Review Article

Tendon Transfers for Radial,

Median, and Ulnar Nerve Palsy

Abstract
John G. Seiler III, MD Tendon transfers are used to restore balance and function to a
Mihir J. Desai, MD paralyzed, injured, or absent neuromuscular-motor unit. In general,
tendon transfer is indicated for restoration of muscle function after
S. Houston Payne, MD
peripheral nerve injury, injury to the brachial plexus or spinal cord,
or irreparable injury to tendon or muscle. The goal is to improve
the balance of a neurologically impaired hand. In the upper
extremity, tendon transfers are most commonly used to restore
function following injury to the radial, median, and ulnar nerves. An
understanding of the general principles of tendon transfer is
important to maximize the outcome.

T endon transfers are reconstruc-

From Georgia Hand, Shoulder, and
Elbow (Dr. Seiler and Dr. Payne)
and the Department of
Orthopaedics, Emory University
School of Medicine (Dr. Desai),
Atlanta, GA.
Dr. Seiler or an immediate family
member serves as a board member,
owner, officer, or committee member
of the American Board of
Orthopaedic Surgery and has stock
or stock options held in Orthovita.
Dr. Payne or an immediate family
member has stock or stock options
held in BioMimetic Therapeutics.
Neither Dr. Desai nor any immediate
family member has received
anything of value from or has stock
or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article.
J Am Acad Orthop Surg 2013;21:
675-684
http://dx.doi.org/10.5435/
JAAOS-21-11-675
Copyright 2013 by the American
Academy of Orthopaedic Surgeons.
tive procedures used to restore
the function of injured or nonfunc-
tional neuromuscular units. A
muscle-tendon unit is strategically
used to replace a nonfunctional unit.
Many of these procedures were first
developed to treat the paralytic se-
quelae of polio. Many techniques
were refined during World Wars I
and II, with fundamental articles
published in the immediate postwar
years.1-4
In general, tendon transfers are in-
dicated to restore function after in-
jury to the peripheral nerve, brachial
plexus, spinal cord, tendons, or mus-
cles. In the setting of nerve injury, a
variety of surgical alternatives is
available to improve function. Nerve
repair, nerve reconstruction, capsul-
odesis, tenodesis, and arthrodesis
performed alone or in combination
with tendon transfer should be con-
sidered. Here, we describe the ten-
don transfers commonly used for re-
construction following injury to the
radial, median, and ulnar nerves.
An understanding of the general
principles of tendon transfer is cru-
cial for maximizing outcomes. These
principles are as follows:
1. The functional loss associated
with the use of donor tendon should
be minimized to maximize functional
gains following transfer. The donor
tendon must be expendable so that
its removal will not result in unac-
ceptable loss of function, and inner-
vation must be intact.1-3
2. The strength of the proposed mus-
cle for transfer must be normal or near
normal and under voluntary control of
the patient. Typically, the strength of
the donor muscle-tendon unit decreases
by one grade following transfer; there-
fore, only donor muscles with 4/5 or
5/5 strength should be used for tendon
transfers.5,6
3. The tendon excursion of the do-
nor unit must be sufficient to restore
the lost function of the recipient
unit.4 For example, in wrist exten-
sion and flexion, there is 33 mm of
tendon excursion. Finger extension
and flexion has a tendon excursion
of 50 mm and 70 mm, respectively.4
Wrist flexion and extension can add
20 to 30 mm of excursion through a
tenodesis effect.7

November 2013, Vol 21, No 11 675

Tendon Transfers for Radial, Median, and Ulnar Nerve Palsy
Figure 1
Photograph of a cadaver
demonstrating the Pulvertaft weave
technique for joining tendons. The
donor tendon has been woven
through the recipient tendon and
joined with a mattress suture. The
next slit is made at a 90° angle to
the first. A minimum of three
weaves is recommended to create
a strong junction.
4. The direction of pull (ie, vector)
of the recipient tendon should be in
line with that of the donor muscle
and, ideally, the transfer should cross
only one joint.1,2
5. A single transferred tendon should
perform one intended function.1-3,5
6. The soft-tissue bed for the trans-
fer must be stable and allow for ten-
don gliding with pliable, unscarred
overlying skin. Transfers must not be
placed through heavily scarred soft-
tissue planes, which limit excur-
sion.1,2
7. Preoperatively, the joints con-
trolled by the transferred tendon
must have nearly full passive range
of motion (ROM). Preoperative oc-
cupational hand therapy may be nec-
essary to improve ROM before ten-
don transfer. In some cases, joint
release may be necessary before the
transfer is performed.1,2
8. Tendons with in-phase functions
should be used preferentially. The syn-
ergistic action of the proposed muscle
for transfer and the recipient muscle
(eg, finger flexors acting in concert with
wrist extensors and finger extensors
with wrist flexors) can facilitate mus-
cle retraining after transfer.1-3
676
Preoperative Assessment
To develop an effective treatment
plan, a comprehensive history must
be obtained and a physical examina-
tion focusing on wrist, hand, and fin-
ger ROM as well as motor function
and sensation must be performed to
identify any deficits. The skin should
be examined for injury that may af-
fect the planned surgical approach.
Examination of the peripheral nerve
of the hand includes evaluation of
the motor and sensory function of
the radial, median, and ulnar nerves.
Sensory function should be deter-
mined with two-point discrimina-
tion.
Decision Making
When evaluating a patient for nerve
reconstruction, several variables af-
fect decision making and the selec-
tion of specific surgical treatment al-
ternatives. The surgeon must
consider the nature of the primary
injury, the time from injury, the ex-
pected success of any previous treat-
ment, and the patient’s goals and ex-
pectations. Electromyography may
be helpful to determine the severity
of the initial injury because sponta-
neous motor recovery is unlikely
with abnormal electromyography
findings 3 months from the time of
injury.1 We find it helpful to con-
struct a table that lists the remaining
intact function postinjury, the func-
tions needed, expendable muscles
available for transfer, the sequence of
transfers that can achieve the in-
tended improvement in hand func-
tion, and adjuvant procedures that
may be performed.
Method of Tendon Suture
The traditional method of joining the
donor tendon to the recipient tendon
Journal of the American Academy of Orthopaedic Surgeons
is the Pulvertaft weave8 (Figure 1). The
principal disadvantages of this tech-
nique are difficulty in tensioning the
transfer, slit propagation, and bulk.
Newer techniques such as spiral link-
ing, loop-tendon suture, and lasso pur-
portedly address drawbacks associated
with the Pulvertaft weave.9-11 Biome-
chanical studies have suggested that
the pull-out strength of these newer
techniques is greater, but they result
in a large cross-sectional area for the
repair site and are only suitable if the
increased size of the transfer juncture
is acceptable and does not interfere
with tendon gliding.9-11
Radial Nerve Tendon
Transfers
Deficits resulting from injury to the
radial nerve are classified as either
high or low radial nerve palsy. Inju-
ries located proximal to the elbow
result in high radial nerve palsy,
whereas injuries to the posterior in-
terosseous nerve (distal to the elbow)
result in low radial nerve palsy. High
radial nerve palsy is associated with
loss of function of the brachioradia-
lis, extensor carpi radialis brevis
(ECRB), extensor carpi radialis lon-
gus (ECRL), extensor digitorum
communis (EDC), extensor indicis
proprius (EIP), extensor digiti min-
imi, extensor carpi ulnaris (ECU),
and extensor pollicis longus (EPL).
The motor deficit associated with
high radial nerve palsy results in an
inability to extend the wrist and fin-
gers at the metacarpophalangeal
(MCP) joints. The ability to extend
and radially abduct the thumb is
compromised as well. On examina-
tion, decreased sensation manifests
as an increased two-point discrimi-
nation or complete anesthesia over
the dorsum of the first web space
with extension onto the dorsum of
the thumb, index, and middle fin-
gers. Sensory recovery after radial

Table 1
Tendon Transfers for Radial Nerve Palsy
Restoration of Wrist
Tendon Transfer
Brand1
Jones14
Boyes superficialis2,15
ECRB = extensor carpi radialis brevis, EDC = extensor digitorum communis, EPL = extensor pollicis longus, FCR = flexor carpi radialis,
FDS = flexor digitorum superficialis, PL = palmaris longus, PT = pronator teres
nerve repair is unpredictable and not
as critical as motor improvement af-
ter tendon transfer. Patients present
with wrist drop and may present
with decreased grip strength because
the wrist cannot be stabilized in a
neutral position or extension to max-
imize flexor tendon excursion for
grip.
Low radial nerve palsy is associ-
ated with the loss of muscle function
distal to the elbow. In patients with
low radial nerve palsy, the ECRL re-
tains its innervation, and wrist exten-
sion has substantial radial deviation
because the balancing effect of the
ECU is absent. Typically, no sensory
deficit is associated with low radial
nerve palsy.
Tendon transfers for radial nerve
palsy restore wrist extension, finger
extension at the MCP joint, and ex-
tension with radial abduction of the
thumb. Timing of radial nerve trans-
fer depends primarily on the initial
management of the radial nerve in-
jury and the potential for recovery.
The more proximal the nerve injury,
the less likely it is that muscle rein-
nervation will occur.4,12 If the nerve is
still intact, 3 months of observation
are advised to allow spontaneous
functional recovery to begin. Patients
are reevaluated 6 weeks after injury
and, if there is no clinical recovery,
electrodiagnostic studies may reveal
evidence of recovery. In the setting of
extensive soft-tissue injuries or irrep-
arable nerve injury, early tendon
transfer is often appropriate.13 In pa-
November 2013, Vol 21, No 11
Restoration of Thumb
Extension Extension
PT to ECRB PL to EPL
PT to ECRB PL to EPL
PT to ECRB FDS of ring finger to EPL
tients with isolated radial nerve in-
jury, muscle-tendon units innervated
by the median and ulnar nerves can
serve as potential donors for tendon
transfer. Classic tendon transfer tech-
niques for radial nerve palsy include
the Brand,1 Jones,14 and Boyes super-
ficialis2,15 transfers (Table 1).
Wrist Extension
To restore wrist extension, the pro-
nator teres (PT) tendon is transferred
to the ECRB tendon. The ECRB is
chosen over the ECRL secondary to
its more central insertion onto the
base of the long metacarpal and bal-
anced radioulnar deviation during
wrist extension. A radial mid fore-
arm longitudinal incision is made,
and the PT and ECRB tendons are
identified. The PT tendon and a strip
of periosteum are harvested from the
middle third of the radius. The PT
muscle-tendon unit is freed from fas-
cial connections proximally to maxi-
mize tendon excursion. The unit is
then routed radially and woven to
the ECRB tendon with the wrist in
45° of extension.
Finger Extension
Finger extension can be restored by
using a flexor carpi radialis (FCR) to
EDC tendon transfer (Figure 2).
Other tendon transfer options in-
clude flexor carpi ulnaris (FCU) to
EDC and flexor digitorum superfi-
cialis (FDS) of the ring or long finger
to EDC. The advantages and draw-
John G. Seiler III, MD, et al
Restoration of Finger
Extension
FCR to EDC
FCR to EDC
FDS of long finger to EDC
backs of these tendon transfers have
been debated. The FCR tends to be
easier to harvest and provides ade-
quate excursion and strength with-
out sacrificing wrist flexion and ul-
nar deviation.13 The potential
drawback of using the FCU is the
sacrifice of coupled wrist flexion and
ulnar deviation, which is critical for
the dart thrower’s motion and power
grip.16
In the FCR transfer, the tendon is
divided at the wrist crease and
routed through the interosseous
membrane or radially around the
forearm. The tendon is attached end-
to-side and en mass to each of the
EDC tendons. The transfer is set
with the wrist in neutral and the
MCP joints in full extension, with
the FCR tendon at <75% of maxi-
mum tension.2 When the FCU trans-
fer is used, the tendon is harvested
through a generous volar forearm in-
cision, released from its insertion to
the pisiform, and mobilized proxi-
mally. Because the FCU is a unipen-
nate muscle, it must be released suffi-
ciently to allow for tendon excursion
after transfer. The tendon is passed
dorsally around the subcutaneous
border of the ulna through a gener-
ous subcutaneous tunnel and is inset
into the EDC tendons proximal to
the extensor retinaculum. The recipi-
ent tendons should be mobilized to
establish full or near full tendon ex-
cursion and then retracted proxi-
mally to place the MCP joints into
extension. The FCU is passed
677
Tendon Transfers for Radial, Median, and Ulnar Nerve Palsy
Figure 2
Photographs of a cadaver demonstrating the flexor carpi radialis (FCR) to extensor digitorum communis (EDC) tendon
transfer for restoration of finger extension. A, A radial incision is made over the FCR tendon for harvest. The FCR
tendon is divided starting at the wrist crease (B), routed dorsoradially around the forearm (C), and attached end-to-side
and en mass to each of the EDC tendons.
Figure 3
Photograph of a cadaver
demonstrating the palmaris longus
(PL) to extensor pollicis longus
(EPL) tendon transfer for
restoration of thumb extension. The
EPL tendon (held with forceps) is
mobilized, divided, and removed
from the third extensor
compartment. The PL tendon (held
with the hemostat) is harvested as
distally as possible and sewn into
the EPL tendon. In this case, the
flexor carpi radialis (FCR) was
used to restore finger extension,
and the PL tendon was routed
radially through the same
subcutaneous tunnel.
obliquely through the EDC tendons
and sewn to each finger’s tendon in-
dividually at approximately 75% of
maximum excursion.2 If this method
is selected, the palmaris longus (PL)
can be transferred through the same
subcutaneous channel that is used
for the PL to EPL tendon transfer.
678
Thumb Extension
A PL to EPL tendon transfer can be
performed to restore thumb exten-
sion and radial abduction (Figure 3).
Other options include the transfer of
the FDS tendon of the long or ring
finger to the EPL tendon.2 For a PL
to EPL tendon transfer, the EPL ten-
don is mobilized and can be divided
and removed from the third extensor
compartment and subcutaneously
routed radially to the volar wrist. We
prefer to harvest the PL tendon as
distal as possible and route it around
the ulna to the EPL. The transfer is
set with the EPL tendon sewn into
the PL tendon and the thumb in full
extension.
For sequencing purposes, we dis-
sect the recipient tendons to ensure
they are appropriate for transfer. The
donor tendons are transferred to the
new location, and the tension of each
proposed transfer is examined.
When possible, we inset the wrist
transfer first and then work down-
stream to insert the tendon transfers
for finger and thumb extension.
After the tendon transfers are com-
plete, the wrist and MCP joints are
immobilized in extension. We prefer
to immobilize the wrist in a pronated
and dorsiflexed position with a sugar
Journal of the American Academy of Orthopaedic Surgeons
tong splint. After 4 weeks of immo-
bilization, a new splint is applied to
keep the wrist in 15° to 30° of exten-
sion; the thumb and fingers are free,
and active ROM is encouraged. At 6
weeks postoperatively, active ROM
of the wrist is allowed and additional
retraining is performed with occupa-
tional therapy. Strengthening exer-
cises begin at 8 weeks postopera-
tively and the splint is discontinued.
Excellent results have been reported
with regard to wrist, thumb, and fin-
ger ROM following tendon transfers
for radial nerve palsy. In a study of
15 patients with radial nerve palsy
treated with tendon transfers,
Ropars et al17 reported a high level
of patient satisfaction and excellent
wrist, thumb, and finger ROM in 11
patients.
Median Nerve Tendon
Transfers
Median nerve palsy is categorized as
either high or low based on the loca-
tion of the nerve injury. Low median
nerve palsy usually results in a loss
of thumb opposition, which is a
composite motion involving prona-
tion, flexion, and palmar abduction
at the trapeziometacarpal joint and

Table 2
Tendon Transfers for Median
Nerve Palsy
Restoration of Thumb Opposition
(Opponensplasty)
EIP to APB (ie, Burkhalter)22
FDS of ring finger to APB (ie, Royle-
Thompson)23
PL to APB (ie, Camitz)24
Restoration of Thumb Interphalan-
geal Flexion
BR to FPL
ECRL to FPL
ECU to FPL
Restoration of Index Distal Interpha-
langeal Flexion
ECRL to FDP
APB = abductor pollicis brevis,
BR = brachioradialis, ECRL = extensor
carpi radialis longus, ECU = extensor
carpi ulnaris, EIP = extensor indicis
proprius, FDP = flexor digitorum
profundus, FDS = flexor digitorum
superficialis, FPL = flexor pollicis longus,
PL = palmaris longus
flexion at the MCP joint.18 Several
muscles control the position of the
thumb, and innervation patterns
vary. Typically, the adductor pollicis
(AP) and flexor pollicis longus (FPL)
muscles are still functional in the pa-
tient with median nerve palsy. The
flexor pollicis brevis (FPB) muscle
typically receives dual innervation,
with the deep muscle head inner-
vated by the ulnar nerve. In a study
of the distribution pattern of the me-
dian nerve in the palmar region,
Olave et al19 found that the median
nerve innervated the abductor polli-
cis brevis (APB) muscle, the superfi-
cial head of the FPB muscle, and the
opponens pollicis muscle in 63% of
cadaver specimens. The principal
motor unit for thumb opposition is
the APB muscle. Because of the ana-
tomic variability in innervation, even
in the setting of complete low me-
dian nerve injury, patients may retain
thumb opposition. In fact, Jensen20
reported that, in 147 cases of injury
to the median nerve, opponensplasty
November 2013, Vol 21, No 11
was necessary in only 14%.
High median nerve palsy second-
ary to an injury proximal to the el-
bow joint results in loss of thumb
opposition, flexion deficits of the dis-
tal interphalangeal (DIP) and proxi-
mal interphalangeal (PIP) joints in
the index and middle fingers, loss of
thumb interphalangeal (IP) flexion,
and decreased strength of forearm
pronation. In addition, high median
nerve palsy can cause a sensory defi-
cit that involves the palmar surface
of the thumb and the index and long
fingers and the radial half of the ring
finger. Wrist flexion typically re-
mains intact secondary to the ulnar
innervation of the FCU muscle.
The goals of tendon transfer are
restoration of thumb IP flexion,
thumb opposition, and flexion of the
index and long fingers. Forearm pro-
nation rarely requires reconstruction
because shoulder motion, the flexor-
pronator mass, and brachioradialis
can position the arm to overcome
most pronation deficits.21 Median
nerve transfers are performed when
motor recovery is no longer expected
following nerve repair or irreparable
injury (Table 2).
Thumb Opposition
Several tendon transfers can be used
to restore thumb opposition, includ-
ing transfer of the EIP, FDS of the
ring finger, PL, or transfer of the ab-
ductor digiti minimi to the APB ten-
don. In transfers that originate in the
forearm, the vector of pull must be
changed to allow opposition. This
can be achieved by several methods.
The pisiform is optimal for place-
ment of a pulley to redirect a tendon
for opposition.25 The Bunnell pulley
uses a half-width thickness of a dis-
tally based portion of FCU tendon
that is looped and then secured back
to itself near the pisiform.23 In a
more recent biomechanical study of
pulley placement in tendon transfers
John G. Seiler III, MD, et al
for restoration of thumb opposition,
the Thompson pulley, which uses the
distal end of the transverse carpal
ligament and the ulnar border of the
palmar fascia,26 and the Guyon canal
pulley, which uses tendon graft
placed through the canal and a sub-
cutaneous palmar tunnel,27 were as-
sociated with the least amount of
frictional force.28
In a Bunnell or Royle-Thompson
transfer, the FDS of the ring finger is
transferred to the APB tendon and a
Bunnell pulley is used23 (Figure 4).
The two slips of FDS are transected
between the A1 and A2 pulleys and
the tendon is retracted into a wrist
incision. The Bunnell pulley is cre-
ated as described previously. Care is
taken when routing the transfer to
avoid ulnar artery and nerve com-
pression. A generous subcutaneous
tunnel is made across the palm, and
the tendon is passed through an inci-
sion on the radial aspect of the
thumb, centered over the MCP. One
slip of the transfer is attached to the
distal radial APB tendon and the
other is attached to the extensor
hood.29 In a biomechanical study,
Cooney et al30 reported a 40% resto-
ration of thenar strength with this
transfer.
Burkhalter et al22 first described
the EIP to APB tendon transfer for
restoration of thumb opposition.
The EIP is divided over the index
MCP joint and is passed proximally
underneath the extensor retinaculum
(Figure 5). The tendon is routed
around the ulnar side of the wrist,
passed subcutaneously through the
palm, and attached to the APB inser-
tion. The length of this transfer is
usually just sufficient for the purpose
of transfer. In a study of 40 hands
managed with this technique, Ander-
son et al31 reported good or excellent
results in 87.5% of patients, with
opposition to tip of index or middle
finger (“good” result) or to the little
or ring finger (“excellent” result)
679
Tendon Transfers for Radial, Median, and Ulnar Nerve Palsy

Figure 4 underwent a Camitz transfer, Ter-

rono et al33 reported high patient sat-
isfaction with regard to thumb dex-
terity in 94% of patients.
Following tendon transfer for
thumb opposition, the wrist, thumb,
and MCP joints are immobilized for
4 weeks. The thumb is placed in full
opposition with the wrist slightly
flexed. A fabricated splint is used at
4 weeks postoperatively, and active
ROM begins. Gentle passive ROM
Photographs of a cadaver demonstrating the Bunnell or Royle-Thompson does not begin until 8 weeks postop-
tendon transfer for restoration of thumb opposition. A, The two slips of the eratively.
flexor digitorum superficialis (FDS) of the ring finger are transected between
the A1 and A2 pulleys and the tendon is retracted into a wrist incision. A loop
is made from a half-width thickness of a distally based portion of flexor carpi Thumb and Index Finger
ulnaris (FCU) and is looped and secured to itself near the pisiform. B, A Flexion
generous subcutaneous tunnel is made across the palm, and the tendon is
passed through an incision on the radial aspect of the thumb, centered over In the setting of high median nerve
the metacarpophalangeal joint. One slip of the transfer is attached to the palsy, thumb IP flexion can be re-
distal radial abductor pollicis brevis tendon; the other is attached to the
extensor hood. PL = palmaris longus stored with a transfer of the brachio-
radialis, ECRL, or ECU tendons.27
Using a radial-sided forearm inci-
Figure 5 sion, the brachioradialis tendon is
harvested from its insertion at the ra-
dial styloid process and is woven
into the FPL tendon proximal to the
wrist crease. The transfer is ten-
sioned such that the thumb MCP
and IP joints are in 30° of flexion
with the wrist in a neutral position.
Loss of flexion at the DIP joint of
the index finger adversely affects grip
strength. If ulnar nerve function is
intact, side-to-side tenodesis of the
Photographs of a cadaver demonstrating the extensor indicis proprius (EIP)
to abductor pollicis brevis (APB) tendon transfer for restoration of thumb
flexor digitorum profundus (FDP)
opposition. A, The EIP is divided over the index metacarpophalangeal joint tendons can be performed to restore
and is passed proximally underneath the extensor retinaculum. B, The flexion. This transfer should be set
tendon is routed around the ulnar side of the wrist, passed subcutaneously with the fingers positioned in the
through the palm, and attached to the APB insertion. EDC = extensor
digitorum communis normal flexor cascade. When the
wrist is extended, there is increased
flexion in the digits from radial to ul-
with the IP joint of thumb extended. (Figure 6). An adequate amount of nar. Another option to restore flex-
The Camitz transfer (using the PL palmar fascia must be harvested to ion is an ECRL transfer to the FDP
tendon) was initially described in provide the necessary length for the tendon of the index finger.27 The
1929 and has been traditionally re- transfer. Unlike other transfers for ECRL tendon is tensioned with the
served for patients with long- thumb opposition, the Camitz trans- index finger in full extension and the
standing carpal tunnel syndrome.24 fer only restores palmar abduction of wrist in 30° of flexion.
The PL tendon is harvested with an the thumb secondary to the resultant Following tendon transfers to the
extension of the palmar fascia, vector of pull following surgery.32 In FPL or FDP of the index finger, the
passed subcutaneously to the thumb, a retrospective review of 29 patients wrist, MCP joints, and IP joints are
and attached to the APB insertion with carpal tunnel syndrome who immobilized in 30° of flexion for 4

680 Journal of the American Academy of Orthopaedic Surgeons


weeks. Active ROM is initiated at 4
weeks postoperatively. Strengthening
and passive ROM exercises are be-
gun at 8 weeks postoperatively.
Ulnar Nerve Tendon
Transfers
Ulnar nerve palsy also can be classi-
fied as high or low. Low ulnar nerve
palsy implies injury at the wrist level.
Physical examination reveals intrin-
sic muscle paralysis and sensory loss
in the ring and small fingers. Intrin-
sic muscle paralysis results in defor-
mity, pinch and grip weakness, and
loss of radioulnar digital motion. In
patients with high ulnar nerve palsy,
the FDP and FCU of the ring and
small finger are paralyzed. Sensation
is absent in the palmar and dorsal as-
pect of the small and ring fingers and
the ulnar third of the palm. Tendon
transfers for management of injuries
to the ulnar nerve are performed
when recovery (either spontaneous
or after nerve repair) is no longer ex-
pected.
Clawing
Clawing of the ring and small fingers
after injury to the ulnar nerve is
caused by an imbalance in muscles
that affect resting digital posture. In
this setting, the intrinsic flexion
forces at the MCP joint are absent
(loss of intrinsic hand function), but
the EDC function remains intact,
creating hyperextension at the MCP
joint. The typical claw hand posture
is caused by hyperextension at the
MCP joints and reciprocal flexion at
the PIP and DIP joints. Clawing is
not present in the index or long fin-
ger because the two most radial lum-
bricals are innervated by the intact
median nerve. IP joint extension can
be accomplished only with the MCP
joints in a neutral or flexed position.
The goal of corrective procedures is
to prevent MCP hyperextension.
November 2013, Vol 21, No 11
John G. Seiler III, MD, et al
Figure 6
Photographs of a cadaver demonstrating the Camitz tendon transfer for
restoration of thumb opposition. The palmaris longus (PL) tendon (dots) is
harvested with an extension of the palmar fascia (A), passed subcutaneously
to the thumb (B), and attached to the abductor pollicis brevis (APB) insertion.
It is important to harvest enough palmar fascia to provide the necessary
length for the transfer. FCU = flexor carpi ulnaris
Table 3
Ulnar Nerve Tendon Transfers for Management of Clawing and Power
Pinch Weakness
Indication Transfer Description
Clawing Zancolli lasso 34
FDS of affected finger
Modified Stiles-Bunnell35 FDS of long finger to radial lat-
eral band of small and ring
fingers
Brand36 FCR or ECRB to radial lateral
bands of small and ring fin-
gers (ulnar nerve palsy) or
index, long, ring, and small
fingers (combined ulnar and
median nerve palsy)
Power pinch weak- Adductorplasty ECRB to AP
ness
Adductorplasty FDS of long finger to AP
AP = adductor pollicis, ECRB = extensor carpi radialis brevis, FCR = flexor carpi ulnaris,
FDS = flexor digitorum superficialis
This can be achieved with both cap- Brand transfer36 (Table 3).
sulodesis and tenodesis. Dynamic The Zancolli lasso uses the FDS of
tendon transfers also prevent MCP the affected finger to restore MCP
hyperextension by providing a flex- flexion.34 The FDS slips are tran-
ion force to the MCP joint or a cou- sected 2 cm proximal to their inser-
pled MCP flexion and IP joint exten- tion and harvested between the A1
sion force. The most commonly used and A2 pulleys (Figure 7). The ten-
tendon transfers for management of don ends are passed from between
clawing of the ring and small fingers the A1 and A2 pulleys and sewn
are the Zancolli lasso,34 the modified back on themselves proximal to the
Stiles-Bunnell transfer,35 and the A1 pulley, creating MCP flexion.
681
Tendon Transfers for Radial, Median, and Ulnar Nerve Palsy
Figure 7
Photograph of a cadaver
demonstrating the Zancolli lasso
transfer for management of
clawing. In the affected finger, the
slips of the flexor digitorum
superficialis (FDS) are transected
2 cm proximal to their insertion and
harvested between the A1 and A2
pulleys. The tendon ends (held with
a hemostat) are passed from
between the A1 and A2 pulleys and
sewn back on themselves proximal
to the A1 pulley, creating
metacarpophalangeal joint flexion.
Transfer tension is set with the MCP
joint in approximately 60° of flex-
ion. This procedure can correct claw-
ing by providing an intrinsic plus
starting position (MCP joint flexion
and the IP joint extension). In a
study of 23 digits with isolated nerve
palsy treated with the Zancolli lasso
procedure, Hastings and McCollam37
reported correction of claw defor-
mity in 19 digits at an average 5-year
follow-up. One potential drawback
of this procedure is that removal of
the FDS tendon’s influence on PIP
flexion can result in postoperative
swan neck deformity.
The modified Stiles-Bunnell transfer
uses the FDS tendon of the long finger
to provide coupled MCP flexion and IP
joint extension.35 The slips of the
FDS tendon are transected 2 cm
proximal to their insertion, split lon-
gitudinally, and retracted proximally
from the tendon sheath (Figure 8).
They are then routed distally through
the lumbrical canal (deep to the inter-
682
Figure 8
Photographs of a cadaver demonstrating the modified Stiles-Bunnell tendon
transfer for management of claw hand deformity. A, The lumbrical canal is
exposed, revealing the radial lateral band. The slips of the flexor digitorum
superficialis are transected 2 cm proximal to their insertion, split
longitudinally, and retracted proximally from the tendon sheath. B, The slips
are then routed distally through the lumbrical canal and inserted into the
radial lateral bands of the small and ring fingers.
metacarpal ligament and palmar to the transfer. Tension is set with the wrist
MCP joint axis of rotation) and in- in extension and fingers in an intrin-
serted into the radial lateral bands of sic plus position.
the small and ring fingers. The trans- Once these transfers are complete,
fer is set with the wrist in neutral and the extremity is immobilized in a
the ring and small finger MCP joints in short arm dorsal splint with the wrist
60° of flexion. Like the Zancolli lasso in 30° of extension and the fingers in
procedure, the modified Stiles-Bunnell an intrinsic plus position. Wrist and
transfer can result in a swan neck de- digital motion is begun after 3 weeks
formity. postoperatively, with strengthening
In the setting of low median and exercises beginning at 8 weeks. In a
ulnar nerve palsy with clawing of all recent randomized trial, 50 claw
four fingers, the Brand transfer can hand deformities were managed with
be used to restore intrinsic function either an immediate active motion
using the FCR or ECRB tendon.36 protocol or immobilization.38 Rath
The tendon is split into two or four et al38 reported that the immediate
tails based on the need to restore in- active motion group had earlier pain
trinsic function to the small and ring relief than did the immobilization
fingers (ulnar nerve palsy) or to the group, with similar outcomes in both
small, ring, long, and index fingers groups at final follow-up.
(ulnar and median nerve palsy). The
tendon tails require extension by free Power Pinch
tendon grafts and are passed palmar Power pinch requires that the AP
to the joint axis of rotation for the muscle, the deep head of the FPB
MCP joint. The tendon tails are at- muscle, and the first dorsal interosse-
tached to the radial lateral bands of ous muscle function properly. In the
the small, ring, and long fingers and patient with normal pinch function,
to the ulnar lateral band for the in- the thumb MCP joint is flexed and
dex finger in a fashion similar to that the IP joint is slightly flexed or ex-
used in the modified Stiles-Bunnell tended. In the patient with low ulnar
Journal of the American Academy of Orthopaedic Surgeons

nerve palsy, impaired power pinch
results in MCP extension and IP hy-
perflexion secondary to compensa-
tion by EPL and FPL tendons (Fro-
ment sign).39 This can be improved
with either ECRB or FDS adductor-
plasty (Table 3).
ECRB adductorplasty is appropri-
ate for patients with low ulnar nerve
palsy and impaired power pinch.39
The ECRB insertion is detached from
the long finger metacarpal base and
withdrawn proximally beneath the
extensor retinaculum. A free tendon
graft is used to obtain the appropri-
ate length, and the donor tendon is
routed between the second and third
metacarpals and then attached to the
AP tendon insertion. In a study of 18
patients with weakened power pinch
force treated with ECRB adductor-
plasty, Smith39 reported a twofold in-
crease in force postoperatively.
Transfer of the FDS tendon of the
long finger to the AP tendon can also
be used to restore power pinch.40
The tendon is harvested in a manner
similar to that used for the Zancolli
lasso procedure and routed proxi-
mally across the palm to the inser-
tion of the AP tendon. The need for
a free tendon graft for the ECRB ad-
ductorplasty is the primary draw-
back of the procedure. Following ad-
ductorplasty, the thumb and wrist
are immobilized for 4 weeks, with
the wrist in neutral or slight flexion.
Active ROM is begun at 6 weeks and
strengthening exercises are initiated
at 8 weeks postoperatively.
Summary
Tendon transfers are one reconstruc-
tive option in a ladder of reconstruc-
tive alternatives that can improve
function after injury to the radial,
median, or ulnar nerves. By adhering
to the general principles of tendon
transfers, function can be predictably
improved, improving quality of life
November 2013, Vol 21, No 11
by allowing patients to complete ac-
tivities of daily living.
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