Superficial Radial Sensory Nerve Release with Tenotomy of the Brachioradialis Tendon

The superficial radial sensory nerve can be entrapped between the brachioradialis and extensor carpi radialis longus tendons as the radial sensory nerve courses superficially from its deep origin. Compression of the radial sensory nerve presents with numbness and/or pain on the dorsal radial aspect of the hand. Pronation of the hand exacerbates these symptoms as […]

Common Peroneal Nerve Release at the Fibular Head

Entrapment of the common peroneal nerve (CPN) at the fibular head is an under-recognized lower extremity neuropathy that contributes to weakness of the musculature within the anterior and lateral compartments of the leg and progress to foot drop. As well, there can be numbness/pain within the territory of the superficial and deep peroneal nerve. Compression […]

Superficial Peroneal Nerve Release in the Lower Leg

Compression of the superficial peroneal nerve (SPN) is due to the superficial fascial layer that encapsulates the SPN and its distal entrapment point called the transverse crural ligament. These structures are typically the cause for numbness and pain in the territory of the SPN. Release of the SPN involves the longitudinal release of the superficial […]

Revision Ulnar Nerve Transposition Following Failed Submuscular Ulnar Nerve Transposition

Failed surgical management of cubital tunnel syndrome may warrant a revision ulnar nerve transposition. Revision surgery is associated with increased technical difficulty depending on the primary procedure. The senior author’s preferred technique for management of cubital tunnel syndrome is a transmuscular ulnar nerve transposition. The technique for revision surgery incorporates methods towards a transmuscular transposition. […]

Saphenous Nerve Release

Entrapment of the saphenous nerve is probably under-recognized and presents with numbness/pain in the infrapatellar region and the medial aspect of the lower leg. The vastoadductor intermuscular septum is responsible for entrapment symptoms as it forms the anterior fascia of the adductor canal, deep to the sartorius muscle. The femoral vessels and saphenous nerve have […]

Medial Triceps to Anterior Branch of Axillary Nerve Transfer: A Case of Specific Reinnervation

The axillary nerve has several distal branches that provide shoulder function through the innervation of the anterior, middle, and posterior deltoid and teres minor, as well as sensation to the lateral arm. Injury to the axillary nerve has been traditionally viewed as either a complete non-favorable injury where recovery does not occur or a favorable […]

Medial Triceps to Axillary Nerve Transfer

Injury to the axillary nerve results in the loss of shoulder function, specifically deltoid and teres minor deficits. This injury can either be isolated or more commonly associated with an upper brachial plexus injury that includes the C5,6 roots. The medial triceps is an available donor for nerve transfer into the axillary nerve and is […]

Brachialis to Anterior Interosseous Nerve Transfer with Extended Forearm Incision

Loss of flexor pollicis longus and radial profundus function results in a deficit of pinch and reduced grip strength in the hand. This palsy can be isolated or commonly included in a lower brachial plexus injury. The brachialis nerve is an available, synergistic, and powerful donor for transfer in these scenarios, especially in C7,8,T1 injuries […]

Median (FCR/FDS) to Radial (PIN/ECRB) Nerve Transfers with PT to ECRB Tendon Transfer

Radial nerve palsy is a debilitating nerve injury that results in lost of wrist and finger extension, which classically presents as wrist drop. The two reconstructive options for managing this injury are tendon transfers and nerve transfers, each with their advantages and disadvantages. Nerve transfers are able to provide independent finger extension, however there is […]

Stage 1 – Cross-Facial Nerve Grafting for Smile

Facial paralysis causes significant morbidity and dynamic reconstruction aims to address functional, aesthetic, and psychological aspects of the impairment. Cross-facial nerve grafting is a reconstructive strategy used to restore smile function and eye closure in both acute and chronic unilateral injury. In an acute injury, nerve grafting provides regenerating fibers from the donor nerve on […]

Posterior Approach – Spinal Accessory to Suprascapular Nerve Transfer

Reconstructing shoulder function following a nerve injury is a challenge due to its dynamic movement originating from several muscles. The supra/infraspinatus muscles are critical for shoulder function in that they initiate abduction of the arm, external rotation, and stabilization of the shoulder joint. In upper brachial plexus injuries, it is common to find a deficit […]

Superficial Peroneal and Sural Neuroma Transposition in a Case of Neuropathic Pain Following Foot Surgery

Pain resulting from nerve injury can originate from the site of injury (local neuroma pain) and from the collateral sprouting of adjacent sensory territories into the deinnervated territory (hyperalgesic pain). Surgical management of neuropathic pain is controversial and typical management of neuroma pain includes excision and transposition. In our institution, management includes a proximal crush […]

Anterior Interosseous to Ulnar Motor Nerve Transfer

Injury to the ulnar nerve results in clawing of the hand due to lost of ulnar intrinsic hand muscles, lost of ulnar-innervated wrist/finger flexion, and numbness/pain within the ulnar nerve territory of the hand. To prevent clawing and reconstruct the ulnar intrinsic hand muscles, the anterior interosseous to ulnar motor nerve transfer is an available […]

Revision Carpal Tunnel Release in a Case of Persistent Symptoms and Incomplete Release

Failure to resolve symptoms of carpal tunnel syndrome following a release of the flexor retinaculum can occur for a number of reasons. Failed carpal tunnel can be classified into three categories and include (1) persistent symptoms, (2) recurrent symptoms, and (3) new symptoms. Persistent symptoms of median nerve dysfunction can imply an incomplete release and/or […]

Posterior Interosseous Nerve Release

Compression of the posterior interosseous nerve can exhibit clinical weakness or functional loss of finger / thumb extension and lack of ulnar wrist extension. Provocative tests can confirm whether the radial tunnel in the region of the posterior interosseous nerve is the area of compression. Multiple anatomical structures can be involved in compressing the nerve […]

Transmuscular Ulnar Nerve Transposition in a Case of Traumatic Medial Cord Injury

Cubital tunnel syndrome can present with pain/numbness in the ulnar nerve territory and weakness in the ulnar-innervated extrinsic/intrinsic muscles. The etiology for cubital tunnel syndrome depends on the case and includes various points of compression along the course of the ulnar nerve. The most common compression point is the medial epicondyle at which the fascial […]

3rd Webspace to Sensory Component of Ulnar Nerve Transfer and PCM to DCU Nerve Transfer

Sensory nerve transfers are an available option for restoring sensation to critical deinnervated territories. Multiple strategies exist for restoring sensation, which include end-to-end nerve transfers for critical territories and end-to-side nerve transfers for non-critical territories. For sensory deficits in the ulnar nerve, the 3rd webspace fascicle from the median nerve can be utilized as a […]

Median Nerve Release in the Forearm

Compression neuropathy of the median nerve in the forearm, also known as pronator syndrome, typically presents with pain in the forearm +/- paresthesia/pain in the median nerve territory. The anterior interosseous nerve can be involved with a mononeuritis. While this usually resolves without surgery, occasionally will require this approach for reconstruction or release. Related anatomical […]

Carpal Tunnel Release

Carpal tunnel syndrome is a compression neuropathy of the median nerve as it travels through the carpal tunnel deep to the transverse carpal ligament. This causes paresthesia and pain in the territory of the median nerve and weakness of the thenar muscles depending on the severity of the neuropathy. Paresthesia is most typically in the […]

Anterior Interosseous to Ulnar Motor Supercharge Nerve Transfer

The supercharge nerve transfer is a procedure that coapts the distal end of a donor nerve to the side of the recipient nerve. Nerve regeneration is facilitated from donor to recipient through a perineurial window to enhance regeneration from the proximal regenerating nerve. This procedure can be used in cases of 2nd/3rd degree nerve injuries […]

Median to Radial Nerve Tendon Transfers: PT to ECRB, FCR to EDC, PL to EPL

Tendon transfers are an available option for reconstructing wrist and finger/thumb extension following radial nerve injury when nerve transfers are contra-indicated. The donor median-innervated tendons are used to reconstruct the recipient radial-innervated tendons. This tutorial describes the following tendon transfers: (1) pronator teres (PT) to extensor carpi radialis brevis (ECRB), (2) flexor carpi radialis (FCR) […]

Median (FCR/FDS) to Radial (PIN/ECRB) Nerve Transfer with Pronator Teres to ECRB Tendon Transfer

The median to radial nerve transfer is an available option for restoring radial nerve hand function following nerve injury. This nerve transfer specifically involves the transferring of two sets of nerves. That is, the flexor carpi radialis (FCR) to posterior interosseous nerve (PIN) and the flexor digitorum superficialis (FDS) to extensor carpi radialis brevis (ECRB) […]

Ganglion Cyst Removal in the Common Peroneal Nerve at the Fibular Head

There are various causes of common peroneal nerve palsy, however common peroneal nerve palsy caused by a ganglion cyst is uncommon. A benign tumor within the nerve sheath can cause compression and present with symptoms of neuropathy depending on the level of injury. In this specific case, the patient presented with a ganglion cyst in […]

Pectoral Fascicle of the Middle Trunk to Spinal Accessory Nerve Transfer

The pectoral fascicle of the middle trunk is an available donor nerve to transfer to restore spinal accessory nerve function. This procedure involves identifying the brachial plexus and the accessory nerve through a supraclavicular exposure. The pectoral fascicle is identified on the anterior aspect of the middle trunk deep to the identified upper trunk. Typically, […]

Tarsal Tunnel Release

Tarsal tunnel syndrome describes the compression of the tibial nerve through the tarsal tunnel which results in pain and numbness in the plantar aspect of the foot. The tibial nerve has three major branches which include the calcaneal, medial plantar, and lateral plantar nerve branches. There are two primary structures responsible for compression of the […]

Superficial Peroneal Nerve Release in the Lower Leg

Symptoms of a compressed superficial peroneal nerve in the lower leg includes numbness and tingling in the dorsal aspect of the foot and lateral aspect of the lower leg. These symptoms can be exaggerated when the peroneal nerve is under tension during movements of the leg and foot. Compression of the superficial peroneal nerve occurs […]

Common Peroneal Nerve Release at the Fibular Head

Compression of the common peroneal nerve at the fibular head is under recognized. Symptoms range from numbness and tingling in the posterior and lateral aspect of the lower leg and dorsal aspect of the foot to foot drop in severe cases of denervation. Symptoms can be exaggerated when the peroneal nerve is under tension during […]

Flexor Digitorum Profundus Tenodesis (Median FDP to Ulnar FDP)

For paralysis of ulnar-innervated flexor digitorum profundus (FDP) to the ring and small finger, tenodesis of the ulnar-innervated FDP tendons will allow the median-innervated FDP to drive the function of the ulnar-innervated FDP function. Specifically, the ulnar-innervated FDP tendons are sutured to the FDP tendon to the long finger, while the FDP tendon to the […]

Thoracic Outlet Decompression

Neurological thoracic outlet ‘inlet’ syndrome (TOS) involves compression of the brachial plexus through the thoracic inlet. The neurologic symptoms of TOS can range from mild paresthesias and numbness in the upper extremity to intrinsic hand muscle atrophy. Thoracic outlet decompression entails decompressing the upper, middle, and lower trunks by dividing the anterior and middle scalene […]

Medial Triceps Branch to Axillary Nerve Transfer

The medial triceps branch to axillary nerve transfer is an available option for reconstructing patients with shoulder deficits that include an axillary nerve injury. Not presented in this tutorial, the accessory to suprascapular nerve transfer is additionally performed to stabilize the humerus during its range-of-motion in these patients. The triceps to axillary nerve transfer specifically […]

Medial Antebrachial Cutaneous Nerve Graft Harvest

The medial antebrachial cutaneous (MABC) nerve is a viable donor for nerve grafts and our institution’s preferred donor nerve graft for upper extremity nerve reconstructions. The MABC nerve is harvested from the medial aspect of the arm and is found branching distally into an anterior and posterior branch. The anterior and/or posterior branch can be […]

Flexor Digitorum Superficialis to Anterior Interosseous Nerve Transfer

For isolated anterior interosseous nerve palsies, the nerve to the flexor digitorum superficialis (FDS) is an available donor to innervate the anterior interosseous nerve (AIN) for transfer. The FDS and AIN branch are found branching from the median nerve within the same upper-middle forearm region. The nerve to the FDS branches from the median nerve […]

Tibial Nerve Decompression at the Soleus

Compression of the tibial nerve by the tendinous leading-edge of the soleus is rare but under recognized. The tibial nerve is decompressed by dividing the soleus arch found deep within the lower leg. The surgical approach involves proceeding between the lateral and medial gastrocnemius muscles. The soleus muscle is then identified deep to the gastrocnemius […]

Thoracodorsal to Long Thoracic Nerve Transfer

Patients with long thoracic nerve injuries exhibit scapular winging and sever shoulder deficits that include the inability to forward flex the shoulder past 90 degrees of range of motion. Thoracodorsal to long thoracic nerve transfer utilizes a distal posterior branch of the thoracodorsal nerve to reinnervate the distal half of the long thoracic nerve. This […]

Submuscular Ulnar Nerve Transposition

A submuscular ulnar nerve transposition is performed to decompress the ulnar nerve in the cubital tunnel at the elbow. The medial antebrachial cutaneous nerve is identified and protected. Proximally, the medial intermuscular septum is resected. A step-lengthening of the fascia of the flexor-pronator muscles is performed. The ulnar nerve is placed in a transmuscular location. […]

Double Fascicular Transfer: Median Fascicle to Biceps Branch and Ulnar Fascicle to Brachialis Branch Nerve Transfers

The double fascicular transfer (DFT) includes two nerve transfers: (1) median fascicle to biceps branch and (2) ulnar fascicle to brachialis branch. The median fascicle contains nerve fibers that innervate flexor digitorum superficialis / flexor carpi radialis. The ulnar fascicle contains nerve fibers that innervate flexor carpi ulnaris. The donor fascicles can be used for […]

Anterior Interosseous to Ulnar Motor (Reverse End-to-side) Nerve Transfer

The donor anterior interosseous nerve (AIN) is transferred to the side of the recipient ulnar motor fascicular group within the distal forearm to preserve ulnar nerve motor intrinsics. Guyon’s canal release is a required part and is completed prior to this procedure. Specific to this case, a revision ulnar nerve transposition was completed proximally. This […]

Carpal Tunnel Release

A carpal tunnel release is performed by decompressing the median nerve in the wrist through the carpal tunnel. This procedure involves transecting the transverse carpal ligament. POSITION Supine. INCISION An incision is made ulnar to the thenar crease between the palmar sensory territories of the median and ulnar nerve. In addition, this approach allows for […]

Median Nerve Forearm Decompression

Disclosure: No authors have a financial interest in any of the products, devices, or drugs mentioned in this production or publication. The median nerve is decompressed in the forearm. A Z-plasty lengthening is performed on the pronator teres tendon. In addition, the tendon of the deep head of the pronator teres is transected and the […]

Guyon’s Canal Release and Carpal Tunnel Release

The ulnar nerve is decompressed in the wrist through Guyon’s canal and in the hand, specifically the deep motor branch of the ulnar nerve. This deep motor branch is released by dividing the tendious arch of the hypothenar muscles. In addition, a carpal tunnel release is performed by transecting the transverse carpal ligament. Standard Extended […]