TENDON TRANSFERS

1082 3131/02 $15.00 + .00

Tendon Transfer for Wrist

Flexion Deformity in Cerebral
Palsy
Thomas W. Wright, MD

Patients with cerebral palsy commonly position their wrist in a palmar-exed,

ulnar-deviated, and pronated position (Fig. 1). This position is assumed because of
increased exor tone of the wrist and nger exors when compared with the
extensors. Grip is markedly weakened by a wrist in a signicant palmar-exed
position. This deformity may become a xed contracture if the patient has poor
motor control and if no program of passive stretching is initiated. This article
focuses on the pathophysiology of cerebral palsy associated wrist exion deformity,
treatment rationale, surgical technique, rehabilitation, complications, and results.
The treatment of wrist pronation contracture or the multiple other procedures performed for patients with cerebral palsy are not discussed.

From the Department of Orthopaedic Surgery, University of Florida, Gainesville, Florida

ATLAS OF THE HAND CLINICS Volume 7 Number 1 March 2002

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Figure 1. A, The typical position of the wrist in a functional patient with cerebral palsy
shows a palmar exed, ulnar deviated, and pronated position. B and C, The Pulvertaft
weave tenorrhaphy (long arrow) and the transferred FCU (asterisk). D, The wrist is near
neutral when it is tested against gravity.

TENDON TRANSFER FOR WRIST FLEXION DEFORMITY IN CEREBRAL PALSY

Multiple tendon transfers have been proposed for treatment of the wrist exion
deformity in functional patients with cerebral palsy and other brain injury patients.
The transfers proposed include exor carpi ulnaris (FCU) to extensor carpi radialis
brevis (ECRB) (i.e., the Green transfer),3 FCU to extensor digitorum communis
(EDC), pronator teres to ECRB,2 extensor carpi ulnaris (ECU) to ECRB, and brachioradialis to ECRB.4
The normal pattern of grasp and release is mandatory for a functional hand. A
wrist in considerable palmar exion has inadequate grasp because the nger exors
are at a mechanical disadvantage from relative shortening. The nger exors are
generally strong in patients with cerebral palsy, but, with the wrist in substantial
exion, the ngers will appear to be weak, and the patient will have difculty
holding onto objects. If the wrist is corrected manually or with the use of a splint to
the neutral position, nger exion will be strong, and, often, the patient will lose his
or her ability to release an object (inadequate release pattern). This problem of
inadequate release is as much a functional concern as weak grasp and must be
addressed at the same time the wrist exion deformity is corrected. Strategies for
treating this problem are presented herein.
Patients with the most severe deformity may also have a xed wrist exion
contracture and not just a deformity secondary to a dynamic imbalance of the wrist
exors and nger exors. The FCU is the largest contributor to the exed and
ulnar-deviated wrist position. This xed deformity is seen predominantly in the
severely involved patient with cerebral palsy. Slow passive stretch with correction
to neutral may not be possible in these patients. Higher-functioning patients generally have a passively correctable deformity that can be positioned in at least neutral.
Two general groups of patients with cerebral palsy are treated for wrist exion
deformities. One group includes high-functioning patients. The other group contains
low-functioning, severely involved patients with cerebral palsy. Treatment of these
two groups of patients is different with respect to surgical decision making. Much
of the treatment described herein can also be applied to patients with other types of
brain injuries and wrist exion deformities.

EVALUATION
The evaluation of the patient with a wrist exion deformity secondary to
cerebral palsy must take into account the entire patient and not just the deformity.
Patients selected for a functional-type tendon transfer should have good cognitive
skills, fair limb placement, and some cortical sensation. The presence of athetosis is
not a contraindication to tendon transfer, but the complication rate may be higher.8
Procedures for the severely involved patient with cerebral palsy are entirely different and are directed at hygiene rather than function.
On examination, the overall posture of the wrist is noted. The medical record
should include a notation of whether the deformity is passively correctable. When
the wrist position is corrected between 20 degrees of palmar exion and neutral, are
the nger extensors strong enough to extend the ngers (Zancolli type 1)?10 A
Zancolli type 2 patient cannot extend the metacarpophalangeal (MP) joints with the
wrist in neutral but can actively extend the joints with the wrist in greater than 20
degrees of palmar exion. If the MP joints cannot be actively extended in any wrist
position, a transfer directed at strengthening the nger extensors may be indicated
(Zancolli type 3).10
Radiographs should be obtained at the time of consideration of denitive treatment of the wrist to assess for any bony deformity. An association between cerebral
palsy and Kienbock disease has been reported.
Dynamic electromyography is time consuming, difcult in the young child, and
not performed in many centers but may provide valuable information as to the
phasic pattern of a particular muscle. In the authors original evaluation, different

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patterns of spasticity were found from patient to patient, but, most consistently, the
FCU and brachioradialis were active through grasp and release. It is not known
whether their phasic activity would change with transfer, but this effect is unlikely.

Treatment Plan Functional Patients

Functional patients who have cerebral palsy with wrist exion deformity are
good candidates for tendon transfer. In most cases, this transfer must be combined
with a need for weakening the nger exors and sometimes the remaining wrist
exors. If a transfer is performed without addressing the exor side, frequently, the
patient will have an inadequate release pattern. In patients with Zancolli type 1
deformity (active MP joint extension with the wrist in less than 20 degrees of
exion), weakening of the nger and wrist exors by fractional lengthening may be
all that is required; these cases are the exception. Most functional patients with
cerebral palsy have deformities in the category of Zancolli type 2 (active MP joint
extension with the wrist in greater than 20 degrees of exion). These patients are
treated with an FCU to ECRB transfer in addition to fractional lengthening of the
nger exors and wrist exors. The FCU transfer has a second benecial effect of
increasing supination when routed along the ulnar border of the forearm.1 In Zancolli type 3 deformity (no active MP joint extension at any position of the wrist), the
FCU is transferred to the EDC, and the wrist and nger exors undergo fractional
lengthening.
An alternative transfer for weak wrist extension is the pronator teres transferred to the ECRB. In the authors opinion, this procedure is a distant second
choice to the FCU transfer because of the greater strength of the tenorrhaphy,
removal of a considerable deforming force, and the supination effect of the FCU
transfer.

TENDON TRANSFER FOR WRIST FLEXION DEFORMITY IN CEREBRAL PALSY

Treatment Plan Low/Nonfunctional Patients

The treatment of wrist exion deformities in patients with a low level of
function is directed at hygiene concerns (Fig. 2).

Figure 2. A, Wrist exion deformity in a patient with severe cerebral palsy. B and C, The
patient underwent a profundus to supercialis transfer, Z-lengthening of exor carpi radialis and exor carpi ulnaris, and a proximal row carpectomy. Note the markedly improved
wrist and nger posture in this patient postoperatively.

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Although most of these patients require no surgery, some patients with severe wrist
exion deformities that are xed contractures may require operation for hygiene
reasons. The ngers may be positioned in a clenched st, creating concerns about
palm hygiene (this concern is actually less common if the wrist exion contracture
is severe). If the wrist deformity is corrected, the nger in palm position will be
exacerbated unless the procedure is combined with a supercialis to profundus
tendon transfer. Another option is proximal row carpectomy, which obtains a relative lengthening of the exors of approximately 1 cm. The wrist xed contracture is
corrected by the proximal row carpectomy, although a wrist fusion may still be
required near skeletal maturity. Wrist exors are tenotomized or Z-lengthened when
a supercialis to profundus transfer is performed (Fig. 3).

Radius

Flexor digitorum
superficialis

Ulna

Flexor digitorum
profundus tendons

Figure 3. A exor digitorum supercialis transfer to the exor digitorum profundus. (From Hisey MS,
Keenan MA: Orthopaedic management of upper extremity dysfunction following stroke or brain injury. In
Green DP, Hotchkiss RN, Pederson WC (eds): Greens Operative Hand Surgery, ed. 4. New York,
Churchill Livingstone, 1999, pp 287 325; with permission.)

In the authors experience, in patients requiring surgery for hygiene issues, a proximal row carpectomy combined with a wrist fusion is a more predictable procedure
than a tendon transfer (see Fig. 2B and C).

TENDON TRANSFER FOR WRIST FLEXION DEFORMITY IN CEREBRAL PALSY

SURGICAL TECHNIQUE IN FUNCTIONAL PATIENTS

Flexor Carpi Ulnaris to Extensor Carpi Radialis Brevis
The FCU to ECRB transfer is performed in functional patients with cerebral
palsy who have a passively correctable deformity and some active MP joint extension with the wrist positioned in greater than 20 degrees of exion. These Zancolli
type 2 patients are the most common group seen. The FCU to ECRB transfer is
performed under general anesthesia with the arm placed on an arm table. Spastic
elbow contractures improve dramatically under anesthesia, making positioning easier. The procedure is performed with an upper arm tourniquet. A long longitudinal
incision is started 1 mm proximal to the proximal wrist exion crease and continued
in a proximal direction over the FCU for the distal one third to one half of the
forearm (Fig. 4).

Figure 4. The procedure is performed with an upper arm tourniquet. A long longitudinal incision
is started 1 mm proximal to the proximal wrist exion crease and continues in a proximal
direction over the exor carpi ulnaris for the distal one third to one half of the forearm. Extensive
insertion of the exor carpi ulnaris (FCU) muscle on surronding fascia. It is mandatory to make
this long incision and dissect the FCU to the proximal edge of the incision. This dissection
obtains the correct line of pull and adequate excursion of the transferred tendon.

The distal FCU tendon is isolated and tenotomized just proximal to the pisiform
insertion. The ulnar neurovascular bundle is encountered radial to the tendon at the
wrist level and protected. The dissection is continued in a proximal direction,
releasing the FCU muscle and tendon from the fascia and the periosteum of the
ulna. Because of the extensive insertion of the FCU muscle on surrounding fascia, it
is mandatory to make this long incision and dissect the FCU to the proximal edge
of the incision. This dissection obtains the correct line of pull and adequate excursion of the transferred tendon.

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A second 4-cm oblique incision is made proximal to the extensor retinaculum

over the ECRB tendon (Fig. 5).

Figure 5. A second 4-cm oblique incision is then made proximal to the extensor retinaculum
over the extensor carpi radialis brevis tendon.

The ECRB is ulnar to the extensor carpi radialis longus (ECRL) and is carefully
separated. The ECRB is a better wrist extender than the ECRL, which is a better
radial deviator. A large window is created in the ulnar forearm fascia adjacent to
the FCU at the proximal edge of the ulnar wound. The FCU is then transferred
subcutaneously using a Bunnell tendon passer. Using a Dieter-Buck Gramco tendon
passer, a Pulvertaft weave is created by passing the FCU through the ECRB (Fig. 6).

Figure 6. Strong Pulvertaft weave tenorrhaphy. (From Gelberman RH: Cerebral palsy. In Gelberman RH (ed): Operative Nerve Repair (vol. 2). Philadelphia, JB Lippincott, 1991, pp 1455 1475,
with permission.)

TENDON TRANSFER FOR WRIST FLEXION DEFORMITY IN CEREBRAL PALSY

Appropriate tensioning of the transfer is performed by placing the wrist in maximum extension, retracting the ECRB proximally, pulling distally on the FCU to its
full length, and then backing off 1 to 2 mm before passing the suture. A 3-0
nonabsorbable suture is passed through both tendons at the tenorrhaphy site in a
horizontal mattress fashion. This preliminary tensioning is tested by holding the
wrist horizontal and noting whether the transfer will hold the wrist in near neutral
against gravity. If the wrist exes greater than 20 degrees, the transfer is not
tensioned tight enough and must be revised. If the wrist is held in dorsiexion, it is
overtensioned and must be adjusted appropriately. Although it is possible to overtension the transfer and create a dorsiexed wrist deformity, in the authors experience, overtension is difcult to achieve. Once the correct tension is obtained, an
additional one or two passes of the FCU tendon through the ECRB are performed,
and the tendon is sutured in place. Excess FCU tendon is then cut and removed.
Figure 7A shows the volar forearm and the approach for harvesting the FCU. Figure
7B shows the dorsum of the forearm and the Pulvertaft weave of the FCU and
ECRB.

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Ulnar
a. and n.

FDS

FDP

FCU

EPL
EPB
ECRB
ECRL

APBL

B
Figure 7. Flexor carpi ulnaris to carpi radialis brevis (ECRB) transfer. A, Volar forearm and
the approach for harvesting the FCU. FDP exor digitorium profundus, FDS exor
digitorum supercilias. B, Dorsum of the forearm and the Pulvertaft weave of the FCU and
ECRB. EPL extensor pollicus longus, EPB extensor pollicus brevis, ECRB extensor
carpi radialis brevis, ECRL extensor carpi radialis longus, APBL abductor pollicus
brevis. (From Gelberman RH: Cerebral palsy. In Gelberman RH (ed): Operative Nerve
Repair (vol. 2). Philadelphia, JB Lippincott, 1991, pp 1455 1475, with permission.)

TENDON TRANSFER FOR WRIST FLEXION DEFORMITY IN CEREBRAL PALSY

Alternatively, the FCU may be transferred through the interosseous membrane,

but this route is not recommended. Such a transfer is at greater risk for adhesion
formation. This route will also lose the benecial supination effect that occurs when
the tendon is transferred around the ulnar border of the forearm.
The FCU to ECRB tendon transfer is almost always performed with a concomitant fractional lengthening of the exors.

Flexor Carpi Ulnaris to Extensor Digitorum Communis

Tendon Transfer
The FCU transfer to the EDC tendons (Fig. 8) is performed when there is no
active extension of the MP joints in any wrist position (Zancolli type 3).

EDC

FCU

Figure 8. Flexor carpi ulnaris

to extensor digitorum communis transfer. (From Gelberman RH: Cerebral palsy. In
Gelberman RH: Operative
Nerve Repair (vol. 2). Philadelphia, JB Lippincott, 1991,
pp 1455 1475, with permission.)

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The FCU is transferred in a similar method as previously described, but is passed

through all four EDC tendons instead of the ECRB tendon. The dorsal incision is 4
to 5 cm proximal to the extensor retinaculum and oblique in orientation. The EDC
tendons are exposed and sutured side-to-side with the MP joints in the normal
cascade. A Pulvertaft weave is created by passing the FCU through each of the EDC
tendons with the EDC tendons pulled proximally, the wrist in maximum extension,
and the FCU pulled out to full length and then allowed to shorten 1 to 2 mm.
Preliminary suture with a nonabsorbable 3-0 material is performed. The appropriate
tension is checked against gravity, which should not allow the wrist to ex beyond
20 degrees with the MP joints at 0 degrees. Once the tension is appropriate, a
second pass of the FCU is made through each of the EDC tendons and sutured in
place. Excess FCU is removed. Care must be taken to ensure this tenorrhaphy does
not bind on the extensor retinaculum. If the transfer impinges on the retinaculum,
the proximal half of the retinaculum can be released. Alternatively, the tenorrhaphy
may be moved more proximally.
In both of the described FCU transfers, there is almost always a need to weaken
the nger exors and sometimes the FCR as well. A third volar longitudinal incision about 4 to 6 cm in length is made over the middle third of the forearm.
Alternatively, the proximal aspect of the incision for harvesting the FCU may be
curved in a radial direction, allowing access to the myotendinous junctions of the
nger exors. The palmaris longus is encountered and the underlying median nerve
gently retracted. The palmaris longus tendon is incised and retracted. The myotendinous junctions of all the nger exors are exposed. Each nger exor tendon that
is tight with the wrist in neutral is lengthened fractionally by carefully cutting
through the tendon and not disturbing the surrounding muscle (Fig. 9). A fractional
lengthening gains about 3 to 5 mm of length. In the patient who has a severely
contracted nger exor, a second more proximal cut may be performed to gain
additional length. Occasionally, the FCR may require fractional lengthening, but
care should be taken not to overlengthen. If the FCR is lengthened too much, the
wrist may become unbalanced, and a reversed dorsiexion deformity may be created. Fractional lengthening of the nger and wrist exors should be performed
before the wrist or nger extension transfer so as to not disrupt the tenorrhaphy
site.

TENDON TRANSFER FOR WRIST FLEXION DEFORMITY IN CEREBRAL PALSY

FCR
FDS

Ulnar
neurovasacular
bundle

FCR
FCU
FDS

Ulnar
neurovasacular
bundle

FCU

C
Figure 9. A fractional lengthening. (From Gerwin M: Cerebral palsy. In Green DP,
Hotchkiss RN, Pederson WC (eds): Greens Operative Hand Surgery, ed 4. New York,
Churchill Livingstone, 1999, pp 287 325.)

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OTHER TRANSFER OPTIONS

In a few patients, the ECU can be transferred to the ECRB. The specic patient
who might benet from this transfer has a good grasp and release pattern and falls
into palmar exion and ulnar deviation during grasp. This patient may also benet
from an ECU transfer to the ECRB along with a fractional lengthening of the FCU.
The surgical technique for ECU transfer consists of a dorsal oblique incision
about 8 cm in length. Through this incision, the ECU and the ECRB can be exposed.
The ECU is tenotomized distal to the retinaculum. It is then rerouted to the ECRB
where a tenorrhaphy is performed with a Pulvertaft weave. A fractional lengthening
of the wrist exors and possibly the nger exors may be required.
The pronator teres transfer to the ECRB (Fig. 10) has been reported to provide
wrist extension with good functional results in two thirds of the transfers.2 The
pronator transfer has the advantage of removing one deforming force, the pronator,
and applying this force to the ECRB. The disadvantage is that, unlike in previously
described FCU transfers, it does not alleviate the deforming ulnar deviation force at
the wrist. Also, the strength of the tenorrhaphy site is less than in the FCU to ECRB
transfer.

EDC

A
ABPL
ECRL

ABPL

ECRB

Brachioradialis

Supinator
Pronator teres
ECRB and ECRL
ECRB

ECRL

D
PT
ECRB
ECRL

C
Figure 10. Pronator teres time to extensor carpi radialis brevis transfer. (From Gelberman
RH: Cerebral palsy. In Gelberman RH (ed): Operative Nerve Repair (vol. 2). Philadelphia, JB
Lippincott, 1991, pp 1455 1475.)

TENDON TRANSFER FOR WRIST FLEXION DEFORMITY IN CEREBRAL PALSY

The technique for pronator teres transfer to the ECRB begins with a 6-cm
incision over the pronator insertion in the middle third of the radial forearm. The
supercial radial nerve is exposed and gently retracted and the pronator insertion
exposed. The pronator teres is elevated along with a strip of periosteum so as to
lengthen the tendon. The muscle is circumferentially mobilized in a proximal direction. The tendon with its attached periosteum is then passed supercial to the
ECRB, and a tenorrhaphy is performed using a Pulvertaft weave. Postoperative
rehabilitation is essentially the same as described in the next section.
The brachioradialis has been used as a transfer for wrist extension with good
results.5 The disadvantage of this transfer is that the dissection to mobilize the
brachioradialis and obtain the appropriate amount of excursion is extensive. The
brachioradialis is a powerful muscle that is often severely spastic in patients with
cerebral palsy. If this transfer is overly tensioned it can create an opposite wrist
extension deformity. Currently, this transfer is used rarely for a wrist deformity
secondary to cerebral palsy.
The surgical technique for brachioradialis transfer to ECRB consists of an incision along the entire length of the radial forearm. The radial sensory nerve is
encountered deep to the brachioradialis and is protected. The brachioradialis is
elevated from its insertion on the radial aspect of the distal radius. It is then
mobilized in a proximal direction, past its musculotendinous junction, circumferentially around its muscle belly. The fascial attachments must be incised to obtain any
signicant excursion. The brachioradialis is then transferred to the ECRB using a
Pulvertaft tenorrhaphy.

Surgical Postoperative Rehabilitation

Patients who have undergone an FCU transfer to the ECRB are treated with a
splint applied in the operating room with the wrist in 20 to 30 degrees of extension.
Two weeks after surgery, the splint is changed to a fabricated cast in this same
position. Six weeks following surgery, the cast is removed and an orthoplast splint
placed. The splint is worn full-time for an additional month but can be removed
several times a day for active range of motion of the wrist. Splint wear is weaned to
a night splinting program by 3 months after surgery. Some patients with signicant
exor tone may require a night splinting program on a long-term basis. This additional splinting may be particularly important during periods of growth.
Patients who have undergone an FCU to EDC tendon transfer are placed in a
splint that blocks the MP joints at 0 degrees and holds the wrist in 20 to 30 degrees
of extension. Two weeks after surgery, a cast is placed that holds the same position
an additional 2 weeks. Four weeks after surgery, an orthoplast splint is truncated
with the wrist in extension and a removable MP joint exion block. The MP joint
component of the splint is removed several times a day for active range of motion
and training of the transfer. Six weeks after surgery, the wrist splint is removed
several times a day to perform active range of motion. Composite nger and wrist
exion should be avoided. Three months following the procedure, splint wear is
weaned to a wrist control splint at night only. In cases with persistent signicant
exor tone, it may be necessary to continue night splinting indenitely.
Most patients undergoing the previous transfers will also have a nger exor
fractional lengthening. In that situation, in addition to the immobilization for the
transfer, the ngers are splinted in full extension to the nger tip. The ngers are
held in full extension for 4 to 6 weeks, at which time the cast is removed, and an
orthoplast splint holding the ngers is made. The splint is removed several times a
day to initiate active range of motion. If considerable exor tone is present, a night
splinting program may be necessary.

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AUTHORS PREFERRED METHOD OF TREATMENT FOR THE

FUNCTIONAL PATIENT WITH CEREBRAL PALSY
The author prefers to use the FCU transfer in all functional patients with
cerebral palsy who have wrist exion deformities and some ability to extend the MP
joints actively at any wrist position (most common group). This procedure is almost
always accompanied by a fractional lengthening of the nger exors, tenotomy of
the palmaris longus, and, possibly, a careful fractional lengthening of the FCR. If the
patient has no ability to extend the MP joints actively even with wrist exion, the
FCU is transferred to the EDC. This procedure is rarely needed because, in most
instances, spasticity of the nger exors, not pure EDC weakness, overpowers the
nger extensors and limits MP joint extension. Fractional lengthening of the tight
nger and wrist exors is important.
Patients with a weak grip who drift into palmar exion when trying to sustain
a hard grasp are treated by weakening the exor side rather than performing a
tendon transfer. A fractional lengthening of the wrist exors and possibly the nger
exors is performed.

COMPLICATIONS
The most signicant and common complication of the FCU to ECRB and FCU
to EDC transfers is over- or undertensioning the transfer. With undertensioning, the
patients ability to extend the wrist to neutral may be compromised, possibly necessitating functional wrist bracing or revision of the procedure. The opposite situation
of overtensioning is less common in the authors experience but, when present, is a
signicant problem often leading to the need for revision surgery. Thometz and coworkers6 had two extension contractures in a series of 25 wrists that underwent an
FCU to ECRB transfer.

RESULTS
Beach and co-workers1 reported on the results of FCU to ECRB transfer. They
found that although the total arc of wrist motion did not change, but the arc was
now centered around neutral rather than exion. Cosmetic improvement was seen
in 88% of patients, 79% had functional improvement, and no patient lost function.
Athetosis did not adversely affect the outcome in this series. Thometz and coworkers6 reported on 25 patients with FCU to ECRB transfer with an average
follow-up of 8 years, 7 months. Mean active wrist extension was 44 degrees and
palmar exion 19 degrees. There were nine good, ve fair, and ve poor results
noted by the modied Green grading system. Other reported series employing this
transfer have noted an improvement of wrist extension ranging from 34 to 44
degrees.6,7 The average resting wrist position after an FCU to ECRB transfer is 11
degrees of exion.1,5,9

TENDON TRANSFER FOR WRIST FLEXION DEFORMITY IN CEREBRAL PALSY

The FCU to ECRB transfer (Fig. 11), when routed the usual way around the
ulnar aspect of the forearm, may improve forearm supination an average of 22
degrees.1 This range of motion can be signicantly improved by the addition of a
pronator rerouting.

Figure 11. A E, A patient who is 9 months postoperative after a exor carpi

ulnaris to extensor carpi radialis brevis transfer and fractional lengthening of the
nger exors. The ability to extend ngers and grasp an object with the wrist in
neutral is shown.
Illustration continued on following page

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Figure 11. (Continued)

TENDON TRANSFER FOR WRIST FLEXION DEFORMITY IN CEREBRAL PALSY

SUMMARY
The treatment of wrist exion deformities secondary to cerebral palsy can be
gratifying from both an appearance and functional standpoint. The mainstay of
treatment in the functional patient with cerebral palsy who has some active MP
extension is the FCU to ECRB transfer with fractional nger exor lengthening. For
the low/nonfunctional patient with cerebral palsy, the treatment goal is to improve
hygiene and is best served without surgery or by a proximal row carpectomy/wrist
fusion and profundus to supercialis transfer. Despite the lack of treatment options
for the brain injury, a balanced wrist with an improved grasp and release pattern
can go a long way toward helping patients with activities of daily living and
improved self-esteem.

References
1. Beach WR, Strecker WB, Coe J, et al: Use of
the Green transfer in treatment of patients with
spastic cerebral palsy: 17 years experience. J
Pediatr Orthop 11:731 736, 1991
2. Colton CL, Ransford AO, Lloyd-Roberts GC:
Transportation of the tendon of the pronator
teres in cerebral palsy. J Bone Joint Surg 58B:
220 223, 1976
3. Gerwin M: Cerebral palsy. In Green DP,
Hotchkiss RN, Pederson WC (eds): Greens
Operative Hand Surgery, ed 4. New York,
Churchill Livingstone, 1999, pp 259 286
4. Green WT, Banks HH: Flexor carpi ulnaris
transplant and its use in cerebral palsy. J Bone
Joint Surg 44A:1343 1352, 1962
5. McCue FC, Honner R, Chapman WC: Transfer
of the brachioradialis for hands deformed by
cerebral palsy. J Bone Joint Surg 52A:1171
1180, 1970

6. Roth JH, OGrady SE, Richards RS, et al: Functional outcome of upper limb tendon transfers
performed in children with spastic hemiplegia.
J Hand Surg 18B:299 303, 1993
7. Thometz JG, Tachdjian M: Long-term followup of the exor carpi ulnaris transfer in spastic
hemiplegic children. J Pediatr Orthop 8:407
412, 1988
8. Tonkin M, Gschwind C: Surgery for cerebral
palsy. Part 2. Flexor deformity of the wrist and
ngers. J Hand Surg 17B:396 400, 1992
9. Wenner SM, Johnson KA: Transfer of the exor
carpi ulnaris to the radial wrist extensors in
cerebral palsy. J Hand Surg 13A:231 233, 1988
10. Zancolli EA, Zancolli ER: Surgical management
of the hemiplegic spastic hand in cerebral
palsy. Surg Clin North Am 61:395 406, 1981

Address reprint requests to

Thomas W. Wright, MD
Department of Orthopaedic Surgery
University of Florida
Box 100246
Gainesville, FL 32610
e-mail: Thomas-wright@u.edu

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