TENDON TRANSFERS

1082 3131/02 $15.00 + .00

Tendon Transfers for Intrinsic

Function in Ulnar Nerve Palsy
David M. Kalainov, MD, and Mark S. Cohen, MD

The ulnar nerve innervates approximately 80% of the intrinsic muscles in the
hand. Consequently, loss of ulnar nerve function can be disabling. The lumbrical
and interosseous intrinsic muscles are responsible for coordinated exion of the
metacarpophalangeal (MCP) joints and extension of the interphalangeal (IP) joints.
Although full nger exion and extension are still possible with intrinsic paralysis,
the ngers tend to roll up during exion owing to asynchronous motion of the
MCP and IP joints. The ability to position the hand effectively around objects such
as a glass or door knob is impaired. In addition, grip and pinch strength are
markedly diminished.
Clinical features of ulnar nerve palsy include muscle wasting with atrophy of
the hypothenar eminence and dorsal rst web space (Fig. 1A). The Froment sign is
positive and involves hyperexion of the thumb IP joint during attempted key
pinch (Fig. 1B). Concomitant hyperextension of the thumb MCP joint may develop
owing to volar plate laxity and paralysis of the adductor pollicis muscle (Jeannes
sign). Loss of the third volar interosseous muscle leads to an abduction deformity of
the small nger from unopposed eccentric pull of the extensor digiti minimi (Wartenbergs sign) (Fig. 1C). Interosseous loss also impairs lateral nger movements,
demonstrated by the cross-nger test (Fig. 1D). Clawing of the ring and small
ngers typically ensues from unopposed actions of the extrinsic exor and extensor
tendons (Fig. 1E). The small nger always exhibits a greater degree of clawing than
the ring nger.

From the Department of Orthopaedic Surgery, Northwestern University Medical School (DMK), and
Rush-Presbyterian St. Lukes Medical Center (MSC), Chicago, Illinois

ATLAS OF THE HAND CLINICS Volume 7 Number 1 March 2002

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Figure 1. Ulnar paralysis leads to several deformities of the hand. A, Intrinsic

muscle wasting is often best visualized in the rst web space. B, Froment sign
involves thumb interphalangeal joint hyperexion during pinch.
Illustration continued on opposite page

TENDON TRANSFERS FOR INTRINSIC FUNCTION IN ULNAR NERVE PALSY

Figure 1 (Continued). C, Wartenburgs sign is an abducted posture to the small nger due to loss of
the third volar interosseous muscle and eccentric pull of the extensor digiti minimi. D, Loss of
interosseous function also leads to an inability to cross the ngers. E, Clawing is most pronounced in
the small nger and to a lesser degree in the ring nger.

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The index and long ngers may appear uninvolved if the median nerve remains functional owing to the intact rst and second lumbrical muscles. Although
relatively weak, the lumbrical muscles often balance the radial digits and maintain
synchronized joint motion. In 50% of individuals, the third lumbrical muscle is
dually innervated (median and ulnar nerves), and the ring nger may be protected
from clawing. When both the ulnar nerve and the distal median nerve are affected
by disease or injury, claw deformities will develop in all ngers, with concomitant
atrophy of the thenar and hypothenar muscles. The appearance is that of a simian
hand.
Variations in intrinsic muscle deciency are encountered occassionally with
ulnar nerve palsy and often can be attributed to normal interconnections between
the median and ulnar nerves. Crossover can occur between the anterior interosseous
branch of the median nerve and the ulnar nerve in the forearm (Martin-Gruber
communication) or between the motor branch of the median nerve and the ulnar
nerve in the palm (Riche-Cannieu communication). Partial nerve injuries and high
palsies of the median or ulnar nerves may also lead to different patterns of hand
dysfunction. Effective management in each case requires an understanding of the
anatomic lesions and the resultant motor and sensory decits. Numerous combinations of nerve palsies are possible. This article focuses on the management of
intrinsic muscle paralysis from isolated ulnar nerve lesions.

ETIOLOGY
Ulnar nerve motor decits most often result from direct trauma to the nerve or
from long-standing nerve compression (e.g., cubital tunnel syndrome). The differential diagnosis in atraumatic cases includes cervical spine disease with impingement
of the lower cervical nerve roots (C8-T1) and lesions of the brachial plexus. Cervical
nerve root compression typically manifests as neck pain with radicular symptoms
down the arm. Weakness and atrophy are expected in the thenar and hypothenar
musculature, both of which are innervated by the lower cervical and rst thoracic
nerve roots. Injury or compression of the lower elements of the brachial plexus (e.g.,
by a Pancoast tumor) may result in similar ndings.
Other causes of peripheral nerve dysfunction can lead to a confusing clinical
presentation, including leprosy (Hansens disease) and hereditary motor-sensory
neuropathy (Charcot-Marie-Tooth disease). Intrinsic atrophy with or without sensory loss may be seen in syringomyelia or amyotrophic lateral sclerosis. These
conditions often result in diffuse and symmetrical involvement of the upper extremities. In all cases, nerve conduction velocity and electromyogram studies may be
helpful in localizing a suspected lesion and in excluding a more generalized nerve
disorder.

TENDON TRANSFERS FOR INTRINSIC FUNCTION IN ULNAR NERVE PALSY

CONSERVATIVE TREATMENT
Optimal treatment of the patient with ulnar nerve dysfunction requires the
expertise and assistance of a hand therapist. Exercises are directed at maintaining or
improving mobility of the nger joints. Fabrication of a hand-based orthosis is
particularly useful to address the initial claw deformity and to prevent the development of xed joint contractures.
A lumbrical bar splint ts over the dorsum of the metacarpal heads and proximal phalanges of the ring and small ngers (Figs. 2A and B).

Figure 2. A, Lumbrical bar splint frontal view. B, Lateral view. This splint blocks the
claw deformity of the ring and small ngers, allowing the extrinsic extensor tendons
to extend the interphalangeal joints. It will improve function and diminish the likelihood of xed contractures and attenuation of the central extensor tendons.

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The design protects the MCP joints from hyperextension without impending nger
exion. The splint will not improve grip strength or correct asynchronous motion of
the digits; however, by blocking the MCP joints, it enables the extrinsic extensor
tendons to extend the IP joints more effectively. The patient will be able to manipulate the ngers around large objects and place the hand into tight spaces. Additionally, attenuation of the extensor tendons may be prevented.

SURGICAL TREATMENT
Many surgical procedures have been described to treat functional decits resulting from intrinsic muscle paralysis in ulnar nerve palsy. Tendon transfers are available to correct the claw deformity, to improve integrated joint motion, and to
increase grip and pinch strength. These transfers require a motivated patient and
full passive mobility of the digits. The choice of transfer depends largely on the age
and expectations of the patient, the availability of donor tendons, and the level of
the ulnar nerve decit (high or low). Lack of protective sensation may adversely
affect outcome.
The differences between high and low ulnar nerve palsy are relatively few. In a
proximal lesion, there is additional loss of the exor carpi ulnaris and the ring and
small nger exor digitorum profundus muscles. Although the same tendon transfer techniques can be applied to both categories of ulnar nerve decit, consideration
should be given to forearm level transfers of the ring and small nger exor
digitorum profundus tendons to the adjacent profundus or supercialis tendons in
high ulnar nerve palsy. This technique will balance nger exion and improve
functional grasp. In addition, one should try to avoid using the exor carpi radialis
tendon as a donor in a high ulnar nerve lesion given the absence of a functional
exor carpi ulnaris muscle.

Integrated Finger Motion, Clawing, and Grasp

Several techniques to correct these specic deciencies have been described,
employing extrinsic muscles of the wrist and ngers as donor tendons. Two of the
more commonly performed operations include transfer of a wrist motor with tendon graft extensions (four-tail graft) and transfer of one exor digitorum supercialis (FDS) from either the index or long nger (Stiles-Bunnell). Although both
procedures rebalance the hand and improve asynchronous nger motion and clawing, only the addition of a wrist motor will increase grip strength. This use of a
wrist motor usually is indicated for younger individuals and for persons with
higher functional demands.
Four-Tail Graft
The extensor carpi radialis brevis (ECRB) is an ideal motor unit for tendon
transfer in intrinsic paralysis. The exor carpi radialis can be substituted if the
ECRB is absent or required for another procedure (e.g., thumb adductorplasty).
Although clawing of the index and long ngers is typically absent in low ulnar
nerve lesions, inclusion of all four ngers in the transfer is recommended for
improved hand strength and dexterity. Four slips of tendon graft are required to
prolong the ECRB for insertion into the proximal phalanges. The plantaris tendons
from both lower extremities are readily accessible, and each will typically supply
two tendon graft lengths. These slips are harvested through limited incisions using
a tendon-stripping instrument. The long toe extensors may be used if the plantaris
tendons are absent or of insufcient size.

TENDON TRANSFERS FOR INTRINSIC FUNCTION IN ULNAR NERVE PALSY

Preoperatively, the function of the ring and small nger extrinsic extensor
tendons is assessed with the Bouvier test (Fig. 3)

Figure 3. The Bouvier test consists of blocking metacarpophalangeal joint

hyperextension while the patient attempts digital extension. With supple
interphalangeal joints, near complete active nger extension should be
present if the central extensor tendons are competent.

If it is difcult to achieve active extension of supple proximal interphalangeal (PIP)

joints with MCP hyperextension blocked, the central tendons have attenuated. In
this setting, an improvement in active extension may be achieved by insertion of the
transfers into the dorsal apparatuses rather than into the proximal phalanges; however, caution is advised with this variation in technique because PIP hyperextension
and swan neck deformities may develop.

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For bony insertion, angled skin incisions approximately 2 cm in length are

made at the radial bases of the middle, ring, and small ngers. A fourth angled
incision is made at the ulnar base of the index nger (Fig. 4).

Figure 4. Proposed incisions for the extensor carpi radialis brevis four-tail tendon
graft procedure.

The lateral bands are identied and retracted dorsally, exposing the proximal phalanges. A 2.0-mm transverse drill hole is made through each proximal phalanx at a
point in the mid axiscorresponding to the second annular pulley. The near cortices
are enlarged with a 2.7-mm drill bit or curette to accommodate insertion of the
tendon grafts (Fig. 5).

Figure 5. Intraoperative view depicting drill hole in the proximal phalanx positioned near the
midline (or slightly palmar) and approximately at the distal half of the second annular pulley.

TENDON TRANSFERS FOR INTRINSIC FUNCTION IN ULNAR NERVE PALSY

Two transverse skin incisions are made over the dorsal hand, one between the
second and third metacarpals and one over the fourth metacarpal. The interosseous
fascia is incised longitudinally between each metacarpal. Sutures are placed in the
distal ends of all four tendon slips using a pull-through technique (Bunnell or
Kessler). A Chevron incision approximately 8 cm in length is designed over the
dorsoradial border of the extensor retinaculum. The insertion of the ECRB is released sharply from the base of the middle metacarpal, taking care to protect
branches of the dorsal sensory radial nerve. The tendon is withdrawn proximally
from beneath the extensor retinaculum.
Two tendon grafts are passed through the interspace between the second and
third metacarpals for the index and middle ngers. One graft is passed through the
interspace between the third and fourth metacarpals and the other slip through the
interspace between the fourth and fth metacarpals. Each graft must follow an
unimpeded course through the interosseous muscles, under the transverse metacarpal ligament (through the lumbrical canal), and toward the prepared insertion site
in the proximal phalanx. A curved tendon passer is helpful in this regard, and
passage is aided by exion of the MCP joints.
The tendons are seated securely by passing the attached sutures through the
bone tunnels with Bunnell or Keith needles (Fig. 6).

Figure 6. Routing of the tendon graft extensions.

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The suture ends are tied snuggly over padded buttons on the opposite side of each
digit. All four tendon grafts are tunneled through subcutaneous tissues proximally
in a direct line toward the ECRB tendon (Fig. 7). Once this maneuver is accomplished, all distal wounds are closed.

Figure 7. Tendon grafts have been secured distally and are drawn in a straight-line path
into the proximal wound. Note the closure of all distal wounds.

TENDON TRANSFERS FOR INTRINSIC FUNCTION IN ULNAR NERVE PALSY

The grafts are rst sutured to one another under appropriate balance. It is
helpful to combine the ring and small and the index and middle grafts separately
before joining all four grafts together. Care should be taken not to overtighten the
index nger graft relative to the others, which can lead to an adduction contracture
of the index nger and scissoring. Once balanced, the tendon mass is woven in a
Pulvertaft fashion into the ECRB and secured (Fig. 8).

Figure 8. Tendon grafts have been sutured to the extensor carpi radialis brevis with a Pulvertaft weave.

Correct tensioning is achieved with the wrist held in full dorsiexion and the nger
MCP joints in maximum exion, taking up approximately 50% of the excursion of
the donor tendon. Following repair, the wrist is brought through a range of motion,
demonstrating tenodesis of all nger MCP joints into exion with the wrist exed.
Full passive MCP joint extension should be possible with the wrist extended. The
wrist is immobilized postoperatively in approximately 45 degrees of extension, with
the MCP joints exed 60 degrees and the IP joints extended.

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Flexor Digitorum Supercialis Transfer (Stiles-Bunnell)

This procedure uses one exor digitorum supercialis (FDS) tendon as the
donor transfer. The FDS tendon from either the index or middle nger is released
and split. The two tendon slips are transferred through the lumbrical canals of the
ring and small ngers and inserted most commonly into the lateral bands of the
nger extensor mechanisms. Usually, the tendon slips are of adequate length and do
not require tendon graft extensions. The goal is to rebalance the hand, correcting the
claw deformities and improving a synchronous nger motion (Figs. 9A and B).

Figure 9. A, Follow-up revealing intrinsic plus posture with metacarpophalangeal exion and interphalangeal joint extension. B,
Restoration of synchronous nger exion.

TENDON TRANSFERS FOR INTRINSIC FUNCTION IN ULNAR NERVE PALSY

No increase in strength is anticipated. Several variations of this technique have been

described, including subdividing the long nger FDS into four slips for transfer to
all four ngers, attachment of the tendon slips to the exor tendon sheaths, and
attachment of the tendon slips to the proximal phalanges through bone tunnels as
previously described.
The middle nger FDS is harvested over the PIP joint palmarly, and both slips
are released sharply, dividing Campers chiasm. A transverse incision is made in
line with the distal palmar crease across the fourth metacarpal. The FDS tendon is
withdrawn into the proximal wound, and the longitudinal split in the tendon is
extended proximally to create two slips of equal caliber (Fig. 10).

Figure 10. Stiles-Bunnell transfer. Two slips of the middle

nger exor digitorum supercialis are created and passed
dorsal to neurovascular structures in preparation for transfer.

Sutures are placed into both distal tendon ends to assist in the transfer.

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Curvilinear or angled skin incisions approximately 2 cm in length are made at

the dorsoradial bases of the ring and small ngers. The lateral band projecting to
each extensor mechanism is identied. Both tendon slips must follow an unimpeded
course through the hand, dorsal to common digital arteries and nerves and palmar
to the transverse metacarpal ligaments. A tendon passer is used to create this path
and to draw each tendon slip separately to the target nger (Fig. 11). The palmar
wounds are closed.

Figure 11. The exor digitorum supercialis tendon slips

are rerouted distally through the lumbrical canals and
passed into the dorsal wounds.

TENDON TRANSFERS FOR INTRINSIC FUNCTION IN ULNAR NERVE PALSY

With the wrist positioned in neutral and the ring and small ngers in the
intrinsic plus position, the tendon slips are sutured to the lateral bands, taking up
50% to 80% of allowable FDS excursion. Proper tensioning is tested with passive
wrist motion. Flexion of the wrist should allow near full extension of the ring and
small nger MCP joints, whereas extension of the wrist should lead to a normal
cascade of MCP joint exion (Figs. 12A and B).

Figure 12. A, Following suture to the lateral bands, extension of the ring and
small ngers is present with passive wrist exion that deactivates the transfer.
B, Normal intrinsic plus cascade of metacarpophalangeal joint exion is seen
with passive wrist extension.

The tendon junctions are loosened or tightened as deemed necessary. Postoperatively, the wrist is positioned in neutral to slight exion, with the MCP joints exed
to approximately 60 degrees and the IP joints extended.

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Thumb Pinch
Many procedures have been developed to restore thumb adduction in patients
with ulnar nerve palsy. Most of these operations address balance and cosmetic
issues rather than improved pinch and adduction strength. Similar to techniques
addressing claw deformities in the ngers, a strong motor is necessary if enhanced
power is to be expected. Adductorplasty with transfer of the ECRB has been shown
to almost double thumb pinch strength. The operation entails lengthening the ECRB
tendon with a graft to insert into the adductor pollicis tendon. A concomitant fusion
of the thumb MCP joint is considered to augment pinch strength and improve
longitudinal stability of the thumb. Not all patients with ulnar nerve palsy are
appropriate candidates for adductor plasty and MCP joint fusion. Even with a
weakened pinch, a patient may report minimal thumb decits.
Extensor Carpi Radialis Brevis Thumb Adductorplasty
A Chevron incision approximately 8 cm in length is made over the dorsoradial
border of the extensor retinaculum. The insertion of the ECRB is released sharply
from the base of the third metacarpal, and the tendon is withdrawn proximally
from beneath the extensor retinaculum. A 2- to 3-cm transverse incision is made
over the proximal aspect of the second intermetacarpal space, and the fascia overlying the second dorsal interosseous muscle is incised longitudinally. A subcutaneous
tunnel is created with a curved clamp, connecting the dorsal wrist and hand
wounds. A 2- to 3-cm curvilinear incision is then made along the dorsoulnar border
of the thumb MCP joint, and the insertion of the adductor pollicis tendon is exposed. If fusion of the MCP joint is planned, then it is completed at this time.
A curved clamp is passed through the second intermetacarpal space beneath
the metacarpal and directed toward the thumb MCP joint in the interval between
the adductor pollicis and rst dorsal interosseous muscles (Fig. 13).

Figure 13. Incisions and donor extensor carpi radialis brevis tendon for adductorplasty. A curved
clamp is positioned in the interval between the adductor pollicis and rst dorsal interosseous
muscles. Note plantaris tendon graft in the foreground.

TENDON TRANSFERS FOR INTRINSIC FUNCTION IN ULNAR NERVE PALSY

The ipsilateral palmaris longus tendon is harvested through two or three small
transverse incisions or with the aid of a tendon stripper. A graft approximately 16
cm in length usually can be obtained. If the palmaris longus is absent or of insufcient size, other sources of autogenous tendon graft may be used (e.g., plantaris,
long toe extensor).
One end of the tendon graft is sutured to the adductor pollicis tendon at its
bony insertion into the phalanx (Fig. 14).

Figure 14. The graft is rst secured to the adductor pollicis tendon at its bony
insertion.

The free end of the graft is then withdrawn through the second intermetacarpal
space with a curved clamp. The graft is then passed through the subcutaneous
tunnel proximally, lying dorsal to the extensor retinaculum. The distal incisions are
closed.

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With the wrist in neutral alignment and the thumb held tightly against the
volar radial border of the index nger, the graft is woven into the ECRB, taking up
50% to 80% of the donor tendons excursion (Fig. 15).

Figure 15. The distal wounds are closed and the tendon graft is woven into the extensor carpi
radialis brevis donor under the appropriate tension.

TENDON TRANSFERS FOR INTRINSIC FUNCTION IN ULNAR NERVE PALSY

When the wrist is placed in exion, the thumb should adduct rmly against the
index metacarpal. With the wrist extended, the thumb should easily be abducted
away from the palm (Figs. 16A and B).

Figure 16. A, Following transfer, passive exion of the wrist results in strong thumb
adduction. B, Full palmar abduction is possible with wrist extension, which deactivates
the transfer.

Postoperatively, the wrist is splinted in 45 degrees of extension with the thumb

in palmar abduction. The thumb IP joint may be left free. Modications in the splint
may be required to accommodate concomitant tendon transfers to the ngers.

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REHABILITATION
In patients treated with an ECRB four-tail graft procedure, a short-arm dorsal
splint is fabricated, which maintains the wrist in 45 degrees of extension and the
MCP joints in 60 degrees of exion. Early active IP joint exion and extension are
encouraged. Composite motion exercises of the wrist and digits are initiated out of
the splint after 3 weeks, and the pull-out sutures are removed between 4 and 6
weeks postoperatively. The forearm splint may be converted to a smaller handbased lumbrical bar splint during that time period. Protective splinting is discontinued 6 to 8 weeks following surgery, and grip-strengthening exercises are added to
the rehabilitation program. Unrestricted activities are permitted after 3 months.
The forearm splint is modied for the Stiles-Bunnell procedure to position the
wrist in neutral-to-slight exion. The MCP joints are maintained in 60 degrees of
exion, and early IP nger motion exercises are encouraged. Composite motion of
the wrist and ngers out of the splint is permitted 3 weeks postoperatively, and
grip strengthening is initiated at 8 weeks. A hand-based lumbrical splint may be
substituted for the forearm splint 3 weeks postoperatively and slowly weaned from
use over a 2- to 4-week period. Unrestricted activities are allowed after 3 months.
Following an ECRB adductorplasty, extension of the thermoplast splint to include the proximal phalanx of the thumb is indicated, and IP joint motion of the
thumb is not restricted. The wrist should be positioned in neutral to 45 degrees of
extension. A supervised range of motion program is initiated after 3 weeks and
includes active thumb abduction with the wrist exed and extended and passive
thumb adduction. Active thumb adduction exercises and strengthening are included
in the rehabilitation program 6 weeks postoperatively. Protective splinting is discontinued at that time, with unrestricted activities permitted 4 to 6 weeks later.

SUMMARY
Ulnar nerve dysfunction leads to sensory loss, a claw deformity with asynchronous nger motion, diminished digital abduction and adduction, and weakened
grip and pinch strength. Often, the index and long ngers appear uninvolved.
Various tendon transfers can effectively treat clawing and improve nger balance.
Transfer of a wrist exor or extensor muscle-tendon unit will enhance grip strength
and maximize hand coordination. Use of a nger exor for transfer simply redistributes balance within the hand and may diminish grip strength.
Transfer selection is based on patient age, expectations, joint mobility, and
tendon availability. Patient compliance with a postoperative rehabilitation program
is important for an optimal outcome.
Thumb adductorplasty is reserved for patients who are functionally impaired
by weak thumb pinch. A concomitant MCP joint arthrodesis can be considered for
improved longitudinal stability to the thumb.

References
1. Brand PW: Tendon transfers for correction of
paralysis of intrinsic muscles of the hand. In
Hunter JW, Schneider LH, Mackin EJ (eds):
Tendon Surgery of the Hand. St. Louis, Mosby,
1987, pp 439 499
2. Brand PW: Ulnar nerve paralysis. In Chapman
MW (ed): Operative Orthopaedics, ed 2. Philadelphia, JB Lippincott, 1993, pp 1477 1485
3. Burkhalter WE, Strait JL: Metacarpophalangeal
exor replacement for intrinsic muscle paralysis. J Bone Joint Surg 55A:1667 1676, 1973

4. Hastings H II: Ulnar nerve paralysis. In Strickland JW (ed): The Hand. Philadelphia, Lippincott-Raven, 1998, pp 335 350
5. Hastings H II, Davidson S: Tendon transfers
for ulnar nerve palsy: Evaluation of results and
practical treatment considerations. Hand Clin
4:167 178, 1988
6. Hentz VR: Stiles-Bunnell tendon transfer for
ulnar nerve palsy. Atlas of the Hand Clinics 5:
31 45, 2000
7. Jebson PJL, Steyers CM: Adductorplasty with

TENDON TRANSFERS FOR INTRINSIC FUNCTION IN ULNAR NERVE PALSY

the extensor carpi radialis brevis. In Blair WF
(ed): Techniques in Hand Surgery. Baltimore,
Williams and Wilkins, 1996, pp 682 687
8. Omer GE Jr: Ulnar nerve palsy. In Green DP,
Hotchkiss RN, Pederson WC (eds): Greens
Operative Hand Surgery, ed 4. Philadelphia,
Churchill Livingstone, 1999, pp 1526 1541

9. Smith RJ: ECRB tendon transfer for thumb adduction: A study of power pinch. J Hand Surg
8:4 15, 1983
10. Smith RJ: Tendon transfers to restore intrinsic
muscle function to the ngers. In Tendon
Transfers of the Hand and Forearm. Boston,
Little, Brown, 1987, pp 103 133
Address reprint requests to
David M. Kalainov, MD
Northwestern Center for Orthopaedics
676 North St. Clair, Suite 450
Chicago, IL 60611
e-mail: dkalainov@aol.com

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