Orthopaedics & Traumatology: Surgery & Research 106 (2020) 307–310

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Orthopaedics & Traumatology: Surgery & Research

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Original article

Tendon transfers for radial nerve palsy with extensor carpi ulnaris
revival: Technique and results
Marion Besnard , Emilie Marteau , Jacky Laulan ∗ , Guillaume Bacle
Services d’orthopédie 1 et 2, unité de chirurgie de la main, CRHU de Tours, 37044 Tours cedex, France

a r t i c l e i n f o a b s t r a c t

Article history: Background: Nerve repair is the gold standard for treatment of radial palsy. In case of failure or con-
Received 6 January 2019 traindication, palliative techniques using tendon transfers provide good results. However, wrist extension
Accepted 13 November 2019 frequently shows radial deviation, impairing grip strength.
Hypothesis: Associating extensor carpi ulnaris (ECU) revival avoids radial deviation.
Keywords: Study design: Single-center retrospective study.
Radial nerve palsy Material and Methods: The inclusion criterion was radial nerve palsy treated by tendon transfers involv-
Tendon transfers
ing revival of the ECU. Nine patients, with a mean age of 33 years [15–60] were included. Four palsies
Finger extension
Wrist extension
were trauma-induced, 3 tumor-induced and 2 idiopathic. The mean time to treatment was 32 months
Thumb abduction [4.6–120].
Hand palsy Results: Mean follow-up was 51 months [3–160.7]. Eight patients could be assessed. Wrist extension was
balanced in 6 cases, in ulnar deviation in 1 and in radial deviation in the other. Wrist motion was 54◦
[30◦ –80◦ ] in extension, 46◦ [20◦ –70◦ ] in flexion, with an active motion in the frontal plane of 21◦ [0◦ –35◦ ].
Finger extension was possible with the wrist in extension in 6 cases. Thumb abduction was subnormal
in 3 cases, incomplete but functional in 4 and barely functional in 1. Fist closure was always complete.
Mean QuickDASH score was 41/100 [14–63].
Conclusion: This technique is reliable and reproducible, giving good functional results and avoiding the
radial deviation of the wrist in extension observed with traditional techniques.
Level of evidence: IV.
© 2020 Elsevier Masson SAS. All rights reserved.

1. Introduction
Radial palsy severely restricts hand function and entails major
disability [1]. Gold standard treatment is nerve repair but, except
in case of clear-cut wound, results, including those of autograft, are
often disappointing and palliative surgery may be indicated [2].
The aim is to restore wrist extension, hand opening and thumb
extension/abduction. Despite the development of nerve transfers
[3], tendon transfers is the gold standard for palliative treatment,
restoring gross but useful function, rapidly and reproducibly [4–6].
Finger extension revival mainly uses flexor carpi radialis (FCR)
[7,8], and flexor carpi ulnaris (FCU) [9–12], which has twice the
strength of FCR. Both have relatively short course, and some authors
prefer one flexor digitorum superficialis (FDS) tendon. For thumb
abduction-extension, some authors also revive the abductor pol-
licis longus (APL) and extensor pollicis brevis (EPB) [1], but most
revive only the extensor pollicis longus (EPL) using the palmaris
longus (PL) [4,7,9–11,13]. EPL is in that case rerouted subcuta-
neously to enhance transfer abduction, which, however, is mainly
restricted to wrist extension [4,11].
To restore wrist extension, the consensus is to use pronator teres
(PT) to revive the two extensor carpi radialis (ECRs) muscles or just
the extensor carpi radialis brevis (ECRB). In the absence of extensor
carpi ulnaris (ECU), however, extension is in radial deviation, caus-
ing fatigue and impairing grip [10]. Compensatory variants have
been described [4,7,8,10,11]. We revive the two ECRs and transfer
the extensor carpi radialis longus (ECRL) to the ECU, on the hypoth-
esis that this avoids radial deviation in wrist extension. The aim of
the present study was to assess wrist extension balance with this
technique.
2. Patients and Methods

A single-center retrospective study included all patients

∗ Corresponding author. treated for radial palsy by tendon transfer with associated ECU
E-mail address: jacky.laulan@orange.fr (J. Laulan). revival between January 2003 and December 2015. The inclusion

https://doi.org/10.1016/j.otsr.2019.11.026
1877-0568/© 2020 Elsevier Masson SAS. All rights reserved.
308 M. Besnard et al. / Orthopaedics & Traumatology: Surgery & Research 106 (2020) 307–310

Table 1
General data of the patients included.

Case General data Palsy

Age (years) Gender Dominant hand Affected side Etiology Palsy duration (months)

1 60 M R R Trauma 120
2 15 F R R Idiopathic 27
3 37 M R R Tumor 5
4 24 M R L Trauma 20
5 22 M Unknown R Tumor 7
6 45 M Unknown R Tumor 28
7 27 M R L Trauma 36
8 34 M R R Idiopathic 32
9 30 M R R Trauma 13

M: male; F: female; R: right; L: left.

Table 2
Details of tendon transfers.

Wrist extension Finger extension Thumb

1 PT → ECRL + ECRBECRL → ECU FCU → EDC + EPL FCU → EDC + EPL

2 PT → ECRL + ECRBECRL → ECU FCU → EDC + EIP PL → EPL
3 PT → ECRL + ECRBECRL → ECU FCU → EDC + EIP PL → EPL
4 PT → ECRL + ECRBECRL → ECU FCR → EDC + EPL FCR → EDC + EPL
5 PT → ECRL + ECRBECRL → ECU FCU → EDC PL → EPL
6 PT → ECRL + ECRBECRL → ECU FCU → EDC + EPL FCU → EDC + EPL
7 PT → ECRL + ECRBECRL → ECU FCU → EDC PL → EPL
8 PT → ECRL + ECRBECRL → ECU FCU → EDC + EIP BR → EPL
9 PT → ECRL + ECRBECRL → ECU FCU → EDC + EIP PL → EPL

PT: pronator teres; ECRB: extensor carpi radialis brevis; ECRL: extensor carpi radi-
alis longus; ECU: extensor carpi ulnaris; EDC: extensor digitorum communis; EPL:
extensor pollicis longus; EIP: extensor indicis propius; PL: palmaris longus; BR:
brachioradialis.

the posterior side of the forearm, and splitting it along 5 cm into

Fig. 1. Schematic representation of the surgical technique. EDC and EIP are revived
by the FCU. After revival of the 2 ECRs, ECRL is transferred on the ECU to rebalance
wrist extension. EPL is rerouted in the second extensor compartment and sutured
to the PL.
criterion was wrist extension paralysis of peripheral origin involv-
ing the radial nerve. Exclusion criteria comprised associated central
neurologic lesion and pathology impairing functional prognosis.
Nine patients were included: 8 male, 1 female; mean age,
33 years (range, 15–60 years) (Table 1). The dominant side was
involved in 5 of the 7 cases in which it was known. The deficit
involved the radial nerve in all cases, and was partial in 1 case in
which the brachio-radialis had recovered (case No. 9). Three cases
were tumoral, 2 idiopathic and 4 traumatic, including 2 with asso-
ciated lesions: humeral non-union, and brachial plexus palsy of the
C5, C6 and C7 roots. Mean interval from onset of palsy to surgery
was 32 months (range, 4.6–120 months).
Surgery was performed under general or locoregional anesthe-
sia with preventive hemostasis by pneumatic tourniquet, using 2
approaches; the technique is shown in Fig. 1. Finger extension was
in most cases restored by passing the FCU subcutaneously over
2 hemitendons, according to Tubiana [4,11], fixed to the exten-
sor digitorum communis (EDC) and extensor indicis propius (EIP)
tendons. The suture was adjusted with the wrist in 40◦ extension,
and the metacarpophalangeal joints in decreasing extension from
index to 5th finger. To restore wrist extension, PT, prolonged by a
periosteal strap and passed subcutaneously, was fixed by multiple
passages in the tendon-muscle junction of the two ECRs, with the
wrist in 40◦ extension. After fixation, the wrist was normally main-
tained gravitationally at 0◦ . The ECRL tendon was then sectioned
flush to its distal insertion, extracted from the 2nd compartment
and transferred onto the ECU under tension to maintain wrist bal-
ance frontally. Finally, the EPL was sectioned at the tendon-muscle
junction, rerouted into the 2nd compartment of the extensors and
sutured onto the PL, with the wrist straight and the thumb in
complete abduction and extension. Postoperatively, 4 weeks’ strict
immobilization was ensured by a brachial-palmar splint, with the
forearm in pronation and wrist and fingers in extension. Subse-
quently, a dynamic orthosis maintained extension for a further 2
weeks between rehabilitation sessions.
At follow-up the main endpoint was wrist extension balance:
neutral, radial deviation or ulnar deviation. Secondary endpoints
comprised range of active wrist motion, fist opening and closure
quality, long-digit metacarpophalangeal extension according to
wrist position, and thumb abduction-extension quality. Assess-
ment also included degree of hand use, change in handedness,
return to identical or reduced occupational and leisure activities,
stability of results, satisfaction and Quick-DASH score.
3. Results
Table 2 details tendon transfers. One patient (case No. 4) under-
went associated scapulohumeral fusion for associated brachial
plexus palsy. There were no early complications. One patient (case
No. 1) underwent revision surgery at 7.5 months for loosening of
 M. Besnard et al. / Orthopaedics & Traumatology: Surgery & Research 106 (2020) 307–310 309

Table 3
Results of the 9 cases evaluated.

Case Wrist extension Finger extension, Thumb abduction Use of the hand Satisfaction QuickDASH
wrist in extension (/100)

1 Balanced Impossible Incomplete but Useful help for Satisfied 56.82

functional bimanual activities
2 Ulnar deviation Possible Subnormal Subnormal Satisfied 36.36
3 Balanced Possible Subnormal Subnormal Satisfied 30
4 Balanced Impossible Barely functional Useful help for Very satisfied 59.09
bimanual activities
5 Balanced Possible Incomplete but Subnormal Unknown Unknown
functional
6 Unknown Unknown Unknown Unknown Unknown Unknown
7 Balanced Possible Incomplete but Subnormal Very satisfied 13.64
functional
8 Radial deviation Possible Incomplete but Subnormal Very satisfied 62.5
functional
9 Balanced Possible Subnormal Subnormal Satisfied 27.27

Fig. 2. Long-term result (case No. 3, 9 years 8 months after surgery; case No. 7, 13 years 4 months after surgery). a: balanced wrist extension; b: long digit extension, wrist
in neutral position; c: long digit extension, wrist in extension; d: thumb abduction-extension; e: wrist extension, fist closed.

the finger and thumb revival sutures; retensioning was performed
and postoperative course was simple.
Seven patients were reassessed in consultation; 1 had died (case
No. 6), and 1 was lost to follow-up (case No. 5) but the data and
photographs from the last consultation allowed assessment of the
objective result (Table 3). Mean follow-up was 51 months (range,
3–160.7 months).
Wrist extension was well-balanced in 6 cases, in 10◦ ulnar devi-
ation in 1 (case No. 2) and in 15◦ radial deviation in 1 (case No.
8) (Fig. 2a–e). Mean range of active wrist motion was 54◦ (range,
30–80◦ ) in extension, 46◦ (20–70◦ ) in flexion, 16◦ (−10◦ to 35◦ )
in ulnar deviation, and 3◦ (0–20◦ ) in radial deviation, with active
motion in the frontal plane of 21◦ (0–35◦ ).
Mean long-digit metacarpophalangeal extension, wrist in neu-
tral position, was 1◦ (range, −50◦ to 30◦ ), for a median 10◦ .
Long-digit extension with wrist in extension was possible in 6 of
the 8 cases. Hand opening was subnormal in 6 cases. Thumb abduc-
tion was subnormal in 3 cases, incomplete but functional in 4 and
barely functional in 1. Fist closure was complete in all cases. The
hand was used subnormally by 6 patients and as useful help for
bimanual activities by 2.
At last follow-up, 4 of the 7 patients had returned to identical
activity; 3 had resumed lighter activity, 2 due to palsy and 1 to asso-
ciated sequelae (brachial plexus palsy). One patient had changed
his dominant hand. Results were stable in 6 cases and impaired
in 1. Mean QuickDASH was 41/100 (range, 14–63). Four patients
310 M. Besnard et al. / Orthopaedics & Traumatology: Surgery & Research 106 (2020) 307–310
were satisfied and 3 very satisfied; all would undergo the procedure
again.
4. Discussion
Associated ECU revival using the ECRL restored well-balanced
wrist extension, with stable results at a mean 5 years, with good
active wrist motion.
With most transfer techniques, due to the absence of ECU, wrist
extension is in radial deviation, causing fatigue and impairing grip
strength [10]. Boyes [1] therefore revived the 2 ECRs, but conserved
the FCU, supposedly to conserve a physiological sector of motion –
although extension was still in radial deviation. Brand [8] first advo-
cated reviving only the ECRB, but this fails to correct the tendency
toward radial deviation [11,12]. Tsuge suggested reviving only the
ECRB, using the FCR to revive finger extension [7]; this seemed to
give better results, but does not preclude radial deviation of the
wrist in extension [14]. In 1985, Tubiana suggested centralizing
the ECRL insertion on the ulnar edge of the 3rd metacarpal base
[4]; this restored more well-balanced extension, but postoperative
functional results have not been assessed.
The ideal means of avoiding radial deviation of the wrist in
extension is to revive the ECU as well. Brand recommended simul-
taneously reviving ECRB and ECU directly using the PT [8] and Said
recommended reviving the 2 ECRs and ECU using the PT [10]. The
present technique likewise revives the ECU, but using the ECRL
revived by the PT. Rerouting the ECRL onto the ECU both neutral-
izes its contribution to radial deviation and balances the action of
the ECRB. This enables finer adjustment than the Brand and Said
variants, acting like the reins of a horse to balance wrist extension
under the single action of the PT. Rerouting the ECRL seems not
to entail problems of adherence, and we found no tenodesis effect
related to transfer to the ECU. It also conserves some motion in the
frontal plane.
The possibility of freely adjusting wrist extension balance
enables finger extension to be revived using the FCU, which has
greater strength than the FCR. The result on metacarpophalangeal
extension remains, however, limited by the short transfer course
and the insufficient extension of the ulnar digits. Transfer adjust-
ment was performed to respect the physiological cascade, so as to
allow full fist closure, resulting in a deficit of active finger exten-
sion of the ulnar fingers. Moreover, one patient (case No. 2), who
did not strictly adhere to postoperative immobilization, had a poor
result for finger extension, which brought down the average for the
series.
When EPL is rerouted subcutaneously, the impact on transfer
abduction is seen mainly in wrist extension [11]. With the present
technique, like with Tubiana’s, the freed up by ECRL removal
enables the EPL to be rerouted in the 2nd compartment of the
extensors [4,11]. This position of the EPL tendon provides more
physiological abduction than a subcutaneous route and the result
is still acceptable if, in absence of PL, EPL is also revived with FCU.
5. Conclusion
This technical variant was reliable and reproducible and can be
used for revival in palsy of the radial nerve or its deep branch.
Reviving ECU by a rerouted ECRL avoids the risk of radial devi-
ation encountered with conventional techniques. It moreover
restores functional wrist motion and more physiological thumb
abduction.
Disclosure of interest
The authors declare that they have no competing interest.
Funding
None.
Author contributions
J.L., G.B., E.M.: treatment.
M.B., J.L.: study design.
M.B.: data extraction, follow-up.
M.B. and JL: article writing.
All co-authors approved the manuscript.
References
[1] Boyes JH. Tendon transfers for radial palsy. Bull Hosp Joint Dis 1960;21:97–105.
[2] Laulan J. High radial nerve palsy. Hand Surg Rehabil 2019;38:2–13 [pii: S2468-
1229(18)30403-1].
[3] Davidge KM, Yee A, Kahn LC, Mackinnon SE. Median to radial nerve trans-
fers for restoration of wrist, finger, and thumb extension. J Hand Surg Am
2013;38:1812–27.
[4] Tubiana R. Our experience in tendon transfers for radial palsy. Ann Chir Main
1985;4:197–210.
[5] Skoll PJ, Hudson DA, De Jager W, Singer M. Long-term results of tendon transfers
for radial nerve palsy in patients with limited rehabilitation. Ann Plast Surg
2000;45:122–6.
[6] Ropars M, Dréano T, Siret P, Belot N, Langlais F. Long-term results of tendon
transfers in radial and posterior interosseous nerve paralysis. J Hand Surg Br
2006;31:502–6.
[7] Tsuge K. Tendon transfers for radial nerve palsy. Aust N Z J Surg
1980;50:267–72.
[8] Brand PW. Clinical mechanics of the hand. St Louis: CV Mosby; 1985.
[9] Riordan DC. Tendon transfers for median, ulnar or radial nerve palsy. Hand
1969;1:42–6.
[10] Said GZ. A modified tendon transference for radial nerve paralysis. J Bone Joint
Surg Br 1974;56:320–2.
[11] Tubiana R. Problems and solutions in palliative tendon transfer surgery for
radial nerve palsy. Tech Hand Up Extrem Surg 2002;6:104–13.
[12] Green D. Radial nerve palsy. In: Green D, Hotchkiss R, Peterson W, Wolfe S,
editors. Operative hand surgery, Vol 2, 5th ed. New York: Churchill Livingstone;
2005. p. 1113–31.
[13] Zachary RB. Tendon transplantation for radial paralysis. Br J Surg
1946;34:358–64.
[14] Ishida O, Ikuta Y. Analysis of Tsuge’s procedure for the treatment of radial nerve
paralysis. Hand Surg 2003;8:17–20.