Anterior subcutaneous ulnar nerve transposition — postoperative protocol

Isolated primary anterior subcutaneous transposition of the ulnar nerve at the elbow, with nerve stability confirmed during surgery. This protocol excludes submuscular transposition, nerve repair or grafting, revision surgery and associated ligament, tendon or fracture procedures.

Review the operative report before rehabilitation: nerve stabilisation, any fascial sling and prescribed restrictions. Record baseline sensation in the little finger and ulnar half of the ring finger, intrinsic hand strength and elbow range of motion.

Default pathway: a soft dressing and gentle active elbow movement during the first days, as permitted by pain, the wound and surgeon instructions. Prolonged immobilisation is not automatic. A sling may be used briefly for comfort or until the anaesthetic block resolves; remove it for permitted exercises.

If the orthopaedic surgeon prescribes a splint to protect the wound or stabilised tissues, follow those instructions, usually for 7–14 days. Do not independently remove it for elbow exercises without permission. Move the fingers, wrist and shoulder within dressing restrictions. The surgeon sets the splint angle and permitted movement.

Elbow: once movement is permitted, slowly bend and straighten actively with the upper arm near the trunk and the hand relaxed. Start with 5 comfortable repetitions, 3–4 times daily. Increase the arc gradually without pushing with the other hand or painful stretching.

Forearm and hand: with the elbow near the trunk, rotate the palm up and down. Bend and straighten the wrist and fingers; gently spread and bring the fingers together, 5–10 repetitions. Move the shoulder without tension at the surgical site.

Short sessions should not increase paraesthesia or cause persistent pain or swelling. Reduce the arc and dosage if symptoms increase. Avoid aggressive nerve tension testing. Individually prescribed nerve sliders must remain symptom-free; they are not mandatory home exercises.

Walking from the first days as tolerated. Stationary cycling without loading the operated arm is possible once anaesthetic effects resolve and balance is safe.

Swimming and outdoor cycling usually from weeks 6–8: a completely closed wound, comfortable movement and exercise tolerance are required; cycling also requires reliable steering and braking. Gradually introduce heavier gym training and weight-bearing in weeks 8–12.

Racquet sports, throwing and contact sports: sport-specific progression usually during weeks 8–12 or later. Full return is generally considered from around month 3 and may take longer. Competitive athletes need a separate programme; starting a throwing programme is not clearance for competition.

A healed wound, minimal or no swelling, functional elbow and forearm motion, stable sensation and controlled grip. Task trials must not cause increasing paraesthesia or deterioration persisting the following day. Assess task-specific strength and endurance before heavy occupational or sporting loads.

Hand therapy is indicated for stiffness, intrinsic weakness, impaired dexterity, scar sensitivity or delayed improvement. Uncomplicated cases may follow an instructed home programme with progress reviews.

Wound healing and recovery of movement precede nerve recovery. Tingling may improve during the first weeks; sensory and strength recovery takes months, and final results may be assessed at 12–18 months. Longstanding denervation and muscle wasting may limit recovery.

A persistent preoperative deficit does not automatically mean surgical failure. New deterioration must not be attributed simply to slow nerve recovery. Clinical reviews are usually at 10–14 days, around week 6 and month 3; further follow-up depends on residual deficits.

Keep the dressing clean and dry. Support the limb and elevate the hand for swelling. Protect the anaesthetised arm from injury and temperature extremes. Wound review is usually at 10–14 days; remove non-absorbable sutures according to healing.

Avoid resting the medial elbow on desks, armrests or firm cushions. Avoid tight sleeves, prolonged deep elbow flexion and movements causing tingling. The transposed nerve is superficial and requires protection from pressure and impact.

Light self-care is permitted. Avoid lifting loads, forceful gripping, pushing, pulling and supporting body weight through the operated arm. Do not exercise with weights.

Following wound review, gradually recover preoperative motion. Comfortable motion is often possible by weeks 3–4 with early mobilisation, but may take longer with stiffness or prolonged protection. Lack of improvement by weeks 4–6 needs assessment, not more forceful stretching.

Increase light activity duration and practise dexterity. Start gentle scar care and mobilisation only after complete wound closure. Avoid deep massage over the transposed nerve. A soft elbow protector may prevent accidental contact, provided it does not compress the area.

Avoid heavy exertion and strength training. Light resistance in weeks 4–6 requires explicit surgeon approval, a healed wound, comfortable motion and no symptom increase.

Generally start low resistance for grip, intrinsic hand muscles, wrist and elbow from week 6. Initially use one set of 8–10 repetitions on alternate days, adjusted to strength and tolerance. Increase easy repetitions before increasing load.

Progress from light activities to occupational tasks. Introduce weight-bearing and heavier loads gradually in weeks 8–12 after functional assessment. Recurrent tingling, pain or swelling requires stepping back to the previous tolerated level.