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Tendon and Nerve Repair

Hand tendon/nerve repair: primary vs secondary reconstruction, Zone II management, and rehabilitation protocols for optimal functional recovery.

Overview

Tendon transfer serves as a primary reconstructive option to restore function following radial, median, or ulnar nerve injuries when surgical nerve repair is not feasible or fails to yield useful function [5]. While nerve transfers have emerged as a first-line reconstructive technique for functional restoration [16], tendon transfer remains a critical alternative, potentially the procedure of choice, particularly when early professional and social reintegration is prioritized [11, 12]. For high radial nerve injuries with defects of nine centimeters or greater, attempting nerve reconstruction within 8 months before proceeding to tendon transfers appears indicated [2]. In cases of high peripheral nerve injury or secondary scenarios where intrinsic hand muscle recovery is not expected after end-to-end repair or graft, intrinsic hand muscle reinnervation via a median-ulnar end-to-side bridge nerve graft is mainly indicated [3].

Clinical outcomes vary by procedure and pathology. Better outcomes were observed in patients undergoing nerve transfer versus tendon transfer for radial nerve paralysis reconstruction [9]; however, pooled analysis indicates that tendon transfers achieved higher rates of superior clinical outcomes compared with nerve transfers and nerve grafts for isolated radial nerve palsy [14]. Simultaneous nerve repair and tendon transfer for peroneal nerve injuries demonstrated no detrimental results and may offer improved function over tendon transfer alone [1]. Selection of the donor nerve for heterotopic nerve transfers requires careful weighing against other treatment alternatives, considering the risk of donor nerve impairment and the potential narrowing of future reconstructive options [17]. Fundamental principles of nerve transfers, including donor site location, strength, safety, and efficacy introduced by Oberlin et al., remain integral to contemporary nerve surgery [16].

Future research must address combined nerve and tendon transfer reconstructions alongside patient-perceived outcome investigations in tetraplegia [4]. More participants with longer follow-up are needed to fully demonstrate the superiority of combined nerve and tendon procedures for grasp and release function in patients with tetraplegia [6].

Anatomy & Pathophysiology

Osseous and Articular Kinematics

Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [37]. Finger forces are more hampered while gripping objects with smaller circumferences than large ones [30], and subjects with stenosing tenosynovitis demonstrate a significant decrease in maximum velocity in slow fist tasks [46]. Despite these mechanical constraints, hand function remains good even when range of wrist motion and strength of the wrist and fingers are less than normal [32]. Extension strengths of the thumb and index finger of the operated hand were approximately 20% lower compared to the contralateral hand, yet clinical functional scores and range of motion were favourable [44].

Ligamentous and Pulley Systems

The pulley system of the thumb is composed of 4 components, as opposed to the traditional view of only 3 [55]. Findings from the study clarify hand surface landmarks in localizing the thumb A1 pulley and digital neurovascular structures [53]. Methods that risk normal DIP joint kinematics should not be popularized until proven otherwise [29].

Vascular and Neural Landmarks

The intrinsic hand muscles have MEPs at consistent distances from bony landmarks both dorsally and volarly [47]. Sensation is the most important factor in thumb or fingertip repair, constituting 40% of the goal, while length and appearance account for 50% [52].

Tendon Dynamics and Reconstruction

Routing of the EPL tendon through the first dorsal compartment allows reproduction of the action of thumb extension and abduction and restores thumb clearance from the palm [42]. There were no significant differences in the motion range of the thumb after EPL rerouting techniques or sites of insertion [49]. At the time of repair, decellularized flexor tendon-bone grafts can exceed the strength and excursion needed for hand therapy immediately after reconstruction [43]. Although both ST and SA constructs recapitulate native joint stiffness, repair with ST demonstrated the greatest biomechanical strength in stiffness and load-to-failure [51]. Modifying the core suture configurations in flexor tendon repairs is common among Finnish hand surgeons, although this does not seem to compromise the biomechanical competence of the repairs [48].

Clinical Outcomes and Validation

Combined nerve and tendon transfer reconstructions require further study alongside patient-perceived outcome investigations [4]. The described dynamic tenodesis is an elegant solution to rheumatoid arthritis-related ulnar drift, but further comparative and biomechanical validation is needed to define its long-term role in rheumatoid hand surgery [41]. Hand surgery and hand therapy practice interventions, including use of RMF orthoses for management of non-surgical and surgical EM injuries, may benefit from an in-depth look at the EM zone III and IV anatomy and biomechanics [50].

Classification

Extensor Tendon Classification: The panel recommends adapting a simpler classification system resembling that for flexor tendons for extensor tendon injuries to facilitate surgical decision-making and rehabilitation [54]. A simpler classification system for extensor tendon zones has been proposed to align with current treatment strategies, such as conservative splinting for closed injuries and strong surgical repair for open injuries [64]. An additional category (Type 3) has been proposed to the Türker classification system to encompass rare findings of two radial-sided accessory extensor tendons in the same individual [60].

Other Considerations: The central nervous system component should be considered in the development of new treatment protocols for flexor tendon injuries [61]. Simultaneous nerve repair and tendon transfer for peroneal nerve injuries showed no detrimental results and may provide improved function over tendon transfer alone [1]. For high radial nerve injuries with defects of nine centimeters or greater, an attempt at nerve reconstruction before proceeding to tendon transfers appears indicated within 8 months [2]. Intrinsic hand muscle reinnervation by median-ulnar end-to-side bridge nerve graft is mainly indicated in high peripheral nerve injury or secondary cases when recovery of the intrinsic muscle of the hand is not expected after end-to-end repair or graft [3]. Tendon transfer is a useful option to restore function after a nerve injury to the radial, median, or ulnar nerve when surgical repair to the nerve does not result in useful function or nerve repair is not possible [5]. Evidence for good nerve recovery or improved function following nerve repair is poor, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels [7]. The presence of fractures is associated with a higher incidence of nerve and tendon injuries, and involvement of these structures is linked to an increased risk of long-term disability [8]. Overall, better outcomes were observed in those who underwent nerve transfer versus tendon transfer procedures for radial nerve paralysis reconstruction [9]. End-to-end repair of fascicular groups provides better results than repair using nerve grafts for partial lacerations of peripheral nerves [15]. Collagen conduits reliably provide a repair that restores nerve function for nerve gaps measuring less than 2 cm [25]. Nerves primarily sutured following types of trauma commonly seen in civilian life provided a definitely higher grade of motor reinnervation of the intrinsic muscles of the hand than did the secondarily sutured nerves [39]. Collagen nerve tubes might offer a clinically effective option for restoration of sensory function in digital nerve repair [63].

Clinical Presentation

History: Patients with ballistic hand injuries often present with associated fractures, a pattern linked to higher incidences of concurrent nerve and tendon trauma and an increased risk of long-term disability [8]. Unrecovered nerve injury can adversely affect outcomes even in acute distal biceps tendon repairs using cortical button fixation [22]. While tendinopathies of the hand and wrist are common conditions diagnosed by history and examination, flexor tendon injuries in children are rare yet generally yield good subjective and objective outcomes [35, 38]. Patients with injury patterns suggestive of nerve damage warrant prompt referral to an upper extremity specialist to optimize outcomes [34].

Inspection and Palpation: Clinical presentation varies by injury type; for instance, high median nerve transection may present with preserved finger flexion despite significant functional loss [33]. A painful neuroma represents a debilitating sequela of nerve injury, characterized by poorly understood pathophysiology involving fascicular escape and scarring [19]. In cases of degenerate abductor tendons, surgical reconstruction is considered when MRI confirms separation and clinical findings align with known tendon disruption [20].

Range-of-Motion and Functional Assessment: Surgical treatment for pediatric trigger thumb via flexor tendon sheath release effectively restores motion with minimal recurrence or neurovascular complication risks, though the optimal age for intervention remains unclear [21]. Collagen tubes are useful for spanning digital nerve defects up to 2.6 cm, yielding good functional outcomes in the majority of cases [40]. For high radial nerve injuries with defects of nine centimeters or greater, nerve reconstruction is indicated within 8 months before proceeding to tendon transfers [2]. Intrinsic hand muscle reinnervation via median-ulnar end-to-side bridge nerve grafts is mainly indicated in high peripheral nerve injuries or secondary cases where recovery is not expected after end-to-end repair [3].

Decision Axes and Outcomes: Tendon transfer is a useful option to restore function after radial, median, or ulnar nerve injuries when surgical repair fails or is not possible [5]. Overall, better outcomes were observed in patients undergoing nerve transfer versus tendon transfer for radial nerve paralysis reconstruction [9]. Simultaneous nerve repair and tendon transfer for peroneal nerve injuries showed no detrimental results and may provide improved function over tendon transfer alone [1]. However, evidence for good nerve recovery or improved function following nerve repair is poor, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels [7]. Patients presenting early who can tolerate a longer time to functional recovery are optimal candidates for nerve transfers in radial nerve palsy [18].

Patient Education and Future Directions: Unless patients, caregivers, and nonsurgical providers possess baseline knowledge of these procedures, they are unlikely to obtain de novo awareness of surgical options through self-initiated searches [13]. There is a foreseen increased need for studies addressing combined nerve and tendon transfer reconstructions alongside patient-perceived outcome investigations in tetraplegia [4]. More participants with longer follow-up are needed to fully demonstrate the superiority of combined nerve and tendon procedures for grasp and release function in patients with tetraplegia [6].

Investigations

MRI: MRI provides critical preoperative information for surgical decision-making and planning in patients presenting late with closed flexor tendon injuries of the hand [62]. It is indicated for surgical reconstruction of degenerate abductor tendons when an MRI-confirmed separation is present alongside clinical findings consistent with known tendon disruption [20]. Furthermore, MRI has demonstrated complete regeneration of subchondral bone and cartilage in patients with Hepple stage V osteochondral lesions of the talus treated with a platelet-rich plasma scaffold [78].

Ultrasonography: Ultrasonographic assessment serves as a valuable complementary tool for objectively evaluating nerve recovery in repaired median nerve lacerations [75].

CT: 3D CT imaging techniques can be utilized to diagnose rare sites of flexor tendon entrapment [77].

Plain Radiography: The presence of fractures in ballistic hand injuries is associated with a higher incidence of concurrent nerve and tendon injuries [8].

Other Considerations: Surgical exploration confirms the diagnosis of closed partial flexor digitorum profundus rupture and allows for excision of the damaged segment to return normal movement without compromising strength [83]. In ballistic hand injuries, involvement of nerve and tendon structures is linked to an increased risk of long-term disability [8]. Diagnosing the cause of ulnar collateral ligament locking may be complicated by the lack of evidence in imaging studies [79]. Follow-up studies on eleven of eighteen tendons treated with plantaris tendon reinforcement revealed excellent results [26].

Regarding nerve and tendon management strategies, simultaneous nerve exploration and tendon transfer for peroneal nerve injuries showed no detrimental results and may provide improved function over tendon transfer alone [1]. For high radial nerve injuries with defects of nine centimeters or greater, an attempt at nerve reconstruction before proceeding to tendon transfers appears indicated within 8 months [2]. Delay in repair of less than 6 months for high radial nerve injury is associated with better recovery outcomes [10], as is a defect length of less than 5 cm [10]. Grafting with three or more donor nerve cables for high radial nerve injury is also associated with better recovery outcomes [10]. End-to-end repair of fascicular groups provides better results than repair using nerve grafts for partial lacerations of peripheral nerves [15]. On pooled analysis, tendon transfers had higher rates of superior clinical outcomes compared with nerve transfers and nerve grafts for isolated radial nerve palsy [14]. Tendon transfers are indicated in longstanding, irreparable, isolated radial nerve lesions to provide selective finger and thumb extension [24]. Intrinsic hand muscle reinnervation via median-ulnar end-to-side bridge nerve graft is mainly indicated in high peripheral nerve injury or secondary cases when recovery of intrinsic hand muscles is not expected after end-to-end repair or graft [3].

Treatment

Non-Operative

In atraumatic posterior interosseous nerve palsy without a space-occupying lesion, a trial of nonoperative management is advisable, though exploration is recommended if no muscle recovery occurs after 6 weeks of observation or if progressive weakness develops [67]. For pediatric trigger thumb, surgical intervention is effective for restoring motion with minimal recurrence and neurovascular risks, although the optimal age for treatment remains unclear [21].

Operative

Indications: Tendon transfer is indicated when surgical nerve repair fails to yield useful function or is not possible following radial, median, or ulnar nerve injuries [5]. It is specifically indicated for longstanding, irreparable, isolated radial nerve lesions [24]. For high radial nerve injuries with defects of 9 cm or greater, nerve reconstruction should be attempted before proceeding to tendon transfers if within 8 months of injury [2]. In cases of high peripheral nerve injury or secondary cases where intrinsic hand muscle recovery is not expected after end-to-end repair or graft, intrinsic hand muscle reinnervation via median-ulnar end-to-side bridge nerve graft is mainly indicated [3]. Tendon transfers are also a useful option for radial nerve palsy when early professional and social reintegration is prioritized [11, 12].

Surgical Approach / Technique: Nerve transfers have become a first-line reconstructive technique for the restoration of function [16]. Simultaneous nerve repair and tendon transfer for peroneal nerve injuries show no detrimental results and may provide improved function over tendon transfer alone [1]. Combined nerve and tendon transfer (CNaTT) for grasp and release function in tetraplegia requires more participants with longer follow-up to fully demonstrate superiority [6]. The anterior approach for transferring the supinator nerve to the posterior interosseous nerve yields similar results to the posterior approach while allowing easier access for simultaneously performing nerve or tendon transfers to reconstruct grasp and pinch [27]. Primary tendon repair is permissible only when strict criteria are met, including early presentation, minimal contamination, and favorable wound conditions; otherwise, secondary repair via tendon graft is recommended [23]. The six-strand double-loop technique for flexor tendon repair in Zone II appears superior to a two-strand technique without an increased rupture rate but offers a shorter rehabilitation period [68]. For patients with tendon deficiency and nerve injuries, the tendon with Z-lengthening (TWZL) technique offers an alternative that avoids donor site morbidity associated with autograft harvest [28].

Implant Selection: Collagen conduits reliably provide a repair that restores nerve function for gaps measuring less than 2 cm [25]. The use of type I collagen conduit is a reliable alternative to nerve grafting for gaps up to 10 mm in length [71].

Adjuncts: Wrapping the nerve with fibrin sealant before division and immediate fixation resulted in less protrusion of the nerve end [69]. Pharmacological intervention as an adjunctive therapy to surgical peripheral nerve repair may prove to be not only beneficial but also necessary for satisfactory long-term functional recovery [65].

Other Considerations: Selection of the donor nerve for heterotopic nerve transfers must be carefully weighed against other treatment alternatives, considering the risk of donor nerve impairment and the potential narrowing of future reconstructive options [17]. Evidence for good nerve recovery following high radial nerve injury grafting is associated with a delay in repair of less than 6 months, a defect length of less than 5 cm, or grafting with three or more donor nerve cables [10]. Evidence for good nerve recovery or improved function following single digital nerve repair is poor, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels [7]. Neurolysis of the superficial radial nerve offers the opportunity for pain relief but does not reliably produce success [73]. Tendon lacerations in a healthy neonate can be managed in a timely and safe manner with modern anesthesia techniques [66].

Complications

Nerve palsy: Primary nerve repair yields poor sensory recovery in only 24% of cases, with most repaired nerves failing to regain pre-injury sensory levels [7]. Outcomes are significantly influenced by follow-up duration and patient age, showing improvement over time [94]. Favorable recovery following high radial nerve injury requires a delay in repair of less than 6 months, a defect length under 5 cm, or grafting with three or more donor nerve cables [10]. For partial lacerations, end-to-end fascicular repair outperforms nerve grafting [15]. In cases of large gaps (≥9 cm) within 8 months, nerve reconstruction is indicated prior to tendon transfer [2]. Intrinsic hand muscle reinnervation via median-ulnar end-to-side bridge graft is reserved for high peripheral nerve injuries or secondary cases where end-to-end repair is not expected to restore function [3]. Patients with sharp major nerve injuries often require grafting if presentation is delayed, whereas primary repair of common and proper digital nerves remains feasible up to two weeks post-injury [89]. Muscle-in-vein conduits and standard conduits are viable options for primary and secondary digital nerve reconstruction [84, 85]. Processed nerve allografts demonstrate outcomes comparable to autografts and superior to conduits in historical controls [93].

Tendon repair complications: Unrecovered nerve injury adversely affects outcomes following acute distal biceps tendon repair with cortical button fixation [22]. Primary tendon repair is permissible only under strict criteria including early presentation, minimal contamination, and favorable wound conditions; otherwise, secondary repair via tendon graft is recommended [23]. Delayed tendon repair at the wrist often necessitates grafts with suboptimal results compared to primary suture, which yields nearly normal restoration [96]. Secondary reconstruction remains a vital technique for complicated flexor tendon injuries or those failing primary repair [99]. A carefully monitored primary repair in sharp wounds reduces recovery time and typically yields better function than secondary grafting [100]. In zone I flexor profundus repair including the palmar plate, a new technique achieved excellent or good outcomes with no ruptures or infections [92]. The plantaris tendon used as a reinforcing membrane demonstrated excellent results in follow-up studies of eleven of eighteen tendons [26].

Combined nerve and tendon procedures: Simultaneous nerve repair and tendon transfer show no detrimental effects and may improve function over tendon transfer alone [1]. For radial nerve paralysis, nerve transfer procedures have been observed to yield better outcomes than tendon transfers [9], though pooled analysis indicates tendon transfers have higher rates of superior clinical outcomes for isolated radial nerve palsy [14]. In late microsurgical nerve reconstruction for brachial plexus birth injury, no difference in outcomes exists between nerve transfer and nerve graft groups at 1 or 2+ years [91]. However, more participants with longer follow-up are needed to fully demonstrate the superiority of combined nerve and tendon procedures [6], and increased studies addressing combined reconstructions alongside patient-perceived outcomes are required [4].

Other Considerations: The presence of fractures is associated with a higher incidence of nerve and tendon injuries, and involvement of these structures increases the risk of long-term disability [8]. Most adverse outcomes following open A1 pulley release for idiopathic trigger finger are short-term pain, stiffness, and swelling, while major complications like nerve injury or deep infection are uncommon [82]. Despite high prevalence of postoperative complications, most patients remain satisfied with complex reconstruction for dorsolateral peritalar subluxation after short follow-up [95]. Although complications are more frequent following arthrodesis for thumb carpometacarpal osteoarthritis, most do not affect the overall outcome [97]. Unless patients, caregivers, and nonsurgical providers have baseline knowledge of these transfers, they are unlikely to discover surgical options via self-initiated searches [13]. More prospective studies using standardized outcome measures are needed to define the precise role of nerve transfers in reconstructive upper limb surgery for tetraplegia [90].

Recovery

Light activity (weeks): Early rehabilitation following hand tendon repair is beneficial, with specific protocols for primary flexor pollicis longus repair combining repair and early active mobilization [58, 59]. Patients with radial nerve palsy who present early and can tolerate a longer time to functional recovery are optimal candidates for nerve transfers [18]. For high radial nerve injuries with defects of 9 cm or greater, an attempt at nerve reconstruction before proceeding to tendon transfers appears indicated within 8 months [2].

Full activity (months): Tendon transfer is a useful option to restore function after radial, median, or ulnar nerve injury when surgical repair does not result in useful function or is not possible [5]. Tendon transfer offers an important alternative, possibly the procedure of choice, to microsurgical nerve reconstruction for radial nerve palsy, particularly when early professional and social reintegration is important [11, 12]. Simultaneous nerve repair and tendon transfer for peroneal nerve injuries showed no detrimental results and may provide improved function over tendon transfer alone [1]. Combined nerve and tendon transfer procedures for grasp and release function in tetraplegia require more participants with longer follow-up to fully demonstrate superiority [6].

Complete recovery / outcome plateau (months): Better nerve recovery following high radial nerve injury grafting is associated with a delay in repair of less than 6 months, a defect length of less than 5 cm, or grafting with three or more donor nerve cables [10]. Evidence for good nerve recovery or improved function following single digital nerve repair is poor, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels [7]. Adequate sensory recovery without any nerve repair occurred by the 2-year follow-up in artery-only fingertip replantations using a controlled nailbed bleeding protocol [86]. Future robust research is needed to ascertain the efficacy of supercharged end-to-side anterior interosseous to ulnar motor nerve transfer before it can become widespread practice [45].

Rehabilitation protocol: A rehabilitative protocol individualized to fit each patient's tendon pathology and surgery is essential following extensor mechanism surgery [57]. When tension-free end-to-end nerve repair is unachievable, options include nerve autograft, nerve allograft, and various autologous or synthetic nerve conduits, with surgeons using all of these options with moderate to good recovery of 2-point discrimination [88]. Polyethylene glycol (PEG) fusion techniques may drastically improve the long-term recovery of more proximal nerve injuries where poor outcomes are more common [81]. Supercharged end-to-side anterior interosseous to ulnar motor nerve transfer has broad clinical utility for augmenting partial recovery and preserving motor end plates in second- and third-degree axonotmetic nerve injuries [87].

Functional milestones: Intrinsic hand muscle reinnervation via median-ulnar end-to-side bridge nerve graft is mainly indicated in high peripheral nerve injury or secondary cases when recovery of intrinsic hand muscle is not expected after end-to-end repair or graft [3]. Heterodigital flexor digitorum profundus hemi-tendon transfer restores good function in most patients with zone 1 and 2 flexor tendon injuries where primary tendon repair has not been performed or was unsuccessful and pulley reconstruction is not required [76].

Key Evidence

  • [L4] The results of our limited case series for this rare condition indicate that simultaneous nerve repair and tendon transfer showed no detrimental results and may provide improved function over tendon transfer alone. (10.1186/s13018-014-0067-6)
  • [L4] Even for large gaps, within 8 months, an attempt at nerve reconstruction before proceeding to tendon transfers appears to be indicated. (10.1016/j.jhsa.2007.10.004)
  • [Case_report] The technique is mainly indicated in high peripheral nerve injury or secondary cases when recovery of the intrinsic muscle of the hand is not expected after end-to-end repair or graft. (10.1016/j.jhsa.2009.10.033)
  • [L5] They foresee an increased need for studies addressing combined nerve and tendon transfer reconstructions alongside patient-perceived outcome investigations. (10.1177/1753193419827814)
  • [L3] More participants with a longer follow-up are needed to fully demonstrate the superiority of combined nerve and tendon procedures. (10.1177/17531934251381202)
  • [L2] Evidence for good nerve recovery or improved function following nerve repair is poor, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels. (10.1177/1753193419846761)
  • [L4] The presence of fractures is associated with a higher incidence of nerve and tendon injuries, and involvement of these structures is linked to an increased risk of long-term disability. (10.1177/15589447221092111)
  • [L4] Overall, we observed better outcomes in those who underwent nerve transfer versus tendon transfer procedures. (10.1016/j.jhsa.2019.12.009)
  • [L4] Delay in repair of less than 6 months, defect length of less than 5 cm, or grafting with three or more donor nerve cables achieved better recovery. (10.1177/17531934221147651)
  • [L4] The tendon transfer offers an important alternative—possibly the procedure of choice—to microsurgical nerve reconstruction, particularly when early professional and social reintegration is important. (10.1016/j.jhsa.2008.11.012)
  • [L4] Accordingly, the tendon transfer offers an important alternative – possibly the procedure of choice – to microsurgical nerve reconstruction, particularly when early professional and social reintegration is important. (10.1016/s0363-5023(09)60108-8)
  • [L4] Unless patients, their caregivers, and nonsurgical health care providers have baseline knowledge of tendon and/or nerve transfers, they are unlikely to obtain de novo awareness of surgical options with self-initiated searches. (10.1177/1558944719878835)
  • [L4] On pooled analysis, tendon transfers had higher rates of superior clinical outcomes as compared with nerve transfers and nerve grafts. (10.1177/15589447221150516)
  • [L4] End-to-end repair of fascicular groups provides better results than repair using nerve grafts. (10.1016/j.jhsa.2014.01.026)
  • [L4] Nerve transfers have become a first line reconstructive technique in the restoration of function, with fundamental principles such as donor site location, strength, safety, and efficacy introduced by Oberlin et al remaining integral to contemporary nerve surgery. (10.1016/j.jhsa.2025.01.013)
  • [L4] Selection of the donor nerve must be carefully weighed against other treatment alternatives, considering the risk of donor nerve impairment and the potential narrowing of future reconstructive options. (10.1016/j.jhsa.2006.12.012)
  • [L3] Patients who present early and can tolerate longer time to functional recovery would be optimal candidates for nerve transfers. (10.1177/1558944720988126)
  • [L5] The painful neuroma is a debilitating sequela of nerve injury with poorly understood pathophysiology involving fascicular escape and scarring; treatment must be tailored to the individual patient as there are a number of approaches available. (10.1016/j.jhsa.2009.12.019)
  • [L4] Surgical reconstruction of degenerate abductor tendons should be considered in the presence of an MRI confirmed separation where clinical findings are consistent with the known tendon disruption. (10.1016/j.arth.2019.11.012)
  • [L4] Surgical treatment consisting of flexor tendon sheath release is effective in restoring motion with minimal risks of recurrence and neurovascular complication, although the optimal age for surgical treatment is unclear. (10.1016/j.jhsa.2008.04.017)
  • [L3] Although rare, unrecovered nerve injury adversely affects outcome. (10.1302/0301-620x.103b7.bjj-2020-2246.r1)
  • [L5] Primary tendon repair is permissible only when strict criteria are met, including early presentation, minimal contamination, and favorable wound conditions; otherwise, secondary repair via tendon graft is recommended. (10.2106/00004623-195941040-00001)
  • [L3] Tendon transfers are indicated in longstanding, irreparable, isolated radial nerve lesions. (10.1016/j.jhsa.2007.10.015)
  • [L4] This study confirms that collagen conduits reliably provide a repair that restores nerve function for nerve gaps measuring less than 2 cm. (10.1016/j.jhsa.2011.06.009)
  • [L4] Follow-up studies on eleven of eighteen tendons so treated revealed excellent results. (10.2106/00004623-196648020-00005)
  • [L4] The anterior approach yields similar results to the posterior approach and has the advantage of allowing easier access for simultaneously performing nerve or tendon transfers to reconstruct grasp and pinch. (10.1177/1753193421996987)
  • [L4] The TWZL technique offers an alternative treatment option for patients with tendon deficiency and nerve injuries, avoiding donor site morbidity associated with autograft harvest. (10.1016/j.jhsa.2022.12.016)
  • [Commentary] A method risking normal DIP joint kinematics should not be popularized until proven otherwise; readers should consider other published methods that meet the needs of strength without interfering with joint kinematics. (10.1016/j.jhsa.2014.08.002)
  • [L4] Finger forces are more hampered while gripping objects with smaller circumferences than large ones. (10.1177/17531934211061220)
  • [L3] This study shows that even though the range of wrist motion and the strength of the wrist and fingers are less than normal, hand function remains good. (10.1177/1753193416651574)
  • [Case_report] This case contributes further to our understanding of the clinical presentation of hand function following high median nerve transection. (10.1186/s12891-025-08469-3)
  • [L3] Patients with an injury pattern that may lead to nerve injury warrant prompt referral to an upper extremity specialist in an effort to optimize outcomes. (10.1177/1558944719866865)
  • [L4] Flexor tendon injuries in children are rare, and both subjective and objective outcomes are generally good. (10.1016/j.jhsa.2007.08.006)
  • [L4] Owing to the good functional outcome in the majority of cases, the use of collagen tubes is useful to span digital nerve defects up to 2.6 cm. (10.1016/j.jhsa.2012.10.017)
  • [Letter] The described dynamic tenodesis is an elegant solution to rheumatoid arthritis-related ulnar drift, but further comparative and biomechanical validation is needed to define its long-term role in rheumatoid hand surgery. (10.1016/j.jhsg.2025.100883)
  • [L4] Routing of the EPL tendon through the first dorsal compartment allows reproduction of the action of thumb extension and abduction and restores thumb clearance from the palm. (10.1016/j.jhsa.2015.01.018)
  • [L5] At the time of repair, decellularized flexor tendon-bone grafts can exceed the strength and excursion needed for hand therapy immediately after reconstruction. (10.1016/j.jhsa.2013.08.092)
  • [L4] Extension strengths of the thumb and index finger of the operated hand were approximately 20% lower compared to the contralateral hand, yet clinical functional scores and range of motion were favourable. (10.1177/17531934241226949)
  • [Letter] Future robust research is needed to ascertain the efficacy of the SETS AIN transfer to elucidate the source of axonal regeneration resulting in functional muscle recovery in these patients before it can become a widespread practice among nerve surgeons. (10.1177/1558944719893052)
  • [L3] Those subjects demonstrate a significant decrease in maximum velocity in slow fist tasks, highlighting the need for comprehensive assessment to ascertain the full extent of functional limitations that can occur in the setting of hand pathology. (10.1177/1558944717729218)
  • [L5] The intrinsic hand muscles have MEPs at consistent distances from bony landmarks both dorsally and volarly. (10.1016/j.jhsa.2020.04.019)
  • [L5] Modifying the core suture configurations in flexor tendon repairs is common among Finnish hand surgeons, although this does not seem to compromise the biomechanical competence of the repairs. (10.1177/1753193416641624)
  • [L5] We were unable to find significant differences in the motion range of the thumb after these rerouting techniques or sites of insertion. (10.1177/1753193419857067)
  • [L5] Hand surgery and hand therapy practice interventions, including use of RMF orthoses for management of non-surgical and surgical EM injuries may benefit from an in-depth look at the EM zone III and IV anatomy and biomechanics. (10.1016/j.jht.2023.01.002)
  • [L5] Although both ST and SA constructs recapitulate native joint stiffness, repair with ST demonstrated the greatest biomechanical strength in stiffness and load-to-failure. (10.1016/j.jhsa.2021.09.028)
  • [L5] Sensation is the most important factor in thumb or fingertip repair, constituting 40% of the goal, while length and appearance account for 50%. (10.1177/17531934211051303)
  • [L5] The findings from our study clarify hand surface landmarks in localizing the thumb A1 pulley and digital neurovascular structures. (10.1016/j.jhsa.2013.02.028)
  • [L5] The panel recommends adapting a simpler classification system resembling that for flexor tendons and outlines specific treatment approaches for acute extensor tendon injuries in each zone to facilitate surgical decision-making and rehabilitation. (10.1177/17531934251363138)
  • [L4] The pulley system of the thumb is composed of 4 components, as opposed to the traditional view of only 3. (10.1016/j.jhsa.2012.08.005)
  • [L5] A rehabilitative protocol that is individualized to fit each patient's tendon pathology and surgery is essential. (10.1016/j.jhsa.2015.04.043)
  • [L4] Our findings suggest the benefit of early rehabilitation after hand tendon repair. (10.1016/j.jht.2014.09.005)
  • [L4] The final combination of repair and early active mobilization for primary repair of FPL tendons compares favourably with previous methods of treatment. (10.1054/jhsb.1999.0230)
  • [L4] The authors propose an additional category (Type 3) to the Türker classification system to encompass rare findings of two radial-sided accessory extensor tendons in the same individual, which were not previously represented in existing classifications. (10.1016/j.jhsg.2023.10.005)
  • [L3] The results suggest that the central nervous system component should be considered in the development of new treatment protocols for flexor tendon injuries. (10.1177/1753193408096017)
  • [L4] MRI provides important preoperative information for surgical decision-making and planning in patients who present late with closed flexor tendon injuries of the hand. (10.1054/jhsb.1999.0306)
  • [L4] Although the patients in this study are still within the early follow-up period, our initial results compare favorably with those reported in the existing literature for various types of nerve repair and reconstruction, suggesting that collagen nerve tubes might offer a clinically effective option for restoration of sensory function. (10.1016/j.jhsa.2008.03.015)
  • [L5] The authors propose a simpler classification system for extensor tendon zones to align with current treatment strategies, such as conservative splinting for closed injuries and strong surgical repair for open injuries. (10.1177/17531934241274112)
  • [L5] Pharmacological intervention as an adjunctive therapy to surgical peripheral nerve repair may prove to be not only beneficial but also necessary for satisfactory long-term functional recovery. (10.1016/j.jhsa.2018.01.023)
  • [L4] With modern anesthesia techniques, tendon lacerations in a healthy neonate can be managed in a timely and safe manner. (10.1016/j.jhsa.2010.09.015)
  • [L5] In the absence of a space-occupying lesion, a trial of nonoperative management is advisable, but exploration of the nerve is recommended if there is no sign of muscle recovery after 6 weeks of observation or if there is progressive weakness. (10.1016/j.jhsa.2017.07.026)
  • [L3] The study notes that while non-randomised, the technique appears better without an increased rate of rupture but with a shorter rehabilitation period. (10.1177/1753193408091570)
  • [L5] Wrapping the nerve with fibrin sealant before division and immediate fixation resulted in less protrusion of the nerve end. (10.1054/jhsb.1999.0250)
  • [L5] The use of type I collagen conduit is a reliable alternative to nerve grafting for gaps up to 10 mm in length. (10.1016/j.jhsa.2007.07.015)
  • [L4] Therefore, while neurolysis of the superficial radial nerve offers the opportunity for pain relief, it does not reliably produce success. (10.1177/1753193407087892)
  • [L4] Ultrasonographic assessment may serve as a valuable complementary tool for objectively evaluating nerve recovery. (10.1177/17531934231174603)
  • [L4] This technique restores good function in most patients with zone 1 and 2 flexor tendon injuries, in which primary tendon repair has not been performed or was unsuccessful, and where pulley reconstruction is not required. (10.1177/1753193417737920)
  • [L4] We present a previously unreported site of flexor tendon entrapment as well as the novel use of CT 3D volume rendering to diagnose the entrapment. (10.1177/15589447231185857)
  • [L4] MRI demonstrated complete regeneration of subchondral bone and cartilage in all patients with significant improvement in functional scores. (10.1155/2017/6525373)
  • [L4] Although diagnosing the cause of UCL locking may be complicated by the lack of evidence in imaging studies, open surgical treatment has traditionally been the most often used with a high success rate. (10.1016/j.jhsg.2022.08.003)
  • [L5] PEG fusion techniques may drastically improve the long-term recovery of more proximal nerve injuries where poor outcomes are more common. (10.1016/j.jhsa.2015.06.060)
  • [Letter] The authors state that surgery should not be taken lightly, but major complications such as nerve injury or deep infection are uncommon, while most adverse outcomes are short-term pain, stiffness, and swelling. (10.1016/j.jhsa.2012.08.038)
  • [L4] Surgical exploration confirms the diagnosis and allows for excision of the damaged segment to return normal movement without compromising strength. (10.1177/1558944716681950)
  • [L4] Muscle-in-vein conduits can be considered for primary and secondary reconstruction of digital nerves. (10.1016/j.jhsa.2022.02.002)
  • [L5] Conduits can be used successfully in appropriate patients with peripheral nerve injury. (10.1016/j.jhsa.2010.02.025)
  • [L4] Furthermore, adequate sensory recovery without any nerve repair had occurred by the 2-year follow-up. (10.1016/j.jhsa.2013.08.110)
  • [L4] The authors believe the procedure has broad clinical utility for augmenting partial recovery and preserving motor end plates in second- and third-degree axonotmetic nerve injuries. (10.1016/j.jhsa.2012.07.022)
  • [L5] When tension-free end-to-end nerve repair is unachievable, several options are available, including nerve autograft, nerve allograft, and various autologous or synthetic nerve conduits, with surgeons using all of these options with moderate to good recovery of 2-point discrimination. (10.1016/j.jhsa.2014.09.022)
  • [L4] Patients with sharp major nerve injuries required grafting more frequently after several days from injury, whereas primary repair of common and proper digital nerves could be achieved up to two weeks or greater after injury. (10.1016/j.jhsa.2023.11.006)
  • [L4] More prospective studies using standardized outcome measures are needed to define the precise role of nerve transfers. (10.1177/1753193419886443)
  • [L4] There was no difference in outcomes between nerve transfer and nerve graft groups at 1 or 2 or more years follow-up. (10.1016/j.jhsa.2019.10.036)
  • [L4] All patients achieved an excellent or good outcome with no ruptures or infections. (10.1177/1753193410365631)
  • [L3] Outcomes from processed nerve allografts are comparable to nerve autograft and exceed those for nerve conduit in historical controls. (10.1016/j.jhsa.2014.06.044)
  • [L3] Follow-up time and age significantly influence the outcome following nerve repair, with significant improvements in the total score seen throughout the follow-up period. (10.1054/jhsb.2001.0567)
  • [L4] Despite the high prevalence of postoperative complications, most patients were satisfied with the result of the procedure after the short duration of follow-up. (10.2106/00004623-199911000-00006)
  • [L5] Primary suture of tendons at the wrist yields nearly normal restoration, whereas delayed repair often requires grafts with far from perfect results. (10.2106/00004623-196547010-00007)
  • [L3] Although complications were more frequent following arthrodesis, most did not affect the overall outcome. (10.2106/00004623-200110000-00002)
  • [L5] Secondary reconstruction remains an important and useful technique for complicated flexor tendon injuries or those that have failed primary repair. (10.1016/j.jhsa.2007.08.018)
  • [L5] A carefully executed and monitored primary repair in a sharp wound reduces the time to maximum recovery and usually results in better function than the previously recommended secondary grafting. (10.2106/00004623-198567050-00024)

See Also

References

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[45] Letter to the Editor Regarding: “Supercharge End-to-Side Nerve Transfer: A Systematic Review,” by Dunn et al.. HAND. 2019. DOI: 10.1177/1558944719893052

[46] Dynamic Functional Assessment of Hand Motion Using an Animation Glove: The Effect of Stenosing Tenosynovitis. HAND. 2017. DOI: 10.1177/1558944717729218

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[49] Extensor pollicis longus rerouting for thumb-in-palm deformity in cerebral palsy: a biomechanical analysis. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419857067

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Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.