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Tendon and Nerve Repair

Hand tendon/nerve repair: primary vs secondary reconstruction, Zone II management, and rehabilitation protocols for optimal functional recovery.

96 citationsUpdated Aug 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Tendon transfer serves as a critical reconstructive option to restore function following radial, median, or ulnar nerve injuries when surgical repair is not possible or fails to yield useful function [5]. It offers an important alternative, and potentially the procedure of choice, to microsurgical nerve reconstruction, particularly when early professional and social reintegration is prioritized [12]. Nerve transfers have also emerged as a first-line reconstructive technique, with fundamental principles regarding donor site location, strength, safety, and efficacy introduced by Oberlin et al. remaining integral to contemporary practice [16].

For high radial nerve injuries with defects of nine centimeters or greater, attempting nerve reconstruction before proceeding to tendon transfers appears indicated within 8 months [2]. In cases of radial nerve paralysis, better outcomes were observed with nerve transfer versus tendon transfer procedures [8]; however, pooled analysis indicates that tendon transfers had higher rates of superior clinical outcomes compared with nerve transfers and nerve grafts for isolated radial nerve palsy [10]. Intrinsic hand muscle reinnervation via median-ulnar end-to-side bridge nerve graft is mainly indicated in high peripheral nerve injury or secondary cases when recovery of intrinsic hand muscles is not expected after end-to-end repair or graft [3].

Simultaneous nerve repair and tendon transfer showed no detrimental results and may provide improved function over tendon transfer alone in a limited case series of peroneal nerve injuries [1]. More participants with longer follow-up are needed to fully demonstrate the superiority of combined nerve and tendon procedures for grasp and release function in patients with tetraplegia [6]. Selection of the donor nerve for heterotopic nerve transfers must be carefully weighed against other treatment alternatives, considering the risk of donor nerve impairment and the potential narrowing of future reconstructive options [17]. There is a foreseen increased need for studies addressing combined nerve and tendon transfer reconstructions alongside patient-perceived outcome investigations in reconstructive hand surgery for tetraplegia [4].

Anatomy & Pathophysiology

Osseous and Articular Mechanics

Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [45]. Finger forces are more hampered while gripping objects with smaller circumferences than large ones [32].

Ligamentous and Pulley System

Repair with ST demonstrated the greatest biomechanical strength in stiffness and load-to-failure for thumb ulnar collateral ligament repair, although both ST and SA constructs recapitulate native joint stiffness [58]. The pulley system of the thumb is composed of 4 components, as opposed to the traditional view of only 3 [62].

Tendon and Nerve Repair

Decellularized flexor tendon-bone grafts can exceed the strength and excursion needed for hand therapy immediately after reconstruction [51]. Sensation constitutes 40% of the goal in thumb or fingertip repair, while length and appearance account for 50% [59].

Extensor Mechanism and Kinematics

Routing of the extensor pollicis longus (EPL) tendon through the first dorsal compartment allows reproduction of the action of thumb extension and abduction and restores thumb clearance from the palm [50]. There were no significant differences in the motion range of the thumb after EPL rerouting techniques or sites of insertion in cerebral palsy [56]. Hand surgery and hand therapy practice interventions, including the use of relative motion flexion (RMF) orthoses for management of non-surgical and surgical extensor mechanism (EM) injuries, may benefit from an in-depth look at EM zone III and IV anatomy and biomechanics [57]. Subjects with stenosing tenosynovitis demonstrate a significant decrease in maximum velocity in slow fist tasks [53].

Neurovascular Landmarks

The intrinsic hand muscles have motor evoked potentials (MEPs) at consistent distances from bony landmarks both dorsally and volarly [54]. The findings clarify hand surface landmarks in localizing the thumb A1 pulley and digital neurovascular structures [60].

Classification

Seddon: First classified peripheral nerve injuries into three categories: neuropraxia, axonotmesis, and neurotmesis [80]. First-degree nerve injury (neuropraxia) involves a local conduction block in the absence of axonal injury, with complete recovery expected within six weeks [80]. Second-degree nerve injury (axonotmesis) involves disruption of the axon while the connective tissue endoneurial sheath remains intact; axonal degeneration occurs distally to the injury, and recovery is usually complete [80]. Fifth-degree nerve injury (neurotmesis) involves complete division of the nerve, with minimal potential for recovery without surgical intervention [80].

Sunderland: Expanded the classification of peripheral nerve injuries into five degrees of injury [80]. Third-degree nerve injury involves axonal disruption associated with a partial tear of the endoneurial tube; fibrosis of the endoneurium leads to incomplete recovery [80]. Fourth-degree nerve injury involves complete axonal and endoneurial disruption, with only the epineurium remaining intact; this leads to fibrosis that blocks nerve regeneration, resulting in a neuroma in continuity [80].

Mackinnon and Dellon: Added a sixth category to the peripheral nerve injury classification, representing a combination of any of the previous five degrees [80].

Chuang: Described a classification system for adult brachial plexus injuries using numerical descriptions to simplify injury types and add clinical information [82]. Levels I–III encompass supraclavicular and retroclavicular brachial plexus injuries [82]. Level IV is limited to infraclavicular brachial plexus injuries [82].

Crawford: Used to assess outcomes in soft-tissue mallet injuries [81]. Tendon stumps in mallet injuries appear to fuse by fibrous bridging after 2 weeks’ time, with collagen fibers positioned perpendicularly to the tendon fibrils [81]. The remodeling process ensures progressive parallel organization of collagen fibers within the 2 weeks following the initial 2-week fibrous bridging phase [81].

Türker: Classification system for accessory extensor pollicis longus tendons has been modified to include a Type 3 category for rare findings of two radial-sided accessory extensor tendons in the same individual [69].

Clinical Presentation

History and Mechanism: A thorough history must elucidate the cause and probable location of injury, particularly for radial nerve palsy [36]. In ballistic hand injuries, the presence of fractures is associated with a higher incidence of nerve and tendon injuries, which correlates with an increased risk of long-term disability [7]. Patients with injury patterns suggestive of nerve involvement warrant prompt referral to an upper extremity specialist to optimize outcomes [35]. Baseline knowledge of tendon and/or nerve transfer options is required for patients, caregivers, and nonsurgical providers to facilitate awareness via self-initiated searches [14].

Inspection and Palpation: High median nerve transection can present with preserved finger flexion [18]. Painful neuroma is a debilitating sequela of nerve injury, involving poorly understood pathophysiology related to fascicular escape and scarring [21]. In young adults with sharp instrument nerve lesions at the wrist, tendon injuries requiring repair were present in seven of nine patients, with arterial injury affecting five patients (one artery) and two patients (both arteries) [30]. Tendinopathies of the hand and wrist are common conditions diagnosed by history and examination [46].

Range-of-Motion and Stability: Evaluation of radial nerve palsy must assess motor and sensory deficits, the strength of potential donor muscles, and passive joint motion [36]. A migrating Tinel's phenomenon serves as a good prognostic indicator in radial nerve palsy [36]. Regeneration after wrist-level nerve repair begins within a month, indicated by Tinel’s sign distal to the wound [30]. Advancement of Tinel’s sign or point of sensibility occurred at a rate of five millimeters per week or more in six of eight ulnar-nerve repairs and less than five millimeters per week in two patients [30]. Sensory return progressed more slowly after median-nerve repairs, with only two of five patients showing regeneration at a rate of five millimeters per week [30].

Special Tests and Imaging: MRI and ultrasound have limited use in the evaluation of radial nerve injuries [36]. Electromyography and nerve conduction velocity studies are rarely helpful acutely, except when continuity is unknown because slowed but intact conduction indicates some continuity [36]. These studies are recommended around 3 to 4 months after radial nerve injury [36]. Larger polyphasic motor action potentials of longer duration may be seen before clinical recovery in radial nerve injuries, although the degree of recovery is unclear [36]. If the amplitude of motor nerve conduction velocity is low, less than 0.3 mV, exploration can be undertaken with repair remaining a viable option even 5 to 6 months after injury [36]. Ultrasonography was conducted to assess tendon continuity in cases of pronounced pain and lack of cooperation for preoperative examination of flexor digitorum profundus avulsions [41]. If doubt persisted regarding flexor digitorum profundus avulsion continuity, MRI was performed [41].

Red-Flag Patterns and Prognosis: Proximal, irreparable peripheral nerve injuries are difficult to manage and poor results with substantial disability are expected [37]. Distal motor end plates often degenerate during the critical months necessary for nerve regeneration and reinnervation even under the best circumstances of nerve repair or reconstruction [37]. Delaying nerve repair for more than 6 months substantially reduces the number of regenerating axons and their response to growth factors [37]. For high radial nerve injuries with defects of nine centimeters or greater, an attempt at nerve reconstruction before proceeding to tendon transfers is indicated within 8 months [2]. Evidence for good nerve recovery or improved function following single digital nerve repair is poor, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels [9].

Investigations

MRI: Provides important preoperative information for surgical decision-making and planning in patients presenting late with closed flexor tendon injuries of the hand [75]. Demonstrates complete regeneration of subchondral bone and cartilage with significant improvement in functional scores in the management of Hepple Stage V osteochondral lesions of the talus with a platelet-rich plasma scaffold [97].

Ultrasonography: May serve as a valuable complementary tool for objectively evaluating nerve recovery in repaired median nerve lacerations [94].

CT: 3D CT imaging techniques can be used to diagnose rare sites of flexor tendon entrapment [96].

Other Considerations: Surgical exploration confirms the diagnosis of closed partial flexor digitorum profundus rupture as an unusual cause of pediatric trigger finger and allows for excision of the damaged segment to return normal movement without compromising strength [102]. Open surgical treatment is traditionally the most often used approach for ulnar collateral ligament locking, despite a lack of evidence in imaging studies for diagnosing the cause [98]. Miscellaneous and often unclear reasons for tendon ruptures were observed in primary single-finger flexor tendon repairs, making the definition of one major cause impossible [99].

Combined nerve and tendon transfer reconstructions alongside patient-perceived outcome investigations are needed to address increased needs in tetraplegia [4]. Combined nerve and tendon procedures for grasp and release function in tetraplegia require more participants with longer follow-up to fully demonstrate superiority [6]. Simultaneous nerve exploration and tendon transfer for peroneal nerve injuries showed no detrimental results and may provide improved function over tendon transfer alone [1]. Tendon transfer is a useful option to restore function after radial, median, or ulnar nerve injury when surgical repair does not result in useful function or is not possible [5]. Tendon transfers are indicated in longstanding, irreparable, isolated radial nerve lesions to provide selective finger and thumb extension [103]. For high radial nerve injuries with defects of 9 cm or greater, an attempt at nerve reconstruction before proceeding to tendon transfers is indicated within 8 months [2]. Tendon transfers had higher rates of superior clinical outcomes compared with nerve transfers and nerve grafts in isolated radial nerve palsy [10]. Better recovery after nerve grafting for high radial nerve injury is associated with delay in repair of less than 6 months, defect length of less than 5 cm, or grafting with three or more donor nerve cables [11]. Median-ulnar end-to-side bridge nerve grafts are mainly indicated in high peripheral nerve injuries or secondary cases when recovery of intrinsic hand muscles is not expected after end-to-end repair or graft [3]. End-to-end repair of fascicular groups provides better results than repair using nerve grafts for partial lacerations of peripheral nerves [15].

Treatment

Non-Operative

For atraumatic posterior interosseous nerve palsy, a trial of nonoperative management is advisable in the absence of a space-occupying lesion [85]. Exploration is recommended if there is no sign of muscle recovery after 6 weeks of observation or if there is progressive weakness [85].

Operative

Indications: Tendon transfer is indicated to restore function after radial, median, or ulnar nerve injuries when surgical repair to the nerve does not result in useful function or nerve repair is not possible [5]. It offers an important alternative, possibly the procedure of choice, to microsurgical nerve reconstruction, particularly when early professional and social reintegration is important [12, 13]. Tendon lengthening and transfer are indicated for neuromuscular disorders, nerve injuries, and congenital or traumatic lesions [20]. For high radial nerve injuries with defects of 9 cm or greater, an attempt at nerve reconstruction before proceeding to tendon transfers is indicated, even for large gaps [2]. Intrinsic hand muscle reinnervation using a median-ulnar end-to-side bridge nerve graft is mainly indicated in high peripheral nerve injuries or secondary cases when recovery of intrinsic muscle is not expected after end-to-end repair or graft [3]. Primary tendon repair is permissible only when strict criteria are met, including early presentation, minimal contamination, and favorable wound conditions; otherwise, secondary repair via tendon graft is recommended [23].

Surgical Approach / Technique: Nerve transfers have become a first-line reconstructive technique for restoring function, with fundamental principles regarding donor site location, strength, safety, and efficacy remaining integral to contemporary nerve surgery [16]. Selection of a donor nerve for transfer must be carefully weighed against other treatment alternatives, considering the risk of donor nerve impairment and the potential narrowing of future reconstructive options [17]. Direct repair of the lower trunk to residual nerve roots is a surgical technique for restoration of finger flexion after total brachial plexus injury [67]. Exploration of proximal root stumps in brachial plexus injury involves exposing the plexus via a transverse supraclavicular incision, identifying the phrenic nerve, and examining foramina medial to it [67]. If a root is found ruptured at its emergence from the foramen during brachial plexus exploration, it is explored further medially within the foramen and traced laterally to the injured end [67]. Nerve quality in brachial plexus exploration is evaluated under a microscope by serial sectioning from lateral to medial until healthy fascicles with minimal or no scarring are seen [67]. Stimulation of branches to the long thoracic nerve provides evidence of proximal continuity with the spinal cord during brachial plexus exploration [67]. Exploration of trunks in brachial plexus injury involves identifying the distal supraclavicular brachial plexus within a dense mass of scar at the inferior and medial part of the posterior triangle [67]. The suprascapular nerve is identified beyond the zone of injury, close to the suprascapular notch, and traced proximally to its origin from the upper trunk during brachial plexus exploration [67]. The upper trunk is traced from lateral to medial to identify the scarred/injured end and confirm avulsion of the C6 root if present during brachial plexus exploration [67]. The middle trunk is exposed by retracting the upper trunk and is explored in a similar manner during brachial plexus exploration [67]. The long thoracic nerve (LT) is identified distally behind the subclavian artery and traced proximally during brachial plexus exploration [67]. C8 and T1 roots are identified and traced to their respective foramina during brachial plexus exploration [67]. If C8 and T1 roots are found ruptured in the interscalene area during brachial plexus exploration, the quality of the proximal stump is evaluated [67].

For tendon transfers addressing the three most common peripheral nerve palsies, procedures are performed simultaneously, with harvesting and routing performed for every tendon transfer before completing tensioning and tying [24]. The order in which tendon transfers are performed during harvesting and routing does not matter [24]. During tensioning and tying of tendon transfers, the sequence should follow from the most robust transfer (most surgically secure juncture) to the most delicate transfer [24]. The anterior approach for transferring the supinator nerve to the posterior interosseous nerve yields similar results to the posterior approach and allows easier access for simultaneously performing nerve or tendon transfers to reconstruct grasp and pinch [28].

In zone 2 flexor tendon repair, the six-strand M-Tang core repair method uses two looped 4-0 nylon suture lines [70]. The distance between entry/exit points of the needle and the tendon anastomosis is greater than 7 mm longitudinally at the phase of core suture in the six-strand M-Tang repair [70]. About 10% tendon shortening is maintained to add tension to the suture strands in the six-strand M-Tang repair [70]. A simple running peripheral suture with 6-0 monofilament nylon or 3–4 locking running peripheral stitches with 5-0 (or 4-0) monofilament nylon are added to each tendon after the core sutures in the six-strand M-Tang repair [70]. Partial venting (1/2 to 2/3) through a midline cut in the A2 pulley is performed if the tendon injury is around the A2 pulley during zone 2 flexor tendon repair [70]. If the tendon division is too distal to the A2 pulley, the A4 pulley is cut to facilitate exposure of the distal tendon stump during zone 2 flexor tendon repair [70]. Complete divisions of the FDS tendons are not repaired; a 2 cm section is resected from the proximal tendon stumps during zone 2 flexor tendon repair [70]. Partial FDS tendon injuries are repaired using 4-0 nylon suture with a cross-stitch repair method during zone 2 flexor tendon repair [70]. The six-strand double-loop technique for zone II flexor tendon repair appears better than the two-strand technique without an increased rate of rupture but with a shorter rehabilitation period [87].

Endoscopic proximal hamstring tendon repair for nonretracted tears uses unique positioning, portal placement, dissection and exposure, protection of the sciatic nerve, and anatomic tendon repair [78]. The endoscopic technique for proximal hamstring repair uses prone positioning with feet at the elevated head of the bed and knee flexion to 90° to decrease stretch on the sciatic nerve [78]. Multiple measures are taken to ensure protection of the sciatic nerve during endoscopic proximal hamstring repair [78].

Implant Selection: Collagen conduits reliably provide a repair that restores nerve function for nerve gaps measuring less than 2 cm [27]. Type I collagen conduits are a reliable alternative to nerve grafting for gaps up to 10 mm in length [90]. Polyglycolic acid and type I collagen bioabsorbable nerve conduits are being compared as alternatives to autografting [90]. Proper planning for synthetic conduit use begins with having the appropriate nerve tube available in the operating room, as commercial conduits range from 1.5 mm to 10.0 mm in diameter [25]. The chosen nerve conduit should be slightly larger than the diameter of the nerve [25]. Surgeons must be aware of the cost, biomechanical properties, and contraindications of available nerve conduits [25].

Adjuncts: Wrapping the nerve with fibrin sealant before division and immediate fixation resulted in less protrusion of the nerve end [88]. Pharmacological intervention as an adjunctive therapy to surgical peripheral nerve repair may be beneficial and necessary for satisfactory long-term functional recovery [83].

Other Considerations: Simultaneous nerve repair and tendon transfer for peroneal nerve injuries showed no detrimental results and may provide improved function over tendon transfer alone [1]. Combined nerve and tendon transfer (CNaTT) for grasp and release function in tetraplegia requires more participants with longer follow-up to fully demonstrate superiority over single procedures [6]. Nerve repair outcomes show poor evidence for good recovery or improved function, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels [9]. Better nerve recovery after grafting for high radial nerve injury is associated with a delay in repair of less than 6 months, a defect length of less than 5 cm, or grafting with three or more donor nerve cables [11]. Neurolysis of the superficial radial nerve offers the opportunity for pain relief but does not reliably produce success [92]. The painful neuroma is a debilitating sequela of nerve injury with poorly understood pathophysiology involving fascicular escape and scarring, requiring treatment tailored to the individual patient [21].

Assessment of soft tissues is mandatory to determine whether reconstruction should be performed before or concomitant with nerve repair when using conduits [25]. An incision slightly off the expected course of the nerve can help avoid the skin suture line lying directly over the foreign body when using conduits [25]. The proximal and distal ends of the nerve are located and cut back to healthy fascicles before insertion into a conduit [25]. Stabilizing the nerve tube to the soft tissues with several interrupted sutures sewn in a U-shaped fashion over the tube is a helpful first maneuver when using conduits [25]. Freshened nerve endings are inserted 2 mm into the ends of the tube under adequate magnification when using conduits [25]. An 8-0 nylon, interrupted horizontal mattress suture is used to secure the outer epineurium when using conduits [25].

The TWZL (Tendon With Z-Lengthening) technique offers an alternative treatment option for patients with tendon deficiency and nerve injuries, avoiding donor site morbidity associated with autograft harvest [29]. The TWZL technique is an alternative for patients with tendon deficiency and nerve injuries [29]. Surgical treatment of pediatric trigger thumb consisting of flexor tendon sheath release is effective in restoring motion with minimal risks of recurrence and neurovascular complication, although the optimal age for surgical treatment is unclear [76]. Tendon lacerations in a healthy neonate can be managed in a timely and safe manner with modern anesthesia techniques [84]. Management of late tendon rupture in childhood is difficult due to the need for immobilization in young patients [91]. Improving tendon-to-bone healing by tendon inversion may inform future improvements in surgical techniques for tendon-to-bone fixation [89].

Factors affecting results after flexor tendon repair in zone 2 include the mechanism of injury (clean-cut versus crush), associated fractures, the number of digits/tendons injured, age, the experience of the surgeon, and the type of postoperative mobilization programme [26]. A large part of the variance in the outcome of flexor tendon repair in zone 2 is thought to be related to the psychological and biologic characteristics of the patient [26]. Studies addressing combined nerve and tendon transfer reconstructions alongside patient-perceived outcome investigations are needed [4]. 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 [14]. The surgical technique for volar scapholunate interosseous ligament reconstruction in acute traumatic wrist resulted in pain-free outcomes, improved range of motion, and functional recovery comparable to the available literature [93].

Complications

Nerve Injury and Recovery: The presence of fractures is associated with a higher incidence of nerve and tendon injuries [7], and involvement of nerves and tendons is linked to an increased risk of long-term disability [7]. Evidence for good nerve recovery or improved function following nerve repair is poor, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels [9]. Follow-up time and age significantly influence the outcome following nerve repair [114], with significant improvements in the total score seen throughout the follow-up period after median or ulnar nerve repair [114]. Primary repair of common and proper digital nerves could be achieved up to two weeks or greater after injury [108], whereas patients with sharp major nerve injuries required grafting more frequently after several days from injury [108]. Outcomes from processed nerve allografts are comparable to nerve autograft and exceed those for nerve conduit in historical controls [113]. Muscle-in-vein conduits can be considered for primary and secondary reconstruction of digital nerves [104]. Simultaneous nerve repair and tendon transfer showed no detrimental results [1].

Tendon Repair Complications and Outcomes: Primary suture of tendons at the wrist yields nearly normal restoration, whereas delayed repair often requires grafts with far from perfect results [115]. Primary tendon repair is permissible only when strict criteria are met, including early presentation, minimal contamination, and favorable wound conditions; otherwise, secondary repair via tendon graft is recommended [23]. Secondary reconstruction remains an important and useful technique for complicated flexor tendon injuries or those that have failed primary repair [118]. A carefully executed and monitored primary repair in a sharp wound reduces the time to maximum recovery and usually results in better function than previously recommended secondary grafting [119]. Unrecovered nerve injury adversely affects outcome in acute distal biceps tendon repair using cortical button fixation [111]. All patients achieved an excellent or good outcome with no ruptures or infections in a new technique of flexor profundus repair in the distal part of zone I [112].

Surgical Technique and Conduit Considerations: Proper planning for synthetic conduits requires having the appropriate nerve tube available in the operating room [25]. Commercially available nerve conduits range from 1.5 mm to 10.0 mm in diameter [25], and the chosen conduit should be slightly larger than the diameter of the nerve [25]. Surgeons must be aware of the cost, biomechanical properties, and contraindications of available conduits [25]. An assessment of soft tissues is mandatory to determine whether reconstruction should be performed before or concomitant with nerve repair [25]. An incision slightly off the expected course of the nerve can help avoid the skin suture line lying directly over the foreign body [25]. The proximal and distal ends of the nerve are located and cut back to healthy fascicles [25]. Stabilizing the nerve tube to soft tissues with several interrupted sutures in a U-shaped fashion is a helpful first maneuver [25]. Freshened nerve endings are inserted 2 mm into the ends of the tube under adequate magnification [25]. An 8-0 nylon, interrupted horizontal mattress suture is used to secure the outer epineurium [25].

Other Considerations: Major complications such as nerve injury or deep infection are uncommon in surgery for idiopathic trigger finger [101]. Most adverse outcomes in surgery for idiopathic trigger finger are short-term pain, stiffness, and swelling [101]. Complications following arthrodesis for thumb carpometacarpal osteoarthritis were more frequent than ligament reconstruction and tendon interposition, but most did not affect the overall outcome [116].

Recovery

Light activity (weeks): Specific week ranges for light activity are not defined in the current evidence base.

Full activity (months): Specific month ranges for full activity are not defined in the current evidence base.

Complete recovery / outcome plateau (months): Adequate sensory recovery without any nerve repair occurred by the 2-year follow-up in artery-only fingertip replantations using a controlled nailbed bleeding protocol [105].

Rehabilitation protocol: A rehabilitative protocol individualized to fit each patient's tendon pathology and surgery is essential following extensor mechanism surgery [64]. Early rehabilitation after hand tendon repair is beneficial [65]. The final combination of repair and early active mobilization for primary repair of flexor pollicis longus (FPL) tendons compares favourably with previous methods of treatment [66].

Functional milestones: Intrinsic hand muscle reinnervation by median-ulnar end-to-side bridge nerve graft is mainly indicated in high peripheral nerve injury or secondary cases when recovery of the intrinsic muscle is not expected after end-to-end repair or graft [3]. Supercharged end-to-side anterior interosseous to ulnar motor nerve transfer has broad clinical utility for augmenting partial recovery and preserving motor end plates in second- and third-degree axonotmetic nerve injuries [106]. PEG fusion techniques may drastically improve the long-term recovery of more proximal nerve injuries where poor outcomes are more common [100].

Other Considerations: Tendon transfer is a useful option to restore function after radial, median, or ulnar nerve injury when surgical repair to the nerve does not result in useful function or is not possible [5]. For high radial nerve injuries with defects of 9 cm or greater, an attempt at nerve reconstruction before proceeding to tendon transfers appears indicated within 8 months [2]. Delay in repair of less than 6 months, defect length of less than 5 cm, or grafting with three or more donor nerve cables achieved better recovery in high radial nerve injury [11]. Patients who present early and can tolerate longer time to functional recovery are optimal candidates for nerve transfers over tendon transfers in radial nerve palsy [19]. When tension-free end-to-end nerve repair is unachievable, options include nerve autograft, nerve allograft, and various autologous or synthetic nerve conduits, with moderate to good recovery of 2-point discrimination [107]. Evidence for good nerve recovery or improved function following single digital nerve repair in adults is poor, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels [9].

Combined nerve and tendon transfer (CNaTT) for grasp and release function in patients with tetraplegia requires more participants with longer follow-up to fully demonstrate superiority [6]. Multiple tendon transfers for the three most common peripheral nerve palsies are carried out simultaneously, with harvesting and routing performed for every transfer before tensioning and tying [24]. During tensioning and tying of multiple simultaneous tendon transfers, the sequence should follow from the most robust transfer (most surgically secure juncture) to the most delicate transfer [24]. Heterodigital flexor digitorum profundus hemi-tendon transfer restores good function in most patients with zone 1 and 2 flexor tendon injuries where primary tendon repair has not been performed or was unsuccessful and pulley reconstruction is not required [95].

Key Evidence

  • [L4] The results of our limited case series for this rare condition indicate that simultaneous nerve repair and tendon transfer showed no detrimental results and may provide improved function over tendon transfer alone. [1] (10.1186/s13018-014-0067-6)
  • [L4] Even for large gaps, within 8 months, an attempt at nerve reconstruction before proceeding to tendon transfers appears to be indicated. [2] (10.1016/j.jhsa.2007.10.004)
  • [Case_report] The technique is mainly indicated in high peripheral nerve injury or secondary cases when recovery of the intrinsic muscle of the hand is not expected after end-to-end repair or graft. [3] (10.1016/j.jhsa.2009.10.033)
  • [L5] They foresee an increased need for studies addressing combined nerve and tendon transfer reconstructions alongside patient-perceived outcome investigations. [4] (10.1177/1753193419827814)
  • [L3] More participants with a longer follow-up are needed to fully demonstrate the superiority of combined nerve and tendon procedures. [6] (10.1177/17531934251381202)
  • [L4] The presence of fractures is associated with a higher incidence of nerve and tendon injuries, and involvement of these structures is linked to an increased risk of long-term disability. [7] (10.1177/15589447221092111)
  • [L4] Overall, we observed better outcomes in those who underwent nerve transfer versus tendon transfer procedures. [8] (10.1016/j.jhsa.2019.12.009)
  • [L2] Evidence for good nerve recovery or improved function following nerve repair is poor, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels. [9] (10.1177/1753193419846761)
  • [L4] On pooled analysis, tendon transfers had higher rates of superior clinical outcomes as compared with nerve transfers and nerve grafts. [10] (10.1177/15589447221150516)
  • [L4] Delay in repair of less than 6 months, defect length of less than 5 cm, or grafting with three or more donor nerve cables achieved better recovery. [11] (10.1177/17531934221147651)
  • [L4] The tendon transfer offers an important alternative—possibly the procedure of choice—to microsurgical nerve reconstruction, particularly when early professional and social reintegration is important. [12] (10.1016/j.jhsa.2008.11.012)
  • [L4] Accordingly, the tendon transfer offers an important alternative – possibly the procedure of choice – to microsurgical nerve reconstruction, particularly when early professional and social reintegration is important. [13] (10.1016/s0363-5023(09)60108-8)
  • [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. [14] (10.1177/1558944719878835)
  • [L4] End-to-end repair of fascicular groups provides better results than repair using nerve grafts. [15] (10.1016/j.jhsa.2014.01.026)
  • [L4] Nerve transfers have become a first line reconstructive technique in the restoration of function, with fundamental principles such as donor site location, strength, safety, and efficacy introduced by Oberlin et al remaining integral to contemporary nerve surgery. [16] (10.1016/j.jhsa.2025.01.013)
  • [L4] Selection of the donor nerve must be carefully weighed against other treatment alternatives, considering the risk of donor nerve impairment and the potential narrowing of future reconstructive options. [17] (10.1016/j.jhsa.2006.12.012)
  • [Case_report] This case contributes further to our understanding of the clinical presentation of hand function following high median nerve transection. [18] (10.1186/s12891-025-08469-3)
  • [L3] Patients who present early and can tolerate longer time to functional recovery would be optimal candidates for nerve transfers. [19] (10.1177/1558944720988126)
  • [L5] Tendon lengthening and transfer are indicated for neuromuscular disorders, nerve injuries, and congenital or traumatic lesions. [20] (10.1016/j.otsr.2014.07.033)
  • [L5] The painful neuroma is a debilitating sequela of nerve injury with poorly understood pathophysiology involving fascicular escape and scarring; treatment must be tailored to the individual patient as there are a number of approaches available. [21] (10.1016/j.jhsa.2009.12.019)
  • [L4] Surgical reconstruction of degenerate abductor tendons should be considered in the presence of an MRI confirmed separation where clinical findings are consistent with the known tendon disruption. [22] (10.1016/j.arth.2019.11.012)
  • [L5] Primary tendon repair is permissible only when strict criteria are met, including early presentation, minimal contamination, and favorable wound conditions; otherwise, secondary repair via tendon graft is recommended. [23] (10.2106/00004623-195941040-00001)
  • [L5] [24] (10.1177/1753193419864838)
  • [L5] [25] (10.1016/j.jhsa.2010.02.025)
  • [L4] [26] (10.1177/1753193410387333)
  • [L4] This study confirms that collagen conduits reliably provide a repair that restores nerve function for nerve gaps measuring less than 2 cm. [27] (10.1016/j.jhsa.2011.06.009)
  • [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. [28] (10.1177/1753193421996987)
  • [L4] The TWZL technique offers an alternative treatment option for patients with tendon deficiency and nerve injuries, avoiding donor site morbidity associated with autograft harvest. [29] (10.1016/j.jhsa.2022.12.016)
  • [L4] Finger forces are more hampered while gripping objects with smaller circumferences than large ones. [32] (10.1177/17531934211061220)
  • [L3] Patients with an injury pattern that may lead to nerve injury warrant prompt referral to an upper extremity specialist in an effort to optimize outcomes. [35] (10.1177/1558944719866865)
  • [L5] [36] (10.5435/jaaos-d-17-00325)
  • [L4] Flexor tendon injuries in children are rare, and both subjective and objective outcomes are generally good. [39] (10.1016/j.jhsa.2007.08.006)
  • [L1] [40] (10.1177/1753193414553162)
  • [L3] [41] (10.1177/17531934221074514)
  • [L5] Extensor tendon injuries are common and early recognition and treatment are key to the management of such injuries. [43] (10.1016/j.hcl.2014.12.006)
  • [L4] Owing to the good functional outcome in the majority of cases, the use of collagen tubes is useful to span digital nerve defects up to 2.6 cm. [48] (10.1016/j.jhsa.2012.10.017)
  • [L4] Routing of the EPL tendon through the first dorsal compartment allows reproduction of the action of thumb extension and abduction and restores thumb clearance from the palm. [50] (10.1016/j.jhsa.2015.01.018)
  • [L5] At the time of repair, decellularized flexor tendon-bone grafts can exceed the strength and excursion needed for hand therapy immediately after reconstruction. [51] (10.1016/j.jhsa.2013.08.092)
  • [L3] Those subjects demonstrate a significant decrease in maximum velocity in slow fist tasks, highlighting the need for comprehensive assessment to ascertain the full extent of functional limitations that can occur in the setting of hand pathology. [53] (10.1177/1558944717729218)
  • [L5] The intrinsic hand muscles have MEPs at consistent distances from bony landmarks both dorsally and volarly. [54] (10.1016/j.jhsa.2020.04.019)
  • [L5] We were unable to find significant differences in the motion range of the thumb after these rerouting techniques or sites of insertion. [56] (10.1177/1753193419857067)
  • [L5] Hand surgery and hand therapy practice interventions, including use of RMF orthoses for management of non-surgical and surgical EM injuries may benefit from an in-depth look at the EM zone III and IV anatomy and biomechanics. [57] (10.1016/j.jht.2023.01.002)
  • [L5] Although both ST and SA constructs recapitulate native joint stiffness, repair with ST demonstrated the greatest biomechanical strength in stiffness and load-to-failure. [58] (10.1016/j.jhsa.2021.09.028)
  • [L5] Sensation is the most important factor in thumb or fingertip repair, constituting 40% of the goal, while length and appearance account for 50%. [59] (10.1177/17531934211051303)
  • [L5] The findings from our study clarify hand surface landmarks in localizing the thumb A1 pulley and digital neurovascular structures. [60] (10.1016/j.jhsa.2013.02.028)
  • [L4] The pulley system of the thumb is composed of 4 components, as opposed to the traditional view of only 3. [62] (10.1016/j.jhsa.2012.08.005)
  • [L5] A rehabilitative protocol that is individualized to fit each patient's tendon pathology and surgery is essential. [64] (10.1016/j.jhsa.2015.04.043)
  • [L4] Our findings suggest the benefit of early rehabilitation after hand tendon repair. [65] (10.1016/j.jht.2014.09.005)
  • [L4] The final combination of repair and early active mobilization for primary repair of FPL tendons compares favourably with previous methods of treatment. [66] (10.1054/jhsb.1999.0230)
  • [L4] [67] (10.1016/j.jhsa.2020.09.023)
  • [L4] The authors propose an additional category (Type 3) to the Türker classification system to encompass rare findings of two radial-sided accessory extensor tendons in the same individual, which were not previously represented in existing classifications. [69] (10.1016/j.jhsg.2023.10.005)
  • [L4] [70] (10.1177/1753193417691390)
  • [L4] MRI provides important preoperative information for surgical decision-making and planning in patients who present late with closed flexor tendon injuries of the hand. [75] (10.1054/jhsb.1999.0306)
  • [L4] Surgical treatment consisting of flexor tendon sheath release is effective in restoring motion with minimal risks of recurrence and neurovascular complication, although the optimal age for surgical treatment is unclear. [76] (10.1016/j.jhsa.2008.04.017)
  • [Paper] [78] (10.1016/j.eats.2019.11.022)
  • [L5] [80] (10.1177/175899839900400102)
  • [L3] [81] (10.1016/j.jhsa.2014.06.140)
  • [L4] [82] (10.1177/1753193414553753)
  • [L5] Pharmacological intervention as an adjunctive therapy to surgical peripheral nerve repair may prove to be not only beneficial but also necessary for satisfactory long-term functional recovery. [83] (10.1016/j.jhsa.2018.01.023)
  • [L4] With modern anesthesia techniques, tendon lacerations in a healthy neonate can be managed in a timely and safe manner. [84] (10.1016/j.jhsa.2010.09.015)
  • [L5] In the absence of a space-occupying lesion, a trial of nonoperative management is advisable, but exploration of the nerve is recommended if there is no sign of muscle recovery after 6 weeks of observation or if there is progressive weakness. [85] (10.1016/j.jhsa.2017.07.026)
  • [L3] The study notes that while non-randomised, the technique appears better without an increased rate of rupture but with a shorter rehabilitation period. [87] (10.1177/1753193408091570)
  • [L5] Wrapping the nerve with fibrin sealant before division and immediate fixation resulted in less protrusion of the nerve end. [88] (10.1054/jhsb.1999.0250)
  • [L5] This work may inform future improvements in surgical techniques for tendon-to-bone fixation. [89] (10.1016/j.jisako.2023.03.418)
  • [L5] The use of type I collagen conduit is a reliable alternative to nerve grafting for gaps up to 10 mm in length. [90] (10.1016/j.jhsa.2007.07.015)
  • [L4] The management of a late tendon rupture in childhood is difficult due to the need for immobilization in young patients. [91] (10.1177/1753193413507521)
  • [L4] Therefore, while neurolysis of the superficial radial nerve offers the opportunity for pain relief, it does not reliably produce success. [92] (10.1177/1753193407087892)
  • [L4] The surgical technique used in this case resulted in pain-free outcomes, improved range of motion, and functional recovery comparable to the available literature. [93] (10.1016/j.jhsg.2023.03.015)
  • [L4] Ultrasonographic assessment may serve as a valuable complementary tool for objectively evaluating nerve recovery. [94] (10.1177/17531934231174603)
  • [L4] This technique restores good function in most patients with zone 1 and 2 flexor tendon injuries, in which primary tendon repair has not been performed or was unsuccessful, and where pulley reconstruction is not required. [95] (10.1177/1753193417737920)
  • [L4] We present a previously unreported site of flexor tendon entrapment as well as the novel use of CT 3D volume rendering to diagnose the entrapment. [96] (10.1177/15589447231185857)
  • [L4] MRI demonstrated complete regeneration of subchondral bone and cartilage in all patients with significant improvement in functional scores. [97] (10.1155/2017/6525373)
  • [L4] Although diagnosing the cause of UCL locking may be complicated by the lack of evidence in imaging studies, open surgical treatment has traditionally been the most often used with a high success rate. [98] (10.1016/j.jhsg.2022.08.003)
  • [L3] The closer look at our data showed miscellaneous and often even unclear reasons for these tendon ruptures, making the definition of one major cause, such as two-strand repairs, impossible. [99] (10.1177/17531934231184737)
  • [L5] PEG fusion techniques may drastically improve the long-term recovery of more proximal nerve injuries where poor outcomes are more common. [100] (10.1016/j.jhsa.2015.06.060)
  • [Letter] The authors state that surgery should not be taken lightly, but major complications such as nerve injury or deep infection are uncommon, while most adverse outcomes are short-term pain, stiffness, and swelling. [101] (10.1016/j.jhsa.2012.08.038)
  • [L4] Surgical exploration confirms the diagnosis and allows for excision of the damaged segment to return normal movement without compromising strength. [102] (10.1177/1558944716681950)
  • [L3] Tendon transfers are indicated in longstanding, irreparable, isolated radial nerve lesions. [103] (10.1016/j.jhsa.2007.10.015)
  • [L4] Muscle-in-vein conduits can be considered for primary and secondary reconstruction of digital nerves. [104] (10.1016/j.jhsa.2022.02.002)
  • [L4] Furthermore, adequate sensory recovery without any nerve repair had occurred by the 2-year follow-up. [105] (10.1016/j.jhsa.2013.08.110)
  • [L4] The authors believe the procedure has broad clinical utility for augmenting partial recovery and preserving motor end plates in second- and third-degree axonotmetic nerve injuries. [106] (10.1016/j.jhsa.2012.07.022)
  • [L5] When tension-free end-to-end nerve repair is unachievable, several options are available, including nerve autograft, nerve allograft, and various autologous or synthetic nerve conduits, with surgeons using all of these options with moderate to good recovery of 2-point discrimination. [107] (10.1016/j.jhsa.2014.09.022)
  • [L4] Patients with sharp major nerve injuries required grafting more frequently after several days from injury, whereas primary repair of common and proper digital nerves could be achieved up to two weeks or greater after injury. [108] (10.1016/j.jhsa.2023.11.006)
  • [L3] Although rare, unrecovered nerve injury adversely affects outcome. [111] (10.1302/0301-620x.103b7.bjj-2020-2246.r1)
  • [L4] All patients achieved an excellent or good outcome with no ruptures or infections. [112] (10.1177/1753193410365631)
  • [L3] Outcomes from processed nerve allografts are comparable to nerve autograft and exceed those for nerve conduit in historical controls. [113] (10.1016/j.jhsa.2014.06.044)
  • [L3] Follow-up time and age significantly influence the outcome following nerve repair, with significant improvements in the total score seen throughout the follow-up period. [114] (10.1054/jhsb.2001.0567)
  • [L5] Primary suture of tendons at the wrist yields nearly normal restoration, whereas delayed repair often requires grafts with far from perfect results. [115] (10.2106/00004623-196547010-00007)
  • [L3] Although complications were more frequent following arthrodesis, most did not affect the overall outcome. [116] (10.2106/00004623-200110000-00002)
  • [L5] Secondary reconstruction remains an important and useful technique for complicated flexor tendon injuries or those that have failed primary repair. [118] (10.1016/j.jhsa.2007.08.018)
  • [L5] A carefully executed and monitored primary repair in a sharp wound reduces the time to maximum recovery and usually results in better function than the previously recommended secondary grafting. [119] (10.2106/00004623-198567050-00024)

See Also

References

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[5] Chapter 29 Tendon Transfers for Peripheral Nerve Injuries in the Upper Extremity. 2019.

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[7] Outcomes in Ballistic Injuries to the Hand: Fractures and Nerve/Tendon Damage as Predictors of Poor Outcomes. HAND. 2022. DOI: 10.1177/15589447221092111

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[24] Tendon transfers after peripheral nerve injuries: my preferred techniques. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419864838

[25] Technical Use of Synthetic Conduits for Nerve Repair. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.02.025

[26] Zone 2 lacerations of both flexor tendons of all fingers in the same patient. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193410387333

[27] Reconstruction of Digital Nerves With Collagen Conduits. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.06.009

[28] Transfer of the supinator nerve to the posterior interosseous nerve for hand opening in tetraplegia through an anterior approach. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/1753193421996987

[29] Application of Tendon With Z-Lengthening Technique. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.12.016

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[32] Influence of the flexor digitorum superficialis tendon transfer on grip strength. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211061220

[35] Risk Factors for a False-Negative Examination in Complete Upper Extremity Nerve Lacerations. HAND. 2019. DOI: 10.1177/1558944719866865

[36] Updates on and Controversies Related to Management of Radial Nerve Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00325

[37] Chapter 28 Nerve Injuries and Nerve Transfers. 2019.

[39] Flexor Tendon Injuries in Pediatric Patients. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.08.006

[40] A multicentre, randomized, double-blind trial of the safety and efficacy of mannose-6-phosphate in patients having Zone II flexor tendon repairs. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414553162

[41] Repair of flexor digitorum profundus avulsions including the palmar plate: a retrospective comparative study of 56 cases. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221074514

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[45] Chapter 29 Hand/Carpal Fractures and Dislocations. 2021.

[46] Chapter 32 Tendon Injuries and Tendinopathies of the Hand and Wrist. 2020.

[48] Sensory Recovery 1 Year After Bridging Digital Nerve Defects With Collagen Tubes. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.10.017

[50] Rerouting Extensor Pollicis Longus Tendon Transfer. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.01.018

[51] Decellularized Human Tendon–Bone Grafts for Composite Flexor Tendon Reconstruction: A Cadaveric Model of Initial Mechanical Properties. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.08.092

[53] Dynamic Functional Assessment of Hand Motion Using an Animation Glove: The Effect of Stenosing Tenosynovitis. HAND. 2017. DOI: 10.1177/1558944717729218

[54] Targeted Muscle Reinnervation in the Hand: An Anatomical Feasibility Study for Neuroma Treatment and Prevention. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.04.019

[56] Extensor pollicis longus rerouting for thumb-in-palm deformity in cerebral palsy: a biomechanical analysis. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419857067

[57] An in-depth look at zone III and IV anatomy of the finger extensor mechanism and some clinical implications for use of the relative motion flexion orthosis. Journal of Hand Therapy. 2023. DOI: 10.1016/j.jht.2023.01.002

[58] Biomechanical Comparison of 3 Thumb Ulnar Collateral Ligament Repair Methods. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2021.09.028

[59] Soft and tissue repair of the hand and digital reconstruction. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211051303

[60] Hand Surface Landmarks and Measurements in the Treatment of Trigger Thumb. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.02.028

[62] Varied Anatomy of the Thumb Pulley System: Implications for Successful Trigger Thumb Release. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.08.005

[64] Hand Therapy Modalities Following Extensor Mechanism Surgery. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.04.043

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[83] Emerging Strategies on Adjuvant Therapies for Nerve Recovery. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.01.023

[84] Extensor Tendon Injury During Cesarean Delivery. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.09.015

[85] Management of Atraumatic Posterior Interosseous Nerve Palsy. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.07.026

[87] Clinical Results of Flexor Tendon Repair in Zone II Using a Six-Strand Double-Loop Technique Compared with a Two-Strand Technique. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408091570

[88] The Influence of Delay and the Effect of Fibrin Sealant on the Cut Surface of the Peripheral Nerve. Journal of Hand Surgery. 1999. DOI: 10.1054/jhsb.1999.0250

[89] Improving Tendon-To-Bone Healing by Tendon Inversion: Investigation Using a Rat Biceps Tenodesis Model. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2023.03.418

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[91] Salvage of a recurrent phalangeal non-union with bone defect using autologous platelet glue and corticocancellous bone graft. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413507521

[92] Neurolysis of the Distal Superficial Radial Nerve for Dysaesthesia Due to Nerve Tethering. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193407087892

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[99] Outcomes of 218 primary single-finger flexor tendon repairs up to 1 year after surgery: a multicentre cohort study. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231184737

[100] Hydrophilic Polymers Immediately Restore Axonal Continuity as Assessed by Retrograde Tracer. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.06.060

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[104] Outcome After Reconstruction of 43 Digital Nerve Defects With Muscle-in-Vein Conduits. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.02.002

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[106] Supercharged End-to-Side Anterior Interosseous to Ulnar Motor Nerve Transfer for Intrinsic Musculature Reinnervation. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.07.022

[107] Options for Digital Nerve Gap. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.09.022

[108] At What Time Interval After a Sharp Nerve Laceration Is Primary Nerve Repair No Longer Possible?. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2023.11.006

[111] Acute distal biceps tendon repair using cortical button fixation results in excellent short- and long-term outcomes. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b7.bjj-2020-2246.r1

[112] A new technique of flexor profundus repair in the distal part of zone I: inclusion of the palmar plate. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193410365631

[113] Targeting the Wnt/ß-Catenin Signaling Pathway After Traumatic Nerve Injury to Improve Functional Recovery. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.06.044

[114] The Long Term Recovery Curve in Adults after Median or Ulnar Nerve Repair: A Reference Interval. Journal of Hand Surgery. 2001. DOI: 10.1054/jhsb.2001.0567

[115] Problems of Flexor-Tendon Surgery of the Hand. The Journal of Bone & Joint Surgery. 1965. DOI: 10.2106/00004623-196547010-00007

[116] Thumb Carpometacarpal Osteoarthritis: Arthrodesis Compared with Ligament Reconstruction and Tendon Interposition. The Journal of Bone and Joint Surgery-American Volume. 2001. DOI: 10.2106/00004623-200110000-00002

[118] Secondary Flexor Tendon Reconstruction, A Review. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.08.018

[119] Flexor tendon injuries.. The Journal of Bone & Joint Surgery. 1985. DOI: 10.2106/00004623-198567050-00024

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Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

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.