Tendon transfers for radial nerve palsy

1. Pronator teres, transferred to extensor carpi radialis brevis, is used to restore wrist extension.

True

In Ropars' long-term review (mean follow-up 9.5 years), the authors settled on a modified Tsuge procedure using pronator teres to restore wrist extension, flexor carpi radialis for finger extension and palmaris longus for thumb extension. Bertelli's tendon transfer group likewise received pronator teres to extensor carpi radialis brevis.

• Ropars M, Dréano T, Siret P, Belot N, Langlais F. Long-term results of tendon transfers in radial and posterior interosseous nerve paralysis. J Hand Surg Br. 2006;31(5):502-6. PMID 16928411
• Bertelli JA. Nerve Versus Tendon Transfer for Radial Nerve Paralysis Reconstruction. J Hand Surg Am. 2020;45(5):418-426. PMID 32093993

2. In a retrospective comparison of flexor carpi ulnaris, flexor carpi radialis and flexor digitorum superficialis as finger-extension motors, superficialis transfer gave significantly better function.

False

Moussavi compared these three donors in 41 patients, all of whom also had pronator teres for the wrist and palmaris longus for the thumb. DASH (Disabilities of the Arm, Shoulder and Hand) score, return to work, satisfaction and range of motion did not differ significantly between the groups, and overall satisfaction was 95%; the authors concluded that success is probably not related to the donor tendon used.

• Moussavi AA, Saied A, Karbalaeikhani A. Outcome of tendon transfer for radial nerve paralysis: Comparison of three methods. Indian J Orthop. 2011;45(6):558-62. PMID 22144751

3. After classic tendon transfers for radial nerve palsy, some patients can fully extend the fingers only with the wrist flexed.

True

In Bertelli's comparison, half of the 13 patients reconstructed with pronator teres, flexor carpi ulnaris and palmaris longus transfers needed to flex the wrist to extend the fingers fully; wrist flexion was limited in 9 and permanent radial deviation persisted in 5. The series is small and non-randomised (level IV).

• Bertelli JA. Nerve Versus Tendon Transfer for Radial Nerve Paralysis Reconstruction. J Hand Surg Am. 2020;45(5):418-426. PMID 32093993

4. Harvesting flexor carpi ulnaris as the finger-extension motor improves the balance of wrist extension.

False

In Ropars' series the main problems were weakened grip and radial deviation of the wrist, particularly after flexor carpi ulnaris transfer to extensor digitorum communis, and the authors moved to preserving flexor carpi ulnaris to maintain wrist stability and flexion. Besnard likewise notes that wrist extension after traditional transfers frequently deviates radially, impairing grip strength.

• Ropars M, Dréano T, Siret P, Belot N, Langlais F. Long-term results of tendon transfers in radial and posterior interosseous nerve paralysis. J Hand Surg Br. 2006;31(5):502-6. PMID 16928411
• Besnard M, Marteau E, Laulan J, Bacle G. Tendon transfers for radial nerve palsy with extensor carpi ulnaris revival: Technique and results. Orthop Traumatol Surg Res. 2020;106(2):307-310. PMID 32061574

5. In pooled published series, most patients with isolated radial nerve palsy achieve a good outcome after tendon transfer.

True

Jain's systematic review of 29 studies (754 patients) converted the reported grading scales to a common three-tier score: tendon transfers had 82% good and 9% poor outcomes, and were superior to nerve grafts and nerve transfers for wrist extension in that analysis. An earlier systematic review (level III) found heterogeneous outcomes and no clearly superior technique.

• Jain NS, Barr ML, Kim D, Jones NF. Tendon Transfers, Nerve Grafts, and Nerve Transfers for Isolated Radial Nerve Palsy: A Systematic Review and Analysis. Hand (N Y). 2024;19(3):343-351. PMID 36692098
• Compton J, Owens J, Day M, Caldwell L. Systematic Review of Tendon Transfer Versus Nerve Transfer for the Restoration of Wrist Extension in Isolated Traumatic Radial Nerve Palsy. J Am Acad Orthop Surg Glob Res Rev. 2018;2(4):e001. PMID 30211383