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Hand Tendon Transfers Workup

  • Author: Steffen Baumeister, MD; Chief Editor: Joseph A Molnar, MD, PhD, FACS  more...
Updated: Jul 30, 2015

Laboratory Studies

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  • The workup of candidates for tendon transfers consists mostly of the physical examination to determine available muscles for transfer and function to be restored.
  • The only laboratory studies needed are those that ensure the safety of the patient during surgery.

Imaging Studies

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  • Plain radiographs of joints that are stiff may be necessary to ensure that obtaining a supple joint is possible. Severe arthritic conditions in joints involved with the function to be restored represent a relative contraindication to proceeding with the procedure.

Other Tests

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  • When loss of function is secondary to neurologic or peripheral nerve injury, nerve conduction studies and electromyography (EMG) can help differentiate permanent injury from recovering injury. EMG denervation patterns are evident early, to be followed by evidence of reinnervation.
Contributor Information and Disclosures

Steffen Baumeister, MD Consulting Staff, Department of Plastic Surgery, Breast Center, Behandlungszentrum Vogtareuth, Bavaria, Germany

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jorge I de la Torre, MD, FACS Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Chief Editor

Joseph A Molnar, MD, PhD, FACS Medical Director, Wound Care Center, Associate Director of Burn Unit, Professor, Department of Plastic and Reconstructive Surgery and Regenerative Medicine, Wake Forest University School of Medicine

Joseph A Molnar, MD, PhD, FACS is a member of the following medical societies: American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Plastic Surgeons, North Carolina Medical Society, Undersea and Hyperbaric Medical Society, Peripheral Nerve Society, Wound Healing Society, American Burn Association, American College of Surgeons

Disclosure: Received grant/research funds from Clinical Cell Culture for co-investigator; Received honoraria from Integra Life Sciences for speaking and teaching; Received honoraria from Healogics for board membership; Received honoraria from Anika Therapeutics for consulting; Received honoraria from Food Matters for consulting.

Additional Contributors

Anthony E Sudekum, MD Consulting Staff, Department of Plastic Surgery, St John's Mercy Health Center of St Louis

Anthony E Sudekum, MD is a member of the following medical societies: American College of Surgeons, American Society for Surgery of the Hand, Missouri State Medical Association

Disclosure: Nothing to disclose.


The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Philip E Higgs, MD, to the development and writing of this article.

  1. Burkhalter WE. Early tendon transfer in upper extremity peripheral nerve injury. Clin Orthop Relat Res. 1974 Oct. 0(104):68-79. [Medline].

  2. Burkhalter WE. Tendon transfers in brachial plexus injuries. Orthop Clin North Am. 1974 Apr. 5(2):259-70. [Medline].

  3. Moberg E. Reconstructive hand surgery in tetraplegia, stroke, and cerebral palsy: some basic concepts in physiology and neurology. J Hand Surg [Am]. 1976 Jul. 1(1):29-34. [Medline].

  4. Riordan DC. Tendon transfers in hand surgery. J Hand Surg [Am]. 1983 Sep. 8(5 Pt 2):748-53. [Medline].

  5. Zancolli EA. Claw-hand caused by paralysis of the intrinsic muscles: a simple surgical procedure for its correction. J Bone Joint Surg Am. 1957 Oct. 39-A(5):1076-80. [Medline].

  6. Lalonde DH, Kozin S. Tendon disorders of the hand. Plast Reconstr Surg. 2011 Jul. 128(1):1e-14e. [Medline].

  7. Sunderland S. The anatomy and physiology of nerve injury. Muscle Nerve. 1990 Sep. 13(9):771-84. [Medline].

  8. Rath S. Split flexor pollicis longus tendon transfer to A1 pulley for correction of paralytic Z deformity of the thumb. J Hand Surg Am. 2013 Jun. 38(6):1172-80. [Medline].

  9. Iba K, Wada T, Hiraiwa T, Kanaya K, Oki G, Yamashita T. Reconstruction of Chronic Thumb Metacarpophalangeal Joint Radial Collateral Ligament Injuries With a Half-Slip of the Abductor Pollicis Brevis Tendon. J Hand Surg Am. 2013 Aug 5. [Medline].

  10. Davidge KM, Yee A, Kahn LC, Mackinnon SE. Median to radial nerve transfers for restoration of wrist, finger, and thumb extension. J Hand Surg Am. 2013 Sep. 38(9):1812-27. [Medline].

  11. Van Heest AE, Bagley A, Molitor F, James MA. Tendon transfer surgery in upper-extremity cerebral palsy is more effective than botulinum toxin injections or regular, ongoing therapy. J Bone Joint Surg Am. 2015 Apr 1. 97 (7):529-36. [Medline].

  12. Schaller P, Baer W, Carl HD. Extensor indicis-transfer compared with palmaris longus transplantation in reconstruction of extensor pollicis longus tendon: a retrospective study. Scand J Plast Reconstr Surg Hand Surg. 2007. 41(1):33-5. [Medline].

  13. Jones NF, Machado GR. Tendon transfers for radial, median, and ulnar nerve injuries: current surgical techniques. Clin Plast Surg. 2011 Oct. 38(4):621-42. [Medline].

  14. Brunelli GA, Brunelli GA. Reconstructive surgery for permanent palsy of the median nerve. Surg Technol Int. 2004. 13:268-75. [Medline].

  15. Kozin SH. Tendon transfers for radial and median nerve palsies. J Hand Ther. 2005 Apr-Jun. 18(2):208-15. [Medline].

  16. Ropars M, Dreano T, Siret P, et al. Long-term results of tendon transfers in radial and posterior interosseous nerve paralysis. J Hand Surg [Br]. 2006 Oct. 31(5):502-6. [Medline].

  17. Wehrli L, Bonnard C, Anastakis DJ. Current status of brachial plexus reconstruction: restoration of hand function. Clin Plast Surg. 2011 Oct. 38(4):661-81. [Medline].

  18. Lieber RL, Murray WM, Clark DL, et al. Biomechanical properties of the brachioradialis muscle: Implications for surgical tendon transfer. J Hand Surg [Am]. 2005 Mar. 30(2):273-82. [Medline].

  19. Sultana SS, MacDermid JC, Grewal R, Rath S. The effectiveness of early mobilization after tendon transfers in the hand: a systematic review. J Hand Ther. 2013 Jan-Mar. 26(1):1-20; quiz 21. [Medline].

  20. Rath S. Immediate active mobilization versus immobilization for opposition tendon transfer in the hand. J Hand Surg [Am]. 2006 May-Jun. 31(5):754-9. [Medline].

  21. Germann G, Wagner H, Blome-Eberwein S, et al. Early dynamic motion versus postoperative immobilization in patients with extensor indicis proprius transfer to restore thumb extension: a prospective randomized study. J Hand Surg [Am]. 2001 Nov. 26(6):1111-5. [Medline].

  22. Hobby J, Taylor PN, Esnouf J. Restoration of tetraplegic hand function by use of the neurocontrol freehand system. J Hand Surg [Br]. 2001 Oct. 26(5):459-64. [Medline].

  23. Hausman MR, Masters JE. Percutaneous Freehand system intramuscular electrode placement. J Hand Surg [Br]. 2002 Oct. 27(5):465-9. [Medline].

  24. Boyes JH. Tendon transfers for radial nerve palsy. Bull Hosp Joint Dis. 1960. 21:97-105.

  25. Brand PW. Tendon transfers for median and ulnar nerve paralysis. Orthop Clin North Am. 1970 Nov. 1(2):447-54. [Medline].

  26. Brand PW, Beach RB, Thompson DE. Relative tension and potential excursion of muscles in the forearm and hand. J Hand Surg [Am]. 1981 MAY. 6(3):209-19. [Medline].

  27. Bunnell S. Restoring flexion to the paralytic elbow. J Bone Joint Surg Am. 1951 Jul. 33-A(3):566-71: passim. [Medline].

  28. Castro-Sierra A, Lopez-Pita A. A new surgical technique to correct triceps paralysis. Hand. 1983 Feb. 15(1):42-6. [Medline].

  29. Cooney WP. Tendon transfer for median nerve palsy. Hand Clin. 1988 May. 4(2):155-65. [Medline].

  30. Eversmann WW Jr. Tendon transfers for combined nerve injuries. Hand Clin. 1988 May. 4(2):187-99. [Medline].

  31. Freehafer AA, Peckham PH, Keith MW. Determination of muscle-tendon unit properties during tendon transfer. J Hand Surg [Am]. 1979 Jul. 4(4):331-9. [Medline].

  32. Freehafer AA, Peckham PH, Keith MW, Mendelson LS. The brachioradialis: anatomy, properties, and value for tendon transfer in the tetraplegic. J Hand Surg [Am]. 1988 Jan. 13(1):99-104. [Medline].

  33. Friden J, Ponten E, Lieber RL. Effect of muscle tension during tendon transfer on sarcomerogenesis in a rabbit model. J Hand Surg [Am]. 2000 Jan. 25(1):138-43. [Medline].

  34. Gellman H, Kan D, Waters RL, Nicosa A. Rerouting of the biceps brachii for paralytic supination contracture of the forearm in tetraplegia due to trauma. J Bone Joint Surg Am. 1994 Mar. 76(3):398-402. [Medline].

  35. Hastings H 2nd, Davidson S. Tendon transfers for ulnar nerve palsy. Evaluation of results and practical treatment considerations. Hand Clin. 1988 May. 4(2):167-78. [Medline].

  36. Hentz VR, Hamlin C, Keoshian LA. Surgical reconstruction in tetraplegia. Hand Clin. 1988 Nov. 4(4):601-7. [Medline].

  37. House JH, Gwathmey FW, Lundsgaard DK. Restoration of strong grasp and lateral pinch in tetraplegia due to cervical spinal cord injury. J Hand Surg [Am]. 1976 Sep. 1(2):152-9. [Medline].

  38. Keith MW, Kilgore KL, Peckham PH, et al. Tendon transfers and functional electrical stimulation for restoration of hand function in spinal cord injury. J Hand Surg [Am]. 1996 Jan. 21(1):89-99. [Medline].

  39. Manktelow RT, Zuker RM, McKee NH. Functioning free muscle transplantation. J Hand Surg [Am]. 1984 Jan. 9A(1):32-9. [Medline].

  40. Mayer L, Green W. Experiences with the Steindler flexorplasty at the elbow. J Bone Joint Surg Am. 1954 Jul. 36-A(4):775-89; passim. [Medline].

  41. Mendelson LS, Peckham PH, Freehafer AA, Keith MW. Intraoperative assessment of wrist extensor muscle force. J Hand Surg [Am]. 1988 Nov. 13(6):832-6. [Medline].

  42. Palande DD. The role of muscle reeducation in dynamic tendon transfer surgery of the hand. Handchirurgie. 1979. 11(3-4):195-7. [Medline].

  43. Schantz K, Riegels-Nielsen P. The anterior interosseous nerve syndrome. J Hand Surg [Br]. 1992 Oct. 17(5):510-2. [Medline].

  44. Thomas CK, Erb DE, Grumbles RM, et al. Embryonic cord transplants in peripheral nerve restore skeletal muscle function. J Neurophysiol. 2000 Jul. 84(1):591-5. [Medline].

  45. Van Heest A, Hanson D, Lee J, et al. Split flexor pollicus longus tendon transfer for stabilization of the thumb interphalangeal joint: a cadaveric and clinical study. J Hand Surg [Am]. 1999 Nov. 24(6):1303-10. [Medline].

  46. Williams HB. The value of continuous electrical muscle stimulation using a completely implantable system in the preservation of muscle function following motor nerve injury and repair: an experimental study. Microsurgery. 1996. 17(11):589-96. [Medline].

Assist devices used in upper limb paralysis.
Natural tenodesis is demonstrated by flexing and extending the wrist with the hand relaxed. The effect shows extension of the fingers when the wrist is flexed and flexion of the fingers when the wrist is extended. If the tendons are not intact, this effect is lost.
Tendons ruptured secondary to rheumatoid arthritis. Repair by transfer of long extensor digitorum communis (EDC) to the ring EDC and the index EDC to the little EDC. The fourth dorsal compartment has been opened to allow inspection of the compartment and repair of any problem causing the ruptures.
Ulnar clawing produced by loss of intrinsics to the little and ring fingers, characterized by hyperextension of the metacarpophalangeal joints and flexion of the interphalangeal joints.
Zancolli-type lasso of A-1 pulley by the superficialis.
Extensor indicis proprius transfer to the extensor pollicis longus.
Side-by-side adjustments of the profundus or extensor tendons for extrinsic balance.
Split flexor pollicis longus transfer for stabilization of the interphalangeal joint.
The neuromuscular stimulator is useful for intraoperative evaluation of tendon excursion and transfer function.
Pulvertaft weave used to connect tendon grafts.
Test excursion and transfer function using a neuromuscular stimulator.
Opponensplasty using the extensor indicis proprius for treatment of low median nerve palsy.
Flexor reconstruction in brachial plexus injury using a brachioradialis to flexor digitorum profundus transfer and a pronator teres to flexor pollicis longus transfer along with extensor tenodesis for release.
Flexor reconstruction in a tetraplegic patient using a extensor carpi radialis longus to flexor digitorum profundus transfer and a pronator teres to flexor pollicis longus transfer along with a split flexor pollicis longus transfer to stabilize the interphalangeal joint.
Table 1. Recommended Transfers for a High Median Nerve Palsy
BrachioradialisFlexor pollicis longus
Extensor carpi radialis longusFlexor digitorum profundus
EIP opponensplasty
Table 2. Tendon Transfers for an Anterior Interosseous Nerve Palsy
BrachioradialisFlexor pollicis longus
Extensor carpi radialis longusFlexor digitorum profundus
Table 3. Tendon Transfers for a High Ulnar Nerve Palsy
BrachioradialisFlexor digitorum profundus
Flexor digitorum superficialisAdductor pollicis
Flexor digitorum superficialis lasso ring and little
Table 4. Tendon Transfers for a High Radial Nerve Palsy
Pronator teresExtensor carpi radialis brevis
Flexor carpi ulnarisExtensor digitorum communis
Palmaris longusExtensor pollicis longus (rerouted)
Table 5. Tendon Transfers for a Low Radial Nerve Palsy or Posterior Interosseous Nerve Palsy
BrachioradialisExtensor pollicis longus
Flexor carpi ulnarisExtensor digitorum communis
Table 6. Muscles Available for Transfer
FunctionNeededActiveMuscles Available
Elbow flexion  Brachialis
Elbow extension  Triceps
Forearm pronation  Pronator teres
   Pronator quadratus
Forearm supination  Supinator
Wrist flexion  Flexor carpi radialis
   Flexor carpi ulnaris
   Palmaris longus
Wrist extension  Extensor carpi radialis longus
   Extensor carpi radialis brevis
   Extensor carpi ulnaris
Finger flexion  Flexor digitorum profundus
   Flexor digitorum superficialis
Finger extension  Extensor digitorum communis
   Extensor indicis proprius
   Abductor digiti minimi
Thumb flexion  Flexor pollicis longus
Thumb extension  Extensor pollicis longus
Thumb opposition  Abductor pollicis brevis
Thumb adduction  Abductor pollicis
Name and other procedures:
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