, ulnar or combined nerve
transfer, usually the FDS of the ring finger105 (Fig. 34.35). The
ring finger FDS is harvested through a transverse incision at
the base of the proximal phalanx and retrieved through a
second incision in the proximal palm. It is then passed through
the flexor pollicis longus sheath to the base of the distal
phalanx through an open incision or attached to a fine rubber
catheter or feeding tube and withdrawn distally through the
sheath. The ring finger FDS to FPL tendon transfer can be
performed in one stage or in two stages if the bed is scarred
with initial placement of a Silastic tendon rod.105 If necessary,
a pulley can be reconstructed using the old FPL tendon
remnant or with a palmaris longus graft.95 The tendon is
sutured to the distal phalanx of the thumb using a pullout
suture fixed over a button. The tension of the transfer can be
checked by wrist tenodesis. With the wrist in full flexion, the
thumb should extend completely and with wrist extension the
thumb tip should overly the ring finger MCP joint.
Tendon transfers to restore finger flexion
Occasionally patients may present with severe crushing or
avulsion injuries involving the forearm flexor muscles. The
options for secondary reconstruction of finger flexion are
either a tendon transfer of the ECRL to all four FDP tendons
Fig. 34.36  Tendon transfers to restore finger flexion. (A) The
extensor carpi radialis longus (ECRL) tendon is transected from
the base of the index finger metacarpal and transferred
subcutaneously around the radial border of the distal forearm.
(B) The ECRL tendon is sutured to the flexor digitorum
profundus (FDP) tendons of the index, long, ring, and small
fingers proximal to the carpal tunnel. Correct tensioning of this
transfer is absolutely crucial, because ECRL only has 30 mm of
amplitude whereas the FDP tendons require 70 mm of excursion
for full finger flexion.
A
B
Extensor carpi
radialis longus
Flexor digitorum
profundus tendons
Flexor digitorum
profundus tendons

798
SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
and their ultimate impact on hand function and return to
work. It has also been suggested that nerve transfers will
usurp the role of tendon transfers in the future and prospec­
tive outcome studies will need to be designed to compare the
relative outcomes of nerve transfers and tendon transfers.106
palsies, as well as severe trauma affecting the extrinsic flexor
and extensor muscles and tendons. Quantitative outcome
data is lacking for many of the tendon transfers described, but
surgeons and patients can attest to the significant benefits
derived from them.
Future directions
Comparative outcome studies must be designed in the future
to document the effectiveness of the various tendon transfers
Fig. 34.37  (A) This boy sustained segmental loss of all the forearm flexor muscles as well as the median
nerve and is unable to flex any of his fingers or thumb. (B) The extensor carpi radialis longus (ECRL) tendon
is transected and mobilized more proximally. The extensor indicis proprius tendon has been harvested for a
simultaneous opposition transfer for the thumb. Brachioradialis was also transferred to flexor pollicis longus
to restore flexion of the thumb. (C) Postoperatively, satisfactory finger flexion has been restored by transfer of
the ECRL to the flexor digitorum profundus tendons of all four fingers.
A
B
C

799
Future directions
4. Brand PW. Clinical Mechanics of the Hand. St. Louis, MO: CV Mosby
Co.; 1985. This is the definitive reference book detailing the biomechanics
of the hand.
17. Boyes J. Tendon transfers for radial palsy. Bull Hosp Joint Dis.
1960;21:97–105. The original description of the Boyes transfer for radial
nerve palsy, using the flexor digitorum superficialis tendons from the
middle and ring fingers transferred through the interosseous membrane to
restore independent index finger and thumb extension.
30. Bunnell S. Opposition of the thumb. J Bone Joint Surg.
1938;20:269–284.
37. Burkhalter W, Christensen RC, Brown P. Extensor indicis proprius
opponensplasty. J Bone Joint Surg Am. 1973;55:725–732. The original
description of the Burkhalter transfer to restore thumb opposition in a low
median nerve palsy using the extensor indicis proprius tendon.
69. Bunnell S. Surgery of the intrinsic muscles of the hand other than
those producing opposition of the thumb. J Bone Joint Surg.
1942;24:1–31.
71. Brand PW. Tendon grafting. J Bone Joint Surg. 1961;43:444–453. This
paper describes the dorsal route of the extensor carpi radialis brevis tendon
extended with free tendon grafts and the palmar route of the extensor
carpi radialis longus tendon extended with free tendon grafts to correct the
clawing in ulnar nerve palsy due to leprosy.
74. Blacker GJ, Lister GD, Kleinert HE. The abducted little finger in low
ulnar nerve palsy. J Hand Surg Am. 1976;1:190–196.
76. Smith RJ. Extensor carpi radialis brevis tendon transfer for thumb
adduction – a study of power pinch. J Hand Surg Am. 1983;8:4–15.
95. Brand PW. Tendon transfers for median and ulnar nerve paralysis.
Orthop Clin North Am. 1970;1:447–454.
98. Smith RJ. Tendon Transfers of the Hand and Forearm. Boston, MA:
Little Brown & Company; 1987. This classic monograph, unfortunately
out of print, is an excellent reference source describing tendon transfers
for nerve injuries, trauma, rheumatoid arthritis, congenital anomalies,
cerebral palsy, and spinal cord injuries.
Access the complete reference list online at

799.e1
References
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SECTION V
CHAPTER 34 • Tendon transfer for reconstruction of the wrist and hand
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70. North ER, Littler JW. Transferring the flexor superficialis tendon:
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77. Bunnell S. Surgery of the Hand. Philadelphia, PA: JB Lippincott;
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78. Omer GE Jr. Reconstruction of a balanced thumb through tendon
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80. Robinson D, Aghasi MK, Halperin N. Restoration of pinch in ulnar
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98. Smith RJ. Tendon Transfers of the Hand and Forearm. Boston, MA:
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congenital anomalies, cerebral palsy, and spinal cord injuries.
99. Christophe K. Rupture of the extensor pollicis longus tendon
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