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Tendon Transfers for Nerve Palsies
Comprehensive Hand Review Course

American Association of Hand Surgeons
Annual Meeting, Friday January 23rd, 2015
Atlantis in Paradise Island, Bahamas
Amy M. Moore, MD
Washington University School of Medicine
I. Introduction
Functional deficits after nerve injury are determined by the specific nerve involved and location of the
injury.
Reconstruction of function after nerve injury is dependent on time from injury, presence of concomitant
injuries (bone and soft tissue) and availability of donors (i.e. redundancy of function).
Definition: Tendon transfer transfer of a functional muscle-tendon unit to replace a lost or missing
muscle-tendon unit in order to restore motion or balance to the wrist and/or hand.
II. Principles
In order for successful return of function, certain principles should be considered:
Tissue Equilibrium: Resolution of Wound Healing, Bony Union, and Correction of Contractures
Local tissue should be in optimal condition: soft, mobile, no evidence of induration
Full passive joint ROM is necessary preoperatively
This may require contracture releases, therapy and splinting
Avoid transfers across scar tissue and skin grafted areas.
Plan incisions to place tendon junctions beneath flaps rather than beneath incisions or scars
Expendable Donor
Avoid downgrading function with unacceptable donor
loss
Patients needs vary for priority
Goal: maintain at least one wrist flexor (not PL alone),
wrist extensor, extrinsic finger flexor and extensor.
Adequate Strength
Goal: balance of power
Consider: lost muscle strength, donor muscle strength
and remaining counterbalance strength
Force is proportional to muscle cross sectional area at
resting length
Expect the muscle to lose one grade of strength after
transfer
Try to avoid using previously denervated muscle
Appropriate Excursion
Tendon Excursion must match for function
Proportional to fiber length
Methods to Augment effective Excursion:
Tenodesis effect: Wrist flexion/extension gives up to
25mm
Straight line of Pull

Avoids loss of power and excursion
One Tendon One Function

Donor function will be dissipated and less effective if multitasking
Synergism
Capitalize on Tenodesis and use muscles that commonly work together
Assists with postoperative rehab and retraining
III. Tendon Transfers for Specific Nerve Injuries
Radial Nerve Tendon Transfers

Distinguish High Versus Low Injury
High (Radial Nerve Proper): Triceps, Brachioradialis, ECRL
Low (Posterior Interosseous Nerve): Supinator, ECRB, EDC, ECU, EDM/Q, APL, EPL, EPB,
EIP
i.e. Loss of finger extension at MP joints and Thumb IP extension
Common Tendon Transfers: Brand, Jones, Boyes
Brand (most common)

Wrist Extension: PT to ECRB
Finger Extension: FCR to EDC
Thumb Extension: PL to EPL
Perform transfers in sequence: wrist, fingers then thumb
Include EDM if EDC to small finger is diminutive
Jones
Finger Extension: FCU* to EDC
Thumb Extension: PL to EPL
Reluctance to use FCU since it is the most powerful wrist flexor
FCU is critical in hammering and dart throwing motion
Boyes
Thumb/Finger Extension*:
FDS (ring) to EIP/EPL
FDS (long) to EDC/EDM
FDS taken through IOM
Median Nerve Tendon Transfers

Distinguish High Versus Low Injury
High: PT, FCR, FDP,PL, FDS, FPL, PQ, ABP, OP, superficial head of FPB, Lumbricals I, II
Functions to Restore: Finger flexion, Thumb Flexion and Opposition
Low: Opposition (ABP)
Low Injuries Most Common: Restoration of Opposition

Restores prehensile pinch and grasp
Vector of pull: Pisiform
Insertions: APB tendon, APB/EPL
Options for Opponensplasty

FDS Ring (Royle-Thompson/Bunnell)
EIP (Zancolli, Burkhalter)
ADM (Huber)
PL (Camitz)
Other Less common options: ECU, APL, FCR, ECRL
High Median Nerve Palsy

Loss of intrinsic and extrinsic function
Finger Flexion, Thumb Flexion and Opposition
No need to address loss of FCR and PL if ulnar function intact
Smith and Hastings(1980)
EIP to APB
BR to FPL (thumb IP arthrodesis for stability)
FDP tenodesis (side to side, powered by ulnar)
Burkhalter (1974)
EIP to APB
BR to FPL
ECRL to FDP (index and middle)
Boyes (1970)
ECU (with graft) to thumb prox phalanx
BR to FDP (index and long)
ECRL or B to FPL
Brand (1975)
ECU (with graft) to Prox Phalanx thumb
FDP tenodesis
ECRL to FPL
FCU split to FCR and FCU for wrist balance
Others less common (Goldner)
Ulnar Nerve Tendon Transfers

Multiple Signs Associated with Ulnar Nerve Palsy
Goldfarb et al. JHS 2003
Distinguish between High Versus Low Injury

Low: Loss of power pinch, claw deformity decreased hand strength and loss of coordinated
hand/finger activity, loss of fine motor control
Interossei, Lumbricals (small and ring), Adductor pollicus, Hypothenar Muscles (FDM/Q,
AbDM, ODM)
High: Loss of extrinsic finger flexion to small and ring(FDP) and ulnar wrist flexion (FCU) and
Intrinsic function
Decreased power grip with up to 50% loss of grip strength in addition to low injury deficits
Correction for Low Ulnar Nerve Palsy

Ulnar Claw Deformity def: Hyperextension of MP joints (from pull of intact extrinsic extensors) and
Flexion of IP joints (from pull of intact extrinsic flexors) due to paralysis of interosseous muscles of
all fingers and ulnar innervate lumbricals to ring and small fingers.
Ring and small finger are most affected but all four fingers can be impacted.
Low injuries result in more dramatic clawing with extrinsic flexors (FDP) intact.
Results in loss of coordinated grasp with DIP joint flexion followed by PIP then MP joint flexion.
Physical Exam
Assess motion, both active and passive, of all joints.
Identify contractures.
Identify any other concomitant nerve injuries.
Bouviers maneuver test the integrity of central slip and lateral bands (function of the PIP joint)
by blocking MP in flexion and testing extension of PIP and DIP joint.
If full active extension of PIP and DIP joint intact then normal function of extensor apparatus
is preserved.
If full extension of PIP and DIP with MP blocking (POSITIVE TEST) then static
procedures are possible to correct hyperextension of MP joint
If PIP remains flexed with MP blocked (NEGATIVE TEST) then dynamic tendon transfer
is needed to extension of PIP joint.
Surgical Options for Anti-Claw
Static Techniques: Prevent hyperextension of MCP joint

Bony blocks on the dorsum of MC head
MP joint capsulodesis with volar plate advancement
Bunnell flexor pulley advancement to create bowstringing of flexor tendon
Tendon graft sutured to the deep transverse intermetacarpal ligament
Dynamic Techniques: Prevent hyperextension of MP joint and also have ability to extend PIP joint by
inserting onto lateral bands.
3 main types:
Dynamic tenodesis tendon is looped through the extensor retinaculum, along the
lumbricals, and inserted into lateral bands
Dynamic procedures using digital flexors
Dynamic procedures using wrist motors (ECRB, ECRL or FCR)
See Table 4 for specifics (see below)
Restoration of Power Pinch

Smith Transfer: ECRB to Adductor Pollicus (AP) with graft
FDS ring to AP
APL to FDI with graft
EIP to AP
Finger Flexion
FDP side to side tenodesis
Gottschalk HP and Bindra RR. 2012
IV. References:
Seiler et al. Tendon Transfers for Radial, Median, and Ulnar Nerve Palsy J aM Acad Orthop Surg 2013;
21:675-684
Ratner and Kozin. Update on Tendon Transfers for Peripheral Nerve Injuries. JHS 2010:35A:1371-1381.
Goldfarb and Stern. Low Ulnar Nerve Palsy. JHS. 2003; 3:1.
Davis, TRC. Median and Ulnar Nerve Palsy. In Wolfe SW, Hotchkiss RN, Pederson WC, Kosin SH
(eds). Greens Operative Hand Surgery (6th ed). Elsevier Churchill Livingston, Philadelphia 2011;
chapter 34, pp 1093 -1137.
Gottschalk HP and Bindra RR. Late Reconstruction of Ulnar Nerve Palsy. OrthopClin N Am 43 (2012)
495-507
Sammer D and Chung K. Tendon Transfers Part II. Transfers for Ulnar Nerve Palsy and Median Nerve
Palsy. Plast Reconstr Surg. 2009 Sept; 124(3):212e-221e.

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Tendon Transfers for Nerve Palsies

Comprehensive Hand Review Course

In order for successful return of function, certain principles should be considered:

Straight line of Pull

One Tendon One Function

III. Tendon Transfers for Specific Nerve Injuries

Radial Nerve Tendon Transfers

Common Tendon Transfers: Brand, Jones, Boyes

Brand (most common)

Median Nerve Tendon Transfers

Low Injuries Most Common: Restoration of Opposition

Options for Opponensplasty

High Median Nerve Palsy

Ulnar Nerve Tendon Transfers

Goldfarb et al. JHS 2003

Distinguish between High Versus Low Injury

Correction for Low Ulnar Nerve Palsy

Surgical Options for Anti-Claw

Static Techniques: Prevent hyperextension of MCP joint

Restoration of Power Pinch

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