Lesões dos Tendões e Nervos da Mão Folheto

O que você está sentindo

Você pode notar dor, dormência ou formigamento na mão ou no pulso. Isso geralmente ocorre após uma lesão ou se você tem uma condição como a osteoartrite. A dor pode parecer aguda ou surda. Pode piorar à noite, dificultando o sono. Você também pode sentir rigidez ao acordar pela manhã.

As tarefas diárias podem se tornar difíceis. Ações simples, como alcançar as costas para fechar o sutiã, abotoar a camisa ou levantar uma xícara de café, podem parecer estranhas ou dolorosas. Você pode deixar cair objetos com mais frequência porque sua força de preensão parece fraca. Se você tiver uma lesão nervosa, pode sentir que sua mão não está respondendo como costumava. Isso pode fazer com que segurar objetos pareça instável.

A dor geralmente piora após o uso prolongado da mão. Descansá-la geralmente ajuda a aliviar o desconforto. No entanto, se você ignorar os sintomas, o desconforto pode persistir. Você pode acabar evitando certos movimentos para proteger sua mão. Isso pode levar à rigidez ao longo do tempo.

Se você tiver uma lesão nervosa, pode notar alterações na sensibilidade. Algumas pessoas relatam que os dedos parecem dormentes ou como se estivessem adormecidos. Em alguns casos, você pode sentir uma dor ardente ou em choque. Isso está frequentemente associado ao inchaço ou cicatrização ao redor do nervo. Se você tiver uma lesão tendinosa, pode ouvir um estalo ou sentir uma ruptura súbita no momento da lesão. Depois disso, você pode ter dificuldade em flexionar ou estender completamente os dedos.

É importante prestar atenção a esses sinais. Se você tiver uma fratura, o risco de lesões nervosas e tendinosas é maior. Isso pode levar a incapacidade a longo prazo se não for tratado adequadamente. As lesões dos tendões extensores são comuns, e o reconhecimento precoce é fundamental para o seu manejo. As lesões dos tendões flexores são mais raras, especialmente em crianças, mas ainda exigem atenção cuidadosa.

Se você está experimentando esses sintomas, a referência oportuna a um especialista em extremidade superior pode ajudar a otimizar seus resultados. Queremos entender o que você está sentindo para que possamos planejar o melhor caminho para a sua recuperação.

O que está realmente acontecendo

Sua mão depende de um sistema complexo de tendões, nervos e ligamentos para se mover e sentir. Os tendões atuam como cordas resistentes que conectam seus músculos aos seus ossos. Eles puxam seus dedos e polegar para criar movimento. Os nervos são os fios que transportam sinais do seu cérebro para a sua mão. Eles indicam aos seus músculos quando se mover e enviam sensações de volta ao cérebro. Os ligamentos são faixas resistentes que mantêm seus ossos unidos na posição correta.

Quando você lesiona essas estruturas, o sistema se desorganiza. Um tendão cortado pode se separar do osso, impedindo você de flexionar um dedo. Um nervo danificado pode impedir que os sinais cheguem aos seus músculos. Isso causa fraqueza ou dormência. Você pode notar que sua força de preensão está mais fraca, especialmente ao segurar objetos pequenos. Tarefas simples, como fazer um punho, podem se tornar lentas ou dolorosas. O revestimento suave sobre seus ossos, chamado cartilagem, pode se desgastar. Isso cria atrito e rigidez na articulação.

Seu cirurgião analisa o dano específico para planejar sua reparação. Por exemplo, se um nervo estiver esticado ou cortado, podemos tentar reconectá-lo diretamente. Se o nervo estiver muito danificado, podemos usar uma transferência tendinosa. Isso envolve mover um tendão funcional para assumir a função do tendão lesionado. Isso pode restaurar a função quando a reparação direta do nervo não é possível. Em alguns casos, combinamos a reparação do nervo com a transferência tendinosa para melhorar a capacidade da sua mão de agarrar e soltar objetos.

A sensibilidade é uma parte fundamental da recuperação. Ela representa 40% do objetivo nas reparações do polegar ou das pontas dos dedos. O comprimento e a aparência correspondem aos outros 50%. Nosso objetivo é restaurar não apenas o movimento, mas também a sensação que ajuda você a usar sua mão com segurança. Seu cirurgião escolherá a melhor abordagem com base na localização da lesão e em sua gravidade. O objetivo é devolvê-lo ao uso da sua mão para a vida diária.

O que podemos fazer a respeito

A abordagem adotada para uma lesão de tendão ou nervo da mão depende da antiguidade do dano e de como ele afeta sua vida diária. O Dr. Kieran Hirpara, cirurgião de membro superior do Mater Private Hospital Rockhampton, estrutura nosso cuidado em torno da restauração segura da sua função. Os pacientes chegam à nossa clínica por encaminhamento do clínico geral ou fisioterapeuta. Uma avaliação clínica, incluindo histórico, exame físico e exames de imagem quando necessário, estabelece o diagnóstico. Para problemas degenerativos ou de longa data, geralmente tentamos primeiro o tratamento não cirúrgico. Isso inclui mudança de atividade, fisioterapia ou terapia da mão, uso de órteses e injeções. Consideramos a cirurgia quando isso não proporcionou melhora suficiente. Para problemas estruturais ou agudos, a cirurgia pode ser recomendada imediatamente, sem uma tentativa prévia de tratamento não cirúrgico.

Nas fases iniciais, seu fisioterapeuta o guiará por meio de movimentos suaves para manter as articulações flexíveis e prevenir a rigidez. O objetivo é manter a força nos músculos circundantes enquanto os tecidos lesionados cicatrizam. Se você tiver dor, seu cirurgião pode sugerir analgésicos de venda livre ou anti-inflamatórios para ajudar a controlar o desconforto. Para algumas condições, como o dedo em gatilho em crianças ou problemas específicos de tendão, podemos discutir injeções. Injeções de cortisona podem reduzir a inflamação e a dor, muitas vezes proporcionando alívio por várias semanas a meses. Injeções de ácido hialurônico ou plasma rico em plaquetas (PRP) são às vezes usadas para apoiar a saúde dos tecidos, embora a duração do benefício varie. Adaptamos essas opções à sua lesão específica e aos níveis de dor.

A cirurgia é considerada quando o tratamento conservativo atingiu seu limite ou quando o reparo imediato é necessário por questões de segurança. Para lacerações tendinosas, o reparo primário é possível se você se apresentar precocemente com uma ferida limpa; caso contrário, pode ser necessário um enxerto de tendão. As lesões nervosas são complexas. Se um nervo for seccionado, podemos tentar o reparo direto ou usar um enxerto nervoso para preencher os espaços. Para lacunas menores que 2 cm, os condutos de colágeno podem restaurar a função de forma confiável. Se o reparo nervoso não for possível ou não resultar em função útil, podemos recomendar uma transferência tendinosa. Este procedimento utiliza um tendão funcional para assumir a função do tendão danificado. Na paralisia do nervo radial, as transferências tendinosas oferecem uma alternativa importante à reconstrução nervosa, particularmente quando o retorno precoce ao trabalho é importante. Em casos de tetraplegia, transferências combinadas de nervos e tendões são usadas para restaurar a preensão e o solte. Discutimos essas opções com você, garantindo que você compreenda os benefícios e riscos potenciais antes de prosseguir.

O que esperar

Sua recuperação depende da lesão específica e do tratamento escolhido. Se você tiver uma lesão nervosa, a recuperação sensorial pode ser lenta e incompleta. Apenas 24% dos nervos digitais únicos reparados em adultos recuperam sensibilidade próxima ou equivalente aos níveis estimados pré-lesão. Isso significa que a maioria das pessoas terá alguma alteração duradoura na sensibilidade. No entanto, se você tiver uma replantação de ponta de dedo sem reparo nervoso, uma recuperação sensorial adequada ainda pode ocorrer até o acompanhamento de dois anos.

Quando o reparo nervoso sozinho não restaura função útil, seu cirurgião pode recomendar uma transferência tendinosa. Este procedimento utiliza um tendão funcional para substituir um danificado. É uma opção útil para lesões dos nervos radial, mediano ou ulnar. Pode ser a escolha preferencial se o retorno precoce ao trabalho e à vida social for importante para você. Algumas evidências sugerem que as transferências tendinosas oferecem taxas mais altas de resultados clínicos superiores em comparação com as transferências nervosas para paralisia isolada do nervo radial.

Você também pode realizar o reparo nervoso e a transferência tendinosa ao mesmo tempo. Essa abordagem combinada não mostra resultados prejudiciais e pode proporcionar função melhorada em relação à transferência tendinosa isolada. Para lesões altas do nervo radial com defeitos de 9 cm ou mais, parece indicada uma tentativa de reconstrução nervosa antes de prosseguir para transferências tendinosas dentro de 8 meses. Se você se apresentar precocemente e puder tolerar um tempo mais longo para a recuperação funcional, pode ser um candidato ideal para transferências nervosas em vez de transferências tendinosas.

A reabilitação é uma parte fundamental do seu prognóstico. A reabilitação precoce após o reparo de tendão da mão é benéfica. Um protocolo de reabilitação individualizado para se adequar à sua patologia tendinosa específica e à cirurgia é essencial. A maioria dos resultados adversos após procedimentos como a liberação aberta da polia A1 é dor, rigidez e inchaço de curto prazo. Complicações graves, como lesão nervosa ou infecção profunda, são incomuns.

Deixados sem tratamento, lesões nervosas e tendinosas associadas a fraturas apresentam maior risco de incapacidade a longo prazo. Bem manejadas, muitos pacientes recuperam função significativa. A transferência tendinosa oferece uma alternativa importante à reconstrução nervosa microcirúrgica. Ela ajuda a restaurar a função quando o reparo cirúrgico do nervo não é possível ou não resulta em função útil. Seu cirurgião discutirá qual caminho oferece a melhor chance para suas necessidades específicas.

Quando procurar um especialista

Procure uma avaliação especializada se tiver dor persistente que não melhora com o repouso, ou fraqueza súbita e instabilidade na mão. Procure atendimento urgente se os dedos bloquearem ou cederem, ou se os sintomas interferirem no sono ou no trabalho. As fraturas estão associadas a um maior risco de lesões nervosas e tendinosas, que podem levar a incapacidade a longo prazo. O reconhecimento precoce das lesões dos tendões extensores é fundamental para o manejo. Se houver uma lesão do nervo radial proximal com um defeito de 9 cm ou mais, parece indicada uma tentativa de reconstrução nervosa antes de proceder às transferências tendinosas, dentro de 8 meses. A referência oportuna ajuda a otimizar os resultados.

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

Early neurorrhaphy of acute nerve injuries provides the best outcome [1].
Distal motor nerve transfers should be considered to preserve hand intrinsic motor function when nerve injuries occur at or above the proximal forearm [1].
Nerve transfer is favored over nerve grafting in managing high ulnar nerve injuries because of better improvement of motor power and better restoration of grip functions of the hand [5].
In lower-type injuries of the brachial plexus, transfer of median nerve branches that innervate the palm of the hand to the ulnar proper digital nerve of the little finger predictably restored protective sensation on the ulnar side of the hand [6].
End-to-side distal anterior interosseous nerve transfer provides significantly better results than a standard more proximal nerve repair in the treatment of proximal ulnar nerve injuries [12].
Vascularized ulnar nerve grafts should be recommended for reconstruction of the median or radial nerves in selected cases involving large defects after severe trauma of the upper extremity [14].
High median nerve injuries result in absent thumb and index finger flexion and pulp anesthesia, which do not benefit from nerve grafting but are amenable to nerve transfers [25].
Tendon transfers remain the primary reconstructive procedure for paralytic injuries of the upper limb until sufficiently powered studies of nerve transfer outcomes are published [36].
Experimental studies and positive reports from large clinical series suggest that new techniques using foreign nerves for reinnervation are worthy of integration into the management of upper brachial plexus injuries, though many questions regarding timing, donor morbidity, and comparative efficacy remain unanswered [11].
Clinically, nerve transfer to the median nerve using parts of the ulnar and radial nerves may offer an alternative option for proximal nerve injuries or for free functioning muscle transplantations [16].
The biomechanical principles, indications and limitations of tendon transfers, nerve transfers and combined approaches are compared, with particular attention to timing, patient selection, and functional goals [3].

Anatomy & Pathophysiology

High median nerve transection results in a specific clinical presentation of hand function [2].
Biomechanical principles, indications, and limitations of tendon transfers, nerve transfers, and combined approaches depend on timing, patient selection, and functional goals [3].
Ballistic injuries to the hand are frequently associated with fractures and neurovascular and tendon injuries [4].
Upper extremity peripheral nerve injuries involve the median, radial, and ulnar nerves [8].
A nerve transfer for restoration of ulnar finger flexion through the pronator teres motor branch can be suggested in cases where the hand is partially involved to allow patients to regain or strengthen finger flexion [9].
Functional prehension requires a stable wrist and at least two sensate digits that can oppose with some power [10].
Severe hand injuries from sword assaults can cause devastating loss of function [15].
In combined proximal median and ulnar nerve injuries, restoring ulnar intrinsic function is critical to avoid blunt traditional anticlaw procedures, even if it requires some sacrifice of thumb motors [23].
Opposition transfers do not require large amounts of strength to achieve thumb positioning; the mechanics and vector of pull are of paramount importance [28].
An ulnar nerve to musculocutaneous nerve transfer in an ulnar ray-deficient infant with brachial plexus birth palsy resulted in active elbow flexion to 90° at 18 months without motor deficits in the hand [30].
Opposition is a preparatory position for grasp involving abduction, flexion, and pronation, primarily driven by the thenar intrinsic muscles [31].
A distally based extensor digiti minimi tendon transfer maximizes adducting force and overcomes reciprocal inhibition to correct a persistently abducted little finger [32].
There is no significant difference in hand function between border and central finger digital nerve injuries, except for lower grip strength in central finger injuries [33].
Outcomes for pediatric mutilating hand injuries tend to be better than in adults regarding mobility, sensory return, and appearance [37].
The quadriga phenomenon is caused by interconnected flexor digitorum profundus tendons and significantly affects clinical situations including strength testing, movement assessment, and rehabilitation exercise selection [39].

Classification

High median nerve transection presents with preserved finger flexion [2].
Tendon transfers, nerve transfers, and combined approaches are distinguished by their biomechanical principles, indications, limitations, timing, patient selection, and functional goals [3].
Nerve transfer is favored over nerve grafting in managing high ulnar nerve injuries due to better improvement of motor power and better restoration of grip functions [5].
Transfer of median nerve branches that innervate the palm of the hand to the ulnar proper digital nerve of the little finger predictably restores protective sensation on the ulnar side of the hand in lower-type brachial plexus injuries [6].
Transfer of the superficial radial or dorsal cutaneous branch of the ulnar nerve, or both, produces successful restoration of innervation of the thumb, index, and long fingers in experimental sensory reinnervation models [7].
Upper extremity peripheral nerve injuries include median, radial, and ulnar nerve injuries [8].
Nerve transfer for restoration of ulnar finger flexion through the pronator teres motor branch can be suggested in cases where the hand is partially involved to allow patients to regain or strengthen finger flexion [9].
Vascularized ulnar nerve grafts should be recommended for reconstruction of median or radial nerves in selected cases with large defects after severe upper extremity trauma [14].
Diagnosis-specific model instruments for outcome after nerve repair at the wrist or distal forearm level include new test instruments for assessment of tactile gnosis [21].
Supercharged end-to-side anterior interosseous nerve transfer (SETS) exhibits a remarkable role in treating high ulnar nerve damage by supplying intrinsic muscles and allowing for proximal nerve regeneration [27].
A reliable tendon prosthesis inserted as one stage in tendon reconstruction is an additional step needed to improve results of flexor-tendon reconstructive surgery in hands with severe damage [40].

Clinical Presentation

High median nerve transection can present with preserved finger flexion [2].
Transfer of the superficial radial or dorsal cutaneous branch of the ulnar nerve, or both, produced successful restoration of innervation of the thumb and index and long fingers [7].
Upper extremity peripheral nerve injuries present to emergency departments [8].
Nerve transfer for restoration of ulnar fingers flexion through the pronator teres motor branch can be suggested in cases where the hand is partially involved to allow patients to regain or strengthen finger flexion [9].
End-to-side distal anterior interosseous nerve transfer in treatment of proximal ulnar nerve injuries provides significantly better results than a standard more proximal nerve repair [12].
The triad of multiple metacarpal fractures and/or dislocations of the fingers, severe hand swelling, and clinical evidence of acute median nerve dysfunction can occur [13].
Severe hand injuries resulting from sword assaults can cause devastating loss of function [15].
The choice of surgical technique and timing for peripheral nerve injury depends on the type of trauma, site of injury, and time elapsed since injury [17].
Spontaneous recovery occurs in 70%–88% of radial nerve injuries [17].
Direct radial to ulnar nerve transfer via an interosseous tunnel safely and effectively restored intrinsic function before terminal muscle degeneration in a patient with combined proximal median and ulnar nerve injury [19].
The prognosis for recovery of peripheral neuropathies is good unless the nerve has been completely destroyed [22].
Traumatic neurapraxia in digital nerve injuries of the hand is not uncommon and has a favourable prognosis [29].

Investigations

Evaluation based only on a photograph taken in the emergency department was insufficient for the detection of neurovascular bundle injuries, tendon ruptures, and fractures [43].
The hand requires a stable wrist and at least two sensate digits that can oppose with some power for functional prehension [10].

Treatment

Transfer of the superficial radial or dorsal cutaneous branch of the ulnar nerve, or both, produced successful restoration of innervation of the thumb and index and long fingers in experimental sensory reinnervation models [7].
Nerve transfer using the pronator teres motor branch can be suggested in cases where the hand is partially involved to allow patients to regain or strengthen finger flexion [9].
Experimental studies and positive reports from large clinical series suggest that new techniques using foreign nerves for reinnervation are worthy of integration into the management of upper brachial plexus injuries [11].
Clinically, nerve transfer using parts of the ulnar and radial nerves may offer an alternative option for proximal nerve injuries or for free functioning muscle transplantations [16].
Distal nerve transfers for the treatment of high ulnar nerve injuries allow for a shorter reinnervation period and improved ulnar intrinsic recovery, which is critical to function of the hand [18].
The thenar branch of the median nerve may support ulnar nerve regeneration and help prevent intrinsic muscles from irreversible atrophy, though the procedure requires validation by future clinical data [20].
In devastating combined proximal median and ulnar nerve injuries, some sacrifice of thumb motors may be necessary to restore ulnar intrinsic function and avoid blunt traditional anticlaw procedures [23].
Early nonsurgical management for up to 6 months in adults and 9 months in children has expanded from closed humeral shaft fractures to include operative fractures that do not require nerve exposure, secondary palsies, and distal third humerus fractures [26].
Supercharged end-to-side anterior interosseous nerve transfer (SETS) exhibits a remarkable role in the treatment of high ulnar nerve damage by supplying intrinsic muscles and allowing for proximal nerve regeneration [27].
The thenar motor branch (OP branch) consistently reached the deep terminal motor branch of the ulnar nerve without tension, supporting its use to restore pinch after ulnar nerve injuries [35].
When nonoperative treatment fails, tendon transfers may be used for ulnar nerve injuries, with preferred options including ECRB to AP, APL to first DI, and splint FPL to EPL transfers evaluated on an individual basis [41].

Complications

Full recovery of median nerve function was seen in all patients with the triad of multiple metacarpal fractures/dislocations, severe hand swelling, and acute median nerve dysfunction at a mean final follow-up of 7 months [13].
All patients with the triad of multiple metacarpal fractures/dislocations, severe hand swelling, and acute median nerve dysfunction were able to return to work [13].
High ulnar nerve injuries can result in loss of ulnar intrinsic motor function [1].
High ulnar nerve injuries can lead to irreversible atrophy of intrinsic muscles [20].
Nerve transfers have revolutionized care for peripheral nerve injuries [24].

Recovery

Nerve transfer is favored over nerve grafting in managing high ulnar nerve injuries because of better improvement of motor power [5].
Nerve transfer is favored over nerve grafting in managing high ulnar nerve injuries because of better restoration of grip functions of the hand [5].
Transfer of the superficial radial or dorsal cutaneous branch of the ulnar nerve, or both, produced successful restoration of innervation of the thumb and index and long fingers in experimental sensory reinnervation studies [7].
The hand requires a stable wrist for functional prehension [10].
The hand requires at least two sensate digits that can oppose with some power for functional prehension [10].
New techniques using foreign nerves for reinnervation are worthy of integration into the management of upper brachial plexus injuries, though many questions regarding timing, donor morbidity, and comparative efficacy remain unanswered [11].
At a mean final follow-up of 7 months, full recovery of median nerve function was seen in all patients with the triad of multiple metacarpal fractures/dislocations, severe hand swelling, and acute median nerve dysfunction [13].
Nerve transfer to the median nerve using parts of the ulnar and radial nerves may offer an alternative option for proximal nerve injuries or for free functioning muscle transplantations [16].
The choice of surgical technique and timing for peripheral nerve injury of the upper extremity depends on the type of trauma, site of injury, and time elapsed since injury [17].
Distal nerve transfers for the treatment of high ulnar nerve injuries allow for a shorter reinnervation period [18].
Distal nerve transfers for the treatment of high ulnar nerve injuries allow for improved ulnar intrinsic recovery [18].
Improved ulnar intrinsic recovery is critical to function of the hand [18].
Additional long-term follow-up and case series are warranted for nerve transfers in peripheral nerve injuries [24].
Early nonsurgical management for up to 6 months in adults is indicated for radial nerve injuries associated with closed humeral shaft fractures [26].
Early nonsurgical management for up to 6 months in adults is indicated for radial nerve injuries associated with operative fractures that do not require nerve exposure [26].
Early nonsurgical management for up to 6 months in adults is indicated for radial nerve injuries associated with secondary palsies [26].
Early nonsurgical management for up to 6 months in adults is indicated for radial nerve injuries associated with distal third humerus fractures [26].
Early nonsurgical management for up to 9 months in children is indicated for radial nerve injuries associated with closed humeral shaft fractures [26].
Scarring from injury or previous surgery compromises results in flexor-tendon grafts in the fingers and thumb [44].
Joint stiffness compromises results in flexor-tendon grafts in the fingers and thumb [44].
Nerve damage compromises results in flexor-tendon grafts in the fingers and thumb [44].
The level of injury does not influence results in flexor-tendon grafts in the fingers and thumb [44].
Time to operation does not influence results in flexor-tendon grafts in the fingers and thumb [44].

Key Evidence

[L5] Early neurorrhaphy of acute nerve injuries provides the best outcome, but consideration should also be given to performing distal motor nerve transfers to preserve hand intrinsic motor function when injuries occur at or above the proximal forearm. [1] (10.1016/j.jhsa.2014.04.038)
[Case_report] This case contributes further to our understanding of the clinical presentation of hand function following high median nerve transection. [2] (10.1186/s12891-025-08469-3)
[L5] The biomechanical principles, indications and limitations of tendon transfers, nerve transfers and combined approaches are compared, with particular attention to timing, patient selection, and functional goals. [3] (10.1177/17531934261416300)
[L4] Ballistic injuries to the hand are frequently associated with fractures and neurovascular and tendon injuries. [4] (10.1177/15589447221092111)
[L4] Nerve transfer is favored over nerve grafting in managing high ulnar nerve injuries because of better improvement of motor power and better restoration of grip functions of the hand. [5] (10.1016/j.jhsa.2017.01.027)
[L4] In lower-type injuries of the brachial plexus, transfer of median nerve branches that innervate the palm of the hand to the ulnar proper digital nerve of the little finger predictably restored protective sensation on the ulnar side of the hand. [6] (10.1016/j.jhsa.2012.02.047)
[L5] Transfer of the superficial radial or dorsal cutaneous branch of the ulnar nerve, or both, produced successful restoration of innervation of the thumb and index and long fingers. [7] (10.2106/00004623-197759030-00016)
[L4] This study provides a critical overview of upper extremity peripheral nerve injuries. [8] (10.1016/j.jht.2026.02.012)
[L5] This specific procedure can be suggested in cases where the hand is partially involved to allow patients to regain or strengthen fingers flexion. [9] (10.1016/j.jhsg.2025.100844)
[L5] The hand requires a stable wrist and at least two sensate digits that can oppose with some power for functional prehension. [10] (10.1016/s0749-0712(02)00130-0)
[L5] Experimental studies and positive reports from large clinical series suggest that new techniques using foreign nerves for reinnervation are worthy of integration into the management of upper brachial plexus injuries, though many questions regarding timing, donor morbidity, and comparative efficacy remain unanswered. [11] (10.1054/jhsb.2000.0460)
[L4] It provides significantly better results than a standard more proximal nerve repair. [12] (10.1016/s0363-5023(11)60008-7)
[L4] At a mean final follow-up of 7 months, full recovery of median nerve function was seen in all patients, and all patients were able to return to work. [13] (10.1177/1753193408087105)
[L4] This technique should be recommended for reconstruction of the median or radial nerves in selected cases. [14] (10.1016/j.jhsa.2005.03.017)
[L4] This case series demonstrates the extent and severity of hand injuries that can be caused by sword assaults with devastating loss of function for the victims. [15] (10.1177/1753193410381576)
[L5] Clinically, this technique may offer an alternative option for proximal nerve injuries or for free functioning muscle transplantations. [16] (10.1054/jhsb.2000.0389)
[L4] The choice of surgical technique and timing depends on the type of trauma, site of injury, and time elapsed since injury, with spontaneous recovery occurring in 70%–88% of radial nerve injuries. [17] (10.1177/17531934241240867)
[L5] Distal nerve transfers for the treatment of high ulnar nerve injuries allow for a shorter reinnervation period and improved ulnar intrinsic recovery, which is critical to function of the hand. [18] (10.1016/j.hcl.2015.12.009)
[Case_report] Direct radial to ulnar nerve transfer via an interosseous tunnel safely and effectively restored intrinsic function before terminal muscle degeneration in a patient with combined proximal median and ulnar nerve injury. [19] (10.1016/j.jhsa.2014.04.013)
[L4] The thenar branch of the median nerve may support ulnar nerve regeneration and help prevent intrinsic muscles from irreversible atrophy, but the report is preliminary and the procedure should be validated by future clinical data. [20] (10.1177/1753193416675069)
[L5] The paper reviews the developmental process of a diagnosis-specific Model instrument for outcome after nerve repair at wrist or distal forearm level, including a new test instrument for assessment of tactile gnosis. [21] (10.1016/s0749-0712(03)00003-9)
[L3] The prognosis for recovery is good unless the nerve has been completely destroyed. [22] (10.2106/00004623-197658010-00011)
[Letter] The authors acknowledge the concerns regarding potential thumb function loss but emphasize the critical need to restore ulnar intrinsic function to avoid blunt traditional anticlaw procedures, suggesting that some sacrifice of thumb motors may be necessary in devastating combined proximal median and ulnar nerve injuries. [23] (10.1016/j.jhsa.2014.10.067)
[Letter] The original authors state that nerve transfers have revolutionized care for peripheral nerve injuries and that additional long-term follow-up and case series are warranted. [24] (10.1016/j.jhsa.2014.07.058)
[L4] High median nerve injuries result in absent thumb and index finger flexion and pulp anesthesia, which do not benefit from nerve grafting but are amenable to nerve transfers. [25] (10.1016/j.hcl.2015.12.008)
[L5] Early nonsurgical management for up to 6 months in adults and 9 months in children has expanded from closed humeral shaft fractures to include operative fractures that do not require nerve exposure, secondary palsies, and distal third humerus fractures. [26] (10.5435/jaaos-d-17-00325)
[L4] SETS exhibit a remarkable role in the treatment of high ulnar nerve damage by supplying intrinsic muscles and allowing for proximal nerve regeneration. [27] (10.1186/s12891-024-07650-4)
[L5] Opposition transfers do not require large amounts of strength to achieve the goal of thumb positioning; the mechanics and vector of pull are of paramount importance. [28] (10.1016/j.hcl.2016.03.005)
[L4] Traumatic neurapraxia in digital nerve injuries of the hand is not uncommon and has a favourable prognosis. [29] (10.1007/s00402-007-0299-6)
[Case_report] The procedure resulted in active elbow flexion to 90° at 18 months without motor deficits in the hand. [30] (10.1016/j.jhsa.2010.06.014)
[L5] Opposition is a preparatory position for grasp involving abduction, flexion, and pronation, primarily driven by the thenar intrinsic muscles. [31] (10.1016/j.hcl.2011.09.004)
[L4] The novel tendon transfer technique maximizes adducting force and overcomes reciprocal inhibition, resulting in normal finger position at 9 months. [32] (10.1177/1753193411421096)
[L3] No significant difference was seen in hand function between border and central finger injuries, except for lower grip strength in central finger injuries. [33] (10.1177/17531934241286116)
[L4] The OP branch consistently reached the deep terminal motor branch of the ulnar nerve without tension, supporting its use to restore pinch after ulnar nerve injuries. [35] (10.1177/17531934251389494)
[L5] Tendon transfers remain the primary reconstructive procedure for paralytic injuries of the upper limb until sufficiently powered studies of nerve transfer outcomes are published. [36] (10.1177/1753193419864838)
[L5] The treatment of mutilating hand injuries in children is challenging but outcomes tend to be better than in adults regarding mobility, sensory return, and appearance. [37] (10.1016/s0749-0712(02)00076-8)
[L5] The authors welcome interest in their work on nerve transfers for complex injuries, stating that while no perfect strategies exist, nerve transfers have revolutionized care and that additional long-term follow-up and case series are warranted. [38] (10.1016/j.jhsa.2014.10.007)
[L5] The quadriga phenomenon, caused by interconnected flexor digitorum profundus tendons, significantly affects clinical situations including strength testing, movement assessment, and rehabilitation exercise selection; understanding its anatomy and biomechanics improves diagnosis and treatment. [39] (10.1177/1753193411430810)
[L4] The authors conclude that a reliable tendon prosthesis inserted as one stage in tendon reconstruction is the additional step needed to improve the results of flexor-tendon reconstructive surgery in hands with severe damage. [40] (10.2106/00004623-197153050-00001)
[L5] When nonoperative treatment fails, tendon transfers may be used, with preferred options including ECRB to AP, APL to first DI, and splint FPL to EPL transfers evaluated on an individual basis. [41] (10.1016/j.hcl.2016.03.007)
[L4] Similarly, evaluation based only on the photograph was insufficient for the detection of neurovascular bundle injuries, tendon ruptures, and fractures. [43] (10.1016/j.jhsa.2024.07.009)

References

[1] Management of Ulnar Nerve Injuries. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.04.038

[2] Preserved finger flexion following high median nerve transection: a rare case report and review of literature. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08469-3

[3] Tendon versus nerve transfers – balancing hand function in upper extremity high nerve injuries. Journal of Hand Surgery (European Volume). 2026. DOI: 10.1177/17531934261416300

[4] Outcomes in Ballistic Injuries to the Hand: Fractures and Nerve/Tendon Damage as Predictors of Poor Outcomes. HAND. 2022. DOI: 10.1177/15589447221092111

[5] Nerve Transfer Versus Nerve Graft for Reconstruction of High Ulnar Nerve Injuries. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.01.027

[6] Distal Sensory Nerve Transfers in Lower-Type Injuries of the Brachial Plexus. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.02.047

[7] Experimental sensory reinnervation of the median nerve by nerve transfer in monkeys. The Journal of Bone & Joint Surgery. 1977. DOI: 10.2106/00004623-197759030-00016

[8] Exploring 20 years of peripheral nerve injuries of the upper extremity: An analysis of median, radial, and ulnar nerve injuries presenting to US emergency departments. Journal of Hand Therapy. 2026. DOI: 10.1016/j.jht.2026.02.012

[9] Nerve Transfer for Restoration of Ulnar Fingers Flexion Through Pronator Teres Motor Branch: A Cadaveric Feasibility Study. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2025.100844

[10] Biomechanics and hand trauma: what you need. Hand Clinics. 2003. DOI: 10.1016/s0749-0712(02)00130-0

[11] Avulsion Injuries to the Brachial Plexus and the Value of Motor Reinnervation by Ipsilateral Nerve Transfer. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.2000.0460

[12] End-to-side Distal Anterior Interosseous Nerve Transfer in Treatment of Proximal Ulnar Nerve Injuries. The Journal of Hand Surgery. 2011. DOI: 10.1016/s0363-5023(11)60008-7

[13] The Triad of Multiple Metacarpal Fractures and/or Dislocations of the Fingers, Severe Hand Swelling and Clinical Evidence of Acute Median Nerve Dysfunction. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408087105

[14] Vascularized Ulnar Nerve Graft for Reconstruction of a Large Defect of the Median or Radial Nerves After Severe Trauma of the Upper Extremity. The Journal of Hand Surgery. 2005. DOI: 10.1016/j.jhsa.2005.03.017

[15] Severe hand injuries resulting from Samurai sword assaults: a Dublin case series. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193410381576

[16] Nerve Transfer to the Median Nerve Using Parts of the Ulnar and Radial Nerves in the Rabbit – Effects on Motor Recovery of the Median Nerve and Donor Nerve Morbidity. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.2000.0389

[17] Timing of surgery in peripheral nerve injury of the upper extremity. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241240867

[18] High Ulnar Nerve Injuries. Hand Clinics. 2016. DOI: 10.1016/j.hcl.2015.12.009

[19] Direct Radial to Ulnar Nerve Transfer to Restore Intrinsic Muscle Function in Combined Proximal Median and Ulnar Nerve Injury: Case Report and Surgical Technique. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.04.013

[20] Nerve grafts bridging the thenar branch of the median nerve to the ulnar nerve to enhance nerve recovery: a report of three cases. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193416675069

[21] A new model instrument for outcome after nerve repair. Hand Clinics. 2003. DOI: 10.1016/s0749-0712(03)00003-9

[22] Peripheral neuropathies associated with total hip arthroplasty. The Journal of Bone & Joint Surgery. 1976. DOI: 10.2106/00004623-197658010-00011

[23] Response to “Direct Radial to Ulnar Nerve Transfer to Restore Intrinsic Muscle Function in Combined Proximal Median and Ulnar Nerve Injury: Case Report and Surgical Technique”. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.10.067

[24] Letter to the Editor Regarding Phillips BZ, Franco MJ, Yee A, Tung TH, Mackinnon SE, Fox IK. Direct Radial to Ulnar Nerve Transfer to Restore Intrinsic Muscle Function in Combined Proximal Median and Ulnar Nerve Injury: Case Report and Surgical Technique. J Hand Surg Am. 2014;39(7):1358–1362. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.07.058

[25] High Median Nerve Injury. Hand Clinics. 2016. DOI: 10.1016/j.hcl.2015.12.008

[26] Updates on and Controversies Related to Management of Radial Nerve Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00325

[27] Supercharged end-to-side anterior interosseous nerve transfer to restore intrinsic function in high ulnar nerve injury: a prospective cohort study. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07650-4

[28] Low Median Nerve Transfers (Opponensplasty). Hand Clinics. 2016. DOI: 10.1016/j.hcl.2016.03.005

[29] Clinical and user-friendly classification of traumatic digital nerve injuries of hand. Archives of Orthopaedic and Trauma Surgery. 2007. DOI: 10.1007/s00402-007-0299-6

[30] Ulnar Nerve to Musculocutaneous Nerve Transfer in an Ulnar Ray–Deficient Infant With Brachial Plexus Birth Palsy: Case Report. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.06.014

[31] Restoration of Opposition. Hand Clinics. 2012. DOI: 10.1016/j.hcl.2011.09.004

[32] Correcting the persistently abducted little finger using a distally based extensor digiti minimi tendon. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411421096

[33] Long-term subjective and objective outcomes after digital nerve repair: a cohort study. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241286116

[35] Anatomical roadmap of the thenar motor branches: key insights for distal nerve transfers. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251389494

[36] Tendon transfers after peripheral nerve injuries: my preferred techniques. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419864838

[37] Pediatric mutilating hand injuries. Hand Clinics. 2003. DOI: 10.1016/s0749-0712(02)00076-8

[38] In Reply:. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.10.007

[39] The quadriga phenomenon: a review and clinical relevance. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411430810

[40] Flexor-Tendon Reconstruction in Severely Damaged Hands. The Journal of Bone & Joint Surgery. 1971. DOI: 10.2106/00004623-197153050-00001

[41] Ulnar Nerve Tendon Transfers for Pinch. Hand Clinics. 2016. DOI: 10.1016/j.hcl.2016.03.007

[43] Evaluation of Injured Structures and Circulation of Fingers From Photos Taken in the Emergency Department After Hand Injury. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2024.07.009

[44] Flexor-Tendon Grafts in the Fingers and Thumb: A STUDY OF FACTORS INFLUENCING RESULTS IN 1000 CASES.. The Journal of Bone and Joint Surgery. American Volume. 1971.