One-stage key pinch and release with carpal-metacarpal fusion, extensor pollicis longus tenodesis, and motor transfer to flexor pollicis longus were analyzed for functional results in tetraplegic patients. Eighteen patients (21 hands)-all with International Classification OCu:4 hand function or worse-were studied. Average follow-up was 42 months. All patients experienced significant increase in functional ability and thought the surgery was highly beneficial. Average pinch strength was 3.3 kg, whereas it had been nonmeasurable preoperatively. Both activities of daily living and pinch strength correlated with tetraplegic functional level. The patients with higher preoperative functional level had better postoperative activities of daily living scores and pinch strength. Sixteen hands had solid fusions, and patients with fibrous nonunions showed no decrease in pinch strength, pain, or functional limitations when compared with the patients who had solid fusions. Six hands showed degenerative changes at one or more adjacent joints, but this was not related to results.