Biceps-to-Triceps Transfer in

Tetraplegic Patients: Report of the

Medial Routing Technique and
Follow-up of Three Cases
Julian E. Kuz, MD, Ann E. Van Heest, MD, James H. House, MD,
Minneapolis, MN

We reviewed 4 biceps-to-triceps transfers for active elbow extension in 3 tetraplegic patients

using a medial routing technique. The biceps-to-triceps transfer to regain active elbow
extension in tetraplegic patients is an alternative to the more commonly described deltoid-
to-triceps transfer. Before surgery, all 3 patients had absent triceps function and active biceps,
brachialis, and supinator function. Postoperative results were assessed by a modified Univer-
sity of Minnesota Functional Improvement questionnaire and by follow-up evaluation of range
of motion and muscle strength. All 3 patients had marked functional improvement in activities
that involve active elbow extension, and no loss of function was noted in any activities. No
patient achieved less than grade 4 extension strength; none had an extension lag greater than
8°. Supination and flexion strength following transfer were rated as at least grade 4 in each
limb. Based on the results of this study, we recommend the biceps-to-triceps transfer as an
alternative to the deltoid-to-triceps transfer in spinal cord injury patients with active brachialis
and supinator function. The medial routing technique has the advantage of avoiding the
potentially devastating radial nerve injury that could occur with the previously described
lateral routing. (J Hand Surg 1999;24A:161–172. Copyright © 1999 by the American Society
for Surgery of the Hand.)
Key words: Tetraplegia, elbow paralysis, tendon transfer

In tetraplegic patients who lack active elbow ex-
tension due to spinal cord injury, active elbow ex-
tension can be achieved through transfer of an active
muscle into the paralyzed triceps. The improvement
in function following triceps reconstruction in tet-
raplegic patients has been termed “fundamental in-
From the Department of Orthopaedic Surgery, University of Min-
nesota, Minneapolis, MN.
Received for publication June 19, 1997; accepted in revised form
June 2, 1998.
No benefits in any form have been received or will be received from
a commercial party related directly or indirectly to the subject of this
article.
Reprint requests: Ann E. Van Heest, MD, Department of Orthopae-
dic Surgery, University of Minnesota Hospital, 420 Delaware St SE,
Box 492 UMHC, Minneapolis, MN 55455.
Copyright © 1999 by the American Society for Surgery of the Hand
0363-5023/99/24A01– 0024$3.00/0
tervention.”1 The functional gains of elbow exten-
sion reconstruction in these patients include reaching
objects above shoulder level, reaching objects when
in a supine position, improved ability and safety of
driving, wheelchair propulsion, pressure relief, and
independent transfer.2,3 In addition, gaining active
elbow extension provides a useful antagonist to el-
bow flexion for improvement of hand positioning in
space and helps stabilize the elbow when the bra-
chioradialis is used as a tendon transfer.
Tetraplegic patients who have an International
Classification of level 4 or less (Tables 1, 2)1,4,5 are
candidates for tendon transfers for elbow extension.
The posterior deltoid-to-triceps and the biceps-to-
triceps transfers have been the 2 most common types
of transfers used for elbow extension. The disadvan-
tages of a posterior deltoid-to-triceps transfer include

The Journal of Hand Surgery 161

162 Kuz, Van Heest, and House / Biceps-to-Triceps Transfer: Medial Routing
the need for a free tendon graft,6,7 a long immobili-
zation time,1 and the potential for the double tendon
repair to stretch out in time, resulting in decreased
strength.1,8 Attempts at earlier mobilization of this
transfer have been associated with poor results.5,9,10
The biceps-to-triceps transfer can be used in pa-
tients who have active supinator and brachialis mus-
cles to provide for the lost functions of the trans-
ferred biceps. The biceps-to-triceps transfer has
several inherent advantages. These include the abil-
ity to correct flexion-supination deformities of the
forearm at a single stage, avoiding the need for a free
tendon graft, earlier time to mobilization due to
having only 1 tendon junction to heal, and no func-
tionally apparent decrease of elbow extension
strength over time. The standard described technique
for biceps-to-triceps transfers has been through a
lateral route.11–13 In high spinal cord injury patients,
the radial nerve is the only functioning nerve below
elbow level. If the radial nerve is injured during
lateral routing, the resultant loss of active wrist ex-
tension can be a devastating complication.2,12,13 The
use of medial routing avoids this potentially devas-
tating complication, as the biceps tendon passes me-
dially over the paralyzed ulnar nerve, with no poten-
tial loss of distal function. The use of medial routing
Table 2. International Classification
Group Muscle Characteristics
0 Weak BR
1 BR (grade 4/MRC)
2 BR and ECRL
3 BR, ECRL, ECRB
4 BR, ECRL, ECRB, PT
5 BR, ECRL, ECRB, PT, FCR
6 BR, ECRL, ECRB, PT, FCR, finger extensors
7 BR, ECRL, ECRB, PT, FCR, fingers and thumb
extensors
8 Group 7 muscles 1 partial digital flexors
9 Lacks only intrinsics
BR, brachioradialis; ECRL, extensor carpi radialis longus;
ECRB, extensor carpi radialis brevis; PT, pronator teres;
FCR, flexor carpi radialis.
Data from McDowell et al.1
 The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 163

of the biceps tendon has been briefly mentioned in
previous reports without a detailed description of the
technique and without follow-up results.14,15
The purpose of this study is to describe in detail
the medial routing technique of the senior author
(J.H.H.) for transferring the biceps to the triceps to
regain active elbow extension in tetraplegic patients.
The surgical results of this technique in 3 patients,
representing 4 transfers, are also presented.
Materials and Methods
Four transfers in 3 patients who underwent a bi-
ceps-to-triceps transfer using a medial route and the
senior author’s (J.H.H.) method were identified.

Table 3. Functional Improvement Questionnaire Results

Much Better Better No Change Worse NA
Hygiene and grooming
Washing 2 1
Shaving 1 1 1
Brushing hair 1 2
Brushing teeth 1 2
Clipping nails 1 2
Faucet use 3
Shower 1 2
Eating
Cutting meat 1 2
Opening 1 2
Pouring 1 2
Using utensils 2 1
Dressing
Dress upper 2 1
Dress lower 1 2
Fastening 2 1
Communication
Using phone 1 1 1
Writing 1 1
Typing 2 1
Homemaking
Prepare meals 1 1 1
Making bed 1 1 1
Wash dishes 2 1
Transfers
Car 3*
Bed 1 2
Shower/tub 1 2
Toilet 1 2
Couch 1 2
Wheelchair
Mobility 2 1†
Elbow extension specific
Opening doors 2 1
Elevator buttons 3
Light switch 3
Retrieving objects from shelf
above shoulder level 2 1
Answering phone while in bed 3
Turning on light while in bed 3
Removing blankets 3
Driving 3
NA, not available.
The results listed are the functions of patients compared with presurgical performance for functional
activities of daily living.
* All use electric lift.
† Uses electric wheelchair.
164 Kuz, Van Heest, and House / Biceps-to-Triceps Transfer: Medial Routing
These patients had their surgery performed by 2 of
the authors (J.H.H. and A.V.H.). Charts were re-
viewed for demographic information, surgical tech-
nique, complications, postoperative rehabilitation,
and additional procedures performed. Surgical re-
sults were assessed by a modified University of Min-
nesota Tendon Transfer Functional Improvement
Questionnaire16 with the addition of triceps-specific
activities as presented in Table 3. This questionnaire
asks patients about general activity improvements,
pain, and satisfaction, as well as 34 specific activities
of daily living with modifications that specifically
address the goals of active elbow extension recon-
struction. The questionnaire requires the patient to
rate postoperative function compared with preoper-
ative function as much improved, improved, no
change, worse, or much worse.
The demographics of the 3 patients who under-
went the procedure are shown in Table 4. Additional
1-stage key pinch reconstructions16 were performed
in all 3 patients, either simultaneously with the bi-
ceps transfer (patient 2) or 6 months later (patients 1
and 3).
All 3 patients had follow-up periods ranging from
12 to 66 months. Two patients (representing 3 trans-
fers) returned to the clinic for follow-up strength and
range-of-motion testing. The third patient lived out
of state and had measurements performed by her
physical therapist. Objective assessment of surgical
results were made by goniometric measurement of
active and passive elbow flexion/extension and fore-
arm pronation/supination. Muscle strength was
graded in the standard fashion (grades 0 –5) through
the extension arc with a rating of 3 indicating anti-
gravity strength; 4, partial resistive strength; and 5,
complete resistive strength.
Surgical Technique
To perform this surgical procedure, the patient is
placed in a supine position. The arm is prepared and
Table 4. Postoperative Range of Motion and Muscle Strength Results
E/F P/S
Patient Side AROM (°) AROM (°)
1 R 4/145 80/80
1 L 6/142 80/75
2 R 5/145 80/75
3 L 8/140 80/80
E/F, elbow extension/flexion; P/S, pronation/supination; AROM, active range of motion.
draped free in a sterile manner. A sterile tourniquet is
placed as proximal on the arm as possible.
An anterior longitudinal incision is made over the
medial aspect of the biceps muscle belly. This inci-
sion passes over the cubital fossa obliquely (Fig. 1).
The musculocutaneous nerve is identified and pro-
tected throughout the procedure. The lacertus fibro-
sus is transected distally with a portion of antebra-
chial fascia in continuity with the biceps tendon to
create a second tail for subsequent tendon weaving.
The biceps tendon is isolated to the insertion on the
radius and then sharply divided. A #5 nonabsorbable
braided polyester suture is placed in the biceps ten-
don using a locked grasping suture. A #0 Ethibond
suture is similarly woven into the lacertus fibrosus as
a second tail of the biceps tendon (Figs. 2, 3).
A posterior incision is made over the triceps ten-
don, being careful not to make the incision directly
over the olecranon (Fig. 4). This incision is biased
laterally to avoid a medial skin bridge that is too
narrow. A subcutaneous tunnel is fashioned along
the medial aspect of the arm by dissecting free, and
resecting if necessary, the medial intermuscular sep-
tum. The biceps muscle and tendon are delivered into
the posterior incision through the subcutaneous tun-
nel (Fig. 5). Attention is directed to ensure a straight
and free line of pull through the subcutaneous tissue.
The tendon is passed superficial to the ulnar nerve.
Through the posterior incision, the biceps tendon is
woven in a Pulvertaft fashion into the distal triceps
tendon. A 4-mm unicortical hole is drilled into the tip
of the olecranon to receive the tendon and suture.
Two small holes are drilled through the far cortex of
this hole to allow passage of Keith needles, allowing
the suture to be tied over the bone, deep to the
aconeus muscle on the posterior lateral side of the
proximal ulna. The transfer is tensioned to permit
90° of passive elbow flexion. A #0 nonabsorbable
braided polyester suture is interwoven in the area of
tendon repair to secure the transfer. The distal end of
Flexion Strength Extension Strength Supination Strength
Grade Grade Grade
5 5 5
5 5 5
5 4 4
5 4 4
 The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 165

(Figs. 6, 7). The incisions are closed in layers in the

usual fashion.
After surgery, the patient is maintained in a well-
padded, long-arm fiberglass cast with the elbow in
less than 30° of flexion. Three weeks after surgery, a
flexion block splint is placed to prevent elbow flex-
ion beyond 45°, and gentle active motion is started.
Training of the biceps to extend the elbow is done on
a “powder board” (a horizontal table to eliminate
gravity and powdered to diminish friction) on which
the patient learns to extend by the elimination of
gravity and use of supination cognizance. Over the
next 6 weeks, the flexion block is progressively ad-
vanced (approximately 15°/wk) to allow more flex-
ion. The medially routed biceps can be palpated and
seen along the medial humerus to assess for control
and function; antigravity strength is achieved as
shown in Fig. 8. If satisfactory progress has been
made by 8 to 10 weeks, strengthening against resis-
tance is started.

Figure 1. Anterior skin incision. (Adapted and reprinted

with permission.17)

Figure 2. Bicipital tendon and aponeurosis have been

the biceps tendon is then secured to the local peri- isolated and tagged. The musculocutaneous nerve is pro-
osteum. The lacertus fibrosus tail is braided as a tected. BT, bicipital tendon; BA, bicipital aponeurosis;
reinforcement, weaving it through the triceps and the MCN, musculocutaneous nerve. (Adapted and reprinted
biceps tendons, securing the tension on the transfer with permission.17)
166 Kuz, Van Heest, and House / Biceps-to-Triceps Transfer: Medial Routing
Figure 3. Clinical view of the drawing in Figure 2. The musculocutaneous nerve can be seen lying on the brachialis muscle
just underneath the elevated biceps.
Results
All patients stated they were highly satisfied with the
surgery, would undergo surgery again under similar
circumstances, and had no residual pain. As shown in
Table 3, no patient lost function in any category. The
functions most greatly improved included driving a
van, performing activities while supine, and retrieving
objects from above shoulder height. All 3 patients
stated that activities which required precision hand
placement had improved. In addition, all 3 patients
stated that they were able to eliminate the need for
several adaptive aides, ie, push stick for elevator but-
tons. Improved wheelchair propulsion and recreational
activity, such as swimming, were reported. The patient
with bilateral transfers reported the greatest number of
functional improvements. The patient with the shortest
follow-up period (12 months) showed the least number
of functional improvements, yet stated that the transfer
was continuing to gain strength and selective control
with time.
Range of motion and muscle grading data are
presented in Table 4. Postoperative elbow exten-
sion strength was grade 4 or 5 in all cases, im-
proved from a preoperative strength of grade 0.
Postoperative elbow flexion strength was main-
tained at grade 5 in all cases. Postoperative supi-
nation strength was maintained at grade 5 in 2
elbows and diminished to grade 4 in 2 elbows.
Preoperative passive range of motion showed less
than a 15° contracture for all limbs in flexion,
extension, supination, and pronation. The average
postoperative flexion contracture was 6° (range, 4°
to 8°). The average postoperative active elbow
flexion was 142° (range, 140° to 145°), unchanged
from that before surgery. The postoperative active
supination was 75° to 80° in all cases.
No postoperative complications were noted. This
included no evidence of radial nerve palsy, rupture of
tendon repair, wound problems, loss of motion
(based on measurements), or loss of strength.
 The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 167
Figure 4. The posterior skin incision should be lateral
enough to avoid being placed over the tip of the olecranon
and leave an adequate skin bridge between the anterome-
dial incision. (Adapted and reprinted with permission.17)
Discussion
Tetraplegic patients who lack active elbow exten-
sion due to spinal cord injury have profound func-
tional loss. These patients have a difficult time per-
forming activities when in the supine position. This
includes turning on a bed lamp, answering a bedside
telephone, and removing blankets. In addition, these
patients cannot reliably use their hands above shoul-
der level because of the difficulty of holding the
elbow extended against gravity. This precludes them
from removing objects from a high shelf or receiving
an object that is handed to them above shoulder
level. The lack of an active antagonist to active
elbow flexion creates imprecisions for functions that
require the hand to be positioned in space. This
especially becomes a hindrance when coordinated
movement is needed, such as with driving, swim-
ming, and writing.18 The ability to extend the elbow
also facilitates dressing and undressing, because zip-
pers can be opened with active elbow extension
using a key ring orthosis to hook the zipper handle.
In 1975, Moberg6 introduced the deltoid-to-triceps
transfer with interposition graft. He noted marked
improvements in the ability of his patients to perform
transfers, reach for objects on high shelves, gain
pressure relief from the sitting position, and drive
more safely.6 Moberg7 also stated that the stabilizing
effect provided by a transfer for elbow extension is
more important than the power actually obtained.
Several investigators have reported their results
using the deltoid-to-triceps transfer.6 –10,12,18 –22 Pre-
dictable functional gains were noted in many of these
reports. A number of complications have been re-
ported with this procedure, including lack of final
60° active extension against gravity in 50% of pa-
tients,12 lack of active extension against gravity,20
stretching of the tendon repair resulting in decreased
strength and extensor lag,1,6,8 and development of
heterotopic ossification in the posterior deltoid mus-
cle.18 Despite these occasional complications, no pa-
tient lost function to a level worse than preoperative
levels.6,8,18,21 The deltoid-to-triceps transfer usually
requires a free tendon graft.6,7 This requires up to a
6-week immobilization time.1 Attempts at earlier
mobilization of this transfer have been associated
with poor results.6,9,10 Improvements in the tech-
niques of tendon suture have helped avoid the
stretching phenomenon and have decreased the post-
operative immobilization time from 6 weeks to 4.5
weeks.20 An additional method uses a “turned-up”
central slip of triceps tendon with a small block of
bone from the ulna. This bone block is attached to
the posterior deltoid insertion, which also has been
elevated with a small block of bone from the hu-
merus.23 Because of failures with this latter tech-
nique, Moberg reported that he had abandoned it.1
Hentz et al24 reported a technique in which the
deltoid was directly attached to the triceps aponeu-
rosis without an interposition graft. This permitted an
168 Kuz, Van Heest, and House / Biceps-to-Triceps Transfer: Medial Routing
Figure 5. The tendons are delivered along the medial route into the posterior incision.
immobilization time of 4.5 weeks, but no results
were reported.
In 1954, Friedenberg11 reported on the first use of
biceps transfer to restore elbow extension in a tet-
raplegic patient. His patient underwent bilateral
transfers that resulted in a full range of motion of the
elbow and the ability to independently transfer. In
this same report, Friedenberg11 also reported a case
by Mayer in which bilateral biceps transfers for
active elbow extension were undertaken in 1951.
This patient lacked the final 30° of extension, but
made gains in the ability to hold objects in front of
his body, use the typewriter, and perform indepen-
dent toileting.11 Both of these cases involved the
lateral routing technique.
Zancolli5 reported 6 cases of biceps-to-triceps
transfer using the lateral route. He preferred this
transfer over the posterior deltoid because of sim-
plicity, and he stated that supination is not lost be-
cause the supinator muscle is active if wrist exten-
sion is present. A distal insertion into the olecranon
was used. Zancolli occasionally used electromyogra-
phy or peripheral nerve blocks to differentiate be-
tween biceps and supinator function in cases in
which it could not be determined clinically.1,5 The
measured extension power was from 250 to 900 g.
Zancolli also noted no clinically significant loss of
elbow flexion power and that re-education of elbow
extension “is very simple.”5 A later report by Zan-
colli2 of 13 patients who underwent biceps-to-triceps
transfer with an average follow-up period of 37
months showed 80% good or excellent results and no
poor results (criteria not mentioned). No function
related to active flexion worsened and there was a
flexion strength loss of 24%. Active supination was
preserved in all patients. One patient did sustain a
radial nerve neurapraxia with resolution by 4
months.2 While a flexion contracture of greater than
20° is considered a contraindication to deltoid trans-
fer, Zancolli stated he would still use a biceps trans-
fer.1
Hentz et al20 briefly reported the use of biceps-to-
triceps transfers for active elbow extension in tet-
raplegic patients. The number of patients who had
this procedure, however, was not specified in the
report since a number of deltoid-to-triceps proce-
dures were also performed. In this series, 2 poor
results occurred. Both patients had bilateral recon-
 The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 169

received a biceps-to-triceps transfer. The patient’s

result “proved unsuccessful.”5 No further informa-
tion was given explaining why this was an unsuc-
cessful result.
In 1988, Ejeskär12 reported the results of 5 patients
who underwent biceps-to-triceps transfers using the
lateral route. Two patients had no active extension.
One of these was subsequently scheduled for a del-
toid-to-triceps transfer. One patient developed a ra-
dial nerve palsy but was beginning to recover after 5
months. Despite this finding, Ejeskär12 reported that
the biceps transfer is “the procedure of choice” and
“preliminary results of the biceps transfer seem to
exceed those of the posterior deltoid transfers.” His
recommendation was to perform a biceps transfer in
all patients who have an elbow flexion contracture
and when the patient does not request very strong
active elbow flexion for a specific activity. His re-

Figure 6. A locking weave is used to secure the biceps

transfer to the triceps. The biceps is delivered into a
unicortical hole and sutures are tied over the distal cortex
to provide additional fixation of the transfer. BA, bicipital
aponeurosis; BT, bicipital tendon. (Adapted and reprinted
with permission.17)

struction for elbow extension: 1 had deltoid-to-tri-

ceps transfers and the other had biceps-to-triceps
transfers. Both patients achieved only grade 2 to 21
extension strength and had “moderate to severe”
elbow contractures before surgery.20 Neither patient
had progression of elbow contractures after surgery.
Despite this “poor” result, both patients were
“pleased” with the procedure.20 In 1996, Hentz and
Ladd15 reported the use of the medial route for the
biceps-to-triceps transfer without describing specific Figure 7. The final appearance of the tendon anastomosis.
results. The probe at the left edge of the incision indicates the
In 1983, Lamb and Chan10 reported a patient who suture that has been tied down over the distal olecranon.
170 Kuz, Van Heest, and House / Biceps-to-Triceps Transfer: Medial Routing
Figure 8. Patient 1 demonstrating full, active, strong el-
bow extension from the supine position following biceps-
to-triceps transfer, with the active biceps seen along the
medial border of the humerus.
sults were briefly updated in 1989.13 Ejeskär reported
on 10 patients, all who had biceps-to-triceps transfers
through a lateral route. Most had “good” results,
especially those patients with a contracture present.
Exercises could be started at 3 to 4 weeks. One radial
neurapraxia and “a few cases” of the insertion pull-
ing out were reported.13 This report, presented in
abstract form in 1988 at the Third International Con-
ference on Surgical Rehabilitation of the Upper Limb
in Tetraplegia (Quadraplegia) (Goteborg, Sweden),
showed that 8 of 10 transfers had full passive elbow
extension with an average follow-up of 9 months.
However, 4 transfers failed to demonstrate active
extension after surgery.
The 3 patients in this study viewed the biceps-to-
triceps transfer procedure with high satisfaction. No
functional loss in any category was identified. Note-
worthy gains were made in the activities of driving,
ease of transfers, pressure relief, handling objects
above shoulder level, use of the hands when supine,
and improvement in precision movement. These cat-
egories are similar to the areas in which Moberg7
saw improvements in his patients undergoing deltoid
transfers. The greatest improvements came in the
patient with bilateral transfers with all 34 categories
rated as “much better.” The patient interviewed at
only 12 months after surgery scored only 9 activities
in the “much better” range. This patient noted grad-
ual improvement of functional activities over time.
In this study, the functional improvements ob-
tained by gaining active elbow extension are consis-
tent with the experience of others.7,10,18,20 –22 It has
been shown that by providing an antagonist to elbow
flexion, these patients can improve their pinch
strength from brachioradialis transfer.25 Gaining ac-
tive elbow extension in these patients helps prevent
further contracture.20 None of the patients in the
current series perceived a worsening of contractures
or any deterioration in strength over time.
Flexion contractures at the elbow diminish the
gains of an active transfer. It has been shown that an
elbow contracture of 50° in tetraplegic patients with
at least grade 4 strength will eliminate the ability to
perform independent transferring.26 Grover et al26
recommend that operative release be considered
when the flexion contracture is greater than 25° in
patients with weak triceps function. Freehafer3 has
shown that biceps tenotomy in tetraplegic patients is
effective in reducing flexion and supination deformi-
ties of the elbow. The advantage of the biceps trans-
fer over the deltoid transfer is that by removing the
deforming force of the unopposed biceps, flexion and
supination deformity can be corrected at a single
stage with the transfer. If the deltoid transfer is used
instead, a 2-stage procedure is required in which the
first stage would be to release the elbow flexion
contracture requiring a biceps tenotomy. Zancolli’s4
biceps rerouting procedure will correct the supina-
tion deformity but not the flexion imbalance.
We believe that biceps-to-triceps transfers have
several important advantages over deltoid transfers.
Because of the small number of patients in this
series, direct comparisons of technique and statistical
analysis comparing techniques cannot be conducted.
The theoretical advantages of this technique over a
posterior deltoid transfer include the ability to correct
 The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 171
flexion-supination contractures of the forearm at the
same stage as the transfer. Having only one very
secure tendon junction to heal also allows for early
mobilization. Furthermore, our technique is arguably
technically easier than the deltoid transfer. No addi-
tional donor site for a free tendon graft, with its
potential for wound healing complications, is neces-
sary. Dynamic flexion-supination deformities of the
forearm can be corrected by removing the deforming
force of the biceps. The advantage of routing medi-
ally over laterally is the avoidance of the area of the
radial nerve and the potentially devastating radial
nerve palsy. In these patients, the only innervation to
the muscles below the elbow is by way of the radial
nerve (Table 1). Any loss of these muscles means
loss of hand function. With medial routing, the ulnar
nerve has the potential for being injured, but in
tetraplegic patients at a spinal cord injury level of C6
or above, the ulnar nerve is nonfunctional. We also
believe that the medial routing of the biceps provides
a more direct route for the tendon transfer with less
risk of adhesions that may occur between a laterally
transferred tendon and adjacent muscles as it passes
across them in the distal lateral arm.
The presence of an active supinator and brachialis
muscle are usually assured if wrist extension or a
strong brachioradialis is present. “Spotty” innerva-
tion of these muscles, however, can exist and must be
checked with a thorough preoperative clinical exam-
ination. Careful observation and palpation of the
muscles are required. The brachialis can be isolated
by resisted flexion of the elbow while the patient
leaves the forearm in a pronated position to inacti-
vate the biceps. The biceps is palpated during muscle
testing to verify that it is inactive while elbow flexion
or forearm supination strength is tested, verifying
brachialis and supinator strength. The supinator is
isolated by testing resisted forearm supination with
the elbow in extension to inactivate the biceps. Ulnar
innervated muscles must be checked to ensure that a
“spotty” tetraplegic level has not left some function
that could be injured.
Our current recommendation is to use the biceps-
to-triceps transfer, with medial routing, for tetraple-
gic patients who lack elbow extension and have
brachialis and supinator function that can be con-
firmed on examination. The biceps-to-triceps transfer
is also advantageous in patients with greater than 30°
flexion or supination deformity caused primarily by
the unopposed biceps. Passive elbow and forearm
range of motion should be maximized before tendon
transfer.
References
1. McDowell CL, Moberg EA, House JH. The second inter-
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2. Zancolli EA. Tetraplegia. In: McFarlane RM, ed. Unsatis-
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Vol. 3. New York: Churchill Livingstone, 1987:274 –280.
3. Freehafer AA. Flexion and supination deformities of the
elbow in tetraplegics. Paraplegia 1977;15:221–225.
4. Zancolli E. Surgery for the quadriplegic hand with active,
strong wrist extension preserved: a study of 97 cases. Clin
Orthrop Rel Res 1975;112:101–113.
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