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Topic: Peripheral Nerve Repair and Regeneration

Nerve transfers of the forearm and hand: a

review of current indications

Paolo Sassu, Katleen Libberecht, Anders Nilsson

Department of Hand Surgery, Sahlgrenska University Hospital, SE41345 Gothenburg, Sweden.
Address for correspondence: Dr. Paolo Sassu, Department of Hand Surgery, Sahlgrenska University Hospital, SE41345 Gothenburg,
Sweden. E-mail: sassupaolo@gmail.com

ABSTRACT
Nerve transfer surgery, also referred to neurotization, developed in the mid 1800s with the use of
animal models, and was later applied in the treatment of brachial plexus injuries. Neurotization
is based on the concept that following a proximal nerve lesion with a poor prognosis, expendable
motor or sensory nerves can be re-directed in proximity of a specific target, whether a muscle or
skin territory, in order to obtain faster re-innervation. Thanks to the contribution of several authors
including Oberlin, MacKinnon and many others, the field of nerve transfer surgery has expanded in
treatment of not only the brachial plexus, but also the arm, forearm and hand. This article reviews the
recent literature regarding current concepts in nerve transfer surgery, including similarities to and
differences from tendon transfer surgery. Moreover, indications and surgical techniques are illustrated
for different types of nerve injury affecting the extrinsic and intrinsic musculature of the hand as well
as sensory function.
Key words:
Brachial plexus, nerve transfer, peripheral nerve

INTRODUCTION proximity to their target muscle or skin territory. The
technique was initially used in brachial plexus injuries
The concept of nerve transfer developed almost two and has slowly become a routine procedure for peripheral
hundred years ago when Flourens reported his first nerve lesions where poor functional results are expected
[1]
experiments with the brachial plexus of a rooster. He due to the distance between the site of injury and the
demonstrated that proximal nerve stumps could be innervated muscles.
coupled to different target nerves, obtaining not only
re‑innervation, but also a function that was dependent on GENERAL CONCEPTS IN NERVE
the new motor nerve. This report stimulated a number TRANSFERS
[2]
[3]
of animal studies under the label of “nerve crossing”,
followed by a series of clinical cases in the early twentieth Brachial plexus injuries and peripheral nerve lesions
century showing the feasibility of suturing a proximal nerve at or proximal to the elbow result in denervation and
stump to a distal one with a different target organ. [4‑7] loss of sensation and may not recover due to the long
Using this concept, several options have been developed distance between the lesion and the target organ. Even
over the years, in which expendable donor nerves or when treated early, the axon regeneration process does
their fascicles are re‑directed to recipient nerves in close not always have the capacity to reach the proper muscle
before irreversible changes have taken place. The primary
aim of nerve transfers is to promote re‑innervation in
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proximity to a certain target organ (whether a muscle or a
Quick Response Code: skin territory) following a proximal nerve injury. [8‑11]
Website:
www.parjournal.net
Axonal regeneration progresses at a rate of 1‑2 mm/day.
[12]
Because muscle fibers undergo irreversible changes after
[13]
DOI: 12‑18 months of denervation, it is imperative that
10.4103/2347-9264.160887 treatment be undertaken promptly for functional recovery.
[14]
Very proximal lesions in the arm or brachial plexus, even
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