Background: Peripheral nerve injury is a significant problem affecting more than 1 million people around the world each year and poses major challenges to the plastic and reconstructive surgeon. For high upper extremity nerve injuries, distal muscle reinnervation and functional outcomes are generally poor. Tendon transfer has been the traditional reconstructive option in these cases to restore hand function. More recently, nerve transfers have been described in the forearm and hand to recover hand and wrist function and critical sensation. Methods: This article reviews the surgical principles, donor nerve options, indications, and outcomes of distal nerve transfers for high upper extremity nerve injuries. Results: The functional results of nerve transfers to date have been comparable to tendon transfers. The primary advantage is the potential for individual finger motion from a donor nerve with singular function. The disadvantage is the longer recovery time required for muscle reinnervation. Conclusions: Nerve transfers are a viable option for peripheral nerve injuries distal to the brachial plexus. The choice of management will depend on the patient's individual goals and priorities in terms of the need or desire for individual finger movement and the length of the recovery period.