longus). It is also an operation whose results allow the patient to gain confidence in the rest of the treatment. Wrist-related tenodesis effect (Tenodesis grasp) means that wrist flexion passively opens the hand and wrist extension passively closes the hand. (see pictures below) Wrist-related tenodesis effect is the key point of any functional surgery in a paralyzed hand, therefore active wrist extension is required and reconstruction of this active wrist extension is of utmost importance for the tetraplegic hand. If no active wrist extension is available (IC group 0 and 1), the brachioradialis (only IC group 1) can be transferred to achieve wrist extension. Active tendon transfers are possible if m. extensor carpi radialis longus and m. extensor carpi radialis brevis are present. The use of the m. extensor carpi radialis longus and the m. brachioradialis are possible to restore hand function. Techniques Elbow There are two major techniques used to gain elbow extension. Deltoid-to-triceps transfer: For this transfer, the posterior part of the deltoid muscle is released from its origin and attached to the triceps muscle (usually by means of a tendon graft or a synthetic graft) leaving the rest of the deltoid muscle intact. This transfer is usually very successful because the line of pull of the posterior deltoid muscle is in the same direction as the triceps muscle. Also, there is hardly any loss of function. The deltoid muscle is usually innervated by the fifth and sixth cervical nerve roots and is therefore often functional in patients with tetraplegia, though the triceps muscle, which is innervated by the seventh cervical root, is paralysed. Because of the location at the back of the arm, the posterior part of the deltoid muscle can give strength in the same direction as the triceps muscle and is therefore theoretically a good donor to regain elbow extension. Not only the direction of the strength provided by the donormuscle is important, Smith et al. showed that the matching between the original functional properties of the donor and recipient muscles affects the outcome of the transfer. Therefore, Fridén studied the architectural properties of the deltoid and triceps muscle in cadavers and concluded that the posterior deltoid would be a very suitable transfer to provide elbow extension. Since the tendon of the triceps is not long enough to reach the posterior deltoid muscle, an interposition graft is needed. Different procedures have been described to achieve