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Tendon Transfers in the Upper Limb

55 citationsUpdated Sep 2026

Overview

Tendon transfers serve as a critical reconstructive option for restoring upper limb function in conditions such as median nerve palsy, tetraplegia, and traumatic brachial plexus injury. Success relies on a thorough preoperative clinical evaluation, precise understanding of biomechanics, appropriate donor and recipient selection, technical execution, and postoperative rehabilitation [8]. When combining proper direction of action, pulley location, and tendon insertion, these procedures are usually quite successful for median nerve palsy [9]. In the context of tetraplegia, approximately 65% to 75% of individuals would benefit from upper extremity surgery, yet only 14% of surgical candidates undergo tendon transfer procedures, indicating that this resource remains underused [5, 14]. Despite this low utilization rate, tendon transfers continue to provide pinch and grip function for many years following spinal cord injury [13].

The role of tendon transfers is evolving alongside advances in nerve transfer surgery. Nerve transfers have expanded reconstructive options by adding new motor donors to the pool available through tendon transfers [6]. While nerve transfers can effectively reanimate muscles in selected cases of tetraplegia [2], they provide comparable strength to tendon transfers for elbow extension but inferior strength for finger and thumb flexion [2]. A combined nerve and tendon transfer may offer benefits for restoring grasp function in patients with tetraplegia [4]. For brachial plexus and other proximal peripheral nerve injuries, nerve transfers are replacing other techniques as the gold standard, offering functional outcomes that surpass those obtained from traditional nerve repair or tendon transfers [20]. However, robust data facilitating the comparison between individual procedures, particularly tendon and nerve transfer, are sparse [17].

Tendon transfers also address specific pathological states and serve as a late treatment option for managing failed primary reconstruction of the traumatic adult brachial plexus [11]. 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 [16]. For the spastic upper extremity, surgical interventions aim to correct common deformities through single-event, multi-level surgery involving soft tissue lengthening, tendon transfer, and joint stabilization [12]. In children with cerebral palsy, tendon transfer surgery provides modest improvement compared with botulinum toxin injections or standard therapy [23]. Specific technical considerations apply to certain populations; for instance, care should be taken when transferring the flexor carpi ulnaris to the extensor carpi radialis brevis in patients less than 13 years of age due to the risk of developing a postoperative extension deformity [18]. Additionally, division of hypertonic musculotendinous units and functional replacement using tendon transfer techniques for radial nerve palsy has provided an effective means of restoring satisfactory distal upper limb function in patients with extensor hypertonia [19].

Anatomy & Pathophysiology

Skeletal Architecture and Kinematics

The hand and wrist skeleton comprises 27 bones, 19 of which are long bones [42]. The hand is organized into five rays, each forming a polyarticulated chain of metacarpals and phalanges [42]. The thumb ray is the shortest, consisting of a metacarpal and two phalanges, and possesses great freedom of movement [42]. The trapezium is angled out in front of the carpal plane, causing the first metacarpal to make an angle of about 45 degrees with the second metacarpal in the sagittal plane [42]. The wrist has three axes of movement, permitting the hand to be positioned in any spatial configuration for grasping [42]. The transverse axis of the palm is oblique, forming an acute angle of approximately 75 degrees with the longitudinal axis [42]. The metacarpophalangeal joints serve as the keystones of the longitudinal arches of the hand [49]. The fifth metacarpal has a range of flexion–extension of approximately 20 degrees at its carpal articulation [49], while the ring metacarpal has about 10 degrees of mobility in flexion and extension [49]. The hand presents a longitudinal and transverse concavity, giving it the shape of a cup with a palmar concavity when the thumb is placed next to the index finger [42].

Musculotendinous Anatomy

Extrinsic extensor muscles run through six different fibroosseous retinacular compartments at the wrist level [41]. The first extensor compartment contains the abductor pollicis longus and the extensor pollicis brevis [41]. The second extensor compartment contains the extensor carpi radialis longus and the extensor carpi radialis brevis [41]. The third extensor compartment contains the extensor pollicis longus, which turns abruptly radialward about Lister tubercle [41]. The fourth extensor compartment contains the extensor indicis proprius lying deep to the four tendons of the extensor digitorum communis [41]. The fifth extensor compartment contains the extensor digiti quinti [41]. The sixth extensor compartment contains the extensor carpi ulnaris [41]. The sagittal bands hold the extrinsic extensor tendon balanced over the prominence of the metacarpal head, keeping it away from the center of rotation to maximize mechanical efficiency [41]. Rupture or attenuation of the sagittal band fibers allows the extrinsic extensor tendon to sublux to the ulnar side of the metacarpal head, causing ulnar deviation of the finger [41].

The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx [41]. The flexor digitorum superficialis inserts via radial and ulnar slips into the proximal metaphysis of the middle phalanx [53]. The flexor pollicis longus inserts into the proximal base of the thumb distal phalanx [53]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [53]. There are seven interosseous muscles, four dorsal and three volar [47]. The dorsal interossei are abductors, while the volar interossei are adductors [47]. The middle finger has two dorsal interossei and no volar interossei because the central axis of the hand lies within it [47]. The deep head of each dorsal interosseous muscle forms a lateral tendon, or lateral band, at the level of the metacarpophalangeal joint [47]. The lateral bands are joined by the lateral slips of the extensor tendon to form the conjoined lateral band, which unites to form the terminal tendon [47].

Gliding Mechanisms and Soft Tissue

In unrestricted areas with a straight tendon trajectory, tendons are surrounded by paratenon and areolar connective tissue [54]. In narrow crowded areas, the gliding mechanism is assured by the synovial sheath, which allows considerable amplitude of movement [54]. Fibrous sheaths keep the tendon close to the skeleton when pulling tendons cross the sinus of an articular angle [54]. The dorsal skin slides distally to allow metacarpophalangeal joint flexion [54]. Flexion of the fingers produces a significant lengthening of the dorsal skin, with an average increase of 3 cm in the middle finger from extension to full flexion [55]. The dorsal skin possesses a normal pilosebaceous system, unlike the palm [55].

The palmar skin is subdivided into two separate zones by the oppositional crease of the thumb [46]. The skin of the radial portion of the palm covers the thenar eminence and is the mobile portion [46]. The skin of the ulnar and distal portion covers the hypothenar eminence and has poor mobility [46]. The central triangular part of the palm has fixed, poorly vascularized skin covering almost directly the superficial palmar aponeurosis [46].

Pathophysiology of Deformity and Spasticity

Control of digital posture requires a complex balance of extrinsic and intrinsic muscle forces [41]. In an "intrinsic-minus" situation, an imbalance between muscular systems results in a break in the continuity of the curves at the level of the metacarpophalangeal joint [49]. There is no consensus in the literature concerning the pathophysiology of limited joint range of motion in cerebral palsy, as several hypotheses involving different secondary changes in muscle and surrounding tissue have been tested with contradictory results [69]. The pennation angle of the extensor digitorum increased with the severity of forearm and wrist and finger deformities in spastic cerebral palsy [64].

Surgical reconstruction for thumb deformity in cerebral palsy aims to create a stable thumb capable of satisfactory grasp and release by decreasing deformity, balancing muscle forces, and stabilising joints [25]. The key to achieving consistent release of the spastic thumb-in-palm deformity and establishing functional lateral pinch is the accurate determination of the deforming forces and the identification of joint instability [43]. Identifying the cause of the deformity is critical for successful treatment of joint contractures in the spastic upper extremity [68].

The magnitude of function regained after reconstructive surgery in tetraplegia depends on the level of the spinal cord lesion, careful patient selection, thoughtful application of tendon transfer principles, absence of severe spasticity, remaining sensory function, and surgical expertise [44]. The initial goal of improved position in the hand and wrist was achieved in twenty-one of the twenty-four patients operated on for superficialis-to-profundus tendon transfer in hemiplegia [29]. If effective prehension was not acquired after rehabilitation, transferring suitable motors improved grasp by providing finger flexion and thumb opposition in cervical spinal cord injuries [30]. A good result from a flexor carpi ulnaris transplant depends upon the careful choice of the patient, requiring reasonable finger control, passive flexibility, stereognosis, reasonable intelligence, and high motivation [45]. In children with spastic hemiplegic cerebral palsy with volitional wrist extension and dynamic wrist flexion contractures, flexor carpi ulnaris fractional lengthening can improve spontaneous use, dynamic wrist posture, grip strength, and dexterity while preserving wrist flexion strength [72]. Most commonly, the flexor carpi ulnaris does not predictably change phase when transferred from a position of wrist flexion to wrist extension [62].

Classification

Nerve versus Tendon Transfer Selection: The choice between nerve and tendon transfers is determined by the level of injury, available donor structures, patient factors, surgical timing, and the specific functional goal [26]. For higher-level injuries, nerve transfers may be the only viable option, whereas lower-level injuries allow access to more distal donor nerves closer to the target, potentially enabling double nerve transfers for grasp [26]. The decision also depends on whether the specific function is more effectively restored by a tendon or nerve transfer, provided both are available [26]. Nerve transfers are generally superior to tendon or muscle transfers for shoulder or elbow paralysis [10], but they provide inferior strength compared to tendon transfers for finger and thumb flexion [2].

Biomechanical and Functional Principles: Nerve transfers restore volitional control to paralysed muscles, re-animate multiple muscles per transfer, and preserve native anatomy and biomechanics, leading to more natural movements [26]. They involve smaller incisions, shorter immobilization times with baseline activities possible within two weeks, and result in a softer, more supple hand with low morbidity and potential for continuous improvement [26]. In contrast, successful tendon transfer surgery depends on thorough preoperative evaluation, understanding of biomechanics, appropriate donor and recipient selection, technical execution, and postoperative rehabilitation [8]. Nerve transfers allow maintenance of original musculotendinous dynamics with unchanged line of pull and excursion, offering the potential for better functional recovery than tendon transfers [31]. However, nerve transfers cannot be delayed indefinitely as tendon transfers can, and situations may exist where the expected power of recovery from an available nerve transfer is inferior to that of a tendon transfer [31].

Timing and Indications: The best results with nerve transfers are achieved when surgery is performed early, specifically 6–9 months post-spinal cord injury [26]. Nerve transfers are time-sensitive when the recipient nerve is denervated [26]. The basic indications for nerve transfer are injuries where direct repair is not possible or where functional recovery with direct repair or nerve grafting is not expected [31]. Early referral is necessary to allow nerve transfer options to be viable in spinal cord injury [7]. Recovery from nerve transfers is not always markedly speedier than other methods, with useful function typically recognized after 12 months [10].

Clinical Outcomes and Efficacy: Nerve transfers can effectively reanimate muscles in selected cases and provide comparable strength to tendon transfers for elbow extension [2]. Published clinical results have demonstrated significant improvements in upper limb function for the contralateral C7 transfer, which has confirmed safety and efficacy [3]. Nerve transfers offer functional outcomes surpassing those obtained from traditional nerve repair or tendon transfers [20]. Adding a S-PIN nerve transfer appears to enhance grasp function in the tetraplegic limb when combined with established tendon transfer techniques [24]. Satisfactory shoulder abduction values can be achieved with tendon transfers in patients with total paralysis regardless of a previous history of neural surgery [16]. If effective prehension was not acquired after rehabilitation, transferring suitable motors improved grasp by providing finger flexion and thumb opposition [30].

Other Considerations: Spinal Cord Injury Context: 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 [6]. Only 14% of surgical candidates with tetraplegia undergo tendon transfer procedures [5]. The magnitude of function regained from reconstructive surgery in tetraplegia depends on the level of the spinal cord lesion, careful patient selection, thoughtful application of basic tendon transfer principles, the absence of severe spasticity, remaining sensory function of the hand, and the surgical program and surgeon's expertise [44]. About two thirds of traumatic tetraplegic patients sustain a midcervical spinal cord injury [44]. A two-stage hand reconstruction program for midcervical tetraplegia was based on the principles of the natural automatic mechanisms of the hand to provide the basic functions of pinching, grasping, and release, which are potentiated by wrist extension and flexion [44]. Reconstructive surgery offers patients not only greater physical independence but also psychological benefits [44].

Cerebral Palsy and Spasticity: Tendon transfers in patients with cerebral palsy are both an art and a science, with clinical assessment predominating decision-making due to the elusive nature of precise spasticity measurement [36]. Surgical interventions for the spastic upper extremity aim to correct common deformities through single-event, multi-level surgery involving soft tissue lengthening, tendon transfer, and joint stabilization [12]. The key to achieving consistent release of the spastic thumb-in-palm deformity and establishing functional lateral pinch is the accurate determination of the deforming forces and the identification of joint instability [43]. Robotic exoskeletons have not yet shown substantial benefit over conventional methods for upper extremity spasticity management [33].

Specific Procedure Considerations: Care should be taken when performing the transfer of the flexor carpi ulnaris to the extensor carpi radialis brevis in patients less than 13 years of age because they may develop a postoperative deformity, commonly an extension deformity [18]. A good result from a flexor carpi ulnaris transplant depends upon the careful choice of the patient, requiring reasonable finger control, passive flexibility, stereognosis, reasonable intelligence, and high motivation [45]. Surgical reconstruction for thumb deformity aims to create a stable thumb capable of satisfactory grasp and release by decreasing deformity, balancing muscle forces, and stabilising joints [25]. Only 5 of 22 patients experienced restoration of elbow flexion and extension following grafting of the anterior and posterior divisions of the upper trunk in complete palsies of the brachial plexus [21]. Existing data on upper-extremity nerve axon counts were relatively weak and included several case reports and series [28]. 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 [1].

Clinical Presentation

Tendon transfers for upper limb reconstruction in tetraplegia remain an underused resource for this population [14]. Only 14% of surgical candidates for upper extremity reconstruction in tetraplegia undergo tendon transfer procedures [5]. Access to specialized upper limb reconstruction is influenced by many factors in unique populations such as those living with cervical spinal cord injury [32]. Patients, their caregivers, and nonsurgical health care providers are unlikely to obtain de novo awareness of surgical options with self-initiated searches unless they possess baseline knowledge of tendon and/or nerve transfers [27].

In patients with cerebral palsy, tendon transfers are both an art and a science, where clinical assessment predominates decision-making due to the elusive nature of precise spasticity measurement [36]. Surgical correction for cerebral palsy followed by intensive hand therapy improves hand position and hand function [22]. In the hemiplegic upper extremity, the initial goal of improved position in the hand and wrist was achieved in twenty-one of the twenty-four patients operated on with superficialis-to-profundus tendon transfer [29].

For patients with cervical spinal cord injuries, transferring suitable motors improved grasp by providing finger flexion and thumb opposition if effective prehension was not acquired after rehabilitation [30].

Investigations

Clinical Examination: Clinical evaluation of the injured or dysfunctional hand and wrist requires combining patient history with a careful physical examination to pinpoint or narrow the scope of possible pathologic processes [39]. A careful physical examination is essential to direct care and future testing if indicated [39]. In patients with cerebral palsy, tendon transfers rely on clinical assessment predominating decision-making due to the elusive nature of precise spasticity measurement [36].

Other Considerations: Diagnostic tests such as imaging and serum laboratory studies are useful in determining pathology but can be expensive, time consuming, and often nonspecific [39].

Treatment

Non-Operative

Nonsurgical management options for upper limb dysfunction include robotic exoskeletons, botulinum toxin type A (BoNT-A) injections, and functional electrical stimulation. Robotic exoskeletons offer the potential to facilitate rehabilitation, though they have not yet demonstrated substantial benefit over conventional methods [33]. In pediatric populations, BoNT-A injections provide clinically meaningful short-term improvements in upper extremity function [34]. For patients with high-level quadriplegia, functional electrical stimulation has demonstrated the potential to provide significant improvement in hand function [35]. In the context of lateral epicondylitis, nonsurgical treatment offers no benefit over observation at six months or longer [23].

Operative

Indications: Tendon transfer surgery success depends on thorough preoperative clinical evaluation, understanding of tendon transfer biomechanics, appropriate donor and recipient selection, technical execution, and postoperative rehabilitation [8]. Approximately 65% to 75% of individuals with tetraplegia would benefit from upper extremity surgery, yet only 14% of surgical candidates undergo tendon transfer procedures [5]. Access to specialized upper limb reconstruction in this unique population is influenced by many factors [32]. Nerve transfers are replacing other techniques as the gold standard for brachial plexus and other proximal peripheral nerve injuries, offering functional outcomes that surpass those obtained from traditional nerve repair or tendon transfers [20]. For higher level injuries, nerve transfers may be the only option, while in lower-level injuries, more distal donor nerves that are closer to the target nerve are available and double nerve transfers to grasp are possible [26].

Surgical Approach / Technique: 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 [2]. 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 [10]. Key advantages of nerve transfers include re-animating more than one muscle per transfer, preserving native anatomy and biomechanics, smaller incisions and surgical field, shorter immobilization times, softer more supple hand for human interaction, low morbidity, and potential for continuous improvement [26]. Nerve transfers have one significant advantage over tendon transfers: they allow for maintenance of the original musculotendinous dynamics [31]. A combined nerve and tendon transfer in patients with tetraplegia may offer benefits [4].

Specific Procedures: The contralateral C7 transfer has demonstrated significant improvements in upper limb function, confirming the procedure's safety and efficacy [3]. The motor function of the C7 nerve largely overlaps with that of the other four cervical roots of the brachial plexus, so resecting this nerve usually results in only transient weakness and numbness in the ipsilateral upper extremity, allowing it to be used as a donor nerve with minimal morbidity [66]. The first case of transferring the C7 root from a non-paralyzed arm to the spastic contralateral side was published in 2011 [66]. A randomized trial assessed changes in clinical function in both central and peripheral neurophysiological activation with transcranial magnetic stimulation and nerve-conduction studies, and in brain activation with functional neuroimaging for the contralateral C7 transfer [66]. Criteria for the contralateral C7 transfer trial included patients aged 12–45 years demonstrating no improvement after at least 5 years of rehabilitation, with decreased but not absent muscle power and tactile sensitivity in the affected hand [66]. In a study of grafting the anterior and posterior divisions of the upper trunk in complete palsies of the brachial plexus, only 5 of 22 patients experienced restoration of elbow flexion and extension [21].

Functional Outcomes: The initial goal of improved position in the hand and wrist was achieved in twenty-one of the twenty-four patients operated on for superficialis-to-profundus tendon transfer in the hemiplegic upper extremity [29]. Nerve transfers provide inferior strength for finger and thumb flexion compared to tendon transfers [2].

Donor Site and Technical Complications: Donor site morbidity associated with the contralateral C7 transfer is typically mild and transient [3]. Patients less than 13 years of age may develop a postoperative extension deformity following the transfer of the flexor carpi ulnaris to the extensor carpi radialis brevis [18].

Other Considerations: Nerve transfers are time sensitive when the recipient nerve is denervated [26]. 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 [11].

Recovery

Rehabilitation protocol: Surgical correction for cerebral palsy is followed by intensive hand therapy, which improves hand position and hand function [22].

Functional milestones: Useful function from distal nerve transfers is typically recognized after 12 months [10].

Other Considerations: Published clinical results for the contralateral C7 transfer 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 [3].

Key Evidence

  • [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. [1] (10.1177/17531934261416300)
  • [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. [2] (10.1177/1753193419886443)
  • [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. [3] (10.1177/17531934251314640)
  • [L3] The study suggests that a combined nerve and tendon transfer in patients with tetraplegia may offer benefits. [4] (10.1177/17531934251338008)
  • [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. [5] (10.5435/jaaos-d-15-00465)
  • [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. [6] (10.1177/17531934211027460)
  • [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. [7] (10.1016/j.jhsa.2023.01.008)
  • [L5] Successful tendon transfer surgery depends on a thorough preoperative clinical evaluation, understanding of tendon transfer biomechanics, appropriate donor and recipient selection, technical execution, and postoperative rehabilitation. [8] (10.1016/j.hcl.2018.06.009)
  • [L5] Tendon transfers for median nerve palsy are usually quite successful when they combine a proper direction of action, pulley location, and tendon insertion. [9] (10.1016/s0749-0712(21)01134-3)
  • [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. [10] (10.1177/17531934231226169)
  • [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. [11] (10.1177/17531934241231170)
  • [L4] Surgical interventions for the spastic upper extremity aim to correct common deformities through single-event, multi-level surgery involving soft tissue lengthening, tendon transfer, and joint stabilization. [12] (10.1177/1753193419878973)
  • [L3] Tendon transfers continued to provide pinch and grip function for individuals with tetraplegia for many years following spinal cord injury. [13] (10.1016/j.jhsa.2013.11.037)
  • [L5] Tendon transfers for reconstruction of the upper limb in tetraplegia is an underused resource for this population. [14] (10.1016/j.hcl.2016.03.013)
  • [L5] Nerve transfer techniques can be applied to restore hand and upper extremity function in the setting of cervical spinal cord injury. [15] (10.1016/j.hcl.2015.12.013)
  • [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. [16] (10.1186/1471-2474-12-74)
  • [L4] Robust data facilitating the comparison between individual procedures, particularly tendon and nerve transfer, are sparse. [17] (10.1016/j.hcl.2013.04.010)
  • [L4] Care should be taken when performing this tendon transfer in patients less than 13 years of age because they may develop a postoperative deformity, commonly an extension deformity. [18] (10.1016/j.jhsa.2010.07.014)
  • [Case_report] Division of hypertonic musculotendinous units and functional replacement using tendon transfer techniques for radial nerve palsy provided an effective means of restoring satisfactory distal upper limb function in a patient with extensor hypertonia. [19] (10.1016/j.jhsa.2013.04.020)
  • [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. [20] (10.1016/j.injury.2020.04.015)
  • [L2] However, only 5 of 22 patients experienced restoration of elbow flexion and extension. [21] (10.1016/j.jhsa.2008.06.007)
  • [L4] The findings support surgical correction for cerebral palsy followed by intensive hand therapy improves hand position and hand function. [22] (10.1177/1758998313514560)
  • [L2] This article summarizes multiple studies on hand and upper extremity surgery, concluding that tendon transfer surgery provides modest improvement compared with botulinum toxin injections or standard therapy in children with cerebral palsy, nonsurgical treatment offers no benefit over observation for lateral epicondylitis at 6 months or longer, and reconstruction plates and elastic stable IM nails offer similar functional results for midshaft clavicular fractures. [23] (10.1016/j.jhsa.2015.08.020)
  • [L3] Adding a S-PIN nerve transfer appears to enhance grasp function in the tetraplegic limb when combined with established tendon transfer techniques. [24] (10.1177/17531934251381202)
  • [L5] Surgical reconstruction aims to create a stable thumb capable of satisfactory grasp and release by decreasing deformity, balancing muscle forces, and stabilising joints. [25] (10.1177/1753193407087891)
  • [L5] [26] (10.1177/17531934261415775)
  • [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. [27] (10.1177/1558944719878835)
  • [L4] Existing data on upper-extremity nerve axon counts were relatively weak and included several case reports and series. [28] (10.1016/j.jhsg.2024.08.002)
  • [L4] The initial goal of improved position in the hand and wrist was achieved in twenty-one of the twenty-four patients operated on. [29] (10.2106/00004623-197456030-00003)
  • [L4] If effective prehension was not acquired after rehabilitation, transferring suitable motors improved grasp by providing finger flexion and thumb opposition. [30] (10.2106/00004623-197456050-00008)
  • [L5] [31] (10.1016/j.hcl.2008.07.001)
  • [L4] There are many factors that influence access to specialized upper limb reconstruction in a unique population such as those living with cervical SCI. [32] (10.1016/j.jht.2024.08.060)
  • [Paper] On the nonsurgical frontier, robotic exoskeletons offer the potential to facilitate rehabilitation, though they have not yet shown substantial benefit over conventional methods. [33] (10.1016/j.hcl.2018.07.002)
  • [L1] Children receiving BoNT-A injections demonstrated clinically meaningful short-term improvements in upper extremity function. [34] (10.1016/j.jhsa.2012.12.019)
  • [L4] Functional electrical stimulation has demonstrated the potential to provide significant improvement in function of the hand in the patient who has high-level quadriplegia. [35] (10.2106/00004623-198870010-00027)
  • [L5] Tendon transfers in patients with cerebral palsy are both an art and a science, where clinical assessment predominates decision-making due to the elusive nature of precise spasticity measurement. [36] (10.1177/17531934231210380)
  • [L4] The anterior approach yields similar results to the posterior approach and has the advantage of allowing easier access for simultaneously performing nerve or tendon transfers to reconstruct grasp and pinch. [37] (10.1177/1753193421996987)
  • [L4] The key to achieving consistent release of the spastic thumb-in-palm deformity and to establishing functional lateral pinch is the accurate determination of the deforming forces and the identification of joint instability. [43] (10.1054/jhsb.2001.0601)
  • [L4] [44] (10.1016/s0749-0712(02)00036-7)
  • [L4] A good result from a flexor carpi ulnaris transplant depends first upon the careful choice of the patient, requiring reasonable finger control, passive flexibility, stereognosis, reasonable intelligence, and high motivation. [45] (10.2106/00004623-196244070-00006)
  • [L4] This study concludes that most commonly the FCU does not predictably change phase when transferred from a position of wrist flexion to wrist extension. [62] (10.1016/j.jhsa.2009.10.004)
  • [L3] In contrast, the pennation angle of the extensor digitorum increased with the severity of forearm and wrist and finger deformities. [64] (10.1177/17531934261480554)
  • [L5] [66] (10.1177/17531934241238885)
  • [L5] Identifying the cause of the deformity is critical for successful treatment. [68] (10.1016/j.hcl.2018.06.011)
  • [L4] There is no consensus in the literature concerning the pathophysiology of limited joint range of motion in cerebral palsy, as several hypotheses involving different secondary changes in muscle and surrounding tissue have been tested with contradictory results. [69] (10.1177/1753193412444401)
  • [L4] In children with spastic hemiplegic cerebral palsy with volitional wrist extension and dynamic wrist flexion contractures that impair function, FCU fractional lengthening can improve spontaneous use, dynamic wrist posture, grip strength, and dexterity while preserving wrist flexion strength. [72] (10.1016/j.jhsa.2015.06.095)

See Also

References

[1] Tendon versus nerve transfers – balancing hand function in upper extremity high nerve injuries. Journal of Hand Surgery (European Volume). 2026. DOI: 10.1177/17531934261416300

[2] Evidence for efficacy of new developments in reconstructive upper limb surgery for tetraplegia. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419886443

[3] Harnessing the uninjured hemisphere for treatment of the stroke or brain-injured patient – evolution of the contralateral C7 transfer. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251314640

[4] Outcome of combined nerve and tendon transfer in tetraplegia: a new surgical strategy to restore grasp function. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251338008

[5] Management of Upper Extremities in Tetraplegia: Current Concepts. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-15-00465

[6] Improving hand function after spinal cord injury. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211027460

[7] Spinal Cord Injury: Epidemiology, Spontaneous Recovery, and Hand Therapy for the Reconstructive Hand Surgeon. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2023.01.008

[8] Technical Pearls of Tendon Transfers for Upper Extremity Spasticity. Hand Clinics. 2018. DOI: 10.1016/j.hcl.2018.06.009

[9] Tendon Transfer For Median Nerve Palsy. Hand Clinics. 1988. DOI: 10.1016/s0749-0712(21)01134-3

[10] Distal nerve transfers for peripheral nerve injuries: indications and outcomes. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934231226169

[11] The failed adult traumatic brachial plexus reconstruction. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241231170

[12] Preferred options and evidence for upper limb surgery for spasticity in cerebral palsy, stroke, and brain injury. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419878973

[13] The Effects of Aging on Upper Limb Tendon Transfers in Patients With Tetraplegia. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.11.037

[14] Tendon Transfers for Tetraplegia. Hand Clinics. 2016. DOI: 10.1016/j.hcl.2016.03.013

[15] Nerve Transfers in Tetraplegia. Hand Clinics. 2016. DOI: 10.1016/j.hcl.2015.12.013

[16] Does primary brachial plexus surgery alter palliative tendon transfer surgery outcomes in children with obstetric paralysis?. BMC Musculoskeletal Disorders. 2011. DOI: 10.1186/1471-2474-12-74

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