Reconstruction of thumb opposition, key pinch and claw correction after irreversible median or ulnar nerve injury · OASES-SP principles
- Median palsy loses thumb opposition (APB paralysis — thumb lies in the plane of the palm). Ulnar palsy loses key pinch (adductor pollicis) and develops clawing of ring and small fingers (interossei/lumbricals); Froment's sign is positive.
- Recite the eight transfer principles FIRST (OASES-SP): one function per tendon, adequate strength (M4 minimum — a transfer loses one grade), synergistic action, expendable donor, straight line of pull, soft-tissue equilibrium, full passive ROM. Correct any fixed contracture before transfer.
- Wait 3 to 6 months after nerve injury for spontaneous recovery and confirm irreversibility with EMG/NCS before transfer; do not wait beyond 12 months, because prolonged denervation causes irreversible muscle fibrosis.
- The workhorse median transfer is the Brand or Burkhalter EIP opponensplasty — harvest EIP (ulnar to EDC), route it subcutaneously around the ulnar border of the wrist toward the pisiform, insert into the APB remnant, and tension so the thumb opposes the BASE of the small finger (not the tip).
- The Pulvertaft weave needs 3 or more passes with non-absorbable suture, and the hand is immobilised for 3 weeks before active motion — the sweet spot, since earlier motion risks rupture and later motion risks adhesions.
When & Why
Indication. A patient with an irreversible median or ulnar nerve injury — confirmed by no clinical or EMG recovery 3 to 6 months after injury or repair — and a corresponding functional deficit that is inadequately compensated, provided the prerequisites for transfer are met. The four deficits worth reconstructing are thumb opposition (median), weak key pinch (ulnar, Froment's sign), clawing of the ring and small fingers (ulnar), and lost flexion of the thumb or ring and small fingers (high lesions). What each palsy loses determines the transfer plan:
Lost thumb opposition only (APB paralysed). Sensation usually intact. Reconstruction is opponensplasty alone.
Opposition lost, plus FPL (thumb IP flexion) and FDP to index and middle, and pronator teres. Multiple transfers required, staged.
Clawing of ring and small fingers (MCP hyperextension, IP flexion), weak key pinch (adductor pollicis, positive Froment's) and weak grip (interossei). FDP is intact, so clawing is severe.
All of the above, plus FDP to ring and small is paralysed — so there is paradoxically LESS clawing (the ulnar paradox). Reconstruction priority is FDP side-to-side tenodesis plus intrinsic/adductor work.
Both median and ulnar deficits. Reconstruction is staged and donor choice is constrained by what remains expendable.
No transfer proceeds until passive ROM is full, the soft-tissue envelope is stable, donor muscles are M4 or stronger, and the patient will commit to therapy.
Wait 3 to 6 months after nerve injury for spontaneous recovery. If there is no clinical or EMG improvement, proceed with transfer. Do not wait beyond 12 months — prolonged denervation causes irreversible muscle fibrosis and a poor result regardless of technique.
The eight principles — recite them first. Every successful transfer must satisfy the OASES-SP criteria, and examiners expect them stated before any technique. They are also the framework for choosing a donor:
Loss of the donor must cause minimal deficit and be compensated by remaining tendons (e.g. EIP is expendable because EDC still extends the index). Never sacrifice an essential function.
A transferred muscle loses one grade — an M5 donor becomes M4 (functional), an M3 donor becomes M2 (unacceptable). Check every donor preoperatively.
Each transfer performs a single function; do not split one tendon to multiple insertions (the Brand four-tail is the exception, but it still serves one function — intrinsic rebalancing).
Route the donor directly to its new insertion; avoid sharp angles (friction, bowstringing, lost efficiency) and use a pulley where the vector demands it.
A donor that moves naturally with the new action (e.g. finger extension with thumb opposition) is easier for the patient to relearn — preferable, not essential.
Donor excursion must match the recipient need: opponensplasty needs 3 to 5 cm, intrinsic transfers 2 to 3 cm. FDS gives 7 cm, EIP/EDC about 5 cm, wrist motors only about 3 cm (often insufficient without a graft).
No active scarring, contracture or infection, and stable cover. Correct contractures before transfer — a transfer cannot create motion beyond the passive range.
Cross only one joint where possible to limit the tenodesis effect and improve control; some intrinsic transfers necessarily cross both MCP and IP and are the accepted exception.
Preoperative assessment. Confirm the lesion is irreversible and that the prerequisites are met before listing for surgery.
- Requirement
- No improvement at 3 to 6 months on EMG/NCS
- Action if not met
- Wait and re-image if still improving
- Requirement
- Full passive motion of all joints
- Action if not met
- Release contractures first
- Requirement
- M4 or greater in every intended donor
- Action if not met
- Choose an alternative donor
- Requirement
- Healed, supple, no infection
- Action if not met
- Delay until resolved
- Requirement
- Motivated and understands the rehab commitment
- Action if not met
- Counsel or reconsider
Setup. Supine, arm on a hand table, shoulder abducted about 90 degrees, upper-arm tourniquet, regional or general anaesthesia. Loupe magnification helps nerve and vessel identification. Consent specifically for a transfer that restores function but not normal strength (expect M3 to M4 final), donor-site morbidity, loss of independent donor function, juncture rupture (2 to 5 percent), and the prolonged therapy requirement.
The Operation
The goal is to redirect an expendable, adequately strong, synergistic donor tendon along a straight line to the paralysed insertion, tensioned precisely and secured with a Pulvertaft weave. The Brand EIP opponensplasty is the median-palsy workhorse and is laid out in full below; the ulnar-palsy transfers (Zancolli lasso, FDS four-tail, adductor reconstruction) follow the same principles with different donors and insertions.
- Preferred transfer
- Brand or Burkhalter EIP opponensplasty
- Donor
- EIP
- Notes
- Workhorse; synergistic and expendable
- Preferred transfer
- Royle-Thompson FDS, Phalen-Miller APL, Camitz PL
- Donor
- FDS ring / APL / PL
- Notes
- FDS for high demand; PL for elderly, low demand
- Preferred transfer
- Zancolli FDP lasso
- Donor
- FDP itself
- Notes
- Simplest; loses 10 to 20 degrees of DIP flexion
- Preferred transfer
- FDS four-tail (modified Stiles-Bunnell)
- Donor
- FDS middle or ring
- Notes
- Physiological, active IP extension, no DIP loss
- Preferred transfer
- EIP or ECRL to adductor pollicis
- Donor
- EIP / ECRL
- Notes
- Release first-web contracture first
- Preferred transfer
- Side-to-side tenodesis to ulnar FDP
- Donor
- FDP middle (median)
- Notes
- Restores mass flexion; ECRL-to-FDP if independence wanted
Brand EIP opponensplasty — the median-palsy workhorse (full exposure and steps)
- Supine, hand table, upper-arm tourniquet, shoulder abducted about 90 degrees, thumb free to oppose.
- Identify EIP before any incision. EIP lies ulnar to EDC-index over the index metacarpal. Confirm the test: with the MCP joints flexed, EIP can extend the index independently — EDC cannot. Cutting EDC instead of EIP causes a permanent index extension deficit.
- Longitudinal incision over the dorsal second metacarpal (about 6 to 8 cm), centred over the index MCP, exposing the extensor apparatus.
- Protect the superficial radial nerve branches in the subcutaneous plane — division causes a painful neuroma and dorsoradial numbness.
- Divide EIP at its insertion on the index extensor hood; confirm EDC-index still delivers full extension, then free EIP proximally with blunt dissection to the musculotendinous junction.
- The PIN lies deep to supinator in the proximal forearm and emerges between the superficial and deep EDC. When freeing EIP proximally, stay superficial and on bone; do not chase the muscle belly deep.
- PIN injury is devastating — it paralyses finger and thumb extension and demands further reconstruction.
- Retrieve EIP into a short transverse or oblique distal-forearm incision.
- Create a wide, superficial subcutaneous tunnel sweeping around the ulnar border of the wrist toward the pisiform, then volar across to the thumb. The pisiform acts as the functional pulley that recreates the abductor pollicis brevis line of pull.
- Identify and protect the dorsal sensory branch of the ulnar nerve, which crosses this exact subcutaneous tunnel — division causes a painful dorsoulnar neuroma.
- The transfer must approach the thumb from the ulnar and proximal direction to deliver true opposition (palmar abduction plus pronation); a purely radial route gives only radial abduction.
- Volar-radial incision over the thumb MCP along the thenar crease (2 to 3 cm); protect the radial digital nerve.
- Identify the APB insertion on the radial base of the proximal phalanx (it may be atrophied to a remnant).
- Pass EIP through a subcutaneous tunnel from wrist to thumb without twisting or kinking, then Pulvertaft weave (3 or more passes, 3-0 non-absorbable suture such as Ethibond or FiberWire) into the APB remnant — or into a bone tunnel in the proximal phalanx if the APB is absent.
- With the wrist neutral and the thumb MCP slightly flexed (30 to 40 degrees), tension so the thumb comfortably opposes the base of the small finger.
- Do not tension to the tip of the small finger — that is too tight and the thumb will not adduct back to the palm.
- Confirm the thumb can still adduct to the palm without excessive force; check the tension by passively flexing and extending the wrist (tenodesis check).
- Absorbable subcuticular skin closure, steri-strips and a soft dressing.
- Apply a thumb spica with the thumb in full opposition to the small finger, wrist neutral, forearm included for stability.
- Immobilise strictly for 3 weeks; remove skin sutures at 2 weeks.
- Weeks 0 to 3: strict immobilisation, edema control, no active motion.
- Weeks 3 to 6: splint off for therapy; active opposition exercises and motor re-education (learning to fire EIP for opposition); splint between sessions.
- Weeks 6 to 12: progressive strengthening and functional activity; wean the splint.
- Months 3 to 6: full strengthening and return to full duty. Expect 85 to 95 percent functional opposition, pulp-to-pulp pinch restored, and strength 60 to 80 percent of the normal side.
The posterior interosseous nerve (deep to supinator) is at risk freeing EIP proximally — stay superficial. The dorsal sensory branch of the ulnar nerve crosses the subcutaneous ulnar-border routing tunnel — identify and retract it. Division of either is a serious, avoidable complication.
EIP is ulnar to EDC-index. Flex all MCP joints and test independent index extension: EIP can extend the index alone, EDC cannot. Confirm this before dividing — cutting EDC leaves a permanent index extension lag.
Tension the EIP so the thumb opposes the base of the small finger with the wrist neutral. Tensioning to the tip is the classic error — the transfer ends up too tight and the thumb cannot adduct back to the palm.
Reconstructing the ulnar-palsy hand Two claw corrections and one adductor reconstruction cover most ulnar-palsy hands. Always release a tight first web space before adductor reconstruction, and stage combined work when the soft-tissue envelope needs to settle.
Zancolli FDP lasso — the simplest claw correction
- Bruner zigzag incisions over the A1 pulleys of the ring and small fingers (add the middle finger if involved), centred on the proximal digital crease.
- Protect the neurovascular bundles — the ulnar digital nerve to the small finger runs along the ulnar border; retract it radially and never cut directly over it.
- Identify the A1 pulley (transverse fibres at MCP level) and the FDP tendon deep to FDS.
- Split FDP longitudinally into two equal slips for 2 to 3 cm proximal to A1.
- Pass one slip volar and one dorsal to the A1 pulley to form the lasso; A1 becomes the pulley for FDP. Do not release A2 or A4 — they prevent bowstringing.
- Tension with the MCP flexed 70 degrees and the wrist neutral; the IP joints should extend fully and passively.
- Tenodesis check: extending the wrist flexes the MCP more; flexing the wrist extends it slightly.
- Suture the two FDS/FDP slips to each other with 3-0 non-absorbable suture.
- Skin closure, hand-based splint with the MCP at 70 degrees, IP joints extended, wrist neutral.
- Strict immobilisation 3 weeks, then active MCP flexion and passive IP extension, then strengthening from week 6.
- Expect claw correction in 85 to 90 percent, at the cost of 10 to 20 degrees of DIP flexion (FDP force is redirected to flex the MCP).
Over-tensioning the lasso to 90 degrees causes an MCP flexion contracture and swan-neck deformity that is hard to reverse. 70 degrees is the number. The accepted trade-off is a 10 to 20 degree loss of DIP flexion — warn the patient preoperatively.
FDS four-tail (modified Stiles-Bunnell) — the physiological claw correction
- Volar zigzag incision over the donor finger (usually middle or ring); divide FDS at its insertion on the middle phalanx and free it from the vincula, then retrieve it proximally into the palm. Confirm FDP is still functional.
- Split FDS longitudinally into four equal slips (one per finger).
- Pass each tail through the lumbrical canal on the radial side of each finger, volar to the transverse metacarpal ligament, out to the lateral band.
- Pulvertaft weave each tail into the lateral band at the proximal-phalanx level (2 to 3 passes, 4-0 non-absorbable suture).
- Tension with the MCP at 70 degrees and the IP joints fully extended, equal on all four tails; check by passive wrist motion. Immobilise 3 weeks, then mobilise as for the lasso.
A four-tail transfer using FDS as the motor split to the lateral bands (or A1/A2 pulleys) is the modified Stiles-Bunnell procedure. Brand's original intrinsic reconstruction used a wrist extensor (ECRB/ECRL) plus a free tendon graft split into four tails. The FDS version is often loosely called "Brand four-tail" in practice, but examiners may expect you to attribute the FDS donor to Stiles-Bunnell.
EIP-to-adductor pollicis — eliminating Froment's sign
- Chronic ulnar palsy develops an adduction contracture. Release the contracted first dorsal interosseous and adductor fascia until full passive thumb abduction is achieved. If this is skipped, the adductor transfer will be too tight and the thumb cannot abduct.
- Harvest EIP exactly as for opponensplasty.
- Route it through the second intermetacarpal space (or subcutaneously across the dorsum) to the ulnar base of the thumb proximal phalanx (the adductor insertion) with a straight line of pull.
- Weave into the adductor insertion (or a bone tunnel if tendon quality is poor).
- Tension with the thumb adducted to the side of the index finger, the thumb IP extended (not flexed), wrist neutral, gentle adduction force.
- Thumb spica 3 weeks, active adduction from week 3, strengthening from week 6, full function by 3 to 6 months. Froment's sign is eliminated in about 90 percent and key pinch improves 50 to 80 percent.
- Zancolli lasso
- FDP itself (no separate donor)
- FDS four-tail
- FDS of one finger
- Zancolli lasso
- Simple, shorter
- FDS four-tail
- More complex, longer
- Zancolli lasso
- Good
- FDS four-tail
- Marginally better (RCT)
- Zancolli lasso
- Faster and slightly higher (RCT)
- FDS four-tail
- Good
- Zancolli lasso
- Passive (tenodesis)
- FDS four-tail
- Active, via the lateral bands
- Zancolli lasso
- 10 to 20 degrees
- FDS four-tail
- None (FDP preserved)
- Zancolli lasso
- Faster recovery, grip priority, elderly
- FDS four-tail
- Young, high demand, claw-correction priority
The Pulvertaft weave is the strongest juncture — 3 to 6 passes with non-absorbable 3-0 suture; it withstands more than 250 N biomechanically. Tensioning is the most critical step: too tight causes a swan-neck or boutonniere deformity, too loose gives inadequate function. Use intraoperative passive wrist motion to test, and apply these targets — opponensplasty to the base of the small finger, FPL reconstruction with the IP at 20 to 30 degrees flexion, intrinsic reconstruction with the MCP at 70 degrees.
Aftercare & Complications
Rehabilitation | Phase | Timing | Immobilisation | Therapy | |-------|--------|----------------|---------| | 1 — Protection | 0 to 3 weeks | Splint in the transfer-specific position | No active motion; edema control; ROM of uninvolved digits | | 2 — Early active | 3 to 6 weeks | Removable splint | Gentle active motion of the transfer; motor re-education; splint between sessions | | 3 — Strengthening | 6 to 12 weeks | Splint weaned | Progressive resistance and functional activity | | 4 — Maturation | 3 to 6 months | None | Full strengthening; return to work; final outcome | Most patients return to desk work by about 6 to 12 weeks and full duty by 3 to 6 months. Around 85 to 90 percent achieve a good or excellent result; final strength is typically M3 to M4 (a transfer cannot restore normal strength — set this expectation preoperatively).
Starting active motion before 3 weeks risks juncture rupture; starting after 6 weeks risks adhesions and stiffness. Three weeks is the sweet spot for most transfers. A rupture in weeks 3 to 6 presents as sudden loss of function and needs reoperation and re-weaving.
- Recognition
- Sudden loss of function, typically weeks 3 to 6
- Prevention
- Strict 3-week immobilisation; 3 or more Pulvertaft passes
- Management
- Reoperation, re-weave, re-immobilise
- Recognition
- Index extension lag after EDC cut; FDP cut for FDS
- Prevention
- Confirm independent function before division; EIP is ulnar to EDC
- Management
- Repair the donor if recognised intra-op; revise the plan
- Recognition
- Numbness or a tender Tinel at the scar
- Prevention
- Identify and retract branches under loupe; superficial atraumatic dissection
- Management
- Usually settles; persistent neuroma — desensitisation, injection, excision or bury
- Recognition
- Loss of finger and thumb extension
- Prevention
- Stay superficial and on bone freeing EIP proximally
- Management
- Further reconstruction required; devastating
- Recognition
- Weak opposition or pinch; cannot reach the small finger
- Prevention
- Tension to the base of the small finger; intra-op tenodesis check
- Management
- Revision re-tensioning
- Recognition
- Thumb cannot adduct; PIP hyperextension after intrinsic transfer
- Prevention
- Opponensplasty to base not tip; Zancolli 70 degrees not 90
- Management
- Release or re-tension the transfer; spiral splint; occasionally arthrodesis
- Recognition
- Limited motion despite therapy beyond 3 months
- Prevention
- Early protected motion at 3 weeks; supervised therapy
- Management
- Intensive therapy; tenolysis after 6 months if plateaued
- Recognition
- Deficit in the harvested tendon's original action
- Prevention
- Verify the donor is expendable and test it preoperatively
- Management
- Counselling; occasional reconstruction
- Good prognosis
- Younger, active
- Poor prognosis
- Elderly, sedentary
- Good prognosis
- Motivated, follows therapy
- Poor prognosis
- Poor attendance
- Good prognosis
- Full preoperative motion
- Poor prognosis
- Fixed contractures
- Good prognosis
- M4 to M5
- Poor prognosis
- M3 or less
- Good prognosis
- 6 to 12 months after injury
- Poor prognosis
- More than 2 years (muscle fibrosis)
- Good prognosis
- Protective sensation intact
- Poor prognosis
- Anaesthetic hand
Viva & Exam Focus
OASES-SPTendon transfer principles — OASES-SP (recite first)
Hook:State OASES-SP before describing ANY transfer in the viva — it shows systematic thinking.
FAPEOpponensplasty donor options — FAPE
Hook:FAPE — four options to restore opposition. EIP (Burkhalter/Brand) is the workhorse.
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 32-year-old mechanic presents 6 months after a laceration to the wrist that divided the median nerve. Despite primary nerve repair, he has no recovery of opposition. Examination shows thenar wasting and inability to oppose the thumb, with intact sensation. How would you manage this?”
“A 45-year-old with traumatic ulnar nerve division at the elbow presents 9 months post-injury with clawing of the ring and small fingers, a positive Froment's sign and interosseous wasting. EMG shows no ulnar nerve recovery. What are your management options?”
“What are the principles of tendon transfer? Apply them to choosing a donor for opponensplasty in median nerve palsy.”
Principles (recite first)
- OASES-SP: One function, Adequate strength (M4 min, loses one grade), Synergistic, Expendable, Straight line, Soft-tissue equilibrium, Passive ROM full
- Confirm irreversible nerve injury with EMG/NCS at 3 to 6 months; do not wait beyond 12 months
Median palsy
- Low median = lost opposition only; high median also loses FPL, FDP index/middle, pronation
- Workhorse = Brand or Burkhalter EIP opponensplasty (synergistic, expendable, 5 cm excursion, 85 to 95 percent success)
- Tension to the BASE of the small finger, wrist neutral — not the tip
- Donor options: FAPE (FDS ring, APL, PL, EIP)
Ulnar palsy
- Low ulnar = clawing ring/small plus Froment's (weak adductor) plus weak grip
- High ulnar also loses FDP ring/small — paradoxically LESS clawing (ulnar paradox)
- Zancolli lasso: FDP around A1, tension MCP 70 degrees (not 90), loses 10 to 20 degrees of DIP flexion
- FDS four-tail (modified Stiles-Bunnell): physiological, active IP extension, no DIP loss, for the young/high demand
- Adductor reconstruction: release the first-web contracture first, then EIP or ECRL to adductor
Technique essentials
- Pulvertaft weave: 3 to 6 passes, non-absorbable 3-0 suture, withstands more than 250 N
- Tensioning is the critical step — too tight (swan-neck or contracture) or too loose (weak) fails
- Immobilise 3 weeks — the sweet spot (earlier ruptures, later adhesions)
- Final outcome 3 to 6 months; expect M3 to M4 strength, never normal
Anatomical danger zones
- PIN: deep to supinator — stay superficial freeing EIP proximally
- Dorsal sensory branch of ulnar nerve: crosses the ulnar-border routing tunnel — protect it
- Superficial radial nerve: at the EIP harvest incision — identify and retract
- Ulnar digital nerve to small finger: at risk in the Zancolli lasso — use Bruner incisions, retract radially
- A2 and A4 pulleys: preserve (release only A1 for the lasso) to avoid bowstringing
Exam-day traps
- Do not skip the principles — state OASES-SP first
- Do not confuse EIP and EDC — EIP is ulnar to EDC; confirm independent index extension before cutting
- Do not over-tension — causes swan-neck (intrinsic) or inability to adduct (opponensplasty)
- Do not forget the first-web release in ulnar palsy
- Do not tension the Zancolli lasso to 90 degrees — use 70
- Do not mobilise before 3 weeks — juncture rupture risk
Background & Evidence
The nerve-palsy patterns. The lesion level dictates the deficit and therefore the transfer plan:
- Deficit
- Lost opposition only (APB)
- Reconstruction
- Opponensplasty alone — EIP workhorse
- Deficit
- Opposition plus FPL and FDP index/middle, pronation
- Reconstruction
- Staged: EIP opponensplasty, brachioradialis-to-FPL, FDP side-to-side
- Deficit
- Clawing ring/small plus Froment's plus weak grip
- Reconstruction
- Zancolli lasso or FDS four-tail plus adductor reconstruction
- Deficit
- All the above plus FDP ring/small (less clawing — ulnar paradox)
- Reconstruction
- FDP side-to-side tenodesis first, then intrinsic and adductor work
- Deficit
- Both patterns
- Reconstruction
- Staged reconstruction around what remains expendable
Pathoanatomy and epidemiology. Tendon transfers are performed for irreversible nerve injury — most commonly sharp lacerations (wrist for median, elbow/wrist for ulnar), stretch or compression contusions, and after failed nerve repair. Median palsy flattens the thenar eminence (APB, opponens, superficial head of FPB paralysed) and the thumb comes to lie in the plane of the palm; sensation may be lost over the radial three and a half digits in a complete lesion. Ulnar palsy wastes the interossei and hypothenar eminence, paralyses the adductor pollicis and the medial two lumbricals, and — when proximal — the FDP to ring and small. Biomechanics of transfer. A transferred muscle loses about one grade of strength (M5 becomes M4) from the altered moment arm and the new vector, plus a learning curve — so an M4 donor is the functional floor. Excursion must match the recipient need:
- Available excursion
- About 7 cm
- Suitable for
- Excellent for most transfers (opponensplasty, four-tail)
- Available excursion
- About 5 cm
- Suitable for
- Good for opposition and intrinsic work
- Available excursion
- About 3 cm
- Suitable for
- Limited; often needs a graft for finger work
- Available excursion
- About 3 cm
- Suitable for
- Insufficient alone for finger excursion; needs a graft
- Available excursion
- 3 to 5 cm
- Suitable for
- Met by EIP (5 cm) and FDS (7 cm); APL marginal
- Available excursion
- 2 to 3 cm
- Suitable for
- Met by FDS and EDC
A high ulnar lesion produces LESS clawing than a low one. In a low lesion the intrinsics are paralysed but FDP to ring and small is intact, so the strong FDP pulls the IP joints into flexion and creates a severe claw. In a high lesion FDP is also paralysed, so there is no strong IP-flexion force and the claw is milder — counterintuitive but a classic exam question.
Froment's sign is flexion of the thumb IP joint during key pinch — the patient substitutes FPL (median) for the paralysed adductor pollicis (ulnar) to maintain lateral pinch. It is a hallmark of ulnar nerve palsy, and restoring key pinch is often a higher functional priority than correcting the claw.
References
Burkhalter EIP opponensplasty for isolated low median palsy
- Prospective series of 11 patients with isolated traumatic low median nerve palsy treated with Burkhalter EIP opponensplasty (EIP harvested proximal to the extensor expansion, inserted into the distal attachment of abductor pollicis brevis)
- 9 of 11 patients (82 percent) achieved excellent results, the remaining 2 (18 percent) good results
- No postoperative complications recorded in this cohort
Camitz transfer and its modifications: systematic review
- Systematic review of the Camitz procedure (palmaris longus plus a strip of palmar aponeurosis transferred to the abductor pollicis brevis insertion) for thenar wasting from severe carpal tunnel syndrome
- Overall hand function improved in 86 to 100 percent of patients undergoing the original Camitz procedure
- Most described modifications add or reposition a pulley to improve the opposition vector; all studies limited by small sample sizes
Three tendon transfer methods for ulnar nerve palsy
- 44 patients with irreparable ulnar palsy reconstructed with FDS four-tail (n equals 24), ECRL four-tail (n equals 11), or Zancolli lasso (n equals 9)
- Zancolli lasso and ECRL four-tail were most effective at restoring grip strength; FDS four-tail was most effective at correcting claw deformity, especially in long-standing paralysis with extensor-apparatus elongation
- Preoperative PIP extensor lag and longer paralysis duration significantly worsened functional outcome; surgical technique alone did not determine outcome
Zancolli lasso versus modified Stiles-Bunnell (FDS four-tail): randomised trial
- Prospective randomised comparative trial of 50 patients with ulnar claw hand: FDS four-tail (n equals 25) versus Zancolli lasso (n equals 25)
- Both groups improved significantly in MCP range of motion and grip strength; grip-strength recovery was higher with the Zancolli lasso (129 percent versus 117 percent, p equals 0.013)
- Claw correction was rated excellent slightly more often after the FDS four-tail (not statistically significant); the lasso had shorter operating time and faster return to activities
Classic and anatomical references 1. Brand PW. Biomechanics of tendon transfers. Hand Clin. 1988;4(2):137-154. doi:10.1016/s0749-0712(21)00622-3 2. Burkhalter WE. Tendon transfer principles and clinical applications in hand surgery. J Hand Surg Am. 1991;16(3):398-404. doi:10.1016/s0363-5023(10)80100-3 3. Anderson GA, Lee V, Sundararaj GD. Opponensplasty by extensor indicis and flexor digitorum superficialis tendon transfer. J Hand Surg Br. 1992;17(6):611-614. doi:10.1016/0266-7681(92)90026-e 4. Zancolli EA. Claw-hand caused by paralysis of the intrinsic muscles: a simple surgical procedure for its correction. J Bone Joint Surg Am. 1957;39(5):1076-1080. 5. Omer GE Jr. Tendon transfers in combined nerve injuries. Orthop Clin North Am. 1974;5(2):377-387. 6. Riordan DC. Tendon transfers in hand surgery. J Hand Surg Am. 1983;8(5 Pt 2):748-753. doi:10.1016/s0363-5023(83)80267-0 7. Hastings H 2nd, Davidson S. Tendon transfers for ulnar nerve palsy: evaluation and preoperative management. Hand Clin. 1988;4(2):167-178. 8. Boyes JH, Stark HH. Flexor-tendon grafts in the fingers and thumb: an evaluation of end results. J Bone Joint Surg Am. 1971;53(7):1332-1342. 9. Pulvertaft RG. Tendon grafts for flexor tendon injuries in the fingers and thumb: a study of technique and results. J Bone Joint Surg Br. 1956;38(1):175-194. doi:10.1302/0301-620x.38b1.175 10. Smith RJ. Intrinsic muscles of the fingers: function, dysfunction, and surgical reconstruction. Instr Course Lect. 1975;24:200-220.