TENDON TRANSFERS FOR

TRAUMATIC NERVE INJURIES

BY GEORGE E. OMER, JR, MD, MS, FACS

The basic steps and principles of tendon transfers in the treatment of patients with
nerve injuries or palsies is presented. Technical tips on tendon selection, tensioning,
and placement are provided. Specific transfers for different types of nerve palsies are
indicated, along with their functional outcomes.
Copyright 2004 by the American Society for Surgery of the Hand

econstructive procedures after peripheral

nerve injuries include skeletal stabilization,
muscle-tendon transfers, and redistribution of
sensibility. Motor reconstruction should be performed
before sensory reconstruction because precise sensibility depends on precise muscle control, as well as
appropriate sensory end organs.
Tendon transfers are performed for the following
reasons: (1) to replace a single motion that assists in
grasp, pinch, or release, (2) to eliminate a deforming
force that will produce further functional imbalance,
such as claw finger, and (3) to improve balance for the
best functional use of the residual active muscletendon units. The anticipated result should be a lim-

From the Department of Orthopaedics and Rehabilitation, University

of New Mexico School of Medicine and Health Sciences Center,
Albuquerque, NM.
Presented at the American Society for Surgery of the Hand Preconference Workshop. Tendon Transfers: Nerve Repair and ReconstructionSurgical Decision-Making and Techniques, September 18,
2003.
Address reprint requests to George E. Omer, Jr, MD, MS, FACS,
Department of Orthopaedics and Rehabilitation, University of New
Mexico Health Sciences Center, Albuquerque, NM 87131-5296.
Copyright 2004 by the American Society for Surgery of the Hand
1531-0914/04/0403-0012$30.00/0
doi:10.1016/j.jassh.2004.06.012

214

ited, but balanced, functional performance by redistributing assets rather than creating new ones.

PATIENT EVALUATION

omeostasis, or tissue equilibrium, should be

regained before tendon transfers are performed. Chronic wounds are contraindications to
elective surgery. Soft tissues should be free of scar
contracture. There should be stable skeletal alignment. Tendon transfers across a bony nonunion fail
because the telescoping skeleton prevents adequate
tension for functional muscle power. Joints should
have normal motion and the functional motion
expected after tendon transfer should be shown
passively before surgery.
The involved neuromuscular mechanisms should be
tested for the extent and level of injury. Return of
good muscle strength across 2 joints distal to the
nerve injury is rare.1 Ongoing assessment requires
multiple quantitative tests that are repeated at regular
intervals, such as a voluntary muscle test with recorded range of motion, a test for light touch 2-point
discrimination distance over autonomous zones for
pertinent peripheral nerves, gross grip and finger
pinch strength tests, and a timed pick-up test for
median or ulnar nerve lesions.2

JOURNAL OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND ! VOL. 4, NO. 3, AUGUST 2004

TENDON TRANSFERS ! OMER, JR

The cause of the neuromuscular imbalance is important. Muscle imbalance usually is static after traumatic
injuries, but unusual functional loss may indicate additional progressive neuromuscular impairment. After
deep laceration of muscle, intact nerves must regenerate
across the site of injury, and distal tissue separated from
the intramuscular nerve must be reinnervated to recover
functional tension and shorten appropriately.3 Even with
recovery of reinnervation, the increased fibrotic tension
from scar and shorter residual fiber length results in
decreased total tension and diminished function of the
involved muscle. One should not transfer muscles that
have had even temporary total denervation, even if they
later regain function.4
Many developmental conditions, such as CharotMarie-Tooth progressive muscular atrophy, are complicated by an unpredictable rate of involvement.
Muscle imbalance related to vascular problems may be
limited, as in an injection injury or Volkmanns ischemia, or may be progressive secondary to a series of
cerebrovascular accidents. In these cases, muscle imbalance will never be static.
Age and intelligence are pertinent because the patient should have developed the cerebral imprint for
the function to be reconstructed, and the patient must
comprehend what is to be performed and accept the
postoperative discipline for appropriate reconstruction. The surgeon should determine if there are related
medical problems, such as chronic pain syndrome or
emotional problems that may cripple functional recovery. It is important to determine whether the
patient desires an increase in functional performance
or only cosmetic improvement.

PREOPERATIVE REHABILITATION

he extremity is immobilized in the appropriate

position to maintain the desired result. For
example, after either median or ulnar palsy, the
thumb-index web must be maintained to prevent
contracture with accompanying thumb adduction
and supination. Maintaining a mobile extremity
without deforming contracture demands a planned
and persistent rehabilitation program. The functional range of motion expected after tendon transfer should be possible to affect by passive movement
before surgery.

TIMING

OF

215

TENDON TRANSFERS

he timing of tendon transfers is a debatable procedure that varies with the level (low/distal or
high/proximal) and severity of the nerve injury. When
a precise neurorrhaphy has been performed early in a
patient with distal nerve laceration, the prognosis for
reinnervation of palsied muscles has improved over
the past decade.5-7 In these patients, selected tendon
transfers may be performed early as internal splints to
support partial function and prevent deformity while
awaiting the potential nerve recovery.
A prospective study1 was performed of 648 nerve
lesions of the upper extremity resulting from either
closed or open injuries, with the involved nerve shown
to be in continuity at the time the wound was debrided. Spontaneous recovery took 1 to 4 months for
85% of fracture dislocations or crush injuries, and 3 to
9 months for 70% of gunshot wounds.
Patients with a severe or extensive extremity injury,
a long nerve graft, or a high/proximal nerve lesion are
all candidates for a complete reconstruction program.
The potential for functional motor action is better
than recovery of normal sensibility in the high/proximal nerve palsy.

THE MOTOR MUSCLE

n the normal forearm and hand there are 50 muscles to activate movement. Five control supination
and pronation, 7 move the hand at the wrist, 18 flex
and extend the digits, and 20 small muscles of the
hand contribute to precise motion.8 The selected muscle-tendon unit should have amplitude adequate for
the anticipated motion. Normal amplitude approximates 33 mm for wrist movers, 70 mm for finger
flexors, and 50 mm for finger extensors and the thumb
extrinsic muscle tendons.8 Although the amplitude/
excursion of a specific tendon cannot be increased, a
muscle can be converted from monoarticular to biarticular or multiarticular by effectively using the natural dynamic tenodesis effect. For example, when the
flexor carpi ulnaris or the flexor carpi radialis (FCR) is
transferred to the extensor digitorum communis
(EDC), it is converted to a multiarticular muscle and
the effective amplitude of the tendon transfer is increased significantly by active volar flexion of the
wrist, thereby allowing the transferred wrist flexor to

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TENDON TRANSFERS ! OMER, JR

extend the fingers fully.9 A second technique to increase amplitude is dissection of the muscle from its
surrounding fascial attachments,10 but this may bring
unwelcome hemorrhage or denervation.
The motor muscle selected for transfer should be 4!
to 5 on the Lovett scale because it will have to pull itself
free of the healing process after surgery and usually will
lose one grade of strength on Lovetts clinical scale.11
After reconstruction, the muscle selected for transfer
should have a work capacity equal to that of the antagonist muscle.12 The present action of the selected motor
muscle should be synergistic with the anticipated action,
or at least be trainable by conscious control.13 Paralyzed
muscles that have regained function after nerve suture
usually lack the individualized control and strength desirable for successful transfer.14
The force of a muscle is proportional to the crosssectional area of all its muscle fibers. Blix found that
the greatest force of contraction is exerted when the
muscle is at its resting length.15 Work is force multiplied by distance. The muscles mass is proportional
to total work capacity. Power is a measurement of
work over a period of time.12,16

MUSCLE-TENDON AMPLITUDE

AND

TENSION

he amplitude of a muscle is the amount it can be

stretched from its resting position, plus the
amount it contracts from its resting position.16 Freehafer et al16 measured the available excursion or amplitude of a muscle-tendon unit in the operating room by
using tendon traction and muscle stimulation. Floyd17
noted that the resting length to contraction length and
the resting length to full passive length are approximately equal measurements. Therefore, the potential excursion would be the resting length to tendon traction
length, multiplied by 2. The required excursion is the
actual distance a tendon must move to produce a specified movement in a joint, and may change after transfer.
Stimulating the muscle after tendon transfer is an
effective technique to evaluate the functional outcome, and was introduced by Omer and Vogel18 and
expanded by Freehafer et al.16
Appropriate tension for the transferred muscle-tendon unit depends on mean fiber length, cross-sectional
area, and total muscle volume.15,19 An intraoperative
laser diffraction technique is used to measure muscle
sarcomere length changes and thus determine the
optimal muscle tension during tendon transfer.20-22

This technique is relatively precise for measurement,

but is underused at this time.
If there has been good evaluation of tissue homeostasis, tension can be evaluated and determined at
surgery. Tension is judged best while the extremity is
placed in the position it will assume when the transferred tendon contracts. The motion expected after
tendon transfer cannot exceed the passive motion that
is present preoperatively. For extensor tendons, the
resting tension should be strong enough to hold the
extremity passively against gravity. However, one
must be sure that the wrist has the potential for a
normal arc of flexion. Flexor tendons often cross more
than one joint and should be fixed at somewhat
greater than normal tension against gravity.
L.J. Goldner described a practical technique to
determine tension for the muscle-tendon unit to be
transferred (oral communication, May-September
2003). In the paralyzed extremity, with a tourniquet
in place, position the extremity and the recipient
tendon in functional position and the transfer tendon
in resting length. Traction is applied to the transferred tendon and distance is recorded in centimeters
and marked in the wound. Sixty percent of the distance should be marked between the resting length
and traction length, and that is the position of the
transferred muscle when the final insertion of the
transferred tendon is initiated.
Cooney23 also has reported an intraoperative technique to determine tension. The distance that a muscle contracts after release from its normal insertion is
measured. The lost length is restored at the time of
transfer, plus slightly more tension to pick-up the
connective tissue elasticity within the muscle.
Restoring the muscle to its actual resting length is
not always easy because of changes that may have
occurred in the muscle fibers, the soft tissues around
the muscle, and the time that has elapsed between
physiologic function of the muscle and the current
state. The tourniquet should be deflated when the
final tension is set for the transfer so that muscle
ischemia does not contract the muscle to such a degree
that the tension is too loose.

SURGICAL TECHNIQUES

ncisions are placed so that tendon junctures are

beneath skin flaps and free of subcutaneous scars.
Incisions should be transverse to the subcutaneous

TENDON TRANSFERS ! OMER, JR

217

TABLE 1
Early Tendon Transfers as Internal Splints
Palsy

Functional Need

Low median

Thumb abduction (APB)

Radial
Low ulnar

Wrist extension
Thumb adduction, improve clawed fingers,
improve metacarpal arch

path of the transferred tendon. The subcutaneous

pathway must glide with the transferred tendon
and not cross raw bone. Muscle-tendon units that
must move through fascia planes, such as an interosseous membrane, should have as large an opening in the fascia as practicable. The muscle should
be drawn into the fascia window because the exterior muscle fibers will freeze, but the interior muscle fibers will retain motion; if the tendon is placed
in the fascial window it will bind quickly and
motion will be lost.14
An appropriate moment arm should be selected
for the direction of muscle-tendon action.16 Most
muscles are parallel to bone, and the angle of approach between the transferred tendon and its new
insertion should be small. The greater the angle,
the greater the force the muscle can exert, but a
pulley is required to increase the approach angle,
and the result is a loss of force secondary to friction
when the angle is greater than 45. The more distal
to the axis of motion of a joint that the transfer is
anchored, the more force the muscle can exert on
the joint, but also the more excursion required of
the tendon to provide a normal range of motion in
the joint. If the insertion of a transferred tendon is
split, the motor will act primarily on the slip under
greater tension.
A tendon transfer is more effective when it
crosses only one joint. If a tendon bowstrings across
a proximal joint, its mechanical advantage at that
joint will be so great that it may force that joint
into unwanted movement or use up all its amplitude so that it cannot move the distal joint. An
example is the transfer of the brachioradialis (BR)
muscle to the flexor pollicis longus (FPL); when the
elbow and wrist are extended the patient can hold
an object tightly, but when the elbow is flexed fully

Available Motors
EIP to APB (and EPL) or EDM or PL or FDS (ring) to APB
(and EPL)
PT to ECRB
FDS (long with 1/2 tendon to AP, plus 2 slips to A2 pulley of
flexor sheath for flexion, or dorsal apparatus for extension)

the muscle power is dissipated at the elbow and the

patient drops the object.
Tendon fixation should be synthetic material
with minimal tissue reaction.24 Suture material can
be relatively large, such as 2-0 or 3-0 for forearm
transfers. Some potential ischemia is prevented
when the suture is inserted through the center of
the tendon and then circles only one half of the
tendon; sutures along the length of the tendon
should alternate the circle to be tied from side to
side to protect circulation further. Lacing a transferred tendon into a group of paralyzed muscletendon units should be avoided because it creates
bulk, twist, scar, and increases friction; a precise
insertion point should be selected. A second technique is leaving the recipient tendon in its bed and
passing the transferred tendon over it. This is an
oblique transfer, and there should be a double line
of nonabsorbable sutures to prevent shifting in the
tension to several tendon slips. A third technique
would be to excise the paralyzed and fibrous muscle
from the recipient tendon. However, excision of the
muscle may result in unwelcome hemorrhage and
should not be performed unless the fibrous muscle
mass is causing deformity.
Early Tendon Transfers as Internal Splints
Selected early tendon transfers enhance function
while awaiting the return of nerve control and total
muscle activity (Table 1). The objectives of early
tendon transfers are to stimulate sensibility re-education and to improve the coordination of residual muscle-tendon units. The early tendon transfer may substitute function during nerve regrowth and allow the
patient to be splint free. Axon regrowth may be less
than optimal for the denervated muscle, and the early
tendon may assist in function. The combined results

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TENDON TRANSFERS ! OMER, JR

of early tendon transfer plus the return from nerve

repair often are better than those of either procedure
separately.25
The muscle tendon units used as internal splints
should be synergistic with the muscle-tendon unit to
be replaced, such as a wrist flexor in substitution for a
finger extensor. A synergistic muscle-tendon unit will
be able to use spinal reflex arcs and other autonomic
feedback mechanisms to enhance re-education. The
early transfer should not cause deformity when nerve
function is recovered.26

RADIAL PALSY: EXTENSION

OF THE

WRIST

ower grip is impossible in radial palsy, even

though there is no volar injury.8 The pronator
teres (PT) transferred to the extensor carpi radialis
brevis (ECRB) will produce active wrist extension,
encourage passive flexion of the metacarpophalangeal
(MCP) joints, and allow ulnar innervated intrinsic
muscle interphalangeal (IP) extension. Increasing dorsal extension power of the wrist by an increment of
one may increase power grip 3 to 5 times.27 After
suture, the wrist should rest for 5 weeks in 20 of
extension against gravity.

LOW MEDIAN PALSY: ABDUCTION

OF THE THUMB

ow median palsy results in a loss of functional

abduction and pronation of the thumb. The functioning extensor pollicis longus (EPL), extensor pollicis brevis (EPB), and abductor pollicis (AP) will
create a supination deformity of the thumb and eventually an adduction contracture of the first metacarpal.
Reconstructive transfers will fail if there is contracture
of the first web space.28
Opposition of the thumb normally is initiated by
the abductor pollicis brevis (APB).29,30 A transfer to
only the tendon of the APB has the appropriate result,
except in patients with very mobile MCP joints. In
these patients, the transfer should include the tendon
of the EPL.31 Postoperatively, a short arm cast is
applied, holding the thumb in full abduction. The
cast is removed after 5 weeks, and the patient is
taught to observe thumb abduction when the fingers
are extended. If there is continued instability in the
longitudinal arch of the thumb, the MCP joint should
be arthrodesed.

LOW ULNAR PALSY: THUMB ADDUCTION,

CLAWED FINGERS, AND METACARPAL

n isolated tendon transfer cannot restore all the

power requirements in a low ulnar palsy, but a
single flexor digitorum superficialis (FDS) tendon can
improve thumb adduction for key pinch, the clawed
position of ring and small fingers, and the flattened
metacarpal arch.11,30 The long FDS is preferred; however, the ring FDS may be used if the ulnar innervated
portion of the flexor digitorum profundus (FDP) is not
paralyzed.
The functional mechanism of this tendon transfer1
is similar to the Bunnell32 tendon T surgery, except
that the distal edge of the palmar fascia is the pulley
rather than a free tendon graft between the first and
fifth metacarpals. Postoperatively, the wrist should be
in slight dorsiflexion, the thumb should be adducted
and pronated, the MCP joints of the fingers should be
flexed, and the IP joints of the fingers should be
extendedthe hoe-hand position. This intrinsic plus
position is maintained with plaster immobilization for
4 weeks before active extension is permitted.24
Distal stability for tip pinch between the thumb
and index finger is improved with arthrodesis of the
MCP joint of the thumb,11 and is indicated when the
patient develops a hyperextension deformity of the
MCP joint (Jeannes sign) after tendon transfers.
Complete Lesions of Individual Nerves
Reconstruction of a complete nerve lesion should be
limited to essential function. The key to success for
transfer procedures is simplicity, because complexity
invites failure. Increased power for a given function
must be introduced from another normal power train.

ISOLATED RADIAL PALSY

he requirements for restoration of forearm and

hand function after radial palsy are as follows: (1)
wrist extension, (2) finger extension, (3) thumb extension, and (4) stability of the carpometacarpal joint
of the thumb (Table 2). Usually, there is loss of
accessory elbow flexion and forearm supination, but
this is not obvious if there is a normal biceps brachi.
Trauma to the upper arm (high lesion) may include
loss of elbow extension, and an injury to the forearm
(low lesion) may spare radially deviated wrist exten-

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219

TABLE 2
Isolated Radial Palsy
Needed Function

Available Motor

Motor Retained for Balance

Wrist extension
Finger and thumb extension

PT to ECRB
FCU to EDC and EPL or FDS (middle and ring) to
EDC, EIP, and EPL or FCR to EDC and PL to FPL

Proximal thumb stability

FCR split insertion to APL and FCR or tenodesis of PL

and EPB (mobilized from first dorsal compartment)

sion.25 Active wrist extension is obtained by transferring the median-innervated PT to the ECRB tendon.8,24,33,34
The oldest procedure for digital extension uses the
ulnar-innervated flexor carpi ulnaris (FCU) muscletendon.8 To increase excursion, the FCU is freed from
its fascial attachments. The limiting factor is the
innervation of the FCU, which enters the muscle in its
proximal 5 cm. The FCU is directed subcutaneously
around the ulna and superficial to the tendons of the
EDC. The extensor digitorum minimi (quinti) (EDM)
is not included unless the EDC slip to the small finger
is absent. After appropriate tension is set for the EDC,
the EPL tendon is included.35 This full FCU transfer
often results in a slight radial deviation of the hand at
the wrist.8,24,31
The fingers and thumb also can be extended by the
median innervated FDS tendons to the middle and
ring fingers.8,9 The tendons are divided proximal to
the chiasma, separated from the profundi tendons and
delivered into the forearm. Just proximal to the pronator quadratus, 2 windows are incised in the interosseous membrane, one on either side of the anterior interosseous artery. The middle FDS passes to the
radial side of the profundus muscle group and the ring
FDS passes to the ulnar side. Bare FDS tendons without muscle cover will adhere to the membrane during
healing with loss of motion. The ring FDS is attached
to the tendons of the EDC and the long FDS is
attached to the EPL and extensor indicis proprius
(EIP). The anastomoses should be made well proximal
to the dorsal retinaculum, and the recipient tendons
are not divided proximal to the suture anastomoses.25
In FCU and FDS transfers, the tendons must be tight
enough to provide functional extension of the wrist,
thumb, and fingers, yet not so tight as to limit
functional flexion of the wrist and fingers. Full flexion
of the wrist is uncommon after reconstruction.

Pronator quadratus
FCR and PL
FDP
FCU
PL and FCU
FCU

Without a stable thumb, strong pinch is impaired.

One technique is to tenodese the extensor pollicis
longus and the EPB for proximal stability of the
thumb. The EPB is mobilized from the first dorsal
compartment before setting the tenodesis.24
Postoperatively, a double sugar-tong splint is applied to immobilize the forearm in 30 pronation, the
wrist in 45 of extension, the MCP joints in 0 of
extension, and the thumb in maximum extension and
abduction. Six weeks after surgery the patient is
placed in a dynamic splint to obtain independent
action for wrist and finger extension. Usually there is
good control of wrist extension and mass extension of
fingers 3 months after surgery.24

ISOLATED MEDIAN PALSY

he requirements for restoration of forearm and

hand function after median palsy are as follows:
(1) thumb abduction and opposition, (2) thumb flexion, (3) flexion of the index and middle fingers, and (4)
improve sensibility over distribution of the median
nerve (Table 3).
A low median palsy involves the intrinsic muscles
of the hand and the cutaneous sensation of the hand
and usually results from injuries in the distal third of
the forearm or wrist. Low median palsy results in a
loss of functional abduction and pronation of the
thumb, and reconstructive transfers will fail if there is
contracture of the first web space.
The EIP is the preferred transfer to achieve abduction of the thumb.24 The tendon is advanced subcutaneously around the ulnar border of the forearm by
using the pisiform and adjacent vertical fibrous tissue
as a pulley. The tendon is passed subcutaneously
across the wrist, though a muscle tunnel in the paralyzed APB, and on to the MCP joint. This helps
prevent the transferred tendon from becoming a pain-

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TENDON TRANSFERS ! OMER, JR

TABLE 3
Isolated Median Palsy
Needed Function

Preferred Motor

Alternate Transfer

Thumb abduction (low

palsy)
Thumb flexion (high
palsy)
Finger flexion (index and
middle) (high palsy)

EIP to APB (and EPL)

EDM, PL, FDS (ring)

BR to FPL

ECRL to FPL

Tenodesis of FDP (ring and small) to FDP

(index and middle)

Sensibility of thumbindex volar pinch

Ulnar digital nerve translocation

ECRL to FDP (index) and tenodesis

of FDP (middle) to FDP (ring and
small)
Neurovascular cutaneous island
pedicle, free nerve grafts,
superficial radial neurocutaneous
flap

ful bowstring across the proximal palm.26 In isolated

median palsy the transfer can be attached to the
tendon of the APB.36 In combined palsies with no
intrinsic muscle activity in the thumb, the transfer
should be attached to the APB tendon and the EPL
tendon over the proximal phalanx.37 If the MCP joint
of the thumb is unstable, it should be arthrodesed.
A high median palsy involves intrinsic and extrinsic muscles of the hand as well as cutaneous sensation
of the hand.
For thumb flexion, the BR is transferred to the
FPL.24 The BR should be freed extensively from all
tissue attachments so that it has approximately 5 cm
of passive mobility.38
For index and middle finger flexion, the tendons of
the FDP are pulled proximally until all 4 finger pulps
are in transverse alignment instead of normal oblique
alignment. The tendons of the median inactive index
and middle FDP are tenodesed to the tendons of the
ulnar innervated ring and small FDP muscles. A
double line of sutures is important to prevent shifting
of the tendons during power grasp. Index finger flexion can be individualized by transferring the tendon of
the extensor carpi radialis longus (ECRL) to the tendon of the index FDP, leaving the middle FDP powered by the ulnar nerve.9,38
Tendon transfers improve motor activity, but the
potential to improve function is equally dependent on
the associated sensory loss. There are no standard
recommendations for restoring sensation, and reconstruction may be a neurovascular cutaneous island
pedicle, a digital nerve translocation, free nerve grafts,
or other techniques.24,31,39 I prefer an ulnar digital

nerve translocation. One should not expect recovery of

tactile gnosis with precise function for thumb-index
pulp pinch. The young person will adapt visual and
position senses with other feedback mechanisms to
obtain better function than indicated by the surgical
reconstruction.

ISOLATED ULNAR PALSY

lnar palsy results in a hand with so many functional problems that there is no accepted program for reconstruction (Table 4). The requirements
for restoration of forearm and hand motor function
after low ulnar palsy are as follows: (1) thumb adduction power for key pinch, (2) power flexion of the
proximal phalanges and integration of MCP-IP motion, (3) thumb-index tip pinch, and (4) metacarpal
transverse arch and small finger adduction, plus (5)
volar sensibility for middle and ring fingers.
For thumb adduction, the ECRB is released from
its insertion and attached to a free tendon graft. The
graft is passed into the palm through the third intermetacarpal space and tunneled superficial (volar) to
the AP and deep (dorsal) to the flexor tendons and
neurovascular structures.40 The graft is attached to the
tendon of the APB, which improves pronation for
pinch.
For thumb-index tip pinch, an accessory slip of the
abductor pollicis longus (APL) can be elongated with
a free tendon graft and transferred to the tendon of the
first dorsal interosseous. This transfer does not appreciably increase the force of tip pinch, but it stabilizes
the index finger. Biomechanical studies show a 75%

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221

TABLE 4
Isolated Ulnar Palsy
Needed Function
Thumb adduction for key
pinch (low palsy)
Thumb-index tip pinch

Proximal phalanx power

flexion and integration of
MCP and IP motion
(clawed fingers)
Metacarpal (palmar)
transverse arch and
adduction for small finger

Volar sensibility for ring and

small fingers
Distal finger flexionfor ring
and small fingers (high
palsy)
Wrist flexionulnar side

Preferred Motor

Alternate Transfer

ECRB, with free tendon graft between

thirdfourth metacarpals, to tendon of
APB
Slip of APL to first dorsal interosseous
tendon, and arthrodesis MCP joint of
thumb
ECRL with 2- or 4-tailed graft passed volar
to deep transverse metacarpal ligament
to either A2 pulley of flexor sheath or to
radial band of the dorsal apparatus
EDM tendon is split and ulnar half is
transferred volar to deep transverse
metacarpal ligament to radial collateral
ligament of proximal phalanx or A2
pulley of the flexor sheath (EDC of small
finger must be effective)
Proximal median digital nerve translocated
to distal ulnar digital nerve
FDP (middle) tenodesed to FDP (ring and
small), with possible tendesis of distal IP
joints in the ring and small fingers
FCR to insertion of FCU

FDS (middle) to abductor tubercle of thumb,

with palmar fascia as pully

to 80% loss of power pinch in patients with ulnar

nerve palsy.41 I recommend arthrodesis of the MCP
joint of the thumb when there is instability in the
longitudinal arch of the thumb.42
A reliable procedure to increase power for gross
grip is to add a muscle-tendon unit to the power
train for flexion of the proximal phalanx. Burkhalter and Strait43 prolonged the ECRL with a free
graft, usually a palmaris longus (PL) or plantaris.
The free graft is split into 2 slips that are passed
through the intermetacarpal spaces between the
middle and ring fingers and the ring and small
fingers. A 4-tailed tendon graft can be used. The
tendon slips pass volar to the deep transverse metacarpal ligament and are sutured either into the A2
pulley of the flexor sheath or into the lateral band of
the extensor apparatus. The flexor pulley insertion
does not assist in finger extension, and the extensor
apparatus insertion is a potential swan-neck deformity. Postoperative immobilization is continued
for 4 weeks, with the wrist maintained in 45
dorsiflexion and the MCP joints in 60 flexion. The
ECRL contracts during finger flexion. The FCR may
be used as the motor transfer in patients with
palmar flexion deformity.44

EPB to first dorsal interosseous tendon, if

MCP joint of thumb arthrodesed
If wrist flexion contracture, FCR with 4-tailed
graft to either flexor sheath (A2 pulley) or
lateral bands of dorsal apparatus
If small finger is clawed as well as
abducted, insert ulnar half of EDM only
into A2 pulley

Free or vascularized nerve graft

PL to insertion of FCU

Paralysis of the 4 dorsal interossei, 3 volar interossei, and abductor digiti quinti prevents active abduction and adduction of the fingers, with associated
instability of the transverse metacarpal arch. Instability (flattening) of the transverse arch may contribute
to recurrent clawing after lumbrical replacement procedures. Blacker et al45 found that the EDM had the
potential to abduct the small finger through its indirect insertion into the abductor tubercle on the proximal phalanx. This action normally is balanced by the
third palmar interosseous, which becomes inactive in
ulnar palsy.46
The ulnar half of the EDM is passed between the
fourth and fifth metacarpals into the palm. If the small
finger is clawed as well as abducted, the tendon slip is
inserted through the A2 pulley of the flexor sheath. If
the small finger is not clawed, the tendon slip is
passed beneath the deep transverse metacarpal ligament and sutured into the radial collateral ligament of
the MCP joint of the small finger.24,44
Low ulnar palsy has loss of sensibility over the volar
side of the small finger and the ulnar aspect of the
volar side of the ring finger, plus additional loss of
sensibility in high ulnar palsy. There is no universal
method for improvement of the loss of sensibility;

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TENDON TRANSFERS ! OMER, JR

TABLE 5
Combined Low (Distal) Median and Ulnar Palsy
Needed Function

Preferred Motor

Alternate Transfer

Thumb adductionkey pinch

ECRB with free tendon graft between

third and fourth metacarpals, to APB
tendon
EIP around pisiform pulley and through
thenar muscle tunnel to APB tendon
insertion and EPL tendon
APL slip with free tendon graft to first
dorsal interosseous tendon and
arthrodesis thumb MCP joint
EDM tendon split and ulnar half
passed volar to deep transverse
metacarpal ligament to radial
collateral ligament of MCP joint of
the small finger or the A2 pulley of
the flexor sheath
ECRL or BR to all 4 fingers using 4tailed free tendon graft and insertion
in flexor sheath (A2 pulley) or lateral
bands of dorsal apparatus

FDS (middle) to abductor tubercle of thumb,

with palmar fascia and flexor tendons as
pulleys
PL to APB tendon insertion, (or) FDS (ring)
to APB tendon

Superficial radial nerve translocation or

cutaneous neurovascular island

Cross-finger index-to-thumb fillet flap

(superficial radial nerve)

Thumb abductionopposition

Thumb-index tip punch

Metacarpal (palmar)
transverse arch and
adduction for small finger

Power flexion for proximal

phalanges and integration
of MCP and
interphalangeal motion
(clawed fingers)
Median and ulnar volar
sensibility

current techniques include free nerve grafts, vascularized nerve grafts, and digital nerve translocation. All
are technically demanding and clinically unpredictable. Lewis et al46 performed digital nerve translocation. A functioning digital nerve of median origin is
sutured into the nonfunctional distal ulnar digital
nerve of the small finger. These investigators reported
that 85% of their patients obtained sensibility of S3!
or S4 after surgery.
High ulnar palsy includes the loss of extrinsic
power for flexion of the ring and small fingers, ulnar
power for wrist flexion, and the loss of sensibility over
the dorsum of the palm and small finger.24,47
If there is marked weakness of the ring and small
fingers in isolated high ulnar palsy, I tenodese the
FDP of the ring and small fingers to the FDP of the
middle finger in the forearm.48 The index FDP is left
free. One should consider tenodesis of the FDP across
the distal IP joints of the ring and small fingers.31
Ulnar deviation is as important for wrist flexion as
radial deviation is for wrist extension. It is useful to
transfer the flexor digitorum radialis tendon to the
insertion of the FCU in a patient with high ulnar
palsy who performs activities requiring strong wrist
flexion.

EPB or PL to first dorsal interosseous

tendon, with arthrodesis thumb MCP joint
FDS (small) to deep transverse metacarpal
ligament between fourth and fifth
metacarpals, (or) FDS (middle or ring)
combined as single transfer for thumb
adduction and metacarpal arch
FCR (if wrist flexion contracture) with 4tailed free tendon graft to either flexor
sheath (A2 pulley) or dorsal apparatus

COMBINED NERVE PALSIES OF

AND HAND

THE

FOREARM

endon transfers in combined nerve palsies are

more complicated than those in isolated nerve
palsy because there may be complex extremity injuries. Muscle-tendon units often are lacerated and
sometimes avulsed, resulting in poor proprioception
and distorted sensibility. Circulation usually is impaired, with pain and increased fibrosis. The need for
multiple surgeries complicates rehabilitation and delays reconstructive procedures.24,49

COMBINED LOW (DISTAL) MEDIAN

AND ULNAR PALSY

ow median-ulnar palsy is the most common combined nerve palsy (Table 5).24,39,49
The complete loss of palmar sensibility and intrinsic motor muscles produces an almost useless
and often clawed hand. Intrinsic muscle loss is the
major motor problem, and evaluation shows a flat
transverse palmar arch (metacarpal arch), with hyperextension at the MCP joints and hyperflexion at

TENDON TRANSFERS ! OMER, JR

223

TABLE 6
Combined High (Proximal) Median and Ulnar Palsy
Needed Function
Thumb adduction
(AP)key pinch
Thumb flexion (IP joint)
Thumb abduction (APB)

Thumbindex tip pinch

Finger flexion (FDP)

Power for flexion of

proximal phalanx with
integration of MCP
and IP motion
(clawed fingers)

Metacarpal (palmar)
arch and adduction
for small finger
Wrist flexion
Median and ulnar volar
sensibility

Preferred Motor

Alternate Transfer

ECRB with free tendon graft between

third and fourth metacarpals to
APB tendon
BR to FPL in forearm
EIP with pisiform pulley to insertion
APB tendon (plus) EPL tendon

BR or EIP with free tendon graft between third and

fourth metacarpals to abductor tubercle of thumb
(APB tendon)
Tenodesis of FPL distal to MCP joint of thumb
EPL or ECU with free graft around pisiform pulley
to APB tendon (thumb MCP is arthrodesed and
no active motion at thumb IP joint)
EPB or PL to first dorsal interosseous, and fusion
of thumb MCP joint

Thumb MCP joint arthrodesis; and

APL slip with free tendon graft to
first dorsal interosseous tendon
ECRL to all 4 tendons of FDP with
possible tenodesis of distal IP of
ulnar 3 fingers
Tenodesis of all 4 digits with free
tendon graft from dorsal carpal
ligament volar to deep transverse
metacarpal ligament to lateral
bands of extensor apparatus (or)
from deep transverse metacarpal
ligament to extensor apparatus
EDM to deep transverse metacarpal
ligament (EDC of small finger must
be active)

Superficial radial innervated index

fillet flap to palm (or) first dorsal
metacarpal artery neurovascular
island pedicle flap

the proximal IP joints. Reconstruction of the

thumb is very important, and special effort must be
made to prevent adduction contracture of the
thumb-index web.40 The patient flexes the wrist to
obtain greater finger extension, a functional tenodesis, but with prolonged use this results in a fixed
flexion contracture of the wrist.
With appropriate postoperative splinting, all tendon transfers can be performed at one time. After the
individualized motor transfers, the residual loss of
sensibility is likely to be a greater functional problem
than motor patterns for grasp and pinch.

COMBINED HIGH (PROXIMAL) MEDIAN

ULNAR PALSY

AND

he involved hand rarely will be used for precision

activities after this severe injury (Table
6).11,24,39,49 The most important clinical problem is
the total loss of volar sensibility, whereas atrophy of

Biceps brachii extended with FCR tendon to

tendons of FDP
Capsulodesis of MCP volar capsule (or)
arthrodesis of PIP joints (or) arthrodesis of MCP
joints

EDM to radial lateral bands (extensor hood) of the

ring and small finger
ECU to insertion of FCU
Superficial radial nerve translocation (or) free
vascularized nerve graft

the finger pulps will discourage both precision and

power grip. If the other hand is normal, then the focus
is on improving key pinch and simple grasp. Before
reconstruction, it may appear that restoration of intrinsic function will not be necessary, but when flexion is restored to the IP joints, the fingers gradually
will assume a clawed position. In time, the wrist will
translocate ulnarward on the radius secondary to the
concentration of extrinsic forces to the radial side of
the hand.50 A sequela of the carpal change is a decrease
in the thumb-index web space, with an inability to
grasp larger objects.39
There are no recognized recommendations for reconstruction of sensibility in this nerve loss. Sensibility can be transferred to the radial volar aspect of the
hand by using the superficial radial nerve.39 Careful
testing of the superficial radial nerve will show the
distal level of sensibility on the dorsum of the index
finger. The skeleton of the index finger is removed
distal to the proximal third of the second metacarpal.

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TENDON TRANSFERS ! OMER, JR

TABLE 7
Combined High (Proximal) Ulnar and Radial Palsy
Needed Function

Preferred Motor

Wrist extension
Thumb adduction (key
pinch)
Clawed fingers: metacarpal
(palmar transverse arch),
and power flexion of
proximal phalanx and
integration of MCP and
IP motion
Thumb-index tip pinch
Proximal thumb stability for
abduction and wrist
flexion (radial side)
Wrist flexion (ulnar aspect)
Finger and thumb
extension

PT to ECRB
One-half FDS (middle) as split transfer,
to abductor tubercle of thumb, and
one-half FDS (middle) in 2 slips to
A2 pulley of flexor sheath for ring
and small fingers, and, later,
arthrodesis of proximal IP joints, ring,
and small fingers, if unable to extend
fully
Arthrodesis of thumb MCP joint
Tenodesis of APL to radius

Finger flexion (ring and

small)

Volar sensibilityring and

small fingers

FDS (index and ring) through

interosseous membrane to EDC and
EPL
Tenodesis of FDP (middle) as active
motor to ring and small FDP, and
tenodesis of DIP joint of ring and
small fingers, using FDP tendons
Median digital nerve translocation

The insensitive distal skin is discarded. The filleted

index finger flap is placed into an additional volar
defect created for it in the insensitive palmar skin.
This procedure will provide protective sensibility
within the thumb-middle finger space.49 An alternative to a fillet flap is a true neurovascular cutaneous
island. Procedures to improve sensibility should be
delayed until tendon transfers have completed initial
rehabilitation because early motion is pertinent to the
sensibility outcome.

COMBINED HIGH (PROXIMAL) ULNAR

RADIAL NERVE PALSY

Alternate Transfer

AND

atients with high ulnar-radial palsy retain radiovolar sensation, and reconstruction will improve
function (Table 7). Surgical rehabilitation is difficult
because surgical procedures need to be performed both
for finger extension and flexion and for thumb adduction and abduction.24,31,39,49 Surgery should be staged,
perhaps at 3-month intervals. The first phase might
include wrist and digit extension procedures with
thumb abduction. The second phase might include

Tenodesis with free tendon graft from

radial lateral band of dorsal
apparatus to deep transverse
metacarpal ligament, or
capsulodesis of MCP volar capsule

FCR (yoke insertion) to APL and

EPB
PL to insertion of FCU
PL to EDC and EPL

Free vascularized nerve grafts, or

neurovascular cutaneous island
pedicle

digit flexion and thumb adduction. Splints need modification for each phase.
Patients have median sensation, but lack the precise
ulnar motor function required for precise sensibility.
Sensibility procedures are the final stage of surgical
reconstruction, and should be delayed until all tendon
transfers have healed and initial rehabilitation has
been initiated.

COMBINED HIGH (PROXIMAL) MEDIAN

RADIAL NERVE PALSY

AND

endon transfers for patients with combined high

median and radial nerve palsy will result in a
hand that functions only slightly more effectively than
a prosthesis (Table 8).39,49 Patients with high medianradial palsy do not regain precise sensibility because
there are so few remaining precision muscle motors
and it is difficult to balance the advantages and disadvantages of digital nerve translocations. Many adult
patients do not have cortical reorientation after surgical procedures to restore sensation.

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225

TABLE 8
Combined High (Proximal) Median and Radial Palsy
Needed Function
Forearm pronation
Wrist extension and
flexion
Finger flexion
Finger and thumb
extension
Proximal thumb stability

Preferred Motor

Alternate Transfer

Biceps brachii tendon rerouting around the

radius
Radiocarpal arthrodesis

Tenodesis of FDP ring and small (active motors)

to FDP index and middle fingers
FCU to tendons of EDC and EPL

Arthrodesis of thumb MCP joint, and tenodesis

of APL tendon to radius

Thumb abduction
(opposition)

Thumb flexion

Tenodesis of FPL across thumb IP joint

Radiovolar sensibility

Ulnar digital nerve translocation

LONG-TERM FOLLOW-UP EVALUATION

here have been only a few reports of long-term

evaluation of tendon transfers after trauma. Some
compare the selection of motor muscles,51 and some
evaluate the changes in function over a period of time.
Dunnet et al52 reported on radial palsy. Tendon transfers were performed an average of 32 months after
injury, then followed-up for an average of 66 months
before reporting. All patients showed functional improvement after surgery. However, 66 months later,

Abductor digitiquinti to the insertion of

the APB, or AP tendon insertion
from adductor tubercle to the
abductor tubercle
Biceps brachii extended with FCR
tendon to tendon of FPL
Neurovascular cutaneous island
pedicle from ring finger, or free
vascularized nerve graft

55% had difficulty grasping or releasing large objects,

64% had impaired coordination and dexterity, and
82% reported premature fatigue with wrist extension.
Force was measured by comparison with the contralateral normal limb; the involved limb was 53% for
power pinch, 40% for power grip, 31% for MCP
extension, and 22% for wrist extension. Is this the
usual 5.5 year outcome? Does the function change in
radial palsy for normally median or ulnar innervated
muscles? We need more long-term follow-up evaluation and functional evaluations of tendon transfers.

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