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Nerve Transfers in the Upper Limb

78 citationsUpdated Sep 2026

Overview

Nerve transfers are a primary reconstructive option for restoring hand and forearm function in patients with peripheral nerve injuries, including brachial plexus lesions and cervical spinal cord injuries [2, 7]. These procedures offer a more reliable outcome in a shorter period than nerve grafting and provide a more natural, functional reconstruction than tendon transfers [1]. By shortening regeneration distances and allowing the selection of pure motor or sensory fascicles, nerve transfers are increasingly replacing other techniques as the gold standard for proximal peripheral nerve injuries, with functional outcomes that surpass those obtained from traditional nerve repair or tendon transfers [12, 17]. In approximately 90% of patients, distal nerve transfers result in functional recovery of shoulder abduction, elbow flexion or extension, and wrist extension [3].

The technique is effective for restoring extension of the elbow, wrist, and fingers in common infraclavicular brachial plexus lesions affecting the posterior cord [4]. When appropriately selected, nerve transfers restore function in cases previously deemed difficult or impossible [9]. Clinical results demonstrate significant improvements in upper limb function with mild and transient donor site morbidity [19]. While nerve transfers can effectively reanimate muscles, they provide comparable strength to tendon transfers for elbow extension but inferior strength for finger and thumb flexion [10]. In patients with recovering flexor carpi ulnaris function, a thorough discussion of potential failure is required, and an alternative nerve transfer should be selected [8].

Current treatment algorithms for brachial plexus injury must generally include functioning free microsurgical transfer of muscle to provide the most functional recovery possible, particularly when nerve repair or transfer is insufficient for hand function or delayed beyond 9 to 12 months [5]. The double free muscle transfer procedure is capable of restoring maximum function in patients with total brachial plexus palsy [27]. In patients with total paralysis, satisfactory shoulder abduction values can be achieved with tendon transfers regardless of a previous history of neural surgery, even if preoperative values differ [18]. Nerve transfer surgery expands reconstructive options for upper extremity function following spinal cord injury by adding new motor donors to the pool available through tendon transfers [13]. Approximately 65% to 75% of individuals with tetraplegia would benefit from upper extremity surgery, yet only 14% of surgical candidates undergo tendon transfer procedures [62]. The anterior approach offers safe access to both radial and axillary nerves and has the added advantage of compatibility with approaches for other common nerve transfers [66]. This review aims to equip reconstructive hand surgeons with a sound understanding of the basic principles of spinal cord injury and recovery, providing a rationale for when to intervene with surgery and highlighting the urgent need for early referral to allow nerve transfer options to be viable [11]. The biomechanical principles, indications, and limitations of tendon transfers, nerve transfers, and combined approaches are compared, with particular attention to timing, patient selection, and functional goals [24].

Anatomy & Pathophysiology

Peripheral Nerve Injury and Regeneration

A complex cascade of events occurs in skeletal muscle immediately after nerve transection, leading to profound, short-term, largely reversible structural and functional changes in the denervated muscle [23]. The consequences of skeletal muscle denervation and the incomplete and imprecise process of muscle reinnervation are the prime contributors to the disability patients experience after peripheral nerve injury [23]. If the denervation interval is prolonged beyond a short time period, or if the number of regenerating motor axons is insufficient, the functional result of reinnervation is compromised [23]. Furthermore, if regenerating motor axons are not motion-specific, meaning they do not produce contractile activity resulting in movement with appropriate volitional control, the functional result is compromised [23]. Age-related biological constraints exist that surgeons must consider when planning peripheral nerve reconstruction [57]. Nerve reconstructions after proximal lesions with long reinnervation distances, large nerve gaps, and a poor surgical bed are associated with inferior outcomes [31].

Upper Limb Functional Anatomy

The hand functions efficiently only if the proximal joints of the limb are stable and yet mobile, with the shoulder, elbow, and wrist operating in different planes [43]. The combined movements of the wrist and forearm place the hand in a position for grasping, with the wrist usually in flexion when close to the trunk and in extension when placed at a distance [43]. The skeleton of the hand and wrist consists of 27 bones, of which 19 are long bones, divided into five rays [47]. The radial ray or first ray is the shortest, made up of only three bones (a metacarpal and two phalanges), and possesses considerable functional importance due to its great freedom of movement [47]. The thumb metacarpal makes an angle of about 45 degrees with the second metacarpal in the sagittal plane, allowing the thumb to oppose the other four digital rays [47]. The transverse axis of the palm is oblique, forming an acute angle of approximately 75 degrees with the longitudinal axis [47].

The extrinsic extensors run through six different fibroosseous retinacular compartments at the wrist level [46]. The extensor digitorum communis tendons of the middle, ring, and little fingers are tethered together by juncturae tendinum over the dorsum of the hand proximal to the metacarpophalangeal joint [46]. The extrinsic finger flexors consist of the flexor digitorum profundus and the flexor digitorum superficialis [46]. The innervation of the flexor digitorum profundus of the index and middle fingers is through the anterior interosseous branch of the median nerve, whereas the profundus of the ring and little fingers is innervated by the ulnar nerve [77]. The entire flexor digitorum superficialis muscle receives innervation from the median nerve [77]. The flexor pollicis longus is innervated by the anterior interosseous branch of the median nerve [77].

There are seven interosseous muscles in the hand, comprising four dorsal and three volar muscles [71]. The dorsal interossei are abductors, while the volar interossei are adductors [71]. The middle finger has two dorsal interossei and no volar interossei because the central axis of the hand lies within it [71]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [77]. The gliding mechanism of tendons in narrow crowded areas is assured by the synovial sheath, which allows a considerable amplitude of movement [78]. The dorsal skin of the hand is thin and possesses loose connections with deeper planes, allowing free gliding and full flexion at the digital joints [79]. Flexion of the fingers produces a significant lengthening of the dorsal skin, with an average increase of 3 cm in the middle finger as it goes from extension to full flexion [79].

Nerve Transfer Principles and Indications

Nerve transfers offer a more reliable outcome in a shorter period of time than nerve grafting and provide a more natural, functional reconstruction than tendon transfers [1]. The basic indications for nerve transfer are injuries in which direct repair is not possible or functional recovery with direct repair or nerve grafting is not expected [34]. Nerve transfers allow for the maintenance of the original musculotendinous dynamics, keeping the line of pull and excursion unchanged [34]. A disadvantage of nerve transfers is that they cannot be delayed indefinitely, unlike tendon transfers [34]. Nerve transfer surgery involves cutting an expendable donor nerve and performing a tension-free coaptation to the sectioned distal nerve stump of a more critical yet non-functioning target [31]. In motor nerve transfers, the expendable donor nerve is usually selected to have very little donor morbidity, such as weakness or paralysis [31].

Nerve transfers provide a means to reestablish volitional control of hand function in people with cervical-level spinal cord injury [22]. In the chronic phase following spinal cord injury, if the triceps do not stimulate, nerve transfer will fail and tendon transfer is the preferred technique to restore elbow extension [48]. If the triceps respond to stimulation in the chronic period, its innervation is in the infralesional segment and nerve transfer can be considered [48]. A two-stage nerve transfer strategy for chronic C5 patients involves connecting the brachialis branch of the musculocutaneous nerve to a sural nerve graft tunneled into the volar forearm to avoid denervation atrophy of target finger flexors [48]. The second stage of this strategy involves transferring supinator branches to the posterior interosseous nerve and connecting the distal end of the sural graft to the anterior interosseous nerve [48].

In international classification group 3 tetraplegia patients, the ECRB nerve can be used as a donor to transfer to the AIN for active finger flexion while preserving the ECRL [30]. The ECRB nerve transfer to the AIN results in more radial deviation from the remaining ECRL, which can be corrected by a distal lateral-lateral tenodesis of the ECRL tendon to the ECRB tendon [30]. Direct radial to ulnar nerve transfer via an interosseous tunnel can safely and effectively restore intrinsic function before terminal muscle degeneration in combined proximal median and ulnar nerve injury [26]. Transfer of supinator motor branches to the posterior interosseous nerve can restore active extension of the thumb and finger in patients with complete spinal cord injury at the C6 level [28]. Nerve transfers can effectively reanimate muscles in selected tetraplegia cases, with comparable strength to tendon transfers for elbow extension but inferior strength for finger and thumb flexion [10].

In approximately 90% of patients with C5–C8 (T1) brachial plexus paralysis, distal nerve transfers resulted in functional recovery of shoulder abduction, elbow flexion or extension, and wrist extension [3]. The described nerve transfer scheme using median and ulnar nerve fascicles is effective for restoring extension of the elbow, wrist, and fingers in common infraclavicular lesions affecting the posterior cord [4]. Prespinal hemicontralateral C7 nerve transfer may allow a higher proportion of patients to achieve M3 hand grip more quickly than conventional hemi-CC7 transfer [32]. A favorable suture method for size-mismatched nerve transfer, such as intercostal-to-musculocutaneous, can be used for any size-mismatched nerve transfer and may lead to effective motor function restoration [64]. Early functional recovery regarding hand function and sensation is promising in patients receiving retropharyngeal contralateral C7 nerve transfer for brachial plexus birth injury [58]. Ulnar nerve to musculocutaneous nerve transfer in an ulnar ray–deficient infant with brachial plexus birth palsy resulted in active elbow flexion to 90° at 18 months without motor deficits in the hand [65]. Anatomic study and case reports support the feasibility of intercostal nerve transfer to the suprascapular nerve for brachial plexus reconstruction [98]. Nerve transfer for restoration of ulnar fingers flexion through the pronator teres motor branch can be suggested in cases where the hand is partially involved to allow patients to regain or strengthen finger flexion [96].

Published clinical results for contralateral C7 transfer have demonstrated significant improvements in upper limb function, confirming the procedure's safety and efficacy with typically mild and transient donor site morbidity [19]. Such a technique can potentially improve motor recovery of elbow and finger flexion in a shorter rehabilitation period (3 to 4 y) and provide finger sensation to the completely paralytic limb [104]. The results of active finger flexion can be improved by direct approximation of the lower trunk to an ipsilateral root stump after total brachial plexus injury [112]. This study demonstrates a distinct clinical presentation of brachial plexus trauma characterized by preserved finger flexion despite complete plexus injury [56].

Sensory Considerations

Sensory perception is critical to normal interaction with the environment, providing tactile gnosis, pressure and vibration detection, and proprioceptive function [31]. Diminished sensation after peripheral nerve injury risks recurrent injury to the trophic skin [31]. Restoration of sensation is a key objective in the management of a peripheral nerve injury, though it has received limited attention compared to motor function restoration [31]. Any digit deprived of sensibility is selectively and unconsciously avoided during use of the hand [52]. Sensibility in a neurovascular island graft is never normal after transfer, with more than half of patients having persistently hyperesthetic skin and all patients lacking precise sensory reorientation [52]. With any level of spinal cord lesion, the better the sensory condition of the hand, the better the motor function achieved [119].

Classification

Clinical Indications and Role: Nerve transfers are key components of the surgeon's armamentarium in brachial plexus and complex nerve reconstruction [12]. They offer advantages such as shortened regeneration distances and the ability to select pure motor or sensory fascicles [12]. Nerve transfers are replacing other techniques as the gold standard for brachial plexus and other proximal peripheral nerve injuries [17]. They offer functional outcomes surpassing those obtained from traditional nerve repair or tendon transfers [17]. Nerve transfers are helpful when it is not possible to anatomically reconstruct the primary neurological lesion or when unfavourable factors, such as increased length of regeneration distance from injury to the target organ, may limit the effectiveness of such repairs [31]. Peripheral nerve transfers must be assessed within the broader framework of neuroplasticity [103].

Tetraplegia and Spinal Cord Injury: Nerve transfers can effectively reanimate muscles in selected cases of tetraplegia [10]. They provide comparable strength to tendon transfers for elbow extension but inferior strength for finger and thumb flexion in tetraplegia [10]. Comprehensive evaluation of preoperative hand use and thorough patient education on rehabilitation protocols are essential components for optimizing functional outcomes in integrated nerve and tendon transfer approaches for tetraplegia [35]. This review aims to equip reconstructive hand surgeons with a sound understanding of the basic principles of spinal cord injury and recovery and provide a rationale for when to intervene with surgery, highlighting the urgent need for early referral to allow nerve transfer options to be viable [11].

Brachial Plexus Paralysis: In approximately 90% of patients, distal nerve transfers resulted in functional recovery of shoulder abduction, elbow flexion or extension, and wrist extension in C5–C8 (T1 Hand) brachial plexus paralysis [3]. Transfer of 10% of the bulk of the ulnar nerve to the biceps restores elbow flexion with no significant impairment of hand function in C5–C6 avulsion [6]. Transfer of the radial nerve branch for the lower triceps medial head and anconeus to the anterior division of the axillary nerve proved to be an effective method of deltoid reinnervation [33]. Prespinal hemicontralateral C7 nerve transfer may allow a higher proportion of patients to achieve M3 hand grip more quickly than conventional hemi-CC7 transfer in total brachial plexus roots avulsion injuries [32]. Active pick-up function was successfully restored in ten patients after undergoing multiple nerve transfers combined with additional secondary functional hand reconstructions for total brachial plexus avulsion injuries [16]. This study validated the effect of nerve transfers for global brachial plexus avulsions from objective MRC grading combining with patients' self-assessments [38].

Limitations and Comparative Outcomes: Nerve transfers allow for maintenance of the original musculotendinous dynamics [34]. However, nerve transfers cannot be delayed indefinitely, as tendon transfers can [34]. Situations may exist in which the expected power of recovery from an available nerve transfer may be inferior to that of a tendon transfer [34]. In patients with recovering flexor carpi ulnaris function, a thorough discussion of potential failure must be undertaken, and an alternative nerve transfer should be selected for ulnar nerve fascicle to biceps motor branch transfer [8]. Complete traumatic brachial plexus palsy is a severe condition that leaves patients markedly handicapped [15]. While microsurgical nerve repair and nerve transfer can restore some function and relieve pain, the overall usefulness of the upper limb remains disappointing due to lack of recovery in distal muscles in complete traumatic brachial plexus palsy [15]. Double free muscle transfer yielded satisfactory function and allowed use of the reconstructed hand in activities that required both hands after traumatic total brachial plexus palsy [14]. This review discusses late treatment options, including tendon transfers, joint fusions, free functioning muscle transfers and prosthetics, for managing the failed primary reconstruction of the traumatic adult brachial plexus [20].

Specific Surgical Strategies: Expandable donor nerve is usually in the context of a motor nerve transfer with very little donor morbidity, such as weakness or paralysis [31]. In international classification group 3, a second wrist extensor is available, making an additional tendon or nerve transfer possible [30]. The ECRB nerve can be used as a donor ensuring the ECRL is intact [30]. The ECRB nerve can be transferred to the AIN for active finger flexion [30]. The remaining ECRL does produce more radial deviation, but this posture can be corrected by a distal lateral-lateral tenodesis of the ECRL tendon to the ECRB tendon, providing more neutral wrist extension [30]. The first stage of a two-stage strategy in chronic C5 patients involves the teres minor to triceps transfer as well as connecting the brachialis branch of the musculocutaneous nerve to a sural nerve graft that is tunneled into the forearm [30]. At the second stage, the distal aspect of the sural nerve is connected to the anterior interosseous nerve within the forearm, recovering the finger flexor muscles [30]. This distal coaptation can be performed at the same time as the supinator to PIN transfer for finger extension [30]. This strategy successfully restored active extension of the thumb and finger in a patient with complete spinal cord injury at the C6 level [28]. If effective prehension was not acquired after rehabilitation, transferring suitable motors improved grasp by providing finger flexion and thumb opposition after injuries of the cervical spinal cord [63]. Brachialis muscle transfer is an effective method for reconstructing digital flexion in patients with lower brachial plexus injury or forearm injury, particularly when nerve transfer or forearm donor muscles are not feasible [67].

Other Considerations: The ICSHT determines the number of muscles present below the elbow with at least grade 4 strength from ASIA grade A to E and as complete or incomplete based on the lowest functioning cord segment [100]. A motor score of 0 to 100 is given based on the sum of the motor grades in 5 key upper and lower extremity functions bilaterally [100]. The total upper extremity score is 0 to 50 and based on elbow flexion, wrist extension, elbow extension, finger flexion, and finger abduction [100]. Although the ASIA classification is widely used to categorize patients with tetraplegia, the levels are too broad to make decisions about reconstructive procedures of the hand [100]. Restoration of grip and key pinch strength improves hand function for daily activities in patients with tetraplegia [97]. Tetraplegic patients with active wrist extension may, even without surgery, achieve a basic grip using the tenodesis effect of their paralysed finger flexor muscles, although this may be too weak to measure effectively [97]. Such a rudimentary grip is not useful for patients, and many opt for surgery to improve hand function [97]. The conventional method for reconstructing hand function in tetraplegia involves tendon transfers [97]. Arthrodesis of the first carpometacarpal joint (TMJ) is typically performed to create a robust key pinch [97]. The reconstructive options increase where more innervated muscles are available below the elbow, particularly in patients with mid-to-low-level injuries (ICSHT groups >3) [97]. Evidence supporting the clinical utility of upper limb reconstructive surgery in patients with mid-to-high-level injuries (ICSHT groups 0–3) remains limited [97]. Most cervical cord injured patients have a loss at cervical mid-level (ICSHT groups 1–5) and will, therefore, lack active finger and thumb extensors [97]. Traditional tendon transfers cannot reconstruct these extensors, and patients generally rely on the tenodesis effect to release objects [97]. Nerve transfers, such as the supinator to posterior interosseous nerve (S-PIN), are used to reconstruct extensors in tetraplegia [97]. Outcomes of long-nerve grafts for axillary nerve palsy are comparable with those of modern nerve transfers [41]. When healthy donor roots or trunks are available, long-nerve grafts should not be overlooked as an effective intervention for the treatment of axillary nerve injuries in adults with brachial plexus injuries [41]. There were no significant differences between the long-nerve graft cohort and the nerve transfer cohort with respect to postoperative range of motion, deltoid recovery, improvement in shoulder abduction, or EMG evidence of deltoid reinnervation [41]. Only 5 of 22 patients experienced restoration of elbow flexion and extension after grafting the anterior and posterior divisions of the upper trunk in complete palsies of the brachial plexus [21].

Clinical Presentation

In complete traumatic brachial plexus palsy, the overall usefulness of the upper limb remains disappointing due to lack of recovery in distal muscles [15]. A distinct clinical presentation of brachial plexus trauma is characterized by preserved finger flexion despite complete plexus injury [56]. Immediately after a severe injury to an extremity, recognition of a peripheral nerve injury is not always easy because pain is often so severe that patient cooperation is limited [90].

Sensory Assessment: In the upper extremity, loss of pain perception in the tip of the little finger indicates ulnar nerve injury [90]. Loss of pain perception in the tip of the index finger indicates median nerve injury [90].

Motor Assessment and Substitution: Inability to extend the thumb in the hitchhiker’s sign usually indicates radial nerve injury, although severed extensor tendons may render this test invalid [90]. Evaluation of motor loss can be inaccurate if relying on analysis of movement alone due to substitution and trick movement [90]. Opposition of the thumb to the little finger can be accomplished by many patients even though the nerve supply to the opponens pollicis is completely severed and the muscle is paralyzed [90]. The wrist can be partially extended even when the muscles supplied by the radial nerve are completely paralyzed by simple flexion of the fingers [90]. The elbow can be forcefully flexed even when the musculocutaneous nerve is completely severed and the biceps paralyzed by substitution of the brachioradialis [90].

Palpation: Palpation of the opponens pollicis, extensor tendons of the wrist, and biceps tendon or muscle prevents diagnostic deceptions caused by substitution movements [90]. The lumbricals, the short adductor of the thumb, and the interossei except for the first dorsal cannot be tested by palpation or sight [90].

Radial Nerve Injury Patterns: A high radial nerve injury proximal to the elbow results in loss of function of all wrist extensors, causing wrist drop and secondary loss of power grip [49]. This injury also results in loss of finger extension including the extensor digitorum communis, extensor indicis proprius, and extensor digiti minimi [49], and loss of thumb extension including the extensor pollicis brevis and extensor pollicis longus [49]. In a high radial nerve injury, the patient cannot extend the wrist, loses power grip, cannot extend the metacarpophalangeal joints of the index through little digits simultaneously with the wrist at neutral, and cannot extend the index and little metacarpophalangeal joints in isolation [49]. Additionally, the patient loses the ability to extend the thumb metacarpophalangeal and interphalangeal joints [49].

A low radial nerve injury distal to the elbow involves only muscles innervated by the posterior interosseous nerve [49]. This results in radial deviation of the wrist during active extension due to continued innervation of the extensor carpi radialis longus with loss of extensor carpi ulnaris function [49], as well as loss of finger and thumb extension [49].

Recovery Indicators: The first muscle innervated by the radial nerve in the anterior compartment of the arm is the brachioradialis [49]. Return of brachioradialis function can indicate an early return of radial nerve function [49]. The last muscle innervated by the radial nerve is the extensor indicis proprius [49]. The last testable muscle innervated by the radial nerve is the extensor pollicis longus [49].

Sensory Outcomes in Neurovascular Island Grafts: Sensibility in a neurovascular island graft is never normal after transfer [52]. More than half of patients have persistently hyperesthetic skin after neurovascular island graft transfer [52]. All patients lack precise sensory reorientation after neurovascular island graft transfer [52]. Reorientation seems to improve with time and with use of the part after neurovascular island graft transfer [52].

Investigations

Clinical Examination: Pinpointing or narrowing the scope of possible pathologic processes in the injured or dysfunctional hand and wrist requires combining patient history with a careful physical examination [44]. A systematic method to approaching this physical examination is essential due to the number of structures contained within a small space [44].

Laboratory: Diagnostic tests such as serum laboratory studies are useful in determining pathology but can be expensive, time consuming, and often nonspecific [44].

MRI: MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing [84]. However, MR assessment of Dupuytren’s is hindered by the resolution of current equipment, orientation issues due to multiplanar deformities of the fingers, and lack of intraoperative availability [84].

Other Considerations: Existing data on upper-extremity nerve axon counts were relatively weak and included several case reports and series [61]. An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences, but false-negatives are possible [84].

Treatment

General Principles and Indications

Surgeons must consider age-related biological constraints while recognizing that modern reconstructive strategies offer opportunities for considerable functional restoration [57]. Comprehensive evaluation of preoperative hand use and thorough patient education on rehabilitation protocols are essential components for optimizing functional outcomes [35]. Unless patients, their caregivers, and nonsurgical health care providers have baseline knowledge of tendon and/or nerve transfers, they are unlikely to obtain de novo awareness of surgical options with self-initiated searches [117].

Operative

Indications: In complete traumatic brachial plexus palsy, microsurgical nerve repair and nerve transfer can restore some function and relieve pain [15]. However, the overall usefulness of the upper limb remains disappointing due to lack of recovery in distal muscles in these cases [15]. In patients with complete root avulsions of the brachial plexus, no functioning spinal nerves are available proximally to restore function to the extremity, and there are no local musculotendinous transfers available for restoration of extremity function [89]. For cervical-level spinal cord injury (SCI), nerve transfers provide a means to reestablish volitional control of hand function [22]. In the chronic phase following SCI, if the triceps do not stimulate preoperatively or intraoperatively, nerve transfer will fail [48].

Surgical Approach / Technique: Brachial Plexus Injury: In patients with complete pan-plexal injuries, the highest priority for nerve reconstruction is elbow flexion [89]. This is achieved by reinnervation of the biceps/brachialis muscle [89]. Elbow flexion is doubly reinnervated when possible, often using intercostal nerve transfers to the biceps motor branch in addition to a gracilis free functional muscle transfer (FFMT), innervated by the intercostals as well [89]. Shoulder stabilization, abduction, and external rotation are prioritized by reinnervation of the suprascapular, axillary nerves, and long thoracic nerve if possible [89]. Specifically, shoulder abduction, stability, and especially external rotation are provided either by using spinal accessory nerve transfer to the suprascapular nerve (when no available intact nerves are present) or by leaving the spinal accessory nerve intact and performing a delayed lower trapezius tendon transfer for external rotation [89]. If available, a proximal nerve stump is used to reinnervate shoulder targets (suprascapular and axillary nerves) in pan-plexus injury [89]. The shoulder is stabilized with nerve grafts to either the suprascapular nerve or axillary nerve, or both, from an available cervical nerve stump or with a planned secondary trapezius tendon transfer [89]. When additional nerve resources are available (i.e., more than one viable nerve), the serratus anterior (with a single intercostal nerve) or pectoralis major is targeted [89].

Hand sensation is restored by reinnervation of the lateral cord (C6-C7 distribution) [89]. Sensation in the median nerve distribution of the hand is provided by the transfer of sensory branches of the intercostal nerves to the lateral cord contribution of the median nerve [89]. Wrist and finger flexion and extension are also priorities for repair [89]. If hand reinnervation is attempted in pan-plexus injury, a single-stage gracilis FFMT is used for both elbow flexion and finger flexion [89]. Intrinsic hand muscle function is not typically attainable in patients with complete pan-plexus injuries [89]. Conventional goals in patients with pan-plexus injury include a stable shoulder and elbow flexion with or without some hand sensation [89]. Advances in microsurgical techniques, as well as novel application of FFMTs in the acute setting (<6 months after injury), have enabled us to achieve rudimentary prehension in select patients with pan-plexus injury [89].

In our experience, only rarely do we find more than one proximal nerve stump that can be used for nerve grafting in severe brachial plexus injuries [89]. Intact extraplexal nerves (spinal accessory, intercostal, C3 and C4 nerves) can be transferred and coapted to the distal peripheral nerve of the brachial plexus as a method for reinnervation of critical sensory or motor nerves [89]. The spinal accessory nerve is transferred to a triceps branch with an intervening nerve graft for reinnervation of elbow extension [89]. Secondary surgeries to provide stability to the hand and assist in rudimentary grasp are performed between 4 and 6 months after the index brachial plexus reconstruction [89]. These secondary surgeries include selected fusions and at times, soft tissue balancing [89]. The fusions include wrist arthrodesis, thumb carpometacarpal arthrodesis (to place the thumb in palmar abduction and pronation), and thumb interphalangeal joint arthrodesis [89]. The soft tissue balancing is primarily achieved with passive flexor digitorum superficialis procedures to create a metacarpophalangeal joint contracture for prevention of a claw deformity [89]. Other options for hand reanimation have also been proposed, including a two-stage FFMT and contralateral C7 (entire or half [hemi]) transfer to the median nerve, as well as extended phrenic nerve transfers to the median nerve [89].

Spinal Cord Injury and Tetraplegia: Tendon transfer is the preferred technique to restore elbow extension if the triceps do not stimulate in the chronic phase following SCI [48]. The biceps to triceps transfer is the preferred technique and precludes the use of the brachialis branch of the musculocutaneous nerve for hand reanimation [48]. If wrist extension is absent, a functioning and strong brachioradialis (BR) tendon should be transferred to the extensor carpi radialis brevis (ECRB) [48]. In cases that the supinator muscle is under voluntary control but the patient is without finger extension, the branches innervating the supinator can be transferred [48]. Cutting the supinator branches and transferring them to the posterior interosseous nerve (PIN) will result in loss of the supinator muscle in exchange for recovery of active function in the finger extensors [48]. An alternative option is to transfer the supinator branches to the anterior interosseous nerve (AIN) to restore grasp (instead of finger extension) [48]. A prerequisite for transferring supinator branches to the AIN is that the AIN targets must respond to stimulation [48].

If the triceps does respond to stimulation, its innervation is in the infralesional segment and nerve transfer can be considered [48]. When all the potential targets stimulate in the chronic period, reanimation is currently undertaken in two nerve transfer stages [48]. The first stage involves the triceps transfer and connecting the brachialis branch of the musculocutaneous nerve to a sural nerve graft that is tunneled into the volar forearm [48]. This strategy avoids any immobilization related to the brachialis nerve transfer and keeps the target finger flexors intact until the axons are in proximity, to avoid denervation atrophy [48]. The axons are allowed to grow through the sural graft (similar to a cross-face nerve transfer) for 9 to 12 months [48]. The second stage involves supinator to PIN and the distal end of the sural graft to the AIN with axons readily available to the AIN at the time of the distal repair [48]. These functions will then emerge at about the same time several months later [48].

The original technique described in the 1960s utilized a mixed nerve of the distal musculocutaneous being directed to the entire median nerve [48]. There were too few axons being directed to many targets (region of muscle and skin with red shading in the forearm and hand) compromising the ultimate result [48]. Subsequently, just the brachialis motor branch was directed into the “AIN fascicle” of the median nerve [48]. Because of the persistent interfasciculations, axons are lost to unintended destinations and nonfunctional axons are maintained within the target distribution [48]. The current approach directs all axons of the brachialis to the AIN distribution alone, avoiding both dilution and disparate targets [48]. The number of axons transmitted can still be compromised by the introduction of a graft [48].

Specific Nerve Injuries and Techniques: Outcomes after sensory nerve transfers are generally good [25]. In a high median nerve injury, the surgeon should consider performing an opposition transfer if forearm pronation is used as a substitute motion [51]. If the nerve has been repaired, extrinsic transfers are seldom required because sufficient extrinsic muscle function is usually regained [51]. If the patient needs a nerve graft, especially if this is done late or under unfavorable conditions, double free muscle transfer yielded satisfactory function and allowed use of the reconstructed hand in activities that required both hands [14]. Active pick-up function was successfully restored in ten patients after undergoing multiple nerve transfers combined with additional secondary functional hand reconstructions [16]. This method can be used for any size-mismatched nerve transfer and may lead to effective motor function restoration [64]. Experimental studies and positive reports from large clinical series suggest that new techniques using foreign nerves for reinnervation are worthy of integration into the management of upper brachial plexus injuries [40]. Many questions regarding timing, donor morbidity, and comparative efficacy remain unanswered for new techniques using foreign nerves for reinnervation in upper brachial plexus injuries [40].

Implant Selection: In group 1 patients (transferable brachioradialis only), wrist extension can be accomplished by transferring the brachioradialis into the extensor carpi radialis brevis tendon [53]. Transfer into the extensor carpi radialis longus produces more radial deviation [53]. Transfer into the extensor carpi ulnaris is not advised because this muscle acts as a wrist extensor only when the wrist is in supination [53]. Elbow extension must be present or reconstructed to stabilize the elbow against the significant flexion moment of the brachioradialis, or the transfer power would be reduced significantly [53]. Only when the brachioradialis muscle has grade 4 power can it be transferred to provide wrist extension [53]. The power of the brachioradialis can be graded by palpation over the muscle mass against resisted elbow flexion with the forearm in neutral [53]. Another option for restoration of wrist extension is nerve transfer [53]. Transfer of the brachialis motor nerve to the extensor carpi radialis longus motor nerve in combination with tenodesis of the flexor pollicis longus to the distal radius can be done to restore tenodesis pinch [53].

Alignment / Balancing Strategy: Key, or lateral, pinch is more desirable and easier to achieve than chuckjaw pinch (three-fingered palmar pinch) [53]. Key pinch should be restored in all tetraplegic patients who have grade 4 or better wrist extensor motor power [53]. At least 75% of all tetraplegic patients may be candidates for a key pinch procedure [53]. Other prerequisites for the transfer include sufficient sensibility and thumb mobility [53]. If ocular input is relied on, only one hand should be restored [53]. If two-point discrimination is less than 12 to 15 mm, both hands should be reconstructed [53]. If no motors are expendable for active transfer, several well-designed tenodeses are available for accomplishing key pinch [53].

Adjuncts: The Moberg key grip procedure is the precursor of and the simplest of all thumb flexion tenodesis procedures [53]. The flexor pollicis longus tendon is tenodesed to the distal radius so that on wrist extension the volar pulp of the thumb strongly contacts the radial side of the index finger [53]. This may require stabilization procedures of the thumb interphalangeal and metacarpophalangeal joints [53]. Moberg released the A1 pulley to increase the torque at the metacarpophalangeal joint by the subluxed flexor pollicis longus tendon [53]. Brand modified the Moberg key grip procedure by leaving the A1 pulley of the thumb metacarpophalangeal joint intact and routing the tendon across the palm, beneath the flexor tendons, and through the Guyon canal before tenodesing it to the distal radius [53]. The line of pull is better with this technique, and bowstringing of the tendon is prevented [53]. A “winch” tenodesis for thumb flexion was described based on preservation of active forearm supination [53]. The flexor pollicis longus tendon is routed around the distal ulna and is anchored to its dorsal aspect through a drill hole [53]. During supination, the anchored tendon flexes the thumb [53].

Other Considerations: In classic tendon transfer tetraplegia surgery, an ECRL to FDP tendon transfer is performed yielding strong finger flexion [30]. Some surgeons may simply preserve the wrist extensor tendon for future needs relying on passive tenodesis grasp [30]. Procedures for wrist extension commonly are combined with other procedures, such as elbow extension and tenodesis procedures for key pinch [53]. There was no difference in outcomes between nerve transfer and nerve graft groups at 1 or 2 or more years follow-up in late microsurgical nerve reconstruction for brachial plexus birth injury [39].

Complications

Vascular complications: Two of 19 gracilis muscle transfers failed due to thrombosis at the site of anastomoses early in the postoperative period of the second stage [36].

Donor site morbidity: Donor site morbidity for the contralateral C7 transfer is typically mild and transient [19].

Recovery

Light activity (weeks): The evidence provided does not specify a typical week range for light activity such as desk work, driving, or light activities of daily living.

Full activity (months): The evidence provided does not specify a typical month range for full activity, including manual work, sport, or full range of motion and strength return.

Complete recovery / outcome plateau (months): Useful function is typically recognized after 12 months [55]. While nerve transfers offer the advantage of quick recovery time due to short regeneration distance without a nerve graft [114], recovery is not always markedly speedier compared to tendon or muscle transfer for shoulder or elbow paralysis [55].

Rehabilitation protocol: Nerve transfer rehabilitation requires a collaborative surgeon-therapist relationship to communicate operative details, expected timelines, and realistic expectations [105]. In a two-stage procedure involving a nerve graft, a positive Tinel’s sign in the arm over the distal end of the nerve graft was used to judge the appropriate time for the second operation, which was typically 1 year after the first surgery [36].

Functional milestones: Upper limb functional restoration results were categorized as good, satisfactory, or failed based on MRC grading of range of motion and power [36]. A good functional outcome denoted the ability to lift a 2 kg weight using the reconstructed hand in a fashion to manage an object while the contralateral normal hand was working on it [36]. A satisfactory functional outcome meant the recovery allowed elbow flexion with fingers retaining a semi-flexed or ‘hook’ position, enabling the previously complete flail limb to work as an assistant to the intact limb [36]. A failed functional outcome meant that the patient recovered neither useful finger nor elbow flexion [36].

Other Considerations: There was no difference in outcomes between nerve transfer and nerve graft groups at 1 or 2 or more years follow-up [39]. In youngest patients aged 27 and 34 years, operated on 6 years after spinal cord injury, transfer of the NS to the PIN partially restored hand span [42]. Direct radial to ulnar nerve transfer via an interosseous tunnel safely and effectively restored intrinsic function before terminal muscle degeneration in a patient with combined proximal median and ulnar nerve injury [26]. In clinical review at 1 month after the second stage of operation, fasciculation was typically observed in the transferred gracilis muscle [36]. This clinical observation of fasciculation in the transferred gracilis muscle was confirmed by electromyographic documentation [36].

Key Evidence

  • [L5] Nerve transfers offer a more reliable outcome in a shorter period of time than nerve grafting and provide a more natural, functional reconstruction than tendon transfers. [1] (10.1016/j.hcl.2008.08.002)
  • [L4] Nerve transfers are an option for restoring hand and forearm function in patients with peripheral nerve injuries adversely affecting their ability to function. [2] (10.2106/jbjs.rvw.24.00150)
  • [L4] In approximately 90% of patients, distal nerve transfers resulted in functional recovery of shoulder abduction, elbow flexion or extension, and wrist extension. [3] (10.1016/j.jhsa.2021.11.014)
  • [L4] The described nerve transfer scheme is effective for restoring extension of the elbow, wrist, and fingers in common infraclavicular lesions of the brachial plexus affecting the posterior cord. [4] (10.1016/j.jhsa.2012.06.016)
  • [L5] Current treatment algorithms for brachial plexus injury must generally include functioning free microsurgical transfer of muscle to provide patients the most functional recovery possible, particularly when nerve repair or transfer is insufficient for hand function or delayed beyond 9 to 12 months. [5] (10.1016/j.hcl.2004.10.005)
  • [L4] Transfer of 10% of the bulk of the ulnar nerve to the biceps restores elbow flexion with no significant impairment of hand function. [6] (10.1016/j.jhsa.2025.01.019)
  • [L5] Nerve transfer techniques can be applied to restore hand and upper extremity function in the setting of cervical spinal cord injury. [7] (10.1016/j.hcl.2015.12.013)
  • [L3] In patients with recovering flexor carpi ulnaris function, a thorough discussion of potential failure must be undertaken, and an alternative nerve transfer should be selected. [8] (10.1177/1753193419851092)
  • [L5] When appropriately selected, nerve transfers have been shown to restore function in cases previously deemed difficult or impossible. [9] (10.1016/j.hcl.2012.08.007)
  • [L4] Nerve transfers can effectively reanimate muscles in selected cases, with comparable strength to tendon transfers for elbow extension but inferior strength for finger and thumb flexion. [10] (10.1177/1753193419886443)
  • [L5] This review aims to equip reconstructive hand surgeons with a sound understanding of the basic principles of SCI and recovery and provide a rationale for when to intervene with surgery, highlighting the urgent need for early referral to allow nerve transfer options to be viable. [11] (10.1016/j.jhsa.2023.01.008)
  • [L5] Nerve transfers are key components of the surgeon's armamentarium in brachial plexus and complex nerve reconstruction, offering advantages such as shortened regeneration distances and the ability to select pure motor or sensory fascicles. [12] (10.5435/jaaos-20-08-506)
  • [L5] Nerve transfer surgery has expanded reconstructive options for restoring upper extremity function following spinal cord injury by adding new motor donors to the pool available through tendon transfers. [13] (10.1177/17531934211027460)
  • [L4] Double free muscle transfer yielded satisfactory function and allowed use of the reconstructed hand in activities that required both hands. [14] (10.2106/jbjs.k.01279)
  • [L4] Complete traumatic brachial plexus palsy is a severe condition that leaves patients markedly handicapped; while microsurgical nerve repair and nerve transfer can restore some function and relieve pain, the overall usefulness of the upper limb remains disappointing due to lack of recovery in distal muscles. [15] (10.2106/00004623-199901000-00004)
  • [L4] Active pick-up function was successfully restored in ten patients after undergoing multiple nerve transfers combined with additional secondary functional hand reconstructions. [16] (10.1177/1753193417728405)
  • [L4] Nerve transfers are replacing other techniques as the gold standard for brachial plexus and other proximal peripheral nerve injuries, offering functional outcomes surpassing those obtained from traditional nerve repair or tendon transfers. [17] (10.1016/j.injury.2020.04.015)
  • [L3] In patients with total paralysis, satisfactory shoulder abduction values can be achieved with tendon transfers regardless of a previous history of neural surgery even if the preoperative values differ. [18] (10.1186/1471-2474-12-74)
  • [L5] Published clinical results have demonstrated significant improvements in upper limb function, confirming the procedure's safety and efficacy, with donor site morbidity that is typically mild and transient. [19] (10.1177/17531934251314640)
  • [L5] This review discusses late treatment options, including tendon transfers, joint fusions, free functioning muscle transfers and prosthetics, for managing the failed primary reconstruction of the traumatic adult brachial plexus. [20] (10.1177/17531934241231170)
  • [L2] However, only 5 of 22 patients experienced restoration of elbow flexion and extension. [21] (10.1016/j.jhsa.2008.06.007)
  • [L4] Nerve transfers provide a means to reestablish volitional control of hand function in people with cervical-level SCI. [22] (10.1016/j.jhsa.2013.08.034)
  • [L5] [23] (10.1016/j.hcl.2008.08.001)
  • [L5] The biomechanical principles, indications and limitations of tendon transfers, nerve transfers and combined approaches are compared, with particular attention to timing, patient selection, and functional goals. [24] (10.1177/17531934261416300)
  • [L4] Outcomes after sensory nerve transfers are generally good. [25] (10.1016/j.jhsa.2024.03.020)
  • [Case_report] Direct radial to ulnar nerve transfer via an interosseous tunnel safely and effectively restored intrinsic function before terminal muscle degeneration in a patient with combined proximal median and ulnar nerve injury. [26] (10.1016/j.jhsa.2014.04.013)
  • [L3] Double free muscle transfer procedure is capable of restoring maximum function in patients of total brachial plexus palsy. [27] (10.1302/0301-620x.98b2.35101)
  • [Case_report] This strategy successfully restored active extension of the thumb and finger in a patient with complete spinal cord injury at the C6 level. [28] (10.1016/j.jhsa.2010.07.012)
  • [L2] [31] (10.1177/17531934231205546)
  • [L4] It may allow a higher proportion of patients to achieve M3 hand grip more quickly than conventional hemi-CC7 transfer. [32] (10.1016/j.jhsa.2023.07.012)
  • [L4] Transfer of the radial nerve branch for the lower triceps medial head and anconeus to the anterior division of the axillary nerve proved to be an effective method of deltoid reinnervation. [33] (10.1016/j.jhsa.2014.01.005)
  • [L5] [34] (10.1016/j.hcl.2008.07.001)
  • [L5] Comprehensive evaluation of preoperative hand use and thorough patient education on rehabilitation protocols are essential components for optimizing functional outcomes. [35] (10.1177/17531934261415775)
  • [L4] [36] (10.1177/1753193409348182)
  • [L4] This study validated the effect of nerve transfers for global brachial plexus avulsions from objective MRC grading combining with patients' self-assessments. [38] (10.1016/j.injury.2012.02.006)
  • [L4] There was no difference in outcomes between nerve transfer and nerve graft groups at 1 or 2 or more years follow-up. [39] (10.1016/j.jhsa.2019.10.036)
  • [L5] Experimental studies and positive reports from large clinical series suggest that new techniques using foreign nerves for reinnervation are worthy of integration into the management of upper brachial plexus injuries, though many questions regarding timing, donor morbidity, and comparative efficacy remain unanswered. [40] (10.1054/jhsb.2000.0460)
  • [L3] [41] (10.1016/j.jhsa.2014.02.032)
  • [L4] In youngest patients aged 27 and 34 years, operated on 6 years after spinal cord injury, transfer of the NS to the PIN partially restored hand span. [42] (10.1016/j.jhsa.2016.08.003)
  • [L5] While generally superior to tendon or muscle transfer for shoulder or elbow paralysis, recovery is not always markedly speedier, with useful function typically recognized after 12 months. [55] (10.1177/17531934231226169)
  • [L4] This study demonstrates a distinct clinical presentation of brachial plexus trauma, characterized by preserved finger flexion despite complete plexus injury. [56] (10.1016/j.jhsa.2024.11.025)
  • [L4] Surgeons should consider age-related biological constraints while recognizing opportunities for considerable functional restoration using modern reconstructive strategies. [57] (10.1016/j.jhsa.2025.07.013)
  • [L4] Early functional recovery in these patients, with regard to hand function and sensation, is promising. [58] (10.1016/j.jhsa.2017.12.001)
  • [L4] Existing data on upper-extremity nerve axon counts were relatively weak and included several case reports and series. [61] (10.1016/j.jhsg.2024.08.002)
  • [L5] Approximately 65% to 75% of individuals with tetraplegia would benefit from upper extremity surgery, yet only 14% of surgical candidates undergo tendon transfer procedures. [62] (10.5435/jaaos-d-15-00465)
  • [L4] If effective prehension was not acquired after rehabilitation, transferring suitable motors improved grasp by providing finger flexion and thumb opposition. [63] (10.2106/00004623-197456050-00008)
  • [L4] This method can be used for any size-mismatched nerve transfer and may lead to effective motor function restoration. [64] (10.1177/17531934231201915)
  • [Case_report] The procedure resulted in active elbow flexion to 90° at 18 months without motor deficits in the hand. [65] (10.1016/j.jhsa.2010.06.014)
  • [L4] The anterior approach offers safe access to both radial and axillary nerves and has the added advantage of compatibility with approaches for other common nerve transfers. [66] (10.1016/j.jhsa.2018.10.019)
  • [L4] Brachialis muscle transfer is an effective method for reconstructing digital flexion in patients with lower brachial plexus injury or forearm injury, particularly when nerve transfer or forearm donor muscles are not feasible. [67] (10.1177/1753193417730656)
  • [L5] This specific procedure can be suggested in cases where the hand is partially involved to allow patients to regain or strengthen fingers flexion. [96] (10.1016/j.jhsg.2025.100844)
  • [L3] [97] (10.1177/17531934251338008)
  • [Case_report] [98] (10.1177/1753193413475963)
  • [L5] [100] (10.1016/j.hcl.2016.03.013)
  • [L4] Peripheral nerve transfers must be assessed within the broader framework of neuroplasticity. [103] (10.1177/17531934251398407)
  • [L2] Such a technique can potentially improve motor recovery of elbow and finger flexion in a shorter rehabilitation period (3 to 4 y) and, more importantly, provide finger sensation to the completely paralytic limb. [104] (10.1016/j.jhsa.2011.10.014)
  • [L5] Nerve transfer rehabilitation requires a collaborative surgeon-therapist relationship to communicate operative details, expected timelines, and realistic expectations. [105] (10.1016/j.jhsa.2023.09.016)
  • [L4] The results of active finger flexion can be improved by direct approximation of the lower trunk to an ipsilateral root stump. [112] (10.1016/j.jhsa.2020.09.023)
  • [L4] These transfers offer the advantage of quick recovery time due to short regeneration distance without nerve graft. [114] (10.1016/j.jhsa.2005.09.019)
  • [L4] Unless patients, their caregivers, and nonsurgical health care providers have baseline knowledge of tendon and/or nerve transfers, they are unlikely to obtain de novo awareness of surgical options with self-initiated searches. [117] (10.1177/1558944719878835)
  • [L4] With any level of spinal cord lesion, the better the sensory condition of the hand, the better the motor function achieved. [119] (10.1016/s0749-0712(02)00036-7)

See Also

References

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[5] Functioning free-muscle transfer for brachial plexus injury. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2004.10.005

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