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Nerve Transfers in the Upper Limb

70 citationsUpdated Oct 2026
Illustration: hand

Overview

Nerve transfer serves as a targeted supplement to traditional repair techniques such as primary suture and nerve grafting, providing a specific approach to reinnervation and recovery of key upper limb functions [1]. By offering shortened regeneration distances and the ability to select pure motor or sensory fascicles, these procedures have become key components of the surgeon’s armamentarium in brachial plexus and complex nerve reconstruction [26]. Nerve transfers are increasingly replacing other techniques as the gold standard for brachial plexus and other proximal peripheral nerve injuries, delivering functional outcomes that surpass those obtained from traditional nerve repair or tendon transfers [28]. When appropriately selected, these interventions restore function in cases previously deemed difficult or impossible [19].

In brachial plexus paralysis, nerve transfer is an effective means to restore elbow and shoulder function [10]. Distal nerve transfers are the preferred option for reconstructing elbow flexion in upper-type brachial plexus injuries where possible [32], and specific schemes effectively restore extension of the elbow, wrist, and fingers in common infraclavicular lesions affecting the posterior cord [9]. In approximately 90% of patients, distal nerve transfers result in functional recovery of shoulder abduction, elbow flexion or extension, and wrist extension [4]. For shoulder function restoration, an appropriate size match between donor and recipient nerves is a factor affecting success [21].

Nerve transfer techniques are also applied to restore hand and upper extremity function in the setting of cervical spinal cord injury [16]. This emerging area of upper limb surgery demonstrates very significant promise [5, 6] by expanding reconstructive options and adding new motor donors to the pool available through tendon transfers [12]. The use of novel extraplexal donor nerves in addition to free functioning gracilis muscle transfers now gives hope for the restoration of hand function [20]. 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 [2]. Early referral is necessary to allow nerve transfer options to be viable in the context of spinal cord injury [36].

Anatomy & Pathophysiology

Peripheral Nerve Physiology and Injury

Following nerve transection, a complex cascade of events occurs in skeletal muscle, leading to profound, short-term, and largely reversible structural and functional changes in the denervated tissue [29]. If skeletal muscle is rapidly supplied with a large number of regenerating motor axons, synaptogenesis proceeds, resulting in reasonable recovery of motor activity [29]. Useful integrated motor function is recovered only if the regenerating axons are motion-specific, producing contractile activity that results in movement with appropriate volitional control [29]. Functional results are compromised, often significantly, if the number of motor axons is insufficient, if the denervation interval is prolonged beyond a short time period, or if the motor axons are not motion-specific [29]. The consequences of skeletal muscle denervation and the incomplete, imprecise process of muscle reinnervation are the prime contributors to the disability patients experience after peripheral nerve injury [29].

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 [133]. Nerve reconstructions after proximal lesions with long reinnervation distances, large nerve gaps, and a poor surgical bed are associated with inferior outcomes [133]. Nerve transfers are helpful when it is not possible to anatomically reconstruct the primary neurological lesion or when unfavorable factors, such as increased length of regeneration distance from injury to the target organ, may limit the effectiveness of such repairs [133]. Transfer of redundant or expendable nerves to recipient nerves close to the end organ allows for earlier reinnervation and preservation of those musculotendinous units [17]. Nerve transfers provide significantly better treatment options in many cases of nerve injury where previous outcomes were expected to be poor, such as with proximal injuries, long nerve gaps, or unavailability of the proximal injured segment [17].

Nerve transfer does not replace traditional nerve repair techniques such as primary suture and nerve grafting, but serves as a useful supplement by providing a targeted approach to reinnervation and recovery of key functions of the upper limb [1]. Nerve transfers have one significant advantage over tendon transfers: they allow for maintenance of the original musculotendinous dynamics [125]. Line of pull and excursion should remain unchanged in nerve transfers, and they should have the potential to provide better functional recovery than tendon transfers [125]. A disadvantage of nerve transfers is that they cannot be delayed indefinitely, as tendon transfers can [125]. Situations may exist in which the expected power of recovery from an available nerve transfer may be inferior to that of a tendon transfer [125]. 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 [125]. Nerve transfers may be viewed as an alternate means of achieving the same goal as tendon transfers, only via the transfer of the intact nerve rather than the musculotendinous unit [125]. The donor nerve in a nerve transfer must be functioning [125].

Conventional or vascularized nerve grafts for reinnervation of the forearm and hand musculature have been demonstrated to be ineffective because of the long distances involved [88]. A viable gracilis transfer, when fixed to the clavicle proximally and tunneled to the forearm, can animate the wrist or hand because the motor point of the muscle is located at the shoulder, allowing reinnervation within 6 months or less [88].

Upper Limb Musculoskeletal Anatomy

The skeleton of the hand and wrist consists of 27 bones, of which 19 are long bones [45]. The skeleton of the hand is divided into five rays, each ray making up a polyarticulated chain comprising the metacarpals and phalanges [45]. The base of each metacarpal articulates with the distal row of the carpus, while the carpus articulates with the skeleton of the forearm through its proximal row [45]. The radioulnocarpal articulation has two axes of movement to which is added a third—pronation and supination from the forearm [45]. The wrist has three axes of movement, permitting the hand to be positioned in any spatial configuration and allowing it to be placed as needed for grasping [45].

The radial ray or first ray is the shortest, made up of only three bones—a metacarpal and two phalanges [45]. The trapezium is clearly angled out in front of the carpal plane so that the first metacarpal makes an angle of about 45 degrees with the second metacarpal in the sagittal plane [45]. The lengths of the metacarpals vary, with the thumb metacarpal being the shortest and the index finger being the longest [45]. The proximal and particularly the middle phalanges of the middle and ring fingers are longer than those of the index finger so that the long finger, and usually the ring finger, are longer than the index finger [45]. The more ulnar the digit, the more obliquely it must deviate as it approaches the palm during flexion [45]. The skeleton of 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 [45]. The transverse axis of the palm, which corresponds to the metacarpophalangeal articulations, is not perpendicular to the longitudinal axis, represented by the median ray [45]. The transverse axis of the palm forms an acute angle of approximately 75 degrees with the longitudinal axis [45]. The epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, whereas they are located at the distal ends of the other metacarpals [45].

Control of digital posture requires a complex balance of extrinsic and intrinsic muscle forces [44]. Extrinsic muscles have their origin outside of the hand and their insertion on the hand or carpus, whereas intrinsic muscles have both origin and insertion within the hand [44]. Extrinsic muscles are either flexors or extensors, and intrinsic muscles contribute to both digital flexion and extension [44]. The extrinsic extensors run through six different fibroosseous retinacular compartments at the wrist level [44].

First Compartment: The first (most radial) compartment contains the abductor pollicis longus and the extensor pollicis brevis [44]. The abductor pollicis longus has multiple slips that insert at the base of the thumb metacarpal and radially abducts the thumb [44]. The extensor pollicis brevis inserts on the dorsum of the proximal aspect of the proximal phalanx of the thumb and actively extends the metacarpophalangeal joint of the thumb [44].

Second Compartment: The second extensor compartment contains the extensor carpi radialis longus and the extensor carpi radialis brevis [44]. The extensor carpi radialis longus inserts on the index metacarpal, dorsiflexes and radially deviates the wrist [44]. The extensor carpi radialis brevis inserts into the base of the middle metacarpal, providing balanced wrist dorsiflexion [44].

Third Compartment: The third compartment contains the extensor pollicis longus, which runs longitudinally down the forearm through the third compartment and turns abruptly radialward about Lister tubercle [44]. The extensor pollicis longus provides forceful extension of the thumb interphalangeal joint [44]. The oblique course of the extensor pollicis longus tendon provides a substantial adduction component to the pull of the extensor pollicis longus [44].

Fourth and Fifth Compartments: The fourth extensor compartment contains the extensor indicis proprius lying deep to the four tendons of the extensor digitorum communis [44]. The fifth compartment contains the extensor digiti quinti [44]. The principal bony insertion of the extrinsic digital extensors is on the dorsal proximal aspect of the middle phalanx [44]. Metacarpophalangeal joint extension is provided by extrinsic extensor force transmitted through the sagittal bands [44]. Distal interphalangeal joint extension is achieved through the conjoined lateral bands that are composed of tendinous slips from the extrinsic and intrinsic tendons [44]. The extensor indicis proprius inserts on the index finger ulnar to the extensor digitorum communis [44]. The extensor digitorum communis inserts on the index, middle, ring, and, in some cases, little fingers [44]. The extensor digiti quinti tendon inserts on the little finger ulnar to the extensor digitorum communis insertion [44].

Sixth Compartment: The extensor carpi ulnaris tendon runs through the sixth compartment and inserts at the base of the little finger metacarpal [44]. The extensor carpi ulnaris provides wrist extension and ulnar deviation [44]. 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 [44]. The extensor indicis proprius tendon may be recognized at the wrist level as possessing the most distal muscle belly of any of the digital extensor tendons [44].

The digital extensor tendons are stabilized over the mid-line of the metacarpophalangeal joint by their attachment to sagittal band fibers [44]. The sagittal band fibers insert onto the volar proximal phalanx and onto the lateral borders of the volar plate [44]. The sagittal band fibers form a sling that allows proximal extrinsic extensor tension to be transmitted to the proximal phalanx, permitting metacarpophalangeal joint extension without a tendinous insertion onto the proximal phalanx [44]. With rupture or attenuation of the sagittal band fibers, the extrinsic extensor tendon can sublux to the ulnar side of the metacarpal head causing ulnar deviation of the finger [44].

The extrinsic finger flexors are the flexor digitorum profundus and the flexor digitorum superficialis [44]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx, flexing the distal interphalangeal joint as well as the proximal interphalangeal and metacarpophalangeal joints [44]. The flexor digitorum superficialis acts as a flexor of the proximal interphalangeal and metacarpophalangeal joints [44]. The extrinsic flexors of the finger consist of the flexor digitorum profundus and the flexor digitorum superficialis [79]. The flexor digitorum profundus originates from the proximal ulna and the interosseous membrane [79]. In the forearm, the flexor digitorum profundus divides into two muscle groups: the most radial component supplying the index finger and the ulnar component supplying the middle, ring, and little fingers [79]. The flexor digitorum profundus and the flexor pollicis longus muscles form the deep compartment of the volar forearm [79]. As the flexor digitorum profundus and flexor pollicis longus tendons travel through the carpal tunnel, they occupy the floor of the carpal tunnel [79]. The tenosynovial sheath of the flexor pollicis longus is continuous with the radial bursa [79]. The tenosynovial sheath to the little finger is continuous with the ulnar digital bursa [79]. In some patients, the radial and ulnar bursae communicate, allowing a so-called horseshoe abscess to spread between the thumb and little finger if infection occurs in the flexor tendon sheath of either one of these digits [79].

The lumbricals originate from the radial side of the index, middle, ring, and little fingers in the palm [79]. The profundus tendon passes through the bifurcation of the flexor digitorum superficialis before inserting into the proximal palmar base of the distal phalanx [79]. The innervation of the flexor digitorum profundus of the index and middle fingers is through the anterior interosseous branch of the median nerve [79]. The profundus of the ring and little fingers is innervated by the ulnar nerve [79]. The flexor digitorum profundus provides digital flexion at both the proximal and distal interphalangeal joints [79].

The flexor digitorum superficialis has two heads: The radial head originates from the proximal shaft of the radius, and the humeral ulnar head originates from the medial humeral epicondyle and coronoid process of the ulna [79]. Each digit has a corresponding independent superficialis muscle [79]. As the superficialis tendons pass through the carpal tunnel, the tendons of the middle and ring fingers are more superficial and central than those of the index and little fingers [79]. In the proximal aspect of the finger, the flexor digitorum superficialis tendon bifurcates around the flexor digitorum profundus at the beginning of the A2 pulley [79]. The flexor digitorum superficialis tendon slips then reunite distally at the Camper chiasm, with approximately half of the fibers staying on the ipsilateral side and half crossing to the contralateral side of the finger [79]. The tendon then inserts via radial and ulnar slips into the proximal metaphysis of the middle phalanx [79]. The entire flexor digitorum superficialis muscle receives innervation from the median nerve [79]. The primary function of the superficialis is digital flexion at the proximal interphalangeal joint [79].

The flexor pollicis longus originates from two heads: The radial head takes origin from the proximal radius and interosseous membrane, and an accessory head originates from the coronoid process of the ulna and from the medial epicondyle of the humerus [79]. In the palm, the flexor pollicis longus tendon transverses between the abductor pollicis brevis and the flexor pollicis brevis [79]. The flexor pollicis longus inserts into the proximal base of the thumb distal phalanx and is innervated by the anterior interosseous branch of the median nerve [79]. The flexor pollicis longus flexes both the interphalangeal and metacarpophalangeal joints of the thumb [79].

As the flexor tendons pass distal to the metacarpal neck, they enter the fibroosseous tunnel, or digital flexor sheath [79]. The fibroosseous tunnel extends distally to the proximal aspect of the distal phalanx [79]. The tendinous sheath consists of annular pulleys, which provide mechanical stability, and cruciate pulleys, which provide flexibility [79]. The first, third, and fifth annular pulleys (A1, A3, and A5) are located over the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints, respectively [79]. The second and fourth pulleys (A2 and A4) are situated over the middle portion of the proximal and middle phalanges [79]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [79]. The tenosynovium that lines the fibroosseous tunnel supplies both nutrition and lubrication to the poorly vascularized flexor tendons [79]. Proximal to the sheath, the tendons are well vascularized by the peritenon [79]. Within the sheath, tendon vascularity is supplied via the vincula system: the vinculum longus and brevis [79].

There are seven interosseous muscles, four dorsal and three volar [72]. The dorsal interossei are abductors [72]. Because the anatomic axis of the hand coincides with the axis of the third metacarpal, the dorsal interossei lie to the radial side of the index and middle fingers and the ulnar side of the middle and ring fingers [72]. The little finger is abducted by the abductor digiti quinti [72]. The volar interossei are adductors and lie to the ulnar side of the index finger and the radial side of the ring and little fingers [72]. The middle finger therefore has two dorsal interossei (abductors) and no volar interossei (adductors) because the central axis of the hand lies within it [72]. Each dorsal interosseous muscle, with the exception of the third, has two muscle heads [72]. The superficial head of each dorsal interosseous muscle arises most dorsally from the shaft of the contiguous metacarpals and is inserted deeply by a medial tendon onto the lateral tubercle of the base of the proximal phalanx [72].

Classification

International Classification for Surgery of the Hand in Tetraplegia (ICSHT): The ICSHT was conceptualized to define the level of injury more precisely and to formulate tendon transfer options more easily [25]. This classification is based on the totality of the key muscles or muscle groups of the forearm [111]. It registers muscles below the elbow with Medical Research Council (MRC) Grade 4 or greater strength as potential tendon transfer donors [25, 111, 121]. The ICSHT lists muscles in the order in which recovery is expected in complete tetraplegia [121]. Patients are classified into 11 groups according to this method [111].

ICSHT Group Hierarchy: * Group 0: No muscles below the elbow [111]. * Group 1: Brachioradialis is the transferable muscle; surgical aims include elbow extension, wrist extension, and passive/active tenodesis pinch [111]. * Group 2: Extensor carpi radialis longus (ECRL) is the transferable muscle [111]. * Group 3: Extensor carpi radialis brevis (ECRB) and pronator teres are transferable muscles; surgical aims include elbow extension, active pinch, active grasp, and active or passive finger extension [111]. A second wrist extensor is available in this group, making an additional tendon or nerve transfer possible [35]. * Group 4: Pronator teres is the transferable muscle [111]. * Group 5: Flexor carpi radialis is the transferable muscle [111]. * Group 6: Extensor digitorum communis (EDC) is the transferable muscle; surgical aims include selective surgery of the paralytic hand [111]. * Group 7: Thumb extension and finger flexion are the transferable muscles [111]. * Group 8: Partial finger flexors are the transferable muscles [111]. * Group 9: Intrinsic hand muscles are the transferable muscles [111]. * Group 10: Triceps and Weber sensibility of 12 mm are considered, with exceptions noted [111].

Surgical Goals by Level: In ICSHT Groups 1 to 3, a realistic goal is the reconstruction of wrist extension and lateral thumb pinch [25]. ICSHT groups with more innervated muscles below the elbow offer the possibility of tendon transfers for grasp and release of fingers and thumb [25]. Allieu et al. specified three main groups of tetraplegic patients with very different surgical goals and possibilities [111]. High-level tetraplegia corresponds to ICSHT Groups 0–2 [111].

Other Considerations: The ASIA classification is widely used to categorize patients with tetraplegia but levels are too broad to make decisions about reconstructive procedures of the upper limb [121]. The ICSHT classification is used to outline reconstructive options in patients with mid-to-low-level injuries (ICSHT groups >3) [114]. Evidence supporting the clinical utility of upper limb reconstructive surgery in patients with mid-to-high-level injuries (ICSHT groups 0–3) remains limited [114]. Most cervical cord injured patients have a loss at cervical mid-level (ICSHT groups 1–5) and will lack active finger and thumb extensors [114]. The interest of the intercostal nerve transfer classification is to permit the evaluation of brachial plexus neurotization results by intercostal nerve transfer, in order to restore elbow flexion [89].

Clinical Presentation

In complete traumatic brachial plexus palsy, patients are markedly handicapped, and the overall usefulness of the upper limb remains disappointing due to the lack of recovery in distal muscles [22]. 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 [38].

Radial Nerve Injury In high radial nerve injury, the patient cannot extend the wrist and loses power grip [48]. The patient cannot extend the metacarpophalangeal joint of the index through little digits simultaneously with the wrist at neutral, nor can they extend the index and little metacarpophalangeal joints in isolation [48]. Additionally, there is a loss of the ability to extend the thumb metacarpophalangeal and interphalangeal joints [48]. In low radial nerve injury, radial deviation of the wrist occurs during active extension due to continued innervation of the extensor carpi radialis longus with loss of extensor carpi ulnaris function [48]. This injury also results in loss of finger and thumb extension [48].

Sensory and Motor Examination Loss of pain perception in the tip of the little finger indicates ulnar nerve injury [94], while loss of pain perception in the tip of the index finger indicates median nerve injury [94]. Inability to extend the thumb in the hitchhiker’s sign usually indicates radial nerve injury, although severed extensor tendons may render this test invalid [94].

Diagnostic Pitfalls and Palpation 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 [94]. The wrist can be partially extended even when the muscles supplied by the radial nerve are completely paralyzed by simple flexion of the fingers [94]. Similarly, the elbow can be forcefully flexed even when the musculocutaneous nerve is completely severed and the biceps paralyzed by substitution of the brachioradialis [94]. Palpation of the opponens pollicis, extensor tendons of the wrist, and biceps tendon or muscle prevents diagnostic deceptions caused by substitution and trick movement [94]. The lumbricals, the short adductor of the thumb, and the interossei except for the first dorsal cannot be tested by palpation or sight [94].

Investigations

Electromyography: Electromyography is an essential component of the preoperative assessment for patients undergoing nerve transfer reconstruction of the upper limb after spinal cord injury [144]. Preoperative electromyography can demonstrate normal motor units within supinator muscles and mild spontaneous activity in extensor indicis, supporting the possibility of re-innervation despite delayed presentation [65].

Clinical Evaluation: 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 [43]. A careful physical examination is essential to direct care and future testing if indicated [43].

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 [43].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy regimens, or pharmacological interventions for nerve injuries.

Operative

Indications: Nerve transfer serves as a supplement to traditional repair techniques like primary suture and nerve grafting, offering a targeted approach to reinnervation and recovery of key upper limb functions [1]. These procedures provide significantly better treatment options in cases where previous outcomes were expected to be poor, such as proximal injuries, long nerve gaps, or unavailability of the proximal injured segment [17]. Modern nerve-to-nerve transfers represent one of the greatest advances in peripheral nerve surgery, allowing for earlier reinnervation and preservation of musculotendinous units by transferring redundant or expendable nerves to recipient nerves close to the end organ [17]. 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 [69]. However, many questions regarding timing, donor morbidity, and comparative efficacy of new reinnervation techniques remain unanswered [69].

Surgical Approach / Technique: In patients with complete pan-plexal injuries, the priority of repair includes elbow flexion by reinnervation of the biceps/brachialis muscle, followed by shoulder stabilization, abduction, and external rotation [93]. In patients with complete root avulsions of the brachial plexus, 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 [93]. Specific transfer techniques include the transfer of 10% of the bulk of the ulnar nerve to the biceps, which restores elbow flexion with no significant impairment of hand function [11, 15]. Sensory neurotisations to the hand allow for the possibility of sensory recovery after proximal ulnar nerve injury, sometimes complete (S4), particularly after transfer of the proper digital ulnar nerve of the index or middle finger to the dV, without functionally disabling sequelae at the donor site [18]. The idea to use a branch of the radial nerve to reinnervate the axillary nerve was suggested in 1940, but reliable results are now obtainable thanks to anatomical studies and detailed operative techniques [24]. The nerve to the long head of the triceps is long enough to be cut and turned back and sutured without tension on the axillary nerve [24]. The axillary nerve gives off a branch to the teres minor, a sensory branch, and in most cases two motor branches: one to the posterior deltoid, and one to the mid and anterior deltoid [24]. The deeper and most volar motor branch of the axillary nerve is probably the anterior motor one, which is selected for the nerve transfer [24]. The sacrifice of a terminal nerve produces a definite atrophy of one third of the deltoid [24]. 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].

Other Considerations: In approximately 90% of patients, distal nerve transfers resulted in functional recovery of shoulder abduction, elbow flexion or extension, and wrist extension in a series of 52 patients with C5–C8 (T1 Hand) brachial plexus paralysis [4]. 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 [22]. Nerve transfer for cervical spinal cord injury is an emerging area of upper limb surgery that demonstrates very significant promise [5, 6]. 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 [30]. Comprehensive evaluation of preoperative hand use and thorough patient education on rehabilitation protocols are essential components for optimizing functional outcomes [40]. The ECRB nerve can be used as a donor ensuring the ECRL is intact [35]. The ECRB nerve can be transferred to the AIN for active finger flexion [35]. The remaining ECRL produces 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 [35]. In the chronic phase following spinal cord injury, if the triceps do not stimulate preoperatively or intraoperatively, nerve transfer will fail [46]. Tendon transfer is the preferred technique to restore elbow extension when triceps do not stimulate [46]. The biceps to triceps transfer is the preferred technique for elbow extension and precludes the use of the brachialis branch of the musculocutaneous nerve for hand reanimation [46]. An alternative option is to transfer the supinator branches to the AIN to restore grasp instead of finger extension [46]. A prerequisite for transferring supinator branches to the AIN is that the AIN targets must respond to stimulation [46]. If wrist extension is absent, a functioning and strong BR tendon should be transferred to the ECRB [46]. If the triceps responds to stimulation, its innervation is in the infralesional segment and nerve transfer can be considered [46]. When all potential targets stimulate in the chronic period, reanimation is currently undertaken in two nerve transfer stages [46]. 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 [46]. This strategy avoids immobilization related to the brachialis nerve transfer and keeps the target finger flexors intact until axons are in proximity to avoid denervation atrophy [46]. Axons are allowed to grow through the sural graft for 9 to 12 months [46]. 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 [46]. The original technique for musculocutaneous to median nerve transfer utilized a mixed nerve of the distal musculocutaneous directed to the entire median nerve, resulting in too few axons being directed to many targets [46]. Subsequently, just the brachialis motor branch was directed into the “AIN fascicle” of the median nerve, but persistent interfasciculations caused axons to be lost to unintended destinations and nonfunctional axons to be maintained within the target distribution [46]. The current approach directs all axons of the brachialis to the AIN distribution alone, avoiding both dilution and disparate targets [46]. The number of axons transmitted can still be compromised by the introduction of a graft [46].

Approximately 65% to 75% of individuals with tetraplegia would benefit from upper extremity surgery, yet only 14% of surgical candidates undergo tendon transfer procedures [60]. Cumulative evidence indicates that chronological age should be considered, but not represent an absolute contraindication for brachial plexus surgery [96]. Healthy older patients can derive meaningful benefits from brachial plexus surgery, particularly if surgical planning is optimized [96]. Recovery will be slower, therapy will be intensive, and the results will not equal those of a young person in older patients [96]. Achieving elbow flexion that can assist in feeding or bringing the hand to the face, or shoulder stability that allows humeral positioning, can greatly improve quality of life in an otherwise flail limb even if muscle grades remain modest (M2—M3) [96]. Neurolysis may help resolve neuropathic pain in some patients, which can be a justification on its own for exploration, unless in the setting of nerve root avulsions [96]. With careful technique favoring nerve transfers and timely intervention, many older patients can attain functional improvements after brachial plexus injury [96]. No clear cutoff age has been justified for brachial plexus surgery [96]. The key to successful outcomes in older patients is judicious patient selection and individualized surgical planning, focusing on functions that matter most to the patient, often elbow flexion for basic arm use [96]. Surgeons must recognize when additional procedures such as tendon transfers or arthrodesis should be combined to augment the overall outcome [96]. Double free muscle transfer procedure is capable of restoring maximum function in patients of total brachial plexus palsy [97].

Complications

Nerve palsy: Sacrifice of a terminal nerve to the deltoid results in definite atrophy of one third of the deltoid [24]. In patients undergoing side-to-end nerve transfers for elbow flexion reanimation, four cases of immediate postoperative deficit affecting the anterior interosseous nerve (AIN) have been outlined; all four patients demonstrated complete spontaneous recovery to preoperative status [99].

Donor site morbidity: Donor site morbidity associated with the contralateral C7 transfer is typically mild and transient [30].

Other Considerations: The double free-muscle transfer technique requires successful free-muscle transfers, stability of the proximal joints, and prolonged postoperative rehabilitation for success [62].

Recovery

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

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

Complete recovery / outcome plateau (months): The provided evidence does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: Nerve transfer rehabilitation requires a collaborative surgeon-therapist relationship to communicate operative details, expected timelines, and realistic expectations [142]. The double free-muscle transfer technique necessitates successful free-muscle transfers, stability of the proximal joints, and prolonged postoperative rehabilitation for the success of the procedure [62].

Functional milestones: In patients with total brachial plexus division, the rapid re-growth of fibres across the graft, clinically indicated by Tinel's sign, and late functional results suggest the technique's efficacy [154]. Of patients who underwent median nerve repair and had the required two-year follow-up to assess motor recovery, 40% achieved M3 function [153]. Nine patients with ten recipient nerves followed for more than two years demonstrated functional recovery in seven cases [146]. All three patients in a specific cohort recovered full function of the involved hand one year after grafting [42]. In the youngest patients, aged 27 and 34 years, operated on six years after spinal cord injury, transfer of the NS to the PIN partially restored hand span [152].

Other Considerations: Current treatment algorithms for brachial plexus injury 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 [2]. Nerve transfers are an option for restoring hand and forearm function in patients with peripheral nerve injuries adversely affecting their ability to function [3]. While microsurgical nerve repair and nerve transfer can restore some function and relieve pain in complete traumatic brachial plexus palsy, the overall usefulness of the upper limb remains disappointing due to lack of recovery in distal muscles [22]. The double free-muscle transfer technique achieved a dramatic revolution in the treatment of total paralysis of the brachial plexus by providing universal prehensile function [62]. Double free muscle transfer yielded satisfactory function and allowed use of the reconstructed hand in activities that required both hands [31].

Predictors of poor outcome include patient age, injury level, preoperative delay, and graft length. The result of nerve repair was poor in patients aged over 54 years, when the level of the injury was more than 56 cm proximal to the finger tip, if the preoperative delay was more than 24 months, or if the graft length was more than 70 mm [141]. One cannot expect a useful result of ulnar nerve repair in patients over 46 years of age, if the level of injury is more than 60 cm from the middle finger tip, if the pre-operative delay is more than 16 months, if the length of grafting is greater than 7.5 cm, and if the width of contusion is more than 23 cm [148]. The failure of nerve grafts is particularly related to prolonged delays, patient age and background, and the location of the lesion far from effectors [149].

Regarding axillary nerve palsy, outcomes of long-nerve grafts are comparable with those of modern nerve transfers [64]. 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 [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, though many questions regarding timing, donor morbidity, and comparative efficacy remain unanswered [69].

Lessons of tendon transfers have taught that nerves to specific musculotendinous units are expendable [17]. Greater understanding of peripheral nerve topography has revealed redundant fascicles in peripheral nerves [17]. Non-vascularized nerve grafts, despite prolonged initial delay in revascularization, eventually developed an apparently normal blood supply through longitudinal sources, even when peripheral vessels were denied access to the grafts [150]. Analysis at 7, 14, and 28 days found blood flow in the middle segments of the nonisolated conventional nerve grafts to exceed that of entubulated nerve grafts with evidence in these segments of both lateral and longitudinal revascularization [151].

Key Evidence

  • [L5] Nerve transfer does not replace traditional nerve repair techniques such as primary suture and nerve grafting, but serves as a useful supplement by providing a targeted approach to reinnervation and recovery of key functions of the upper limb. [1] (10.1016/j.hansur.2016.11.007)
  • [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. [2] (10.1016/j.hcl.2004.10.005)
  • [L4] Nerve transfers are an option for restoring hand and forearm function in patients with peripheral nerve injuries adversely affecting their ability to function. [3] (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. [4] (10.1016/j.jhsa.2021.11.014)
  • [Paper] Nerve transfer for CSCI is an emerging area of upper limb surgery that demonstrates very significant promise. [5] (10.1177/1558944716660555fd)
  • [L4] Nerve transfer for CSCI is an emerging area of upper limb surgery that demonstrates very significant promise. [6] (10.1177/1558944716660555fe)
  • [L4] None of the 13 end-to-side nerve transfers in the 10 patients with adequate follow-up demonstrated objective evidence of motor recovery. [7] (10.1016/j.jhsb.2004.03.006)
  • [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)
  • [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. [9] (10.1016/j.jhsa.2012.06.016)
  • [L4] We conclude that nerve transfer is an effective means to restore elbow and shoulder function in brachial plexus paralysis. [10] (10.1053/jhsu.2001.21518)
  • [L4] Transfer of 10% of the bulk of the ulnar nerve to the biceps restores elbow flexion with no significant impairment of hand function. [11] (10.1016/j.jhsa.2025.01.019)
  • [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. [12] (10.1177/17531934211027460)
  • [L4] For the dorsal forearm plane, results are good in the vast majority of cases, but it is essential to control the absence of flexor carpi ulnaris paralysis before using it as a transfer. [14] (10.1016/j.main.2013.10.088)
  • [L4] Transfer of 10% of the bulk of the ulnar nerve to the motor nerve of the biceps resulted in no significant impairment of hand function. [15] (10.1016/0363-5023(94)90011-6)
  • [L5] Nerve transfer techniques can be applied to restore hand and upper extremity function in the setting of cervical spinal cord injury. [16] (10.1016/j.hcl.2015.12.013)
  • [Paper] [17] (10.1097/bth.0b013e31812714f3)
  • [L4] Sensory neurotisations to the hand allow for the possibility of sensory recovery after proximal ulnar nerve injury, sometimes complete (S4), particularly after transfer of the proper digital ulnar nerve of the index or middle finger to the dV, without functionally disabling sequelae at the donor site. [18] (10.1016/j.hansur.2018.10.094)
  • [L5] When appropriately selected, nerve transfers have been shown to restore function in cases previously deemed difficult or impossible. [19] (10.1016/j.hcl.2012.08.007)
  • [L5] Use of novel extraplexal donor nerves in addition to free functioning gracilis muscle transfers now give hope for the restoration of hand function. [20] (10.1097/01.bth.0000199972.16703.e1)
  • [Paper] In nerve transfers to restore the function of the shoulder, an appropriate size match between donor and recipient nerves was proved to be a factor affecting success. [21] (10.1016/j.hansur.2016.10.117)
  • [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. [22] (10.2106/00004623-199901000-00004)
  • [L5] [24] (10.1016/j.main.2008.11.010)
  • [L4] [25] (10.1177/1753193419886443)
  • [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. [26] (10.5435/jaaos-20-08-506)
  • [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. [28] (10.1016/j.injury.2020.04.015)
  • [L5] [29] (10.1016/j.hcl.2008.08.001)
  • [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. [30] (10.1177/17531934251314640)
  • [L4] Double free muscle transfer yielded satisfactory function and allowed use of the reconstructed hand in activities that required both hands. [31] (10.2106/jbjs.k.01279)
  • [L3] Distal nerve transfers are the preferred option for the reconstruction of elbow flexion in upper-type brachial plexus injuries, where possible. [32] (10.1142/s2424835520500332)
  • [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. [36] (10.1016/j.jhsa.2023.01.008)
  • [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. [38] (10.1186/1471-2474-12-74)
  • [L5] Comprehensive evaluation of preoperative hand use and thorough patient education on rehabilitation protocols are essential components for optimizing functional outcomes. [40] (10.1177/17531934261415775)
  • [L4] All three patients recovered full function of the involved hand 1 year after grafting. [42] (10.1016/0363-5023(89)90069-5)
  • [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. [60] (10.5435/jaaos-d-15-00465)
  • [L5] The double free-muscle transfer technique achieved a dramatic revolution in the treatment of total paralysis of the brachial plexus by providing universal prehensile function, although several requirements such as successful free-muscle transfers, stability of the proximal joints and prolonged postoperative rehabilitation are necessary for the success of this procedure. [62] (10.1177/1753193408090140)
  • [L3] [64] (10.1016/j.jhsa.2014.02.032)
  • [L5] [65] (10.1177/1753193419830068)
  • [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. [69] (10.1054/jhsb.2000.0460)
  • [L4] The interest of this original classification is to permit the evaluation of brachial plexus neurotization results by intercostal nerve transfer, in order to restore elbow flexion. [89] (10.1016/s1297-3203(01)00028-2)
  • [L4] [96] (10.1016/j.jhsa.2025.07.013)
  • [L3] Double free muscle transfer procedure is capable of restoring maximum function in patients of total brachial plexus palsy. [97] (10.1302/0301-620x.98b2.35101)
  • [L4] [99] (10.1016/j.hansur.2018.07.004)
  • [L5] [111] (10.1097/00130911-200003000-00008)
  • [L3] [114] (10.1177/17531934251338008)
  • [L5] [121] (10.1016/j.hcl.2016.03.013)
  • [L5] [125] (10.1016/j.hcl.2008.07.001)
  • [L2] [133] (10.1177/17531934231205546)
  • [L4] The result of nerve repair was poor in patients aged over 54 years, when the level of the injury was more than 56 cm proximal to the finger tip, if the preoperative delay was more than 24 months, or if the graft length was more than 70 mm. [141] (10.1016/0266-7681(93)90205-t)
  • [L5] Nerve transfer rehabilitation requires a collaborative surgeon-therapist relationship to communicate operative details, expected timelines, and realistic expectations. [142] (10.1016/j.jhsa.2023.09.016)
  • [L4] Electromyography is an essential component of the preoperative assessment of patients for nerve transfer reconstruction of the upper limb after spinal cord injury. [144] (10.1177/1558944716660555fz)
  • [L4] Nine patients with ten recipient nerves have been followed up for more than two years and seven have obtained a functional recovery. [146] (10.1016/s0266-7681(05)80235-9)
  • [L4] On the basis of the material, one cannot expect a useful result of ulnar nerve repair in patients over 46 years of age, if the level of injury is more than 60 cm from the middle finger tip, if the pre-operative delay is more than 16 months, if the length of grafting is greater than 7.5 cm, and if the width of contusion is more than 23 cm. [148] (10.1016/0266-7681(93)90053-i)
  • [L4] The failure of nerve grafts is particularly related to prolonged delays, patient age and background, and the location of the lesion far from effectors. [149] (10.1016/j.hansur.2018.10.181)
  • [L3] Non-vascularized nerve grafts, despite prolonged initial delay in revascularization, eventually developed an apparently normal blood supply through longitudinal sources, even when peripheral vessels were denied access to the grafts. [150] (10.1016/s0266-7681(05)80238-4)
  • [L3] Analysis at 7, 14, and 28 days found blood flow in the middle segments of the nonisolated conventional nerve grafts to exceed that of entubulated nerve grafts with evidence in these segments of both lateral and longitudinal revascularization. [151] (10.1053/jhsu.2002.36996)
  • [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. [152] (10.1016/j.jhsa.2016.08.003)
  • [L4] Of the patients who had the required follow-up of 2 years to assess motor recovery of the median nerve, 40% achieved function - M3. [153] (10.1016/j.hansur.2016.05.006)
  • [L5] The rapid re-growth of the fibres across the graft, as shown clinically by Tinel's sign, and the late functional results in this total brachial plexus division suggest the technique's efficacy. [154] (10.1016/s0266-7681(84)80004-2)

See Also

References

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g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.