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Page 10 of 12 Bryan et al. Plast Aesthet Res 2022;9:53 https://dx.doi.org/10.20517/2347-9264.2022.39

available as an expendable donor nerve. For wrist extension, both FDS to ECRB and distal AIN (PQ) to
ECRB can be used to regain MRC grade 4 extension. The choice of donor nerve will depend on the
mechanism of injury.

Although specific nerve transfer methods may be reported more than others, it is essential to remember that
the optimal donor nerve may vary in different patients. Available donor nerves would vary in patients with
tetraplegia, brachial plexus injury or proximal median or ulnar nerve injury. Nerve transfers should be
tailored to the requirements of the patient to potentially achieve the best possible outcome. While physical
examination remains the most important method for determining the candidacy of donor nerves, imaging
techniques such as magnetic resonance imaging may have a role in decision making .
[18]

CLINICAL RECOMMENDATIONS
Median and radial nerve transfers are reliable methods for upper extremity reanimation after nerve injury.
The authors recommend that decisions on the technique used for nerve transfer should be made on a case-
by-case basis depending on injury patterns and available donor nerves. Based on the comprehensive review,
if there are multiple nerve transfer options for reinnervation of the AIN, we recommend ECRB to AIN as it
has better overall reported outcomes compared to brachialis to AIN. Supinator to AIN is another option,
but only a few cases have been published.

For wrist and finger extension restoration, we recommend supinator to PIN as a well-documented, reliable
method with good results and high overall reported patient satisfaction. FCR to PIN also has good results.
We believe it can still be considered when supinator to PIN is not possible with proximal radial nerve
injuries or when imaging or physical exam suggests FCR to be a better donor nerve. When only wrist
extension restoration is indicated, we recommend distal AIN (PQ) to ECRB as it has good outcomes and is
more widely reported than FDS to ECRB, although the latter has good outcomes as well.

Lastly, we reiterate that our clinical recommendations are based on the current documented outcomes in
the literature and may evolve as more cases are reported. We recommend that the final decision for
choosing a nerve transfer technique should be based on the clinician’s best judgment by utilizing physical
exam and imaging to choose a donor nerve that allows a technically feasible dissection and coaptation with
the highest return to function and least donor site morbidity.

DECLARATIONS
Authors’ contributions
Made substantial contributions to the article including data curation, background research, interpretation,
writing, editing, and revising: Bryan J
Made substantial contributions to writing, editing, and revising: Nichols DS
Contributed to writing, editing, and background research: Polansky C, Cox E
Contributed to writing, editing, and figure illustration: Oberhofer Barker H
Contributed to writing, editing, and project idea: Sullivan B, Chim H

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.