We reviewed 4 biceps-to-triceps transfers for active elbow extension in 3 tetraplegic patients using a medial routing technique. The biceps-to-triceps transfer to regain active elbow extension in tetraplegic patients is an alternative to the more commonly described deltoid-to-triceps transfer. Before surgery, all 3 patients had absent triceps function and active biceps, brachialis, and supinator function. Postoperative results were assessed by a modified University of Minnesota Functional Improvement questionnaire and by follow-up evaluation of range of motion and muscle strength. All 3 patients had marked functional improvement in activities that involve active elbow extension, and no loss of function was noted in any activities. No patient achieved less than grade 4 extension strength; none had an extension lag greater than 8 degrees. Supination and flexion strength following transfer were rated as at least grade 4 in each limb. Based on the results of this study, we recommend the biceps-to-triceps transfer as an alternative to the deltoid-to-triceps transfer in spinal cord injury patients with active brachialis and supinator function. The medial routing technique has the advantage of avoiding the potentially devastating radial nerve injury that could occur with the previously described lateral routing.