July 18, 2024

Ulnar nerve palsy treatment options depend upon the level of injury, its severity, and surgeon expertise.

  • Usual tightness of the metacarpophalangeal joint of [Ring and little finger] may limit clawing of these fingers and enable the long extensors to extend these IP joints. (No treatment is necessary)
  • If the function is troublesome:- Tendon transfer procedure is preferred
Ulnar nerve palsy of the hand
Ulnar nerve injury of the hand

Summary of some procedures for Ulnar nerve palsy are discussed here:


Bunnell’s transfer

  • Detach the flexor sublimis tendon of each finger
  • Split the tendon
  • Pass one slip to each side of the extensor aponeurosis of each finger
  • Removing powerful flexion of PIP joint:- Converting into extensors

Strong flexor pull convert into the intrinsic minus hand so in modified Bunnell’s transfer only one sublimis is splitter into 4 extensors

Fowler transfer

  • Split EPI of the index finger and EDQ of the little finger to form 4 slips
  • Attach each to extensor aponeurosis and 4 fingers (through the volar side of deep carpal ligaments)

Riordan transfer

  • Divide extensor indices proprius tendon into 2 slips
  • Slip passes volar to deep carpal ligaments
  • Attach to the radial side of extensor aponeurosis of 2 fingers (little and ring finger)
  • Palmaris longus / Plantaris graft to Index and middle finger

Brands transfer

  • Free graft ( Plantaris tendon )
  • Extensor carpi radialis is lengthening by free graft
  • Split it into 4 slips
  • attach to the extensor apparatus

Riordan advised

  • Free insertion of FCR and transfer to the dorsum of the wrist, prolonged with 4-tailed graft (Plantaris tendon)
  • Each attached to the radial side of the extensor apparatus

Burkhalter: Direct attachment of the tendon to proximal phalanx diaphysis

In higher ulnar nerve palsy: Sublimis is not transferred as FDP is paralyzed

Alternative to tendon transfer is Zancolli capsulodesis

Zancolli Capsulodesis

Zancolli capsulodesis of ulnar nerve palsy
Zancolli capsulodesis

Surgical Steps

  • The transverse incision in the palm at the level of the distal crease
  • Undermine widely skin, and fat and expose flexor tendon sheath to protect NV bundles
  • Over each MCP joint make a longitudinal incision in para tendinous fascia
  • Expose flexor tendon and retract
  • Expose underlying MCP Joint
  • Resect elliptical segment of the volar fibrocartilagenous plate including verticle septum and its deep origin
  • Resect enough tissue so it produces 10-30 flexion contracture when closed (maybe fixed with k-wire)
  • Close volar plate and nonabsorbable sutures laterally in the thickest part ( site of insertion of accessory collateral ligaments)
  • Close wound and apply a dorsal plaster splint
  • Holding MCP joint in flexion and wrist in extension


  • Movement of IP joint is continued after surgery at 3 weeks
  • Cast and K-wire removed and MCP exercise begins

See also: Peripheral Nerve Injury