1082 3131/02 $15.00 + .

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TENDON TRANSFERS

Tendon Transfer for Radial

Nerve Palsy
Michael E. Rettig, MD, and Keith B. Raskin, MD

Complete injury to the radial nerve results in the inability to extend the wrist
and ngers actively, resulting in a considerable impairment of hand function. Loss
of active wrist extension impairs the ability to pick up objects and inhibits wrist
stabilization for power grip. When an attempt is made to extend the digits, the
wrist is simultaneously exed to use the tenodesis effect of wrist exion. Tendon
transfers for radial nerve palsy must restore active wrist, nger, and thumb extension without sacricing key median nerve and ulnar nerve innervated motor
units.

ANATOMY
The radial nerve is the continuation of the posterior cord of the brachial plexus.
It passes through the triangular space beneath the teres major muscle in the posterior aspect of the shoulder. In the arm, the nerve lies on the posterior humeral
spiral groove, between the lateral and medial heads of the triceps muscle. After
giving off branches to the lateral head of the triceps, the radial nerve penetrates the
lateral intermuscular septum and enters the anterior compartment. After the nerve
enters the anterior compartment, motor branches exit to the brachioradialis and the
extensor carpi radialis longus (ECRL).
The radial nerve traverses down the arm anterior to the elbow in the interval
between the brachialis and the brachioradialis. It then divides into the posterior
interosseous nerve (PIN), which enters the arcade of Froshe at the proximal edge of
the supinator muscle and the supercial radial nerve. The PIN then innervates, in
order, the supinator, extensor digitorum communis (EDC), extensor carpi ulnaris
(ECU), extensor digiti quinti (EDQ), abductor pollicis longus (APL), extensor pollicis
longus (EPL), extensor pollicis brevis (EPB), and extensor indicis proprius (EIP). The
extensor carpi radialis brevis (ECRB) can receive its innervation from the radial
nerve proper, supercial radial nerve, or PIN.1

From the Department of Orthopaedic Surgery, New York University Medical Center, New York, New
York (MER, KBR)

ATLAS OF THE HAND CLINICS Volume 7 Number 1 March 2002

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RETTIG & RASKIN

Most injuries to the radial nerve occur distal to its innervation of the triceps.
The nerve is vulnerable to injury from an adjacent fracture of the humerus typically
at the junction of the middle and distal thirds of the humerus where the radial
nerve can be tethered as it enters the lateral intermuscular septum. Many of these
injuries are neurapraxias and spontaneously recover. The radial nerve also can be
damaged by traumatic lacerations in this area, or during surgical procedures around
the lateral aspect of the elbow and the posterior aspect of the proximal forearm.

GENERAL PRINCIPLES
Tendon transfers to restore wrist and digit extension are performed when radial
nerve recovery can no longer be expected or for wrist stabilization alone as an
internal splint after radial nerve repair. Depending on the mechanism of injury and
the time elapsed from injury, this damage can be determined by repeat physical
examination in conjunction with electromyography of the radial nerve innervated
muscles.
General principles of tendon transfer must be followed to ensure a satisfactory
functional outcome when performing tendon transfer for radial nerve palsy. A
thorough examination of the upper extremity should be completed preoperatively to
identify any previous lacerations that could adversely affect the tendon transfer
procedure. Alternatively, previous surgical incisions can be used for tendon transfers as long as the basic principles of transfer are followed. Tendon transfer surgery
should be performed only after tissue equilibrium has been reached. The skin and
subcutaneous tissues must be pliable and soft, and all of the joints that will be
motored by the tendon transfer need to be supple without contractures. The active
range of motion achieved by the transfer will not exceed the preoperative passive
range of motion.
The strength and excursion of the potential donor tendons are tested. If the
potential donor tendon has been injured, or if the nerve supplying innervation to
the donor tendon has been traumatized, an alternative donor tendon should be
considered. The donor tendon must be expendable without residual functional impairment. Planning of radial nerve tendon transfers can be facilitated by evaluating
what decits need to be replaced and what donor tendons are available to transfer.
In an upper extremity with an isolated injury to the radial nerve, all muscle-tendon
units innervated by the median and ulnar nerve are potentially available to transfer
for wrist and nger extension.
One of the earliest descriptions of tendon transfer for radial nerve palsy was by
Franke in 1899, who transferred the exor carpi ulnaris (FCU) to the EDC through
the interosseous membrane. During the same year, Capellen reported transfer of the
exor carpi radialis (FCR) to the EPL. Sir Robert Jones, regarded as one of the major
contributors describing radial nerve tendon transfers, added the pronator teres (PT),
ECRL and ECRB to these transfers. Jones made further modications in 1916 and
again in 1921. In 1946 Zachary reported that the FCR should be preserved for wrist
exion.38
Over 50 modications of tendon transfers have been described for radial nerve
palsy. Three major groups of transfers have gained popularity. The FCU and the
FCR transfer use the pronator teres to the ECRB and the palmaris longus to the
rerouted EPL. These two transfers differ in the motor to the EDC, using either the
FCU or the FCR. The major criticism of the FCU transfer is the detrimental loss of
the major wrist exor and ulnar deviator of the wrist, the FCU being too short and
too strong to be effective for nger extension, and the potential disabling radial
deviation with wrist extension that can occur with loss of stabilization on the ulnar
aspect of the wrist.58

TENDON TRANSFER FOR RADIAL NERVE PALSY

Boyes developed the supercialis transfer for digital extension.2 The supercialis tendons have a greater excursion than the FCU or FCR and are ideal motors for
nger extension. The supercialis transfer uses the pronator teres to ECRL or ECRB,
FDS III to EDC, FDS IV to EIP and EPL, and FCR to APL and EPB.
The most common tendon transfer used for radial nerve palsy remains the
pronator teres to ECRB, FCU to EDC, and a rerouted palmaris longus to EPL,
despite the potential problems with the FCU transfer. Raskin and Wilgis demonstrated the long-term maintenance of wrist range of motion and power to perform
daily activities and an overall excellent functional recovery with the FCU transfer.
Furthermore, cadaver studies showed the ability to deviate the wrist despite loss of
the FCU.4
The nal decision as to which transfer to perform ultimately depends on the
requirements of the patient, the experience of the surgeon, and the available donor
tendons. All of these tendon transfers adhere to the principles of one tendon one
function, synergism, adequate excursion and strength of the donor tendon, and
establishing a straight line of pull to the tendon insertion. Only when these concepts
can be adhered to should surgery proceed to restore wrist and digit extension.

SURGICAL TECHNIQUE
Tendon transfer for radial nerve palsy is performed as an outpatient procedure
under either regional or general anesthesia. The arm is prepared and draped in the
usual sterile fashion, and hemostasis is obtained through exsanguination and upper
arm tourniquet elevation.
Preoperative planning includes skin markings in the appropriate locations
based on an accurate assessment of surface anatomy. Two incisions are used. For
harvesting of the FCU and palmaris longus tendon, an inverted L-shaped incision is
drawn out on the volar ulnar aspect of the distal forearm and wrist, extending from
the transverse wrist crease along the ulnar border of the forearm. The insertion of
the palmaris longus can be accessed through the most radial aspect of the transverse
component of the incision. For exposure of the pronator teres and the insertion sites
of the transfer, a Chevron incision with the apex ulnarly is drawn over the middle
to distal forearm level, allowing the skin ap to be elevated to harvest the pronator
teres with an extended strip of periosteum, as well as the performance of transfers
into the EPL, EDC, and ECRB. Any previously healed surgical incisions should be
evaluated and incorporated into these incisions.

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RETTIG & RASKIN

The incision over the volar ulnar aspect of the wrist is followed by elevation of
the skin ap while cutaneous nerves are identied and protected. The FCU tendon
is isolated and dissected in a distal-to-proximal direction. Protecting the ulnar nerve
and artery, the surgeon transects the FCU at its insertion into the pisiform. The FCU
tendon and its proximal muscle belly are dissected from surrounding fascial attachments in a distal-to-proximal direction while protecting the ulnar nerve and artery.
This mobilization increases the FCU excursion and allows for adequate redirection
of the tendon for transfer. The most distal muscle belly of the FCU can be trimmed
to decrease the muscle bulk around tendon to improve coaptation to the EDC
tendon. The FCU proximal muscle belly must be mobilized adequately. The fascial
layer along the ulnar border of the forearm, between the FCU and the ECU, is
excised to facilitate this mobilization and to ensure a straight line of pull to the
EDC. Care is taken to avoid the motor branches of the ulnar nerve that enter the
FCU distal to the medial epicondyle. The palmaris longus is located after identication and protection of the palmar cutaneous branch of the median nerve, transected
at its distal insertion into the palmar fascia, and mobilized in a distal-to-proximal
direction (Fig. 1A C).

TENDON TRANSFER FOR RADIAL NERVE PALSY

Palmar incision

FCU

PL

PT

FCU

FCU
Ulnar n.
Ulnar a.

B
Figure 1. A, Volar ulnar incision for exposure of exor carpi ulnaris (FCU) and palmaris longus
(PL) tendon insertion. PT pronator teres. B, Transection of FCU at its insertion into the
pisiform and proximal mobilization.
Illustration continued on following page

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RETTIG & RASKIN

FCU
Cutaneous branch
of median n.
PL

C
Figure 1 (Continued). C, Palmaris longus transected at its insertion into
the palmar fascia.

Once both of these tendons have been prepared for transfer, the dorsal incision
is made. The soft-tissue aps are carefully elevated. The wrist and nger extensor
tendons are identied proximal to the extensor retinaculum. The tendon of the
pronator teres is identied on the volar radial aspect of the forearm at its attachment to the radial shaft. The tendon insertion of the pronator teres is sharply
elevated off of the radial shaft with a several-centimeter, broad-based strip of periosteum to ensure satisfactory length to complete the transfer to the ECRB. The
tendon is then dissected in a distal-to-proximal direction to free the fascial attachments of the muscle to allow for a straight line for tendon transfer insertion. The
periosteal strip is imbricated before completing the transfer to increase the strength
of the distal aspect of the pronator teres (Fig. 2A C).

TENDON TRANSFER FOR RADIAL NERVE PALSY

Dorsal incision
Radial view

Brachioradialis

Periosteal
strip

Insertion of
PT

Insertion of
PT

Supinator

B
Dorsal view

Extensor
retinaculum

Branches of radial
sensory n.

Transect
EPL

HA0203.12.02abc.lay
Figure 2. A, Dorsal Chevron incision for exposure of the extensor tendons and pronator teres (PT). B,
Elevation of the PT tendon from the radial shaft with a periosteal strip. C, Rerouting of the extensor pollicis
longus (EPL) from the extensor retinaculum after proximal transection.

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RETTIG & RASKIN

At the extensor retinaculum, the EPL is identied and rerouted out of the third
compartment to the radial aspect of the thumb after transection of the most proximal end of the tendon at the musculotendinous junction. The distal stump of the
EPL is now dorsal to the rst dorsal compartment. The terminal branches of the
radial sensory nerve remain supercial to the EPL so they are not compressed by
the tendon transfer.
Subcutaneous tunnels are made in preparation for transfer. All of the donor
tendons must be freed sufciently from the surrounding fascial and muscle attachments to allow a straight line of pull to their recipient tendon. The FCU is brought
around the subcutaneous ulnar aspect of the forearm to the EDC with a tendon
passer (Fig. 3).

Dorsal view

Branches of radial
sensory n.

Extensor
retinaculum

Transected EPL
above extensor
retinaculum

FCU

PT with imbricated
periosteal strip

Figure 3. Flexor carpi ulnaris is brought around ulnar forearm to the extensor digitorum
comminus (EDC) tendons. Pronator teres periosteal sleeve imbricated in preparation for transfer.

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TENDON TRANSFER FOR RADIAL NERVE PALSY

The EDC tendons are identied proximal to the extensor retinaculum. The EIP
and EDQ, lying ulnar to the EDC to the index and little ngers, are not included in
the transfer. The skin is elevated in the volar radial distal forearm for the palmaris
longus tendon stump to be delivered to the EPL, and the pronator teres is tunneled
to the ECRB, supercial to the brachioradialis and ECRL.
Once the donor tendons are tunneled to their insertion sites and the three
motor muscles are ready for transfer, the tourniquet can be deated. Hemostasis can
be obtained before competing the transfers. The incision over the volar ulnar distal
forearm can be repaired.
Setting the proper tension for the transfer is one of the critical steps in the
procedure. The tension must be enough to provide for sufcient extension of the
wrist, ngers, and thumb, but not too tight to restrict wrist or digit exion. The
tendon transfer tends to lose slight tension than that obtained intraoperatively;
therefore the transfer is performed with a slightly increased tension. The tendon
transfer for the thumb and ngers should be completed before the wrist transfer
because the tenodesis effect through passive wrist exion and extension is used to
gauge the tension of the thumb and nger extensor transfer. Once the wrist extensor
tension is completed intraoperatively, wrist exion should be avoided.
Transfer to the EDC is completed by using a No. 11 scalpel blade or tendon
braider to fenestrate each of the EDC tendons, proximal to the extensor retinaculum.
The FCU is then passed through each of the recipient EDC tendons in a slight
oblique fashion from proximal ulnar to distal radial (Fig. 4A and B).

Fenestration of
EDC tendons

FCU
FCU

A
B
Fenestration of
EDC tendons
EDC tendons

EDC tendons

Figure 4. A and B, Flexor carpi ulnaris tendon transferred to fenestrated EDC recipient tendons in an
oblique fashion proximal to extensor retinaculum.

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RETTIG & RASKIN

The transfer is set by placing the FCU under maximum tension and securing it to
each of the EDC tendons individually with 4-0 nonabsorbable suture. The wrist is
placed in slight extension and the metacarpophalangeal joints in full extension. The
tension is then evaluated by passively exing and extending the wrist. With the
wrist in 30 degrees of exion, the ngers should be in full extension; with the wrist
fully extended, the ngers should be able to be exed passively into the palm. The
ngers should all extend while maintaining a normal cascade. Once the appropriate
tension is set, additional sutures between the FCU and each individual digital
extensor tendon secure the repair.
Intraoperative assessment of the completed transfer with wrist exion and extension must also include evaluating the line of pull and the excursion. The EDC
tendons proximal to the transfer can be transected if their intact musculotendinous
junction seems to be interfering with a direct line of pull to digit extension. If the
excursion of the transfer is impeded by the proximal aspect of the extensor retinaculum, the leading edge of the retinaculum should be opened.
The next transfer is the palmaris longus to the EPL. The transfer is dorsal to the
extensor retinaculum overlying the rst dorsal compartment tendons. A Pulvertaft
weave of three passes of the palmaris longus through the EPL is accomplished and
secured with 4-0 nonabsorbable sutures (Fig. 5A and B).

EPL
EPL

PL

FCU
PL

EDC

Figure 5. A and B, PL woven into rerouted extensor pollicis longus (EPL) supercial to the
extensor retinaculum.

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TENDON TRANSFER FOR RADIAL NERVE PALSY

The palmaris longus is transferred under maximum tension, with the EPL also
under maximum tension, with the wrist in neutral and the thumb extended and
abducted in a radial direction. The tension is again evaluated by passively exing
and extending the wrist. With the wrist in exion, the thumb extends and abducts.
With the wrist in full extension, the thumb should be able to contact the radial
border of the index nger at the interphalangeal joint.
The pronator teres and periosteal extension are then woven into the ECRB, just
distal to its musculotendinous junction with a Pulvertaft weave. If the periosteal
strip is not substantial, part of the ECRB proximal to the weave can be divided and
folded back on itself to improve the strength of the transfer. The transfer is sutured
into position with the wrist in 60 degrees of extension and with maximum tension
on the pronator teres. The ECRB tendon proximal to the transfer can be transected if
its intact musculotendinous junction seems to be interfering with a direct line of
pull to wrist extension (Fig. 6A and B).

ECRB
ECRL

ECRB

PT
PT

B
Figure 6. A and B, Transfer completed with the PT woven into the extensor carpi radialis brevis (ECRB)
with the wrist in 60 of extension. ECRL extensor carpi radialis longus.

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RETTIG & RASKIN

After completion of the tendon transfers, the wrist and digits are supported and
the dorsal wound approximated. The upper extremity is placed into a volar plaster
splint maintaining the elbow exed at 90 degrees, the wrist in extension, and
supporting the metacarpophalangeal joints in exion of approximately 30 to 45
degrees. The plaster splint maintains the thumb in an extended and abducted
position.
After suture removal, a berglass cast is applied and maintained for 4 to 6
weeks. The wrist and ngers are then placed into a volar orthoplast splint providing resting extension support. The splint is worn between occupational therapy
sessions for an additional 4 weeks. A formal occupational therapy program is
instituted for transfer training.

References
1. Adams RA, Ziets RJ, Lieber RL, et al: Anatomy
of the radial nerve motor branches in the forearm. J Hand Surg 22A:232 237, 1997
2. Chiunard RG, Boyes JH, Stark HH, et al: Tendon transfers for radial nerve palsy: Use of supercialis tendons for digital extension. J Hand
Surg 3:560 570, 1978
3. Jones R: Tendon transplantation in cases of
musculospiral injuries not amenable to suture.
Am J Surg 35:333 335, 1921
4. Raskin KB, Wilgis EFS: Flexor carpi ulnaris
transfer for radial nerve palsy: Functional testing of long-term results. J Hand Surg 20A:737
742, 1995

5. Riordan DC: Tendon transfers in hand surgery.

J Hand Surg 8:748 753, 1983
6. Riordan DC: Radial nerve paralysis. Orthop
Clin North Am 5:283 287, 1974
7. Smith RJ: Tendon transfers to restore wrist and
digit extension. In Tendon Transfers of the
Hand and Forearm. Boston, Little, Brown, 1987,
pp 35 56
8. Strickland JW, Kleinman WB: Tendon transfers
for radial nerve paralysis. In Strickland JW: The
Hand. Philadelphia, Lippincott-Raven, 1998, pp
303 318

Address reprint requests to

Michael E. Rettig, MD
Department of Orthopedic Surgery
New York University Medical Center
317 East 34th Street, 3rd Floor
New York, NY 10016