On this page
EI to EPL tendon transfer
An EI to EPL tendon transfer restores movement to a thumb that can no longer be straightened or lifted, usually after the tendon that does this has ruptured. A working tendon from the index finger is rerouted to take over the job. This page explains what the operation involves, recovery, and the risks and benefits.
At a glance
Anaesthetic
General anaesthetic or sedation
Where
The Avenue Hospital
Day case or overnight
Day case - home the same day
First post operative review
Approximately one week after surgery
Driving
Not until the splint is removed and thumb movement/control has returned, generally 6 weeks
Post Operative Hand Therapy
Essential - a structured tendon transfer rehabilitation program is required to re-train the transferred muscle and prevent adhesions
Splinting
Yes - a thumb and wrist splint is worn for approximately 6 weeks after surgery
Pain relief
Usually paracetamol and/or ibuprofen; stronger pain relief may be needed initially
Return to repetitive & heavy loading
Usually 3 months or more before resuming unrestricted use of the thumb
Tendon transfer to restore thumb extension after extensor pollicis longus (EPL) tendon rupture
Extensor indicis (EI) to extensor pollicis longus (EPL) tendon transfer is surgery to restore the ability to straighten the thumb after the EPL tendon has ruptured, most commonly after a distal radius fracture (where the tendon can rupture weeks to months later due to a poor blood supply at a specific point along its course) or from longstanding rheumatoid tenosynovitis. Because a ruptured EPL tendon usually cannot simply be repaired end-to-end (the ends fray and retract), the extensor indicis tendon, which normally helps extend the index finger, is rerouted to take over the job of straightening the thumb.
Who is this procedure for?
- People who have lost the ability to lift the thumb up out of the plane of the palm (a positive retropulsion test) due to EPL tendon rupture
- People with EPL rupture following a distal radius fracture, whether treated surgically or non-surgically
- People with EPL rupture from rheumatoid arthritis or other inflammatory tenosynovitis
- People whose EPL tendon cannot be directly repaired due to the gap and tissue quality at the rupture site
What does the surgery involve?
Surgery involves a small incision over the back of the index finger metacarpal to identify and divide the extensor indicis tendon, which is then rerouted through the tissues of the back of the hand to the ruptured end of the EPL tendon near the base of the thumb, where the two tendons are woven together and secured. The index finger retains normal extension via its other extensor tendon (extensor digitorum communis), so this transfer does not typically cause a significant functional deficit to the index finger. However, the surgery generally takes away independent pointing of the index finger, and sometimes the index finger does not straighten fully (ie has an ‘extensor lag’ after the surgery) if the remaining tendon is unusually small.
Alternatives to surgery
EI to EPL transfer is the standard option once the EPL tendon has ruptured and retracted. Depending on your situation, the alternatives may include:
- Direct tendon repair: only possible if surgery is performed very soon after tendon injury, when the tendon has been cut by a sharp object, which is uncommon in practice
- Tendon graft reconstruction: an alternative to EI transfer in some circumstances, using a graft to bridge the gap
What happens if left untreated: without treatment, the thumb permanently loses the ability to actively extend, which significantly affects grip, pinch and the ability to open the hand fully.
Dr Tomlinson will discuss which options suit your specific situation at your consultation. There is no urgency to make a decision about reconstruction of the ruptured EPL tendon, as waiting does not close off any of the reconstruction options.
Frequently Asked Questions
Where will my surgery be done?
At The Avenue Hospital.
How much time will I need to have away from work?
This depends on what your job involves, and whether the surgery is to your dominant or non-dominant hand. Desk-based work may be possible within a couple of weeks with the thumb splinted. Manual work or anything requiring thumb use is usually deferred for weeks to months while the transfer is protected and retrained. Dr Tomlinson will give you advice tailored to your job at your consultation.
When will I be able to drive again?
Multiple things affect this: which hand was treated, whether you’re wearing a bandage, whether you can grip the wheel and respond safely in an emergency, whether you are driving for personal or commercial purposes, the nature of the vehicle you are driving, and your pain levels and medications. You also need to be safely in control of the vehicle for insurance purposes – you should be able to grip the steering wheel strongly with both hands and be able to take evasive action in an emergency before you get behind the wheel. As a guide: plan not to drive for six weeks after the procedure.
When can I do a full day of administrative or desk work?
Often from 2-4 weeks after surgery, particularly with some temporary adjustments (see below). Keeping your hand elevated and taking regular breaks helps reduce swelling and discomfort in the early days. If you need to drive to work or carry or lift objects as part of your administrative work then alternate or half days may be a prudent measure when first returning to work.
What workplace modifications might help?
Depending on your job, helpful temporary modifications can include:
– Half days or alternate days to begin with
– No heavy lifting
– Lighter duties or being off tools
– More frequent breaks
– Using a headset instead of holding a phone
– Voice-to-text or dictation instead of typing
– Keeping the hand elevated at your workstation
– Avoiding repetitive gripping
– Help with carrying or moving items
– Moving temporarily to reception or phone duties if your role is normally manual
– Protecting the wound if your work exposes your hands to water or contamination (e.g. food handling, healthcare, wet trades)
We’re happy to provide a letter for your employer outlining recommended modifications.
I take a GLP-1 medication (such as Ozempic, Wegovy, Mounjaro or Trulicity) — how does this affect my procedure?
GLP-1 medications, used for diabetes or weight management, slow the emptying of the stomach. This can increase the risk of stomach contents being present during sedation or a general anaesthetic. In line with current ANZCA guidance, if you’re having sedation or a general anaesthetic you’ll be asked to follow a clear-fluid-only diet for 24 hours before your procedure, followed by the standard 6-hour fast. Please tell us and your anaesthetist that you take this medication – your anaesthetist will give you specific instructions.
How long will I need to wear a splint?
A splint is typically worn for around 6 weeks to protect the tendon transfer while it heals into its new position, while a structured rehabilitation program begins.
Will I need to see a hand therapist afterwards?
Hand therapy is essential after tendon transfer surgery. Because the extensor indicis muscle is being re-trained to perform a new function (straightening the thumb instead of the index finger), a structured, supervised rehabilitation program significantly influences the functional outcome.
What pain medication will I need afterwards?
Usually simple pain relief – paracetamol and ibuprofen – is all that’s needed. Some procedures are more uncomfortable and you may need stronger pain relief. We can always prescribe stronger painkillers if you need them.
Risks & complications
General risks of hand surgery
- Bleeding and bruising; rarely, a collection of blood (haematoma) that may need draining
- Infection, which may require antibiotics or, rarely, further surgery
- Pain — usually temporary, occasionally persistent
- Swelling – common, and usually settles over weeks to months
- Scarring – scars are permanent and occasionally become thickened, raised or sensitive
- Allergic reaction to the local anaesthetic, antiseptic, dressings, tape or suture material
- Delayed or problematic wound healing
- Stiffness or reduced movement in the fingers, hand or wrist
- Injury to nerves, causing numbness, altered sensation or, rarely, a painful neuroma
- Injury to blood vessels (arteries)
- Injury to tendons
- Injury to bone (fracture)
- Failure to fully relieve your symptoms, or symptoms returning over time (recurrence)
- Complex regional pain syndrome (CRPS) – an uncommon but significant condition causing ongoing pain, stiffness and swelling
- Cold intolerance – the hand becoming more sensitive to cold, usually improving with time
- The need for further surgery
- Blood clots in the leg or lung (DVT/PE) – uncommon in hand surgery, with a slightly higher risk after a general anaesthetic or prolonged immobilisation
Specific risks of this surgery
- Incomplete restoration of thumb extension strength or movement, since a tendon transfer rarely performs exactly like the original tendon
- Some loss of strength or independence of index finger extension, since the tendon used for the transfer is taken from the index finger
- Adhesions limiting tendon movement (glide), sometimes requiring further surgery to release them
- Re-rupture of the transfer or failure to restore thumb extension, particularly if there is an unrecognised additional tendon injury
Anaesthetic
Your anaesthetist will discuss the specific risks of anaesthesia with you separately.
Recovery & rehabilitation
First 48 hours
Keep your hand elevated for 48 hours to reduce bleeding and post-operative swelling. Local anaesthetic lasts 6–24 hours (occasionally 1–3 days); your hand will have numb areas during this time. Do not grip or lift objects with your treated hand.
First week
Keep the bandages and plaster dry and intact until your post-operative review. You should find that your post surgery discomfort lessens each day. You will see your hand therapist to be placed in a thermoplastic splint (unless this splint was made prior to surgery and placed on your hand immediately after surgery) and to commence range of movement exercises.
Second week
The thumb and wrist remain splinted to protect the transferred tendon while it heals into its new position and route. Range of movement exercises reduce the adhesions formed around the tendon, so the tendon does not get stuck at the repair site.
6 weeks
Range of movement and full grip strength will take several months to return. The scar will feel tight and firm. Massage assists with improving scar mobility and minimising scar firmness and tendon adhesion.
3 months
The scar firmness and tendon adhesions will start to resolve after 3 months, and will take up to 12 months to settle.
Long term
The splint is usually removed around 6 weeks. Functional thumb extension typically continues to improve over 3 months or longer as the brain adapts to the tendon's new role and the tendon adhesions release.
Want to know more about EI to EPL Tendon Transfer?
Contact us to schedule an appointment with Dr Tomlinson.
Fees and costs
You will receive a written financial quotation after your consultation, once your operation and any third-party requirements are confirmed. See our Fees and informed financial consent page for how our fees work, what your quotation includes, and the resources available to you.