Biceps to Triceps Transfer In

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Biceps-to-Triceps Transfer inTetraplegic Patients: Report of the

Medial Routing Technique andFollow-up of Three Cases

Julian E. Kuz, MD, Ann E. Van Heest, MD, James H. House, MD,Minneapolis, MN

We reviewed 4 bi ceps-to-triceps transfers for active elbow extension in 3 tetraplegic patients

using a medial routing technique. The biceps-to-triceps transfer to regain active elbow

extension in tetraplegic patients is an alternative to the more commonly described deltoid-

to-triceps transfer. Before surgery, all 3 patients had absent triceps function and active biceps,

brachialis, and supinator function. Postoperative results were assessed by a modi fied Uni ver-

sity of Mi nnesota Functional Improvement questionnaire and by foll ow-up evaluation of range

of motion and muscle strength. All 3 patientshad marked functional i mprovement in activi ties

that i nvolve active elbow extension, and no loss of function w as noted i n any activities. N o

patient achi eved less than grade 4 extension strength; none had an extension l ag greater than

8. Supination and fl exion strength foll owi ng transfer were rated as at least grade 4 in each

limb. Based on the results of this study, we recommend the biceps-to-triceps transfer as an

alternative to the deltoid-to-triceps transfer i n spinal cord injury patientsw ith active brachialis

and supinator function. The medial routing technique has the advantage of avoiding the

potentially devastating radial nerve i njury that could occur w ith the previously described

lateral routing. (JHand Surg 1999;24A:161172. Copyright 1999 by the American Society

for Surgery of the Hand.)

Key words: Tetraplegia, elbow paralysis, tendon transfer

In tetraplegic patients who lack active elbow ex-tension due to spinal cord injury, active elbow ex-

tension can be achieved through transfer of an activemuscle into the paralyzed triceps. The improvement

in function following triceps reconstruction in tet-raplegic patients has been termed fundamental in-

tervention.1 The functional gains of elbow exten-

sion reconstruction in these patients include reaching

objects above shoulder level, reaching objects when

in a supine position, improved ability and safety of

driving, wheelchair propulsion, pressure relief, and

independent transfer.2,3 In addition, gaining active

elbow extension provides a useful antagonist to el-bow flexion for improvement of hand positioning in

space and helps stabilize the elbow when the bra-

chioradialis is used as a tendon transfer.

Tetraplegic patients who have an International

Classification of level 4 or less (Tables 1, 2)1,4,5 are

candidates for tendon transfers for elbow extension.

The posterior deltoid-to-triceps and the biceps-to-

triceps transfers have been the 2 most common types

of transfers used for elbow extension. The disadvan-

tages of a posterior deltoid-to-triceps transfer include

From the Department of Orthopaedic Surgery, University of Min-

nesota, Minneapolis, MN.

Received for publication June 19, 1997; accepted in revised form

June 2, 1998.

No benefits in any form have been received or will be received from

a commercial party related directly or indirectly to the subject of this

article.

Reprint requests: Ann E. Van Heest, MD, Department of Orthopae-

dic Surgery, University of Minnesota Hospital, 420 Delaware St SE,

Box 492 UMHC, Minneapolis, MN 55455.

Copyright 1999 by the American Society for Surgery of the Hand

0363-5023/99/24A010024$3.00/0

The Journal of Hand Surgery 161


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the need for a free tendon graft,6,7 a long immobili-zation time,1 and the potential for the double tendon

repair to stretch out in time, resulting in decreasedstrength.1,8 Attempts at earlier mobilization of this

transfer have been associated with poor results.5,9,10

The biceps-to-triceps transfer can be used in pa-

tients who have active supinator and brachialis mus-cles to provide for the lost functions of the trans-

ferred biceps. The biceps-to-triceps transfer hasseveral inherent advantages. These include the abil-

ity to correct flexion-supination deformities of the

forearm at a single stage, avoiding the need for a freetendon graft, earlier time to mobilization due tohaving only 1 tendon junction to heal, and no func-

tionally apparent decrease of elbow extensionstrength over time. The standard described technique

for biceps-to-triceps transfers has been through alateral route.1113 In high spinal cord injury patients,

the radial nerve is the only functioning nerve belowelbow level. If the radial nerve is injured duringlateral routing, the resultant loss of active wrist ex-

tension can be a devastating complication.2,12,13 The

use of medial routing avoids this potentially devas-tating complication, as the biceps tendon passes me-

dially over the paralyzed ulnar nerve, with no poten-tial loss of distal function. The use of medial routing

Table 2. International Classification

Group Muscle Characteristics

0 Weak BR1 BR (grade 4/MRC)

2 BR and ECRL3 BR, ECRL, ECRB4 BR, ECRL, ECRB, PT5 BR, ECRL, ECRB, PT, FCR6 BR, ECRL, ECRB, PT, FCR, finger extensors7 BR, ECRL, ECRB, PT, FCR, fingers and thumb

extensors8 Group 7 muscles partial digital flexors9 Lacks only intrinsics

BR, brachioradialis; ECRL, extensor carpi radialis longus;ECRB, extensor carpi radialis brevis; PT, pronator teres;FCR, flexor carpi radialis.

Data from McDowell et al.1

162 Kuz, Van Heest, and H ouse / Biceps-to-Triceps Transfer: M edial Routing


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of the biceps tendon has been briefly mentioned in

previous reports without a detailed description of the

technique and without follow-up results.14,15

The purpose of this study is to describe in detail

the medial routing technique of the senior author

(J.H.H.) for transferring the biceps to the triceps to

regain active elbow extension in tetraplegic patients.

The surgical results of this technique in 3 patients,

representing 4 transfers, are also presented.

Materials and Methods

Four transfers in 3 patients who underwent a bi-

ceps-to-triceps transfer using a medial route and the

senior authors (J.H.H.) method were identified.

Table 3. Functional Improvement Questionnaire Results

Much Better Better No Change Worse NA

Hygiene and groomingWashing 2 1Shaving 1 1 1Brushing hair 1 2Brushing teeth 1 2

Clipping nails 1 2Faucet use 3Shower 1 2

EatingCutting meat 1 2Opening 1 2Pouring 1 2Using utensils 2 1

DressingDress upper 2 1Dress lower 1 2Fastening 2 1

CommunicationUsing phone 1 1 1Writing 1 1

Typing 2 1Homemaking

Prepare meals 1 1 1Making bed 1 1 1Wash dishes 2 1

TransfersCar 3*Bed 1 2Shower/tub 1 2Toilet 1 2Couch 1 2

WheelchairMobility 2 1

Elbow extension specificOpening doors 2 1

Elevator buttons 3Light switch 3Retrieving objects from shelf

above shoulder level 2 1Answering phone while in bed 3Turning on light while in bed 3Removing blankets 3Driving 3

NA, not available.The results listed are the functions of patients compared with presurgical performance for functional

activities of daily living.* All use electric lift. Uses electric wheelchair.

The Journal of Hand Surgery / Vol. 24A No. 1 January 1999 163


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These patients had their surgery performed by 2 of

the authors (J.H.H. and A.V.H.). Charts were re-viewed for demographic information, surgical tech-

nique, complications, postoperative rehabilitation,and additional procedures performed. Surgical re-

sults were assessed by a modified University of Min-

nesota Tendon Transfer Functional ImprovementQuestionnaire16 with the addition of triceps-specificactivities as presented in Table 3. This questionnaire

asks patients about general activity improvements,pain, and satisfaction, as well as 34 specific activities

of daily living with modifications that specificallyaddress the goals of active elbow extension recon-

struction. The questionnaire requires the patient torate postoperative function compared with preoper-

ative function as much improved, improved, nochange, worse, or much worse.

The demographics of the 3 patients who under-went the procedure are shown in Table 4. Additional

1-stage key pinch reconstructions16 were performedin all 3 patients, either simultaneously with the bi-

ceps transfer (patient 2) or 6 months later (patients 1and 3).

All 3 patients had follow-up periods ranging from12 to 66 months. Two patients (representing 3 trans-fers) returned to the clinic for follow-up strength and

range-of-motion testing. The third patient lived outof state and had measurements performed by her

physical therapist. Objective assessment of surgical

results were made by goniometric measurement ofactive and passive elbow flexion/extension and fore-arm pronation/supination. Muscle strength was

graded in the standard fashion (grades 05) throughthe extension arc with a rating of 3 indicating anti-

gravity strength; 4, partial resistive strength; and 5,complete resistive strength.

Surgical Technique

To perform this surgical procedure, the patient is

placed in a supine position. The arm is prepared and

draped free in a sterile manner. A sterile tourniquet is

placed as proximal on the arm as possible.

An anterior longitudinal incision is made over the

medial aspect of the biceps muscle belly. This inci-

sion passes over the cubital fossa obliquely (Fig. 1).

The musculocutaneous nerve is identified and pro-

tected throughout the procedure. The lacertus fibro-sus is transected distally with a portion of antebra-

chial fascia in continuity with the biceps tendon to

create a second tail for subsequent tendon weaving.

The biceps tendon is isolated to the insertion on the

radius and then sharply divided. A #5 nonabsorbable

braided polyester suture is placed in the biceps ten-

don using a locked grasping suture. A #0 Ethibond

suture is similarly woven into the lacertus fibrosus as

a second tail of the biceps tendon (Figs. 2, 3).

A posterior incision is made over the triceps ten-

don, being careful not to make the incision directly

over the olecranon (Fig. 4). This incision is biased

laterally to avoid a medial skin bridge that is too

narrow. A subcutaneous tunnel is fashioned along

the medial aspect of the arm by dissecting free, and

resecting if necessary, the medial intermuscular sep-

tum. The biceps muscle and tendon are delivered into

the posterior incision through the subcutaneous tun-

nel (Fig. 5). Attention is directed to ensure a straight

and free line of pull through the subcutaneous tissue.

The tendon is passed superficial to the ulnar nerve.

Through the posterior incision, the biceps tendon is

woven in a Pulvertaft fashion into the distal tricepstendon. A 4-mm unicortical hole is drilled into the tip

of the olecranon to receive the tendon and suture.

Two small holes are drilled through the far cortex of

this hole to allow passage of Keith needles, allowing

the suture to be tied over the bone, deep to the

aconeus muscle on the posterior lateral side of the

proximal ulna. The transfer is tensioned to permit

90 of passive elbow flexion. A #0 nonabsorbable

braided polyester suture is interwoven in the area of

tendon repair to secure the transfer. The distal end of

Table 4. Postoperative Range of Motion and Muscle Strength Results

Patient SideE/F

AROM ()P/S

AROM ()Flexion Strength

Grade Extension Strength

GradeSupination Strength

Grade

1 R 4/145 80/80 5 5 51 L 6/142 80/75 5 5 52 R 5/145 80/75 5 4 43 L 8/140 80/80 5 4 4

E/F, elbow extension/flexion; P/S, pronation/supination; AROM, active range of motion.



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the biceps tendon is then secured to the local peri-

osteum. The lacertus fibrosus tail is braided as areinforcement, weaving it through the triceps and the

biceps tendons, securing the tension on the transfer

(Figs. 6, 7). The incisions are closed in layers in the

usual fashion.After surgery, the patient is maintained in a well-

padded, long-arm fiberglass cast with the elbow inless than 30 of flexion. Three weeks after surgery, a

flexion block splint is placed to prevent elbow flex-

ion beyond 45, and gentle active motion is started.Training of the biceps to extend the elbow is done ona powder board (a horizontal table to eliminate

gravity and powdered to diminish friction) on whichthe patient learns to extend by the elimination of

gravity and use of supination cognizance. Over thenext 6 weeks, the flexion block is progressively ad-

vanced (approximately 15/wk) to allow more flex-ion. The medially routed biceps can be palpated and

seen along the medial humerus to assess for controland function; antigravity strength is achieved as

shown in Fig. 8. If satisfactory progress has beenmade by 8 to 10 weeks, strengthening against resis-

tance is started.

Figure 2. Bicipital tendon and aponeurosis have been

isolated and tagged. The musculocutaneous nerve is pro-

tected. BT, bicipital tendon; BA, bicipital aponeurosis;

MCN, musculocutaneous nerve. (Adapted and reprinted

with permission.17)

Figure 1. Anterior skin incision. (Adapted and reprinted

with permission.17)



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Results

All patients stated they were highly satisfied with the

surgery, would undergo surgery again under similarcircumstances, and had no residual pain. As shown in

Table 3, no patient lost function in any category. Thefunctions most greatly improved included driving a

van, performing activities while supine, and retrievingobjects from above shoulder height. All 3 patients

stated that activities which required precision hand

placement had improved. In addition, all 3 patientsstated that they were able to eliminate the need forseveral adaptive aides, ie, push stick for elevator but-

tons. Improved wheelchair propulsion and recreationalactivity, such as swimming, were reported. The patient

with bilateral transfers reported the greatest number offunctional improvements. The patient with the shortest

follow-up period (12 months) showed the least numberof functional improvements, yet stated that the transferwas continuing to gain strength and selective control

with time.

Range of motion and muscle grading data are

presented in Table 4. Postoperative elbow exten-

sion strength was grade 4 or 5 in all cases, im-

proved from a preoperative strength of grade 0.

Postoperative elbow flexion strength was main-

tained at grade 5 in all cases. Postoperative supi-

nation strength was maintained at grade 5 in 2

elbows and diminished to grade 4 in 2 elbows.

Preoperative passive range of motion showed less

than a 15 contracture for all limbs in flexion,extension, supination, and pronation. The average

postoperative flexion contracture was 6 (range, 4

to 8). The average postoperative active elbow

flexion was 142 (range, 140 to 145), unchanged

from that before surgery. The postoperative active

supination was 75 to 80 in all cases.

No postoperative complications were noted. This

included no evidence of radial nerve palsy, rupture of

tendon repair, wound problems, loss of motion

(based on measurements), or loss of strength.

Figure 3. Clinical view of the drawing in Figure 2. The musculocutaneous nerve can be seen lying on the brachialis muscle

just underneath the elevated biceps.



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Discussion

Tetraplegic patients who lack active elbow exten-

sion due to spinal cord injury have profound func-tional loss. These patients have a difficult time per-forming activities when in the supine position. This

includes turning on a bed lamp, answering a bedsidetelephone, and removing blankets. In addition, these

patients cannot reliably use their hands above shoul-

der level because of the difficulty of holding the

elbow extended against gravity. This precludes them

from removing objects from a high shelf or receiving

an object that is handed to them above shoulder

level. The lack of an active antagonist to active

elbow flexion creates imprecisions for functions that

require the hand to be positioned in space. Thisespecially becomes a hindrance when coordinated

movement is needed, such as with driving, swim-

ming, and writing.18 The ability to extend the elbow

also facilitates dressing and undressing, because zip-

pers can be opened with active elbow extension

using a key ring orthosis to hook the zipper handle.

In 1975, Moberg6 introduced the deltoid-to-triceps

transfer with interposition graft. He noted marked

improvements in the ability of his patients to perform

transfers, reach for objects on high shelves, gain

pressure relief from the sitting position, and drivemore safely.6 Moberg7 also stated that the stabilizing

effect provided by a transfer for elbow extension is

more important than the power actually obtained.

Several investigators have reported their results

using the deltoid-to-triceps transfer.610,12,1822 Pre-

dictable functional gains were noted in many of these

reports. A number of complications have been re-

ported with this procedure, including lack of final

60 active extension against gravity in 50% of pa-

tients,12 lack of active extension against gravity,20

stretching of the tendon repair resulting in decreased

strength and extensor lag,1,6,8 and development ofheterotopic ossification in the posterior deltoid mus-

cle.18 Despite these occasional complications, no pa-

tient lost function to a level worse than preoperative

levels.6,8,18,21 The deltoid-to-triceps transfer usually

requires a free tendon graft.6,7 This requires up to a

6-week immobilization time.1 Attempts at earlier

mobilization of this transfer have been associated

with poor results.6,9,10 Improvements in the tech-

niques of tendon suture have helped avoid the

stretching phenomenon and have decreased the post-

operative immobilization time from 6 weeks to 4.5weeks.20 An additional method uses a turned-up

central slip of triceps tendon with a small block of

bone from the ulna. This bone block is attached to

the posterior deltoid insertion, which also has been

elevated with a small block of bone from the hu-

merus.23 Because of failures with this latter tech-

nique, Moberg reported that he had abandoned it.1

Hentz et al24 reported a technique in which the

deltoid was directly attached to the triceps aponeu-

rosis without an interposition graft. This permitted an

Figure 4. The posterior skin incision should be lateral

enough to avoid being placed over the tip of the olecranon

and leave an adequate skin bridge between the anterome-

dial incision. (Adapted and reprinted with permission.17)



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immobilization time of 4.5 weeks, but no results

were reported.In 1954, Friedenberg11 reported on the first use ofbiceps transfer to restore elbow extension in a tet-

raplegic patient. His patient underwent bilateraltransfers that resulted in a full range of motion of the

elbow and the ability to independently transfer. Inthis same report, Friedenberg11 also reported a case

by Mayer in which bilateral biceps transfers foractive elbow extension were undertaken in 1951.

This patient lacked the final 30 of extension, butmade gains in the ability to hold objects in front of

his body, use the typewriter, and perform indepen-

dent toileting.11

Both of these cases involved thelateral routing technique.

Zancolli5 reported 6 cases of biceps-to-triceps

transfer using the lateral route. He preferred thistransfer over the posterior deltoid because of sim-plicity, and he stated that supination is not lost be-

cause the supinator muscle is active if wrist exten-sion is present. A distal insertion into the olecranon

was used. Zancolli occasionally used electromyogra-phy or peripheral nerve blocks to differentiate be-

tween biceps and supinator function in cases in

which it could not be determined clinically.1,5 The

measured extension power was from 250 to 900 g.Zancolli also noted no clinically significant loss ofelbow flexion power and that re-education of elbow

extension is very simple.5 A later report by Zan-colli2 of 13 patients who underwent biceps-to-triceps

transfer with an average follow-up period of 37months showed 80% good or excellent results and no

poor results (criteria not mentioned). No functionrelated to active flexion worsened and there was a

flexion strength loss of 24%. Active supination waspreserved in all patients. One patient did sustain a

radial nerve neurapraxia with resolution by 4

months.2

While a flexion contracture of greater than20 is considered a contraindication to deltoid trans-fer, Zancolli stated he would still use a biceps trans-

fer.1

Hentz et al20 briefly reported the use of biceps-to-

triceps transfers for active elbow extension in tet-raplegic patients. The number of patients who hadthis procedure, however, was not specified in the

report since a number of deltoid-to-triceps proce-dures were also performed. In this series, 2 poor

results occurred. Both patients had bilateral recon-

Figure 5. The tendons are delivered along the medial route into the posterior incision.



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struction for elbow extension: 1 had deltoid-to-tri-

ceps transfers and the other had biceps-to-tricepstransfers. Both patients achieved only grade 2 to 2

extension strength and had moderate to severe

elbow contractures before surgery.20 Neither patienthad progression of elbow contractures after surgery.

Despite this poor result, both patients werepleased with the procedure.20 In 1996, Hentz and

Ladd15 reported the use of the medial route for thebiceps-to-triceps transfer without describing specificresults.

In 1983, Lamb and Chan10 reported a patient who

received a biceps-to-triceps transfer. The patients

result proved unsuccessful.5 No further informa-tion was given explaining why this was an unsuc-

cessful result.In 1988, Ejeskar12 reported the results of 5 patients

who underwent biceps-to-triceps transfers using the

lateral route. Two patients had no active extension.One of these was subsequently scheduled for a del-toid-to-triceps transfer. One patient developed a ra-

dial nerve palsy but was beginning to recover after 5months. Despite this finding, Ejeskar12 reported that

the biceps transfer is the procedure of choice andpreliminary results of the biceps transfer seem to

exceed those of the posterior deltoid transfers. Hisrecommendation was to perform a biceps transfer in

all patients who have an elbow flexion contractureand when the patient does not request very strong

active elbow flexion for a specific activity. His re-

Figure 7. The final appearance of the tendon anastomosis.

The probe at the left edge of the incision indicates the

suture that has been tied down over the distal olecranon.

Figure 6. A locking weave is used to secure the biceps

transfer to the triceps. The biceps is delivered into a

unicortical hole and sutures are tied over the distal cortex

to provide additional fixation of the transfer. BA, bicipital

aponeurosis; BT, bicipital tendon. (Adapted and reprinted

with permission.17)



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sults were briefly updated in 1989.13 Ejeskar reportedon 10 patients, all who had biceps-to-triceps transfers

through a lateral route. Most had good results,

especially those patients with a contracture present.Exercises could be started at 3 to 4 weeks. One radialneurapraxia and a few cases of the insertion pull-

ing out were reported.13 This report, presented inabstract form in 1988 at the Third International Con-

ference on Surgical Rehabilitation of the Upper Limbin Tetraplegia (Quadraplegia) (Goteborg, Sweden),

showed that 8 of 10 transfers had full passive elbowextension with an average follow-up of 9 months.

However, 4 transfers failed to demonstrate activeextension after surgery.

The 3 patients in this study viewed the biceps-to-

triceps transfer procedure with high satisfaction. Nofunctional loss in any category was identified. Note-

worthy gains were made in the activities of driving,ease of transfers, pressure relief, handling objects

above shoulder level, use of the hands when supine,

and improvement in precision movement. These cat-egories are similar to the areas in which Moberg7

saw improvements in his patients undergoing deltoid

transfers. The greatest improvements came in thepatient with bilateral transfers with all 34 categories

rated as much better. The patient interviewed atonly 12 months after surgery scored only 9 activities

in the much better range. This patient noted grad-ual improvement of functional activities over time.

In this study, the functional improvements ob-tained by gaining active elbow extension are consis-

tent with the experience of others.7,10,18,2022 It hasbeen shown that by providing an antagonist to elbow

flexion, these patients can improve their pinchstrength from brachioradialis transfer.25 Gaining ac-

tive elbow extension in these patients helps preventfurther contracture.20 None of the patients in the

current series perceived a worsening of contracturesor any deterioration in strength over time.

Flexion contractures at the elbow diminish the

gains of an active transfer. It has been shown that anelbow contracture of 50 in tetraplegic patients with

at least grade 4 strength will eliminate the ability to

perform independent transferring.

26

Grover et al

26

recommend that operative release be consideredwhen the flexion contracture is greater than 25 in

patients with weak triceps function. Freehafer3 hasshown that biceps tenotomy in tetraplegic patients is

effective in reducing flexion and supination deformi-ties of the elbow. The advantage of the biceps trans-

fer over the deltoid transfer is that by removing thedeforming force of the unopposed biceps, flexion and

supination deformity can be corrected at a singlestage with the transfer. If the deltoid transfer is used

instead, a 2-stage procedure is required in which the

first stage would be to release the elbow flexioncontracture requiring a biceps tenotomy. Zancollis4

biceps rerouting procedure will correct the supina-

tion deformity but not the flexion imbalance.We believe that biceps-to-triceps transfers have

several important advantages over deltoid transfers.Because of the small number of patients in this

series, direct comparisons of technique and statisticalanalysis comparing techniques cannot be conducted.The theoretical advantages of this technique over a

posterior deltoid transfer include the ability to correct

Figure 8. Patient 1 demonstrating full, active, strong el-

bow extension from the supine position following biceps-

to-triceps transfer, with the active biceps seen along the

medial border of the humerus.



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flexion-supination contractures of the forearm at the

same stage as the transfer. Having only one verysecure tendon junction to heal also allows for early

mobilization. Furthermore, our technique is arguablytechnically easier than the deltoid transfer. No addi-

tional donor site for a free tendon graft, with its

potential for wound healing complications, is neces-sary. Dynamic flexion-supination deformities of theforearm can be corrected by removing the deforming

force of the biceps. The advantage of routing medi-ally over laterally is the avoidance of the area of the

radial nerve and the potentially devastating radialnerve palsy. In these patients, the only innervation to

the muscles below the elbow is by way of the radialnerve (Table 1). Any loss of these muscles means

loss of hand function. With medial routing, the ulnarnerve has the potential for being injured, but in

tetraplegic patients at a spinal cord injury level of C6or above, the ulnar nerve is nonfunctional. We also

believe that the medial routing of the biceps providesa more direct route for the tendon transfer with less

risk of adhesions that may occur between a laterallytransferred tendon and adjacent muscles as it passes

across them in the distal lateral arm.The presence of an active supinator and brachialis

muscle are usually assured if wrist extension or astrong brachioradialis is present. Spotty innerva-

tion of these muscles, however, can exist and must bechecked with a thorough preoperative clinical exam-

ination. Careful observation and palpation of themuscles are required. The brachialis can be isolatedby resisted flexion of the elbow while the patient

leaves the forearm in a pronated position to inacti-vate the biceps. The biceps is palpated during muscle

testing to verify that it is inactive while elbow flexionor forearm supination strength is tested, verifying

brachialis and supinator strength. The supinator isisolated by testing resisted forearm supination with

the elbow in extension to inactivate the biceps. Ulnarinnervated muscles must be checked to ensure that a

spotty tetraplegic level has not left some function

that could be injured.Our current recommendation is to use the biceps-

to-triceps transfer, with medial routing, for tetraple-

gic patients who lack elbow extension and havebrachialis and supinator function that can be con-

firmed on examination. The biceps-to-triceps transferis also advantageous in patients with greater than 30

flexion or supination deformity caused primarily bythe unopposed biceps. Passive elbow and forearmrange of motion should be maximized before tendon

transfer.

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