General Principles of Tendon Transfers

Certain key elements play crucial roles in tendon transfer operations. Three important principles should
be emphasized. First, the transfer should not significantly decrease the remaining function of the hand.
Second, the transfer should not create a deformity if significant return of function occurs following a nerve
repair. Third, the transfer should be phasic or capable of phase conservation. For more information on
tendon transfer in the hand, see eMedicine Plastic Surgery article Hand, Tendon Transfers.

Fundamental principles of muscle-tendon units include the following:

 Correction of contracture
o In any patient with peripheral nerve palsy, all joints must be kept supple because soft
tissue contracture is far easier to prevent than to correct.
o Maximum passive motion of all joints must be present before a tendon transfer because
no tendon transfer can move a stiff joint.
 Adequate strength
o The tendon chosen as a donor for transfer must be strong enough to perform its new
function in its altered position. Selecting an appropriate motor is important because a
muscle will lose one grade of strength following transfer.
o Do not transfer muscle that has been reinnervated or muscle that was paralyzed and has
returned to function.
 Amplitude of motion
o Consider the amplitude of tendon excursion for each muscle. A wrist flexor with an
excursion of 33 mm cannot substitute fully for a finger extensor with an amplitude of 50
mm.
o Although the true amplitude of a tendon cannot be increased, its effective amplitude can
be augmented 2 ways. First, the natural tenodesis effect can be used by converting a
muscle from monoarticular to biarticular or multiarticular. Second, extensively dissecting
a muscle from its surrounding fascial attachments can increase amplitude.
 Straight line of pull
o In the most effective transfer, the muscle passes in a direct line from its origin to the
insertion of the tendon being substituted.
o Although not always possible, this configuration is desirable.
 One tendon, one function
o A single tendon cannot be expected to simultaneously perform diametrically opposing
actions, eg, flex and extend the same joint.
o If a muscle is inserted into 2 tendons with separate functions, the force of amplitude of
the donor tendon is dissipated and less effective than that of a muscle motored by a
single tendon.
 Synergism
o The use of synergistic muscles, eg, finger flexors acting in concert with wrist extensors
and finger extensors with wrist flexors, has been advocated for transfer.
o Muscle function is easier to retain after synergistic muscle transfer.
 Expendable donor
o The removal of a tendon for transfer must not result in an unacceptable loss of function.
o Sufficient muscle must remain to substitute for the donor muscle.
 Timing of tendon transfer
 o No transfer should be performed until the local tissues are in optimal condition. The term
often used to describe this is tissue equilibrium. Tissue is in equilibrium when soft tissue
induration has resolved, when any reaction in the wound is absent, when joints are
supple, and when the scars are as soft as they are likely to become.
o Tendon transfers function best when passed between subcutaneous fat and the deep
fascial layer; they are not likely to be functional if placed in the pathway of a scar.

Radial Nerve Palsy

Although an infinite number of possible combinations for transfer of the radial nerve are available,
currently, 3 sets of transfers are considered most reasonable. For more information on radial nerve injury,
see eMedicine Orthopedic Surgery article Radial Nerve Entrapment.

Standard flexor carpi ulnaris transfer

In standard flexor carpi ulnaris (FCU) tendon transfer (see Image 1), the first incision (incision 1) is
directed longitudinally over the FCU in the distal half of the forearm. Its distal end is J-shaped with a
transverse extension long enough to reach the palmaris longus (PL) tendon. The FCU tendon is
transected from the pisiform and detached as far proximally as the incision allows.

The second incision (incision 2) begins 2 inches below the medial epicondyle and angles across the
dorsum of the proximal forearm, moving directly toward the Lister tubercle. The rest of the fascial
attachments to the muscle are incised. The third incision (incision 3) begins on the volar-radial aspect of
the mid forearm, passes dorsally around the radial border of the forearm in the region of insertion of the
pronator teres (PT) muscle, and angles back on the dorsum of the distal forearm towards the Lister
tubercle.

The PT muscle and tendon are passed subcutaneously around the radial border of the forearm, to be
inserted into the extensor carpi radialis brevis muscle just distal to its musculotendinous junction. The
FCU muscle is pulled into the dorsal wound. The line of pull must be as straight as possible from the
medial epicondyle to the extensor digitorum communis tendon just proximal to the dorsal retinaculum
(see Image 2). The extensor pollicis longus (EPL) muscle is divided and rerouted toward the volar aspect.
The PL tendon is transected at the wrist and detached proximally to allow a straight line of pull between
the PL and EPL tendons (see Image 3). The PT tendon is then sutured to the extensor carpi radialis
brevis tendon. The FCU transfer is then sutured. The PL muscle is rerouted to the EPL tendon.

Superficialis transfer

To perform a transfer of the flexor digitorum superficialis (FDS), a long incision is made on the volar side
of the radial aspect of the mid forearm, and the tendons of the PT, extensor carpi radialis longus, and
extensor carpi radialis brevis are exposed. The PT tendon is sutured to the extensor carpi radialis brevis
tendon. The FDS (also called sublimis) tendons of the long (FDS 3) and ring (FDS 4) fingers are exposed,
divided, and delivered into the forearm wound. Then, 1- to 2-cm openings are made in the interosseous
membrane, and the flexor tendons are passed to the dorsum through the openings in the interosseous
membrane.

The FDS 3 is rerouted to the radial side of the profundus mass, and the FDS 4 is rerouted to the ulnar
side of the profundus mass. Kinking of the median nerve must be carefully avoided as the muscles are
passed into the opening. The FDS 4 is interwoven into the tendons of the extensor indicis proprius and
the EPL, and the FDS 3 is interwoven into the extensor digitorum communis tendon. Then, the flexor
carpi radialis tendon at the base of the thumb is divided and detached. The flexor carpi radialis is passed
through the substance of the abductor pollicis longus and extensor pollicis brevis tendons and sutured in
place.

Flexor carpi radialis transfer

First, the PT to the extensor carpi radialis brevis transfer is performed. The flexor carpi radialis tendon is
exposed through a longitudinal incision on the volar-radial aspect of the forearm. The tendon is divided at
the wrist and redirected around the radial border of the forearm to the wrist dorsally via a subcutaneous
tunnel. The finger extensor tendons are tested for extension of the metacarpophalangeal (MP) joint and
then divided. They are then withdrawn distally and sutured to the flexor carpi radialis. After that, reroute
the PL to the EPL (see Image 4).

Ulnar Nerve Palsy

Ulnar nerve palsy results in an awkward hand with significant sensory loss and profound weakness. Signs
and symptoms of ulnar nerve palsy include motor loss and sensory loss. For more information on ulnar
nerve injury, see eMedicine Orthopedic Surgery article Ulnar Nerve Entrapment.

 Motor loss
o Loss of flexion of the proximal phalanges of the fingers occurs due to paralysis of the
interossei and other intrinsic muscles.
o Loss of integration of MP and interphalangeal joint flexion occurs due to paralysis of the
lumbrical muscles to the little and ring fingers.
o Loss of lateral or key pinch of the thumb occurs due to paralysis of the adductor pollicis.
o Flattened metacarpal arch (palmar arch) and loss of hypothenar elevation occur due to
paralysis of the opponens digiti quinti and the decreased range of flexion of the little
finger MP joint.
o Loss of extrinsic power to the ulnar-innervated portion of the flexor digitorum profundus is
present with an inability to flex the distal phalanges of the ring and little fingers.
o Partial loss of wrist flexion occurs due to paralysis of the FCU.
o Precision grip is impaired.
o Loss of distal stability and rotation for a tip pinch between the thumb and the index finger
occurs due to paralysis of the first and second palmar interossei and the adductor pollicis.
 Sensory loss
o Sensibility function is lost in ulnar nerve palsy over the volar side of the little finger and
the ulnar aspect of the volar side of the ring finger.
o In high ulnar nerve palsy, sensibility loss occurs over the dorsoulnar aspect of the palm
and the dorsal side of the little finger.

Low ulnar nerve palsy

An isolated tendon transfer cannot restore all of the power requirements lost in a low ulnar nerve palsy. A
single FDS tendon transfer can improve integration of the MP joint and interphalangeal joint flexion, key
pinch of the thumb, and the flattened metacarpal arch. In this procedure, the superficialis tendon of the
ring finger is exposed. The radial slip of insertion is released proximal to the proximal interphalangeal joint
and tenodesed to prevent hyperextension of the joint after the transfer is completed. The ulnar slip is
released at its terminal insertion and split into 2 slips. These 2 slips are directed volarly to the deep
transverse metacarpal ligament and then dorsally to be sutured at the insertion of the central slip of the
dorsal apparatus on the middle phalanx of the ring and little fingers. Traction on the transferred slips
should flex the MP joint and extend the proximal interphalangeal joint.

When increased power of grip is desirable, a different insertion is preferred. In this circumstance, the
superficialis slips are passed distally through the flexor sheaths and around the distal edge of the second
annular pulley and sutured into place. With this insertion, the tendon does not extend the proximal
interphalangeal joint, and the result is similar to dynamic transfers for proximal phalanx flexion. Pass the
radial half of the tendon volar to the adductor pollicis muscle and dorsal to the flexor digitorum profundus
tendons into the insertion of the abductor pollicis brevis (APB). Traction on the transferred tendon should
adduct and pronate the first metacarpal. The MP joints of the claw fingers are placed in 45° flexion, and
the proximal interphalangeal joints are placed in 0° extension. The first metacarpal is adducted so that it is
parallel to the plane of the second metacarpal. This position is maintained in plaster immobilization for 4
weeks.

Distal stability for tip pinch between the thumb and the index finger is improved by arthrodesis of the MP
joint, and this procedure is indicated when the patient develops the Jeanne sign following transfer of the
FDS (see Image 5). The transfer of a single FDS tendon and arthrodesis of the thumb MP joint improves
4 of the 6 lost motor functions in a person with low distal ulnar nerve palsy.

Methods for managing other motor losses associated with ulnar nerve palsy include the following:

 Capsulodesis of the MP joint to control claw deformity: In capsulodesis of the MP joint, a

transverse incision is made in the distal palmar crease, and a triangle is cut into the deep
transverse metacarpal ligament on each side of the volar plate flap (see Image 6). The volar plate
flap is then advanced, inserted into the metacarpal neck, and immobilized for 6 weeks.
 Dorsal tenodesis to control claw deformity: To perform dorsal tenodesis, the extensor carpi
radialis longus and extensor carpi ulnaris muscles are exposed. Each tendon is cut at the junction
of the middle and distal thirds of the muscle. The freed half of the tendon is cut distally but left
attached to its insertion on the metacarpal. Each half tendon is then split once longitudinally to
obtain 4 slips. Each slip is routed through the interosseous space and passed to the radial side of
each finger. The slip passes volar to the deep transverse metacarpal ligament and inserts into the
lateral band of the dorsal apparatus (see Image 7).
 Transfer of FDS to control claw deformity: In FDS transfer for claw deformity, the FDS tendon is
divided into 4 slips and passed through the lumbrical canals and volar to the deep transverse
metacarpal ligament. Each slip may be inserted into the lateral band of the dorsal apparatus or
into the second annular pulley of the flexor sheath (see Image 8).
 Method to increase power grip: The best available method to increase power for grip requires
adding an extra muscle-tendon unit to the power train for flexion of the proximal phalanx. Gross
grip power is improved by transferring a wrist extensor or the brachioradialis to flex the MP joint.
 Transfer to combine proximal phalanx power and integrate finger flexion: After the extensor carpi
radialis longus is passed around the radial side of the forearm, it is extended by a free graft in 2-4
slips. It is then passed through the carpal tunnel and volar to the deep transverse metacarpal
ligament and into the lateral band of the dorsal apparatus (see Image 9). This transfer adds
power to finger flexion.
 Transfer to improve key pinch and flat metacarpal arch: Transfer the brachioradialis, extended
with a free tendon graft, through the interspace between the third and fourth metacarpals, to
 insert on the abductor tubercle of the thumb (see Image 10). This transfer adds power to the key
pinch.
 Metacarpal arch restoration: The extensor digiti minimi tendon is step-cut at its insertion, leaving
a strip to be sutured to the extensor digitorum communis. The muscle-tendon unit is withdrawn to
the wrist and passed through the forearm between the abductor pollicis longus and the flexor
carpi radialis. The extensor digiti minimi tendon is then passed subcutaneously in a diagonal
course so that it can be sutured to the periosteum of the neck of the fifth metacarpal.
 Method to improve tip pinch: A slip of the abductor pollicis longus is elongated with a free tendon
graft from the PL or plantaris and inserted into the tendon of the first dorsal interosseous
(see Image 11).
 Tendon transfer for little finger abduction: The ulnar half of the extensor digiti minimi is directed
volar to the deep transverse metacarpal ligament and sutured to the phalangeal attachment of the
radial collateral ligament of the MP joint of the little finger. If the little finger is clawed and
abducted, the tendon is inserted through the second annular pulley of the flexor sheath
(see Image 12).
 Side-to-side tenodesis for finger and wrist flexion: Side-to-side tenodesis of the profundus
tendons of the ring and little fingers to the profundus of the long finger in the forearm increases
the power for gross grip (see Image 13).

Median Nerve Palsy

Median nerve palsy is caused by penetrating or perforating wounds of the forearm or wrist area.
(Click here for news and CME on trauma.) The motor deficit primarily involves loss of opposition of the
thumb in injuries at the level of the wrist or distal forearm or, in more proximal injuries, loss of opposition
of the thumb and severe weakness of the extrinsic flexors of the hand. Opposition is a composite of 2
motions. The first is rotation of the thumb into pronation so that the pulp fingers of the thumb and index
fingers face one another. The second is abduction or lifting of the thumb away from the palm of the hand
(palmar abduction).

In the case of high median nerve palsy or low median nerve paralysis associated with tendon injury at the
level of the wrist, a proprius tendon transfer is usually the first choice. However, in case of a low injury at
the level of the wrist with a median nerve repair, often, no opponens transfer is indicated. These patients
usually regain the function of the APB in 6 months and, in the case of sharp lacerations, have good return
of function in one year.

Royle-Thompson opponensplasty

The most frequently used motor for opponensplasty of the thumb is the FDS of the ring or middle finger.
In the Royle technique, the motor is passed up the sheath of the flexor pollicis longus and the split
superficialis tendon is attached to the superficial head of the flexor pollicis brevis and the opponens
pollicis. The Thompson modification of this procedure uses a pulley and a more superficial location for
this transfer. The distal end of the transverse carpal ligament and the ulnar border of the palmar fascia act
as the pulley, and the route of the transferred digitorum superficialis is subcutaneous. A dual attachment
is made. The first slip of the superficialis is attached through a hole drilled in the neck of the first
metacarpal, while the other is drawn over the MP joint and sutured into the hood mechanism of the
proximal phalanx.

Typical Bunnell opponensplasty

In a typical Bunnell opponensplasty, the superficialis tendon of the ring finger is removed. Another incision
is made proximal to the wrist over the ulnar artery and nerve area. The FCU tendon is identified. The FCU
is exposed proximal to the pisiform and divided in half, with both halves remaining attached distally to the
pisiform. A subcutaneous tunnel is created across the palm from the thumb to the pisiform area. The FDS
of the ring finger is then delivered into the wrist incision and passed subcutaneously from the pisiform to
the thumb incision. The distal tip of the FCU is then sutured to the pisiform to create a fixed loop through
which the FDS can easily pass.

Methods of distal attachment

Both the Bunnell opponensplasty and the Royle-Thompson opponensplasty use bony attachments
(see Image 14). This can complicate the procedure of opposition transfer. If opposition transfer can
duplicate the function of the APB, satisfactory function can result. Therefore, the transferred tendon is
simply interwoven into the tendon of the APB. The Riordan attachment uses the interweaving of the
transfer into the APB tendon, but continues it distally into the hood of the thumb MP joint and to the EPL
tendon over the proximal phalanx. This larger attachment markedly increases the power of extension of
the interphalangeal joint of the thumb. However, without a flexor pollicis longus, a hyperextension
deformity can result.

Brand's method of distal attachment interweaves one slip of the superficialis through the tendon of the
APB and continues it on to the EPL. However, the other slip comes across the extensor mechanism
subcutaneously and is attached to the area of the adductor pollicis (see Image 14). This method creates
considerable stability in the MP joint.

Proprius extensor tendon opponensplasty

Recently, proprius tendon transfers have become popular. Both the extensor indicis proprius and the
extensor digiti minimi have been described for restoration of opposition. A short incision is made over the
MP joint of the index or the small finger. Another incision is made over the base of the fifth metacarpal.
The extensor digiti minimi is brought into the more proximal incision, and a subcutaneous tunnel is
created around the ulnar border of forearm across the palm to the area of the thumb MP joint. The pulley
for this transfer is the ulnar aspect of the forearm.

When the extensor indicis proprius is used, the tendon is removed along with a small portion of the
tendon hood. The defect in the hood is repaired. A larger dorsal ulnar incision is made in the distal
forearm. This incision allows the surgeon to displace the tendon into the forearm on its ulnar aspect. An
additional incision is made in the area of the pisiform and the thumb MP joint. The tendon is then passed
through the ulnar aspect of the wrist across to the MP joint. The attachment is made using Riordan's
method, and, again, the pulley is the ulnar aspect of the forearm (see Image 15).

Extrinsic replacement in median nerve paralysis

In high median nerve paralysis, a lack of function occurs in the forearm and wrist pronator-flexor group,
with the exception of the FCU. Absent muscles include all of the FDS, the 2 radial profundi, and the flexor
pollicis longus.

When considering extrinsic replacement, the functions that need to be replaced must be determined. The
flexor power in the long and index fingers, range of motion in the index finger, and range of motion and
power in the interphalangeal joint of the thumb are desired. Only 2 or 3 muscle-tendon units are truly
available for transfer. In high median nerve palsy, the brachioradialis and the extensor carpi radialis
longus are available.

An alternative to direct transfer for restoration of the extrinsic function is side-to-side suturing of the flexor
digitorum profundi of the ring and small fingers, which are ulnarly innervated, to the denervated portions
on the radial side. The use of suturing the extensor carpi radialis longus to the FDP of the index and long
fingers is reserved for those patients who need radial side power and are unlikely to obtain significant
reinnervation following neurorrhaphy (seeImage 16). In order to perform a tendon transfer of new motors
to the index finger or to the index and long fingers and thumb, the wrist must have a full range of motion.
Similarly, the use of the brachioradialis to the flexor pollicis longus requires a full range of wrist motion.

Multimedia

Media file 1: Tendon transfer principles and mechanics. Incisions used in the
standard (flexor carpi ulnaris) combination of transfers.

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Media file 2: Tendon transfer principles and mechanics. Pronator teres (PT) to
extensor carpi radialis brevis (ECRB) transfer. Also pictured are the extensor carpi
radialis longus (ECRL) and brachioradialis (BR).

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 Media file 3: Tendon transfer principles and mechanics. Palmaris longus (PL) to
rerouted extensor pollicis longus (EPL) transfer.

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Media file 4: Tendon transfer principles and mechanics. Flexor carpi radialis
(FCR) to extensor digitorum communis (EDC) transfer. Also pictured are the
extensor pollicis longus (EPL), extensor carpi radialis brevis (ECRB), and
pronator teres (PT).

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Media file 5: Tendon transfer principles and mechanics. Flexor digitorum

superficialis (FDS) transfer used as an "internal splint" for low ulnar nerve
palsy. Also pictured are the flexor digitorum profundi (FDP), the adductor
pollicis, and the abductor pollicis brevis (APB).

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 Media file 6: Tendon transfer principles and mechanics. Capsulodesis of the
metacarpophalangeal (MP) joint to control claw deformity.

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Media file 7: Tendon transfer principles and mechanics. Dorsal tenodesis to

control claw deformity.

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Media file 8: Tendon transfer principles and mechanics. Transfer of a

flexor digitorum superficialis (FDS) to control claw deformity.

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 Media file 9: Tendon transfer principles and mechanics. Transfer of the extensor carpi
radialis longus (ECRL) to control claw deformity.

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Media file 10: Tendon transfer principles and mechanics. Transfer of flexor digitorum
superficialis (FDS), through a facial pulley, to the abductor tubercle of the thumb.

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Media file 11: Tendon transfer principles and mechanics. Tip pinch. A slip of the
abductor pollicis longus (APL) is elongated with a free tendon graft from the palmaris
longus (PL) or plantaris and inserted into the tendon of the first dorsal interosseous.

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 Media file 12: Tendon transfer principles and mechanics. Transfer of the ulnar
half of the extensor digiti minimi (EDM) to correct persistent abduction of the
little finger.

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Media file 13: Tendon transfer principles and mechanics. Finger and wrist
flexion. Side-to-side tenodesis of the profundus tendons of the ring and the
little fingers to the profundus of the long finger in the forearm increases the
power for gross grip.

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Media file 14: Tendon transfer principles and mechanics. Techniques of distal
attachment as described by Brand, Littler, Riordan, and Royle and Thompson.

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 Media file 15: Tendon transfer principles and mechanics. Extensor indicis
proprius (EIP) opponensplasty.

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Media file 16: Tendon transfer principles and mechanics. Extrinsic

replacement using the brachioradialis to the flexor pollicis longus (A)
and the extensor carpi radialis longus to the profundi of the index and
long fingers (B). In both situations, the transfers as shown are end-to-
end. If the patient has any chance of extrinsic return following grafting,
the transfer should be end-to-side. The end-to-end technique shown
here is used in patients with no chance of extrinsic return.

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Keywords

standard flexor carpi ulnaris transfer, FCU transfer, superficialis transfer, flexor digitorum superficialis
transfer, FDS transfer, flexor carpi radialis transfer, FCR transfer, ulnar nerve palsy, low ulnar nerve
palsy, flattened metacarpal arch, tenodesis, claw deformity, capsulodesis of the metacarpophalangeal
joint, dorsal tenodesis, metacarpal arch restoration, median nerve palsy, Royle-Thompson
opponensplasty, Bunnell opponensplasty, proprius extensor tendon opponensplasty, extrinsic
replacement, muscle-tendon unit, muscle transfer, tendon transfer, muscle transplant, tendon transplant,
muscle repair, tendon repair, muscle, tendon