The surgeon may be presented with a child who has sustained a substantial loss of median nerve substance. Defects larger than 4–6 cm restored by nerve grafts are associated with poorer reinnervation outcomes than smaller defects. Another difficult situation involves median nerve lacerations well proximal to the elbow where the distance from repair to the first points of innervation may be longer than what the muscles have for time to reinnervate (usually associated with other serious injury involving the ulnar nerve, the brachial artery, and even the musculocutaneous nerve). In the latter situation, the healing nerve repair may simply take too long to ever innervate critical musculature before irreversible end-plate demise. One option is to resort to tendon transfer reconstruction early, and the techniques are detailed below. The other option is to restore critical portions of the median nerve using nearby healthy nerve tissue. Previously described donor motor nerves include the motor nerve to the brachialis muscle and the posterior interosseous nerve (both the supinator and extensor carpi radialis brevis branches). Donor sensory nerves include the lateral antebrachial cutaneous nerve, the superficial radial sensory nerve, and the common digital nerve to the small/ring finger (ulnar nerve). Examine the thumb carefully by noting its resting position, state of all the muscles moving the thumb and its three joints: the carpometacarpal (CMC) joint at the base, the metacarpophalangeal (MCP) joint in the middle and the IP joint at the distal part. Check the CMC joint for subluxation or contracture in the extended and externally rotated position. Check the MCP joint for arthritis and instability in flexion. Check the IP joint for contracture. Further, verify that the thumb web is adequate and not contracted. When you suspect any joint problem like subluxation or arthritis, radiographs must be taken to confirm the suspicion. When joint problems are present, or, when there is contracture of the thumb web or the IP joint flexion contracture of more than 20°, then transfer cannot be done before correcting them