CME

Tendon Transfers: Part II. Transfers for Ulnar

Nerve Palsy and Median Nerve Palsy
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Douglas M. Sammer, M.D.

Learning Objectives: After reading this article (part II of II), the participant
Kevin C. Chung, M.D., M.S.
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should be able to: 1. Describe the anatomy and function of the median and ulnar
Ann Arbor, Mich. nerves in the forearm and hand. 2. Describe the clinical deficits associated
with injury to each nerve. 3. Describe the indications, benefits, and drawbacks
for various tendon transfer procedures used to treat median and ulnar nerve
palsy. 4. Describe the treatment of combined nerve injuries. 5. Describe
postoperative care and possible complications associated with these tendon
transfer procedures.
Summary: This article discusses the use of tendon transfer procedures for treat-
ment of median and ulnar nerve palsy and combined nerve palsies. Postoperative
management and potential complications are also discussed. (Plast. Reconstr. Surg.
124: 212e, 2009.)

ULNAR NERVE PALSY nerve innervation of intrinsic hand muscles.2 This

anomaly can result in intact intrinsic hand func-
Anatomy tion following proximal ulnar nerve injury. The
In the arm, the ulnar nerve lies anterior to the Riche-Cannieu anomaly is a connection between
triceps muscle. It travels through the cubital tun- the motor branch of the ulnar nerve and the re-
nel at the elbow, and then passes between the two current motor branch of the median nerve in the
heads of the flexor carpi ulnaris, which it inner- hand, with ulnar to median innervation.3 This
vates. As it courses distally, it lies on the volar anomaly can result in preservation of thenar func-
aspect of the flexor digitorum profundus, and in- tion after median nerve injury at the wrist or more
nervates the flexor digitorum profundus to the proximally.
small and ring fingers. Approximately 7 cm prox-
imal to the wrist, it gives off a dorsal sensory Clinical Findings
branch, which provides sensibility to the ulnar Ulnar nerve palsy is a more devastating injury
aspect of the dorsal hand. At the wrist, the main than radial nerve palsy (discussed in part I). In
nerve passes into the Guyon canal along with the both high and low ulnar nerve palsy, key pinch is
ulnar artery. Within the Guyon canal, it divides lost because of absent adductor pollicis and first
into deep and superficial branches. The superfi- dorsal interosseous muscle function. Clawing oc-
cial branch gives sensibility to the small finger and curs as a result of paralysis of the intrinsic muscles
the ulnar half of the ring finger. The deep motor in the presence of functioning extrinsic finger
branch innervates the hypothenar muscles, the flexors and extensors. Clawing causes a loss of
ulnar two lumbricals, the interossei, the adductor active interphalangeal joint extension and meta-
pollicis, and the deep head of the flexor pollicis carpophalangeal joint flexion, which prevents the
brevis. The most distal motor branch innervates patient from cupping the hand around objects. In
the first dorsal interosseous muscle. Anomalous addition, integration of metacarpophalangeal
ulnar nerve anatomy is common in the forearm joint and interphalangeal joint flexion is lost. In
and hand.1 The Martin-Gruber connection is seen the normal hand, integrated finger flexion begins
when the median nerve contributes motor fibers to at the metacarpophalangeal joint powered by the
the ulnar nerve in the forearm, resulting in median intrinsic muscles, followed by flexion of all three
From the Section of Plastic Surgery, Department of Surgery,
University of Michigan Health System.
Received for publication February 27, 2007; accepted August Disclosure: The authors have no financial inter-
16, 2007. ests to declare in relation to the content of this
Copyright ©2009 by the American Society of Plastic Surgeons article.
DOI: 10.1097/PRS.0b013e3181b037c7

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 Volume 124, Number 3 • Tendon Transfers for Nerve Palsy

finger joints powered by the flexor digitorum pro-

fundus and flexor digitorum superficialis, folding
the fingers smoothly into the palm. In ulnar nerve
palsy, metacarpophalangeal joint flexion is not
initiated by the intrinsic muscles, and finger flex-
ion begins at the interphalangeal joints, followed
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by late metacarpophalangeal joint flexion. This

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results in a rolling motion of the fingers, which

prematurely closes them before they reach the
palm, making it difficult to grasp objects. In ad-
dition to the above findings, high ulnar nerve palsy
results in loss of the flexor carpi ulnaris and flexor
digitorum profundus to the ring and little fingers.
This causes diminished grip strength and the loss
of ulnar deviation with wrist flexion. A small ben-
efit of diminished flexor digitorum profundus
function is that clawing is less severe than in low
ulnar nerve palsy, in which the flexor digitorum
profundus to the ring and small fingers remains
intact. Unlike radial nerve palsy, the sensory def-
icit in ulnar nerve palsy is clinically disabling. Pro-
tective sensation in the ulnar nerve distribution is
important for preventing injury when the hand is
placed in resting positions. Fig. 1. Drawing showing adjacent suturing of ring and small fin-
Special attention should be paid to the ex- ger flexor digitorum profundus (FDP) to middle finger flexor digi-
amination of the clawed hand. The Bouvier test torum profundus for restoration of distal interphalangeal joint
involves passively correcting the metacarpopha- flexion in ulnar palsy.
langeal joint hyperextension and checking for
improved interphalangeal joint extension. If the
patient’s flexed interphalangeal joint posture im- ring and small finger flexor digitorum profundus
proves, the Bouvier test is positive and the clawing function is reestablished, and corrective measures
is defined as simple. If the interphalangeal joints may be required.
remain flexed even after passive correction of the In the normal hand, key pinch is the result of
metacarpophalangeal joint hyperextension, the combined first dorsal interosseous and adductor
Bouvier test is negative and the clawing is defined pollicis function. Many different tendon transfer
as complex.4 procedures for restoration of key pinch have been
described, including the use of wrist and finger
extensors, finger flexors, and the brachioradialis
Tendon Transfer Procedures to power adductor pollicis function. In most cases,
The primary goals of tendon transfer proce- it is only necessary to restore adductor pollicis
dures for ulnar nerve palsy are restoration of small function to restore functional key pinch, because
and ring finger distal interphalangeal joint flexion the index finger can be stabilized against the ad-
(in cases of high ulnar nerve palsy), restoration of jacent fingers during pinch. Occasionally, first
key pinch, correction of clawing, integration of dorsal interosseous reconstruction is necessary in
metacarpophalangeal joint and interphalangeal patients who require very fine use of the fingers.
joint flexion, and improvement in grip strength. Even though restoration of key pinch is consid-
Restoration of small and ring finger distal inter- ered to be one of the primary goals of tendon
phalangeal joint flexion can be achieved by adja- transfer procedures in ulnar nerve palsy, it should
cent suturing of their respective flexor digitorum be noted that not all patients will complain of a
profundus tendons to the functioning middle fin- loss of key pinch. This may be attributable to the
ger flexor digitorum profundus. The index finger compensatory action of the flexor pollicis longus
flexor digitorum profundus should not be in- or to anomalous innervation of the adductor pol-
cluded in the adjacent suturing to preserve its licis muscle by the median nerve. A tendon trans-
independent functioning (Fig. 1). It should be fer procedure should only be performed if the
remembered that clawing may become worse after patient perceives a deficit.

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 Plastic and Reconstructive Surgery • September 2009

Both the extensor carpi radialis brevis5 and digitorum superficialis transfer should be used
brachioradialis6 are strong donor muscle-tendon only in patients with low ulnar nerve palsy, in
units that can be used to restore key pinch and that whom the ring flexor digitorum profundus is func-
do not leave a functional deficit when harvested. tional. The use of finger extensors such as the
They must be lengthened by tendon grafts and extensor digiti quinti, the index extensor digito-
then passed between the second and third meta- rum communis, and the extensor indicis proprius
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carpals into the palm. Here, they are routed to- has also been described. These tendons can be
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ward the thumb, using the second metacarpal as routed a variety of ways and inserted onto the
a pulley, and inserted on the adductor pollicis adductor pollicis. These transfers are generally
insertion (Fig. 2). The direction change that oc- weak and have suboptimal vectors of pull.
curs at the second metacarpal pulley orients the Correction of clawing is another primary goal
tendon along the original direction of pull of the in the treatment of ulnar nerve palsy. This requires
adductor pollicis. correction of metacarpophalangeal joint hyper-
The ring or middle finger flexor digitorum extension, the problem that initiates clawing. Pro-
superficialis can also be used to restore adductor cedures can be categorized as static or dynamic. If
pollicis function.7 The flexor digitorum superfi- the Bouvier test is positive, static procedures may
cialis is divided distally in the finger and is re- be successful. Osseous blocks on the dorsum of the
trieved into the palm. It is then passed across the metacarpal head have been described.8 Zancolli
palm to the thumb, passing deep to the flexor described a metacarpophalangeal joint capsulode-
tendons, and inserted on the adductor pollicis sis, in which a distally based flap of the volar plate
insertion. The direction of pull of this transfer was advanced proximally and sutured to the meta-
does not replicate that of the adductor pollicis as carpal neck, effectively limiting metacarpophalan-
well as extensor carpi radialis brevis or brachiora- geal joint extension.9 Bunnell described a partial
dialis transfer. In addition, harvest of the flexor release of the A1 and A2 pulleys to allow bow-
digitorum superficialis results in weakening of stringing of the flexor tendons.10 This results in
grip strength. It should be noted that ring flexor increasing the moment arm of the flexor ten-
dons at the metacarpophalangeal joint, thereby
preventing metacarpophalangeal joint hyperex-
tension. Static tenodesis with a tendon graft can
also be performed. The tendon graft is sutured
to the deep transverse intermetacarpal liga-
ment, passed through the lumbrical canal, and
sutured to the extensor apparatus or to the lat-
eral band. This type of static tendon graft ef-
fectively limits the amount of metacarpophalan-
geal joint extension.11
Dynamic tenodesis can also be performed, as
popularized by Fowler and by Tsuge.12–14 A tendon
graft is looped through the extensor retinaculum
at the wrist (Fig. 3). The two free ends of the
tendon graft are passed through the intermeta-
carpal spaces into the palm, along the course of
the lumbricals, and out to the fingers, where they
are inserted into the lateral bands. When the wrist
is flexed, an active tenodesis effect occurs, result-
ing in metacarpophalangeal joint flexion and in-
terphalangeal joint extension. Both the static pro-
cedures and the active tenodesis procedure are
most useful in patients with simple clawing.
There are a number of tendon transfer pro-
cedures available that provide dynamic correction
of clawing, integrate metacarpophalangeal joint
Fig. 2. Drawing showing extensor carpi radialis brevis (ECRB) and interphalangeal joint flexion, and in some
(with tendon graft) transfer to adductor pollicis insertion for res- cases augment grip strength. These can be divided
toration of key pinch in ulnar palsy. into superficialis transfers and transfers powered

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superficialis transfers is that although they reliably

correct clawing and integrate finger flexion, they
do not improve grip strength, and may even result
in further weakening of an already diminished grip.
Brand, Enna and Riordan, and others de-
scribed the use of wrist-level motors to treat claw-
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ing and integrate finger flexion and augment grip

strength.16,18,19 The flexor carpi radialis, extensor
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carpi radialis longus, extensor carpi radialis brevis,

or brachioradialis may be used. These muscle-ten-
don units require a free tendon graft that is split
into two or four slips to pass through the inter-
metacarpal spaces into the corresponding lumbri-
cal canals (Fig. 4). It should be noted that if ad-
hesions develop in the intermetacarpal space, the
excursion of these transfers will be severely lim-
ited. It is important to make the opening large
enough that the tendon graft can easily pass
through this area. The insertion can be into the
lateral band, the proximal phalanx, or the A1 or
A2 pulley. The main advantage of these tendon
transfer procedures over the superficialis transfers
is that they improve rather than worsen grip
Fig. 3. Drawing showing dynamic tenodesis with tendon graft
strength. In addition, there is no great loss of
for correction of clawing.
function at the level of the wrist. Also, because the
superficialis tendon is preserved, the transfer

by wrist motors. In the modified Stiles-Bunnell

procedure,10,15 the middle finger superficialis ten-
don is divided distally in the finger and retrieved
into the palm. It is then split into four slips. Each
slip is then passed along the path of the lumbrical,
volar to the deep transverse metacarpal ligament,
and back into the finger, where it is inserted onto
the lateral band. One drawback to this procedure
is that proximal interphalangeal joint hyperexten-
sion can occur, particularly in patients with lax
joints. This is because the main flexor of the prox-
imal phalanx, the superficialis tendon, is removed,
and power is added to the extensor apparatus
simultaneously. Burkhalter recommended insert-
ing the tendon onto the proximal phalanx instead
of the lateral band, thereby preventing proximal
interphalangeal joint hyperextension.16 Zancolli
described a “lasso” insertion, wherein the flexor
digitorum superficialis is passed through the A1
pulley and then sutured back onto itself, resulting
in improved metacarpophalangeal joint flexion
and avoiding proximal interphalangeal joint
hyperextension.17 An insertion into the lateral
band may be preferred if the Bouvier test is neg-
ative (clawing is complex), but it should be re- Fig. 4. Drawing showing extensor carpi radialis brevis transfer
membered that proximal interphalangeal joint hy- (ECRB) (extended with tendon graft to all four fingers) for correc-
perextension may occur. The main drawback of tion of clawing.

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 Plastic and Reconstructive Surgery • September 2009

can be inserted onto the lateral band with less dle finger distal interphalangeal joint flexion re-
chance of developing proximal interphalangeal sulting from loss of the anterior interosseous
joint hyperextension. nerve–innervated muscles. This results in a lack of
fine motor control of the hand, which is normally
MEDIAN NERVE PALSY provided by precise movements of the interpha-
langeal joint of the thumb and the interphalan-
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Anatomy
geal joints of the index and middle fingers. In
The median nerve enters the forearm between
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addition to these deficits, crucial thumb opposi-

the two heads of the pronator teres, which it in- tion is lost. Low median nerve palsy, in contrast,
nervates, and then runs deep to the flexor digi- results in loss of thumb opposition and sensory
torum superficialis. It innervates all four muscle loss only. The fact that some degree of sensory
bellies of the flexor digitorum superficialis, the reinnervation is likely when a low median nerve
flexor carpi radialis, and the palmaris longus mus- injury has been repaired makes this a potentially
cles. Approximately 6 to 8 cm distal to the medial less devastating injury than high median nerve
epicondyle, it gives off a deep motor branch, the palsy.
anterior interosseous nerve. This branch inner-
vates the flexor pollicis longus, the flexor digito-
rum profundus of the index and middle fingers, Tendon Transfer Procedures
and the pronator quadratus muscles. The palmar The most devastating loss of movement fol-
cutaneous branch arises from the median nerve a lowing high or low median nerve injury is the loss
few centimeters proximal to the wrist, and pro- of thumb opposition. This can be restored with an
vides sensation to the radial palm. The median opponensplasty, or opposition transfer. Thumb
nerve then passes through the carpal tunnel. The opposition is a complex movement that involves
recurrent motor branch innervates the thenar palmar abduction, pronation, and flexion of the
muscles, including the abductor pollicis brevis, thumb metacarpal and proximal phalanx. The ideal
the opponens pollicis, and the superficial head insertion for an opposition transfer is the abductor
of the flexor pollicis brevis. The distal branches of pollicis brevis insertion. Insertion at this point
the median nerve provide sensibility to the volar most reliably causes the combination of move-
aspect of the thumb, index, middle, and radial half ments that result in thumb opposition. The angle
of the ring fingers. Short motor branches arising of pull should be from the location of the pisiform,
from the common digital nerves innervate the because this approximates the normal direction of
index and middle finger lumbricals. pull of the abductor pollicis brevis. A pulley is
often necessary to create the proper line of pull.
Clinical Findings The transverse carpal ligament, the palmar fascia
Median nerve palsy is perhaps the most dev- edge, a loop of the flexor carpi ulnaris tendon, and
astating single-nerve injury of the upper extremity. the flexor carpi ulnaris tendon itself have all been
Not only is there a loss of fine motor control and used as pulleys.
opposition, but sensibility is lost over the area of The superficialis opponensplasty, described
the hand used for precision movements and pre- by Royle in 1938,20 involves dividing the ring finger
hensile functioning. Tendon transfer procedures flexor digitorum superficialis distally in the finger,
to restore movement may be ineffective if sensi- retrieving the flexor digitorum superficialis prox-
bility cannot be restored. High median nerve palsy imal to the carpal tunnel, redirecting the tendon
is defined as an injury proximal to the innervation distally through the flexor pollicis longus sheath,
of the forearm muscles. Although pronator teres and inserting it into the thumb. This transfer was
and flexor carpi radialis function is lost, forearm later modified by Thompson21 by redirecting the
pronation and wrist flexion are compensated for tendon subcutaneously to the thumb, instead of
by other muscles and do not need to be restored. through the flexor pollicis longus tendon sheath.
Although the flexor digitorum superficialis to all Bunnell recommended rerouting the tendon
four fingers is lost, flexion is maintained in the around a looped strip of flexor carpi ulnaris to
ring and small fingers by the functioning ulnar- achieve a more effective line of pull.22 The main
innervated flexor digitorum profundus muscle disadvantage of the superficialis opponensplasty is
bellies. However, even though ring and small fin- that it can be used only in cases of low median
ger flexion is preserved, grip strength is dimin- nerve palsy, because the flexor digitorum super-
ished. More importantly, there is a loss of thumb ficialis is paralyzed in high median nerve palsy
interphalangeal joint flexion and index and mid- (Fig. 5).

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The extensor indicis proprius opponensplasty,

however, is available in cases of both low and high
median nerve injury, and is the most commonly
used opposition transfer in high median nerve
palsy (Fig. 6). Although the extensor indicis pro-
prius is a weak motor, it is sufficiently strong to
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move the thumb into opposition. The extensor

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indicis proprius is tunneled around the ulnar as-

pect of the wrist, routed across the palm from the
level of the pisiform, and inserted onto the ab-
ductor pollicis brevis. It is important to close the
extensor hood of the index metacarpophalangeal
joint after extensor indicis proprius harvest to pre-
vent postoperative extension lag at the index
metacarpophalangeal joint. Functional loss with
the extensor indicis proprius transfer is minimal,
and retraining the extensor indicis proprius to
perform thumb opposition is not difficult.
Although the use of the palmaris longus for
restoring thumb opposition was first described by
Bunnell, it was popularized by Camitz.23 Although
the palmaris longus transfer effectively restores
palmar abduction, the pronation and flexion com-
Fig. 5. Drawing showing superficialis opponensplasty using ponents of opposition are not reestablished. The
ring finger flexor digitorum superficialis (FDS) for restoration of primary indication for performing a Camitz trans-
opposition in low median nerve palsy. fer is to augment palmar abduction in patients
who have motor loss from severe carpal tunnel

Fig. 6. Drawing showing extensor indicis proprius (EIP) opponensplasty

for restoration of opposition in high median nerve palsy.

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 Plastic and Reconstructive Surgery • September 2009

syndrome. A strip of superficial palmar fascia is tal interphalangeal joint flexion can be restored
raised in continuity with the palmaris longus ten- with transfer of the brachioradialis, the extensor
don to achieve enough length for the transfer. carpi radialis longus, or the extensor carpi ulnaris.
The greatest advantage of the Camitz transfer is The most common transfers are brachioradialis to
that there is no functional loss, and it can be easily flexor pollicis longus and extensor carpi radialis
performed at the time of carpal tunnel release. longus to index flexor digitorum profundus. How-
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The main disadvantages are that the palmaris lon- ever, it should be remembered that reinnervation
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gus is a weak motor and that true opposition is not of the flexor pollicis longus and flexor digitorum
restored. profundus is common after a high median nerve
The Huber transfer uses the ulnar nerve–in- injury has been repaired. If a return of function is
nervated abductor digiti minimi to restore anticipated, an end-to-side transfer should be per-
opposition.24 This transfer is usually used in cases formed. If recovery is not expected, an end-to-end
of congenital absence of the thenar muscles and transfer results in a more direct line of pull.
in cases where the flexor digitorum superficialis In median nerve injury, the loss of sensibility
and extensor indicis proprius are not available. is of critical importance. Complete median nerve
The abductor digiti minimi is released from its distribution sensory loss is considered by some to
insertion, turned over 180 degrees, and inserted be a contraindication to tendon transfer. A hand
onto the abductor pollicis brevis insertion (Fig. 7). in which median nerve sensibility is present, or in
Because the entire muscle is turned over into the which a return of sensation is expected, will have
thenar area, this transfer provides bulk to the the- a much better outcome following the tendon
nar eminence, which is cosmetically appealing in transfer procedures. Although they are beyond
cases of thenar atrophy or congenital absence. the scope of this article, sensate flaps or sensory
Strength and excursion are well matched to the nerve transfers have been used before or following
deficit, and the transfer is synergistic. However, tendon transfer procedures to improve outcomes
the palmar abduction component of opposition is in median nerve palsy.
not corrected to the same degree to which the
pronation and flexion components are corrected. COMBINED PALSIES
The extensor digiti quinti, extensor carpi ulnaris, Combined peripheral nerve injuries are usu-
and extensor carpi radialis longus can all be used ally the result of severe trauma to the extremity,
to restore opposition if the above muscle-tendon and are often associated with substantial soft-tis-
units are not available. These transfers are all sue, vascular, and bony injuries. Multiple muscle-
routed around the ulnar border of the wrist and tendon units may be lacerated and require repair,
across the palm subcutaneously to the thumb. In making them unsuitable donors for tendon trans-
many cases, tendon grafting is required. fer. Loss of sensibility and proprioception is often
In cases of high median nerve injury, thumb more profound than with single-nerve palsies,
interphalangeal joint flexion and index finger dis- making reconstruction much more complicated.25
In addition, because of the extensive scarring that
is often present, it becomes difficult to route a
tendon transfer through an unscarred bed. Out-
comes are worse than with single-nerve palsies,
both because of the lack of donor muscle-tendon
units and because of the severity of the associated
injuries. Standardized tendon transfer procedures
are often not possible and treatment must there-
fore be individualized. Attention to the principles
of tendon transfer is more important than ever if
there is to be a successful outcome. The staging
and timing of multiple procedures must also be
carefully thought out, and only those tendon
transfer procedures that can be rehabilitated to-
gether should be performed at the same time.
The most common combined injury is a low
median-ulnar palsy, usually caused by laceration of
Fig. 7. Photograph showing exposure of the abductor digiti the volar wrist.26 This injury results in complete
minimi for use in Huber transfer. palmar numbness throughout the hand, fingers,

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and thumb. All four fingers become clawed and can be reestablished with side-to-side suturing of
integration of finger flexion is lost. Key pinch and the ring and small finger flexor digitorum pro-
thumb opposition are also lost. In addition, the fundus to the functioning middle finger flexor digi-
wrist extrinsic flexors have often been lacerated in torum profundus. Metacarpophalangeal joint and
the injury and have been repaired, making them interphalangeal joint integration during flexion and
unsuitable donor muscle-tendon units. Treatment treatment of clawing can be accomplished with static
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requires restoration of opposition and key pinch, procedures or with a flexor digitorum superficialis
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reintegration of metacarpophalangeal joint and transfer. Key pinch can also be restored with a flexor
interphalangeal joint flexion, and treatment of digitorum superficialis transfer.27
clawing.26 Radial nerve–innervated muscle-ten- High median-radial palsy is a devastating in-
don units and more proximal median and ulnar jury that is extremely difficult to reconstruct. Un-
nerve–innervated muscle-tendon units (if they fortunately, even after multiple reconstructive op-
have not been injured) are available donors for erations, the hand often does not work much
reconstruction. One potential reconstructive plan better than a prosthesis.27 All wrist muscle-tendon
might include extensor carpi radialis brevis or units are lost except the flexor carpi ulnaris, mak-
flexor digitorum superficialis transfer for key ing wrist arthrodesis necessary. The flexor digito-
pinch, flexor digitorum superficialis or extensor rum profundus tendons are usually sutured side-
indicis proprius opponensplasty, and an extensor to-side, creating simultaneous flexion, innervated
carpi radialis longus or brachioradialis transfer to by the ulnar nerve. After wrist arthrodesis, the
integrate finger flexion and improve clawing. flexor carpi ulnaris is available and can be used to
High median-ulnar nerve palsy is a less common power finger and thumb extension. Opposition
but much more severe injury that is more difficult to can be restored with a Huber transfer. Thumb
treat than low median-ulnar nerve palsy. Restoration flexion is accomplished by flexor pollicis longus
of key pinch, opposition, and simple grip are the tenodesis. Again, loss of median nerve sensibility
primary reconstructive goals.26 Only radial nerve– is a critical problem. If sensory reinnervation is not
innervated muscle-tendon units are available as expected and another procedure cannot be per-
donors. In some cases, wrist fusion may be con- formed to establish protective sensibility, tendon
sidered so that the extensor carpi radialis longus, transfer procedures should not be attempted.
extensor carpi radialis brevis, and extensor carpi
ulnaris can be used as donor muscle-tendon units. BRACHIAL PLEXOPATHY, CEREBRAL
A potential reconstructive plan might include an PALSY, AND TETRAPLEGIA
extensor carpi radialis brevis, brachioradialis, or Brachial plexus injuries, cerebral palsy, tetra-
extensor indicis proprius transfer to restore key plegia, and other disabilities commonly present
pinch, and an extensor carpi radialis longus–to– complex and challenging reconstructive prob-
flexor digitorum profundus transfer to restore fin- lems. Standard tendon transfer motors are often
ger flexion and grip. Clawing could be corrected not available for a given functional deficit in the
with tenodesis or metacarpophalangeal joint volar hand. It is often necessary to use alternatives such
capsulodesis. Thumb opposition might be pro- as splinting, tenodesis, arthrodesis, nerve transfer,
vided by extensor indicis proprius or extensor or free functional muscle transfer in combination
carpi ulnaris opponensplasty. Unfortunately, with with tendon transfer procedures to improve the
this injury, the loss of sensibility is profound, and function of the extremity.
unless sensory return is expected, tendon transfer
procedures probably will not be successful. POSTOPERATIVE MANAGEMENT
High ulnar-radial palsy requires transfers to A bulky plaster splint or cast is made in the
restore both flexion and extension functions at operating room. This splint should take tension
the wrist and in the hand, and therefore recon- off the tendon transfer(s) performed. For exam-
struction must be staged. Fortunately, median ple, if a transfer was performed to improve claw-
nerve sensibility in the palmar hand is intact, so ing, the splint should keep the metacarpophalan-
tendon transfer procedures have the potential to geal joints flexed and the interphalangeal joints
result in functional improvement. A pronator extended. If an extensor muscle-tendon unit was
teres–to– extensor carpi radialis brevis transfer can used for the transfer, the wrist should be placed in
be used to restore wrist extension, whereas finger 30 degrees of extension. However, if a flexor digi-
and thumb extension can be achieved with a torum superficialis transfer was performed, the
flexor digitorum superficialis transfer. Ring and wrist should be in a more neutral position or slightly
small finger distal interphalangeal joint flexion flexed. If a muscle-tendon unit that crosses the elbow

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 Plastic and Reconstructive Surgery • September 2009

(such as the brachioradialis) was used in the transfer, ferred tendon passes over or adjacent to another
an above-elbow splint or cast should be made, keep- tendon. They can also occur following a postop-
ing the elbow in 90 degrees of flexion. erative infection. If adhesions develop, manage-
The postoperative splint should be changed 1 ment should begin with aggressive hand therapy.
to 2 weeks after surgery to check the incisions and Tenolysis sometimes is necessary, but should not
refit the splint. At 4 weeks, a thermoplastic splint be carried out until tissue equilibrium has again
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should be made by the occupational therapist. been reached following the transfer. During this
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During these first 4 weeks, it is important to main- waiting period, it is crucial to continue therapy to
tain mobility in the nonimmobilized joints of the maintain passive mobility of the joints. Within 24
upper extremity. hours of performing tenolysis, aggressive active
At 4 weeks, the therapist will begin mobiliza- and passive mobilization should begin. Tendon
tion. Mobilization should start with gentle active rupture is unusual but can occur, particularly if
and assisted range-of-motion exercises. It is im- postoperative immobilization is inadequate or if
portant to mobilize one joint at a time to prevent the transfer is set under excess tension. Once the
placing too much tension on the transfer. For rupture is recognized, the patient should be re-
example, if an extensor carpi radialis brevis trans- turned to the operating room as soon as possible
fer to treat clawing was performed, the therapist for repair.
should mobilize the metacarpophalangeal joints Occasionally, a tendon transfer turns out to be
while keeping the wrist and interphalangeal joints too weak to be effective. This is usually attributable
immobile. The patient should wear the thermo-
plastic splint except when performing the pre-
scribed exercises. Table 1. CPT Codes Commonly Used for Tendon
During the sixth week, the therapist should Transfers in Median and Ulnar Nerve Palsy
add exercises that activate the muscles used in the CPT Code Description
tendon transfer and should begin muscle retrain-
25310 Tendon transplantation or transfer, flexor or
ing. Electrical stimulation and biofeedback may be extensor, forearm and/or wrist, single:
used to assist with retraining. For example, neuro- each tendon
muscular electrical stimulation uses a pulsating 25312 Tendon transplantation or transfer, flexor or
extensor, forearm and/or wrist, single:
current to stimulate specific muscle bellies.28 with tendon graft(s) (includes obtaining
Whether neuromuscular electrical stimulation is graft), each tendon
capable of preventing atrophy or improving mus- 26471 Tenodesis: of proximal interphalangeal joint,
each joint
cle strength is debated. However, it can be used to 26474 Tenodesis: of distal joint, each joint
help the patient become accustomed to the trans- 26480 Tendon transplantation or transfer,
ferred muscle being activated in its new location. carpometacarpal area or dorsum of hand:
without free graft, each tendon
Another commonly used modality, electromyo- 26483 Tendon transplantation or transfer,
graphic biofeedback, is a method of giving the carpometacarpal area or dorsum of hand:
patient a visible or audible signal when he or she with free tendon graft (includes obtaining
graft), each tendon
activates the transferred muscle. By attempting to 26485 Transfer or transplant of tendon, palmar:
control the signal, the patient learns to voluntarily without free tendon graft, each tendon
activate the transferred muscle.29 26489 Transfer or transplant of tendon, palmar:
with free tendon graft (includes obtaining
At 8 weeks postoperatively, strengthening ex- graft), each tendon
ercises should be initiated, and the patient can be 26490 Opponensplasty: superficialis tendon transfer
weaned off the splint over the next 4 weeks. Full type, each tendon
26492 Opponensplasty: tendon transfer with graft
activity is resumed at 12 weeks. (includes obtaining graft), each tendon
26494 Opponensplasty: hypothenar muscle transfer
COMPLICATIONS OF TENDON 26496 Opponensplasty: other methods
26497 Transfer of tendon to restore intrinsic
TRANSFER PROCEDURES function: ring and small finger
Some potential complications that are unique 26498 Transfer of tendon to restore intrinsic
to tendon transfer surgery include tendon adhe- function: all four fingers
26499 Correction claw finger: other methods
sions, transfer rupture, and transfer weakness. Ad- 26516 Capsulodesis, metacarpophalangeal joint:
hesions around the transferred tendons will in- single digit
variably occur if the transfer passes through a 26517 Capsulodesis, metacarpophalangeal joint:
two digits
scarred or inflamed tissue bed. Adhesions fre- 26518 Capsulodesis, metacarpophalangeal joint:
quently complicate multiple simultaneous tendon three or four digits
transfer procedures, particularly if one trans- Dr. Ray Janevicius compiled this information.

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 Volume 124, Number 3 • Tendon Transfers for Nerve Palsy

to poor preoperative planning, such as choosing 7. Hamlin C, Littler JW. Restoration of power pinch. J Hand Surg
a donor muscle-tendon unit that has a poor (Am.) 1980;5:396–401.
8. Mikhail IK. Bone block operation for clawhand. Surg Gynecol
strength match with the muscle that is being re- Obstet. 1964;118:1077–1079.
placed, or because an atrophied or injured donor 9. Zancolli EA. Claw-hand caused by paralysis of the intrinsic
muscle-tendon unit was used. Sometimes, how- muscles: A simple surgical procedure for its correction. J Bone
ever, the problem occurs because the transfer was Joint Surg (Am.) 1957;39:1076–1080.
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set at inadequate tension or because the moment 10. Bunnell S. Surgery of the intrinsic muscles of the hand other
than those producing opposition of the thumb. J Bone Joint
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arm was not great enough. It is difficult to precisely Surg. 1942;24:1–31.

determine the cause of inadequate strength post- 11. Parkes A. Paralytic claw fingers: A graft tenodesis operation.
operatively. However, if the donor muscle-tendon Hand 1973;5:192–199.
unit was healthy and appropriate for the transfer, 12. Fowler SB. Extensor apparatus of the digits. J Bone Joint Surg
it may be necessary to return to the operating (Br.) 1949;31:477.
room to reset the tension of the transfer or to 13. Tsuge K. Tendon transfers in median and ulnar nerve pa-
ralysis. Hiroshima J Med Sci. 1967;16:29–48.
increase the moment arm by moving the insertion 14. Riordan DC. Tendon transplantations in median-nerve and
farther from the joint axis of rotation. Occasion- ulnar-nerve paralysis. J Bone Joint Surg (Am.) 1953;35:312–320;
ally, weakness can occur if the transfer is set under passim.
too much tension. In most cases, this problem will 15. Stiles HJ, Forrester-Brown MF. Treatment of Injuries of the Pe-
resolve spontaneously with time as the transferred ripheral Spinal Nerves. London: Henry Frowde and Hodder &
Stoughton; 1922.
muscle-tendon unit elongates. CPT codes com- 16. Burkhalter WE. Restoration of power grip in ulnar nerve
monly used for tendon transfers in tendon trans- paralysis. Orthop Clin North Am. 1974;5:289–303.
fers in median and ulnar nerve palsy are listed in 17. Hastings H II, McCollam SM. Flexor digitorum superficialis
Table 1. lasso tendon transfer in isolated ulnar nerve palsy: A func-
tional evaluation. J Hand Surg (Am.) 1994;19:275–280.
Kevin C. Chung, M.D., M.S. 18. Brand PW. Tendon grafting illustrated by a new operation
Section of Plastic Surgery for intrinsic paralysis of the fingers. J Bone Joint Surg (Br.)
University of Michigan Health System 1961;43:444–453.
2130 Taubman Center 19. Enna CD, Riordan DC. The Fowler procedure for correction
1500 East Medical Center Drive of the paralytic claw hand. Plast Reconstr Surg. 1973;52:352–
Ann Arbor, Mich. 48109-0340 360.
kecchung@med.umich.edu 20. Royle ND. An operation for paralysis of the thumb intrinsic
muscles. JAMA. 1938;111:612–613.
ACKNOWLEDGMENTS 21. Thompson TC. A modified operation for opponens paralysis.
Supported, in part, by a Midcareer Investigator J Bone Joint Surg. 1942;26:632–640.
Award in Patient-Oriented Research (K24 AR053120) 22. Bunnell S. Opposition of the thumb. J Bone Joint Surg. 1938;
20:269–284.
from the National Institute of Arthritis and Musculo- 23. Camitz H. Uber die Behandlung der Oppositionslahmung.
skeletal and Skin Diseases (to Kevin C. Chung). Acta Chir Scand. 1929;65:77–81.
24. Huber E. Hilfsoperation bei median Uhlahmung. Dtsch Arch
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