- •
Upper extremity peripheral nerve injuries may lead to incomplete recovery and persistent functional impairment.
- •
Tendon transfers offer the potential for restoration of function.
- •
The three most common ulnar nerve palsy-related deficits corrected by tendon transfers include claw hand, weak power grip, and weak pinch.
- •
Opponensplasty can restore function of the thumb after median nerve palsy.
- •
The loss of wrist, finger, and thumb extension after radial nerve palsy is reliably treated with tendon
Tendon Transfers for Peripheral Nerve Palsies
Section snippets
Key points
Ulnar nerve palsy
Three main functional deficits predominate in low ulnar palsy: ulnar claw, difficulties with grip, and weakened pinch (Table 1). We do not routinely correct the small finger abduction deformity (ie, Wartenberg sign), although techniques exist to address this rare complaint.4, 5 High ulnar palsy rarely leads to a claw deformity because the paralyzed flexor digitorum profundus muscle (FDP)ring and FDPsmall do not pull the digits into flexion (Fig. 1). We consider early tendon transfer for
Low median nerve palsy
Low median nerve palsy results in the loss of thumb opposition, because the median nerve innervates the thenar muscles and contributes 70% to 74% of thumb abduction strength.24 Median nerve injuries tend to have better outcomes with primary repair than other peripheral nerve injuries.1 For example, Jensen25 found that 55% recovered opposition following neurorrhaphy alone, with opponensplasty indicated in only 14% of patients.
High median nerve palsy
In addition to the loss of opposition, high median nerve palsy leads to loss of extrinsic finger flexion. High median nerve palsy has been shown to cause a 36% decrease in pinch strength and a 43% decrease in grip strength. Pronation is also weakened to 65% the unaffected side.37 These injuries are rare, representing approximately 0.1% of all upper extremity peripheral nerve injuries.38 Because of the poor recovery of function with high median nerve injuries, early tendon transfer should be
Radial nerve palsy
Radial nerve palsy results in an inability to extend the wrist, extend the fingers at the MCPJs, and radially abduct the thumb. Grip strength is substantially weakened in radial nerve palsy because of an inability to stabilize the wrist to transmit the power of the flexors, and an early tendon transfer to restore wrist extension should be considered. Bevin39 found only 66% of patients with a high radial nerve injury and primary nerve repair without tendon transfers achieved results good enough
References (51)
- et al.
The abducted little finger in low ulnar nerve palsy
J Hand Surg Am
(1976) - et al.
Extensor indicis proprius transfer for the abducted small finger
J Hand Surg Am
(2008) - et al.
Tendon transfers for ulnar nerve palsy. Evaluation of results and practical treatment considerations
Hand Clin
(1988) - et al.
Correction of the claw hand
Hand Clin
(2012) Paralytic claw fingers: a graft tenodesis operation
Hand
(1973)Tendon transfers in hand surgery
J Hand Surg Am
(1983)- et al.
Flexor digitorum superficialis tendon transfer for intrinsic replacement. Long-term results and the effect on donor fingers
J Hand Surg Br
(1992) - et al.
Three tendon transfer methods in reconstruction of ulnar nerve palsy
J Hand Surg Am
(2003) - et al.
Ulnar nerve tendon transfers for pinch
Hand Clin
(2016) - et al.
Transferring the flexor superficialis tendon: technical considerations in the prevention of proximal interphalangeal joint disability
J Hand Surg Am
(1980)
Restoration of power pinch
J Hand Surg Am
Extensor carpi radialis brevis tendon transfer for thumb adduction: a study of power pinch
J Hand Surg Am
The effects of low median nerve block on thumb abduction strength
J Hand Surg Am
Restoration of opposition of the thumb
Hand
Extensor indicis proprius opponensplasty
J Hand Surg Br
Camitz palmaris longus abductorplasty for severe thenar atrophy secondary to carpal tunnel syndrome
J Hand Surg Am
Opposition of the thumb: an anatomic and biomechanical study of tendon transfers
J Hand Surg Am
Opponensplasty by extensor indicis and flexor digitorum superficialis tendon transfer
J Hand Surg Br
Reappraisal of clinical deficits following high median nerve injuries
J Hand Surg Am
Early tendon transfer for radial nerve transection
Hand
Radial nerve paralysis
Orthop Clin North Am
Long-term results of tendon transfers in radial and posterior interosseous nerve paralysis
J Hand Surg Br
Flexor carpi ulnaris transfer for radial nerve palsy: functional testing of long-term results
J Hand Surg Am
Tendon transfers for radial nerve palsy
Orthop Clin North Am
Median and ulnar nerve injuries: a meta-analysis of predictors of motor and sensory recovery after modern microsurgical nerve repair
Plast Reconstr Surg
Cited by (6)
Examination of accessory extensor carpi radialis longus and brevis musculotendinous units for functional impact and tendon transfer suitability
2024, Translational Research in AnatomyComparison of nerve versus tendon transfer for radial nerve palsy
2024, Clinical Neurology and NeurosurgerySecondary surgical procedures following motor nerve injuries
2023, NervenarztOutcomes after Anterior Interosseous Nerve to Ulnar Motor Nerve Transfer
2023, Journal of Brachial Plexus and Peripheral Nerve InjuryReconstructive Options for the Thumb Axis in a Brachial Plexus Injury
2021, Operative Brachial Plexus Surgery: Clinical Evaluation and Management StrategiesNeurological Complications in Shoulder Arthroscopy
2019, Complications in Arthroscopic Shoulder Surgery
Disclosure Statement: The authors have no financial interest in commercial ventures related to this article.