Hand Service: Orthopaedic and Therapy Post Operative Guidelines (586)

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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Introduction

Background

Hand surgery is performed by a variety of surgeons over a number of locations in NHSGG&C. Currently the post operative care provided is based on individual surgeon’s specific protocols and/ or historical processes.

Objective

The guideline was developed to standardise the post-operative care for hand surgical procedures carried out in NHSGG&C.

Aims

  • To make post operative treatment recommendations based on evidence and sound clinical reasoning.
  • To improve both the quality and consistency of post operative care in NHSGG&C

Scope

The guideline provides recommendations for post operative care for six common surgical procedures - Carpal Tunnel Release, Cubital Tunnel Decompression, Dupuytrens Contracture - Fasciectomy, De-Quervain’s Release, Trapeziectomy and Trigger Finger Release. The information contained in this guide is not exhaustive. There are many other operations performed across NHSGG&C.

Target user of guideline

This guideline has been developed for use by orthopaedic surgeons/ registrars/ AHP’s and orthopaedic nurses.

This guide is not intended to replace individual clinical reasoning. It is recognized that at times there may be some local variance in procedures and protocol. If there is any doubt regarding the procedures and protocols for a particular patient, please contact the clinic responsible for the procedure.

Carpal Tunnel Release

Day of Surgery

  • Bulky dressing in situ, to be reduced in 48hrs by the patient.
  • Give patient 2 mepore dressings.
  • Discharge with/ without sling as per surgeon’s protocol.
  • Check circulation, sensation and movement.
  • Instructions on elevation of limb, mobilisation of fingers and rest of the upper limb.
  • Patient provided with post operative patient information leaflet if they do not already have one.
  • Specify how and who to contact at clinic, if there are any problems.
  • Fit note provided for the duration of expected absence if required.
  • Prescribe analgesia appropriate to the anticipated level of pain relief required. Follow local guidelines if available.

Review Clinic (10-21 days)

(in some localities suture removal may be done by practice nurse with/ without additional post operative review)

  • Remove dressing/ sutures as required.
  • Check wound
    • Any evidence of infection contact surgical team.
  • Apply dressing (if required).
  • Check ROM
    • Stiffness of wrist and hand - is the patient able to fully open and close fist? Advise on exercises as per patient information leaflet.
  • Scar Care
    • Once wound has healed gently massage with an emollient hand cream 3-4 times daily.
  • Returning to work
    • Avoid dirty environments and ensure dressing remains dry.
    • Light manual 2-3 weeks.
    • Heavy manual 4-6 weeks.
  • Driving
    • Once feels safe to do so and they feel they are in complete control of the car. Advice that they may want to check with their insurance company.
  • Provide post operative patient information leaflet if they don’t already have one.
  • Reiterate that up to 1 in 4 patients can expect to have problems with scar/ proximal palmar pain, and this can be variable in its duration
  • Specify how and who to contact at clinic if there are any problems.
  • If patient had bilateral symptoms provide relevant phone number for them to call, should they decide to have the second surgery (appointment can be provided without a further referral up to 6/12 post surgery)

Ulnar Nerve Decompression

Day of Surgery

  • Dressing in situ, to be reduced in 48 - 72hrs by the patient.
  • Discharge with/ without sling as per surgeon’s protocol.
  • Check circulation, sensation and movement.
  • Encourage full active movement of shoulder, wrist and hand.
  • Advise regarding the use of ice and elevation.
  • Patient provided with post operative patient information leaflet if they do not already have it.
  • Specify how and who to contact at clinic, if there are any problems.
  • Fit note provided for the duration of expected absence if required.
  • Prescribe analgesia appropriate to the anticipated level of pain relief required. Follow local guidelines if available.

Review Clinic (10-21 days)

(in some localities suture removal may be done by practice nurse with/ without additional post operative review)

  • Remove dressing/ sutures if required (most wounds will be closed with a subcuticular suture).
  • Check wound
    • Any evidence of infection contact surgical team
  • Apply dressing (if required).
  • Splinting may be indicated if fingers are clawed.
  • Check ROM of elbow.
  • Encourage full active movement of shoulder, wrist and hand.
  • Active assisted progressing to active exercises for elbow flexion
    • Aim for full active range of movement at each joint, avoid over- stretching.
  • Scar Care
    • Once wound has healed gently massage with an emollient hand cream 3-4 times daily.
  • Returning to work
    • Avoid dirty environments and ensure dressing remains dry for 7 days.
    • Light manual 2-3 weeks.
    • Heavy manual 4-6 weeks.
  • Driving
    • Once feels safe to do so and they feel they are in complete control of the car. Advice that they may want to check with their insurance company.
  • Provide post operative patient information leaflet if they don’t already have one.
  • Specify how and who to contact at clinic, if there are any problems.

Dupuytren’s Contracture - Fasciectomy

Day of Surgery

  • Record pre-operative contracture.
  • Operative procedure recorded, including any contracture that was not correctable.
  • Hand placed in padded bandage/ slab and elevated as per surgeons protocol.
  • Check circulation, sensation and movement (CSM).
  • Patient provided with post operative patient information sheet if they do not already have one.
  • Fit note provided for the duration of expected absence if required.
  • Prescribe analgesia appropriate to the anticipated level of pain relief required. Follow local guidelines if available.
  • Arrange an urgent appointment with hand therapist in addition to nurse led dressing clinic appointment if required per surgeon’s protocol.

First Review Clinic (3 - 7 days)

  • Reduce dressing.
  • Clean and check wound site (leave sutures in situ)
    • Any evidence of infection contact surgical team.
  • Redress wound and apply light dressing.
  • Advise on active/ passive ROM exercises as per patient information leaflet 4-6 times per day.
  • The patient may be provided with a splint depending on surgeon’s protocol.
  • Re-assure the patient that if the wound bleeds this is ok.
    • If wound dressing becomes exceptionally soiled before next appt, patient can contact clinic.
  • Arrange follow up appointment for 1/52 at review clinic.
  • Provide post operative patient information leaflet if the patient does not already have one.

Subsequent Review Clinic

  • Sutures removed at 10-14 days post op.
  • Check CSM and assess for wound infection/ breakdown as above.
  • Once wound has healed gently massage with an emollient hand cream 3-4 times daily.
  • Check fitting of splint (if they have a splint).
  • Over subsequent visits the aim is to have a healed wound, full composite flexion and maintenance of the extension obtained on the operating table (Please refer to op note).
  • Monitor as required until wound healed and/or until therapy no longer required.
  • Further review if required, depending on clinical progress.

De-Quervain’s Release

Day of Surgery

  • Dressing in situ, to be reduced in 48-72hrs by the patient.
  • Give patient 2 mepore dressings.
  • Check circulation, sensation and movement.
  • Instructions on elevation of limb, mobilisation of fingers and the rest of upper limb.
  • Patient provided with post operative patient information leaflet if they do not already have it.
  • Specify how and who to contact at clinic if there are any problems.
  • Fit note provided for the duration of expected absence if required.
  • Prescribe analgesia appropriate to the anticipated level of pain relief required. Follow local guidelines if available.

Review Clinic (10-21 days)

  • Remove dressing/ sutures if required.
  • Check wound
    • Any evidence of infection contact surgical team.
  • Continue with light dressing if required.
  • Check ROM
    • Stiffness of wrist and hand. Advise on exercises as per patient information leaflet.
  • Scar Care
    • Once wound has healed gently massage with an emollient hand cream 3-4 times daily.
  • Returning to work
    • Avoid dirty environments and ensure dressing remains dry.
    • Light manual 2-3 weeks.
    • Heavy manual 4-6 weeks.
  • Driving
    • Once feels safe to do so and they feel they are in complete control of the car. Advice that they may want to check with their insurance company.
  • Provide post operative patient information leaflet if they don’t already have one.
  • Specify how and who to contact at clinic, if there are any problems.

Trapeziectomy

Day of Surgery

  • Check circulation, sensation and movement.
  • May have a cast in situ dependent on surgeon’s protocol.
  • Patient provided with post operative information sheet if they do not already have one.
  • Fit note provided for the duration of expected absence if required.
  • Prescribe analgesia appropriate to the anticipated level of pain relief required. Follow local guidelines if available.

First Review Clinic (7-14 days)

  • Remove backslab if in situ and reduce dressing.
  • Check wound site and remove sutures.
  • Re-apply cast/ splint.
  • Refer to AHP for rehabilitation to be commenced once cast removed if required.
  • Provide patient information leaflet if the do not already have one.

Subsequent Review Clinic (4-6 weeks)

  • Remove cast if required.
  • Re-apply cast if required.
  • Encourage ROM
    • Reassurance to be given that it will be sore, no damage is being done.
    • Don’t force the movement as they will be acute.
  • Encourage regular use of analgesia if required.
  • Thumb range of motion exercises active and active assisted.
  • Scar Care
    • Once wound has healed gently massage with an emollient hand cream 3-4 times daily.
  • Returning to work
    • Avoid dirty environments and ensure dressing remains dry.
    • Heavy lifting should be avoided for 12 weeks.
  • Driving
    • Once feels safe to do so and they feel they are in complete control of the car. Advice that they may want to check with their insurance company.
  • Further review if required, depending on clinical progress.

Trigger Finger Release

Day of Surgery

  • Bulky dressing in situ, to be reduced in 48hrs by the patient.
  • Give patient 2 mepore dressings.
  • Discharge with/without sling as per surgeon’s protocol.
  • Check circulation, sensation and movement.
  • Instructions on elevation of limb, mobilisation of fingers and the rest of upper limb.
  • Patient provided with post operative information sheet if they do not already have it.
  • Specify how and who to contact if there are any problems.
  • Fit note provided for the duration of expected absence if required.
  • Prescribe analgesia appropriate to the anticipated level of pain relief required. Follow local guidelines if available.

Review Clinic (10-21 days)

(in some localities suture removal may be done by practice nurse with/ without additional post operative review)

  • Remove dressing/ sutures if required.
  • Check wound
    • Any evidence of infection contact surgical team.
  • Continue with light finger dressing only if required.
  • Check ROM
    • Stiffness of wrist and hand - is the patient able to fully open and close fist. Advise on exercises as per leaflet.
  • Scar Care
    • Once wound has healed gently massage with an emollient hand cream 3-4 times daily.
  • Returning to work
    • Avoid dirty environments and ensure dressing remains dry.
    • Light manual 2-3 weeks.
    • Heavy manual 4-6 weeks.
  • Driving
    • Once feels safe to do so and they feel they are in complete control of the car. Advice that they may want to check with their insurance company.
  • Provide patient information leaflet if they don’t already have.
  • Specify how and who to contact, if there are any problems.

Last reviewed: 11 May 2022

Next review: 11 May 2022

Author(s): Louise Ross

Version: 1

Approved By: Clyde Sector Clinical Governance Group; North Sector Clinical Governance Group; South Sector Clinical Governance Group; Regional Directorate Clinical Governance Group

Document Id: 586