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website: www.diuchirurgiemain.


Management of upper
limb nerve palsies

Christian Dumontier, MD, PhD
Centre de la Main, Guadeloupe (French West Indies)
With the Help of Caroline Leclercq (Paris) and Francis Chaise (Nantes)


Are not included in this

Are included

Brachial plexus palsy

Tetraplegia, spastic,…

Recent nerve injuries that
are repairable

Sensory deficits

Motor deficit of
median, ulnar or
radial nerve not
amenable to direct
nerve repair

The different topics



Radial nerve palsy (high or low):
functioning (ECRB innervation
g is variable)

a low, regarding the IOA)
Median nerve palsyav
o eo
Ulnar nerve
or Low)
Combined nerve palsies (i.e. Median + ulnar, high or
low, Median + radial, Ulnar + radial,…)

50 different muscles are used to
activate movement in the hand
and forearm

5 muscles that control

7 muscles control movement of
the hand at the wrist

18 muscles that flex and extend
the digits

20 small muscles of the hand
that contribute to precise motion

Innervation and transferable

Motor territories

Main transferable


High (humerus): BR, ECRL, ECRB


High (elbow): FCR, PL, FDS MII-V,
Low (wrist): Opp, CF, Lb


Low: Add, IO


First of all: the goal is to restore a
function (not a movement)

The radial nerve opens the hand through extension of the
elbow, wrist and fingers;

The median nerve allows precise thumb-finger pinching
through motricity of the thumb and index, along with
independence of the long fingers through the flexor
digitorum superficialis (FDS);

The ulnar nerve is the nerve of forceful grasping as it
controls the flexor digitorum profundus (FDP), intrinsic
muscles in the long fingers and deep thenar muscles

Not all patients want the same function,
as they do not have the same demands
You’ll have to tailor
your surgery

To restore a function (not a
movement) can be done by:

Bone & joint surgery,

Passive motion (i.e using tenodesis

Active motion (tendon transfer
mostly, rarely nerve transfer or direct

Joint stabilization

Arthrodesis may be needed in severe cases but
is usually avoided (lost of the tenodesis effect).

Ligamentous repair may be needed before
tendon transfer

Capsulodesis can help in lax patients


Only done in very severe cases when there is not
enough transfer to use

Passive function

Nerve transfers

Many have been described,
mostly for brachial plexus

One major limitation: The
recipient nerve must have
viable muscle motor plates

Muscle fibrosis and atrophy
begins immediately after
denervation and plateaus after
four months when 60–80% of
muscle volume has been lost.

SK. Lee and S. W. Wolfe, “Peripheral nerve
injury and repair,” JAAOS 2000; 8 (4):243–252

Motor end plates

There is an accepted window period of 12–18 months
for muscle reinnervation to occur in order to achieve
functional recovery before irreversible motor end plate
degeneration occurs.

Although there is no definite evidence to support this

The timeframe for sensory reinnervation is longer but
not infinite.

Scientific evidences

Failure of functional recovery has historically been attributed predominantly to
irreversible atrophy of muscle targets and their replacement by fat,

Animal experiments indicates that it is the progressive failure of the neurons and
Schwann cells to sustain axon regeneration over distance and time

Fu and Gordon (1995) using a rat tibial nerve model demonstrate that, after delayed
repair of more than four months, regeneration declined to ~33% of the number of
axons that could regenerate after an immediate nerve repair. Muscle function was
equivalent (despite denervation), due to compensation by innervating 3-fold the
number of muscle fibres compared to normal - With increasing denervation times,
the pool of successfully regenerated axons dwindled and overall muscle function

S.Y. Fu and T. Gordon, “Contributing factors to poor functional recovery after delayed nerve repair: prolonged
denervation,” Journal of Neuroscience, vol. 15, no. 5, pp. 3886–3895, 1995.
S. Y. Fu and T. Gordon, “Contributing factors to poor functional recovery after delayed nerve repair: prolonged
axotomy,” Journal of Neuroscience, vol. 15, part 2, no. 5, pp. 3876–3885, 1995.

Some basic knowledge on

Suggested Reading:
Coulet B. Principles of tendon transfers. Hand Surgery and Rehabilitation 35
(2016) 68–80
Livermore A., Tueting JL. Biomechanics of Tendon Transfers. Hand Clin 32
(2016) 291–302

Tension of muscle

The functional unit of active
contraction is the sarcomere

At resting length, the potential
for force generation is greatest
due to the maximal overlap of
myosin and actin.

Muscle cross- sectional area
directly relates to a muscle’s
ability to generate tension,
with a figure of about 3.6 kg/

Elasticity of the muscle

Elasticity of muscle causes it to shorten when stretched or released from

This is due both to connective tissue, and to titin an intrasarcomeric
cytoskeletal protein.

This interplay is
diagrammed with
the Blix curve

Schematic relation
between active
contraction and elasticity

When the hammer strikes, it is
using both the active
contraction of B plus the elastic
recoil in B that has been put
into it by A ( From Brand)

Excursion and

Excursion is a function of the length of the muscle fibers and the
pennation angle (a). Force is a function of the muscle’s volume
(V) and its length (‘). The cross-sectional area (CSA) is equal to
V/‘. The physiologic CSA (PCSA) takes into account the
pennation angle (a): PCSA = V.cos a / l.

Anatomic cataloging

Brand classified all the muscles below the elbow
according to their fiber length (excursion), and crosssectional area (reformulated as tension fraction).

Lieber developed a difference index that quantifies the
architectural (fiber length and cross section) similarity
between 2 muscles

Calculations were made for all
muscles. See

Brand PW, Beach MA, Thompson DE.
Relative tension and potential
excursion of muscles in the forearm
and hand. J Hand Surg Am 1981;6(3):

Lieber RL, Jacobson MD, Fazeli BM, et al. Architecture of selected muscles of the arm and
forearm: anatomy and implications for tendon transfer. J Hand Surg Am 1992;17(5):787–98

Choosing a transfer
FCR Removal

Tendon chosen as a donor for transfer must be
sufficiently strong to perform its new function in its
altered position.

Use Brand and Thompson tables

If possible, avoid using a muscle that has been
previously denervated or injured

A muscle should not be used for transfer unless it
can be graded as being at least good (Steindler
recommended 85% of normal).

Omer noted that a muscle usually loses one grade
of strength (on Highet’s clinical scale) after transfer.

Expandable donor: do not harm a function

Modification after transfer: a muscle loss one grade ?

Muscle tension ( function of cross- sectional area), should not change if
appropriate tensioning is made.
Limits to excursion
✤ Partially related to the mismatch of excursion of the native muscle to the
vector and excursion of the substitute.
✤ Resistance.
✤ Avoid scars and poorly vascularized tissues.
✤ Place the transfer in the subcutaneous fatty tissue above the deep fascia
as scarring will be minimal and will be reasonably mobile.
✤ As adherence to local tissues is unavoidable, avoid placing the hand in
an extreme position that would only allow a small amount of motion in
the opposite direction
Overtensioning: Laser diffraction studies have shown that clinical judgement
of the surgeon resulted in over tensioning the muscle which can only generate
approximately 28% of its maximal contraction.

Force-generating ability of muscles in
the upper limb (Brand)

Finger flexors with high
force generation and greater
than 70 mm excursion;

Finger extensors, are
weaker and have less than
50 mm excursion;

Wrist flexors and extensors,
which have less than 30 mm
excursion but have
significant force-generating

Boyes, 3, 5, 7 rules

Muscle synergy

Motor muscles of the long
fingers and of the wrist are

Finger flexion is associated with
wrist extension and vice-versa—
tenodesis effect.

Functional synergies are
supplemented by the summation
of the excursion of the transfers,
PLUS the wrist’s tenodesis effect.

Brand’s diagram is used to identify two major systems for the extrinsics

A high energy system that requires a long excursion and high force
production (finger flexors and wrist extensors) → always need a strong
muscle transfer

A low energy system that requires less excursion and force (wrist flexion
and finger extension) → can be activated by gravity during wrist flexion
and a weaker muscle transfer or simple tenodesis effect for the extensors

Functional systematization of the
paralyzed hand - The rationale

To activate the various degrees of freedom in the joints of
the hand you need many muscular motors

Which is not compatible with the small space in the hand.

The solution is to use two systems: an extrinsic one where
the motors are located in the forearm and an intrinsic
system located in the hand itself.

The two are cleverly synergistic and complementary.

Functional systematization of the
paralyzed hand - The thumb

Main function of the intrinsic
system is to position of the first

Activation of the pinching motion
is mainly controlled by the
extrinsic system.

Thumb motion will depend of the
injured nerve

Functional systematization of the
paralyzed hand - The long fingers

The two motors of flexion and extension, extrinsic and
intrinsic, have offsetting application points, which allows
them to be complementary and synergistic:

The extrinsic system activates the flexion of the proximal
interphalangeal (PIP) and distal interphalangeal (DIP) joints,
and the extension of the metacarpophalangeal (MCP) joints,

The intrinsic system controls MCP flexion and PIP and DIP

Functional systematization of the
paralyzed hand - The long fingers

The extrinsic system is essential for opening and closing the
fingers, but without the action of the intrinsic system, extension
is incomplete, stopping at the MCP joints, and their flexion is
uneven with early MCP flexion inhibiting proper gripping


The extrinsic flexors are powerful motors with significant excursion (highenergy system). The extensors require less force and excursion (low- energy

Functional systematization of the
paralyzed hand - The wrist

Wrist motricity reinforces the action of the extrinsic

Flexion belongs to the low-energy system and can
mostly be ensured through gravity alone.

In contrast, active wrist extension is essential for
strong grasping actions; any deficiency here must be
addressed first.

Principles of tendon transfers

To remember: you are not allow to
do mistakes (Riordan)

“…in muscle tendon surgery there is very little hope
that errors in technique can be overcome by local
adaptation. The success or failure of an operation
depends upon the technical competence of the
operator and his painstaking after-care.”
“…there is usually only one chance to obtain good
restoration of function in such a paralyzed hand.”

As tendon transfer
surgery started long
time ago, many
important points
have been

A pre-requisite: tissue equilibrium

Quality of soft-tissues, Supple,
of good quality;

Skin must be healed, wait until
all tissues are mature

No scars should limit tendon

Revision scar surgery or flaps
coverage must be needed
before tendon transfer

A pre-requisite: The articulations

All joints should be supple and mobile : No tendon
transfer can move a stiff joint.

Hypermobile joints or excessive joint laxity can
predispose tendon transfers to overcorrection. Be
cautious in patients with collagen disorders or

Key points

One tendon, one function (Scuderi 1949)

Key points: balance and synergism

Achieve balance does not imply equal strength on either side of a
joint, but rather sufficient strength to ensure stability

Synergism is integrally related to balance. It denotes 2 or more
muscle functions that amplify the effect of the others

Active synergism involves 2 concurrent actions (ex: wrist
extension with finger flexion). Synergistic relationships during
tendon transfer facilitates post retraining.

Sequential synergism relates to the passive stretch placed into a
muscle by the active contraction of a complementary muscle.
This places it in a more mechanically advantageous position

Surgical approaches

Must allow release of the muscle being transferred and exposure of
the distal tendon attachment, while keeping the functional cutaneous
units intact and avoiding any restrictive bridle scars.

The transferred muscle must pass through the fewest possible
incisions to reduce the potential for adhesions as much as possible.

A large incision provides access to all of the areas needed to release
and reattach the transferred tendon (should cross the transfer and
not parallel to it).

Multiple smaller incisions over the working areas that are joined by
subcutaneous tunnels.

Increase tendon excursion

Transform a mono-articular muscle in a bi or pluri-articular
(i.e. using the tenodesis effect)

Muscle Release:

Reorient some of the tendon and muscle fascicles,

Allows for a straighter line of pull, without the angulation
that causes excessive resistance.

Example: BR release increases excursion from 5 to 30 mm

Tendon trajectory

The trajectory of a transferred muscle–tendon unit greatly determines its action.

Example: EIP transfer : when proximal to the pisiform, the transfer has a
larger abduction component; when it is distal to the pisiform, the adduction
component will be greater.

A straighter trajectory results in greater activity, and less energy lost to friction.

When not possible a pulley should be strong and generate minimal soft tissue

Distal fixation

It determines the action of the transfer:

If the fixation point is away from the rotational axis of the
joint, the moment arm of the transfer will be larger ➡ a
larger force will be applied to the joint, but a larger
excursion will be needed for the same movement amplitude

Distal fixation

The fixation must allow for early mobilization

If fixed to the tendon of the muscle being
revived, it will not alter its function,

If fixed to a bone segment, its action is altered
or even amplified.

The fixation must allow the tension on the
transfer to be set and adjusted (a Pulvertafttype weave is preferred).

Setting the tension: most important
and delicate

Keep the following principles in

Contrary to excessive tension,
rehabilitation can never make
up for inadequate tension;

Excessive tension can cause
muscle dysfunction.

Mark intraoperatively the donor
muscle with sutures at fixed
intervals before is detachment.

Setting the tension: methods used
to set the tension

For postural transfers such as restoring elbow or wrist extension, tendons
must have maximum tension on them so that only 50% of the movement
amplitude against gravity is restored (for example a wrist extension transfer
must be tensioned so that flexion against gravity does not exceed the neutral

Transfers for restoring finger flexors: Tension must be such that the fingers
are practically fully closed by wrist extension only, while maintaining full
extension of the fingers when the wrist is flexed.

Transfers for restoring extensors: The transfer must be tensioned so that it
produces MCP extension up to the neutral position of the wrist when straight,
while maintaining full flexion of the fingers when the wrist is extended.

Multiple tendon transfers

Fixation of a transfer should not compromise the
fixation of the others

Usually, fix the most distal first then from distal to
proximal (to test tennis using the tenodesis effect) .

Postoperative period and
rehabilitation: not to be minimized

Very important

Allows tendon healing and
prevents adhesion

Complication, such as hematoma, infection or wound
dehiscence, will negatively affect the outcome because of
the risk of suture failure and adhesions.

Rehabilitation: Principles

Sutures must be protected (outside of rehabilitation work) throughout
the 6–8 weeks tendon healing period.

Early mobilization is debated; it reduces adhesions and facilitates the
integration of the transfer versus could cause the sutures to release.

Typically immobilize transfers for 3 weeks. Starting in the 4th week,
the transfers will be ‘‘awakened’’ mainly through passive motion
using the tenodesis effect in the wrist and elbow. Active loading can be
initiated during the 6th week; patients will only be allowed to perform
resisted contractions starting in the 8th week.

Cortical integration of the transfers is generally not a problem

One more challenge

Tendon transfers have been described in the era of poliomyelitis (pure
motor palsies) and world war I & II (few if any nerve repair, combined

Today most traumatic nerve injuries are repaired and we face patients with
« some » recovery. A meta-analysis of median and ulnar nerve repairs
demonstrated that only 51.6% achieve satisfactory motor recovery (M4-5),
with even less (42.6%), experiencing satisfactory sensory recovery (S3+ to

In ulnar nerve injuries, the chance of motor recovery was 71 percent lower
than in median nerve injuries (odds ratio, 0.29; 95 percent confidence
interval, 0.15 to 0.55).

Ruijs AC et al. Median and ulnar nerve injuries: a meta-analysis of predictors of motor and
sensory recovery after modern microsurgical nerve repair.PRS 2005 116(2):484-96

Application of
principles to
upper limb
motor palsies

Radial nerve palsy

High radial nerve palsy due to
humeral shaft fractures

1,8 to 18% (< 10%) pre-op palsies; expect recovery

Indications for open surgery and radial nerve
control could be open fractures, fractures which
cannot be aligned satisfactory, fractures with
associated vascular injuries, and poly-fractured

Most authors agree that nonoperative management of
the radial nerve palsy is the treatment of choice.

Radial nerve palsy
and humeral shaft #

Motor recovery may not appear
until 4 or 5 months (EMG evidence
of reinnervation may precede the
clinical appearance by 4 weeks,)

The major advantages of this plan
of management are (1) unnecessary
operative intervention is avoided,
(2) most patients achieve full
recovery of the radial nerve without
surgical treatment, and (3) the
humerus fracture usually is healed.

Do not wait longer than 6 months

High radial nerve palsy

High radial palsy is the likely the most satisfying
indication for tendon transfers.

Both wrist and finger extension are paralyzed.

Loss of grip strength 25-50%

Difficulty in grasping objects

The hand’s intrinsic function is intact and there are no
major sensory deficits in the hand.

Two of the systems are deficient, the ‘‘high-energy’’ one,
which is the priority for restoring wrist extension, and
the ‘‘low-energy’’ one that controls finger extension.

Available donors

A patient with irreparable radial nerve palsy needs to be
provided with:

Wrist extension,

Finger (MP joint) extension,

and a combination of thumb extension and abduction.

Motors available include all the extrinsic muscles
innervated by the median and ulnar nerves.

Radial nerve palsy

To restore wrist extension:

PT to ERCB (Jones, 1916)

If using the FCU for finger
extension, consider rerouting

If PT not available,
Brachioradialis can be used
(Vulpius, 1920)

Radial nerve palsy - Finger extension

al g
m in
x g
r ofrithe
n FCU in the
Use FCU to EDC (con’s: Importance
b w
dart throwing motion)
d bo
u d
or FCR to EDC- especially
nerve palsy
t m
s lu
n u
✤ in both cases, wrist
excursion (33mm) is
e ti
, tendons
inferior to sEDC
excursions (50 mm) - a
e or
a ns
good wrist
l motion
a ext
In e

or FDS to EDC (Boyes)

FCU Transfer according to Merle D’aubigné (1946)

FCR Transfer through the IOM
(Tsuge 1969)

Radial nerve palsy

To restore thumb

PL to re-routed EPL
(anterior or 2nd

FDS IV to EPL and
EIP( Boyes, 1960)

Three clinical results

Results: Dunnett 1995

49 injury to the radial nerve (22) or brachial plexus (27).

5.6 years FU. Function improved in 84%

Impaired coordination and dexterity > 60%

Premature fatigue > 80%

Wrist power extension 22% of contralateral side (8% to
80%), power of digital extension was 31% (5% to 130%),
and power grip was reduced to 40% (5% to 86%).

Nerve transfer for radial nerve palsy ?
(Mackinnon 1999)

Through a single volar radial
incision in the proximal
forearm, the radial nerve with
its posterior interosseous
component and the median
nerve are exposed.

The median nerve branches to
the FDS, pronator quadratus,
FCR, and PL are identified as
potential donor nerves

Median nerve palsy

Suggested readings:
Chadderdon RC, Gaston RG. Low Median Nerve Transfers (Opponensplasty). Hand Clin 32
(2016) 349–359.
Omer GE. Tendon Transfers For Traumatic Nerve Injuries. JASSH 2004; 4(3) 214-226.

Low Median nerve palsy

Motor function greatly depends on the sensibility of
the hand +++, the contralateral hand function,
patient’s motivation and ability to adapt to sensory

Low Median nerve palsy

Loss of function is
due to loss of
opposition (grasp a
coffee cup, hold a
telephone, throw a
ball, and write)

Low Median nerve palsy

Low median nerve palsy: surgery is rarely needed !

60% of patients regain or never lose good opposition
after median nerve repair, and thenar muscle function
frequently recovers after carpal tunnel release.

Dual innervation of the thenar muscles. FPB remains
functional in 73% of complete median and 58% of
complete ulnar nerve injuries.

Opponensplasty was required in only 14% of median
nerve injuries (Jensen)
Jensen EG: Restoration of opposition of the thumb, Hand 10:161- 167, 1978.

Distal insertion

Onto the APB +++ on the
radial aspect of the
thumb MP joint (the APB
does the three elementary

Avoid trying to restore
two functions (stabilize
the MP if needed)

The pulley

Except for Camitz's, you
need a pulley around
the pisiform

Of paramount
importance is the
orientation of the
transfer, while its
strength is less

The pulley

Adduction is proportional
to the length of the moment
between tendons and axis of
flexion (X)

Anteflexion is proportional
to the length of the moment
between tendon and axis of
TM (Y)

Most widely used tendon transfers
for restoring opposition

FDS opponensplasty: (3-8% of PIP contractures)

EIP opponensplasty +++ (High and low palsy)

Huber-Littler transfer (ADM)

Camitz procedure (palmaris longus) for severe CTS or
FDS5 (Peimer)

EIP opponensplasty
Aguirre & Caplan


Absence ?
Radial position ?
Multiple slips ?

How to find the EIP
at the wrist level ?


Absence: 0% to 4%
Radial position : 10%
Multiple slips: 3% to 14%

The EIP is the most
ulnar tendon and
the one which
muscular fibers are
the more distal

FDS (ring) but usually either severed or paralyzed and
need more force (43%) to obtain the same function
(Anderson 1992)

According to the choice of the pulley you will have
more antepulsion or more abduction

FDS Transfer
for thumb
using the FDS 5
in sever longstanding CTS

Richer 2005:
50 FDS transfer

FDS transfer

Loss of grip strength

Loss of PIP extension (8° in 50% of patients North

Good to excellent results in 60-85% of patients (Bohr
1953, Jensen 1978, Anderson 1992)


Anderson 1992 (166 pts)

89% good to excellent after EIP,
85% after FDS

EIP > FDS in their series

FDS (ring) needs more force
(43%) to obtain the same

Camitz’s transfer


Foucher 1991: 73 Camitz opponensplasty with > 90%
good results (good antepulsion and/or pronation)

Huber’s transfer

Short excursion
High tension
Limited indication to
congenital hands
(hypoplastic thumb)

High median nerve palsy

All the flexor compartment forearm
muscles apart from the ulnarinnervated FCU and the profundi to
the little and ring fingers are

Goals: restore thumb opposition
(especially if forearm pronation is
used as a substitute motion), FPL and
FDP2 (they usually recover in high
median nerve injuries)

Limitations: loss of hand sensations
dramatically reduces the functional
benefit of tendon transfers

High median nerve palsy

Only the brachioradialis, ECRL, and ECU are available
and suitable for transfer



Prefer laterolateral sutures FDP2,3 ➡ FDP4,5 to
ECRL ➡ FDP2 (Functional results only if the wrist is

Ulnar nerve palsy

Low ulnar nerve palsy =
loss of intrinsics of the

Very detrimental with deformity,
weakened grip, asynchronous motion
and loss of lateral finger mobility. 50% of
hand strength and 80% of pinch strength
are lost. The fingers roll up from distal to
proximal, with flexion of PIP and DIP
before MCP

Low ulnar nerve palsy = loss of intrinsics
of the hand

Low ulnar nerve palsy = loss of intrinsics
of the hand

Loss of adduction of the thumb: EIP ➡ ADD, or

EPB ➡ 1st IOD (or a slip of APL)

Claw hand: Passive stabilization (Zancolli 1), active
transfer (Lasso), active transfer of tendon graft over
a wrist extensor (Volar to deep intermetacarpal lgt)

Wartenberg’s sign: Rerouting EDQ

Restauration of
thumb adduction

FDS (ring) to ulnar side of the

EIP (or ECRB + graft) through
the metacarpals


Fischer 2003, 9 patients, ECRL to
AP, APL to 1st DIO

Key pinch 73%, pulp-to-pulp
pinch 72%, power grip 73%

Force of thumb adduction 63%

Force of index finger abduction

Large variations between

1st interosseous restoration

APL accessory slip (+ graft)
(Neviaser 1980)
PL (+ graft) (Hurayama 1986)
EPB (Bruner 1948)

Thumb MP / IP

In lax patients and longstanding ulnar nerve palsy, the
MP or IP joints may need to be
stabilized at the time of tendon

Thumb MP /
IP instability

This can be done through MP capsulodesis,
or sesamoids-metacarpal arthrodesis or MP

IP instability

If flexum < 40°, prefer
Tsuge tenodesis to IP

Correction of

Bouvier’s maneuvers will
differentiate reducible or
irreducible PIP joint


Stretch with time
whatever the technical
variations used in lax

FDS transfer (Lasso)

Patients will loose 20% of
their grip strength

FDS transfer

Bone (Burkhalter)

Stiles-Bunnell (if
maneuver does not


Brandsma (1992) observed 15%
swan-neck deformity, 29% DIP
flexion contracture and 26% PIP
flexion contracture over 158 FDS

North (1980) observed no


Ozkan 2003 (44 patients)

Lasso and ECRL-4 tail most effective for
grip strength

FDS 4-tail most successful in correcting
the claw hand deformity, especially in
long-standing paralysis in which there
was elongation of the extensor

Wartenberg ’s sign

Very disabling

How do you explain it ?

What is the Wartenberg’s
syndrome ?

Correction of
Wartenberg’s sign

Transfer of the ulnar
slip of the EDM to the
radial side

Correction of
Wartenberg’s sign

In case of clawing, the
radial slip is transferred


terior interosseous nerve is identified on the interosseous membrane 2- to 3-cm proximal to the
pronator quadratus muscle (Fig 1). The nerve is isolated from the accompanying anterior interosseous
vessels and then traced distally to and
pronator quadratus muscle.
within ! WOOD
228 HAND The
proximal third of the muscle will begin to branch and
at this level is sectioned sharply.
poor. Such would be the case for ulnar nerve inju
within or proximal to the proximal forearm or ex
Depending on the intended target nerve either the
sive median nerve loss distal to the anterior intero
thenar branch of the median nerve within the carpal
ous nerve branch point.
tunnel or the deep motor branch of the ulnar nerve
within Guyon’s canal is identified and isolated. Either
hrough a palmar distal forearm incision the
nerve then is traced proximally for 8 to 10 cm by
terior interosseous nerve is identified on the
terosseous membrane 2- to 3-cm proximal to
interfascicular dissection (Fig 2). For both of these
pronator quadratus muscle (Fig 1). The nerve is
nerves at the distal level there are usually few if any
lated from the accompanying anterior interosse
vessels and then traced distally to and within
intraneural interfascicular
cross-branches that require
pronator quadratus muscle. The nerve within
FIGURE 1. Photograph of an isolated distal portion of the
interosseous nerve
lying on the interosseous
memdisruption. Interfascicular
proximal third of the muscle will begin to branch
brane just proximal to the pronator quadratus muscle (cadavat this level is sectioned sharply.
eric specimen). to permit a tensionas far proximally as is necessary
Depending on the intended target nerve either
branch of the median nerve within the ca
free coaptation between the distal anterior interossetunnel or the deep motor branch of the ulnar n
that have athenar
poor prognosis
for recovery
ous nerve and the mobilized
or of within Guyon’s canal is identified and isolated. Ei
function by orthotopic means.
nerve then is traced proximally for 8 to 10 cm
ulnar deep motor branchWang
and Zhu were
the first to
reportisothis techinterfascicular dissection (Fig 2). For both of t
nique for reconstruction of either the thenar motor
nerves at the distal level there are usually few if
lated distal fascicular group
then is sectioned sharply
branch of the median nerve or the deep motor branch
intraneural interfascicular cross-branches that req
the ulnar
The primary
indication for this
and accurately coaptedof to
the nerve.
disruption. Interfascicular dissection is continued o

Motor nerve transfer

FIGURE 1. Photograph of an isolated distal portion of the
anterior interosseous nerve lying on the interosseous membrane just proximal to the pronator quadratus muscle (cadaveric specimen).

situations that have a poor prognosis for recovery of
function by orthotopic means.7-10
were the first to report this tech✤
nique for reconstruction of either the thenar motor
branch of the median nerve or the deep motor branch
of the ulnar nerve. The primary indication for this
procedure is an irreparable injury to the median nerve
distal to the branch point of the anterior interosseous
nerve or the ulnar nerve at any level proximal to the
wrist. This technique, however, also may be indicated
in nerve lesions amenable to nerve graft reconstructions if the prognosis for intrinsic motor recovery is

Terminal branch of anterior
interosseous nerve to deep motor
branch of ulnar nerve (Wang &
Zu 1997, Battiston 1999, Novak
2002, Wood 2004)




procedure is an irreparable injury to the median nerve
distal to the branch point of the anterior interosseous
nerve or the ulnar nerve at any level proximal to the
wrist. This technique, however, also may be indicated
in nerve lesions amenable to nerve graft reconstructions if the prognosis for intrinsic motor recovery is

as far proximally as is necessary to permit a tens
free coaptation between the distal anterior intero
ous nerve and the mobilized median thenar branc
ulnar deep motor branch fascicular group. The
lated distal fascicular group then is sectioned sha
and accurately coapted to the anterior interosse

FIGURE 6. Nerve transfers to restore ulnar mo
transferred to the deep motor branch of the ulnar
dorsal sensory ulnar nerve are transferred end-to

FIGURE 2. (A) Photograph of an isolated thenar branch of median nerve with proximal interfascicular dissection within

High ulnar nerve palsy

Add to the previous the lack of FDP 4,5 that
contraindicate the Lasso procedure

Restauration of FDP 4,5 is made by lateral suturing to
FDP 2,3

Combined nerve palsies

More complicated

Less tendons available for transfer

Moreover after traumatic injury muscles/tendons may
have been lacerated

Loss of sensibility is a major issue

Combined low and median nerve

Low median and ulnar nerve palsy

Thumb positioning ➡ EIP to APB

MCP stabilization ➡ Passive (Zancolli 1), Active
(Lasso), Transfer (ECRL ➡ IO), Tenodesis cross-over

Low Median and Ulnar nerve palsy:
the thumb is insensate and unstable

IP stabilization is frequently needed as the unbalanced
FPL places the IP in Flexion (Froment sign) with loss
of the pulp pinch.

If severe MP hyperextension (Jeanne sign) is present,
arthrodesis may be necessary.

Combined high and median nerve

Combined High median and ulnar

The most severe lesion (almost identical to low-level
tetraplegia). Loss of volar sensibility and atrophy of the finger
pulps will discourage both precision and power grip.

At least two stages: 1st Extrinsics, then intrinsics

ECRL ➡ FDP synchronized, BR ➡ FPL

Thumb positioning ➡ EIP to APB

MCP stabilization ➡ Passive (Zancolli 1), Active (Lasso),
Transfer (ECRL ➡ IO), Tenodesis cross-over (House)

Omer GE. Tendon Transfers For Traumatic Nerve Injuries. JASSH 2004; 4(3) 214-226.

Expected results ?

Difficult to compare

Most patients (≥ 80%) improve

But they report difficulty for grasping or releasing
large objects, impaired coordination and dexterity, and
premature fatigue with loss of strength

Sensory deficits increases the disability


Tendon transfer is a very stimulating surgery, the most important is
the pre-op evaluation of both the deficits and the needs of the patient

The classification that uses three segments (wrist, thumb, fingers)
and three systems (extrinsic high-energy (1st priority): wrist extension
and finger flexion;  extrinsic low-energy: wrist flexion and finger extension;
 intrinsic facilitator: thumb, positioning/stabilizing of finger MCP joints) is
useful to determine which type of transfer you will use

Then the choice between the different transfers depends of your
experience, your readings and the available tendons