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Tendon Transfers in the Upper Limb

76 citationsUpdated Oct 2026
Illustration: hand

Overview

Tendon transfers serve as a primary reconstructive intervention for the upper limb and hand, particularly in patients with tetraplegia [2]. Despite their utility, these procedures remain an underused resource for this population [37], with the potential benefits not yet fully realized by many hand surgeons [2, 11]. Epidemiological data indicate that approximately 65% to 75% of individuals with tetraplegia would benefit from upper extremity surgery, yet only 14% of surgical candidates undergo tendon transfer procedures [52]. The field is expanding through the integration of nerve transfer surgery, which adds new motor donors to the pool available through traditional tendon transfers [19]. While nerve transfers can effectively reanimate muscles in selected cases, they offer comparable strength to tendon transfers for elbow extension but inferior strength for finger and thumb flexion [10]. Consequently, the choice between nerve transfer and tendon transfer requires balancing individual patient factors, early functional recovery, and long-term outcomes [27]. 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 [23].

The biomechanical principles, indications, and limitations of tendon transfers, nerve transfers, and combined approaches are compared with particular attention to timing, patient selection, and functional goals [39]. Nerve transfer for cervical spinal cord injury is an emerging area of upper limb surgery that demonstrates very significant promise [29]. Specific combinations, such as a supinator nerve to posterior interosseous nerve transfer, can be performed alongside other tendon or nerve transfers to maximize functional reconstruction in tetraplegia [30]. Biomechanical considerations are critical; for instance, the absence of triceps function significantly decreases the effectiveness of the brachioradialis when used to motor a tendon transfer [14]. In C6-spared quadriplegics, transfer for active elbow extension does not necessarily need to be performed before distal transfers [36]. Good results in brachioradialis transfer for digital palsy require careful patient selection and strict attention to established principles of tendon transfer [5].

Tendon transfers are indicated across a spectrum of pathologies, including congenital radial dysplasia, traumatic brachial plexus palsy, radial nerve injury, obstetric brachial plexus palsy, and spastic hemiplegia. Abductor digiti minimi opponensplasty in congenital radial dysplasia improved both function and appearance of the hand [1]. Following transfer of the recovered biceps to the long flexors of the digits after complete traumatic brachial plexus palsy, total active movement of the digits averaged 55 (range 30–90)° and the strongest measurable grip strength was 6 kg [3]. In cases of unexpected late spontaneous recovery from radial nerve injury, a tendon transfer procedure performed to restore finger extension did not inhibit full recovery of thumb or finger motion [4]. Brachialis transfer to the forearm muscles in obstetric brachial plexus palsy resulted in restoration of some degree of active wrist extension and pronation [20]. A review of upper limb tendon transfers in spastic hemiplegia has indicated positive outcomes [13]. The surgeon must know the indications and contraindications of functional surgery, which includes procedures on the elbow, wrist, fingers, and thumb such as release or lengthening of spastic muscles, tendon transfers, and joint stabilizations [33]. Late treatment options for managing the failed primary reconstruction of the traumatic adult brachial plexus include tendon transfers, joint fusions, free functioning muscle transfers, and prosthetics [12]. Indications and advantages of toe-to-finger free flexor tendon transfer for digital flexion reconstruction are discussed [7]. The lateral upper arm flap is preferred for its safety, acceptable donor site morbidity, and suitability for extensor tendon reconstruction [38].

Anatomy & Pathophysiology

Skeletal Architecture and Kinematics

The hand and wrist skeleton comprises 27 bones, 19 of which are long bones, organized into five rays forming polyarticulated chains of metacarpals and phalanges [45]. The radioulnocarpal articulation possesses two axes of movement, supplemented by a third axis of pronation and supination from the forearm, granting the wrist three total axes that permit spatial positioning for grasping [45]. The radial ray is the shortest, consisting of a metacarpal and two phalanges, with the trapezium angled anteriorly so the first metacarpal forms a 45-degree angle with the second metacarpal in the sagittal plane [45]. The thumb metacarpal is the shortest, while the index metacarpal is the longest; conversely, the proximal and middle phalanges of the long and ring fingers are longer than those of the index finger [45]. The transverse palmar axis is oblique, positioned more distally at the index metacarpophalangeal joint and more proximally at the fifth metacarpophalangeal joint, forming an acute angle of approximately 75 degrees with the longitudinal axis [45]. Epiphyseal plates are located at the proximal ends of the phalanges and first metacarpal, and at the distal ends of the other metacarpals [45].

Metacarpal mobility varies significantly: the index metacarpal is the most firmly fixed, while the fifth metacarpal is semi-independent with approximately 20 degrees of flexion–extension range, and the ring metacarpal exhibits about 10 degrees of mobility in flexion and extension [69]. The metacarpophalangeal joints serve as the keystones of the hand’s longitudinal arches, with volar plates preventing hyperextension [69]. Stability at these joints is essential for supporting both longitudinal and transverse metacarpal arches [69]. The axes of flexion are arranged such that flexion of all metacarpophalangeal and proximal interphalangeal joints causes the fingers to converge toward the scaphoid [77].

Extrinsic Musculature and Extensor Mechanism

Digital posture control requires a complex balance of extrinsic and intrinsic muscle forces, with extrinsic muscles originating outside the hand and inserting on the hand or carpus, while intrinsic muscles have both origin and insertion within the hand [44]. The extrinsic extensors traverse six fibroosseous retinacular compartments at the wrist [44]. The first compartment contains the abductor pollicis longus, which inserts at the base of the thumb metacarpal to radially abduct the thumb, and the extensor pollicis brevis, which inserts on the dorsum of the proximal phalanx to actively extend the metacarpophalangeal joint [44]. The second compartment houses the extensor carpi radialis longus, inserting on the index metacarpal to dorsiflex and radially deviate the wrist, and the extensor carpi radialis brevis, inserting into the base of the middle metacarpal to provide balanced wrist dorsiflexion [44].

The third compartment contains the extensor pollicis longus, which turns abruptly radialward about Lister tubercle to provide forceful extension of the thumb interphalangeal joint, with its oblique course providing a substantial adduction component [44]. The fourth compartment contains the extensor indicis proprius, lying deep to the four tendons of the extensor digitorum communis, while the fifth compartment contains the extensor digiti quinti [44]. The principal bony insertion of 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, while distal interphalangeal joint extension is achieved through conjoined lateral bands composed of tendinous slips from extrinsic and intrinsic tendons [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 carpi ulnaris runs through the sixth compartment, inserting at the base of the little finger metacarpal to provide wrist extension and ulnar deviation [44].

The sagittal band fibers insert onto the volar proximal phalanx and the lateral borders of the volar plate, forming a sling that transmits proximal extrinsic extensor tension to the proximal phalanx, permitting metacarpophalangeal joint extension without a direct tendinous insertion [44]. These bands keep the extrinsic extensor tendon balanced over the metacarpal head prominence to maximize mechanical efficiency [44]. Rupture or attenuation of sagittal band fibers allows the extrinsic extensor tendon to sublux to the ulnar side of the metacarpal head, causing ulnar deviation of the finger [44].

Extrinsic Flexor Musculature and Sheaths

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 flexor digitorum profundus originates from the proximal ulna and interosseous membrane, dividing in the forearm into a radial component supplying the index finger and an ulnar component supplying the middle, ring, and little fingers [73]. It forms the deep compartment of the volar forearm along with the flexor pollicis longus [73]. The tenosynovial sheath of the flexor pollicis longus is continuous with the radial bursa, while the sheath to the little finger is continuous with the ulnar digital bursa; in some patients, these bursae communicate, allowing a horseshoe abscess to spread between the thumb and little finger [73].

Innervation of the flexor digitorum profundus for the index and middle fingers is via the anterior interosseous branch of the median nerve, while the profundus of the ring and little fingers is innervated by the ulnar nerve [73]. The flexor digitorum superficialis has a radial head originating from the proximal radius shaft and a humeral ulnar head from the medial humeral epicondyle and coronoid process of the ulna [73]. Its tendon bifurcates around the flexor digitorum profundus at the beginning of the A2 pulley, with slips reuniting distally at the Camper chiasm, where approximately half of the fibers stay ipsilateral and half cross to the contralateral side [73]. The flexor digitorum superficialis inserts via radial and ulnar slips into the proximal metaphysis of the middle phalanx and receives entire innervation from the median nerve, with its primary function being digital flexion at the proximal interphalangeal joint [73].

The flexor pollicis longus originates from a radial head on the proximal radius and interosseous membrane, and an accessory head on the coronoid process of the ulna and medial epicondyle of the humerus, inserting into the proximal base of the thumb distal phalanx [73]. Innervated by the anterior interosseous branch of the median nerve, it flexes both the interphalangeal and metacarpophalangeal joints of the thumb [73]. The fibroosseous tunnel, or digital flexor sheath, extends distally to the proximal aspect of the distal phalanx and consists of annular pulleys providing mechanical stability and cruciate pulleys providing flexibility [73]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [73]. The tenosynovium lining this tunnel supplies nutrition and lubrication to the poorly vascularized flexor tendons, with vascularity within the sheath supplied via the vincula system, specifically the vinculum longus and brevis [73].

Intrinsic Musculature

There are seven interosseous muscles, comprising four dorsal and three volar muscles [66]. The anatomic axis of the hand coincides with the axis of the third metacarpal [66]. The dorsal interossei are abductors, lying to the radial side of the index and middle fingers and the ulnar side of the middle and ring fingers, while the little finger is abducted by the abductor digiti quinti [66]. The volar interossei are adductors, lying to the ulnar side of the index finger and the radial side of the ring and little fingers [66]. The middle finger possesses two dorsal interossei (abductors) and no volar interossei (adductors) because the central axis of the hand lies within it [66]. Each dorsal interosseous muscle, with the exception of the third, has two muscle heads [66].

The superficial head of the dorsal interosseous muscles abducts and weakly flexes the proximal phalanx [66]. The deep head forms a lateral tendon, or lateral band, at the level of the metacarpophalangeal joint, flexing and weakly abducting the proximal phalanx while extending the middle and distal phalanges [66]. Transverse fibers arch dorsally from each lateral band to join over the dorsum of the finger, flexing the proximal phalanx [66]. Oblique fibers, or spiral fibers, from the lateral bands sweep over the distal third of the proximal phalanx to insert onto the lateral tubercles at the base of the middle phalanx, extending the middle phalanx at the proximal interphalangeal joint [66]. The lateral bands are joined by the lateral slips of the extensor tendon to form the conjoined lateral band, which unites at the distal third of the middle phalanx to form the terminal tendon inserting at the base of the distal phalanx to extend it [66]. The flexor digiti quinti brevis is structurally and functionally similar to the deep head of the dorsal interossei, forming the ulnar lateral band of the little finger [66].

The three volar interossei arise from adjacent surfaces of contiguous metacarpal shafts, each having only one muscle head and none inserting onto the proximal phalanx [66]. They form the ulnar lateral band of the index finger and the radial lateral band of the ring and little fingers [66]. The abductor digiti quinti and flexor digiti quinti brevis are similar in structure and function to the superficial and deep heads of the dorsal interossei, respectively [66]. The opponens digiti quinti arises from the pisohamate ligament and the hook of the hamate, inserting onto the ulnar side of the diaphysis of the fifth metacarpal, which it flexes and supinates [66].

Gliding Mechanisms and Soft Tissue Dynamics

The gliding mechanism of tendons depends on the nature of the anatomic area and the direction and amplitude of tendon movement [74]. In unrestricted areas with a straight trajectory, tendons are surrounded by paratenon and areolar connective tissue, whereas in narrow crowded areas, the gliding mechanism is assured by the synovial sheath [74]. Synovial sheaths at specific sites are surrounded by fibrous sheaths that keep the tendon close to the skeleton, assuming the role of a pulley when the tendon changes direction [74]. The gliding mechanism represented by synovial sheaths is much more developed on the palmar aspect, with three digitopalmar synovial sheaths for the flexor tendons of the index, long, and ring fingers [74]. On the dorsal aspect, extensor synovial tendon sheaths are present only at the level of the wrist, which is the only joint in the hand capable of active dorsal flexion [74]. Each synovial sheath has a visceral and parietal component separated by a potential synovial cavity containing a very thin layer of synovial fluid [74].

Dorsal skin slides distally to allow metacarpophalangeal joint flexion, while interphalangeal flexion is accomplished by a special arrangement of skin folds on the dorsum of each articulation [74]. The position of each articulation depends on the equilibrium of forces acting at that level, which is subject to the position of the immediately proximal articulation [74]. The wrist influences the position of the metacarpophalangeal joint, which affects the proximal interphalangeal joint, which in turn affects the distal interphalangeal joint [74]. The active factor in articular equilibrium is the dynamic balance between antagonist muscles, while passive factors include the restraining action of ligaments and muscular viscoelasticity [74]. Single articular movements around a fixed perpendicular axis do not exist in the hand; almost all movements are around oblique and variable axes, resulting in combined movements permitting optimal orientation of the phalanges at the time of prehension [74].

Cutaneous Anatomy and Vascularization

The dorsal skin is thin, lined by a horny layer only 0.02 mm thick, and possesses a normal pilosebaceous system [75]. The dermis of the dorsal skin is thinner and less resistant than the palmar dermis, with loose connections to deeper planes [75]. Flexion of the fingers produces significant lengthening of the dorsal skin; in the middle finger, the distance between the wrist and the ungual fold shows an average increase of 3 cm as the finger goes from extension to full flexion [75]. Flexion at the metacarpophalangeal joint alone requires an average skin lengthening of 1.25 cm [75]. The dorsal and palmar areas of skin are independent because of a system of adhesions that anchors their common boundary to the underlying plane [75].

The superficial palmar fascia lies in a coronal plane beneath the palmar subcutaneous tissue [76]. The palmaris longus tendon, when present, terminates in continuity with the fibers of the proximal corner of the superficial palmar fascia [76]. Four central bands of fascia extend distally from the proximal corner toward each of the fingers, with no central band for the thumb [76]. The digital neurovascular structures are surrounded by a diffuse network of thin transverse oblique fibers [76]. Fibers dorsal to the neurovascular bundle are collectively called Cleland ligament, while fibers palmar to the neurovascular bundle are called Grayson ligament [76]. The "princeps pollicis" artery is the terminal branch of the radial artery that

Classification

International Classification of Surgery in the Hand in Tetraplegia (ICSHT): This system outlines reconstructive options based on the number of innervated muscles available below the elbow [32]. ICSHT groups 0–3 correspond to mid-to-high-level injuries where evidence supporting the clinical utility of upper limb reconstructive surgery remains limited [32]. Conversely, ICSHT groups >3 correspond to mid-to-low-level injuries where reconstructive options increase due to more innervated muscles available below the elbow [32].

The classification defines specific expendable muscles for transfer at each level: * Group 0: No muscles below the elbow are available for transfer [56]. * Group 1: The brachioradialis (BR) is the expendable elbow flexor available for transfer [56]. * Group 2: The extensor carpi radialis longus (ECRL) provides extension of the wrist and is available for transfer [56]. * Group 3: The extensor carpi radialis brevis (ECRB) provides expendable wrist extension and is available for transfer [56]. * Group 4: The pronator teres (PT) provides pronation of the forearm and is available for transfer [56]. * Group 5: The flexor carpi radialis (FCR) provides flexion of the wrist and is available for transfer [56]. * Group 6: Finger extensors provide extrinsic finger extension, which can be partial, and are available for transfer [56]. * Group 7: The thumb extensor provides thumb extension at the interphalangeal joint (IPJ) and is available for transfer [56]. * Group 8: Digital flexors provide thumb and finger flexion, which is often partial, and are available for transfer [56]. * Group 9: The hand has full finger flexion but lacks intrinsic muscle function (intrinsic minus) [56]. * Group 10: There are exceptions to the standard classification [56].

Other Considerations: Tendon transfers for reconstruction of the upper limb in tetraplegia is an underused resource, and the potential for these procedures has not yet been fully realised by many hand surgeons [11, 37]. Clinical outcomes vary by group: patients in ICSHT Group III had either a good to fair automatic grasp or a poor or ineffective automatic grasp [48]. Patients in ICSHT Group IV had an ineffective voluntary grasp and all had flexor transfers to enhance grasp [48]. Patients in ICSHT Group V had an effective voluntary grasp and did not require a flexor tendon transfer [48].

Tendon transfer is necessary where flaccid paralysis has persisted for 18 months so that nerve repair cannot produce useful motor end plate reinnervation, where nerve repair has failed, or where the nerve is irreparable [8]. The results of successful nerve repair are far superior to musculo-tendinous transfer [8]. While generally superior to tendon or muscle transfer for shoulder or elbow paralysis, nerve transfer recovery is not always markedly speedier, with useful function typically recognized after 12 months [9]. In the context of the spastic upper extremity, surgical interventions aim to correct common deformities through single-event, multi-level surgery involving soft tissue lengthening, tendon transfer, and joint stabilization [22]. Tendon transfers are a late treatment option for managing the failed primary reconstruction of the traumatic adult brachial plexus [12].

Clinical Presentation

The clinical assessment of the upper limb for tendon transfer requires a precise understanding of neurological status and functional deficits. In tetraplegia, patients with active wrist extension may achieve a basic grip using the tenodesis effect of their paralysed finger flexor muscles [32]. However, most cervical cord injured patients have a loss at cervical mid-level (ICSHT groups 1–5) and will lack active finger and thumb extensors [32]. Traditional tendon transfers cannot reconstruct finger and thumb extensors in these patients, who generally rely on the tenodesis effect to release objects [32]. The surgeon must know the indications and contraindications of functional surgery for the spastic upper limb, which includes tendon transfers [33].

Pre-operative evaluation relies on specific diagnostic modalities and patient selection criteria. EMG provides meaningful guidance in selecting optimal forearm muscles for tendon transfers to hands in the setting of slowly progressive polyneuropathies [34]. Improvement in hand function is more likely after a transfer in a dominant hand than a non-dominant one [24]. Careful selection of patients for operation and strict attention to the established principles of tendon transfer are required for good results [5].

Specific anatomical and functional prerequisites dictate the viability of particular procedures. The ECRL transfer yields good results if the intrinsic muscles of the hand are functioning, the extensor compartment is uninjured, and the lower third of the forearm where the tendon junction is performed is relatively unscarred [28]. All prerequisites for tendon transfer must be satisfied, among them adequate skin cover, soft-tissue stability permitting tendon gliding, and a supple thumb CMC joint [85]. Any first web space adduction contracture should be dealt with prior to tendon transfer for thumb opposition [85].

Three concepts underpin the development of radial palsy tendon transfer: the preservation of wrist mobility, maintenance of one wrist flexor, and the independence of thumb action [8]. Ulnar deviation with some extension is necessary for optimum power grip [8]. The tendon transfer procedure performed for unexpected late spontaneous recovery from a radial nerve injury did not inhibit full recovery of thumb or finger motion [4]. Emergency tendon transfers can be used with good results, allowing treatment of lesions in one stage and avoiding a second surgical intervention [50].

Investigations

Other Considerations: A careful physical examination is essential to direct care and future testing if indicated [43]. The choice of the thumb to preserve must be based on a good clinical examination and radiographic analysis [139].

Treatment

Non-Operative

Preoperative management is critical for patients presenting with stiffness and contractures due to imbalanced forces and progressive tissue remodeling [101]. These preoperative visits offer a golden opportunity to improve mobility and reduce contractures before surgery, as even one stiff joint can compromise a tendon transfer by monopolizing the entire excursion of the tendon [101]. Mild contractures can sometimes be remediated by exercise alone, and if joint stiffness has occurred solely from disuse, joint movement and muscle strengthening may be sufficient to restore function [101]. While a supple hand may not require preoperative treatment per se, it can benefit from initial measurements and planning [101].

Operative

Indications: The selection between nerve and tendon transfer for a given function depends on the level of injury and the available donor muscles and nerves [115]. For higher-level injuries, nerve transfers may be the only option, whereas lower-level injuries allow for more distal donor nerves and double nerve transfers to grasp [115]. Tendon transfers are indicated when specific muscle groups are available for reconstruction, such as in tetraplegia where the conventional method for reconstructing hand function involves tendon transfers [32]. In severe forms with contractures, surgical treatments include selective neurotomy, muscle–tendon release, transfer or lengthening, and procedures on bone and joints [116].

Surgical Approach / Technique: The timing of nerve transfers is critical, with the best results achieved when surgery is performed early (6-9 months post SCI) [115]. While generally superior to tendon or muscle transfer for shoulder or elbow paralysis, recovery is not always markedly speedier, with useful function typically recognized after 12 months [9]. For brachial plexus palsy, transfer of the recovered biceps to the long flexors of the digits restores grip function [3]. In radial nerve palsy, a single flexor carpi ulnaris tendon transfer can restore finger and MCP joint extension similar to the normal hand, though wrist extension range may be reduced [18]. For posterior cord lesions, tendon transfers restore active wrist extension (40°), long finger extension, and thumb abduction and extension [25]. Specific techniques include the abductor digiti minimi transfer for opposition in children, which is safe if the origin is left attached [53], and the abductor pollicis longus transfer for thumb extension, which yields results comparable to or better than other transfers [63]. The by-pass extensor tendon transfer uses the extensor indicis muscle prolonged with a tendon graft attached to the middle phalanx, aiming to avoid adhesions and joint stiffness [112]. This technique allows immediate active mobilization of the PIP joint while the wrist is immobilized in extension [112]. Loosening of the extensor tendon by as little as 3 mm can cause a lag of 20° without hope of spontaneous restoration, a risk the by-pass technique aims to mitigate [112]. The FDS lasso tendon transfer is not recommended for thick-handed individuals requiring maximum power; a transfer procedure to add power is preferred [119]. In tetraplegia, an improved posterior deltoid to triceps transfer eliminates stretching by avoiding tendon grafts [145]. For Volkmann ischemic contracture, a 2-stage approach allows evaluation of injury and nerve/vascular repairs in the first stage, with free functioning muscle transfer performed only after goals are achieved [58]. Proper inset of the gracilis muscle must allow tension-free anastomoses while maintaining proper flexor tendon tension [58]. The latissimus dorsi myocutaneous island uses the central third of the muscle, with 2 cm of posterior lumbar fascia raised for length, and the proximal end attached to the medial epicondyle with the elbow in 30° of flexion [106].

Implant Selection: The extensor indicis proprius donor site is suggested as a second choice if the palmaris longus tendon is unavailable for grafting [146].

Other Considerations: Preoperative planning must account for two major patient groups: those with supple joints and those with stiffness and contractures [101]. The potential for hand improvement before surgery is often overlooked but should be considered because results from tendon transfers can be dramatically affected [101]. A few additional degrees of finger motion can make a significant difference in patient satisfaction and functional use [101]. Clinical outcomes vary; after biceps transfer for brachial plexus palsy, total active digit movement averaged 55 (range 30–90)° with a strongest measurable grip strength of 6 kg [3]. Tendon transfer for finger extension in late radial nerve recovery did not inhibit full recovery of thumb or finger motion [4]. Palmaris longus transfers for thenar augmentation in low median palsy re-established thumb elevation from the palmar surface [15]. Muscle transfer for an opposable small finger contracted well and improved functional capability [16]. Extensor indicis proprius opponensplasty can be performed simultaneously with other reconstructive procedures [17]. Published results for contralateral C7 transfer demonstrate significant improvements in upper limb function with mild and transient donor site morbidity [21]. Transfers in six patients were regarded as failures, associated with a poor tendon bed and noncompliant patients [57]. Immediate active mobilization of opposition tendon transfer may achieve similar outcomes in reduced time [61]. Nerve-crossing procedures using intercostal nerves are more likely to be successful when target muscle neuromotor units are in the upper arm [31]. In double free-muscle transfer for brachial plexus avulsion, the second transplant acts as a weak supplement rather than a strong elbow flexor, allowing independent finger flexion with the elbow in extension or flexion [31]. Arthrodesis of the first carpometacarpal joint is typically performed to create a robust key pinch in tetraplegia reconstruction [32]. Reconstructive options increase with more innervated muscles below the elbow, particularly in mid-to-low-level injuries (ICSHT groups >3), though evidence for mid-to-high-level injuries (ICSHT groups 0–3) remains limited [32]. Most cervical cord injured patients lack active finger and thumb extensors, relying on the tenodesis effect to release objects [32]. Transfer for active elbow extension does not necessarily need to be performed before distal transfers [36]. The procedure can be performed in combination with other tendon or nerve transfers to maximize functional reconstruction in tetraplegia [30]. The authors present surgical treatment for patients with grade III 'non-functional hands' according to Zancolli's classification [140]. The majority (90%) of participants reported that both nerve and tendon transfer surgeries were performed at their institutions [102]. Unless patients, caregivers, and nonsurgical providers have baseline knowledge of these transfers, they are unlikely to obtain de novo awareness of surgical options with self-initiated searches [142].

Complications

Functional Deficits: Initial treatment of wrist extension paralysis via wrist fusion or tenodesis of the extensor carpi radialis (ECR) to the radius results in the loss of the active tenodesis effect of wrist extension and the enhancement of power grip [8]. Similarly, a significant loss of power grip accompanied by extension deformity occurs when both wrist flexors, the flexor carpi ulnaris (FCU) and flexor carpi radialis (FCR), are transferred [8].

Other Considerations: When tendon transfer is performed for unexpected late spontaneous recovery from radial nerve injury, the procedure does not inhibit full recovery of thumb or finger motion [4]. Donor site morbidity associated with the contralateral C7 transfer is typically mild and transient [21].

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, and final functional outcomes.

Rehabilitation protocol: Immediate active mobilization of opposition tendon transfer achieves similar outcomes in reduced time [61].

Functional milestones: Following transfer of the recovered biceps to the long flexors of the digits, total active movement of the digits averaged 55 (range 30–90)° and the strongest measurable grip strength was 6 kg [3]. In comparison with the contralateral hand, wrist extension range was less, but extension of the fingers and MCP joints were similar to that of the normal hand following transfer of a single flexor carpi ulnaris tendon for radial nerve palsy [18]. All tendon transfers for brachial plexus posterior cord lesion were successful with recovery of active wrist extension (40°), long fingers extension and thumb abduction and extension (12.5 cm between the tips of index and thumb) [25]. Hand opening or passive finger extension was complete in 30-degree wrist flexion following extensor tenodesis for plexic hands with C7 to T1 or C8, T1 root avulsions [46]. 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 [60]. At last follow up, 7 of the 13 reviewed patients presented an excellent functional recovery, with complete resolution of pain and stability with attainment of ROM comparable to the contralateral finger following flexor digitorum superficialis tenodesis for finger PIP joint volar plate chronic avulsion [147].

Other Considerations: Tendon transfers in the upper limb and hand are a main indication in tetraplegia, with potential benefits not yet fully realised by many hand surgeons [2]. The biological response of transferred tendon units, the appropriateness of most commonly used tendon transfers, and the underlying controversies are consistently reinforced throughout the text of Clinical Mechanics of the Hand [6]. Tendon transfer is necessary where flaccid paralysis has persisted for 18 months so that nerve repair cannot produce useful motor end plate reinnervation, where nerve repair has failed, and where the nerve is irreparable [8]. While generally superior to tendon or muscle transfer for shoulder or elbow paralysis, recovery from distal nerve transfers is not always markedly speedier, with useful function typically recognized after 12 months [9]. Published clinical results for the contralateral C7 transfer have demonstrated significant improvements in upper limb function, confirming the procedure's safety and efficacy, with donor site morbidity that is typically mild and transient [21]. Functional reconstruction of the hand in high-level tetraplegia has two stages: restoration of wrist extension and construction of the pollici digital pinch [41]. The superficial radial nerve compression case illustrates the potential vulnerability of the radial and/or ulnar branches of the superficial radial nerve in opposition transfers [62]. Follow-up examination, at an average 5 years and 10 months after operation, showed that the results of ten of 11 transfers of extensor carpi radialis longus or brevis for opponensplasty were excellent and the other was good [137].

Key Evidence

  • [L4] The transfers improved both function and appearance of the hand. [1] (10.1016/s0363-5023(78)80006-9)
  • [L5] Tendon transfers in the upper limb and hand are a main indication in tetraplegia, with potential benefits not yet fully realised by many hand surgeons. [2] (10.1016/0266-7681_89_90114-9)
  • [L4] After transfer, the total active movement of the digits averaged 55 (range 30–90)° and the strongest measurable grip strength was 6 kg. [3] (10.1016/j.main.2010.03.010)
  • [L5] The tendon transfer procedure that we performed did not inhibit full recovery of thumb or finger motion. [4] (10.1016/j.hansur.2017.05.001)
  • [L4] Careful selection of patients for operation and strict attention to the established principles of tendon transfer are required for good results. [5] (10.1016/0266-7681(90)90010-2)
  • [Paper] [6] (10.1053/jhsu.2001.ajhsu25a0373)
  • [L4] Indications and advantages of this free tendon transfer are also discussed. [7] (10.1016/s0363-5023(03)80402-1)
  • [L4] [8] (10.1016/s0266-7681(05)80010-5)
  • [L5] While generally superior to tendon or muscle transfer for shoulder or elbow paralysis, recovery is not always markedly speedier, with useful function typically recognized after 12 months. [9] (10.1177/17531934231226169)
  • [L4] Nerve transfers can effectively reanimate muscles in selected cases, with comparable strength to tendon transfers for elbow extension but inferior strength for finger and thumb flexion. [10] (10.1177/1753193419886443)
  • [L5] The potential for tendon transfers in the upper limb and hand in tetraplegia has not yet been fully realised by many hand surgeons. [11] (10.1016/0266-7681(89)90114-9)
  • [L5] This review discusses late treatment options, including tendon transfers, joint fusions, free functioning muscle transfers and prosthetics, for managing the failed primary reconstruction of the traumatic adult brachial plexus. [12] (10.1177/17531934241231170)
  • [L4] A review of upper limb tendon transfers in spastic hemiplegia has indicated positive outcomes. [13] (10.1016/0266-7681(93)90045-h)
  • [L4] The absence of triceps function significantly decreases the effectiveness of the brachioradialis when used to motor a tendon transfer. [14] (10.1016/s0363-5023(87)80278-2)
  • [L4] All transfers appear to have re-established elevation of the thumb from the plane of the palmar surface. [15] (10.1016/s0363-5023(78)80145-2)
  • [L5] At follow-up, the transfer contracted well and the functional capability of the hand was improved. [16] (10.1016/s0363-5023(10)80140-6)
  • [L4] It can be transferred simultaneously with other reconstructive procedures on the same hand. [17] (10.1016/0266-7681(91)90065-v)
  • [L4] In comparison with the contralateral hand, the range of extension of the wrist was less but extension of the fingers and the MCP joints were similar to that of the normal hand. [18] (10.1016/j.jhsb.2006.05.003)
  • [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. [19] (10.1177/17531934211027460)
  • [L4] In this series, brachialis transfer to the forearm muscles resulted in restoration of some degree of active wrist extension and pronation. [20] (10.1016/j.jhsb.2005.11.001)
  • [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. [21] (10.1177/17531934251314640)
  • [L4] Surgical interventions for the spastic upper extremity aim to correct common deformities through single-event, multi-level surgery involving soft tissue lengthening, tendon transfer, and joint stabilization. [22] (10.1177/1753193419878973)
  • [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. [23] (10.1016/j.hansur.2016.11.007)
  • [L4] Improvement in hand function is more likely after a transfer in a dominant hand than a non-dominant one. [24] (10.1016/0266-7681(87)90045-3)
  • [L4] All tendon transfers were successful with recovery of active wrist extension (40°), long fingers extension and thumb abduction and extension (12.5 cm between the tips of index and thumb). [25] (10.1016/j.main.2013.04.002)
  • [L4] The ECRL transfer yields good results if the intrinsic muscles of the hand are functioning, the extensor compartment is uninjured, and the lower third of the forearm where the tendon junction is performed is relatively unscarred. [28] (10.1016/j.jhsa.2004.11.017)
  • [L4] Nerve transfer for CSCI is an emerging area of upper limb surgery that demonstrates very significant promise. [29] (10.1177/1558944716660555fe)
  • [L4] It can be performed in combination with other tendon or nerve transfers to maximize functional reconstruction of the upper limb in tetraplegia. [30] (10.1177/1558944716660555ft)
  • [L4] [31] (10.1016/s0363-5023(05)80097-8)
  • [L3] [32] (10.1177/17531934251338008)
  • [L5] The surgeon must know the indications and contraindications of functional surgery, which includes procedures on the elbow, wrist, fingers, and thumb such as release or lengthening of spastic muscles, tendon transfers, and joint stabilizations. [33] (10.1016/j.main.2008.07.024)
  • [L4] EMG provides meaningful guidance in selecting optimal forearm muscles for tendon transfers to hands in the setting of slowly progressive polyneuropathies. [34] (10.1053/jhsu.1999.0732)
  • [L4] Transfer for active elbow extension does not necessarily need to be performed before distal transfers. [36] (10.1016/s0266-7681(98)80164-2)
  • [L5] Tendon transfers for reconstruction of the upper limb in tetraplegia is an underused resource for this population. [37] (10.1016/j.hcl.2016.03.013)
  • [L4] The lateral upper arm flap is preferred for its safety, acceptable donor site morbidity, and suitability for extensor tendon reconstruction. [38] (10.1177/175319340703201s14)
  • [L5] The biomechanical principles, indications and limitations of tendon transfers, nerve transfers and combined approaches are compared, with particular attention to timing, patient selection, and functional goals. [39] (10.1177/17531934261416300)
  • [L5] Functional reconstruction of the hand has two stages: restoration of wrist extension and construction of the pollici digital pinch. [41] (10.1097/00130911-200003000-00009)
  • [L4] Patients have achieved considerable strength recovery from both nerve and tendon transfers, with current evidence demonstrating poor outcomes after brachialis-to-anterior interosseous nerve transfers. [42] (10.1016/j.jhsg.2026.101116)
  • [L4] Hand opening or passive finger extension was complete in 30-degree wrist flexion. [46] (10.1097/01.bth.0000236987.50793.ef)
  • [L4] [48] (10.1016/s0363-5023(85)80168-4)
  • [L5] Emergency tendon transfers can be used with good results, allowing treatment of lesions in one stage and avoiding a second surgical intervention. [50] (10.1016/j.main.2013.02.009)
  • [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. [52] (10.5435/jaaos-d-15-00465)
  • [L4] The transfer is safe, especially if the origin is left attached, and is simple and effective in restoring abduction and rotation of the thumb. [53] (10.1016/0266-7681(94)90137-6)
  • [L5] [56] (10.1016/j.hcl.2015.12.013)
  • [L4] Transfers in six patients were regarded as failures, associated with a poor tendon bed and noncompliant patients. [57] (10.1016/s0363-5023(88)80054-6)
  • [L4] [58] (10.1097/bth.0b013e3181d4459d)
  • [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. [60] (10.1186/1471-2474-12-74)
  • [L3] This study supports the hypothesis and suggests that similar outcomes can be achieved in reduced time by immediate active mobilization of opposition tendon transfer. [61] (10.1016/j.jhsa.2006.01.018)
  • [L5] The case illustrates the potential vulnerability of the radial and/or ulnar branches of the superficial radial nerve in opposition transfers. [62] (10.1016/s0363-5023(96)80321-2)
  • [L4] It gives results which are certainly comparable and in some ways better than other tendon transfers that have been evaluated. [63] (10.1016/0266-7681(93)90117-x)
  • [L5] [85] (10.1097/bth.0000000000000061)
  • [L5] [101] (10.1016/s0894-1130(12)80308-5)
  • [L4] [102] (10.1016/j.jht.2024.08.060)
  • [L5] [106] (10.1016/0266-7681(89)90019-3)
  • [L4] [112] (10.1016/s0266-7681(05)80101-9)
  • [L5] [115] (10.1177/17531934261415775)
  • [L5] Surgical treatments, which are often indicated in severe forms with contractures, include selective neurotomy, muscle–tendon release, transfer or lengthening, and procedures on bone and joints. [116] (10.1016/j.otsr.2023.103763)
  • [L4] However, it is not recommended for the thick-handed individual who requires maximum power; a transfer procedure to add power to the hand is preferred. [119] (10.1016/0363-5023(94)90019-1)
  • [L4] Follow-up examination, at an average 5 years and 10 months after operation, showed that the results of ten of 11 transfers were excellent and the other was good. [137] (10.1016/s0266-7681(99)90027-x)
  • [L4] The choice of the thumb to preserve must be based on a good clinical examination and radiographic analysis. [139] (10.1016/j.hansur.2016.10.131)
  • [L4] The authors present and justify their surgical treatment for patients with grade III 'non-functional hands' according to Zancolli's classification. [140] (10.1016/s0266-7681(85)80016-4)
  • [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. [142] (10.1177/1558944719878835)
  • [L4] Since no tendon grafts are used, stretching is eliminated. [145] (10.1016/0266-7681(91)90176-o)
  • [L5] The authors suggest this donor site is considered as second choice if the palmaris longus tendon is unavailable for grafting. [146] (10.1177/1753193419864904)
  • [L4] At last follow up, 7 of the 13 reviewed patients presented an excellent functional recovery, with complete resolution of pain and stability with attainment of ROM comparable to the contralateral finger. [147] (10.1142/s2424835519500267)

See Also

References

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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.