Cẩm Nang Các Quy Trình Cốt Lõi Trong Phẫu Thuật Tạo Hình (Core Procedures)

339
Peripheral nerves
Figure 19.37  The median nerve classically lends sensibility to the palmar aspect and the distal dorsum of the thumb, index, long, and radial half of the ring fingers.
Intrinsic muscles radial to the flexor pollicis longus and the two radial lumbricals receive motor innervation from the median nerve. (Reprinted with permission from
© Elsevier Inc. All Rights Reserved.)
Anterior view
Note: Only muscles innervated by median nerve shown
Musculocutaneous nerve
Median nerve (C5, 6, 7, 8, T1)
Inconstant contribution
Pronator teres muscle (humeral head)
Articular branch
Flexor carpi radialis muscle
Palmaris longus muscle
Pronator teres muscle (ulnar head)
Flexor digitorum superficialis muscle
(turned up)
Anterior interosseous nerve
Flexor pollicis longus muscle
Pronator quadratus muscle
Palmar branch of median nerve
Abductor pollicis brevis
Opponens pollicis
Superficial head of
flexor pollicis brevis
(deep head
supplied by
ulnar nerve)
Thenar
muscles
1st and 2nd
lumbrical muscles
Dorsal branches to
dorsum of middle and
distal phalanges
Medial
Posterior
Lateral
Cords of
brachial
plexus
Medial brachial
cutaneous nerve
Medial antebrachial
cutaneous nerve
Axillary nerve
Radial nerve
Ulnar nerve
Cutaneous
innervation
Palmar view
Posterior (dorsal) view
Proper palmar
digital nerves
Common palmar
digital nerves
Communicating branch
of median nerve with
ulnar nerve
Flexor digitorum profundus muscle
(lateral part supplied by median
[anterior interosseous] nerve;
medial part supplied by ulnar nerve)

340
•
• Essential anatomy of the upper extremity
19
Figure 19.38  The ulnar nerve classically gives sensory innervation to the little finger and the ulnar half of the ring finger. All hypothenar muscles, all interossei, the two
ulnar lumbricals, the adductor pollicis, and the ulnar half of the flexor pollicis brevis are usually innervated by the ulnar nerve. (Reprinted with permission from
© Elsevier Inc. All Rights Reserved.)
Ulnar Nerve
Ulnar nerve (C7, 8, T1)
(no branches above elbow)
Inconstant contribution
Medial epicondyle
Articular branch
(behind condyle)
Flexor digitorum profundus
muscle (medial part only;
lateral part supplied by
anterior interosseous
branch of median nerve)
Dorsal branch of ulnar nerve
Flexor carpi ulnaris muscle
(drawn aside)
Palmar branch
Superficial branch
Deep branch
Palmaris brevis
Abductor digiti minimi
Flexor digiti minimi brevis
Opponens digiti minimi
Hypothenar muscles
Common palmar digital nerve
Palmar and dorsal interosseous muscles
Communicating branch of median nerve with
ulnar nerve
3rd and 4th lumbrical muscles (turned down)
Proper palmar digital nerves
(dorsal digital nerves are from dorsal branch)
Dorsal branches to dorsum of middle and distal phalanges
Adductor pollicis muscle
Posterior
(dorsal) view
Flexor pollicis brevis muscle
(deep head only; superficial
head and other thenar muscles
supplied by median nerve)
Palmar view
Cutaneous
innervation
Anterior view
Note: Only muscles innervated
by ulnar nerve shown

341
Further reading
■ The deep posterior interosseous nerve supplies the
supinator as well as muscles in all the extensor
compartments: ECRB, EDC, EDM, ECU, EIP, EPL, EPB,
and APL. It terminates to supply carpal joint sensation.
■ The dorsal or superficial branch of the radial nerve
courses through the forearm in relationship to the
brachioradialis muscle on the radial side of the arm.
■ It crosses the “anatomic snuffbox” between the EPB
and the EPL in the loose subcutaneous tissue and
divides into multiple branches to supply sensation to
the dorsum of the hand over the radial two-thirds, the
dorsum of the thumb, and the index, long, and half of
the ring finger proximal to the distal interphalangeal
joint.
Median nerve
• Arises from the lateral and medial cords of brachial
plexus (C5–T1) (Fig. 19.37).
• The anterior interosseous branch of the median nerve
innervates the FPL, FDP (index and middle digits), and
the pronator quadratus muscles, and provides wrist
sensation.
• Proximal to the wrist and running between the FCR and
PL tendons, the palmar cutaneous branch provides lateral
palmar sensation.
• As the median nerve passes through the carpal tunnel,
the recurrent motor branch innervates the thenar muscles
(APB, opponens pollicis, and superficial head of the FPB).
• Sensory branches supply digital nerves to the thumb,
index, and middle fingers, as well as the radial aspect of
the ring finger.
Ulnar nerve
• Arises as a branch of the medial cord of the brachial
plexus (C8–T1) (Fig. 19.38).
• Muscular branches innervate the FCU and FDP muscles
to the ring and small fingers.
• The palmar cutaneous branch of the ulnar nerve provides
sensation to hypothenar eminence and medial portion of
the palm.
• The dorsal branch of the ulnar nerve courses around the
ulnar aspect of the forearm after branching from the main
trunk at a variable site in the distal one-third of the
forearm.
• It passes from deep to the FCU out through the dorsal
fascia to supply sensation to the ulnar portion of the
dorsum of the hand, the dorsum of the little finger, and
at least part of the dorsum of the ring finger.
• The deep motor branch of the ulnar nerve passes through
the pisohamate and opponens tunnel with the deep
branch of the ulnar artery and gives off motor branches
to the four hypothenar muscles, all the interossei, the two
ulnar lumbricals, and the thumb intrinsics ulnar to the
flexor pollicis longus – the adductor pollicis brevis and
the deep head of the flexor pollicis brevis.
Further reading
Bell C. The Hand – Its Mechanism and Vital Endowments as
Evincing Design. London: William Pickering; 183.
This treatise by Sir Charles Bell is a literary classic that
should be read by any student of hand surgery and anatomy.
Berger RA. The gross and histologic anatomy of the
scapholunate interosseous ligament. J Hand Surg.
1996;21:170.
In this journal article, Dr Berger clearly describes the
unique anatomy of the scapholunate interosseous ligament.
He discusses clinical implications of the anatomy for injury
patterns and repair/reconstruction.
Bunnell S. Surgery of the Hand. Philadelphia: J.B. Lippincott;
1944.
This is the first edition of the first modern textbook in hand
surgery, written by Sterling Bunnell, widely regarded as the
father of American hand surgery.
Gelberman RH, Menon J. The vascularity of the scaphoid
bone. J Hand Surg. 1980;5:508.
The authors perform dye injection studies to determine the
vascular anatomy to the scaphoid. The relative decreased
blood flow to the proximal pole has implications for poor
healing of scaphoid fractures in this region.
Legueu F, Juvara E. Des aponèvroses de la paume de la
main. Bull Mem Soc Anat Paris. 1892;67:383.
In this original manuscript, Legueu and Juvara perform
anatomic dissections to outline the palmar aponeurosis of
the hand. The vertical fibers that bear the authors’ names are
described. These vertical fibers separate the neurovascular
and flexor tendon compartments within the palm.

©2014, Elsevier Inc. All rights reserved.
Chapter
20 
Examination of the upper extremity
Patient history
• The patient’s history can be the most important tool in
developing an accurate diagnosis and should include the
following components:
■ Patient demographics including age, occupation, hand
dominance, hobbies, and history of previous injuries or
diseases.
■ Medical history including a history of diabetes,
cardiac, pulmonary and/or renal disease or whether
the patient has a history of rheumatologic disease.
■ Current complaint including symptoms, and
ameliorating or aggravating activities or treatments.
• In trauma cases:
■ The time of the injury and the interval between the
injury and the patient’s presentation.
■ The environment in which the injury occurred.
■ The mechanism of injury.
■ Any previous treatment associated with the injury.
• In non-trauma cases:
■ The time at which symptoms began and their
subsequent progression.
■ The effects of the symptoms on the patient’s daily life,
hobby or job.
■ Are the symptoms limited to one part of the body.
■ The association between time and the intensity of
symptoms.
Physical examination of the hand
Inspection
• When inspecting the upper extremities, it is essential to
compare the affected extremity with the contralateral
This chapter was created using content from
Neligan & Chang, Plastic Surgery 3rd edition,
Volume 6, Hand and Upper Extremity, Chapter 2,
Examination of the upper extremity,
Ryosuke Kakinoki.
SYNOPSIS
■ Physical examination of the upper extremity starts with a detailed
and accurate patient history.
■ Physical examination of the upper extremity consists of inspection,
palpation, measurement of length, girth and ranges of motion,
assessment of stability, and detailed assessment of the associated
nerve and vascular systems.
■ Thorough understanding of the anatomy, physiology and
biomechanics of the upper extremity is essential to perform a
physical examination correctly and to make a correct diagnosis of
pathologic conditions of the upper extremity.
■ Examiners must master correct physical examination techniques
based on the anatomic, physiologic and biomechanical
rationale.
■ Even if a patient’s complaint focuses on only the hand, the entire
upper extremity should be examined.
■ Each technique of physical examination is based on the anatomic,
physiologic and biomechanical rationale of the musculoskeletal,
nerve or vascular systems.
■ Examiners should have their own routine protocol for examination
of the upper extremity so as not to leave a part unexamined.
■ Comparison of the affected upper extremity with the contralateral
unaffected one helps examiners identify pathologic conditions of
the affected one.
■ Imaging tools such as X-rays, CT or MRI should be used to
confirm the diagnosis drawn from the physical examinations or to
choose the most possible diagnosis among the several differential
diagnoses.

343
Physical examination of the hand
musculotendinous assessment. The following elements
should be evaluated and documented:
■ Posture.
■ Motion: To evaluate muscle function, each
muscle should be evaluated in a posture or
situation in which the cooperative muscles do not
function.
■ Power: Classified according to the Medical Research
Council scale, which ranges from zero to five (Table
20.1).
■ Grip strength is a good indicator of the global muscle
strength of the upper extremity.
extremity because the latter can be used as a normal
reference if the injury is unilateral.
• Make note of any discoloration, gross deformity,
muscular atrophy, trophic changes (e.g., increased hair
growth, abnormal perspiration), swelling, and/or
changes to skin creases.
Palpation
• Palpation is a powerful maneuver for identifying masses,
abnormal skin temperature, areas of tenderness,
crepitance, clicking or snapping and effusion.
Range of motion assessment
• Both passive and active ranges of motion should be
documented and the range of motion of both the
contralateral healthy limb and the affected limb should
be measured and compared.
• The passive range of motion is measured by holding the
patient’s structures proximal and distal to the joint in
question and then moving the joint from one limit of
motion to the other in the absence of any muscular
contraction by the patient. A limited range of passive
motion is associated with joint stiffness and soft tissue
contracture.
• The active range of motion of a joint is that which occurs
when the patient contracts his or her muscles. The active
range of motion is affected by tendon excursion, the
posture of the hand and fingers, nerve function and
muscular strength.
Stability assessment
• The tightness of the ligaments around a joint,
morphology of the surface of a joint and
musculotendinous balance around a joint are useful
indices of joint stability.
• When assessing joint stability, the biomechanical and
physiological properties of the ligaments should be taken
into consideration and the stress forces applied should be
appropriate for the ligament in question.
• The stability of ligaments is tested by holding the
portions distal and proximal to the joint and gently
moving the joint passively to stress the ligaments that
stabilize the joint. It is useful to measure the opening
angle of the affected joint under stress using X-rays and
to compare the opening angle of the affected joint with
that of the corresponding healthy joint of the opposite
hand (Fig. 20.1).
• The stability of the wrist joint is determined by the
stability of the radiocarpal, ulnocarpal, distal radioulnar
and midcarpal joints. Special tests for assessing the
stability of specific ligaments or imaging tools such as
X-rays, CT or MRI may be helpful in making a diagnosis.
Musculotendinous assessment
• The integrity of the tendon and the strength of the muscle
should be considered when conducting a
Figure 20.1  Rupture of the radial collateral ligament of the index finger PIP joint.
Measure the opening angle of the affected joint under the radial and ulnar stress
forces on X-ray films and compare the angle with that of the corresponding normal
joint of the opposite hand. (A) Affected finger; (B) normal opposite finger.
A
B

344
•
• Examination of the upper extremity
20
• The extensor pollicis longus (EPL) muscle.
■ To test the EPL, place the hand palm down on a table
with the thumb adducted. The patient is asked to lift
only the thumb off the surface of the table, keeping the
thumb adducted (Video 20.3). The taut EPL tendon is
palpable in the radiodorsal aspect of the wrist.
• The extensor digitorum communis (EDC) muscles.
■ EDC function is examined by asking the patient to lift
the MP joints of four fingers (the index to the small
finger) keeping the PIP and DIP joints flexed (Video 20.4).
• The extensor indicis proprius (EIP) muscle.
■ The EIP is functional if the patient can straighten the
index finger completely when the other fingers are
flexed in a fist.
• The extensor digiti minimi (EDM) muscle.
■ The EDM is evaluated by asking the patient to
straighten the small finger when the other fingers are
flexed into a fist.
• The extensor carpi ulnaris (ECU) muscle.
■ The ECU tendon is evaluated by asking the patient to
make a fist and to lift and deviate the wrist ulnarly.
The tendon is palpable radial to the ulnar styloid
process.
Intrinsic muscles
• The thenar muscles (APB, FPB, OP).
■ These muscles are evaluated by asking the patient to
place the dorsum of the hand flat on a table and to
raise the thumb until it is perpendicular to the palm.
The patient is then asked to resist a downward force
by the examiner on the thumb (Video 20.5).
• The adductor pollicis muscle (ADP).
■ Together with the first dorsal interosseous muscle, the
ADP approximates the thumb to the second
metacarpal.
• The interosseous and lumbrical muscles.
■ Flex the MP joints and extend the PIP and DIP joints of
the fingers.
■ Four dorsal interosseous muscles abduct the thumb
and the radial three fingers.
■ Three palmar interosseous muscles adduct the fingers.
■ The second and third dorsal interosseous muscles are
evaluated by asking the patient to place the hand flat
on a table and then to stretch the long finger upward
(i.e., to hyperextend it) and to deviate it radially and
ulnarly. Patients with ulnar nerve palsy cannot do this
because of loss of power in the interosseous muscles
(the Pitres–Testut sign).
■ The first palmar interosseous and the second dorsal
interosseous muscles are tested by the “crossed
fingers” sign. The patient is asked to cross a flexed
long finger over the index finger or to cross a flexed
index finger over the long finger when the palm and
the ring and little fingers are placed flat on a table
(Video 20.6).
• The hypothenar muscles.
■ The hypothenar muscles (ADM, FDM, ODM, palmaris
brevis) abduct the small finger, moving it away from
the other fingers.
Tests for specific muscles
Extrinsic muscles
• The flexor digitorum profundus (FDP) muscle.
■ Flexor profundus test: The patient’s hand is placed
palm upward on a table. The examiner holds the
proximal and middle phalanges of the target finger
down to keep the metacarpophalangeal (MP) and
proximal interphalangeal (PIP) joints in extension and
asks the patient to flex the distal interphalangeal (DIP)
joint. The test should be performed on each finger
(Video 20.1). The FDP muscles share a common origin,
thus holding the DIP joint of a finger in full extension
may prevent motion of all FDPs.
• The flexor digitorum superficialis (FDS) muscle.
■ Flexor sublimis test: Because each FDS tendon has its
own muscle belly, its function is independent of the
FDS of the adjacent fingers. The patient’s hand is
placed palm upward on a table. The examiner holds
the distal phalanges of all fingers down except that of
the finger to be tested to keep the MP, PIP and DIP
joints of the other fingers in full extension. The patient
is asked to flex the finger to be tested. Each finger is
tested individually (Video 20.2).
• The flexor pollicis longus (FPL) muscle.
■ The FPL can be tested by asking the patient to flex the
interphalangeal (IP) joint of the thumb.
• The extensor pollicis brevis (EPB) and the abductor
pollicis longus (APL) muscles.
■ Both tendons pass through the first dorsal component
at the wrist (the APL tendon lies radial to the EPB in
the compartment).
■ When the patient abducts the thumb maximally, the
EPB and APL tendons are palpable as taut tendons in
the radiopalmar border of the snuffbox.
• The extensor carpi radialis longus (ECRL) and brevis
(ECRB) muscles.
■ When the ECRB does not function, extension of the
wrist deviates radially because of the intact ECRL
tendon.
■ Because the extensor digitorum communis (EDC)
tendon also may function as a wrist extensor, to test
the ECRL and ECRB only, ask the patient to make a fist
and then extend the wrist, which eliminates EDC
function.
Video
20.1
Video
20.2
Video
20.3
Video
20.4
Video
20.5
Video
20.6
Table 20.1  Medical Research Council scale
Grade
Physical examination findings
0
No contraction
1
Flicker or trace contraction
2
Active movement with gravity eliminated
3
Active movement against gravity
4
Active movement against gravity and resistance
5
Normal power
Reproduced with permission from Seddon HJ. Peripheral Nerve Injuries. Medical
Research Council Special Report Series. London: 282 Her Majesty’s Stationery
Office; 1954

345
Physical examination of the hand
■ The vibrotactile test: Assesses the threshold of the
perception receptors and is performed using two
types of tuning fork (30 cycles per second (cps) and
250 cps). The vibrating forks are touched on the area
examined and recognition of vibration is recorded
(Table 20.3).
■ The cold-heat test: The perception of heat is evaluated
by touching the skin with a test tube containing water
at 40–45°C and the perception of cold is tested using a
test tube containing water at 10°C. Stimuli of the
cold–heat test are mainly sensed by free nerve endings
of the skin.
Vascular assessment
• Vascular problems are assessed according to the color,
capillary refill, pressure (turgor) and temperature of the
affected part.
• The Allen’s test is helpful for determining if there is an
intact circulatory connection between the radial and ulnar
arteries in the hand. In this test, the examiner presses
down on the radial and ulnar arteries at the wrist to
occlude them, while the patient repeatedly makes and
releases a tight fist to exsanguinate the hand. The patient
then opens the hand and the examiner releases the
pressure on one of the arteries at the wrist. If the released
artery has an intact circulatory path in the hand, the palm
and fingers should turn pink within 2-5 s. The test should
then be repeated releasing the pressure on the other
artery (see specific tests) (Video 20.10).
• To assess the circulatory connection between the radial
and ulnar palmar digital arteries, the same maneuver is
performed at the base of the fingers and thumb (digital
Allen’s test) (Video 20.11). If there is no circulatory
connection between the palmar digital arteries, pedicled
island flap harvest should be avoided.
Additional special provocative tests
for the hand
• Intrinsic tightness test (Bunnell): Assesses the contracture
of the interosseous muscles.
■ The PIP joint is more easily flexed when the MP joint
is flexed than when it is extended (0 degree extended
position) if tightness of the interosseous muscles is
present (Fig. 20.2). The test should be performed
using radial and ulnar deviation of the finger to
Nerve assessment
• Both motor and sensory nerve assessment is critical.
• When the outcome of a motor assessment does not
coincide with that of a sensory assessment, abnormal
innervation of muscles or an unusual anastomosis
between peripheral nerves should be considered.
• Martin–Gruber connection: An abnormal innervation of
the median nerve to the motor branch of the ulnar nerve
(e.g., cubital tunnel syndrome with this nerve connection
may have a sensory palsy of the ulnar nerve without a
motor palsy).
• Comprehensive sensibility evaluation includes:
■ 2 point discrimination (PD) test: Evaluates the tactile
sensation of the skin and assesses density of the
perception receptors in the skin (Merkel cells – slow-
adapting receptors). The normal distance for the
fingertips is 6 mm (Video 20.7).
■ Moving 2 PD test: Assesses the density of Meissner
corpuscles (quick-adapting receptors) (Video 20.8). The
normal distance for the fingertips is 3 mm for the
moving 2PD test.
■ The Semmes–Weinstein test: Evaluates the pressure
perception of the skin of the fingers and assesses the
threshold of the perception receptors in the skin. This
test is conducted by touching the fingers with
filaments of various diameters (Video 20.9) (Table 20.2).
Video
20.7
Video
20.8
Table 20.2  Semes–Weinstein test
Evaluator
size
Pressure
force (g)
Color
Interpretation
1.65–2.83
0.008–0.07
Green
Normal
3.32–3.61
0.16–0.4
Blue
Normal
3.84–4.31
0.6–2
Purple
Diminished light
touch sensation
4.56–4.93
4–8
Red
Diminished
protective sensation
5.07–6.45
10–180
Red
Loss of protective
sensation
6.65
300
Red
Deep pressure
sensation only
Reproduced with permission from Bell-Krotosoki J, Tomancik E. The repeatability
of testing with Semmes–Weinstein monofilaments. J Hand Surg. 1987;12A:155–
161.
Table 20.3  Specific sensory testing and main receptors
Test
Perception
Main receptor
Type of
adaptation
Evaluation of
innervation
Static 2PD
Tactile
Merkel cell
Slowly
Density
Moving 2PD
Tactile
Meissner corpuscle
Quickly
Density
Tune fork (250 cps)
Vibration
Pacinian corpuscle
Quickly
Threshold
Tune fork (30 cps)
Vibration
Meissner corpuscle
Quickly
Threshold
S–W test
Pressure
Merkel cell
Slowly
Threshold
Video
20.9
Video
20.10
Video
20.11

346
•
• Examination of the upper extremity
20
Figure 20.2  Intrinsic tightness test. If there is a tightness of the interosseous
muscles, the PIP joint can be more easily flexed when the MP joint is held flexed
than when the MP joint is extended. Top: the MP joint is extended. Bottom: the MP
joint is flexed.
A
B
Figure 20.3  Lumbrical muscle tightness test. Because the lumbrical muscle
connects the flexor digitorum profundus tendon and the radial lateral band of the
extensor tendon, the PIP and DIP joint are apt to be extended when the patient
intends to flex the finger (paradoxical movement).
A
B
distinguish between tightness of the radial and ulnar
lateral bands.
• Extrinsic tightness test: Assesses the contracture of the
extrinsic muscles.
■ In contrast to intrinsic tightness, the PIP joint is more
easily flexed when the MP joint is kept extended than
when it is flexed signifying that tightness of the
extrinsic muscles is present.
• Lumbrical muscle tightness test.
■ Because the lumbrical connects the FDP and the radial
lateral band of each extensor tendon, in lumbrical
tightness the PIP and DIP joints are extended when the
MP joint is flexed (paradoxical movement of the
finger) (Fig. 20.3).
• Scaphoid shift test (Watson): Detects loosening or
disruption of the scapholunate interosseous ligament, a
scaphoid fracture or scapholunate advanced collapse
(SLAC) arthritis.
■ When the wrist deviates radially, the scaphoid rotates
palmarly (flexes) and the palmar prominence of the
scaphoid tubercle becomes evident. However, when
the wrist deviates ulnarly, the scaphoid rotates dorsally
(extends) and the bony prominence is less evident.
■ The examiner holds the dorsum of the patient’s hand
with his or her fingers and places his or her thumb
onto the radial palmar wrist to palpate the bony
prominence of the scaphoid tubercle. When the
examiner holds the patient’s hand and deviates the
wrist radially and ulnarly, he or she will feel the
motion of the bony prominence under his or her
thumb. When the examiner feels the palmar movement
of the bony prominence of the scaphoid tubercle when
moving the patient’s wrist from the ulnar to the radial
deviation, he or she pushes dorsally up on the tubercle
against the force of the palmar movement. If
scapholunate ligament insufficiency is present, the
examiner will feel a clunk on the thumb over the distal
tubercle. If the scaphoid tubercle does not move
despite deviation of the wrist, the scaphoid may be
fractured. If pain is produced by this maneuver, a
scaphoid fracture or scapholunate arthritis is indicated
(Video 20.12).
• Finger extension test: To detect the pre-dynamic rotary
subluxation of the scaphoid (dorsal wrist syndrome).
■ When being asked to extend the DIP and PIP joints of
all fingers fully, keeping the wrist and the MP joints of
all fingers in a full-flexed position, patients with
overloaded scapholunate ligaments (pre-dynamic
rotary subluxation of the scaphoid) experience pain
around the scapholunate joint in the dorsal wrist.
• Triquetrolunate ballottement test and the lunotriquetral
shunk test: To evaluate the stability of the lunotriquetral
ligament.
■ The examiner places his or her thumb dorsally over
the triquetrum and the index finger palmarly over the
pisiform bone to keep the triquetrum–pisiform unit
between the thumb and index finger. The examiner
then places his or her opposite thumb on the dorsum
of the lunate and pushes it palmarly down. If there is
triquetrolunate ligament incompetence, the examiner
will feel palmar movement of the lunate and the
patient will complain of pain in the wrist (Fig. 20.4).
The lunotriquetral shuck test is similar to the
Video
20.12

347
Physical examination of the hand
aspect of the ulnar head and pushes dorsally upward.
This maneuver should be repeated on the healthy
wrist. If abnormal dorsal movement of the distal ulna
is felt with the thumb, insufficiency of the deep layer
of the palmar distal radioulnar ligament (palmar
portion of the triangular ligament of the TFCC) is
present. Next, the patient’s forearm is fully supinated
and the examiner places his or her thumb on the
dorsum of the distal ulna and pushes palmarly down.
If abnormal palmar movement of the distal ulna
compared with that of the opposite wrist is felt
with the thumb, insufficiency of the deep layer of
the dorsal distal radioulnar ligament (dorsal portion
of the triangular ligament of the TFCC) is present
(Fig. 20.6).
• Ulnocarpal abutment test: To evaluate TFCC injuries.
■ The examiner places a thumb on the patient’s distal
ulna and holds the patient’s hand with the remaining
four fingers. The patient’s forearm is stabilized by the
examiner’s opposite hand. The patient’s wrist is fully
deviated ulnarly and the forearm is pronated and
supinated. A patient with a TFCC injury may complain
of ulnar wrist pain and a click or pop may be felt
when the examiner’s thumb is placed on the
ulnocarpal joint (Fig. 20.7).
• Pisiformis gliding test: To evaluate arthritis in the
pisotriquetral joint.
■ The examiner palpates the pisiform and pushes it
down against the triquetrum and applies shear force
between the two bones. If there is arthritis in the
pisotriquetral joint, the patient will feel pain in the
joint during this procedure (Fig. 20.8).
• Extensor carpi ulnaris (ECU) synergy test: To detect ECU
tendinitis.
■ The patient’s forearm is held fully supinated. The
examiner asks the patient to abduct all fingers and
applies a counterforce to the index and small fingers
sufficient to prevent abduction of the index and small
fingers. A patient with ECU tendinitis will experience
pain in the sixth extensor compartment (Fig. 20.9).
triquetrolunate ballottement test. The patient is asked
to place the elbow on a table with the forearm in
neutral rotation. The examiner’s thumb is placed over
the dorsal side of the lunate just beyond the
radiolunate joint. The examiner’s opposite thumb
pushes the palmar side of the pisiformis dorsally to
load the pisotriquetral joint. In lunotriquetral ligament
incompetence, the triquetrum–pisiform unit is moved
dorsally and the patient will complain of pain in the
lunotriquetral joint (Fig. 20.5).
• Distal radioulnar joint instability test: To evaluate the
integrity of the deep layer of the dorsal or palmar distal
radioulnar ligaments.
■ The deep layers of the dorsal and palmar ligaments of
the distal radioulnar joint (DRUJ) comprise the
triangular ligament of the triangular fibrocartilage
complex (TFCC) and play a primary role to stabilize
the DRUJ. The deep dorsal ligament becomes taut
when the forearm is supinated and the deep palmar
ligament is taut when the forearm is pronated. The
deep layers of the palmar and dorsal ligaments thus
restrict dorsal and palmar shift of the ulna head,
respectively. The examiner sits opposite the patient at a
table. The patient’s elbow is flexed 90° and placed on
the table. The patient’s forearm is fully pronated and
the examiner places his or her thumb on the palmar
Figure 20.4  Triquetrolunate ballottement test.
A
B
Figure 20.5  Lunotriquetrum shuck test.

348
•
• Examination of the upper extremity
20
effect. This test is useful for distinguishing nerve palsy
from tendon laceration. Because the FPL tendon is
intact in patients with anterior interosseous syndrome,
it would show the positive dynamic tenodesis effect.
However, in patients with FPL rupture, the thumb
does not flex when the wrist is held in the extended
position (Video 20.13). This maneuver is also used to
determine the appropriate tension of transferred or
transplanted tendons.
• Milking test of the finger and thumb flexor tendons: To
evaluate the continuity and excursion of the extrinsic
flexors of the thumb and fingers. This test and the
dynamic tenodesis test are useful for distinguishing nerve
palsy from tendon rupture.
■ The patient is asked to place the dorsum of the
forearm and the hand on a table and to relax. The
examiner pushes down on the musculotendinous
junctions of the flexor tendons around the palmar
aspect of the middle forearm. If the tendons have
normal excursion and no adhesions, the fingers and
thumb flex as the forearm is pushed down (Video 20.14).
A
Radius
Push
Loosened deep dorsal radioulnar ligament
Taut deep palmar radioulnar ligament
Ulna
B
Radius
Push
Loosened deep palmar radioulnar ligament
Taut deep dorsal radioulnar ligament
Ulna
Figure 20.6  Distal radioulnar joint (DRUJ) instability test. (A) Examination for the palmar instability of the DRUJ. The examiner pushes the ulna head from the palmar side
when the forearm is pronated to examine the deep palmar distal RU ligament. The deep palmar ligament is taut in the forearm pronated. (B) Examination for the dorsal
instability of the DRUJ. The examiner pushes the ulna head from the dorsal side when the forearm is supinated to examine the deep dorsal distal RU ligament. The deep
dorsal ligament is taut in the forearm supinated.
• Midcarpal instability test: To evaluate midcarpal stability.
■ The examiner places a thumb on the dorsal midcarpal
joint and holds the patient’s affected hand with the
remaining four fingers. The patient’s forearm is
stabilized by the examiner’s opposite hand. A patient
with midcarpal instability will complain of pain in the
midcarpal joint when the wrist is deviated ulnarly or
radially. Patients with dorsal intercalary segmental
instability (DISI) often complain of pain in the
ulnodorsal portion of the midcarpal joint, and a click
or pop may be felt when the wrist is deviated ulnarly.
• Dynamic tenodesis effect: To evaluate the continuity and
mobility of the extrinsic tendons of the hand.
■ The examiner asks the patient to place an elbow flexed
at 90° on a table. If the hand is relaxed, it should flex
palmarly and the fingers and thumb should be
extended if there are no contractures of the joints and
nothing prevents the tendons from sliding in the hand
and forearm. When the patient’s wrist is held fully
extended, the thumb and fingers flex. This
phenomenon is called a positive dynamic tenodesis
Video
20.14
Video
20.13

349
Physical examination of the hand
Figure 20.7  Ulnocarpal abutment test. The wrist is subjected to ulnar deviation and axial forces with the forearm fully supinated or pronated.
Supination
Ulna deviation and axial loading
Pronation
Ulna deviation and axial loading
Figure 20.8  Pisiform gliding test.
Figure 20.9  Extensor carpi ulnaris synergy test. The patient is asked to abduct the
fingers with the forearm fully supinated. The examiner applies counterforce to the
index and little fingers.

350
•
• Examination of the upper extremity
20
keep the IP joint of the thumb extended. If the patient
has weakness of thumb adduction caused by ulnar
nerve palsy, the patient attempts to hold the paper by
flexing the thumb IP joint using the flexor pollicis
longus and (hyper)extends the thumb MP joint to
stabilize it (Jeanne’s sign). Such patients also flex the
PIP joint and hyperextend the DIP joint of the index
finger to compensate for weakness of MP joint flexion
of the index finger (Fig. 20.11).
• Jeanne’s sign: To assess the motor function of the ulnar
nerve.
■ When patients with ulnar nerve dysfunction attempt a
lateral or key pinch of the thumb, they hyperextend
the thumb MP joint, which locks it to compensate for
the lateral instability of the joint secondary to
weakness of the thumb adductors (see Fig. 20.11).
• Wartenberg’s sign: To assess the motor function of the
ulnar nerve.
■ The patient is asked to keep the fingers adducted with
the MP, PIP and DIP joints fully extended. If the
patient has motor dysfunction of the ulnar nerve, the
small finger deviates away from the ring finger
because the third palmar interosseous muscle does not
function and the extensor digiti minimi muscle
abducts the small finger (Fig. 20.12).
• Other signs associated with ulnar nerve palsy.
■ Duchenne’s sign: If the FDP muscles are functioning
and the intrinsic muscles are paralyzed (low-level
ulnar nerve palsy), the ring and little fingers show
hyperextension of the MP joint and flexion of the PIP
and DIP joints (claw finger deformity).
■ André–Thomas sign: A conscious effort to extend the
fingers by tenodesing the extensor tendons with
palmar flexion of the wrist only increases the claw
deformity.
■ Bouvier’s maneuver: When hyperextension of the MP
joint of the ring and little fingers is corrected, the
flexion of the PIP and DIP joints of the fingers is
reduced.
• Finkelstein test: To detect de Quervain’s tendinitis
(tendinitis in the first extensor compartment).
■ The patient places their hand on a table with the
thumb up. The examiner pushes down on the proximal
phalanx of the thumb. A patient with de Quervain’s
tendinitis will experience pain or discomfort in the first
extensor compartment of the wrist.
• Eichhoff test: To detect de Quervain’s tendinitis
(tendinitis in the first extensor compartment).
■ The patient is asked to hold the thumb with the four
flexed fingers of the affected hand. The hand is
deviated ulnarly by the examiner. A patient with de
Quervain’s tendinitis will experience pain or
discomfort in the first extensor compartment of the
wrist (Video 20.15).
• Tinel’s sign: To detect nerve regeneration.
■ When the examiner taps on a peripheral nerve distal to
a nerve injury such as a compression neuropathy or a
laceration, the patient will experience tingling that
radiates distally along the course of the nerve. This
phenomenon is called a Tinel’s sign. The most distal
point of the pain indicates the site at which axon
sprouting has occurred. Peripheral nerve recovery after
a nerve injury can be assessed by observing the
advancement of Tinel’s sign along the nerve
(approximately 1 mm per day of advancement).
• Phalen’s test: This test is used as a provocative test
specific to carpal tunnel syndrome.
■ With the elbow in neutral position, the patient’s wrist
is held in maximum palmar flexion for up to 2 min.
This increases pressure on the carpal tunnel and
provokes paresthesia in the area innervated by the
median nerve in patients with carpal tunnel syndrome
(Fig. 20.10). Maximum extension of the wrist also
increases pressure on the carpal tunnel. This is called
the reverse Phalen’s test.
• Froment’s test: To assess the motor function of the ulnar
nerve.
■ The patient is asked to hold a piece of paper between
the ulnar tip of the thumb and the radial tip of the
index fingers. The examiner slowly pulls the paper
away from the patient while encouraging the patient
to hold onto it. Patients with normal strength of the
first dorsal interosseous and adductor pollicis muscles
Figure 20.10  Phalen test.
Figure 20.11  Froment’s sign. A patient with left ulnar nerve palsy attempts to hold
the paper by flexing the thumb IP joint using the flexor pollicis longus and
hyperextending the thumb MP joint to stabilize it. He also demonstrates flexion of
the PIP joint and hyperextension of the DIP joint of the index finger to compensate
for weakness of MP joint flexion of the finger (Jeanne’s sign).
Video
20.15

351
Physical examination specific to the forearm
■ 20% of an axial force applied to the radius is
transferred to the ulna through the interosseous
membrane (IOM).
■ After resection of the radial head, 90% of an axial load
applied to the forearm is transferred through the IOM.
• The interosseous membrane of the forearm (IOM).
■ Divided into three portions. Each portion contains
several fibers that connect the radius and the ulna
(Fig. 20.13).
■ Distal membranous portion.
■ Dorsal oblique band (DOB): This band functions as a
stabilizer of the DRUJ, in particular by restricting a
palmar shift of the ulna in the supination position.
■ Middle ligamentous portion.
■ Central band (CB): This is the strongest fiber of the
IOM and extends from the proximal radius to the
distal ulna. When the radial head is removed, the CB
carries 71% of the overall mechanical stiffness of the
forearm.
■ Distal ligament of accessory band (DLAB).
■ Proximal ligament of accessory band (PLAB).
• Proximal membranous portion.
■ Distal oblique accessory cord (DOAC).
■ Proximal oblique cord (POC): a stabilizer of the
proximal radioulnar joint.
• Measurement of forearm rotation.
■ The patient should be seated on a chair with their
elbow joints tucked in lateral to their abdomen. The
Figure 20.12  Wartenberg’s sign. A patient with left ulnar nerve palsy demonstrates
inability to perform adduction of the left little finger when attempting to adduct all
fingers.
■ The Pitres–Testut sign: This sign reveals the function of
the second and third interosseous muscles. The patient
is asked to place their hand flat on a table and then to
stretch the long finger upward (i.e., to hyperextend it)
and to deviate it radially and ulnarly.
■ The “crossed fingers” sign: The function of the first
palmar interosseous and the second dorsal
interosseous muscles is evaluated by this sign.
The patient is asked to cross a flexed long finger
over the index finger or to cross a flexed index
finger over the long finger when the palm and the
ring and little fingers are placed flat on a table. See
the section on interosseous and lumbrical muscles
(Video 20.6).
• Moberg’s pick-up test: To generally evaluate the motor
and sensory function of the hand. This test is applied to
patients with median nerve injuries or injuries of both the
ulnar and median nerves.
■ Small items such as a button, a key and a paperclip are
placed on a cloth mat. The patient is asked to pick up
each item and put it into a small box as quickly as
possible with their eyes open and again with their eyes
closed. The times required to finish these tasks are
measured.
Physical examination specific
to the forearm
• The main functions of the forearm are to transmit force
between the elbow and hand and to enable pronation
and supination.
■ 80% of an axial load applied to the wrist is transmitted
to the radius and 20% is transmitted to the ulna.
■ 60% of the axial force is distributed to the
radiocapitellar joint and 40% to the ulnohumeral
joints.
Figure 20.13  Interosseous membrane of the forearm. DOB: dorsal oblique band;
CB: central band; DLAB: distal ligament of accessory band; PLAB: proximal
ligament of accessory band; DOAC: distal oblique accessory cord; POC: proximal
oblique cord.
Ulna
Radius
Distal membranous portion
Middle ligamentous complex
Proximal membranous portion
DOB
AB
AB
CB
Dorsal oblique
accessory cord
Proximal oblique
cord
Video
20.6

352
•
• Examination of the upper extremity
20
Physical examinations specific
to the elbow
• Landmarks of the elbow.
■ The medial epicondyle, lateral epicondyle and the tip
of the olecranon are located along a straight line
(Hüter’s line) when the elbow is extended and form an
equilateral triangle (Hüter’s triangle) when the elbow
is flexed (Fig. 20.14).
• Lateral/radial:
■ The capitellum of the humerus and the radial head are
easily palpable.
■ The extensor muscles originate from the lateral
epicondyle.
■ The radial nerve is palpable in the interface between
the BR muscle and the brachialis muscle.
• Antero-medial:
■ The cubital fossa is bordered by the BR muscle
laterally and the pronator teres muscle medially.
patient is asked to grasp a pen in each hand and to
rotate the forearm. The angle between the pen and a
line perpendicular to the floor should be measured.
• Measurement of the muscle strength of the forearm.
■ Supination: The main supinators of the forearm
are the supinator muscle and the biceps brachii
muscle. The extensor carpi radialis longus
(ECRL) and brachioradialis (BR) muscles act
as the forearm supinators when the forearm is
pronated.
■ Pronation: The main pronators are the pronator teres
and pronator quadratus (PQ) muscles. The flexor carpi
radialis and palmaris longus muscles also act as
forearm pronators. The BR muscle is a forearm
pronator when the forearm is in the supinated
position.
■ Evaluated with the elbow joint at 90° of flexion.
Pronation strength is measured by grasping the wrist
with the forearm in a neutral or supination position.
To test supination strength, the forearm should be in a
neutral or pronation position.
Figure 20.14  Bony landmarks of the elbow. The medial
epicondyle, lateral epicondyle, and tip of the olecranon locate
on a straight line when the elbow is extended and form an
equilateral triangle when the elbow is flexed.
M
M
L
L
O
O

353
Physical examination of thoracic outlet syndrome
■ Valgus instability of the elbow is evaluated with the
humerus in full external rotation while valgus stress is
applied to the joint in slight flexion (Fig. 20.17).
• Posterolateral rotatory instability (PLRI).
■ Insufficiency (loosening, rupture or laceration) of the
lateral ulnar collateral ligament causes posterolateral
instability of the elbow joint. PLRI is evaluated using
the pivot shift test maneuver (Fig. 20.18).
Physical examination of thoracic
outlet syndrome
• Thoracic outlet syndrome (TOS): refers to compression of
the neurovascular structures in the area just above the
first rib and behind the clavicle resulting in upper
extremity symptoms.
• Trauma to the neck, shoulder girdle, and upper extremity,
particularly the lower trunk and C8–T1 spinal nerves, is
thought to play an important role in developing the
symptoms of thoracic outlet syndrome.
• TOS is usually classified into two groups:
• Neurogenic group:
■ Caused by compression or irritation of the brachial
plexus trunks.
■ Comprises 90% of the TOS.
■ Divided into three types, depending on involvement of
cervical nerve roots:
■ The upper type (C5, C6, C7 spinal nerve involvement).
■ Lower type (C8, T1 spinal nerve involvement).
■ Combined type.
■ The lower and combined types comprise 85–90% of all
patients with TOS.
■ 40–50% of TOS is associated with distal compression
neuropathies.
• Vascular group:
■ Subtyped into the venous type and arterial type.
■ The venous type comprises 70–80% of the vascular
group of TOS.
■ The musculocutaneous nerve is located deep to the
brachioradialis muscle and medial to the biceps brachii
tendon.
■ The brachial artery is palpable medial to the biceps
brachii tendon.
■ The median nerve is located just medial to the brachial
artery.
■ The ulnar nerve groove is palpable between the medial
epicondyle and the ulna.
• Posterior:
■ The olecranon and olecranon fossa of the humerus are
palpated.
■ The triceps brachii tendon is attached to the olecranon.
• Lateral ligament complex: consists of the following four
ligaments (Fig. 20.15):
1. Lateral ulnar collateral ligament: functions as a
primary stabilizer of the joint when a varus stress is
applied.
2. Radial collateral ligament: located near the axis of the
elbow joint and is uniformly taut during elbow
motion.
3. Annular ligament: originates from the anterior
sigmoid notch and inserts on the posterior sigmoid
notch of the ulna to connect the radial head to the
ulna.
4. Accessory collateral ligament: supports the annular
ligament during varus stress.
• Medial collateral ligament complex: consists of three
portions: the anterior bundle, the posterior bundle and
the transverse ligament. The anterior bundle functions as
the prime stabilizer of the elbow joint against valgus
stress (Fig. 20.16).
• Instability of the elbow joint.
■ To assess collateral ligament integrity, the elbow
should be flexed by about 15°. This position relaxes the
anterior capsule and unlocks the olecranon from the
fossa.
■ Varus instability of the elbow is assessed with the
humerus in full internal rotation and varus stress is
applied to the slightly flexed joint.
Figure 20.15  Lateral complex of the elbow.
Radial collateral
ligament
Lateral ulnar collateral
ligament
Accessory collateral
ligament
Annular ligament
Figure 20.16  Medial complex of the elbow.
Anterior bundle
Posterior bundle
Transverse ligament

354
•
• Examination of the upper extremity
20
■ Symptoms include pain, swelling, distended vein, and
discoloration of the affected upper limb.
■ Compression of the subclavian vein usually occurs at
the area between the anterior scalene insertion to the
first rib and at the costcoracoid ligament and
subclavius tendon insertion of the first rib.
■ The arterial type comprises only 20–30% of the
vascular group and occurs from direct pressure of the
cervical rib, or an abnormal middle scalene muscle to
the first rib, or anomalous band-like structure under
the subclavian artery.
Important TOS anatomy
• The brachial plexus trunks and subclavian vessels are
subject to compression or irritation in thee spaces at the
thoracic outlet region:
■ Interscalene space (triangle).
■ The most important and most proximal site of
compression.
Figure 20.17  Assessment of the lateral instability of the elbow. (A) Varus
instability of the elbow is examined with the humerus in full internal rotation.
(B) Valgus instability is assessed with the humerus in full external rotation.
A
B
Figure 20.18  Pivotal shift test of the elbow.
A
Valgus
Axial compression
Supination
Subluxation
B

355
Physical examination of thoracic outlet syndrome
■ Bordered by the anterior scalene muscle anteriorly, the
middle scalene muscle posteriorly, and the medial
surface of the first rib inferiorly. This area may be
small at rest and may become even smaller with
extremity motion or anomalous anatomy.
■ Costoclavicular space.
■ Bordered anteriorly by the middle third of the clavicle,
posteromedially by the first rib, and posterolaterally by
the upper border of the scapula.
■ Subpectoralis minor space.
■ Located beneath the coracoid process just deep to the
pectoralis minor tendon (Fig. 20.19).
Provocative maneuvers
• These provocative tests should be performed on the
bilateral upper limbs and the outcomes of the involved
limb should be compared with those of the opposite one,
because the tests can be positive in a normal person.
Figure 20.19  The three spaces that potentially entrap the neurovascular bundle in patients with thoracic outlet syndrome.
Middle scalene
Long thoracic nerve
Anterior scalene
Phrenic nerve
1st rib
Costoclavicular space
Interscalene space
Subpectoral minor space
■ Adson test: Patient is asked to inhale deeply with the
chin up and tilt their neck towards the involved arm
while holding their breath. If the radial artery
pulsation disappears or is diminished, the test is
positive (Video 20.16). This test is considered sensitive
to compression in the interscalenus space (Fig. 20.20).
■ The neck tilting test: Patient is asked to inhale deeply
and tilt their neck to the opposite direction of the
involved arm while holding their breath. In patients
with TOS, this action produces arm heaviness,
numbness, and tingling in the fingers or/and arm,
with some pain.
■ The costclavicular compression test: Patient is asked to
inhale deeply and hold their breath. The examiner
depresses the patient’s shoulder of the involved limb.
Patients with TOS complain of symptoms such as
heaviness, pain, numbness or tingling in the limb, and
the pulsation of the radial artery is often diminished.
This maneuver calls attention to compression in the
costclavicular space (Fig. 20.21).
Video
20.16

356
•
• Examination of the upper extremity
20
■ Wright test: The examiner holds the patient’s
arm in 90° abduction with the elbow 90° flexed, and
rotates the arm externally. If the pulsation is
diminished and the symptoms are provoked by this
maneuver, the test is positive. Entrapment of the
neurovascular bundle at the subpectoralis minor space
or the costclavicular space can make the test positive
(Fig. 20.22).
■ Roos extended arm stress test: The patient is asked
to hold both arms with the shoulders in 90°
abduction and 90° external rotation position and
open and close the hands repetitively. If the patient
develops any fatigue, pain, numbness or tingling in
the hand or arm within 3 min, the test is positive
(Video 20.17).
■ Morley’s test: The patient complains of pain,
numbness, tingling or uncomfortable feelings when the
examiner pushes the patient’s brachial plexus in the
supraclavicular fossa.
Figure 20.20  Adson test is sensitive to entrapment of the neurovascular bundle in
the interscalene space (arrows).
Figure 20.21  The costclavicular compression test is considered to detect the
entrapment in the costclavicular space (arrow).
Figure 20.22  The neurovascular bundle can be potentially entrapped in the
costclavicular space (red arrow) and the subpectoralis minor space by the
Wright test.
Video
20.17

357
Further reading
forearm: pathomechanics of proximal migration of the
radius. J Hand Surg. 1989;14A:256–261.
When the radial head was resected, 90% of the axial load
applied to the wrist joint was transmitted to the ulna
through the interosseous membrane. The central band of the
interosseous membrane provided 71% of the overall
mechanical stiffness of the forearm.
Kleinman WB. Stability of the distal radioulnar joint:
Biomechanics, pathophysiology, physical diagnosis and
restoration of function what we have learned in 25
years. J Hand Surg. 2007;32A:1086–1106.
The author describes detailed anatomy and biomechanics of
the ulnar side of the wrist, including the TFCC. The deep
layer of the distal radioulnar ligament plays an important
role to stabilize the distal radioulnar joint. The dorsal deep
layer of the ligament becomes tight in the supinated forearm
and the palmar deep layer increases the strain in the
pronated forearm.
O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory
instability of the elbow. J Bone Joint Surg.
1991;73A:440–446.
The authors addressed grades of dislocation of the joint
caused by lateral ligament insufficiency (from instability of
the joint to complete dislocation) and described a maneuver
of the pivot shift test that was provocative of the elbow
dislocation due to the lateral ligament instability.
Ranade AV, Rai R, Prabhu LV, et al. Incidence of extensor
digitorum brevis manus muscle. Hand (NY).
2008;3:320–323.
Small vestigial extensor tendons are sometimes found in the
long and ring fingers besides the extensor digitorum
communis tendons, which are called the extensor digitorum
brevis manus. This muscle is often found as a soft tissue
mass and sometimes causes pain in the dorsum of the hand.
Watson HK, Ryu J, Akelman E. Limited triscaphoid
intercarpal arthrodesis for rotatory subluxation of the
scaphoid. J Bone Joint Surg. 1968;68:245–349.
Watson described his original maneuver of the so-called
“scaphoid test” in this article. This maneuver has been
modified by several authors and is now recognized as the
“scaphoid shift test”, which is a useful physiological
examination to identify the instability of the scapholunate
ligament complex.
Physical examination of the upper
extremity in children
• Often difficult because of communication issues.
• Physical examination should include observing the
child’s activities when he or she is held by a parent or is
playing.
• The affected limb should be examined from the tip of
fingers to the hemithorax, which should be compared
with the contralateral limb to confirm the anomaly.
• Primitive reflexes, including the Moro reflex, the systemic
tonic neck response, the mouth lip reflex, and palmar
grasp stimulation are used to assess neuromuscular
function in newborns.
Video 20.1: Flexor profundus test in a normal long finger.
Video 20.2: Flexor sublimis test in a normal long finger.
Video 20.3: Test for the extensor pollicis longus (EPL) muscle in a normal hand.
Video 20.4: Test for the extensor digitorum communis (EDC) muscle in a normal
hand.
Video 20.5: Test for assessing thenar muscle function.
Video 20.6: The “cross fingers” sign.
Video 20.7: Static two point discrimination test (s-2PD test).
Video 20.8: Moving 2PD test (m-2PD test) performed on the radial or ulnar aspect
of the finger.
Video 20.9: Semmes–Weinstein monofilament test. The patient should sense the
pressure produced by bending the filament.
Video 20.10: Allen’s test in a normal patient.
Video 20.11: Digital Allen’s test in a normal person.
Video 20.12: Scaphoid shift test.
Video 20.13: Dynamic tenodesis effect in a normal hand.
Video 20.14: The milking test of the fingers and thumb in a normal hand.
Video 20.15: Eichhoff test.
Video 20.16: Adson test.
Video 20.17: Roos test.
Further reading
Hotchkiss RN, An KN, Sowa DT, et al. An anatomic and
mechanical study of the interosseous membrane of the

©2014, Elsevier Inc. All rights reserved.
Chapter
21 
Flexor tendon injury and reconstruction
Brief introduction
• Tendons are composed of dense connective tissues that
transmit forces generated by muscles to move the joints
or to create action power. Functionally, the hand is
dependent upon the integrity and ample gliding of the
tendons.
• Difficulties in restoration of function of digital flexor
tendons relate chiefly to the intricate anatomy of flexor
tendon systems: the coexistence of superficialis and
profundus tendons within a tight fibro-osseous tunnel.
• (Box 21.1)
• Whenever possible, acutely lacerated flexor tendons in
the hand and forearm should be treated primarily or at
the delayed primary stage.
■ Primary tendon repair is the end-to-end repair
performed immediately after wound cleaning and
debridement, usually within 24 h of trauma.
■ Delayed primary repair is defined as repair performed
within 3 or even 4 weeks after tendon lacerations.
■ The tendon injured in critical areas (such as zone 2)
should not be repaired by an inexperienced surgeon.
This chapter was created using content from Neligan
& Chang, Plastic Surgery 3rd edition, Volume 6,
Hand and Upper Extremity, Chapter 9, Flexor
tendon injury and reconstruction, Jin Bo Tang.
SYNOPSIS
■ Tendons transmit forces generated by muscles to move joints or
to create action power. Flexor tendon injuries are common, but
recovery of satisfactory function, particularly after injuries within
the digital sheath, is sometimes difficult. Lacerated flexor tendons
should be treated by primary surgical repair whenever possible.
■ The current trend of end-to-end surgical tendon repairs is to use
multistrand core sutures (four-strand repairs such as cruciate,
double-Tsuge, Strickland, modified Savage, or six-strand repairs
such as modified Savage, Tang).
■ In tendon repairs in the digital sheath area, a number of surgeons
advocate that the A2 pulley can be released up to two-thirds of its
length, and the A4 pulley can be entirely released when necessary
and tendon repair is in the proximity of the pulley, given the
integrity of the other pulleys. The release may reduce the
resistance to tendon motion and the chance of repair ruptures.
This technique is somewhat controversial.
■ Postoperatively, early tendon mobilization should always be
employed, except in children or in some rare instances; motion
protocols vary greatly among different treatment centers.
■ Repair ruptures, adhesion formations, and finger joint stiffness are
major complications of primary surgery.
■ Combined use of multistrand core repairs, release of constricting
pulley parts, and well-designed postoperative combined passive
and active motion protocols – that do not overload, but sufficiently
move the tendon – can help minimize adhesions, avoid repair
ruptures, and restore optimal function.
■ Secondary surgeries include tenolysis, free tendon grafting, and
staged tendon reconstruction. Tenolysis is indicated when
restricting adhesions hamper tendon gliding and soft tissues and
joint conditions of the hand are favorable. Free tendon grafting is
a salvage operation for failed primary repairs, delayed treatment
(>1 month) of an acute cut, or lengthy tendon defects. Staged
reconstruction is indicated in cases of extensive scar formation or
multiple failed surgeries. Preservation or reconstruction of major
annular pulleys is vital to restoring function of the digits during
these secondary surgeries.
■ Closed ruptures of flexor tendons usually require surgical repairs.
■ The success of flexor tendon surgeries is very expertise-
dependent. A thorough mastery of anatomy and meticulous
surgical techniques are requirements for satisfactory restoration of
function.

359
Preoperative considerations
of obvious retraction of the tendon end or extensive
scarring in the intact flexor digitorum superficialis (FDS)
tendon when the the flexor digitorum profundus (FDP)
tendon ruptures.
• Traumatic FDP tendon avulsion from the tendon–bone
junction accounts for a major portion of closed rupture
cases. The tendon disrupts at its insertion to the distal
phalanx.
■ The injury mechanism is hyperextension of the distal
interphalangeal (DIP) joint, which subjects the FDP
tendon to excessive load.
■ Athletic injuries can lead to this type of injury. When
one player grabs another’s jersey, a finger may be
caught and pulled, resulting in disruption of flexor
tendons. This injury (“jersey finger”) is seen most
commonly in the ring finger.
• Closed tendon ruptures at the wrist can be associated
with fractures in carpal bones.
• Flexor pulleys are prone to sprains and ruptures during
climbing. Rupture of the pulleys occurs in up to 20% of
climbers. The A2 pulley of the ring finger is the most
often injured. Closed pulley ruptures are treated
conservatively or by surgical reconstruction.
• Closed tendon ruptures can be classified into the
following types:
■ Class I: the FDP tendon is avulsed from the phalanx
and retracts into the palm. The vincula of the FDP
tendon are disrupted. There is no active flexion of the
DIP joint. A tender mass is present in the palm.
■ Class II: the FDP tendon retracts to the level of the
proximal interphalangeal (PIP) joint. This is the most
common type. The sheath is not compromised, and
muscle contracture does not develop easily.
■ Class III: a large bone fragment is attached to the FDP
tendon. This bone fragment frequently prevents the
tendon from retracting proximal to the A4 pulley.
■ Class IV: the FDP tendon avulses from the bony
fragment and retracts beyond the middle phalanx and
even into the palm.
• Early recognition of closed tendon ruptures is of
paramount importance. In cases where there is late
diagnosis, primary repair is difficult or even impossible.
Chronic cases require free tendon grafting.
• Tendon grafting is indicated: (1) when the lacerated
tendons are not treated during primary or delayed
primary stage; (2) when the primary repairs have
ruptured and cannot be re-repaired directly; and (3) in
the cases not indicative of primary tendon repairs
because of severe contamination, infection, lengthy loss
of tendon substance, extensive destruction of the pulleys,
or accompanying injuries.
Preoperative considerations
• Flexor tendon injuries are open in most cases, resulting
from a sharp cut or a crush, but they can also present as
closed injuries.
■ Open injuries due to extensive trauma are frequently
associated with neurovascular deficits.
Rather, tendon repair can be delayed until an
experienced surgeon is available.
■ My preferred period of deliberate delay is 4–7 days,
when the risk of infection can be properly addressed
and edema has reduced substantially.
■ Delay of the repair beyond 3–4 weeks may cause
myostatic shortening of the muscle–tendon unit; for
these late cases, lengthening the tendon within the
muscles in the forearm can ease the tension (Fig. 21.1).
• Rupture of the repaired flexor tendons after surgery can
be re-repaired if the rupture occurs within a few weeks
up to a month after surgery; secondary tendon grafts
may be the only choice for ruptured cases in the presence
Figure 21.1  A decision-making flow chart of primary and delayed primary flexor
tendon repairs.
In making a decision of primary repair, consider:
• General conditions of the patient
• Availability of an experienced surgeon
Perform delayed primary repair after
wound infection controlled, edema
subsided and an experienced
surgeon available
Delayed repair with
difficulty, may need to
release muscle tension
Primary
repair
< 1day
Delayed primary repair
3 weeks
1 month
Tendon
trauma
Day 0
Ideal within 2–3 weeks, possible at 1 month or even later
BOX 21.1  General tips for surgeons of flexor tendon repairs
• Repairing flexor tendons requires meticulous surgery built upon
a thorough master of anatomy and biomechanics of the flexor
tendon system. Surgeons should know the anatomy in detail,
including the length of major pulleys, characteristic changes in
the diameter of the sheath, and tendon gliding amplitude
• Primary repairs should be performed by experienced surgeons
whenever possible, or if a less experienced surgeon has to be
the operator, before surgery the surgeon must review the
anatomy of the flexor tendon system, and understand every
detail of the requirements of an optimal tendon repair
• The mastery of atraumatic techniques is essential for the
operator. The outcome of the repair is very expertise-
dependent : repair of tendons by an inexperienced surgeon is a
frequent cause of tendon adhesions and poor function, thus
should be avoided
• Conventional two-strand repairs are weak; stronger surgical
repairs are preferable
• Complete closure of the tendon sheath is not a necessity.
Venting of a part of sheath (<2.0 cm), including a critical portion
of the pulleys, provides easy access to injured tendons, and
may decrease resistance to tendon gliding after surgery; this
procedure does not lead to loss of digital function, when other
sheath parts are intact
• Surgeons should emphasize strengthening suture techniques
and decreasing compression to the tendons, which facilitate
increases in safety and expertise in hand therapy

360
•
• Flexor tendon injury and reconstruction
21
• Primary or delayed primary end-to-end tendon repairs
are mainly indicated in clean-cut tendon injuries with
limited damage to peritendinous tissues.
• Serious crush injuries, severe wound contamination, loss
of extensive soft tissues, or extensive destruction of
pulleys and tendon structures are contraindications for
primary tendon repairs.
• Fractures involving multiple bones, particularly at
different levels or not yielding stable internal fixation, are
contraindications for primary tendon repairs (Box 21.2).
• Flexor tendon repairs in children have a better prognosis
than those in adults. As children may be less compliant
with instructions to limit movement, the repaired digits
are usually immobilized for 3–3.5 weeks after surgery.
Either a two-strand or a four-strand repair can be used.
Anatomical/technical pearls
• There are 12 flexor tendons in the hand and forearm
regions including finger and thumb flexors and wrist
flexors.
■ Finger flexor tendons are: the flexor digitorum
superficialis (FDS), the flexor digitorum profundus
(FDP), and the flexor pollicis longus (FPL).
■ The FDS and FDP originate from muscles at about the
midforearm, while the FPL tendon arises from the
volar aspect of the midportion of the radial shaft and
from its adjacent interosseous membrane.
■ The tendons of the FDP come from a common muscle
belly while the tendons of the FDS originate from
separate muscle bellies, which allows more
independent finger flexion.
■ The wrist flexors are: the flexor carpi radialis (FCR)
and ulnaris, and the palmaris longus.
■ The PL is absent in about 15–20% of the normal
population and wrist flexion power is not affected by
its absence.
• Within the carpal tunnel, nine tendons exist – four FDS,
four FDP, and one FPL.
■ The relationship of these tendons within the carpal
tunnel is fairly constant.
■ Closed injuries often relate to forced extension during
active flexion of the finger.
■ Flexor tendon rupture can also occur as a result of
chronic attrition in rheumatoid disease, Kienbock
disease, scaphoid nonunion, or hamate or distal radius
fracture.
• Careful attention to the patient’s history and the
mechanism of injury can alert the surgeon to the extent of
the tendon trauma and associated injuries.
• The natural resting posture of the wounded digits is
important for evaluation.
■ Complete lacerations of both FDP and FDS tendons are
easily diagnosed when the affected fingers are seen in
a relatively extended position with loss of active finger
flexion at PIP and DIP joints.
■ If the patient can actively flex the DIP joint while
the motion of the PIP joint is blocked, no injuries
or only partial injuries to the FDP tendon can be
diagnosed.
■ To assess the continuity of the FDS tendon, the
adjacent fingers are held in full extension by the
examiner. If the patient cannot actively flex the PIP
joint, the FDS tendon is completely severed.
■ Variations in the FDS tendons in the little finger are
frequent. The FDS in 30–35% of the little fingers is
connected with the FDS in the ring or middle fingers.
Some little fingers (10–15%) are missing an FDS
tendon. These patients have limited or no PIP flexion
of the little finger during testing.
■ Weakness during resisted finger flexion indicates a
possible partial tendon cut.
■ To test the FPL tendon, the thumb
metacarpophalangeal joint (MCP) is stabilized in a
neutral position. The patient is asked to flex the IP
joint. Loss of active flexion at the joint indicates
complete severance of the FPL tendon.
• Nerve and vascular function should be assessed
routinely, because accompanying injuries in the
neurovascular bundles in one or both sides of the fingers
or median and ulnar nerves at the carpal tunnel or distal
forearm are common.
■ Loss of sensation in the finger pulps or loss of function
of intrinsic muscles in the hand is indicative of such
accompanying injuries; treatment of neurovascular
injuries must be included when planning surgical
strategies.
■ If fingers or hands are found to be hypovascular
or avascular due to vascular lacerations,
vascular anastomosis should be a surgical
emergency.
■ Otherwise, after wound debridement, either the
lacerated flexor tendons can be repaired (when
experienced surgeons are readily available) or the skin
can be closed to allow for delayed primary repairs
within days by experienced surgeons.
• Radiographs should always be taken. Associated
fractures are not infrequent and require treatment.
• CT or MRI should be prescribed for the cases suspicious
of closed tendon ruptures. Ultrasonographic examination
may also reveal rupture of the tendons.
BOX 21.2  Primary flexor tendon repairs
Indications
• Clean-cut tendon injuries
• Tendon cut with limited peritendinous damage, no defects in
soft tissue coverage
• Regional loss of soft tissue coverage or fractures of phalangeal
shafts are borderline indications
• Within several days or at most 3 or 4 weeks after tendon
laceration
Contraindications
• Severe wound contamination
• Bony injuries involving joint components or extensive soft tissue
loss
• Destruction of a series of annular pulleys and lengthy tendon
defects
• Experienced surgeons are not available

361
Anatomical/technical pearls
■ The FDS tendons to the ring and middle fingers lie
superficially, deeper are the FDS tendon to the index
and small fingers, and deeper still are the FDP
tendons.
■ The FPL tendon is located deep and radially adjacent
to the scaphoid and the trapezium.
■ After emerging from the carpal tunnel, the tendons
enter the palm. At about the level of the superficial
palmar artery arch, the lumbrical tendons originate
from the FDP tendons.
• The most intricate portions of the flexor tendons are
within the fingers, where the tendons glide within a
closed fibro-osseous sheath with segmental, semirigid,
constrictive dense connective tissue bands present.
■ The digital sheath forms a closed synovial
compartment extending from the distal palm to the
middle of the distal phalange.
■ The FDS tendons lie superficial to the FDP tendons up
to the bifurcation of the FDS tendon at the level of the
MCP. There, in the A2 pulley area, the FDS tendons
become two slips coursing laterally and then deeper to
the FDP tendons.
■ Now deep to the FDP tendon, the FDS slips rejoin
to form Camper’s chiasm (a fibrous interweaved
connection between two FDS slips), and distally insert
on the proximal and middle parts of the middle
phalanx as two separate slips.
■ The FDP tendon inserts into the volar aspect of the
distal phalanx.
■ The FPL tendon is the only tendon inside the flexor
sheath of the thumb and inserts at the distal phalanx.
• The synovial sheath is a thin layer of continuous smooth
paratenon covering the inner surface of the fibrous
sheath, providing a smooth surface for tendon gliding
and nutrition to the tendons.
• The pulley system of the digital flexor tendon is unique;
it consists of annular pulleys (condensed, rigid, and
heavier annular bands) and cruciate pulleys (filmy
cruciform bands) (Fig. 21.2). The annular pulleys
maintain the anatomical paths of tendons close to bones
and phalangeal joints, thus optimizing the mechanical
efficiency of digital flexion. The more compressible
cruciate pulleys allow for digital flexion to occur with
condensation of the fibro-osseous sheath at the inner part
of flexed fingers.
■ There are five annular pulleys (A1–A5), three cruciate
pulleys (C1–C3), and one palmar aponeurosis pulley.
■ The A1, A3, and A5 pulleys originate from the palmar
plates of the MCP, proximal (PIP) and distal
interphalangeal (DIP) joints, and the A2 and A4
pulleys originate from the middle portion of the
proximal and middle phalanges respectively.
■ The broadest annular pulley is the A2 pulley, which
covers the proximal two-thirds of the proximal
phalanx and encompasses the bifurcation of the FDS
tendon at its middle part.
■ The A4 pulley is located at the middle third of the
middle phalanx.
■ The A2 and A4 pulleys are the largest among
five annular pulleys and have the most important
function.
Figure 21.2  Annular pulleys (condensed, rigid, and heavier annular bands) and
cruciate pulleys (filmy cruciform bands) are present in the fingers. There are five
annular pulleys (A1–A5), three cruciate pulleys (C1–C3), and one palmar
aponeurosis pulley.
A5
A4
A3
A2
A1
Transverse metacarpal ligament
Vertical septa
Palmar
aponeurosis
C3
C2
C1
• In the thumb, there are three pulleys (A1, oblique, and
A2) with no cruciate pulleys (Fig. 21.3).
■ The A1 and oblique pulleys are functionally
important.
■ The A1 pulley is located palmar to the MCP joint while
the oblique pulley spans the middle and distal parts of
the proximal phalanx.
■ The A2 pulley is near the site of insertion of the FPL
tendon.
• The FDP tendon has two vincula: a fan-like short
vinculum and a cord-like long vinculum. The short
vinculum is located at the insertion of the FDP tendon
(Fig. 21.4). The long vinculum connects the FDP tendon
through the short vinculum of the FDS tendon to the
floor of the palmar surface of the phalanges.
• The FDS tendon also has two vincula: one connecting to
the proximal phalanx, and another at the insertion of the
FDS tendon.
• Vincula carry blood vessels to the dorsum of these
tendons, providing limited nutrition. Tendon insertion

362
•
• Flexor tendon injury and reconstruction
21
Figure 21.4  Insertions and relative positions of the flexor digitorum superficialis
(FDS) and flexor digitorum profundus (FDP) tendons and vincula. Each of the FDS
and FDP tendons has two vincula, one short and one long. The relations of the FDS
and FDP tendons are complex in the middle part of the proximal phalanx under the
A2 pulley (zone 2C).
IID
IIC
IIB
FDP tendon
Vinculum longus
FDS tendon
Vinicula brevia
Vinculum brevia
Vinculum longus
A
B
Figure 21.5  Division of the flexor tendons into five zones according to anatomical
structures of the flexor tendons, presence of the synovial sheath, and the transverse
carpal ligament.
1
1
2
2
3
3
4
5
Figure 21.3  Locations of flexor pulleys of the thumb. There are three pulleys in the
thumb: A1, oblique, and A2 pulley, from distal to proximal.
A2
A1
Oblique pulley
Abductor pollicis
Flexor (deep head)
sites to bones also carry vessels into tendons over a very
short distance.
• According to anatomical features, the flexor tendons in
the hand and forearm are divided into five zones, which
offer the fundamental nomenclature for flexor tendon
anatomy and surgical repairs (Figs 21.5, 21.6):
■ Zone 1: from the insertion of the FDS tendon to the
terminal insertion of the FDP tendon.
■ Zone 2: from the proximal reflection of the digital
synovial sheath to the FDS insertion.
■ Zone 3: from the distal margin of the transverse carpal
ligament to the digital synovial sheath.
■ Zone 4: area covered by the transverse carpal ligament.
■ Zone 5: proximal to the transverse carpal ligament.
• In the thumb, zone 1 is distal to the interphalangeal (IP)
joint, zone 2 is from the IP joint to the A1 pulley, and
zone 3 is the area of the thenar eminance.
Flexor tendon healing
• Flexor tendons derive nutrition from both synovial and
vascular sources. Tendons outside the synovial sheath are
supplied with a segmental vascular network through
paratenon; however, the tendons within the synovial
sheath are mostly deprived of a vascular network with
only limited dorsal regions around the vincular insertions
being vascularized.

363
Anatomical/technical pearls
• Intrasynovial flexor tendons can heal through two
mechanisms – intrinsic and extrinsic.
■ Intrinsic healing takes place through the proliferation
of tenocytes and production of extracellular matrix by
intrinsic cells.
■ Intrinsic healing capacity is innately weak and healing
exclusively through this mechanism does not occur
in vivo.
■ Extrinsic healing is through the growth of tissues or
cells seeding from outside the tendon.
■ Extrinsic healing becomes dominant when intrinsic
healing capacity is disabled (such as in the case of
severe trauma to the tendon or peritendinous tissues)
or under conditions (such as postsurgical
immobilization) favoring extrinsic healing.
■ Extrinsic healing may act on the tendon-healing
process either by forming adhesions or seeding the
extrinsic cells without adhesions to the laceration site.
■ Clinically, the lacerated tendon heals through a
combination of both intrinsic and extrinsic
mechanisms, whose balance depends upon the
condition of the tendon and surrounding tissues.
• The following five variants (grades) of adhesions and
their effects on tendon motion are seen clinically:
1. No adhesions; no effect on motion.
2. Filmy adhesions: formation of visible, filmy, and
membranous tissue from tendon to outside tissues;
no effect on motion.
Figure 21.6  Subdivisions of zones 1 and 2 of flexor
tendons in the fingers and their relations to the flexor
pulleys.
Subdivision of zone 1
(Moiemen and Elliot)
Subdivision of zone 2
(Tang)
1A
2A
2B
2C
2D
1B
1C
3. Loose adhesions: loose and largely movable; mildly
affects motion.
4. Moderately dense adhesions: of limited mobility;
dramatically affects motion.
5. Dense adhesions: dense, almost immovable, and
invading deep into the tendon; dramatically affects
motion.
• The most effective methods to prevent adhesions in clinic
are meticulous surgery and early postoperative motion;
the prime cause of adhesions is tendon repair by
inexperienced surgeons.
Biomechanics of tendon repair and gliding
• Many factors affect the strength of a surgical repair (Fig.
21.7): (1) the number of suture strands across the repair
sites – strength is roughly proportional to the number of
core sutures; (2) the tension of repairs – this is most
relevant to gap formation and stiffness of repairs; (3) the
core suture purchase; (4) the types of tendon–suture
junction – locking or grasping; (5) the diameter of suture
locks in the tendons – a small-diameter lock diminishes
anchor power; (6) the suture caliber (diameter); (7) the
material properties of suture materials; (8) the peripheral
sutures; (9) the curvature of tendon gliding paths – the
repair strength decreases as tendon curvature increases;
and (10) above all, the holding capacity of a tendon,
Figure 21.7  Factors affecting the surgical repair strength of the
tendon.
Strands: 2, 4, 6 or 8
Suture purchase length
Tension of repair
Suture caliber
Locking or grasping anchor
A Core suture
Holding capacity of tendon
tissue (degrees of trauma
and softening of tendon)
E
Number of runs
Suture purchase
Caliber and tension
B Peripheral suture
Material properties
of sutures
C
Curvature of the
gliding path
D
Repair strength
Factors affecting surgical repair strength

364
•
• Flexor tendon injury and reconstruction
21
edges; (7) postsurgical extensor tethering and joint
stiffness that burden the movement of the flexor tendon;
and (8) adhesions that restrict tendon gliding.
• Biological healing strength is a central issue underlying
all tendon repairs. After tendon repair, studies have
demonstrated that the strength either remained consistent
or actually decreased somewhat over the initial few
weeks after surgery.
■ Decreases in strength, typically those in the second
postsurgical week, are thought to be caused by
softening of the tendon stumps, which lower the
sutures’ holding power.
■ Animal models have demonstrated that the strength of
a healing tendon is steady during the initial 4 weeks,
followed by a substantial increase (greater than
threefold) in the fifth and sixth weeks; thereafter, the
tendon heals strongly and is difficult to disrupt.
■ The fifth and sixth weeks after surgery appear crucial
to regaining strength.
Operative techniques
• Brachial plexus block is usually sufficient; general
anesthesia can also be used when associated injuries are
severe.
• The tendons are exposed through zigzag skin incisions on
the volar side of the fingers, e.g., Bruner’s incision, or a
lateral incision. When the wounds are in the palm or
forearm, incision by extending the wound opening is
often necessary (Fig. 21.9).
affected by varying degrees of trauma and posttraumatic
tissue softening, plays a vital role in repair strength.
• To achieve an optimal surgical repair, the factors outlined
above must be considered and incorporated into repair
design.
■ A core suture purchase of at least 0.7–1.0 cm is
necessary to generate maximal holding power.
■ A locking tendon–suture junction is generally better
than a grasping junction in terms of holding power
(Fig. 21.8).
• Clinically, the caliber of suture used in adults is either 3-0
or 4-0; sutures of 2-0 or greater are too large and rigid in
the hand.
• Annular pulleys are critical to the function of the digital
flexor tendons. Lengthy loss of the sheath and pulleys
causes anterior displacement – bowstringing – of the
flexor tendon during finger flexion.
■ In fingers, the A2 and A4 pulleys are most critically
located and functionally important.
■ Preservation or reconstruction of the two pulleys is
necessary in the absence of other pulleys or sheath.
■ Nevertheless, given the presence of other pulleys and
sheaths, the loss of any individual pulleys, including
the A2 or A4 pulley, appears to result in few
detrimental consequences.
■ Incision of the A2 pulley up to one-half or two-thirds
of its length or of the entire A4 pulley has been shown
to result in no tendon bowstringing and little loss of
digital flexion.
• Flexor tendons in the digits glide in a fairly resistance-
free synovial environment. Resistance to tendon motion is
increased when the tendons are injured and repaired. The
following create resistance to tendon gliding: (1) rough
tendon gliding surface; (2) biological reactions of the
wound, e.g., subcutaneous and tendon edema; (3) friction
caused by exposure of suture materials; (4) increases in
tendon bulkiness due to placement of sutures; (5) tight
closure of sheath or pulleys that narrows the tendon
gliding tunnel; (6) tendon-catching at pulley or sheath
Figure 21.8  Different tendon–suture junctions in tendon repairs: locking and
grasping junctions.
Cross-lock (embeded)
Cross-lock (exposed)
Circle-lock
Loop-lock
Pennington-lock
Grasp (non-lock)
Figure 21.9  Skin incisions utilized to approach the tendons in the digits and
palms.

365
Operative techniques
out through the nail, and tied over a button above
the nail.
• Injuries more proximal in this zone, usually create tendon
stumps of sufficient length (~1 cm) for a direct surgical
repair, which can be treated by methods similar to
treatment in zone 2.
■ Core tendon sutures, such as the modified Kessler,
cruciate, modified Becker, or double Kessler repair, can
be placed to the proximal end through a window
opening in the proximal sheath.
Zone 1 injuries
• In this area, only the FDP tendon is located.
• When the tendon laceration is in the distal part of this
zone, the distal stump is usually too short for direct
end-to-end repair. In this instance, the proximal tendon
end can be sutured with Bunnell or modified Becker
suture with 3-0 polypropylene, and an osteoperiosteal
flap is raised at the base of the distal phalanx (Fig. 21.10).
The suture is led through an oblique drill hole, brought
Figure 21.10  Methods of making a tendon-to-bone junction in zone 1. (A) A conventional method of anchoring the flexor digitorum profundus (FDP) tendon to the bone by
pull-out sutures through the nail tied over a button. Alternative ways to anchor the distal tendon stump to the bone by: (B) directly suturing the stump to residual FDP
tendon, (C) looping the tendon through the bone, (D) pull-out suture over the fingertip, (E) mini-anchors, and (F) looping the sutures through a transverse hole in the bone
(F).
A
B
C
D
E
F
Mini anchors
Sutures
FDP tendon
Button

366
•
• Flexor tendon injury and reconstruction
21
Figure 21.11  Summary of methods used to make core sutures in flexor tendon repairs.
B
A
D
C
F
E
H
G
J
I
Bunnell
Tsuge
Cruciate
4-strand Savage
Tang or 6-strand Tsuge
Modified Kessler
Double Kessler
Indiana or 4-strand Strickland
Modified Becker
Modified Savage
■ The proximal end is brought underneath the intact
sheath between the wound and the proximal opening
to approximate the distal end.
Zone 2 injuries (Video 21.1)
• Tendon injuries in this area are often exposed through a
Bruner skin incision and a window opening in the
synovial sheath, a release, or local excision of a short part
of the annular pulleys.
• If the tendon ends have not retracted far proximally,
flexion of the MCP or PIP joint can effectively bring the
proximal end into sight.
■ Sometimes the proximal tendon end is found retracted
even to the middle of the palm. In this instance, an
additional incision is made in the palm to expose the
tendons, and the proximal tendon end is pulled
distally within the synovial sheath by loosely suturing
the tendon to a catheter.
■ The end is brought out of the distal opening in the
sheath to approximate the distal end. While the finger
is held in slight flexion, a 25 G needle is then inserted
at the base of the finger through the proximal tendon
to hold the tendon temporarily and to release the
tension at the surgical suture site.
• Stronger suture materials are preferred: 3-0 or 4-0 sutures
(nylon or coated nylon) are common choices.
• Basic requirements of a tendon repair are: (1) sufficient
strength; (2) smooth tendon gliding surface, with minimal
suture (and knot) exposure; (3) prevent gapping of the
repair site under tension; and (4) easy to perform.
• Surgical suture techniques vary among surgeons. Some
core suture methods are shown in (Figure 21.11). The
modified Kessler and cruciate techniques are further
shown in (Figures 21.12–21.14).
• Epitendinous stitches smooth the approximation of the
tendon ends and resist gapping during tendon
movement.
• Simple running peripheral, locking running peripheral,
cross-stitch peripheral, and Halsted horizontal mattress
sutures are among those most often used, with the first
two more popular (Fig. 21.15). My preference is to use a
simple running peripheral suture with 6-0 nylon after
completion of a four- or six-strand core suture repair.
Video
21.1

367
Operative techniques
Figure 21.12  Two common techniques in flexor tendon repairs: (A) modified Kessler method; and (B) cruciate method.
A
B
i
ii
iii
i
ii
iii
• Technically, to make an optimal surgical repair, the length
of core suture purchase in each tendon end should be at
least 7 mm to 1 cm as surgical repair strength decreases
as the length of the suture purchase decreases (Fig. 21.16).
• After completing the repair, the cut tendon ends should
align well, and no gapping between the tendon ends
should be observed (Box 21.3).
• Closure of the synovial sheath is no longer considered
essential for tendon repairs after hot debate in the 1980s
and early 1990s. Closure may be attempted in clean-cut
injury when sheath defects or abrasions are absent. It is
now agreed that avoiding compression or constriction to
the edematous tendons by the sheath or annular pulleys
after surgery is very important to tendon healing.
• With major pulleys and a majority of the sheath intact,
leaving a part of the synovial sheath open has no
significant adverse effect on tendon function and healing.
On the other hand, incision of one single annular pulley
(A1, A3, or A4) or a critical part (up to two-thirds of its
length) of the A2 pulley does not significantly affect
tendon gliding when all other pulleys or the synovial
sheath are intact. Such a release can in fact be beneficial
to tendon healing and gliding: as healing responses and
adhesions arise, it releases constrictions on edematous
tendons.
• Contrary to the practice of 10 or 20 years ago, releasing
the A4 pulley entirely and releasing a part of the A2
has become accepted clinical practice in recent years
(Fig. 21.17).
• Whether or how to repair the FDS tendon when
both flexor tendons are injured is a subject of diverse
opinions, particularly in the areas covered by the
A2 pulley or distal to it. A few reports have discussed
it specifically. Repair of one slip of the FDS is also
feasible.
• Surgical options currently advised to deal with tendons
and pulleys in the most complex areas of finger flexor
tendons are summarized in Table 21.1.
Zone 3, 4, and 5 injuries
• The repair techniques for injured flexor tendons proximal
to zone 2 are almost identical to those used in zone 2.
These zones have a better prognosis because of richer
vascularity around the tendon and lack of constricting
pulleys over the tendons. Adhesions in these areas are
less likely to impede tendon motion.
• Zone 4 tendon injuries are frequently accompanied by
lacerations in the median nerve and arteries. The
transverse carpal ligament may be partly opened to
facilitate repairs and left partly open after tendon
repairs.
• In most cases zone 5 tendon injuries are presented as
multiple tendon lacerations with neurovascular injury.
• A wrist with transection of a majority of tendons, vessels,
and nerves (at least 10 out of 15 of these structures,
excluding palmaris longus) is called a “spaghetti” wrist.
A “spaghetti” wrist was reported to have an adverse
effect on the recovery of the independent FDS action but
not on the recovery of the digital range of motion.
BOX 21.3  Recommended surgical tendon repairs
• More than two strands as the core repair – four or six strands are
recommended
• Certain tension across the repair site – 10% shortening of tendon
segment after repair
• Core suture purchase: 7–10 cm
• Locking tendon–suture junctions in core suture
• Diameter of the locks: 2 mm or over
• Suture calibers: 3-0 or 4-0 for core suture
• A variety of nylon sutures, or a FiberWire suture
• A simple running or locking peripheral suture
• No peripheral suture if core repair is very strong
• Avoid extensive exposure of sutures over the tendon surface

368
•
• Flexor tendon injury and reconstruction
21
■ If the proximal stump of the FPL tendon has retracted
proximal to the thenar muscles, a separate incision in
the forearm is required to locate the stump. The FPL
stump usually lies deep to the FCR tendon and the
radial artery.
Partial tendon lacerations
• Laceration through less than 60% of the diameter of the
tendon does not necessitate a repair by core sutures.
■ For lacerations less than 60%, the tendon wound
can be trimmed to lessen the chance of entrapment
by pulley edges and friction against the sheath.
Alternatively, the cut portion of the tendon can be
repaired with epitendinous stitches to smooth the
tendon surface and to strengthen the tendon.
• An increased risk of triggering, entrapment, or ruptures
is associated with partial laceration over 60%.
■ Laceration of 60–80% requires at least an epitendinous
repair and is better repaired using a two-strand core
suture through the cut portion.
■ Laceration of 80–90% is treated identically to a
complete laceration.
Closed tendon rupture
• Class I: the FDP tendon is avulsed from the phalanx and
retracts into the palm.
■ The tendon should be reinserted within 7–10 days
before the sheath collapses, which may prevent
advancing the tendon distally. Muscle contracture may
also prevent tendon advancement.
• Class II: the FDP tendon retracts to the level of the PIP
joint.
■ Repair may be attempted 1 month after injury.
• Class III: a large bone fragment is attached to the FDP
tendon.
■ Bony fixation using a K-wire or a screw usually
suffices.
• Class IV: the FDP tendon avulses from the bony
fragment.
■ The bony fragment is attached into the distal phalanx
first
■ The avulsed tendon is advanced.
■ The DIP joint is immobilized for 4–5 weeks, or a gentle
motion regimen is prescribed.
Postoperative considerations
• With the exception of a few instances – such as tendon
repairs in children, adults who are unable to follow
through the protocol, or associated with fractures
or particular health conditions – motion of repaired
tendons should be initiated from the early postsurgical
period.
• Several postoperative motion protocols have been
described.
• In zone 5, repair of the FDS tendon is preferred, and early
postoperative tendon motion is advised. This favors
independent movement of the superficialis.
FPL injuries
• Repair of the injured FPL tendons in the thumb usually
follows the same principles and methods of repair of the
FDP tendon in fingers.
• In repairing the FPL tendon, the proximal cut end of the
tendon frequently retracts into the thenar muscles. This
end can be retrieved with the techniques described for
retracted FDS and FDP tendons.
Figure 21.13  The technique for making a six-strand M-Tang tendon repair. Two
separate looped sutures are used to make an M-shaped repair within the tendon.
(A–C) A U-shaped four-strand repair is completed, which can be used alone for
tendon repair. (D and E) An additional looped repair is added at the center, to
complete the six-strand repair. In tendon cross-sections, three suture groups are
placed at points of a triangle to avoid interference to the dorsal center of the tendon
where the vascular networks converge. The dorsolateral sutures may act as tension
bands to resist gapping of the tendon.
A
B
C
D
E

369
Postoperative considerations
Figure 21.14  Other designs of four-strand repairs by two separate strands or one looped suture line led by a single needle. These repairs, with fewer needle passages
within the tendon, have strengths identical to the double Kessler method. (A) A four-strand repair with knots on two lateral sides of the tendon. (B) A U-shaped four-strand
repair made with one looped suture line. (C and D) Two separate strands carried by a single needle to make a four-strand cross-lock repair or a four-strand Kessler repair
(knots on one side of the tendon).
A
B
C
D
i
ii
iii
Figure 21.15  Two simple common methods of peripheral suture. (A) Simple
running peripheral suture. (B) Running locking peripheral suture.
B
A
Simple running peripheral suture
Locking running peripheral suture
Figure 21.16  (A) Sufficient core suture purchase and (B) a certain pretension
favor resisting gapping and decreases the chance of repair failure during tendon
motion after surgery.
B
A
Gapping / disruption
Solution : Maintain core suture purchase
>7-10 mm
< 4 mm
Tension
Gapping
Loose repair
Solution : Repair with a certain
light tension
Tension

370
•
• Flexor tendon injury and reconstruction
21
Figure 21.17  Drawings depicting the length and areas of release of the pulley–sheath complex to decompress the repaired tendons, without bowstringing or loss of tendon
function. (A) Release of the entire A4 pulley when the flexor digitorum profundus tendon has been cut around the A4 pulley and the tendon cannot pass easily beneath this
pulley during surgery. (B) Release of a part of the sheath distal to the A2 pulley and the distal half of the A2 pulley, when the tendons are cut slightly distal to the A2 pulley.
(C) Release of a short part of the sheath distal to the A2 pulley and the distal two-thirds of the A2 pulley when repairing tendons cut at the edge of, or in the distal part of,
the A2 pulley. (D) Release of the proximal two-thirds of the A2 pulley when repairing a cut in the middle, or proximal part of, the A2 pulley.
A1
A2
C1
A3
C2
A4
C3
A5
Tendon laceration
A1
A2
C1
A3
C2
A4
C3
A5
Sheath-pulley release
Tendon laceration
Sheath-pulley release
Tendon laceration
Sheath-pulley release
Tendon laceration
Sheath-pulley release
A
B
C
D
Table 21.1  Summary of mechanical basis and surgical options advised to deal with the flexor digitorum superficialis (FDS) tendon and
pulleys in zone 2 of the finger
Investigations
Area of FDS insertion
(2A)
Distal to A2 pulley
(2B)
Beneath A2 pulley
(2C)
Proximal to A2 pulley
(2D)
Anatomic
FDS tendon
Insertion
2 slips, dorsal to FDP,
with vincula
Bifurcation
One single band, flattened
palmar to FDP
Pulleys
A4, C2 narrow
A3, C1
A2, narrow
A1, PA
Biomechanical
FDS tendon
No gliding
Not constricting FDP
Constricting FDP, as a moving
and second “pulley”
Little constriction
Pulleys
A4 release is feasible
May incise one pulley
Partial release is feasible
Clinical options
FDS tendon
Repair
Resection or do not repair
Resect one slip
Repair both tendons when
possible
Pulleys
A4 venting
Partial release
Pulley shortening or plasty
FDP, flexor digitorum profundus; PA, palmar aponeurosis.

371
Postoperative considerations
• Within the first 4.5 weeks, the patients perform 10 passive
DIP joint extensions with PIP and MCP joint flexions, and
10 passive PIP joint extensions with MCP and DIP joint
flexions hourly within the splint (see Fig. 21.18).
• This protocol decreased the frequency of PIP joint
contracture seen with Kleinert’s rubber band traction.
Early active motion
• Postoperatively, a splint is applied from the elbow to the
fingertips with the wrist in midflexion, the MCP joint at
slightly less than 90° flexion, and the IP joints straight.
• The light dressing is removed from the digits and
exercises are started 48 h after surgery.
• Under supervision, the exercises consist of two passive
movements followed by two active movements and are
performed at 2 h intervals.
The modified Kleinert method
• The wrist is palmarly flexed with a dorsal protective
splint with 30–40° wrist flexion, 60–70° MCP joint flexion,
and the IP joints are allowed full extension.
• Rubber bands are secured to the volar forearm and
attached to the tip of the injured finger (Fig. 21.18).
• Patients are allowed to extend the fingers actively and
the fingers are brought back to flexion passively by the
tensed rubber bands. In recent years, some surgeons have
advised abandoning rubber band traction.
Duran–Houser method
• A dorsal splint is applied with the wrist in 20° flexion,
the MCP joint in 50° flexion, and the IP joints are allowed
full extension (see Fig. 21.18).
B
A
C
Duran and Houser passive motion regimen
Nail hook
Nylon fishing line
Rubber band
Rubber band
Pulley
Modified Kleinert regimen (Chow)
Original Kleinert regimen
Figure 21.18  (A) Original and (B) modified Kleinert passive extension protocols, and (C) Duran passive tendon motion protocols. A volar bar was added to increase flexion
of the interphalangeal joints in the modified Kleinert protocol.

372
•
• Flexor tendon injury and reconstruction
21
■ In this 2.5-week period, full active extension is
particularly encouraged, and prevention of extension
deficits rather than achieving full range of active
flexion is emphasized.
Complications and outcomes
• Review of outcomes reported over 20 years show
excellent or good active range of finger motion in more
than three-fourths of primary tendon repairs.
• Multistrand core sutures have dramatically reduced the
incidence of repair ruptures.
• Adhesions remain one of the most common
complications preventing satisfactory return of active
joint motion.
Author’s preferred combined active–passive
method (Nantong regimen)
• After surgery, the hand is protected in a dorsal
thermoplastic splint, with the wrist at 20–30° flexion,
MCP joint at slight flexion, and the IP joints in extension
for the initial 2.5 weeks (Fig. 21.19).
■ We do not encourage patients to move the finger in the
initial postoperative days.
■ Exercise starts at 3–5 days (in most cases, at 4 or
5 days) after surgery.
■ Patients are instructed to flex the finger actively with
gentle force 20–30 times in the morning, noon,
evening, and before sleep, up to the range they feel
comfortable with.
Figure 21.19  Author’s combined passive–active tendon motion protocol. This protocol is divided into two 2.5-week periods. In the first 2.5 weeks, with wrist in slight
flexion, finger extension is emphasized. Only partial active digital flexion is allowed, but full range of passive motion is implemented. In the second 2.5 weeks, with wrist in
extension, full active finger flexion is encouraged. This protocol incorporates the concept of synergistic wrist and finger motion. When the wrist is flexed, finger extension is
less tensed; when the wrist is extended, finger flexion is less tensed.
Emphasize on full active digital flexion
Emphasize on full digital extension
Partial active digital flexion and full passive digital flexion
The Second 2.5 Weeks
The First 2.5 Weeks

373
Further reading
This classic article reported perhaps the largest case
series of free tendon grafting in the fingers and thumbs.
The authors analyzed the factors influencing the
prognosis for free tendon grafting and showed that the
tendon-grafting procedure used can produce clinically
acceptable function. However, hand conditions are extremely
important. Prognostic factors include conditions of the soft
tissues and joints. Extensively scarred tendon bed and joint
damage led to the worst prognosis after tendon graft
surgeries.
Elliot D. Primary flexor tendon repair – operative repair,
pulley management and rehabilitation. J Hand Surg
(Br). 2002;27:507–513.
This article summarized developments in surgical tendon
repair techniques, methods of venting the annular pulleys,
and active tendon motion regimes for primary flexor tendon
repairs in the hand. Of particular clinical interest, the
authors reviewed methods of early active or combined
passive–active tendon motion (representing a current trend
in digital flexor tendon rehabilitation) and the pulley
venting procedure that the author and his colleagues have
been using in their practice.
Giesen T, Sirotakova M, Copsey AJ, et al. Flexor pollicis
longus primary repair: further experience with the
Tang technique and controlled active mobilisation.
J Hand Surg (Eur). 2009;34:758–761.
This clinical study reported the most up-to-date clinical
outcomes of repairs of lacerated fl exor pollicis longus (FPL)
tendons from a renowned center dealing with flexor tendon
injuries. These authors have made a series of reports of their
results in treating FPL injuries over the past two decades;
this most recent report documents their outcomes in 50 FPL
injuries. With a six-strand core tendon repair alone (without
peripheral repairs), they achieved good or excellent
functional recovery in 80% of thumbs, with zero tendon
rupture with an active motion regimen. These are the
best clinical results of FPL tendon repairs reported thus far.
It is worth noting that the authors did not elaborate
peripheral sutures in these FPL tendon repairs, and the
oblique pulley in the thumb was vented to accommodate
tendon repairs.
Hunter JM, Salisbury RE. Flexor-tendon reconstruction in
severely damaged hands. A two-stage procedure using
a silicone-Dacron reinforced gliding prosthesis prior to
tendon grafting. J Bone Joint Surg (Am).
1971;53:829–852.
Kleinert HE, Schepel S, Gill T. Flexor tendon injuries. Surg
Clin North Am. 1981;61: 267–286.
Savage R, Risitano G. Flexor tendon repair using a “six
strand” method of repair and early active mobilization.
J Hand Surg (Br). 1989;14:396–399.
Strickland JW. Delayed treatment of flexor tendon injuries
including grafting. Hand Clin. 2005;21:219–243.
This article provides an update on historical developments of
surgical techniques, the author’s personal approaches, and
current practice of these secondary repair procedures, which
are generally considered classic operations. Little has
changed over recent decades.
Tang JB. Clinical outcomes associated with flexor tendon
repair. Hand Clin. 2005;21:199–221.
■ Tenolysis is indicated when the passive range of digital
motion greatly exceeds the range of active flexion
several months after direct end-to-end tendon repair or
tendon grafting.
• Outcomes of flexor tendon repairs are affected by patient
age, extent and zones of injuries, timing of the repairs,
postoperative exercise, and the expertise of the surgeon.
■ Results of tendon repairs in children are generally
better than those in adults.
■ Tendon repairs associated with extended soft tissue
damage or accompanied by phalangeal fractures are
likely to have worse outcomes.
• Secondary tendon repairs are achieved by free tendon
grafting, or a staged reconstruction.
■ These procedures are reserved for severed tendons that
could not be repaired primarily or for lengthy tendon
defects.
■ These techniques, developed by the early masters
of hand surgery, remain largely unchanged today
(Box 21.4).
■ Patients who have serious scarring in the tendon bed
or failed previous efforts at secondary flexor tendon
procedures are appropriate for a staged tendon
reconstruction, rather than one-stage tendon grafting.
■ Before surgery is attempted, the soft tissue wound
should be well healed, with supple passive motion of
the hand. Lack of passive range of joint motion is
contraindicated for one-stage tendon grafting, but may
be suitable for staged tendon reconstruction.
■ The timing of tendon grafting is usually 3 months after
injury.
Further reading
Boyes JH, Stark HH. Flexor-tendon grafts in the fingers and
thumb. A study of factors influencing results in 1000
cases. J Bone Joint Surg (Am). 1971;53:1332–1342.
BOX 21.4  Secondary surgery: grafting and staged
reconstruction
Indications
• Tendon injuries not treated within about 1 month of injuries
• Rupture of the tendon repairs at primary or delayed primary
stages
• Tendon injuries not indicated for primary repair
• Badly scarred digits are indicative for staged tendon
reconstruction
Essential requirements
• Supple passive motion of the hand
• Soft tissue conditions: good
• Sufficient time passed after initial tendon injury: 3 months
Contraindications
• Joint motion is very limited (but may be suitable for staged
reconstruction)
• Presence of soft tissue wounds or defects, and fractures not well
healed

374
•
• Flexor tendon injury and reconstruction
21
facilitate tendon repairs. The author highlights the
importance of releasing the critical pulley parts and strong
surgical repairs in achieving predictable primary flexor
tendon repairs in this most difficult area. Subdivision of
zone 2 and novel criteria for outcome evaluation are also
presented in this article.
Verdan CE. Primary repair of flexor tendons. J Bone Joint
Surg (Am). 1960;42:647–657.
Tang JB. Indications, methods, postoperative motion and
outcome evaluation of primary flexor tendon repairs in
zone 2. J Hand Surg (Eur). 2007;32:118–129.
This article provides a comprehensive and updated review of
the current indications for primary tendon repairs in zone 2.
The author’s techniques of multistrand repairs and
rehabilitation are detailed. Most importantly, the author
defines the needs, mechanical basis, and areas of releasing
the critical parts of the major digital annular pulleys to

©2013, Elsevier Inc. All rights reserved.
Chapter
22 
Nerve transfers
• Advantages of nerve transfers:
■ Bring regenerating motor fibers closer to the target
end organ more rapidly, essentially converting
a more proximal-level injury to a more distal-level
injury.
■ Enable surgical reconstruction outside the zone
of the original injury, avoiding complex dissections
and limiting injury to critical neurovascular
structures.
■ Allow for a very targeted intervention in cases of
partial nerve.
■ Unlike tendon transfers, nerve transfers require only
minimal immobilization (7–10 days), which is
especially valuable in patients presenting with
significant baseline stiffness.
■ Preserve the biomechanical properties of the
musculotendinous unit.
■ Can restore unique function such as pronation, which
is incredibly difficult to restore by traditional surgical
techniques.
• Indications for nerve transfers (Table 22.1).
• Absolute contraindications:
■ End organ unresponsiveness.
■ Muscle that is in complete discontinuity with the
nerve for greater than 1 year will not be reinnervated
no matter the elaborate reinnervation strategy
employed.
• Relative contraindications:
■ Extensive time required for regeneration
■ Surgeon inexperience: challenges of the surgery, the
anatomic knowledge required, and problems of
postoperative retraining and therapy.
■ Patients who may prefer the more rapid recovery
associated with tendon transfer at the expense of the
independent fine motor control that could be achieved
through the use of nerve transfers.
This chapter was created using content from
Neligan & Chang, Plastic Surgery 3rd edition,
Volume 6, Hand and Upper Extremity, Chapter 33,
Nerve transfers, Kirsty U. Boyd, Ida K. Fox and
Susan E. Mackinnon.
SYNOPSIS
■ Nerve injuries are often devastating, with associated pain and
impaired function.
■ Motor nerve injuries must be managed expeditiously, because
regenerating axons must reach target muscle prior to degeneration
and fibrosis – “time is muscle”.
■ Nerve transfers offer an advantageous method of reconstruction by
delivering regenerating nerve fibers to the target end organ more
quickly, thus converting a proximal injury to a more distal injury.
■ Nerve transfers allow for dissection outside the original zone of
injury, providing a safer and more technically straightforward
procedure.
■ Unlike tendon transfers, the muscle–tendon biomechanical
structure is preserved, thus excursion, origin, insertion, and
length–tension relationships are undisturbed.
■ Nerve transfers require time for the nerve to regenerate and
extensive physical therapy for retraining.
■ Intraneural dissection is technically demanding, and nerve transfers
require intimate knowledge of nerve topography.
Brief introduction
• Nerve transfers can be performed to restore sensory or
motor deficits and essentially convert a proximal injury
to a distal injury, providing a source of regenerating
axons in close proximity to the end target.

376
•
• Nerve transfers
22
• The biggest challenge facing peripheral nerve surgeons is
that with increasing time since injury, the ability to
achieve good motor function becomes increasingly
limited.
■ For any nerve injury where there is complete
discontinuity with the motor end organ, no
reinnervation procedure will be able to restore muscle
once denervation and fibrosis have occurred, a process
which occurs as early as 1 year.
• Direct nerve repair and nerve grafting also remain
valuable tools for the peripheral nerve surgeon and
should continue to be the treatment of choice in a variety
of scenarios, including:
■ Multiple nerve injuries where there is a paucity of
nerve donor material for nerve transfer.
■ Distal single-function nerve injuries where direct or
graft repair is preferable to nerve transfer because
one-to-one function is preserved, no retraining is
necessary, no donor function is sacrificed, and the
distance to the end target is short.
• 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.
■ 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.
Figure 22.1  The various options for coaptation in nerve transfer. (A) End-to-end
coaptation between the donor nerve (red) and the recipient nerve (blue). (B)
End-to-side coaptation, where the distal end of the divided recipient nerve (blue) is
transferred to the side of the intact donor nerve (red). In this transfer, fascicles from
the donor will “sprout” into the distal donor nerve. The recipient nerve essentially
“pulls” the donor fascicles into the distal nerve. (C) Reverse end-to-side
coaptation. In this transfer, the donor nerve (red) has been divided and transferred
to the side of the intact recipient nerve (blue). The donor essentially “pushes”
regenerating fascicles into the distal donor nerve.
Donor
Recipient
Donor
Recipient
Donor
Recipient
A
B
C
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.
Hints and tips
The end-to-side transfer can be considered as the recipient nerve
“pulling” regenerating axons out of the intact donor, whereas the
reverse end-to-side transfer can be considered as the donor nerve
“pushing” regenerating axons out into the intact recipient.
Table 22.1  Indications for nerve transfer
• Proximal brachial plexus injuries where grafting is not possible
• Proximal peripheral nerve injuries requiring long distance for
reinnervation of distal targets
• Severely scarred areas with risk of damage to critical structures
• Segmental nerve loss
• Major upper-extremity trauma
• Partial nerve injuries with functional loss
• Delayed presentation with inadequate time for reinnervation of
distal targets with grafting
• Sensory nerve deficits in critical regions
• The most relevant recent basic science advances
pertaining to nerve transfers relate to end-to-side
transfers (Fig. 22.1).
■ End-to-side neurorrhaphy involves the coaptation of
the distal end of an injured recipient nerve into the
lateral aspect of an intact nerve, which serves as a
proximal source of axons to regenerate into the injured
nerve.
■ Sensory recovery has typically been more impressive
than motor recovery.
• Reverse end-to-side nerve transfers involve the complete
transection of the donor nerve, which is then coapted into
the side of the intact recipient nerve.
■ This maximizes the potential number of available
motor axons from the donor nerve.
■ This procedure does not interrupt any recovery in the
injured recipient nerve because the nerve remains in
continuity; however, the additional axons recruited
from the donor nerve improve distal target
reinnervation, a concept known as “supercharging.”
■ In a proximal nerve injury, with a long distance
required for reinnervation, this technique can
protect target muscles from denervation atrophy and
fibrosis.
• 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, 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
combined with tendon transfer, or even arthrodesis, may
be warranted.

377
Anatomical/technical pearls for specific injury patterns
• Electrodiagnostic testing, performed by an experienced
person, can be a useful adjunct to physical examination
for serial assessment of reinnervation in closed nerve
injuries.
• Initial electrodiagnostic testing should be deferred until a
minimum of 6–8 weeks postinjury to assess for signs of
both axonal injury and root-level avulsion.
• In patients with no evidence of recovery 3 months after a
closed nerve injury, the balance should tilt towards
consideration of surgical intervention.
Preoperative considerations
• On history, details of the mechanism and timing of injury
are crucial. The mechanism of injury will determine
timing of intervention, with prompt exploration of
penetrating sharp trauma, and more expectant
management of closed injuries and gunshot wounds.
• Specific patient symptoms such as loss of function, both
sensory and motor, and pain should be precisely elicited,
as this will help focus the subsequent physical
examination.
• A complete physical examination of the upper extremity
includes assessment of sensory and motor function, deep
tendon reflexes, joint suppleness, and range of motion.
• Particularly in patients with late presentation, the
presence of fixed joint contractures may preclude
functional recovery.
• Sensation should be examined by both dermatome and
peripheral nerve distribution, and can be helpful in
distinguishing these injuries. The authors advocate the
use of both two-point discrimination and the ten-test to
evaluate sensory loss in the hand.
• A Tinel’s sign, the tingling sensation elicited with
percussion over a regenerating nerve, will help to localize
the level of nerve injury, and may also be followed on
serial clinical examination to check for signs of
advancement, indicating spontaneous recovery.
• An advancing Tinel’s sign quite often precedes actual
motor recovery, which might be quite distal to the site of
the initial injury.
• The scratch collapse test is useful primarily for patients
with nerve compression pathology, but also has a role in
evaluating the patient for potential nerve transfer
procedures, as it can provide additional confirmation of
the level of nerve injury (Video 22.1).
• The test is performed by having the patient sit facing the
examiner with their shoulders adducted, elbows held in
90° of flexion, neutral prosupination, and wrist and
fingers extended. The examiner will then lightly scratch
the area of the presumed nerve injury and exert force to
the patient’s arms in the direction of internal shoulder
rotation as the patient resists. Nerve injury at the test site
is indicated by the inward collapse of the arm on the side
ipsilateral to the injury.
• One of the most important components of the physical
examination is the simple determination of what is
functioning, and what function has been lost.
• In the presence of an injury requiring surgical
intervention, it is important to examine the patient
for putative nerve donors, both intraplexal and
extraplexal (spinal accessory, medial pectoral, and
thoracodorsal).
Video
22.1
Hints and tips
Order baseline electrodiagnostic studies at 6–8 weeks and subsequent
testing as indicated by the injury. Fibrillations and positive sharp waves
suggest denervation. Motor unit potentials and nascent units suggest
reinnervation.
Hints and tips
Remember to check not only for what muscles have lost function, but
also for potential nerve transfer donors.
Hints and tips
• Avoid, or use short-term paralytics with anesthesia
induction to allow for nerve stimulation
• Minimize or avoid tourniquet time to avoid interference with
nerve stimulation
• Use plain epinephrine in proximal incisions to minimize
blood loss without lidocaine paralysis
• Obtain wide surgical exposure to identify nerves and
appropriate branches
• Choice of optimal nerve donor is based on quantity of
motor axons, proximity to target muscles, synergy of
muscle function, and donor expendability
• Conduct neurolysis with your “eyes” except at the site of
actual transfer to avoid prolonged dissection and increased
trauma to nerve branches
• Confirm no intraoperative stimulation in putative recipient
before dividing donor
• Divide donor nerve distally and recipient nerve proximally
• Use 9-0 nylon and the operating microscope to perform
tension-free epineurial repair
• Use bupivacaine block at end of case for postoperative
pain control
Anatomical/technical pearls for specific
injury patterns
Upper plexus injury
Specific patient exam findings
• Upper plexus injuries involve injuries at the C5, C6, and/
or C7 root or upper trunk level.
• Commonly include deficits of:
■ The dorsal scapular n. innervates the rhomboid
muscles and the levator scapulae muscles, which
contribute to scapular adduction, retraction, and
elevation.

378
•
• Nerve transfers
22
the spine of the scapula. Dissection is carried through
the trapezius in a muscle-splitting fashion and an
end-to-end coaptation, sparing the upper trapezius
nerve branches, is performed.
• Anterior approach:
■ An incision is designed 2 cm superior to and
parallel to the clavicle extending laterally from
the posterior border of the sternocleidomastoid
(Fig. 22.4).
■ The upper trunk is identified between the anterior and
middle scalene muscles.
■ The suprascapular nerve is a distinct branch of the
upper trunk that sits on the superolateral aspect.
■ The spinal accessory nerve is located in the posterior
aspect of the incision on the deep surface of the
trapezius muscle.
■ Although an end-to-end transfer can be performed, the
end-to-side approach with a partial neurectomy of the
donor accessory nerve is preferred as this preserves
some donor function.
■ In the end-to-side transfer, a short interpositional
graft from the recipient suprascapular nerve to the
donor spinal accessory nerve is required to avoid
tension.
Use of triceps to axillary nerve transfer
(motor component)
• Additional reduction of glenohumeral subluxation and
abduction of the shoulder are provided by transferring a
branch of the triceps, usually from the medial head, to
the axillary nerve (Fig. 22.5).
• Better results in upper plexus injury patients are achieved
by reinnervating both the suprascapular and axillary
nerves.
• Through a longitudinal incision on the posterior surface
of the arm that extends in a curvilinear fashion above the
posterior axillary fold (Fig. 22.6), the axillary nerve is
identified in the quadrangular space and dissected
proximally to include the branch to teres minor, then
divided proximally.
• The natural cleavage plane between the lateral and long
heads of the triceps is identified and blunt dissection is
conducted to expose the donor radial nerve running
along the humerus.
■ The branch to the medial triceps sits superficially and
medially on the surface of the radial nerve as a distinct
branch.
■ The donor triceps nerve is dissected as far distally
as possible and then coapted to the axillary nerve
(Fig. 22.7).
Use of the double fascicular (ulnar/median redundant
branches to biceps brachii and brachialis branches of the
musculocutaneous) nerve transfer (motor)
• Restoration of elbow flexion is achieved with the double
fascicular nerve transfer (Fig. 22.8).
■ This transfer reinnervates the biceps brachii and
brachialis muscles using redundant fascicles from the
ulnar and median nerves.
■ The long thoracic n. innervates the serratus anterior
muscle, which abducts the scapula, permitting the full
range of shoulder flexion past 90°.
■ The suprascapular n. innervates the supraspinatus and
infraspinatus muscles. These muscles are rotator cuff
muscles. The supraspinatus contributes to shoulder
abduction with the deltoid muscle. The infraspinatus
contributes to shoulder external rotation with the teres
minor.
■ The axillary n. arises from the posterior cord,
receiving innervation from C5 and C6. Supplies the
deltoid and teres minor muscles, which provide
shoulder abduction and external rotation respectively.
Provides cutaneous innervation over the lateral
shoulder.
■ The musculocutaneous n. arises from the lateral
cord and is primarily innervated by C5, C6, and
occasionally C7. Innervates coracobrachialis, biceps
brachii, and brachialis, which power elbow flexion.
The biceps is also the primary forearm supinator. The
lateral antebrachial cutaneous (LABC) nerve is a
terminal branch and provides cutaneous innervation to
the lateral forearm.
• Patients with upper plexus injuries present with
glenohumeral joint subluxation, loss of shoulder
abduction and external rotation, and absent or weakened
elbow flexion depending on the involvement of C7.
Numbness over the lateral shoulder and forearm
is noted.
Specific operative techniques
Hints and tips
Priorities for upper plexus injuries include restoration of shoulder
external rotation and abduction, as well as elbow flexion. Standard
transfers include: (1) spinal accessory to suprascapular nerve;
(2) medial triceps to axillary nerve; and (3) double fascicular nerve
transfer.
Use of spinal accessory nerve (cranial nerve XI) to
suprascapular nerve transfer (motor)
• Restoration of shoulder stability and external rotation are
facilitated by transferring the spinal accessory nerve
(cranial nerve XI) to the suprascapular nerve. This
transfer can be conducted by either an anterior or a
posterior approach (Fig. 22.2).
• Posterior approach:
■ The spinal accessory nerve runs parallel to the border
of trapezius and is localized 40% of the way along a
line connecting the acromion to the dorsal midline
at the level of the superior border of the scapula
(Fig. 22.3).
■ The suprascapular nerve is located midway between
the medial border of the scapula and the acromion as
it runs through the suprascapular notch.
■ The nerves are accessed through an incision located
slightly obliquely just above the superior border of

379
Anatomical/technical pearls for specific injury patterns
■ The ulnar and median nerves are then neurolyzed at
the appropriate level, and redundant fascicles to the
flexor carpi ulnaris (FCU: ulnar), flexor carpi radialis
(FCR), flexor digitorum superficialis (FDS), or palmaris
longus (median) are identified.
■ The redundant fascicles are divided distally and
coapted end to end. Reinnervation occurs at
approximately 5–6 months postoperatively.
Other potential donors (medial pectoral nerve and
thoracodorsal nerve)
• Other potential donors that can be used to restore elbow
flexion include the medial pectoral nerves and the
thoracodorsal nerve.
■ The medial pectoral nerves are identified by
making an incision in the deltopectoral groove,
dividing the pectoralis major tendon distally, and
• A longitudinal incision in the bicipital groove facilitates
exposure of the musculocutaneous, median, and ulnar
nerves.
• An intramuscular dissection at the underside of the
biceps brachii muscle allows exposure of the
musculocutaneous nerve.
■ The biceps brachii branch is the more proximal branch
and is located about halfway between the shoulder
and elbow exiting the nerve from the lateral side.
■ The brachialis branch exits the musculocutaneous
branch on the medial side of the arm approximately
13 cm proximal to the medial epicondyle, usually
under a leash of crossing vessels (Fig. 22.9).
■ These branches are divided and draped over to the
median and ulnar nerves to determine best donor–
recipient pairings.
■ Confirmation of a tension-free inset with elbow range
of motion is mandatory.
Figure 22.2  The posterior approach for spinal accessory to suprascapular nerve transfers. (A) The nerves can be seen in their original orientation. (B) The end-to-end
transfer has been completed. The transfer includes the functional spinal accessory nerve (donor) being transposed and coapted to the non-functional suprascapular nerve
(recipient).
A
B
Spinal accesory nerve
Spinal accesory nerve
Trapezius
Supraspinatus
Infraspinatus
Non-functional musculature
Functional musculature
Suprascapular nerve
Suprascapular nerve
Acromion

380
•
• Nerve transfers
22
Figure 22.3  Surface markings for posterior approach to spinal accessory to
suprascapular. The spinal accessory nerve is located 44% of the way along a line
connecting the dorsal midline to the acromion. The suprascapular nerve is located
at the halfway point between the medial border of the scapula and the acromion on
an obliquely oriented line at the superior aspect of the scapular spine. It runs in the
suprascapular notch.
Figure 22.4  In the anterior approach to the spinal accessory to suprascapular nerve transfer, upper trapezius function is preserved by performing the nerve transfer in an
end-to-side manner. (A) To inset this transfer with no tension, an interpositional lateral antebrachial cutaneous (LABC) nerve graft is used. (B) To facilitate regenerative
sprouting, injury to the donor nerve is required proximally. This is accomplished by “crushing” the nerve with a hemostat to cause a second-degree nerve injury. (C)
Wallerian degeneration occurs distal to the site of compression. (D) Axons regenerate from the level of the crush injury, with some axons following the donor nerve and
restoring function to the upper trapezius muscle, and some axons diverting into the distal recipient nerve via the LABC graft.
A
B
C
D
Spinal accessory nerve
Spinal accessory nerve
Suprascapular nerve
Suprascapular nerve
Compression site
Compression site
Epineurotomy
LABC autograft
LABC autograft
LABC autograft
LABC autograft
Proximal
Proximal
Proximal
Proximal
Distal
Distal
Distal
Distal
elevating pectoralis minor from lateral to medial
(Fig. 22.10).
■ The thoracodorsal nerve runs along the lateral chest
wall and can be exposed through an incision running
along the free border of latissimus dorsi.
Lower plexus injury
Specific patient exam findings
• Lower plexus injuries usually involve damage to C8 and
T1 nerve roots or to the lower trunk.
• Often they are a result of a forceful pull on an
adducted arm.
• The lower trunk contributes primarily to the ulnar nerve,
and thus patients have a resultant loss of the intrinsic
muscles of the hand, with weakened wrist and finger
flexion.
• Contribution to the median and radial nerves may impact
thumb and finger flexion and extension respectively.
• Involvement of C7 can dramatically influence available
options for nerve transfer.
Hints and tips
Priorities for lower plexus injuries include restoration of hand extrinsic
function. Restoration of hand intrinsic function is virtually unobtainable
except in the very young pediatric patient.
Specific operative techniques
• There are few good options for lower plexus injury
reconstruction. Recently, the authors have incorporated
transferring the nerve to brachialis (a branch of the
musculocutaneous nerve) to the anterior interosseous
nerve to regain thumb and finger flexion.
Complete/near-complete plexus injury
Specific patient exam findings
• Often results from high-velocity, penetrating, or crush-
type mechanisms and result in devastating loss of
function.

381
Anatomical/technical pearls for specific injury patterns
• These patients will typically have an insensate, flail upper
extremity with glenohumeral joint subluxation and a
positive sulcus sign.
• Most will lack shoulder stability, abduction, rotation,
flexion and extension, elbow flexion and extension, wrist
flexion and extension, finger flexion, extension, and
intrinsic function.
Specific operative techniques
Figure 22.5  The triceps to axillary nerve transfer via a posterior approach to the upper arm. (A) The axillary and radial nerves in their normal anatomical position. (B) The
branch to the medial head of the triceps (donor) is transposed to meet the divided end of the axillary nerve (recipient). The branch to the medial head is coapted end to end
to the axillary nerve.
A
B
Teres minor
Teres major
Triceps brachii
Non-functional musculature
Functional musculature
Superior lateral
cutaneous nerve
Nerve to lateral head
Nerve to medial head
Nerve to long head
Nerve to lateral
head
Nerve to medial
head
Nerve to
long head
Axillary nerve
Superior deltoid
motor nerve
Deep deltoid
motor nerve
Superior lateral
cutaneous nerve
Superior deltoid
motor nerve
Deep deltoid
motor nerve
Acromion
Axillary nerve
Figure 22.6  Set-up and incision for triceps to axillary. The patient is positioned in
the prone position and draped with the entire extremity free and the medial border
of the scapula exposed. A line connecting the olecranon and the acromion is drawn
on the posterior aspect of the arm and then extended in a curvilinear fashion just
above the posterior axillary fold. Positioning is facilitated by placing a “bump”
beneath the anterior shoulder preventing internal rotation and anterior subluxation.
The arm is draped free so that distal function can be assessed with intraoperative
nerve stimulation.
Hints and tips
Priorities for complete plexus injuries are to restore function in the
following order of priority: (1) elbow flexion; (2) shoulder stability/
external rotation; and (3) hand extrinsic function/grasp. Techniques
include extraplexal to intraplexal nerve transfers and free functional
muscle flap reconstruction. Contralateral C7 and phrenic nerve
transfers are also described with modest results.
Use of spinal accessory and intercostal nerves
as donors (motor)
• Reconstruction in this scenario has very different goals
and outcomes from less traumatic injuries. The extremity
will often be a “helper” extremity at best. The severe

382
•
• Nerve transfers
22
Figure 22.7  A clinical example of the triceps to axillary nerve transfer. The patient is positioned with their head to the top right. The cross-hatchings of the posterior midline
incision in the upper arm are visible and the quadrangular space is exposed. (A) The intact nerve in situ prior to division. A white vessel loop surrounds the entire nerve at
that level. (B) The divided nerve transposed caudally with the proximal-most aspect held by the forceps. The branches are clearly visible with vessel loops around motor
branches. The superior-most branch is the branch to teres minor. The sensory branch is the most inferior branch (no vessel loop) and can be visualized heading more
superficially than the other branches. (C) The cut end of the recipient axillary nerve is visible on the most proximal blue background. The radial nerve is visualized at the
base of the wound, with vessel loops around branches to the medial, long, and lateral heads of triceps. (D) The divided branch to the medial head (donor) is transposed
proximally and anastomosed to the recipient axillary nerve.
A
B
C
D
Figure 22.8  A schematic of the double fascicular
nerve transfer. The divided recipient branches of the
musculocutaneous nerve (biceps brachii laterally and
brachialis medially) are transposed medially to the median
and ulnar nerves. In this example, a redundant fascicle to
flexor digitorum superficialis (median donor) is transferred to
the biceps brachii branch and a redundant fascicle of the
flexor carpi ulnaris (ulnar donor) is transferred to the
brachialis branch.
Posterior cord
Medial cord
Ulnar nerve
Radial nerve
Median nerve
Musculocutaneous nerve
Axillary nerve
Flexor carpi
ulnaris fasicle
Brachialis nerve branch
Biceps brachii
nerve branch
Lateral antebrachial
cutaneous nerve
Flexor carpi radialis fasicle
Lateral cord

383
Anatomical/technical pearls for specific injury patterns
• 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. This is often
accomplished as a two-stage procedure.
Median nerve injury
Specific patient exam findings
• The median nerve is a mixed motor and sensory nerve
that is derived from C5, C6, C7, C8, and T1.
• There are no branches in the arm as the nerve courses
lateral to the brachial artery and then passes over
brachialis in the antecubital fossa.
• In the forearm, the median nerve proper supplies
pronator teres (PT), FCR, palmaris longus, and FDS. The
nerve then divides.
■ The anterior interosseous nerve innervates flexor
pollicus 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 pollicus brevis, opponens pollicus, and the
superficial head of flexor pollicus brevis) and the two
radial lumbricals.
■ The sensory contribution is to the volar surface of the
thumb, index, long, and radial half of the ring and to
the dorsal aspect of those digits distal to the distal
interphalangeal joint.
Figure 22.9  Operative photo of double fascicular nerve transfer. A clinical example
of the double fascicular nerve transfer. The superior nerve is the musculocutaneous
nerve with vessel loops around the branch to biceps brachii (proximal and lateral)
and branch to brachialis (distal and medial). The ulnar nerve is also neurolyzed at
the level appropriate for transfer. Redundant fascicles determined by intraoperative
nerve stimulation that can serve as potential donors are marked with vessel loops.
Figure 22.10  Harvesting medial pectoral nerve. Clinical photograph of a patient
with medial pectoral nerve harvested as a donor. The divided pectoralis major
muscle is flipped proximally and lying on the anterior chest wall. The medial
pectoral nerves have been dissected from the deep surface of the pectoralis minor
and divided distally. They have then been transposed towards the donor nerves in
the arm and are lying on the most proximal blue background.
Figure 22.11  Harvesting intercostals. Clinical photograph of a female patient
undergoing intercostal to musculocutaneous nerve transfer. The anterior
subcutaneous flap has been turned over medially to expose the anterior chest wall.
White vessel loops are around intercostal nerves at the inferior border of each rib.
The recipient nerve is visualized in the upper arm on a blue background.
damage to the brachial plexus means that options for
nerve transfers are limited, and that extraplexal donors
must be considered. Specifically, available extraplexal
nerve donors include the spinal accessory, medial
pectoral, thoracodorsal, and intercostal nerves.
■ The spinal accessory nerve is harvested as described
previously.
■ Intercostal nerves are harvested through an L-shaped
incision extending from the anterior axillary fold and
curving anteriorly below the nipple-areolar complex.
Rib periosteum is incised and peeled down to expose
the neurovascular bundles running along the posterior
inferior surface of each rib (Fig. 22.11). The motor
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.

384
•
• Nerve transfers
22
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.
• Patients presenting with a median nerve injury will have:
■ Numbness in the distribution of the median nerve
and depending on the level of injury, motor deficits
will vary.
■ Distal forearm injury: the primary deficits will be
thumb abduction and opposition.
■ Proximal forearm injuries: the patient will also have
loss of pronation, thumb flexion and index (and
possibly long) finger flexion. Flexion of the wrist will
be present with ulnar deviation, due to the intact FCU
function provided by the ulnar nerve. Similarly, finger
flexion to the ring and small fingers will be retained
because of the ulnarly innervated preserved FDP
function.
Specific operative 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.
■ 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. 22.12).
■ Recovery of pronation occurs approximately 3–4
months postoperatively.
Use of brachialis branch to AIN branch nerve transfer
• The brachialis branch of the musculocutaneous nerve
may be used to restore AIN function (Fig. 22.13).
• The LABC nerve is identified traveling with the
cephalic vein, and a tug test is used to confirm
the identity of this cutaneous nerve. The LABC is
followed proximally to its branch point from the
musculocutaneous nerve where the nerve to brachialis is
identified medially approximately 13 cm proximal to the
elbow crease (Fig. 22.14).
• Knowledge of the internal topography of the median
nerve is crucial to performing 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 deep
medial aspect of the nerve.
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
• The ulnar nerve is a mixed motor and sensory nerve that
receives contribution from C7, C8, and T1.
• There are no branches in the arm as the nerve courses
medial to the brachial artery, dorsal to the medial
intermuscular septum, and then posteriorly around the
medial epicondyle.
• Branches of the ulnar nerve proper in the forearm include
FCU and FDP to the ring and small fingers.
• The nerve then courses through the forearm deep to FCU
and gives off the dorsal cutaneous branch approximately
9 cm proximal to the wrist crease providing sensation to
the dorsal ulnar aspect of the distal forearm and hand. A
superficial motor branch provides innervation to palmaris
brevis.
• As the nerve courses into the wrist through Guyon’s
canal, it divides into a superficial sensory branch and a
deep motor branch.
■ Superficial sensory branch: provides sensation
to the small finger and the ulnar aspect of the ring
finger.
■ Deep motor branch, which courses around the hook of
the hamate under the tendinous leading edge of the
hypothenar muscles and innervates the hypothenar
muscles (flexor digiti minimi, opponens digiti minimi,
and abductor digiti minimi), the palmar and dorsal
interossei, the lumbricals to the small and ring fingers,
the deep head of flexor pollicis brevis, and the
adductor pollicus.
• Patients presenting with an ulnar nerve injury will have:
■ Numbness in the sensory distribution of the ulnar
nerve and 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 devastating.
■ 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 FDP to the small and ring fingers
and FCU.

385
Anatomical/technical pearls for specific injury patterns
Figure 22.12  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 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
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.
Specific operative techniques
Use of median to ulnar branch nerve transfers (motor)
• The median nerve may be used to restore ulnar nerve
function, 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.
■ 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. 22.15).

386
•
• Nerve transfers
22
Figure 22.13  A schematic of the nerve to brachialis to anterior interosseous nerve transfer. (A) The median nerve (red) and musculocutaneous nerve (green) 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 medial and deep
aspect of the median nerve.
A
B
Median nerve
Musculocutaneous nerve
Musculocutaneous nerve
Brachialis branch
Brachialis branch
Posterior fascicle
Anterior
interosseus
nerve
Figure 22.14  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

387
Anatomical/technical pearls for specific injury patterns
■ Tenodesis 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 extensor
indicis proprius to adductor pollicus tendon transfer.
■ In patients with a prominent Wartenburg’s sign,
abductor digiti minimi is transferred to the extensor
digitorum communis tendon of the small finger.
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.
• In the axilla, the radial nerve gives off the posterior
cutaneous nerve of the arm. It then provides innervation
■ 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 (Fig. 22.16).
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.
Figure 22.15  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
Figure 22.16  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