Intramuscular and submuscular ulnar nerve transposition — postoperative protocol

This protocol covers primary anterior intramuscular or submuscular ulnar nerve transposition. The shared pathway protects a divided, lengthened or reattached flexor-pronator mass. It excludes nerve repair or grafting, revision surgery, ligament reconstruction and fracture fixation.

Review the operative report: extent of muscle dissection, repair method and nerve stability. If the origin was not repaired, the orthopaedic surgeon may shorten protection and permit earlier movement. The label “intramuscular” alone does not justify accelerated rehabilitation.

Start with 5 comfortable elbow movements, 3–4 times daily, within permitted limits. Gently open and close the hand and spread and bring together the fingers. No forceful squeezing, exercise balls, weights or resistance bands. Adjust dosage to swelling, pain and sensory symptoms.

Until the end of week 6, avoid resisted pronation, wrist flexion and forceful grip, including isometrics that load the repair. No lifting loads, pushing, pulling or weight-bearing through the operated limb. Light self-care is permitted within protective restrictions.

Avoid pressure on the medial elbow and aggressive nerve mobilisation. Gentle nerve sliders require individual instruction and must not increase paraesthesia. Begin scar care only after complete wound closure; avoid deep pressure over the nerve.

Walking from the first days as tolerated. Lower-limb training must avoid gripping, weight-bearing or loading the operated arm and avoid fall risk.

Gentle swimming and outdoor cycling are usually considered from weeks 8–12: a healed wound, functional motion and good exercise tolerance are required. Cycling requires reliable steering and braking. Vigorous swimming is treated as sport training.

Heavy gym training, climbing, throwing, racquet and contact sports: gradual return usually during months 3–6 or later. Completion of strength progression and sport-specific testing is required. Time alone does not provide clearance.

Healed wound, no increasing swelling, adequate task-specific motion, stable sensation and hand control. Before loading, assess repair-site tenderness, strength and endurance, then review the response through the following day.

Hand therapy supports orthosis fitting, motion recovery and monitoring of sensation, intrinsic strength and dexterity. Lack of motion progress by weeks 4–6 needs review; do not independently increase stretching force. Additional treatments for established stiffness require repair assessment first.

Reviews are usually at 10–14 days and around weeks 6 and 12, more often for wound problems, stiffness or neurological deficits. Document little-finger and ulnar ring-finger sensation, finger movement, elbow motion and loading tolerance.

Muscle and fascial healing and restored motion do not mean nerve recovery is complete. Sensory and strength recovery takes months; final results may be assessed at 12–18 months. Advanced neuropathy with muscle wasting may recover incompletely. New deterioration requires investigation regardless of time since surgery.

After flexor-pronator repair, use a long-arm splint as prescribed, usually for 10–14 days. The elbow is commonly flexed approximately 60–90°, with the wrist neutral or slightly flexed; the surgeon determines exact forearm and joint positioning.

Keep the dressing clean and dry. Support the limb and elevate the hand for swelling. A sling provides comfort and protection during mobility. Protect the anaesthetised arm from injury and temperature extremes. Gently move the fingers and the shoulder within restrictions. Do not remove the splint for elbow exercises without permission.

Earlier controlled motion requires explicit surgeon instructions and does not authorise loading. Wound review and removal of non-absorbable sutures are usually at 10–14 days.

After review, start gentle active or active-assisted elbow motion, initially with the forearm neutral or pronated. Increase the arc gradually without forcing extension. Introduce supination with the elbow flexed according to tolerance and surgeon instructions.

Initially avoid combining end-range elbow extension, supination and wrist extension. Exercise joints separately without sustained stretching. After origin repair, a wrist orthosis may be prescribed until around week 6; its position and removal for exercises are individualised.

Gentle active wrist motion is usually introduced during weeks 3–4 after clearance, avoiding end-range or sustained extension. Discontinue or convert the elbow splint to a removable orthosis according to repair stability; six weeks of complete elbow immobilisation is not automatic.

After healing assessment and surgeon clearance, gradually discontinue wrist protection, increase motion and introduce light resistance. Begin with submaximal isometrics, followed by low resistance through movement. Progress particularly cautiously when loading the repaired flexor-pronator mass.

Initial dosage: one short set of 5–10 repetitions on alternate days without maximal effort. Persistent origin tenderness or nerve irritation requires postponing load increases. Do not apply a universal weight limit independently of repair quality.

Develop grip, wrist, forearm, elbow and shoulder strength and endurance. Increase one demand at a time: repetition tolerance first, then resistance and task difficulty.

Consider work conditioning from around weeks 10–12. Weight-bearing and heavier loads are generally introduced around week 12 or later, after surgeon clearance and functional testing. Pain, swelling or paraesthesia persisting the next day requires reduced dosage.