CME

The Best of Tendon and Nerve Transfers in the

Upper Extremity
Jennifer L. Giuffre, M.D.
Learning Objectives: After reading this article, the participant should be able
Allen T. Bishop, M.D.
to: 1. Identify the prerequisite conditions to perform a tendon or a nerve
Downloaded from https://journals.lww.com/plasreconsurg by aQNSO2S548o31W5b7ostr18n2EuUlo2UCR/dmebe7/HtOA/U7VNgw3OKqgDhqQUo8qMPVEsbH8EQfzOPfpXtDdTtPVZMRWAKySHZY6rigAKmJ2zKfvL8eIyt1+FH9qAGMOYvGaiosXc= on 04/24/2021

Robert J. Spinner, M.D.

Alexander Y. Shin, M.D.
Winnipeg, Manitoba, Canada; and
Rochester, Minn.
transfer. 2. Detail some of the current nerve and tendon transfer options in
upper extremity peripheral nerve injuries. 3. Understand the advantages and
disadvantages of tendon and nerve transfers used in isolation and in combina-
tion. 4. Appreciate the controversies that surround the nerve/tendon transfers.
5. Realize the treatment outcomes of peripheral nerve injuries.
Summary: Traditional treatment of a Sunderland fourth- or fifth-degree pe-
ripheral nerve injury has been direct neurorrhaphy, nerve grafting, or ten-
don transfers. With increasing knowledge of nerve pathophysiology, additional
treatment options such as nerve transfers have become increasingly popular.
With an array of choices for treating peripheral nerve injuries, there is debate
as to whether tendon transfers and/or nerve transfers should be performed
to restore upper extremity function. Often, tendon and nerve transfers are
used in combination as opposed to one in isolation to obtain the most nor-
mal functioning extremity without unacceptable donor deficits. The authors
tend to prefer reconstructive techniques that have proven long-term efficacy to
restore function. Nerve transfers are becoming more common practice, with
excellent results; however, the authors are wary of using nerve transfers that
sacrifice possible secondary tendon reconstruction should the nerve transfer
fail. (Plast. Reconstr. Surg. 135: 617e, 2015.)

P
eripheral nerve injuries deemed to be Sun-
derland fourth- or fifth-degree injuries will
require surgical intervention for recovery of
function. The determination of whether a periph-
eral nerve injury is reconstructed with nerve trans-
fers and/or tendon transfers depends on several
factors: the mechanism and location of injury,
concomitant injuries (i.e., soft tissue, bone, or vas-
culature), and elapsed time from injury.
Direct neurorrhaphy or nerve grafting close
to the target motor endplate can successfully
restore peripheral nerve function. Patients with
root avulsions, multilevel nerve injuries, injuries
with significant tissue loss or large neuromas-in-
continuity, excessive scarring at the primary injury
site, proximal nerve injuries, injuries that have
failed previous nerve grafting or neurorrhaphy, or
From the Section of Plastic Surgery, Department of Surgery,
University of Manitoba; and the Department of Orthopedic
Surgery, Division of Hand and Microvascular Surgery,
Mayo Clinic.
Received for publication June 20, 2014; accepted October
4, 2014.
Copyright © 2015 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000001071
delayed presentation following injury will require
either tendon transfers or nerve transfers (if
within a reasonable time from injury) for recovery
of function.
Before restoration of function, the joints must
be supple and there must be osseous stability. The
overlying soft tissues must be supple and pliable
to provide a bed within which the reconstruction
will be performed and rehabilitated. Careful physi-
cal examination and understanding of the injury
characteristics will determine whether there are
available donor nerves or muscle-tendon units that
can be used without creating significant deficits.
The time from injury to reconstruction dictates
whether tendon transfers or nerve transfers are
Disclosure: The authors have no financial interest in
any of the products or devices mentioned in this article.
Related Video content is available for this
article. The videos can be found under the
“Related Videos” section of the full-text article,
or, for Ovid users, using the URL citations pub-
lished in the article.

www.PRSJournal.com 617e
 Plastic and Reconstructive Surgery • March 2015
appropriate. There are time-dependent, irrevers-
ible changes that occur in the motor endplates;
therefore, the longer the target muscle is dener-
vated, the lower the likelihood of successful rein-
nervation and the higher the likelihood for the
requirement of tendon transfers.1 In general, the
optimal time of surgical intervention with nerve
transfers is before 6 months. Early exploration
and reconstruction with nerve transfers between
3 and 6 weeks is indicated when there is a high
suspicion of root avulsion1 or a proximal nerve
injury that will not reach the distal motor endplate
before it becomes refractory to reinnervation. Rou-
tine exploration is performed 3 to 6 months after
injury in patients who have not demonstrated ade-
quate reinnervation. Results from delayed (9 to 12
months) or late (>12 months) nerve transfers are
poor because the time for the nerve to regenerate
to the target muscles is greater than the survival
time of the motor endplate after denervation. It
is in these cases that tendon transfer or a micro-
vascular transfer of a normal muscle in conjunc-
tion with an extraplexus motor nerve transfer is
recommended.2
NERVE TRANSFERS
The goal of nerve transfers is to restore func-
tion by transferring a functional but less important
nerve to a distal but more important denervated
nerve.3 An appropriate donor nerve should be in
close proximity to the motor endplate of the target
muscle, should be from a muscle whose function is
expendable or has redundant innervation, should
have a large number of motor axons and be a good
size match to the recipient nerve, and should have
synergistic function to the motor function of the
muscle to be reconstructed.4 Nerve transfers are
advantageous in that they minimize time to reinner-
vation, have more reliable outcomes, have few co-
contraction issues, require dissection in uninjured
and unscarred tissue planes, and avoid disruption
of the tendon-muscle unit balance. Disadvantages
of nerve transfers include a longer recovery time,
the potential for an incomplete recovery, and dif-
ficult motor reeducation. A general contraindica-
tion to a nerve transfer is when other reconstructive
options provide an equivalent or superior outcome
with less morbidity or shorter recovery time. Nerve
transfer techniques have been published in instruc-
tional videos and articles.4,5
TENDON TRANSFERS
Tendon transfers are a means of restoring a
lost function rather than a means of substituting
618e
a specific muscle.6 By identifying muscles that are
denervated and evaluating the resultant func-
tional deficits, the muscles that are available are
considered for transfer. The donor muscle-tendon
unit must be expendable, have adequate power
and excursion to restore the lost function, pass in
a direct line of pull, perform one function, and
be synergistic with the function of the muscle to
be restored.7 Tendon transfers are advantageous
in that they result in return of function soon after
the immobilization period (within 4 to 6 weeks).
The disadvantages of tendon transfers include
extensive dissection, the postoperative immobi-
lization to allow the tendon-to-tendon weave to
heal, potential adhesive scar formation that may
restrict muscle and tendon glide, one grade of
transferred muscle strength loss, and potential
inadequacy of the tendon-muscle balance. Ten-
don transfer techniques have been described
in the literature.6,8 The purpose of this review is
to detail some of the current nerve and tendon
transfer treatment options in upper extremity
peripheral nerve injuries and give the reader an
understanding of the controversies of treatment
and the outcomes of treatment.
SHOULDER STABILITY, ABDUCTION,
AND EXTERNAL ROTATION
A functioning shoulder requires stabilization
of the humeral head within the glenoid fossa,
shoulder abduction, and external rotation. Sta-
bilization of the humeral head and shoulder
abduction is obtained from the supraspinatus
(innervation: suprascapular nerve) and deltoid
muscles (innervation: axillary nerve), and shoul-
der external rotation is obtained from the infra-
spinatus (innervation: suprascapular nerve) and
teres minor muscles (innervation: axillary nerve).
Shoulder abduction and external rotation
by means of the supraspinatus and infraspinatus
muscles (suprascapular nerve), respectively, can
be obtained by transferring the terminal branch
of the spinal accessory nerve to the suprascapular
nerve (Fig. 1). (See Video, Supplemental Digital
Content 1, which displays a 3-year follow-up of a
spinal accessory nerve–to–suprascapular nerve
transfer for shoulder function in a 32-year-old
man with an upper trunk injury. This patient also
had an intercostal nerve–to–biceps motor branch
transfer for elbow function. This video is avail-
able in the “Related Videos” section of the full-
text article on PRSJournal.com or at http://links.
lww.com/PRS/B218.) The proximity of the spinal
accessory nerve to the suprascapular nerve allows
Volume 135, Number 3 • Upper Extremity Tendon/Nerve Transfers

Fig. 1. Intraoperative photograph of a dorsal approach to a spinal

accessory nerve–to–suprascapular nerve transfer. The long nerve on
the right side of the photograph is the terminal branch of the spinal
accessory nerve and the nerve on the left side of the photograph is the
suprascapular nerve at the suprascapular notch.

especially with more extensive injury patterns

Video 1. Supplemental Digital Content 1 displays a 3-year
follow-up of a spinal accessory nerve–to–suprascapular nerve
transfer for shoulder function in a 32-year-old man with an
upper trunk injury. This patient also had an intercostal nerve–
to–biceps motor branch transfer for elbow function. This video
is available in the “Related Videos” section of the full-text article
on PRSJournal.com or at http://links.lww.com/PRS/B218.
direct coaptation without an interpositional graft.
Nerve transfers to the shoulder are significantly
more effective without an intercalated nerve graft
(References 9 and 10, Level of Evidence: Thera-
peutic, IV).9,10 Songcharoen et al. obtained 80 per-
cent Medical Research Council motor recovery
greater than or equal to M3, 60 degrees of shoul-
der abduction, and 45 degrees of shoulder flexion
in the spinal accessory nerve–to–suprascapular
nerve transfer.11 The literature highlights incon-
sistent recovery of external rotation in spinal
accessory nerve–to–suprascapular nerve transfers,
(Reference 14, Level of Evidence: Therapeutic,
IV).12–14 Should the nerve transfer fail, the patient
will be left with an internally rotated shoulder.
There has been recent controversy that surrounds
using the spinal accessory nerve to improve
shoulder motion given its unreliable results and
its potential to paralyze the trapezius muscle, a
major muscle of scapulothoracic articulation and
a potential donor muscle for secondary shoulder
reconstruction with tendon transfers should the
nerve transfer fail.
Shoulder abduction by means of the deltoid
(axillary nerve) can be further restored with the
addition of a second nerve transfer. Oberlin et
al.15 described transferring intercostal nerves to
the axillary nerve, whereas Leechavengvongs et
al.16 described transferring a triceps branch of
the radial nerve to the axillary nerve (Fig. 2).
Leechavengvongs et al.16 reported excellent
results in five of seven cases, with a mean shoul-
der abduction of 124 degrees by 28 months (Level
of Evidence: Therapeutic, IV). A recent review of
21 patients with an isolated axillary nerve injury
treated with a triceps motor branch transfer
resulted in an average deltoid Medical Research
Council grade strength of 3.5 ± 1.1.17 (See Video,
Supplemental Digital Content 2, which displays
a 6-year follow-up of a triceps nerve branch–to–
anterior division of the axillary nerve transfer in
a 16-year-old male patient with isolated axillary
nerve avulsion following a left shoulder disloca-
tion. This video is available in the “Related Vid-
eos” section of the full-text article on PRSJournal.
com or at http://links.lww.com/PRS/B219.) Del-
toid muscle strength correlated with the patient’s

619e
 Plastic and Reconstructive Surgery • March 2015
Fig. 2. Schematic depiction of the intended triceps nerve
branch–to–axillary nerve transfer. (Published with permission of
the Mayo Foundation for Medical Education and Research. All
rights reserved, copyright 2010.)
Video 2. Supplemental Digital Content 2 displays a 6-year follow-
up of a triceps nerve branch–to–anterior division of the axillary
nerve transfer in a 16-year-old male patient with isolated axillary
nerve avulsion following a left shoulder dislocation. This video is
available in the “Related Videos” section of the full-text article on
PRSJournal.com or at http://links.lww.com/PRS/B219.
age, body mass index, and delay from injury to
surgery.17 Dual transfers for shoulder function
(spinal accessory nerve–to–suprascapular nerve
transfer and triceps nerve branch–to–axillary
nerve transfer) leads to improved results over iso-
lated transfers.10,18,19
In patients in whom shoulder function fails
to improve after nerve repair/transfer or who
present late after their injury with no possibility
of nerve repair/transfer options, tendon transfers
of functioning muscles or shoulder arthrodesis20
620e
should be considered. The options for shoulder
reconstruction with tendon transfers include
using trapezius (when not denervated from use of
the spinal accessory nerve), the levator scapulae,
pectoralis major, long heads of biceps and triceps,
and latissimus muscles (when not denervated from
injury). The trapezius muscle is generally spared
because of its spinal accessory nerve innervation
and is, historically, the most commonly reported
transfer in adult patients for shoulder reconstruc-
tion (including patients who have undergone a
spinal accessory nerve transfer as part of their bra-
chial plexus reconstruction) (Reference 22, Level
of Evidence: Therapeutic, IV).21,22 A single ten-
don transfer of the lower portion of the trapezius
muscle to the infraspinatus tendon for improved
shoulder external rotation has been described
with promising outcomes (Figs. 3 through 7).23
Provided the patient presents within a reason-
able time from injury, the authors perform a tri-
ceps branch of the radial nerve–to–axillary nerve
transfer for shoulder stability and abduction. For
external rotation, comparative outcome studies
of axillary nerve–to–suprascapular nerve versus
lower trapezius tendon transfer to the infraspina-
tus tendon are needed to determine which tech-
nique is superior in obtaining external shoulder
rotation specific to the type of brachial plexus
injury (upper trunk versus complete).
ELBOW FLEXION
The musculocutaneous nerve includes motor
fibers for the biceps brachii and brachialis and
sensory fibers to the lateral antebrachial cutaneous
nerve. The literature reports that 65 to 72 percent
of patients obtain greater than M3 biceps recovery
Fig. 3. The inferior trapezius is aligned such that transfer to
the infraspinatus tendon would be ideal for external rotation.
(By permission of Mayo Foundation for Medical Education and
Research. All rights reserved.)
Volume 135, Number 3 • Upper Extremity Tendon/Nerve Transfers
Fig. 4. The inferior trapezius muscle is harvested. (By permis-
sion of Mayo Foundation for Medical Education and Research.
All rights reserved.)
following intercostal nerve–to–musculocutaneous
nerve transfers9,11 and 77 percent greater than or
equal to M3 and 29 percent greater than or equal
to M4 following spinal accessory nerve–to–muscu-
locutaneous nerve transfers.9 Motor axons are lost
to the sensory pathway when nerves are transferred
into the musculocutaneous nerve; therefore, the
authors prefer to identify the biceps motor branch,
on the deep surface of the biceps at mid brachium,
and separate it from the lateral antebrachial cuta-
neous fibers with interfascicular dissection to allow
direct reinnervation of the biceps (Fig. 8).
Elbow flexion may be restored by transferring
functioning fascicle(s) of the ulnar nerve (to the
flexor carpi ulnaris)24 or of the median nerves
Fig. 5. The inferior trapezius muscle is prolonged with a cadav-
eric tendon graft. (By permission of Mayo Foundation for Medi-
cal Education and Research. All rights reserved.)
Fig. 6. The prolonged trapezius muscle is then secured into
the infraspinatus attachment at the humeral head and tendon.
(By permission of Mayo Foundation for Medical Education and
Research. All rights reserved.)
(to the flexor carpi radialis or flexor digitorum
superficialis)25 directly into the motor branches
of the biceps and/or the brachialis muscles
without donor motor or sensory deficits. Recent
results have demonstrated greater than 94 per-
cent M4 strength.15,26 (See Video, Supplemental
Digital Content 3, which displays a patient 1 year
after an Oberlin procedure in which an ulnar
motor nerve branch to the flexor carpi ulnaris
is transferred to a biceps motor nerve branch.
This video is available in the “Related Videos”
section of the full-text article on PRSJournal.com
or at http://links.lww.com/PRS/B220.) Carlsen
et al.27 found comparable outcomes in elbow
flexion and supination strength and postopera-
tive Disabilities of the Arm, Shoulder, and Hand
scores between patients that underwent a dou-
ble nerve transfer to the biceps and brachialis
nerve branches and those that had a single nerve
transfer to the biceps branch alone.27 Similarly,
a recent study randomized 40 patients prospec-
tively to either single- or double-muscle rein-
nervation and found that the strength of elbow
flexion did not differ significantly between the
groups.28 The results of these studies suggest that
a single transfer may be sufficient, allowing the
median nerve to be used for other transfers or
not subjected to injury.27,28 The medial pectoral
nerve, intercostal nerves, and spinal accessory
nerve with nerve graft to musculocutaneous
nerve or biceps branch are additional alterna-
tives for restoring elbow flexion.
If the time from injury to surgery is more than 9
to 12 months, the nerve transfer has failed, or there
are no donor nerves available for nerve transfer,
621e
 Plastic and Reconstructive Surgery • March 2015
Fig. 7. A single tendon transfer of the lower portion of the trapezius muscle extended with an allograft to the infraspinatus muscle
at the glenohumeral joint improves shoulder external rotation.
Video 3. Supplemental Digital Content 3 displays a patient 1
year after an Oberlin procedure in which an ulnar motor nerve
branch to the flexor carpi ulnaris is transferred to a biceps motor
nerve branch. This video is available in the “Related Videos” sec-
tion of the full-text article on PRSJournal.com or at http://links.
lww.com/PRS/B220.
local muscle transfers, a proximal advancement
of the flexor-pronator mass, or a free-functioning
muscle transfer in conjunction with an extraplexus
motor nerve transfer to restore elbow function
is recommended. Elbow flexion may be recon-
structed by transferring innervated, local muscles
such as the pectoralis major (bipolar pectoralis
major tendon transfer), latissimus dorsi, triceps,
and trapezius muscles.29 The caveat to using local
muscle transfers is that the outcome of elbow flex-
ion will depend on the preoperative donor muscle
strength, which tends to be impaired in peripheral
nerve and brachial plexus injuries. The literature
reports M4 recovery of elbow flexion with pedi-
cled latissimus dorsi transfers; however, flexion
strength remains less than 5 kg with, an average
622e
contralateral strength of 12 kg.30 In addition, most
of the local muscles are important for either shoul-
der stability or shoulder reconstruction; therefore,
their sacrifice may impair function of the upper
extremity rather than improve it.
A variety of free-functioning muscles can be
transferred, including the latissimus dorsi (thora-
codorsal nerve), the rectus femoris (femoral nerve),
and the gracilis (anterior division of the obturator
nerve). Free-functioning muscles transferred for
a specific purpose should have the strength and
excursion comparable to the paralyzed muscles they
are replacing.2 The authors prefer to transfer the
gracilis muscle because of its reliable, proximally
based neurovascular pedicle (allows earlier reinner-
vation) and its long tendon length (which has the
potential to restore elbow flexion, wrist extension,
or finger flexion).1,31–33 (See Video, Supplemental
Digital Content 4, which displays a free functional
innervated gracilis muscle secured proximally to
the clavicle and woven into the distal flexor digito-
rum profundus and flexor pollicis longus tendons
to restore finger flexion. This video is available in
the “Related Videos” section of the full-text arti-
cle on PRSJournal.com or at http://links.lww.com/
PRS/B221.) The free functioning muscle transfers
may be powered by two or three intercostal motor
nerves or the spinal accessory nerve. Proximally, the
gracilis is secured to the lateral clavicle and, distally,
the gracilis tendon is woven into the biceps ten-
don (Fig. 9).32 Seventy-nine percent of the gracilis
free-functioning muscle transfers for elbow flexion
alone achieved at least M4 strength.2
RADIAL NEUROPATHY
High radial neuropathy, involving the radial
nerve proper, results in motor deficits, including
Volume 135, Number 3 • Upper Extremity Tendon/Nerve Transfers
Video 4. Supplemental Digital Content 4 displays a free func-
tional innervated gracilis muscle secured proximally to the clav-
icle and woven into the distal flexor digitorum profundus and
flexor pollicis longus tendons to restore finger flexion. This video
is available in the “Related Videos” section of the full-text article
on PRSJournal.com or at http://links.lww.com/PRS/B221.
loss of wrist extension (extensor carpi radialis
longus and brevis and extensor carpi ulnaris), fin-
ger extension at the metacarpophalangeal joints
(extensor digitorum communis, extensor indicis
proprius, and extensor digiti minimi), thumb
extension (extensor pollicis longus and extensor
pollicis brevis), thumb radial abduction (abductor
pollicis longus), and sensory deficits in the radial
nerve distribution. Patients also present with weak
grip strength caused by the transmission of flexion
force through an unstable wrist.6 Low radial neu-
ropathy primarily affects the muscles innervated
by the posterior interosseous nerve, including the
extensor carpi radialis brevis, extensor digitorum
communis, extensor indicis proprius, extensor
pollicis longus, extensor digiti minimi, and exten-
sor carpi ulnaris.
The three classic tendon transfers for high
radial nerve palsy include the Brand, Jones, and
modified Boyes transfers.8 Universally, the prona-
tor teres is transferred to the extensor carpi radi-
alis brevis for wrist extension and the palmaris
longus is transferred to the extensor pollicis lon-
gus. Disagreement exists regarding whether the
flexor carpi radialis or the flexor carpi ulnaris is
used to restore finger extension. Some authors
argue that by using the flexor carpi radialis
rather than the flexor carpi ulnaris, the impor-
tant movement of wrist flexion and ulnar devia-
tion (power grip) is preserved.6 The authors
prefer to use the flexor carpi radialis because
it preserves power grip, has a longer tendinous
portion, requires less mobilization, and can be
used in low radial nerve neuropathy without
causing increased radial wrist deviation. When
the palmaris longus or either of the wrist flexors
are unavailable or unsuitable for transfer, consid-
eration should be made to using the flexor digi-
torum superficialis of the middle or ring finger.
It is imperative to have adequate flexor digito-
rum profundus strength of these digits before
harvest. These tendon transfers are reliable, with
excellent long-term results in wrist, finger, and
thumb mobility and in patient satisfaction (Level
of Evidence: Therapeutic, IV).34 Controversy
exists regarding the order in which the transfers
should be performed. Some recommend per-
forming the pronator teres–to–extensor carpi
radialis brevis transfer first,35 whereas it is the
authors’ preference to perform this transfer last,
to ensure proper tensioning of the transfers for
finger and thumb extension (Fig. 10).
Tendon transfers for radial neuropathy have
been theorized to produce unnatural ergonom-
ics, weak power grip,5 loss of endurance,36 and
impaired coordination and dexterity36; therefore,
nerve transfers targeting the posterior interosse-
ous nerve and the extensor carpi radialis brevis
nerve branch have been proposed to restore
radial nerve function (Reference 36, Level of
Evidence: Therapeutic, IV). Nerve transfers have
been advocated, transferring nerve branches of
the flexor digitorum superficialis to the extensor
carpi radialis brevis nerve branch and branches
of the flexor carpi radialis and palmaris longus
to the posterior interosseous nerve. An alter-
native nerve transfer option includes using the
ulnar nerve–innervated branch of the flexor
carpi ulnaris to the posterior interosseous nerve.
An internal splint to hold the wrist in extension
using a pronator teres–to–extensor carpi radialis
brevis tendon transfer has been advocated as an
adjunct to the nerve transfers.5 Ray and Mackin-
non37 report greater than M4 wrist and finger
extension in 11 of 19 patients; however, five of
the 19 patients obtained minimal finger exten-
sion and one patient failed to recover either wrist
or finger extension. Nine of these patients under-
went simultaneous pronator teres–to–extensor
carpi radialis brevis tendon transfers and nerve
transfers, confounding the results of nerve trans-
fers versus tendon transfers (Level of Evidence:
Therapeutic, IV).37
Controversy surrounds using nerve transfers
for radial neuropathy. Should the nerve transfer
fail, there are limited options for tendon trans-
fers that remain because the nerve branches to
623e
 Plastic and Reconstructive Surgery • March 2015
the usual donor tendons have been sacrificed
by the nerve transfer; in addition, unaccept-
able weak tendon-muscle groups may result.
Given the excellent functional results with ten-
don transfers and the significantly faster recov-
ery, there is debate as to whether nerve transfers
should be performed. The authors typically
perform tendon transfers for radial neuropathy
in lieu of nerve transfers for the reasons listed
above. (See Video, Supplemental Digital Content
5, which shows a 25-year-old woman 7 months
after pronator teres–to–extensor carpi radialis
brevis, palmaris longus–to–extensor pollicis lon-
gus, and flexor carpi radialis–to–extensor digito-
rum communis transfer following a radial nerve
laceration with no return of function. This video
is available in the “Related Videos” section of the
full-text article on PRSJournal.com or at http://
links.lww.com/PRS/B222.)
MEDIAN NEUROPATHY
Low median neuropathy primarily affects
true thumb opposition (palmar abduction and
pronation) and sensation. A high median neu-
ropathy results in motor deficits, including the
loss of thumb interphalangeal joint flexion
(flexor pollicis longus), flexion of the index and
long fingers (flexor digitorum profundus and
flexor digitorum superficialis), forearm prona-
tion (pronator teres and pronator quadratus),
Video 5. Supplemental Digital Content 5 shows a 25-year-old
woman 7 months after pronator teres–to–extensor carpi radialis
brevis, palmaris longus–to–extensor pollicis longus, and flexor
carpi radialis–to–extensor digitorum communis transfer follow-
ing a radial nerve laceration with no return of function. This video
is available in the “Related Videos” section of the full-text article
on PRSJournal.com or at http://links.lww.com/PRS/B222.
624e
thumb opposition, and sensory deficits in the
median innervated digits.
In isolated low median neuropathy, thumb
opposition has traditionally been restored with
tendon transfers using various radial or ulnar
innervated muscles such as the extensor indicis
proprius, extensor pollicis longus, extensor carpi
ulnaris, extensor carpi radialis longus, extensor
digiti minimi, or abductor digiti minimi,8 or
high median innervated muscles (if available)
such as the palmaris longus or flexor digitorum
superficialis of the long or ring finger. Nerve
transfers for low median neuropathies have
been proposed5 in which the terminal branch of
the anterior interosseous nerve is transferred to
the median recurrent motor branch; however, it
requires an interpositional nerve graft and can-
not be used in high median nerve injuries. Func-
tional outcomes of this nerve transfer have yet to
be published.
In addition to restoration of thumb oppo-
sition, high median neuropathies require res-
toration of muscles innervated by the anterior
interosseous nerve (flexor digitorum profun-
dus to index and long fingers and flexor pol-
licis longus). Typical tendon transfers include
brachioradialis-to–flexor pollicis longus and
side-to-side transfer of the flexor digitorum
profundus of the ring and small fingers to the
flexor digitorum profundus of the index and
long fingers. Although good functional results
exist for these tendon transfers, few tendon
transfers are described to reestablish adequate
pronation. Loss of pronation can be restored by
a biceps rerouting procedure.38
Nerve transfers have been described for
high median neuropathies in which radial nerve
branches to the supinator and extensor carpi
radialis brevis are transferred into the anterior
interosseous nerve and pronator teres branches
of the median nerve.5,39 Alternatively, a nerve
branch of the brachialis can be transferred into
the anterior interosseous nerve (Fig. 11).5 The
benefit of these transfers is that they can in the-
ory be performed as an initial reconstruction
without sacrificing the option for the typical ten-
don transfers described above should the nerve
transfers fail.
In a high median neuropathy, the authors
prefer to perform tendon transfers for thumb
opposition (extensor indicis proprius oppo-
nensplasty–to–abductor pollicis brevis transfer)
(Fig. 12), thumb flexion (brachioradialis-to–
flexor pollicis longus transfer) (Fig. 13), and
index finger flexion (side-to-side flexor
Volume 135, Number 3 • Upper Extremity Tendon/Nerve Transfers
Fig. 8. The musculocutaneous (MC) motor nerve branches to
the brachialis and biceps muscles are dissected away from the
lateral antebrachial cutaneous (LABC) sensory nerve.
digitorum profundus tendon transfer) (Fig. 14).
It has been the experience of the authors that
the results of these tendon transfers are signifi-
cantly faster and more reliable than nerve trans-
fers. (See Video, Supplemental Digital Content
6, which shows a 22-year-old man 6 months after
brachioradialis-to–flexor pollicis longus trans-
fer and side-to-side index, long, ring, and small
finger flexor digitorum profundus and exten-
sor indicis proprius opponensplasty following
a left high median and ulnar nerve laceration
that failed to recover after primary repair. This
video is available in the “Related Videos” sec-
tion of the full-text article on PRSJournal.com
or at http://links.lww.com/PRS/B223.)
ULNAR NEUROPATHY
In low ulnar neuropathy, motor deficits
include loss of the intrinsic muscles (hypo-
thenar muscles, adductor pollicis, deep head
of flexor pollicis brevis, ulnar two lumbricals,
and interossei muscles). Loss of the interossei
muscles but preservation of the long extrin-
sic flexors and extensors of the hand and the
median innervated lumbricals to the index and
long fingers results in a notable clawed posture
of the hand. Sensory deficits exist to the small
finger and the ulnar half of the ring finger. A
high ulnar neuropathy results in motor deficits
of the flexor carpi ulnaris and flexor digito-
rum profundus to the ring and small fingers,
in addition to the loss of the intrinsic muscles
and the sensory deficits within the ulnar nerve
distribution. The goals of tendon transfers in
the reconstruction of the low ulnar intrinsic
minus hand are to restore thumb adduction
Fig. 9. Proximally, the innervated free functional gracilis
muscle is secured to the clavicle and, distally, the gracilis
tendon is woven into the biceps tendon to obtain elbow
flexion. (Published with permission of the Mayo Founda-
tion for Medical Education and Research. All rights reserved,
copyright 2010.)
and index abduction for pinch and to restore
intrinsic metacarpophalangeal joint flexion
with interphalangeal joint extension.8
When considering tendon transfers, a Bou-
vier test will decide whether the tendon transfer
must be static or dynamic to restore interpha-
langeal joint extension. A Bouvier test is per-
formed by blocking the hyperextension of the
metacarpophalangeal joints and asking patients
to extend the interphalangeal joints. A posi-
tive Bouvier test indicates that the extrinsic
extensors are able to extend the interphalan-
geal joints with the metacarpophalangeal joints
flexed; thus, the goal of the tendon transfer is
to provide metacarpophalangeal joint flexion
with a static transfer. A negative Bouvier test
reveals that the extrinsic extensors are unable
to extend the interphalangeal joints while the
metacarpophalangeal joint is flexed; therefore,
a dynamic tendon transfer is required into the
lateral bands of the extensor apparatus. Two
commonly performed tendon transfers include
the flexor digitorum superficialis (Stiles-Bun-
nell) transfer or the transfer of extensor carpi
radialis longus with tendon graft extensions
(four-tail graft).8 Common options for tendon
transfers to restore thumb adduction include
using either extensor carpi radialis brevis or
625e
 Plastic and Reconstructive Surgery • March 2015

Fig. 10. One year after pronator teres–to–extensor carpi radialis brevis, palmaris longus–to–extensor pollicis
longus, and flexor carpi radialis–to–extensor digitorum communis transfer for high radial neuropathy.

Video 6. Supplemental Digital Content 6 shows a 22-year-old

man 6 months after brachioradialis-to–flexor pollicis longus
transfer and side-to-side index, long, ring, and small finger flexor
digitorum profundus and extensor indicis proprius opponens-
plasty following a left high median and ulnar nerve laceration
that failed to recover after primary repair. This video is available Fig. 11. A nerve branch of the brachialis can be transferred
in the “Related Videos” section of the full-text article on PRSJour- into the anterior interosseous nerve (AIN) in high median neu-
nal.com or at http://links.lww.com/PRS/B223. ropathies. MCN, musculocutaneous nerve.

626e
Volume 135, Number 3 • Upper Extremity Tendon/Nerve Transfers

Fig. 12. The authors’ preference to perform extensor indicis proprius opponensplasty to abductor pollicis brevis for thumb opposi-
tion in median neuropathy.

Fig. 13. The authors’ preference to obtain index finger flexion (side-to-side flexor digitorum profundus tendon transfer) in high
median neuropathy. (Left) The blue vessel loop is around the flexor digitorum profundus tendons to the index, long, ring, and small
fingers. (Right) The assistant is placing proximal traction on the tendons to set equal tension on all the fingers.

Fig. 14. The authors’ preference to obtain thumb flexion [brachioradialis (BR) to flexor pollicis longus (FPL)] in high median
neuropathy.

flexor digitorum superficialis. Other transfers
using brachioradialis, extensor carpi radialis
longus, extensor indicis proprius, and extensor
digiti minimi have been described. To restore
key pinch, reconstruction of index finger abduc-
tion is required by restoring function of the first
dorsal interosseous with either a slip of abduc-
tor pollicis longus or extensor indicis proprius
tendon. Tendon transfers for low ulnar neurop-
athy are a useful salvage procedure to improve
the function of the significantly impaired hand.
Selective joint fusions may also assist in improv-
ing hand function, such as a thumb carpometa-
carpal joint arthrodesis.40
An alternative to tendon transfers is to rein-
nervate the ulnar nerve innervated intrinsic

627e
 Plastic and Reconstructive Surgery • March 2015
Fig. 15. The terminal branch of the anterior interosseous nerve
(AIN) is transferred into the deep ulnar motor nerve branch.
muscles of the hand by performing a distal nerve
transfer from the terminal branch of the anterior
interosseous nerve into the deep ulnar motor
nerve branch (Fig. 15). At 18-month follow-up,
eight patients had reinnervation of the ulnar
nerve intrinsic hand muscles, with improved
postoperative lateral pinch and grip strength and
without any donor functional deficits (Fig. 16).41
The benefit of this nerve transfer is that it does
not prohibit the use of the typical tendon trans-
fers should the nerve transfer fail. The disad-
vantage to performing this nerve transfer is the
significant time needed for reinnervation that
Fig. 16. Eighteen months after left distal nerve transfer from the terminal branch of the anterior interosseous nerve into the deep
ulnar motor nerve branch for restoration of the intrinsic musculature of the hand.
628e
could have been used to rehabilitate a tendon
transfer.
In high ulnar neuropathy, in addition to the
above-mentioned tendon/nerve transfers for
low ulnar neuropathy, the flexor digitorum pro-
fundus muscles of the ring and small fingers are
transferred side to side into the flexor digitorum
profundus of the median innervated flexor digi-
torum profundus of the index and long fingers.
HAND SENSATION
Sensation can be restored with either repair
of the peripheral sensory nerve or a nerve trans-
fer. End-to-end and end-to-side neurorrhaphies
have been proposed to restore sensation in the
distal radial, median, and ulnar nerve distribu-
tions. Priorities of sensation are to the ulnar
side of the thumb, the radial side of the index
finger, and the ulnar border of the hand. Donor
nerves include the sensory intercostal nerves (to
be transferred into the lateral cord contribution
of the median nerve in brachial plexus injuries),
lateral antebrachial cutaneous nerve, distal sen-
sory radial nerve branches,26 distal median nerve
innervated third webspace, and distal ulnar nerve
innervated fourth webspace.5 The recovery of
sensation is aimed at preventing cutaneous ulcers
and restoring protective sensation.26
Volume 135, Number 3 • Upper Extremity Tendon/Nerve Transfers
CONCLUSIONS
Peripheral nerve injuries result in motor and/
or sensory deficits that can significantly impair a
patient’s function. There are advantages and dis-
advantages to both tendon and nerve transfers,
without one technique consistently being superior
to the other. Often, tendon and nerve transfers are
used in combination as opposed to one in isolation
to obtain the most normal functioning extremity
without unacceptable donor deficits. The authors
tend to prefer reconstructive techniques that have
proven long-term efficacy to restore function. Nerve
transfers are becoming more common practice,
with excellent results; however, the authors are cau-
tious regarding use of nerve transfers that sacrifice
possible secondary tendon reconstruction should
the nerve transfer fail.
Alexander Y. Shin, M.D.
Department of Orthopedic Surgery
Division of Hand and Microvascular Surgery
Mayo Clinic
200 First Street Southwest
Rochester, Minn. 55905
shin.alexander@mayo.edu
‍REFERENCES
1. Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult
traumatic brachial plexus injuries. J Am Acad Orthop Surg.
2005;13:382–396.
2. Bishop AT. Functioning free-muscle transfer for brachial
plexus injury. Hand Clin. 2005;21:91–102.
3. Chuang DC. Neurotization procedures for brachial plexus
injuries. Hand Clin. 1995;11:633–645.
4. Mackinnon SE, Humphreys DB. Nerve transfers. Operative
Tech Plast Reconstr Surg. 2002;9:89–99.
5. Brown JM, Mackinnon SE. Nerve transfers in the forearm
and hand. Hand Clin. 2008;24:319–340, v.
6. Jones NF, Machado GR. Tendon transfers for radial, median,
and ulnar nerve injuries: Current surgical techniques. Clin
Plast Surg. 2011;38:621–642.
7. Smith RJ, Hastings H. Principles of tendon transfers to the
hand. AAOS Instruct Course Lect. 1993;21:129–149.
8. Ratner JA, Peljovich A, Kozin SH. Update on tendon
transfers for peripheral nerve injuries. J Hand Surg Am.
2010;35:1371–1381.
9. Merrell GA, Barrie KA, Katz DL, Wolfe SW. Results of nerve
transfer techniques for restoration of shoulder and elbow
function in the context of a meta-analysis of the English lit-
erature. J Hand Surg Am. 2001;26:303–314.
10. Terzis JK, Kostas I. Suprascapular nerve reconstruction
in 118 cases of adult posttraumatic brachial plexus. Plast
Reconstr Surg. 2006;117:613–629.
11. Songcharoen P, Wongtrakul S, Spinner RJ. Brachial plexus
injuries in the adult. Nerve transfers: The Siriraj Hospital
experience. Hand Clin. 2005;21:83–89.
12. Shin AY. Nerve transfers: The ones I no longer perform.
Paper presented at: 64th Annual Meeting of the American
Society for Surgery of the Hand; September 3–5, 2009; San
Francisco, Calif.
13. Bertelli JA, Ghizoni MF. Transfer of the accessory nerve to
the suprascapular nerve in brachial plexus reconstruction.
J Hand Surg Am. 2007;32:989–998.
14. Suzuki K, Doi K, Hattori Y, Pagsaligan JM. Long-term results
of spinal accessory nerve transfer to the suprascapular nerve
in upper-type paralysis of brachial plexus injury. J Reconstr
Microsurg. 2007;23:295–299.
15. Oberlin C, Durand S, Belheyar M, Shafi M, David E,
Asfazadourian H. Nerve transfers in brachial plexus palsies.
Chir Main 2009;28:1–9.
16. Leechavengvongs S, Witoonchart K, Uerpairojkit C, et al.
Nerve transfer to deltoid muscle using the nerve to the
biceps muscle after avulsions of upper roots of the brachial
plexus. J Hand Surg Am. 2003;28:633–638.
17. Lee JY, Kircher M, Spinner RJ, Bishop AT, Shin AY. Factors
affecting the outcomes of triceps motor branch to isolated
axillary nerve injury. J Hand Surg Am. 2012;37:2350–2356.
18. Lee SK, Wolfe SW. Nerve transfers for the upper extremity:
New horizons in nerve reconstruction. J Am Acad Orthop Surg.
2012;20:506–517.
19. Kostas-Agnantis I, Korompilias A, Vekris M, et al. Shoulder
abduction and external rotation restoration with nerve
transfer. Injury 2013;44:219–304.
20. Atlan F, Durand S, Fox M, Levy P, Belkheyar Z, Oberlin
C. Functional outcome of glenohumeral fusion in bra-
chial plexus palsy: A report of 54 cases. J Hand Surg Am.
2012;37:683–688.
21. Saha AK. Surgery of the paralyzed and flail shoulder. Acta
Orthop Scand. 1967;(Suppl 97):5–90.
22. Rühmann O, Schmolke S, Bohnsack M, Carls J, Wirth CJ.
Trapezius transfer in brachial plexus palsy: Correlation of
the outcome with muscle power and operative technique.
J Bone Joint Surg Br. 2005;87:184–190.
23. Elhassan B, Bishop AT, Hartzler RU, Shin AY, Spinner
RJ. Tendon transfer options about the shoulder in
patients with brachial plexus injury. J Bone Joint Surg Am.
2012;94:1391–1398.
24. Oberlin C, Beal D, Leechavengvongs S, et al. Nerve transfer
to biceps muscle using a part of ulnar nerve for C5-C6 avul-
sion of the brachial plexus: Anatomical study and report of
four cases. J Hand Surg Am. 1994;19:232–237.
25. Mackinnon SE, Novak CB, Myckatyn TM, Tung TH. Results
of reinnervation of the biceps and brachialis muscles with a
double fascicular transfer for elbow flexion. J Hand Surg Am.
2005;30:978–985.
26. Wong AH, Pianta TJ, Mastella DJ. Nerve transfers. Hand Clin.
2012;28:571–577.
27. Carlsen BT, Kircher MF, Spinner RJ, Bishop AT, Shin AY.
Comparison of single versus double nerve transfers for
elbow flexion after brachial plexus injury. Plast Reconstr Surg.
2011;127:269–276.
28. Martins RS, Siqueria MG, Heise CO, Foroni L, Teixeira MJ.
A prospective study comparing single and double fascicular
transfer to restore elbow flexion after brachial plexus injury.
Neurosurgery 2013:72:709–715.
29. Stern PJ, Caudle RJ. Tendon transfers for elbow flexion.
Hand Clin. 1988;4:297–307.
30. Cambon-Binder A, Belkheyar Z, Durand S, Rantissi M,
Oberlin C. Elbow flexion restoration using pedicled latissi-
mus dorsi transfer in seven cases. Chir Main 2012;31:324–330.
31. Giuffre JL, Kakar S, Bishop AT, Spinner RJ, Shin AY. Current
concepts of the treatment of adult brachial plexus injuries.
J Hand Surg Am. 2010;35:678–688.
32. Giuffre JL, Bishop AT, Shin AY. Harvest of an entire gracilis
muscle and tendon for use in functional muscle transfer: A
novel technique. J Reconstr Microsurg. 2012;28:349–358.
629e
 Plastic and Reconstructive Surgery • March 2015
33. Doi K, Muramatsu K, Hattori Y, et al. Restoration of pre-
hension with the double free muscle technique following
compete avulsion of the brachial plexus: Indications and
long-term results. J Bone Joint Surg Am. 2000;82:652–666.
34. Ropars M, Dréano T, Siret P, Belot N, Langlais F. Long-term
results of tendon transfers in radial and posterior interosse-
ous nerve paralysis. J Hand Surg Br. 2006;31:502–506.
35. Green DP. Radial nerve palsy. In: Green’s Operative Hand
Surgery. Vol. 1, 5th ed. Philadelphia: Elsevier Health Sciences;
2005:1113–1129.
36. Dunnet WJ, Housden PL, Birch R. Flexor to extensor tendon
transfers in the hand. J Hand Surg Br. 1995;20:26–28.
37. Ray WZ, Mackinnon SE. Clinical outcomes following median
to radial nerve transfers. J Hand Surg Am. 2011;36:201–208.
630e
38. Rühmann O, Hierner R. Z-plasty and rerouting of the biceps
tendon with interosseous membrane release to restore pro-
nation in paralytic supination posture and contracture of the
forearm (in German). Oper Orthop Traumatol. 2009;21:157–169.
39. Brown JM, Shah MN, Mackinnon SE. Distal nerve transfers:
A biology-based rationale. Neurosurg Focus 2009;26:E12.
40. Giuffre JL, Bishop AT, Spinner RJ, Kircher MF, Shin AY.
Wrist, first carpometacarpal joint, and thumb interphalan-
geal joint arthrodesis in patients with brachial plexus inju-
ries. J Hand Surg Am. 2012;37:2557–2563.e1.
41. Novak CB, Mackinnon SE. Distal anterior interosseous
nerve transfer to the deep motor branch of the ulnar nerve
for reconstruction of high ulnar nerve injuries. J Reconstr
Microsurg. 2002;18:459–464.