Definition
- Restore function lost to nerve palsy or tendon loss
- Used when nerve recovery is not expected
Management
- Supple joints with full passive range first
- Mature, well healed tissue bed (soft tissue equilibrium)
- Donor loses about one MRC grade after transfer
- Expendable donor, creating no new deficit
- Excursion about 33 mm wrist, 50 mm finger extensors, 70 mm finger flexors
- Straight line of pull and one function per transfer
- Synergistic donors where possible
- Early transfer acts as an internal splint alongside nerve repair
- Radial palsy, pronator teres to ECRB for wrist extension
- Radial palsy, FCR to EDC (Brand) or FCU to EDC (Jones)
- FCU transfer sacrifices ulnar deviation and the dart thrower’s motion
- Radial palsy, palmaris longus to rerouted EPL
- Boyes transfer, FDS middle and ring through interosseous membrane to EDC, EIP and EPL
- PIN palsy spares ECRL, so skip wrist extension transfer and preserve FCU
- Low median palsy, EIP opponensplasty (Burkhalter)
- Ring FDS around an FCU pulley (Bunnell)
- Palmaris longus with palmar fascia (Camitz) for severe carpal tunnel in the elderly
- Abductor digiti minimi (Huber) for congenital thumb hypoplasia
- High median palsy, brachioradialis to FPL
- Side to side tenodesis of index and middle FDP to ulnar FDP
- Low ulnar palsy causes clawing, weak lateral pinch and loss of index abduction
- Zancolli lasso, Stiles-Bunnell FDS to lateral bands, or ECRL with grafts (Brand)
- Volar plate capsulodesis as a static option
- Adductorplasty with ECRB and graft, or FDS
- EIP or accessory APL slip to first dorsal interosseous
- Ulnar slip of EDQ for Wartenberg sign
- High ulnar palsy, tenodesis of ring and little FDP to middle FDP
- Less clawing in high lesions, the ulnar paradox
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.