# CQ Hand + Upper Limb — full-content corpus > Specialist orthopaedic practice of Dr Kieran Hirpara — fellowship-trained shoulder, elbow, wrist and hand surgeon based at Mater Private Hospital Rockhampton. This is the full-content companion to llms.txt; it concatenates the substantive text of every /conditions/* and /education/* page so an LLM ingesting this one file has the complete clinical corpus without crawling each URL. Practice contact: 07 4863 6556 · office@cqupperlimb.com.au · Mater Private Hospital Rockhampton, 31 Ward Street, The Range QLD 4700. AHPRA registration: MED0001905888. --- ## Conditions (procedure-led practice pages) ### Carpal tunnel surgery URL: https://www.cqupperlimb.com/conditions/carpal-tunnel-surgery/ Treats: Carpal tunnel syndrome Carpal tunnel release is one of the most common procedures performed at the practice, with patients seen at Mater Private Hospital Rockhampton from across Central Queensland. Day case surgery, local anaesthetic in most cases, and a return to light duties within one to two weeks. **About the condition.** Carpal tunnel syndrome is compression of the median nerve as it crosses the wrist. Patients typically describe night-time numbness or pins-and-needles in the thumb, index and middle fingers, weakness when gripping, and waking to shake the hand to relieve symptoms. The condition is common in middle age, in pregnancy, and in occupations that involve repetitive gripping. Diagnosis is usually clinical, often confirmed with nerve conduction studies where the picture is unclear or surgery is being planned. Most patients have tried wrist splints, activity modification or a corticosteroid injection before surgery is offered. **When surgery is recommended.** Surgery is generally recommended when symptoms persist despite conservative measures, when nerve-conduction studies show significant compression, or when there is muscle wasting at the base of the thumb. Earlier release tends to give a more complete recovery; nerves that have been compressed for a long time can be slow to settle and may not return all the way to normal. Severe cases — constant numbness, thenar wasting, weakness — are referred for surgical opinion sooner. **What the procedure involves.** Carpal tunnel release divides the transverse carpal ligament, the firm band of tissue that forms the roof of the carpal tunnel, taking pressure off the median nerve. The practice performs the operation through a small open incision in the palm, usually under local anaesthetic with light sedation, as a day case. Surgery takes around 15 minutes; the wound is closed with stitches that are removed at around two weeks, and dressed with a soft bulky dressing. Full clinical detail and what to expect on the day is on the [education page](/education/wrist/carpal-tunnel-release/), and the [carpal tunnel syndrome](/education/wrist/carpal-tunnel-syndrome/) education page covers the underlying condition. **Recovery.** Someone else will need to drive you home on the day. Most patients return to desk work within a week or two, and to driving over a similar time — once the wound is comfortable and the wheel can be gripped firmly. Heavier lifting and gripping is held off for around six weeks while the cut ligament reforms with scar tissue. A small amount of pillar pain — discomfort in the heel of the hand on either side of the scar — is normal for the first two to three months and settles with use. Numbness usually improves rapidly; nerve recovery in long-standing cases can continue for up to a year. The practice's full phase-by-phase rehabilitation plan is on the [carpal tunnel release rehabilitation protocol](/education/rehabilitation/carpal-tunnel-release/) page. **Practice context.** Carpal tunnel release is a well-suited day case operation for patients travelling from out of town. The practice tries to coordinate the consult, surgical booking and pre-admission paperwork into a single visit where it can be arranged. Post-operative review is typically at six weeks; this six-week review is aftercare and is included in the surgical fee. All carpal tunnel patients are seen by Ruby Doolan at Extend Rehabilitation for the first dressing change and scar care; this is built into the routine pathway. The [carpal tunnel check](/tools/cts-6/) — a validated two-question screen plus the six-question symptom score recorded at the practice's own appointments — is a useful way to check whether symptoms fit the pattern and track severity before and after treatment. **MBS items:** - 39331 — Carpal tunnel release (primary) (Covers all primary carpal tunnel decompressions — open or endoscopic — since the previous endoscopic-specific item was consolidated) - 39332 — Revision carpal tunnel release (Repeat carpal tunnel decompression after a previous release) **Frequently asked:** - *What's the difference between open and endoscopic carpal tunnel release?* Both procedures divide the same ligament and decompress the same nerve. Open release uses a small palmar incision to visualise the structures directly; endoscopic release uses one or two smaller incisions and a camera. Published outcomes are similar in symptom relief and complication rates. The practice performs open release as the standard approach because direct visualisation makes injury to the median nerve and to the recurrent motor branch extremely uncommon, and the small palmar scar settles to a barely visible line within a few months. - *What's the chance my symptoms will come back after carpal tunnel surgery?* True recurrence after a properly executed open release is uncommon — the divided ligament does not re-form into the same constricting band. What patients sometimes notice is a slow, partial return of symptoms over many years if the underlying contributors (occupation, weight, diabetes, pregnancy in some patients) persist. Persistent or returning symptoms after surgery are investigated carefully — sometimes the original diagnosis was incomplete and another nerve site is also involved. Any concern post-operatively is worth raising at review. - *How much does carpal tunnel surgery cost? What does Medicare cover?* Carpal tunnel release fees vary with the anaesthetic. Under local anaesthetic — Dr Hirpara performs the block himself — there is no anaesthetist fee; under a general anaesthetic, a separate anaesthetist gap applies. The surgeon, hospital and consumable fees are the same in either case. The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent. - *When can I drive again after carpal tunnel surgery?* Driving requires a safe grip on the wheel and the ability to manage indicators and gears. Most patients are back to driving within one to two weeks, once the dressing has been reduced and the hand is comfortable. A UK consensus of hand surgeons and hand therapists put the expected return at 5 to 14 days (Newington et al., 2022), and a 2026 study of 107 patients found an average of 16 days, ranging from 2 days to 2 months (Lataste and Bigorre, 2026). In that study, whether the car was automatic or manual made no measurable difference. Practical signs you are likely safe to drive: you can grip the wheel firmly with the operated hand, perform an emergency stop without needing to protect the hand, you are off prescription pain medication, and the bulky dressing has been reduced to a small adhesive cover. The practice does not certify fitness to drive for insurance purposes — driving fitness is a decision between the patient, the GP and the insurer — but the question is discussed at the post-operative review. - *Can both wrists be operated on at the same time?* The practice prefers to operate on one hand at a time. Many patients with bilateral symptoms find the unoperated side settles considerably after the first hand is released — relief from the wakeful nights, restored sleep posture, and reduced overall nerve sensitisation often calm the contralateral hand without further intervention. Practically, releasing both hands at once also makes the first week harder than it needs to be: dressings on both hands make cooking, dressing and basic self-care surprisingly difficult. The worse hand is usually done first; the second hand is reviewed at the post-operative visit and only operated on later if it hasn't settled. - *What is "pillar pain" — should I be worried about it?* Pillar pain is a discomfort or tenderness in the heel of the hand on either side of the scar, usually appearing in the first few weeks after surgery and settling over two to three months as the divided ligament reforms with scar tissue. It's a normal part of recovery rather than a complication; the cause is thought to be a small change in the geometry of the small bones of the wrist as the transverse ligament releases its tension. Activity is comfortable through it, and it resolves on its own in nearly all patients. - *Do I need physiotherapy or hand therapy after carpal tunnel surgery?* Yes — every patient sees the on-site hand therapist for the first dressing change, scar management instruction, and a structured set of post-operative exercises to keep the fingers gliding and the scar mobile. Hand therapy is integrated into the post-operative pathway rather than offered as an extra. Additional sessions are scheduled where the recovery is slower than expected — a stiff hand, a tender or hypertrophic scar, or any wound concern. Hand therapy is provided by Ruby Doolan through Extend Rehabilitation, in the same suite as Dr Hirpara's rooms. --- ### Trigger finger release URL: https://www.cqupperlimb.com/conditions/trigger-finger-release/ Treats: Trigger finger (stenosing tenosynovitis) Trigger finger treatment in Rockhampton ranges from splinting and corticosteroid injection through to trigger finger release. When surgery is needed, it is a small day case procedure performed under local anaesthetic at Mater Private Hospital Rockhampton. Patients are usually back at desk work within a few days and back to most physical activities within two to four weeks. **About the condition.** Trigger finger — stenosing tenosynovitis — is a thickening of the pulley at the base of a finger that catches on the flexor tendon as it glides through. Patients describe a clicking or locking of the finger as they straighten it, sometimes with a painful nodule at the base of the digit, sometimes with the finger getting stuck in a bent position and needing to be straightened with the other hand. Multiple fingers can be involved at the same time. The condition is more common in diabetes, in middle age, and in the dominant hand of manual workers. **When surgery is recommended.** Many patients are managed first with a corticosteroid injection into the affected pulley, which settles the thickening and resolves the trigger in a sizeable fraction of cases. Surgery is offered when the trigger is recurrent after one or two injections, when the finger is locked or markedly catching, or in patients where injection is contraindicated. The threshold for surgery is lower in diabetics, where injections are less reliable. **What the procedure involves.** Surgical release divides the thickened A1 pulley through a small palmar incision, freeing the tendon to glide. The procedure is typically done under local anaesthetic alone as a day case, takes around ten minutes per digit, and the wound is closed with stitches that are removed at around two weeks. The full clinical and aftercare detail is on the [education page](/education/hand/trigger-finger-release/), and the [trigger finger](/education/hand/trigger-finger/) education page covers the underlying condition. **Recovery.** The dressing is reduced to a small adhesive cover at the first review and the hand is used freely from day one — gentle finger flexion and extension actually helps the tendon settle. Most patients are back to non-physical work within a few days; lifting, gripping and weight-bearing are held off for up to four weeks. Some tenderness around the scar is common for four to six weeks and settles with use. The practice's full phase-by-phase rehabilitation plan is on the [trigger finger release rehabilitation protocol](/education/rehabilitation/trigger-finger-release/) page. **Practice context.** Trigger finger release suits a same-day visit pattern: travelling patients can usually combine the consult and the procedure on the one day where the diagnosis and indications are clear and the patient is fit for local anaesthetic. The practice will discuss this option at booking. All trigger finger patients are seen by Ruby Doolan at Extend Rehabilitation for the first dressing change and scar care; this is built into the routine pathway. **MBS items:** - 46363 — Trigger finger release (per digit) (Same item is billed once per digit when multiple fingers are released in a single sitting) **Frequently asked:** - *Should I try a steroid injection first, or go straight to surgery?* A corticosteroid injection into the affected pulley settles the trigger in a sizeable fraction of cases — perhaps half — and is offered first in most patients. Surgery is recommended when one or two injections haven't held, when the finger is locked or markedly catching, or in patients where injection is contraindicated. The threshold for surgery is lower in diabetics, where injections are less reliable and the trigger tends to return. The decision is individual and discussed at the consultation; either pathway is reasonable in many patients. - *What's the chance the trigger comes back after surgery?* True recurrence after a properly executed A1 pulley release is uncommon — once the thickened pulley is divided, it does not re-form into the same constricting band. The condition is occasionally found in adjacent fingers over time, but that is a new trigger in a different pulley rather than recurrence of the operated one. Persistent triggering or stiffness after surgery is investigated at review; sometimes a tight A2 pulley or another digital mechanism is contributing. - *How much does trigger finger surgery cost? What does Medicare cover?* Trigger finger release fees vary with the anaesthetic. The procedure is normally performed under local anaesthetic — Dr Hirpara performs the block himself and there is no anaesthetist fee. A general anaesthetic is occasionally used, in which case a separate anaesthetist gap applies on top of the surgeon and hospital fees. The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent. - *Can multiple trigger fingers be released at the same time?* Yes — multiple trigger fingers in the same hand are routinely released in a single sitting; the procedure is small and the recovery is comparable to a single digit, with the dressing covering the whole hand for a few days regardless. Trigger fingers in the opposite hand are released separately at a later date — same logic as bilateral carpal tunnel: dressings on both hands make the first week of self-care surprisingly difficult, and the worse hand is dealt with first. The decision is practical and is discussed at the consultation. - *Will I lose strength in the finger after the A1 pulley is divided?* No measurable strength loss results from dividing the A1 pulley alone. The flexor tendon system has multiple pulleys (A1 through A5 and the cruciate pulleys), and the A2 and A4 pulleys do most of the mechanical work of holding the tendon close to the bone during finger flexion. The A1 pulley is the most proximal and the most expendable; divided in isolation, it does not produce bowstringing or weakness. The published evidence on long-term function after A1 release is reassuring. - *When can I drive after trigger finger release?* Driving is held off for the first week; most patients are back to driving within one to two weeks, once the dressing is comfortable, a full fist can be made and the hand can grip a wheel safely. The practice does not certify fitness to drive for insurance purposes — driving fitness is a decision between the patient, the GP and the insurer — but the question is discussed at the post-operative review. - *Do I need hand therapy after trigger finger release?* Yes — every patient sees the on-site hand therapist for the first dressing change, scar management instruction, and a structured set of post-operative exercises. Hand therapy is integrated into the post-operative pathway rather than offered as an extra. Additional sessions are scheduled where the recovery is slower than expected — a stiff finger, a tender or hypertrophic scar, or a patient with several digits released at once who needs more structured early loading. Hand therapy is provided by Ruby Doolan through Extend Rehabilitation, in the same suite as Dr Hirpara's rooms. --- ### Dupuytren's surgery URL: https://www.cqupperlimb.com/conditions/dupuytrens-surgery/ Treats: Dupuytren's disease Dupuytren's contracture is treated surgically at Mater Private Hospital Rockhampton — open palmar fasciectomy (Dupuytren's contracture release) is the operation most often offered for established contractures. Patients are seen at the practice from across Central Queensland. **About the condition.** [Dupuytren's disease](/education/hand/dupuytrens-disease/) is a slow thickening of the fascia in the palm and fingers that pulls one or more digits — most often the ring and little fingers — into a flexed position. The earliest sign is usually a firm nodule in the palm that's mistaken for a callus. Over years the nodules form cords, and the cords contract. The disease is more common in men over 50, in patients with northern European ancestry, and runs in families. The progression is unpredictable: some patients have stable disease for decades, others contract a finger over a single year. **When surgery is recommended.** Surgery is considered when the contracture starts to interfere with hand function — putting the hand flat on a table (the "tabletop test"), reaching into a pocket, washing the face. Roughly speaking the threshold is a metacarpophalangeal joint contracture of around 30 degrees or any proximal interphalangeal joint contracture that is progressing. Earlier surgery on PIP joint contractures gives better outcomes than late surgery; once the joint capsule has tightened around a long-standing contracture the joint may not fully straighten even with the cord excised. **What the procedure involves.** Open palmar fasciectomy excises the diseased cords and nodules through zigzag incisions in the palm and fingers, preserving the digital nerves and arteries that often run through the diseased tissue. The operation is usually performed under regional or general anaesthesia as a day or short-stay case. The full clinical and aftercare detail is on the [education page](/education/hand/dupuytrens-fasciectomy/), and the [Dupuytren's disease](/education/hand/dupuytrens-disease/) education page covers the underlying condition. **Recovery.** A bulky dressing is replaced with a softer one at the first dressing change. Hand therapy with a custom night extension splint typically begins within two weeks; daytime motion is encouraged early to keep the fingers gliding through the healing tissues. Most patients are back to desk work within two to three weeks and to heavier use by six to eight weeks. Recurrence over the long term is possible, particularly in patients with strong family history and early onset. The practice's full phase-by-phase rehabilitation plan is on the [Dupuytren's release rehabilitation protocol](/education/rehabilitation/dupuytrens-fasciectomy/) page. **Practice context.** Hand therapy is on-site at Mater through Extend Rehabilitation, with the option to coordinate ongoing therapy with a clinic closer to the patient's home if travel is an issue. Dr Hirpara reviews each Dupuytren's case individually before recommending the surgical option that fits the contracture pattern. **MBS items:** - 46372 / 46375 / 46378 / 46379 / 46380 — Fasciectomy for Dupuytren's contracture (Primary fasciectomy, graded by number of rays operated on (1 / 2 / 3 / 4 / 5)) - 46381 — Interphalangeal joint release (Per joint, when performed alongside fasciectomy for a long-standing PIP contracture) - 46384 — Z-plasty or local skin flap (Per flap, when local skin rearrangement is needed to close the wound without tension) - 46387 / 46390 / 46393 / 46394 / 46395 — Revision fasciectomy (Repeat fasciectomy after a previous Dupuytren's operation, graded by number of rays) **Frequently asked:** - *What's the recurrence rate after Dupuytren's surgery?* Dupuytren's disease has a higher recurrence rate than most hand conditions because the underlying disorder is biological rather than mechanical — surgery removes the thickened tissue but doesn't change the underlying tendency of the palm to produce it. Published recurrence rates after open fasciectomy vary widely and depend on definition (clinical recurrence vs symptomatic re-contracture), follow-up duration, age at first surgery, family history, and bilateral involvement. Patients with strong family history and early onset of symptoms are at the highest risk. Surgical revision is feasible but more demanding than primary surgery, and is discussed individually. - *Are needle aponeurotomy or collagenase (Xiapex) options I should consider?* Collagenase clostridium histolyticum (Xiapex) was an injection-based alternative to surgery available in Australia for a number of years; the product was withdrawn from the Australian market by the manufacturer in 2020 and is no longer available. Needle aponeurotomy (also called needle fasciotomy) — a percutaneous division of the cord with a needle, performed under local anaesthesia — remains an option in some practices for early metacarpophalangeal joint contractures with a discrete palpable cord; it does not address the underlying nodules and has higher early recurrence rates than open fasciectomy. The practice's standard approach for established contractures is open palmar fasciectomy. - *Needle fasciotomy versus open surgery for Dupuytren's — what's the difference?* Both techniques aim to straighten a Dupuytren's contracture, but they address the disease differently. Needle fasciotomy (also called percutaneous needle aponeurotomy) divides the cord with a needle through the skin under local anaesthesia; no incision is made, and use of the hand resumes within days. The diseased fascia and nodules are left in place. Open palmar fasciectomy excises the diseased fascia and cords through zigzag palmar incisions under regional or general anaesthesia; recovery is longer (dressings for one to two weeks, hand therapy and a custom night extension splint over several months) but the diseased tissue is removed rather than divided. In the published comparison, needle fasciotomy has a substantially higher recurrence rate at three to five years than open fasciectomy, and is less effective at the proximal interphalangeal joint and in nodular disease. The [Cochrane review of surgical interventions for Dupuytren's contracture](https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010143.pub2/full) sets out the comparative evidence in detail. The practice offers open palmar fasciectomy as the standard approach for established contractures because the comparative evidence favours durability over short-term recovery, and because PIP joint and nodular disease — the cases most likely to need a surgical opinion — are not reliably addressed by the percutaneous technique. - *How much does Dupuytren's surgery cost? What does Medicare cover?* Dupuytren's surgery is normally performed under regional or general anaesthesia, so a separate anaesthetist gap applies on top of the surgeon and hospital fees. The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. The Medicare item is graded by the number of rays operated on (more involved cases attract a larger schedule fee, but also a larger gap). Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent. - *Will I need a skin graft?* In severe or long-standing contractures, the skin can shorten over a contracted cord and simple closure of the surgical incisions may not be possible. Three options are available: a Z-plasty or small local skin flap (the most common technique — skin rearrangements that lengthen the closure without a graft); the open-palm technique (leaving a small area to heal by secondary intention, which heals reliably and limits early stiffness); or a dermofasciectomy in severe or recurrent disease, where both the diseased fascia and the overlying skin are excised and replaced with a small skin graft from the forearm or upper arm. Dermofasciectomy is performed in the same operation by Dr Hirpara — the ortho-plastic hand training at Wythenshawe and Salford covers all three approaches. - *Can multiple fingers be done at the same time?* Yes — several rays in the same hand are commonly addressed in a single operation; the surgical exposure runs in zigzag fashion across the palm and into the involved fingers, and the recovery is comparable to a single-digit case. Bilateral surgery — both hands at once — is generally avoided for the same reason as bilateral carpal tunnel: dressings on both hands make self-care difficult through the early recovery, and the second hand is usually addressed at a later date. - *What are the main risks of Dupuytren's surgery?* Risks of open palmar fasciectomy include injury to the digital nerves or arteries (uncommon but recognised — the diseased tissue often surrounds these structures, requiring careful dissection), wound-healing problems (more likely in smokers or patients with poor circulation), infection, and persistent stiffness in operated joints, particularly the proximal interphalangeal joint where the contracture has been long-standing. Recurrence over the longer term is the most clinically important risk and is discussed pre-operatively. Individualised risk is set out at the consultation. - *Do I need hand therapy after Dupuytren's surgery?* Yes — hand therapy is integrated into Dupuytren's recovery and is more intensive than for routine carpal tunnel or trigger finger. Every patient sees Ruby Doolan at Extend Rehabilitation for the first dressing change and ongoing care, including a custom night extension splint that is worn for several months to maintain extension while the surgical incisions heal. Daytime motion is encouraged early to keep the fingers gliding through the healing tissues. The therapy schedule typically runs over several weeks to months depending on the contracture pattern and the post-operative response. --- ### Rotator cuff repair URL: https://www.cqupperlimb.com/conditions/rotator-cuff-repair/ Treats: Rotator cuff tear Arthroscopic rotator cuff repair is performed at Mater Private Hospital Rockhampton by Dr Kieran Hirpara, a dual fellowship-trained orthopaedic surgeon (orthoplastic hand surgery, Manchester; shoulder & elbow surgery, Brisbane). As a fellowship-trained shoulder and rotator cuff surgeon, Dr Hirpara manages the full pathway — diagnosis, surgical repair, sling protocol and graduated physiotherapy — for patients across Central Queensland. **About the condition.** The rotator cuff is the group of four tendons that wrap around the head of the humerus and stabilise the shoulder while the larger deltoid drives motion. Cuff tears can be acute (a fall, a sudden lift, a forced overhead pull) or, more commonly, chronic — degenerative tears that develop with age in the dominant arm, often without a single moment of injury. Symptoms are typically pain at night, weakness with overhead reach, difficulty sleeping on the affected side, and a feeling that the arm has lost "snap" with quick movements. Disturbed sleep is close to universal by the time patients come to surgery — reported by 96% of patients in one large repair series — and is often the symptom that finally drives treatment. **When surgery is recommended.** Acute tears in active patients are repaired sooner where possible — within the first three to six months — while the tendon is still mobile and amenable to repair to bone. Chronic, degenerative tears are managed individually: small to medium tears in patients who are tolerating physiotherapy, accepting limitations, and getting on with life can be left alone. Larger tears, tears that fail conservative management, and any tear with progressive weakness are considered for surgical repair. The same features that shape the decision also drive the healing odds: published reviews identify tear size, tendon retraction and muscle quality (fatty infiltration) as the main predictors of whether a repair heals — more so than age or surgical technique. Massive, retracted, irreparable tears with cuff arthropathy are managed differently — see reverse shoulder arthroplasty. **What the procedure involves.** Arthroscopic cuff repair is performed through several small portals around the shoulder. The torn tendon edge is mobilised, the bone bed prepared, and the tendon reattached to the greater tuberosity with anchors and high-strength sutures. The operation usually takes 60 to 90 minutes and is done under a light general anaesthetic with a supraclavicular nerve block — the block switches off pain from the arm for the first hours, so most patients are comfortable through the operation and into the first night; the [nerve block education page](/education/recovery/supraclavicular-nerve-block/) explains what to expect as it wears off. Patients leave hospital the same or next day. Full clinical detail is on the [education page](/education/shoulder/rotator-cuff-repair/), and the [rotator cuff disorders](/education/shoulder/rotator-cuff-disorders/) education page covers the underlying condition. **Recovery.** The repaired tendon needs protected healing for the first six weeks. Patients wear a simple sling for daytime support through that period — sleep is out of the sling, with the arm supported on a pillow — and hand and wrist mobility is encouraged, but no active shoulder lift. The nerve block usually wears off during the first night; starting regular pain relief before it fades, rather than waiting for pain to arrive, makes the first days far more comfortable, and most patients sleep better semi-upright (a recliner, or a wedge of pillows) for the first couple of weeks. Physiotherapy starts at around two weeks with passive range-of-motion exercises; active motion is added at six weeks and strengthening from twelve weeks — later again for large and massive tears, which follow a more cautious version of the same phases. Many people are back to desk work from about six weeks, although jobs that use the arm more can take twelve weeks or longer; gym and light sport usually restart at four to six months, heavy manual work at about five to eight months, and overhead or contact sport often takes nine to twelve months or longer. The practice's full phase-by-phase plan, including the early exercise program to share with your physiotherapist, is on the [rotator cuff rehabilitation protocol](/education/rehabilitation/rotator-cuff-repair/) page, and [daily life after shoulder surgery](/education/recovery/daily-life-after-shoulder-surgery/) covers washing, dressing and sleeping with the arm in recovery. **Practice context.** In-person post-operative review is preferred at the routine six-week, three-month and six-month checkpoints; telehealth review can be arranged for travelling patients where the protocol allows it and travel is genuinely a barrier. Coordinated post-op physiotherapy with a local clinic is arranged where the patient prefers therapy closer to home. **MBS items:** - 48960 — Rotator cuff repair / reconstruction (Arthroscopic cuff repair (item also covers arthroscopic-assisted and mini-open techniques)) **Frequently asked:** - *Who performs rotator cuff surgery in Rockhampton?* Dr Kieran Hirpara is a fellowship-trained shoulder and rotator cuff surgeon based at Mater Private Hospital Rockhampton, with subspecialty fellowship training in shoulder and elbow surgery (Brisbane). He manages the full rotator cuff pathway — diagnosis, arthroscopic repair, and graduated rehabilitation — for patients across Central Queensland. A GP referral lets the practice arrange assessment and, where surgery is indicated, schedule the repair. - *What's the difference between conservative management and surgery for a rotator cuff tear?* Many small to medium chronic cuff tears settle with a structured physiotherapy programme — the rotator cuff includes four tendons and the unaffected ones can compensate for a damaged one in many patients. Surgery is offered when the tear is acute, when the tear is large or progressing, when weakness is dominating function, or when a patient has tried physiotherapy and isn't getting where they want to be. The decision is individual; the consultation walks through both pathways. - *What's the chance of the cuff re-tearing after surgery?* Published re-tear rates on follow-up imaging are around 20 to 39% overall, and strongly size-dependent: figures of roughly one in three for small-to-medium tears versus around four in five for large-to-massive tears have been described, with historical series in tears beyond 2 cm reporting anywhere from 41 to 94% — although modern arthroscopic repairs of large tears can do considerably better. What drives failure is tear size, tendon retraction and muscle quality (fatty infiltration), more than age or surgical technique. The reassuring counterweight: a 2023 systematic review found that although a re-tear worsens pain and function scores on average, the difference falls below the threshold patients can actually notice, and most patients can expect a satisfactory outcome even when follow-up imaging shows a re-tear. Individual risk is discussed at consult. - *How much does rotator cuff repair cost? What does Medicare cover?* Rotator cuff repair involves separate fees for the surgeon, anaesthetist, assistant, hospital and surgical implants (anchors and sutures). The practice quotes the surgical fee in writing before the operation is booked — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent. - *Why does the sling stay on for six weeks?* The repaired tendon is held to bone by anchors and sutures, but the biological healing — tendon reattaching to bone — takes around six weeks for the soft attachment and many months for the full mature attachment. Active use of the shoulder during the first six weeks puts load through the repair before the biology has caught up, and is the most common cause of early failure. The sling protects the repair until the tendon-bone interface is strong enough to tolerate load. - *How should I sleep after rotator cuff repair?* Out of the sling — Dr Hirpara's protocol uses a simple sling for daytime support only, so at night the sling comes off and the arm rests supported on a pillow, where it cannot drag on the shoulder. Most patients sleep far better semi-upright for the first couple of weeks: a recliner, or a wedge of pillows behind the back and head, because lying flat tends to make the shoulder ache more. A pillow tucked along your side helps stop you rolling onto the operated shoulder during the night. Sleep does recover: published series show comfortable sleep — including sleeping on the operated side — returning steadily and plateauing around six months, though sleep recovery after cuff repair is slower than after shoulder replacement. The daily-life and sleep pages in the education section cover the practical detail. - *How much pain is normal in the first weeks after rotator cuff repair?* The first hours are usually comfortable because the nerve block is still working. The most important step is to start the prescribed pain tablets before the block wears off — usually during the first night — rather than waiting for pain to arrive, because sensation can return quite suddenly. The first few days after that are the sorest stretch, settling steadily over the following weeks; regular paracetamol plus an anti-inflammatory covers most patients unless advised otherwise, with stronger tablets kept for the early days, and a dose before physiotherapy exercises helps. As a guide to the longer arc, a large published series reported typical pain scores of five out of ten before surgery falling to around two out of ten at three months, one at six months and near zero by a year. Pain that is escalating after the first week, a fever, or a wound that becomes red or discharges is not part of normal recovery — contact the practice. - *When can I drive again after rotator cuff repair?* Driving requires both arms free of a sling and the ability to control the wheel and indicators safely. That is at least six weeks after surgery, and never while you still need the sling; a manual car may take a little longer. The practice does not certify fitness to drive for insurance purposes — driving fitness is a decision between the patient, the GP and the insurer — but the post-operative review at six weeks is the natural point at which the question is discussed. - *Will physiotherapy be enough on its own?* For many patients, yes — particularly small to medium chronic tears in older patients with low overhead demands. A structured programme of scapular control, gradual cuff loading and posterior-chain strengthening can reliably settle pain and restore function. For acute tears in younger patients, large tears with weakness, and tears that have failed a course of physiotherapy, surgical repair gives a more reliable outcome. The first consult is often as much about deciding the pathway as it is about scheduling surgery. - *What activities can I return to after rotator cuff repair?* The aim is a pain-free shoulder with enough range and strength for work, sport and daily life. Many people return to desk work from about six weeks, recreational gym at four to six months, and heavy manual work at about five to eight months; full sport including overhead and contact activities often takes nine to twelve months, and some people take longer. Manual occupational labour is staged carefully — heavy overhead work in the first six months risks the repair. Long-term outcomes correlate with the pre-operative tear pattern and the post-operative rehab compliance more than they do with the surgical technique itself. --- ### Calcific tendinitis URL: https://www.cqupperlimb.com/conditions/calcific-tendinitis/ Treats: Calcific tendinitis of the rotator cuff Calcific tendinitis — a deposit of calcium hydroxyapatite within a rotator cuff tendon — is treated at Mater Private Hospital Rockhampton when conservative measures have failed. The practice sees patients from across Central Queensland, often after a course of barbotage, injection or physiotherapy. **About the condition.** Calcific tendinitis is the painful deposition of calcium hydroxyapatite crystals within the substance of a rotator cuff tendon, most commonly the supraspinatus. Patients describe a deep, severe shoulder pain — often disproportionate to anything that might have triggered it — that can wake them at night and limit overhead reach. The pain is at its worst during the resorptive phase, when the body is actively reabsorbing the deposit and the surrounding tissue is highly inflamed. X-rays show a characteristic dense calcium deposit at or near the cuff insertion. The condition is most common in middle age and is more frequent in women than men. **When surgery is recommended.** Most calcific tendinitis settles spontaneously over weeks to months as the body reabsorbs the deposit. Conservative management — anti-inflammatories, activity modification, structured physiotherapy, and ultrasound-guided barbotage (needle aspiration of the calcium deposit) — is the first line in nearly all cases. Surgery is reserved for patients with persistent severe pain despite a thorough non-operative course, where imaging confirms a substantial deposit and where barbotage and corticosteroid injection have failed. The threshold is genuinely high; most patients never need surgery. **What the procedure involves.** When surgery is offered, the calcium deposit is excised arthroscopically through several small portals around the shoulder. The cuff is opened over the deposit, the calcium is removed, and the residual cuff defect is repaired in the same way as a routine rotator cuff tear when the cuff has been weakened. The procedure usually takes 60 to 90 minutes under regional and general anaesthesia; patients leave hospital the same or next day. Full clinical detail and the choice between barbotage, injection and surgical excision is on the [education page](/education/shoulder/calcific-tendinitis/). **Recovery.** After removal of the deposit alone, recovery is an early-movement pathway: the sling is for comfort only and is usually off within days, the arm can be used below shoulder height from day one, and strengthening starts at about eight weeks. The split in the tendon left by the deposit is often closed with stitches; that is a lighter repair than a standard rotator cuff repair, so recovery is quicker than after a cuff repair: a sling for three to four weeks, assisted movement first with full active movement from about four weeks, and strengthening from about ten to twelve weeks. Most people return to desk work by six weeks; gym and sport usually return from about three months after removal alone, or four to six months if the tendon was repaired. Driving is not allowed for at least six weeks after any shoulder operation. Pain often eases within weeks, but it can take several months to settle fully. The practice's full phase-by-phase rehabilitation plan is on the [calcific tendinitis rehabilitation protocol](/education/rehabilitation/calcific-tendinitis/) page. **Practice context.** Calcific tendinitis is one of the rare shoulder conditions where surgery is genuinely a last resort — many patients are referred during the resorptive phase when surgery is not yet indicated, and timing matters. The first consult is focused on confirming the diagnosis, structuring the non-operative pathway, and arranging barbotage where appropriate before considering surgical excision. Shoulder physiotherapy through Kurt Nichols in the same suite is integrated into the post-operative pathway when surgery is required. **MBS items:** - 48948 — Excision of calcium deposit (calcific tendinitis only) (Used when the calcium is excised but the cuff does not require formal repair) - 48960 — Cuff repair / reconstruction (Used when the cuff is incised and formally repaired in the same arthroscopic operation — the more common scenario, since the cuff is often weakened by the deposit) **Frequently asked:** - *Is surgery actually needed for calcific tendinitis?* In most cases, no. The natural history of calcific tendinitis is favourable — the deposit is reabsorbed by the body over weeks to months, and the pain settles as the deposit disappears. Conservative measures — anti-inflammatories, physiotherapy, ultrasound-guided barbotage and corticosteroid injection — settle the great majority of cases. Surgery is reserved for patients with severe persistent pain despite a thorough non-operative course; the threshold is genuinely high and most patients never need an operation. - *What is barbotage and is it offered at the practice?* Barbotage — also called calcium aspiration or needle lavage — is an ultrasound-guided procedure in which a needle is passed into the calcium deposit and the calcium is aspirated or fragmented under ultrasound vision, often combined with a small corticosteroid injection. It is performed by an interventional radiologist rather than the surgical practice, and Dr Hirpara will arrange referral where it is the appropriate next step. Barbotage settles the pain in a substantial proportion of cases without recourse to surgery. - *What's the difference between calcific tendinitis surgery and rotator cuff repair?* The two operations overlap. Both are arthroscopic procedures focused on the cuff. Where the cuff is intact and only the calcium is excised, the Medicare item is 48948 (excision of calcium deposit). Where the cuff is incised and formally repaired in the same arthroscopic operation — which is the more common scenario, since the cuff is often weakened by the deposit — the item is 48960, the same as a routine cuff repair. Recovery differs: after removal of the deposit alone most people are back to full activity at about three months; when the tendon split is also stitched, it is usually four to six months. - *How much does calcific tendinitis surgery cost? What does Medicare cover?* Surgery for calcific tendinitis is performed under regional and general anaesthesia, so a separate anaesthetist gap applies on top of the surgeon and hospital fees. The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent. - *Will the calcium come back after surgery?* True recurrence at the same tendon site after a properly executed excision is uncommon, because the deposit is the focus of the disease and removing it addresses the cause directly. New calcium deposits can occasionally form in adjacent rotator cuff tendons over years in patients with a strong predisposition. Persistent or returning shoulder pain after surgery is investigated carefully; sometimes the calcific tendinitis was masking another shoulder mechanism. - *What's the success rate of surgery for calcific tendinitis?* Published outcomes consistently show high satisfaction rates after surgical excision of a calcium deposit — the surgery addresses the underlying pathology directly. The best outcomes are in patients with a single dominant deposit, no other shoulder pathology, and a thoroughly trialled non-operative programme. Outcomes are individual and discussed at the consultation. - *Do I need physiotherapy after calcific tendinitis surgery?* Yes — shoulder physiotherapy is integrated into the post-operative pathway. After removal alone, movement starts straight away and strengthening begins at about eight weeks; when the tendon split is stitched, the sling stays on for three to four weeks, assisted movement comes first, and strengthening starts at about ten to twelve weeks, which is a lighter schedule than a standard cuff repair. Shoulder physiotherapy is provided by Kurt Nichols in the same suite as Dr Hirpara's rooms. Patients from outside Rockhampton can usually arrange ongoing therapy closer to home after the early intensive sessions. --- ### Shoulder stabilisation URL: https://www.cqupperlimb.com/conditions/shoulder-stabilisation/ Treats: Shoulder instability Shoulder dislocation surgery — arthroscopic shoulder stabilisation with a Bankart-style soft-tissue repair, plus capsular shift or remplissage where indicated — is performed at Mater Private Hospital Rockhampton. The practice has long-standing experience in surgery for a recurrently dislocating shoulder for patients across Central Queensland. **About the condition.** Shoulder instability is the tendency of the shoulder to dislocate or subluxate (partly slip out) — usually anteriorly, after an initial traumatic dislocation in a younger patient. The first dislocation typically tears the labrum, the cartilage rim around the glenoid, and stretches the anterior capsule; subsequent dislocations occur with progressively less force as the labral and capsular restraints fail. Younger patients (teens and twenties) at the time of first dislocation have the highest risk of recurrence — published rates approach 80–90% in the highest-risk groups. Symptoms range from frank dislocation requiring reduction to a sense of the shoulder "going" with overhead or apprehension positions. MRI arthrogram quantifies the labral and bony damage that guides the surgical choice. **When surgery is recommended.** Surgery is offered for recurrent dislocation or for a first dislocation in a high-risk patient (typically a young athlete in a contact sport). The choice between an arthroscopic Bankart-type soft-tissue repair and an open or arthroscopic Latarjet bone-block procedure turns on bone loss: when glenoid bone loss is below the critical threshold (broadly under 15–20%) and the labrum is repairable, an arthroscopic stabilisation is appropriate. Where bone loss is more substantial, where a soft-tissue repair has failed previously, or where contact-sport demands require the most durable construct, a Latarjet is recommended instead. The decision is made from imaging, examination and a discussion of the patient's activity demands. **What the procedure involves.** Arthroscopic shoulder stabilisation is performed through several small portals around the shoulder. The torn labrum is reattached to the glenoid rim with anchors and high-strength sutures; a capsular shift can be added to tighten the redundant anterior capsule, and a remplissage — filling of a Hill-Sachs bony defect on the humeral head with a tendon transfer — is added where indicated. The procedure typically takes 60 to 90 minutes under regional and general anaesthesia; patients leave hospital the same or next day. For glenoid bone loss too substantial for arthroscopic repair, a [Latarjet procedure](/conditions/latarjet/) is offered instead. Full clinical detail is on the [education page](/education/shoulder/anterior-shoulder-stabilisation/), and the [shoulder instability](/education/shoulder/shoulder-instability/) education page covers the underlying condition. **Recovery.** The repaired labrum and capsule need protected healing for the first six weeks. A sling is worn continuously for that period, with hand and wrist mobility encouraged. Physiotherapy starts at around two weeks with gentle range-of-motion work, active motion at six weeks, and progressive strengthening from twelve weeks. Most patients return to non-physical work by six weeks, gym at four months, non-contact sport at six months, and contact sport at six to nine months depending on the construct and the demands of the sport. The practice's full phase-by-phase rehabilitation plan is on the [shoulder stabilisation rehabilitation protocol](/education/rehabilitation/anterior-stabilisation-latarjet/) page. **Practice context.** Shoulder instability is one of the practice's subspecialty interests — Dr Hirpara's two Brisbane shoulder fellowships at the Brisbane Hand & Upper Limb Clinic and at St Andrew's / Prince Charles Hospitals included extensive instability work, and he has published on the arthroscopic Latarjet technique. Patients are seen for both first-dislocation assessment and for recurrent or revision instability. Shoulder physiotherapy through Kurt Nichols in the same suite is integrated into the post-operative pathway. **MBS items:** - 48958 — Shoulder stabilisation (Single item covering Bankart repair, capsular shift, remplissage and the various soft-tissue stabilisation options performed in a single operation) **Frequently asked:** - *Will my shoulder dislocate again after stabilisation?* Recurrence after stabilisation depends mostly on the same factors that cause instability in the first place: age (younger patients have higher rates), bone loss on the glenoid or humeral head, the demands of the patient's sport or work, and whether the surgical construct addressed all the contributing factors. Published recurrence rates after arthroscopic Bankart repair vary widely — rates are higher in young contact-sport athletes than in older patients with first-time dislocations. The Latarjet bone-block alternative offers lower recurrence rates in high-demand patients with bone loss, at the cost of a more invasive operation. - *What's the difference between an arthroscopic stabilisation and a Latarjet?* Arthroscopic stabilisation is a soft-tissue operation: the torn labrum is reattached and the anterior capsule is tightened. It works well when the labrum is repairable and bone loss is minimal. A Latarjet is a bone-block operation: a piece of the coracoid process is transferred to the front of the glenoid to compensate for bone loss and to add soft-tissue restraint via the conjoint tendon. Latarjet is more invasive but offers lower recurrence rates in high-risk patients. The choice is made from imaging and the patient's demands; Dr Hirpara has published on the arthroscopic Latarjet technique. - *When can I return to contact sport?* Six to nine months is typical, depending on the construct, the sport's demands, and the post-operative response. Non-contact sport (running, swimming, cycling) is usually possible by four to six months. Contact and overhead-throwing sports — rugby, AFL, water polo, throwing events — require the longest rehabilitation because they impose the most stress on the repair. The post-operative review schedule includes a sport-specific clearance discussion at three and six months. - *What's the success rate of shoulder stabilisation?* Published outcomes for arthroscopic Bankart repair report shoulder stability in roughly 80–90% of properly selected patients at medium-term follow-up, with high rates of return to pre-injury function. Outcomes are best in patients with classic anterior labral tears, minimal bone loss, careful adherence to post-operative protocol, and a thorough rehabilitation programme. Outcomes are poorer where bone loss has been under-recognised or where the patient returns to high-demand contact sport before the construct is mature; the consult discusses individual risk factors. - *How much does shoulder stabilisation cost? What does Medicare cover?* Shoulder stabilisation is performed under regional and general anaesthesia, so a separate anaesthetist gap applies on top of the surgeon and hospital fees. The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent. - *What if my shoulder keeps dislocating after the surgery?* Recurrent instability after a stabilisation operation is investigated carefully. The MRI is usually repeated to assess the labral repair and to look for bone loss that may have progressed since the original surgery. Where the failure is from progressive bone loss or a failed soft-tissue construct, a revision procedure — most commonly a Latarjet — is considered. The decision is individualised; revision instability surgery is more demanding than primary surgery and is best managed by a surgeon who handles the full instability spectrum. - *Do I need physiotherapy after shoulder stabilisation?* Yes — shoulder physiotherapy is integrated into the post-operative pathway and is the most important factor in the long-term result. The schedule runs gentle range of motion in the first six weeks (under sling protection), active motion from six weeks, scapular and rotator cuff strengthening from twelve weeks, and sport-specific rehabilitation from four to six months. Shoulder physiotherapy is provided by Kurt Nichols in the same suite as Dr Hirpara's rooms. Patients from outside Rockhampton can usually arrange ongoing therapy closer to home after the early intensive sessions. --- ### Latarjet procedure URL: https://www.cqupperlimb.com/conditions/latarjet/ Treats: Shoulder instability with glenoid bone loss The Latarjet procedure — open or arthroscopic — is performed at Mater Private Hospital Rockhampton for patients with shoulder instability and significant glenoid bone loss. Dr Hirpara has published on the arthroscopic Latarjet technique and offers it as the durable bone-block solution for high-demand patients. **About the condition.** The Latarjet procedure addresses shoulder instability that cannot be reliably managed by soft-tissue repair alone. The most common indication is significant bone loss from the front of the glenoid, where the socket has lost a critical proportion of its width through repeated dislocations. Without enough bone, a soft-tissue Bankart repair has a high failure rate. The Latarjet addresses this by transferring a piece of the coracoid process — a hook-shaped projection of the scapula — to the front of the glenoid, where it both replaces missing bone and provides a sling effect through the conjoint tendon attached to it. The result is a more durable construct in high-demand and contact-sport patients. **When surgery is recommended.** Latarjet is recommended when glenoid bone loss is substantial — broadly above 15–20% of the glenoid width — when a previous soft-tissue stabilisation has failed, or when the patient's activity demands (contact sport, manual occupation, high-demand recreational activities) call for the most durable construct available. The decision is made from MRI arthrogram or CT bone-loss measurements, careful examination of the shoulder, and a thorough discussion of the patient's goals. For patients with adequate bone stock and lower demands, an arthroscopic [shoulder stabilisation](/conditions/shoulder-stabilisation/) is the appropriate choice instead. **What the procedure involves.** The Latarjet procedure is performed through an open or arthroscopic approach depending on the patient and the surgical findings. The coracoid process is osteotomised — cut from its base — and transferred through a split in the subscapularis tendon to the anterior glenoid rim, where it is fixed with two screws. The conjoint tendon attached to the coracoid creates a dynamic sling that further stabilises the joint when the arm is in the at-risk position. The procedure usually takes 90 to 120 minutes under regional and general anaesthesia; patients spend one to two nights in hospital. Full clinical detail is on the [education page](/education/shoulder/latarjet/), and the [shoulder instability](/education/shoulder/shoulder-instability/) education page covers the underlying condition. **Recovery.** Latarjet recovery follows a similar early pathway to arthroscopic stabilisation. A sling is worn for approximately four to six weeks, with hand and wrist mobility encouraged. Physiotherapy starts at around two weeks with gentle range-of-motion work, progressing to active motion at six weeks and strengthening from twelve weeks. The bone graft requires twelve to sixteen weeks for radiographic union; contact sport is held off until graft consolidation is confirmed, typically at six to nine months. The practice's full phase-by-phase rehabilitation plan is on the [anterior stabilisation & Latarjet rehabilitation protocol](/education/rehabilitation/anterior-stabilisation-latarjet/) page. **Practice context.** Latarjet is one of Dr Hirpara's specific subspecialty interests — the technique was a substantial part of his Brisbane Hand & Upper Limb Clinic shoulder fellowship under Ass. Prof Cutbush, and he co-authored the published technique paper on the procedure (Cutbush K, Hirpara KM. *Arthroscopic Latarjet Stabilization of the Shoulder With Capsulolabral Repair*. Tech Shoulder Elbow Surg. 2015). Shoulder physiotherapy through Kurt Nichols in the same suite is integrated into the post-operative pathway. **MBS items:** - 48959 — Latarjet procedure (Used when a Latarjet is performed, whether open or arthroscopic) **Frequently asked:** - *Why a Latarjet rather than an arthroscopic repair?* The Latarjet procedure is recommended when bone is missing from the front of the glenoid — broadly more than 15–20% of the glenoid width — or when a previous soft-tissue stabilisation has failed. Without enough bone in the socket, a soft-tissue repair fails at high rates because the construct cannot prevent the humeral head from sliding off the deficient front edge. The Latarjet replaces the missing bone with a transferred piece of the coracoid and adds a soft-tissue sling effect; it offers lower recurrence rates than arthroscopic stabilisation in high-risk patients. - *What's the recurrence rate after a Latarjet?* Published recurrence rates after Latarjet are markedly lower than for arthroscopic Bankart repair in high-risk patients — generally in the low single-digit percentage range at medium-term follow-up. The Latarjet was originally developed to address the very patients in whom soft-tissue repair was failing, and the published evidence consistently shows superior stability outcomes in contact-sport athletes and patients with bone loss. Outcomes are best when the surgery is correctly indicated and the bone graft heals to the glenoid; the consultation discusses individualised risk factors. - *What are the specific risks of a Latarjet?* The Latarjet has a few risks specific to its bone-block nature: graft non-union or graft lysis (the transferred bone failing to heal or progressively resorbing), screw or hardware-related problems, and injury to nearby structures (most importantly the musculocutaneous nerve and the axillary nerve, both of which run close to the operative field). Loss of external rotation can occur where the subscapularis is split. The reported complication rate in experienced hands is acceptable; the consultation discusses risk in the context of the patient's own circumstances. - *When can I return to contact sport after a Latarjet?* Most surgeons hold contact sport until the bone graft has consolidated — typically six to nine months from surgery, confirmed on follow-up imaging. Non-contact sport is usually possible at four to six months. The Latarjet is the operation that allows the most reliable return to contact sport at competitive level, which is why it is preferred in high-demand patients despite being more invasive than arthroscopic stabilisation. The post-operative review schedule includes a clearance discussion at three, six and nine months. - *How much does a Latarjet cost? What does Medicare cover?* The Latarjet procedure is performed under regional and general anaesthesia, so a separate anaesthetist gap applies on top of the surgeon and hospital fees. The practice quotes the surgical fee in writing before booking — the Medicare item (48959), the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent. - *Open or arthroscopic — which is better?* Both approaches achieve the same surgical goal: the coracoid is osteotomised, transferred to the anterior glenoid, and fixed with screws. Published outcomes are broadly similar. The open approach has the longer track record and is the more commonly performed worldwide; the arthroscopic approach offers smaller incisions and the ability to address concomitant intra-articular pathology arthroscopically in the same operation. Dr Hirpara has published on the arthroscopic technique and offers both approaches; the choice is made individually depending on the patient's anatomy, prior surgery and the specific findings. - *Do I need physiotherapy after a Latarjet?* Yes — shoulder physiotherapy is integrated into the post-operative pathway and is critical to the final result. The schedule runs gentle range of motion in the first six weeks (under sling protection), active motion from six weeks, scapular and rotator cuff strengthening from twelve weeks, and sport-specific rehabilitation from four to six months. Bone graft consolidation is monitored on follow-up imaging at three to six months. Shoulder physiotherapy is provided by Kurt Nichols in the same suite as Dr Hirpara's rooms. --- ### Shoulder replacement URL: https://www.cqupperlimb.com/conditions/shoulder-replacement/ Treats: Glenohumeral osteoarthritis Total and reverse shoulder arthroplasty are performed at Mater Private Hospital Rockhampton by Dr Kieran Hirpara, a dual fellowship-trained orthopaedic surgeon (orthoplastic hand surgery, Manchester; shoulder & elbow surgery, Brisbane). The practice covers primary, reverse and revision cases for patients across Central Queensland. **About the condition.** Shoulder replacement is the surgical treatment for advanced [shoulder arthritis](/conditions/shoulder-arthritis/) or for irreparable rotator cuff tears with cuff-tear arthropathy. Patients describe a deep, persistent ache in the shoulder, loss of overhead reach, difficulty sleeping on the affected side, and grinding when the arm is moved. X-rays show loss of joint space, bony spurs, and in cuff arthropathy, an upward migration of the humeral head as the cuff fails. The decision between an anatomic total shoulder replacement and a reverse shoulder replacement depends on the state of the rotator cuff: anatomic if the cuff is intact and the bone glenoid is workable, reverse if the cuff is failed. **When surgery is recommended.** Surgery is considered when pain dominates day-to-day life, when sleep is consistently disturbed, when imaging shows established arthritis, and when non-operative measures — physiotherapy, pain management, occasional injection — are no longer providing acceptable function. Earlier replacement in younger, active patients is balanced against expected implant longevity; older patients with cuff arthropathy and a low-demand lifestyle do particularly well with reverse arthroplasty. **What the procedure involves.** An anatomic total shoulder replacement substitutes the diseased humeral head and glenoid with metal and polyethylene components shaped to mimic the natural anatomy. A reverse arthroplasty inverts the geometry — a ball on the glenoid and a socket on the humerus — so the deltoid can power the arm in the absence of a working cuff. Either operation takes around 90 to 120 minutes under regional and general anaesthesia, with a one to two night hospital stay. Full clinical detail and the choice between procedures is on the [education page](/education/shoulder/total-shoulder-arthroplasty/), and the [shoulder arthritis](/education/shoulder/shoulder-arthritis/) education page covers the underlying condition. **Recovery.** Patients are out of hospital in a sling within one to two days. The sling stays on for around six weeks, with formal physiotherapy starting at two weeks. Most patients are back to non-physical work by six weeks, light recreational use by three months, and full functional recovery by six to nine months. Final outcomes — strength, range, confidence — settle over twelve to eighteen months. The practice's full phase-by-phase rehabilitation plan is on the [shoulder replacement rehabilitation protocol](/education/rehabilitation/total-shoulder-arthroplasty/) page. **Practice context.** Shoulder replacement is a major operation where the practice strongly favours coordinated peri-operative care — pre-admission planning, in-hospital pain control, structured early physiotherapy, and a defined six-week / three-month / six-month follow-up cadence. In-person review is preferred at each checkpoint; telehealth review can be arranged for patients from outside Rockhampton where travel is genuinely a barrier. **MBS items:** - 48918 — Total or reverse shoulder arthroplasty (Without bone graft) - 48919 — Total or reverse shoulder arthroplasty (With bone graft) - 48921 — Revision shoulder arthroplasty (Without bone graft) - 48924 — Revision shoulder arthroplasty (With bone graft) **Frequently asked:** - *What's the difference between an anatomic and a reverse shoulder replacement?* An anatomic shoulder replacement keeps the natural ball-on-socket geometry — a metal ball replaces the diseased humeral head and a polyethylene socket replaces the glenoid. It relies on a working rotator cuff to drive movement. A reverse replacement inverts the geometry — the ball is fixed to the shoulder blade and the socket to the upper arm — so the larger deltoid muscle can power the shoulder in patients whose rotator cuff has failed. The choice is made from the X-ray, MRI and the surgeon's examination, and is the most important pre-operative decision. - *How long does a shoulder replacement last?* Modern shoulder replacements have improved markedly. Australian Orthopaedic Association joint registry data show that around 90% of anatomic total shoulder replacements and reverse replacements are still functioning well at ten years. Longevity beyond fifteen years is increasingly the norm in lower-demand patients. Heavy lifting, contact sport and occupational manual labour shorten implant life and are discussed individually before surgery. - *How much does shoulder replacement cost? What does Medicare cover?* Shoulder replacement involves separate fees for the surgeon, anaesthetist, assistant, hospital and prosthesis. The practice quotes the surgical fee in writing before the operation is booked — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why, and what that means for joint-replacement cover under the federal private-health-tier system. Surgery does not proceed without itemised written informed financial consent. - *When can I drive after shoulder replacement?* Driving requires both arms free of a sling and the ability to control the wheel and indicators safely. For most patients that is around six weeks for an automatic vehicle and a little longer for a manual. The practice does not certify fitness to drive for insurance purposes — driving fitness is a decision between the patient, the GP and the insurer — but the post-operative review at six weeks is the natural point at which the question is discussed. - *Will I be able to sleep on the operated shoulder afterwards?* For the first six weeks the sling makes side-sleeping on the operated shoulder uncomfortable; most patients sleep on the back or the unaffected side, often slightly propped up. Once the sling comes off and motion is regained, sleeping on the operated side becomes possible again, typically by three to six months. Pre-operative shoulder pain often disturbs sleep more than post-operative recovery does — many patients report sleeping better after surgery than they have for years. - *What activities will I be able to do after a shoulder replacement?* The aim is a pain-free shoulder with enough range and strength for the activities that matter to the patient — reaching overhead, dressing, gardening, swimming, golf, recreational tennis. Heavy weight-training, repetitive overhead manual work and contact sport are best avoided long-term to preserve the implant. Activities are reintroduced progressively across the first six to nine months, guided by physiotherapy and the post-operative review schedule. - *What are the main risks of shoulder replacement?* Shoulder replacement is a well-established operation, with Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) data showing around 90% of anatomic total and reverse replacements functioning well at ten years. No surgery is risk-free. The most clinically important risks are infection (uncommon but serious; controlled with strict peri-operative protocols), nerve injury (most often a temporary axillary nerve neuropraxia), dislocation (more common in reverse replacements and addressed with sling protocol compliance), and loosening of the components over time. The practice discusses individualised risk in writing before consent — risk varies with age, cuff status, bone quality and general health. --- ### Tennis elbow release URL: https://www.cqupperlimb.com/conditions/tennis-elbow-release/ Treats: Tennis elbow (lateral epicondylitis) Tennis elbow treatment in Rockhampton starts with diagnosis, loading exercises, splinting and injection options. Surgery for refractory tennis elbow — lateral epicondylitis — is performed at Mater Private Hospital Rockhampton when conservative measures have failed. The practice sees patients from across Central Queensland after a course of physiotherapy, splinting and injections. **About the condition.** Tennis elbow is a degenerative tendinopathy of the common extensor origin on the outside of the elbow, despite the name being shared with the racquet sport. The underlying problem is failed healing in the tendon rather than active inflammation. Symptoms are pain on the lateral elbow worsened by gripping, lifting with the palm down, or wringing motions; tenderness is sharply localised to the lateral epicondyle. The natural history is favourable — most cases settle within twelve to eighteen months with structured loading, activity modification and time — but a minority go on to need surgery. **When surgery is recommended.** Surgery is reserved for patients with persistent symptoms beyond six to twelve months despite a structured programme of eccentric loading, activity modification, and one or two cortisone or platelet-rich plasma injections. The threshold is higher than for some other elbow conditions because the natural history is good and surgery is not without recovery cost. **What the procedure involves.** Surgical release excises the small area of degenerate tendon at the lateral epicondyle through a short incision and reattaches the healthy extensor origin to bone. The procedure is typically done under regional or general anaesthesia as a day case, takes around 30 to 45 minutes, and is followed by a soft splint for one to two weeks. Full clinical detail is on the [education page](/education/elbow/tennis-elbow-release/), and the [tennis elbow](/education/elbow/tennis-elbow/) education page covers the underlying condition. **Recovery.** Desk work usually starts again between two and six weeks, once the splint is off and pain has settled. Heavy gripping and lifting wait for six to eight weeks while the tendon heals, and most people go back to physical work at about three months. The lateral elbow can remain tender at the scar for several months and settles gradually as activity is rebuilt; pain and strength often keep improving for up to twelve months. **Practice context.** Because conservative management is the right answer for most patients with tennis elbow, the practice's first consult is typically focused on confirming the diagnosis, ruling out other causes of lateral elbow pain (radial tunnel, posterolateral instability, capitellar pathology), and structuring a non-operative programme. Patients searching for a tennis elbow surgeon in Rockhampton are usually at this stage because pain has persisted despite a structured trial of non-operative care. Surgery is the exception rather than the rule. Patients who do proceed to surgery are seen by Ruby Doolan at Extend Rehabilitation for the first dressing change and structured rehabilitation; this is built into the routine pathway. **MBS items:** - 47903 — Tennis elbow release (common extensor origin release) (The standard item for isolated lateral epicondyle release) - 39329 — Radial tunnel decompression (Billed instead of 47903 when a radial tunnel decompression is performed at the same operation) **Frequently asked:** - *What does a non-surgical management plan look like?* A structured programme runs three components. Eccentric loading exercises — slowly lowering the wrist against resistance — gradually rebuild the tendon. Activity modification reduces the loads that triggered the tendinopathy: shifting from a thin-handled to a thick-handled grip, swapping pulling for pushing where possible, and pacing the activity. A cortisone or platelet-rich plasma (PRP) injection is offered to settle the active phase if exercises and activity modification aren't enough on their own. Most patients get significant relief from the combination over three to six months. - *What's the difference between cortisone and PRP injections — is one better?* Cortisone provides faster pain relief — patients often feel much better within a week or two — but the relief tends to be short-term and repeated injections may weaken the tendon. PRP takes longer to work (six to twelve weeks) and is uncomfortable for the first few days, but appears to give more durable relief in published trials and may modify the underlying tendinopathy rather than just suppressing pain. PRP is not Medicare-rebated and carries an additional out-of-pocket cost. The choice between them is individual. - *How successful is tennis elbow surgery?* Reported success rates after surgical release of the common extensor origin are around 80–90% — most patients report meaningful improvement in pain and grip function over six to twelve months. Outcomes are best in patients with classic localised lateral epicondyle tenderness, MRI changes confined to the common extensor origin, and a thoroughly trialled non-operative programme. Patients whose pain has another underlying cause (see below) tend to do less well; that's why the diagnostic consultation matters. - *How much does tennis elbow surgery cost? What does Medicare cover?* Tennis elbow surgery is performed under regional or general anaesthesia, so a separate anaesthetist gap applies on top of the surgeon and hospital fees. The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent. - *What if my pain isn't actually tennis elbow?* Several other elbow conditions cause lateral pain and are confused with tennis elbow on initial presentation. Radial tunnel syndrome — compression of a branch of the radial nerve — produces aching pain a few centimetres below the elbow rather than at the bony point of the lateral epicondyle. Posterolateral rotatory instability of the elbow gives a sense of instability or clicking with certain movements. Capitellar pathology (cartilage damage on the joint surface) often gives mechanical symptoms — locking, catching, swelling. Confirming the diagnosis at the first consult is the single most important step in deciding what treatment will help; surgery for tennis elbow only works if tennis elbow is what's actually wrong. - *Will the pain come back after surgery?* True recurrence after a properly executed release is uncommon — the diseased portion of tendon is excised and the rebuilt extensor origin reattaches to healthy bone. Persistent or returning lateral elbow pain after surgery is investigated carefully; sometimes the original diagnosis was incomplete, or a different mechanism (radial tunnel, posterolateral instability) is contributing. Any concern post-operatively is worth raising at review. - *Do I need physiotherapy or hand therapy after surgery?* Yes — every patient sees the on-site hand therapist for the first dressing change, scar management, and a structured programme of gentle wrist motion and gradual eccentric loading. The therapy schedule typically runs over the first two to three months while the rebuilt extensor origin heals to bone. Hand therapy is integrated into the post-operative pathway, provided by Ruby Doolan through Extend Rehabilitation in the same suite as Dr Hirpara's rooms. --- ### Thumb joint replacement URL: https://www.cqupperlimb.com/conditions/thumb-cmc-arthroplasty/ Treats: Basal thumb arthritis (CMC osteoarthritis) Thumb arthritis treatment in Rockhampton starts with splinting, hand therapy and injection, then progresses to surgery only when pinch pain remains disabling. Thumb base — carpometacarpal — joint replacement, commonly called a thumb replacement, is performed at Mater Private Hospital Rockhampton for end-stage basal thumb arthritis. The practice sees patients from across Central Queensland for both pyrocarbon and dual-mobility implants, alongside the more traditional trapeziectomy and suspensionplasty options. A thumb replacement restores pinch and grip when the joint at the base of the thumb has worn out. **About the condition.** Basal thumb arthritis — osteoarthritis of the joint between the trapezium and the first metacarpal — is one of the most common forms of osteoarthritis in the hand. Patients describe deep aching pain at the base of the thumb that worsens with pinch and grip — turning a key, opening a jar, writing for any length of time. The thumb base looks squared off as the metacarpal subluxes radially. The condition is more common in women, in middle age and beyond, and runs in families. Splints, activity modification and intra-articular corticosteroid injections settle a meaningful fraction of cases; surgery is offered when the pain and functional loss have become disabling despite a thorough non-operative trial. **When surgery is recommended.** Surgery is reserved for patients with established radiographic arthritis and persistent pain that interferes with daily activities — pinch grip, dressing, kitchen tasks, work — despite at least three to six months of splint use, activity modification and one or two corticosteroid injections. The threshold reflects that the operations are durable but not reversible: trapeziectomy with ligament reconstruction tendon interposition (LRTI) removes the trapezium, so it cannot easily be converted to a fusion later, and joint-replacement implants commit the patient to a prosthesis. Earlier surgery on a less-deformed thumb tends to give better results than late surgery on a thumb with established adduction contracture. **What the procedure involves.** Two main operations are offered. **Trapeziectomy with suspensionplasty / LRTI** — the trapezium is removed and a strip of the flexor carpi radialis tendon is woven through the metacarpal base to suspend it. **Joint replacement** — a dual-mobility prosthesis (similar to a small hip replacement) is implanted into the trapezium and metacarpal base. Both are performed under regional or general anaesthesia as a day case, take around 60 to 90 minutes, and are followed by a thumb splint for several weeks; after a joint replacement it is worn full-time for about two to three weeks, then at night until about six weeks. The choice between trapeziectomy and replacement depends on bone quality, activity level, and patient preference — the consult sets out the trade-offs. Full clinical detail is on the [education page](/education/hand/touch-thumb-arthroplasty/) and the [basal thumb arthritis education page](/education/hand/basal-thumb-arthritis/). **Recovery.** After a joint replacement, the splint is worn full-time for about two to three weeks, then at night until about six weeks. Gentle movement starts at the first hand-therapy review, and pinch strengthening starts at about six weeks. Most patients are off the splint at four to six weeks and back to most activities by three months. Strength keeps improving for six to twelve months. Joint replacement tends to allow earlier return of pinch grip than trapeziectomy; trapeziectomy has a longer track record of durability over decades. Heavy or pinch-heavy work usually resumes at two to three months after a replacement, and three to four months after trapeziectomy. **Practice context.** The practice's approach to basal thumb arthritis emphasises a thorough non-operative trial first — splinting, activity modification, hand-therapy guidance, and a corticosteroid injection where appropriate. For patients who progress to surgery, the trapeziectomy / LRTI vs dual-mobility joint replacement decision is made jointly with the patient, with both options' trade-offs explained in detail. Patients with broader hand arthritis are assessed for adjacent finger-joint arthritis as well, because selected PIP and MCP joints may be better treated with [finger joint replacement](/conditions/finger-joint-replacement/) or fusion rather than thumb-base surgery. Hand therapy with Ruby Doolan at Extend Rehabilitation is built into the post-operative pathway from day one. Where the contralateral thumb is also symptomatic, surgery is staged — never both thumbs at the same operation. **MBS items:** - 46324 — Carpometacarpal joint arthroplasty (joint replacement) (Billed for dual-mobility or pyrocarbon thumb-base joint replacement) **Frequently asked:** - *Should I have a trapeziectomy or a joint replacement?* Both operations reliably relieve pain — published outcomes give similar pain scores at one year. The differences are in the recovery curve and the trade-offs over time. Trapeziectomy has a longer track record (it has been done for over 70 years) and is forgiving of bone loss; the recovery is slower and pinch strength returns gradually over six to nine months. Joint replacement returns pinch grip faster (at three months, pinch is usually stronger after a replacement than after trapeziectomy) and tends to feel more 'normal' to patients who pinch a lot — for instance manual workers, musicians and tradespeople. The replacement has a small risk of needing revision over decades; the trapeziectomy does not. The choice is individual and is worked through at the consult with reference to bone quality on imaging, activity demands, and what a patient wants prioritised — speed of recovery vs absolute durability. - *How long does a thumb replacement last?* Modern thumb base joint replacements — dual-mobility and pyrocarbon implants — have improved markedly over earlier silicone designs, and the majority are still functioning well at ten years. A thumb replacement can wear or loosen over decades, and a revision is more involved than the first operation, which is why implant choice and activity level are discussed carefully before surgery. Trapeziectomy, the main alternative, removes the worn bone rather than replacing the joint and so has no implant to wear out — the durability trade-off between the two is a central part of the consult. - *Do I need any tests before surgery?* Plain X-rays of the thumb base in standard views are required to confirm the diagnosis and stage the arthritis (Eaton-Littler grade I–IV). Where the picture is mixed — or if the surgeon is considering a joint replacement — a CT scan may be requested to assess bone quality in the trapezium. Pre-operative blood tests and an anaesthetic review are arranged ahead of theatre. Patients on blood thinners are managed in coordination with the prescribing GP or specialist. - *How long is the recovery?* Recovery is staged. After a joint replacement, the splint is worn full-time for about two to three weeks, then at night until about six weeks. Hand therapy starts at the first dressing change with gentle movement; pinch strengthening starts at about six weeks. Desk work usually resumes at four to six weeks, and driving waits until the splint is off; heavy or pinch-heavy work usually resumes at two to three months after a replacement, and three to four months after trapeziectomy. Strength and comfort keep improving for six to twelve months. Joint replacement tends to give earlier pinch grip; trapeziectomy continues to improve over the first year. - *What's the difference between this and a thumb fusion?* Thumb base fusion (CMC arthrodesis) eliminates the joint by fusing the trapezium and metacarpal together — pain relief is reliable, but the thumb loses the circling movement at its base (circumduction), so tasks such as flattening the hand, for example to slide it into a pocket, become harder. Fusion is reserved for younger, very high-demand patients (particularly tradespeople doing heavy gripping) or as a salvage after a failed reconstruction. Most patients are better served by trapeziectomy or joint replacement, both of which preserve thumb motion. Fusion is rarely performed at the practice as a primary operation for basal thumb arthritis. - *Will I be able to pinch and grip normally?* Pinch and grip return progressively. Most patients regain enough function for daily activities — buttons, jars, cooking, writing — by two to three months. Heavy pinch (turning a key, opening a tight lid) and heavy grip (gripping tools, pulling weeds) take longer. By six to nine months the thumb feels like a thumb again. Pinch strength typically returns to 80–90% of the contralateral side after either operation, sometimes more after joint replacement. - *How much does thumb joint replacement cost? What does Medicare cover?* The operation is performed under regional or general anaesthesia at Mater Private Hospital Rockhampton, so a separate anaesthetist gap applies on top of the surgeon and hospital fees. The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Joint replacement implants are typically covered by private health funds (a no-gap arrangement is in place for most major funds); patients without private cover can be quoted self-funded. Surgery does not proceed without itemised written informed financial consent — see the fees page for the full process. - *Do I need hand therapy after surgery?* Yes — hand therapy is integral. Every patient sees Ruby Doolan at Extend Rehabilitation (in the same suite as Dr Hirpara's rooms) for the first dressing change, splint adjustment, scar management, and a structured programme of pinch and range-of-motion exercises. Therapy typically runs weekly for the first six to eight weeks, then tapers. Therapy is built into the post-operative pathway and the surgical quote covers the hand-therapy referral. --- ### Finger joint replacement URL: https://www.cqupperlimb.com/conditions/finger-joint-replacement/ Treats: Finger joint arthritis (PIPJ and MCPJ osteoarthritis) Finger replacement in Rockhampton usually means finger joint replacement — arthroplasty of the middle (PIP) or knuckle (MCP) joint. It is performed at Mater Private Hospital Rockhampton by Dr Kieran Hirpara for finger joints worn out by osteoarthritis or rheumatoid arthritis. A finger replacement uses a small silicone or pyrocarbon implant to relieve pain while keeping the finger moving, for patients across Central Queensland. **About the condition.** Finger joint arthritis affects two main joints — the middle (proximal interphalangeal, PIP) joint and the knuckle (metacarpophalangeal, MCP) joint. Patients describe pain, swelling, stiffness and a knobbly, sometimes crooked finger that catches when bending. Osteoarthritis is the commonest cause; rheumatoid and other inflammatory arthritis also destroy these joints and frequently affect several fingers together. The fingertip (distal interphalangeal, DIP) joint is commonly affected too, but is rarely replaced — it is small and pinch depends on its stability, so it is usually fused rather than replaced. Joint replacement is considered chiefly for the PIP and MCP joints, where keeping movement matters most. **When surgery is recommended.** Surgery is considered once a finger joint is painful, stiff or deformed enough to interfere with hand function, and after non-operative measures — analgesia, hand-therapy splinting, activity modification and, in inflammatory arthritis, medical control of the disease — have been given a fair trial. X-rays confirm the joint is worn through. The choice between replacement and fusion depends on which finger and which joint: replacement suits the ring and little finger PIP joints and the MCP joints, where motion is valuable and load is lower; fusion is preferred for the index PIP joint and wherever stability for pinch matters more than movement. **What the procedure involves.** A finger joint replacement removes the worn joint surfaces and inserts a small implant — a flexible silicone spacer or a two-part pyrocarbon resurfacing implant — through a short incision over the back of the joint. It is a day-case procedure under regional or general anaesthesia, taking around 45 to 60 minutes per joint, followed by a hand-therapy splint. The alternative, joint fusion (arthrodesis), removes the joint and fixes the bones together for a stable, pain-free but stiff finger. Full clinical detail is on the [finger joint replacement education page](/education/hand/pipj-replacement/), with the underlying arthritis covered on the [PIP joint arthritis](/education/hand/pipj-arthritis/) page. **Recovery.** The finger is supported in a hand-therapy splint, with guided movement starting within the first week to keep the new joint mobile — early controlled motion is important after a finger replacement. Light use returns over two to six weeks as the splint is weaned. Most patients are using the hand for everyday tasks by six to eight weeks, with the final range and comfort settling over three to six months. Hand therapy is central to the result and runs alongside recovery from the first dressing change. **Practice context.** Finger joint replacement is an uncommon, technically demanding operation, and the replacement-versus-fusion decision is made joint by joint with the specific finger and the patient's hand demands in mind. It sits in the same hand-arthritis cluster as [thumb arthritis and thumb joint replacement](/conditions/thumb-cmc-arthroplasty/), but the operation and rehabilitation are different. Hand therapy with Ruby Doolan at Extend Rehabilitation is built into the pathway from the first dressing change, because the early-motion programme largely determines the final movement. Where several finger joints are involved — as is common in rheumatoid arthritis — surgery is planned in stages and coordinated with the patient's rheumatologist. **MBS items:** - 46309 — Finger joint replacement (arthroplasty) (One joint) - 46312 — Finger joint replacement (arthroplasty) (Two joints) - 46315 — Finger joint replacement (arthroplasty) (Three joints) - 46318 — Finger joint replacement (arthroplasty) (Four joints) - 46321 — Finger joint replacement (arthroplasty) (Five joints) - 46322 — Revision finger joint replacement (One joint) **Frequently asked:** - *Can a finger joint really be replaced?* Yes. The middle (PIP) joint and the knuckle (MCP) joint can be replaced with a small silicone or pyrocarbon implant that relieves pain while preserving movement. The fingertip (DIP) joint is the exception — it is small and pinch relies on its stability, so it is almost always fused rather than replaced. A finger replacement is a smaller operation than a hip or knee replacement, but the principle is the same: the worn joint surfaces are removed and an implant takes their place. - *Should I have the joint replaced or fused?* Both relieve the pain reliably; the difference is movement versus stability. Replacement keeps the finger bending, which matters most for the ring and little fingers and for the knuckle joints, and for tasks like making a fist or gripping a rail. Fusion gives a stable, strong, pain-free but stiff joint, and is preferred for the index finger PIP joint and for high-load joints where pinch strength matters more than movement. The decision is made joint by joint at the consult, taking account of which finger, the bone quality on X-ray, and how the hand is used. - *How long does a finger replacement last?* Silicone implants have been used for finger joints for decades and have a long track record; they can fracture or wear over many years, but are straightforward to revise. Pyrocarbon resurfacing implants aim to preserve more natural movement and bone, with good medium-term results reported. As with any implant, heavy manual loading shortens its life, which is part of why the replacement-versus-fusion choice is weighed against how the hand is used. Longevity and the small chance of needing a revision are discussed individually before surgery. - *Will my finger bend normally after a replacement?* The aim is a comfortable finger with useful, not perfect, movement — typically a functional arc that lets you grip and make a fist, rather than the full range of a normal joint. How much movement returns depends heavily on the early hand-therapy programme, the starting stiffness and deformity, and the joint involved. The trade-off is favourable compared with fusion, which gives a permanently stiff (though stable and pain-free) joint. Realistic expectations for the specific finger are set out at the consult. - *How much does finger joint replacement cost? What does Medicare cover?* The operation is performed under regional or general anaesthesia at Mater Private Hospital Rockhampton, so a separate anaesthetist gap applies on top of the surgeon and hospital fees. The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Implants are typically covered by private health funds; patients without private cover can be quoted self-funded. Surgery does not proceed without itemised written informed financial consent — the fees page explains the full process. --- ### Cubital tunnel release URL: https://www.cqupperlimb.com/conditions/cubital-tunnel-release/ Treats: Cubital tunnel syndrome Cubital tunnel decompression — surgical release of the ulnar nerve at the elbow — is performed at Mater Private Hospital Rockhampton for symptomatic ulnar nerve compression. The practice covers patients from across Central Queensland presenting with little-finger numbness, weak pinch, or wasting of the small hand muscles. **About the condition.** Cubital tunnel syndrome is compression of the ulnar nerve as it passes behind the medial epicondyle of the elbow — the funny-bone region. Patients describe pins-and-needles or numbness in the little and ring fingers, often worse with the elbow bent (driving, holding a phone, sleeping with the elbow flexed). More advanced cases bring weakness of pinch and grip, loss of dexterity (clumsiness with fine tasks like buttoning a shirt or handling coins), clawing of the ring and little fingers in long-standing compression, and visible wasting between the thumb and index finger as the small hand muscles supplied by the ulnar nerve atrophy. The condition is the second-most-common compression neuropathy of the upper limb after carpal tunnel; it can develop with no obvious trigger or follow elbow trauma, prolonged elbow flexion, or work activity. **When surgery is recommended.** Surgery is recommended when symptoms persist despite a reasonable trial of activity modification (avoiding sustained elbow flexion), night splinting in extension, and ergonomic adjustment — typically three to six months. Earlier surgical release is offered when nerve-conduction studies show significant slowing across the elbow, when there is muscle wasting or measurable weakness, or when sensation is constantly abnormal rather than intermittent. Established muscle wasting recovers slowly and sometimes incompletely; that's the argument for not waiting indefinitely once compression is confirmed. **What the procedure involves.** The standard operation is **in-situ cubital tunnel release** — a 5–8 cm incision behind the medial epicondyle, dividing the fascial roof of the cubital tunnel and releasing the nerve along its course. The nerve is left in its normal anatomical bed unless it subluxes anteriorly with elbow flexion, in which case anterior subcutaneous transposition is performed. The procedure is typically done under regional or general anaesthesia as a day case, takes around 30 to 45 minutes, and is closed with absorbable sutures and a soft dressing. Full clinical detail is on the [education page](/education/elbow/cubital-tunnel-release/), and the [cubital tunnel syndrome education page](/education/elbow/cubital-tunnel-syndrome/) covers the underlying condition. **Recovery.** The dressing comes off at one week and the elbow can be moved freely from day one — there is no period of immobilisation. Light household tasks can start in the first few days, and most people return to desk work within one to two weeks; lifting, pushing and gripping stay light for the first six weeks and are then built up step by step. Numbness and pins-and-needles often start improving within days of release; established wasting and weakness recover over months and may not return all the way to normal in long-standing cases. Most people are back to heavier work by six to eight weeks; sport and full grip strength can take up to about three months. **Practice context.** The practice's first consult typically focuses on confirming the diagnosis — examination, pattern of symptoms, and review of nerve-conduction studies — and ruling out other causes of medial elbow or hand symptoms (cervical radiculopathy, double-crush at wrist and elbow, thoracic outlet). Where compression is mild and symptoms are intermittent, a structured non-operative trial is offered first. Where there is wasting or constant numbness, surgery is brought forward. Hand therapy with Ruby Doolan at Extend Rehabilitation is used selectively post-operatively for patients with significant pre-operative weakness. **MBS items:** - 39336 — Cubital tunnel decompression / ulnar nerve release at the elbow (The standard item for in-situ release) - 39342 — Anterior subcutaneous transposition of the ulnar nerve (Billed when the nerve is moved out of the cubital groove) - 39339 — Revision cubital tunnel decompression (Used for revision of a previous in-situ release) - 39329 — Extensive neurolysis of ulnar nerve (Used when revising a previous transposition — there is no specific item for that scenario) **Frequently asked:** - *Will the numbness in my little finger go away?* Intermittent symptoms — pins-and-needles when the elbow is bent, transient numbness — usually resolve quickly after release, often within the first few weeks. Constant numbness has been there longer and represents more sustained nerve compression; it can take six to twelve months to settle, and in long-standing cases some residual numbness can persist. The earlier the surgery is done in the disease course, the more complete the recovery tends to be. - *Will my hand strength come back?* Pinch and grip strength supplied by the ulnar nerve typically improve over months. Visible wasting of the small hand muscles takes longer to reverse than numbness, and may not fully recover if it has been present for a long time. That's the case for not delaying surgery indefinitely once nerve-conduction studies confirm significant compression. Patients with mild wasting tend to recover most or all of their strength; patients with severe long-standing wasting often regain meaningful — but not complete — function. - *Do I need a transposition or just a release?* Most patients do well with simple in-situ release — the cubital tunnel is opened up, the nerve stays where it is, and recovery is straightforward. Anterior transposition (moving the nerve to the front of the elbow) is reserved for the minority of patients in whom the nerve subluxes out of its groove with elbow flexion, or for revision after a failed in-situ release. The decision is made intra-operatively after testing the nerve's behaviour with the elbow flexed and extended. Published outcomes are similar between in-situ release and transposition in straightforward primary cases. - *How long is the recovery?* There is no formal immobilisation period. Light activities resume immediately. Driving is reasonable once pain has settled and you can control the car safely, usually two to three weeks after surgery. Manual work, gripping, and lifting are held off for about six weeks while the deeper soft tissues heal. Numbness improvement is often noticed in the first weeks; feeling and hand strength can keep improving for up to a year. - *Is cubital tunnel release the same as ulnar nerve surgery?* Yes — these terms refer to the same operation. Cubital tunnel syndrome describes the underlying condition; cubital tunnel release (or ulnar nerve decompression at the elbow, or ulnar nerve surgery at the elbow) describes the surgical treatment. Some patients have ulnar nerve compression at the wrist (Guyon's canal) instead of the elbow — that's a different operation and the diagnosis is sorted out at consult. - *How much does cubital tunnel surgery cost? What does Medicare cover?* The procedure is performed under regional or general anaesthesia, so a separate anaesthetist gap applies on top of the surgeon and hospital fees. The practice quotes the surgical fee in writing before booking — Medicare item, rebate and out-of-pocket gap shown separately. Most major private health funds offer no-gap arrangements; the fees page sets out the full process. Surgery does not proceed without itemised written informed financial consent. --- ### Wrist ganglion excision URL: https://www.cqupperlimb.com/conditions/wrist-ganglion-excision/ Treats: Wrist ganglion cyst Surgical excision of wrist and hand ganglion cysts is offered at Mater Private Hospital Rockhampton when a ganglion is symptomatic, recurrent after aspiration, or where the diagnosis is uncertain. Most ganglia do not need surgery — the practice's first job is to confirm the diagnosis and walk through the trade-offs. **About the condition.** A ganglion cyst is a fluid-filled outpouching from a joint capsule or tendon sheath, most commonly on the back of the wrist (dorsal scapholunate ganglion), the front of the wrist near the radial artery (volar ganglion), or at the base of a finger (flexor tendon sheath ganglion / 'pearl ganglion'). The cyst contains thick mucinous fluid — not pus, not tumour — that has leaked from a small defect in the joint capsule and become walled off. Patients describe a soft, sometimes-tender lump that can change size with activity. Around half of all ganglia resolve spontaneously over months or years; another fraction settle with aspiration alone. Surgery is reserved for the minority with persistent symptoms, mechanical problems, or diagnostic uncertainty. **When surgery is recommended.** Surgical excision is offered when a ganglion is causing persistent pain or functional limitation, has recurred after one or two aspirations, presses on a nerve (occult dorsal-wrist ganglia can cause posterior interosseous nerve symptoms), or where the diagnosis is in doubt and tissue is required for histology. Many ganglia are best left alone — the cosmetic concern is usually outweighed by the recovery cost of surgery and the small but real recurrence rate. Ultrasound or MRI is requested when the diagnosis is unclear, when the lesion has unusual features, or when a deep ganglion is suspected. **What the procedure involves.** **Open ganglion excision** removes the cyst together with its capsular stalk — a 2–3 cm incision over the cyst, identification of the capsular origin, and excision of both. Excising the stalk (rather than just the cyst) is thought to lower the recurrence rate. Across studies, about 1 in 5 ganglia return after excision on average, and up to about 4 in 10 when people are followed for five years or more, compared with about 6 in 10 after aspiration. **Arthroscopic excision** is offered for selected dorsal-wrist ganglia and avoids a visible scar. The procedure is typically done under regional or general anaesthesia as a day case, takes around 30 minutes, and is followed by a soft dressing. Full clinical detail is on the [education page](/education/wrist/wrist-ganglion-excision/), and the [wrist ganglia education page](/education/wrist/wrist-ganglia/) covers the underlying condition. **Recovery.** Light activities resume within days; the dressing comes off at one week. Heavy gripping, lifting and impact are held off for about four to six weeks while the joint capsule heals, then built back up slowly. Most people are back to normal daily activity by four to six weeks. The wrist may feel tight for a few weeks as scar tissue softens. Hand therapy is offered selectively for patients with stiffness or scar sensitivity. **Practice context.** The practice's standard pathway for a wrist ganglion is: confirm the diagnosis (clinically or with imaging if needed), explain the natural history (many resolve), and discuss the options — observation, aspiration, or surgical excision. For most patients, observation or aspiration is the right first step. Surgery is offered for persistent symptomatic ganglia, recurrent ganglia after aspiration, or where the diagnosis is uncertain. Ruby Doolan at Extend Rehabilitation provides post-operative hand therapy for selected cases — most patients do not need it. **MBS items:** - 46500 — Open excision — dorsal wrist ganglion (The standard item for open excision of a dorsal-wrist ganglion) - 46502 — Open excision — dorsal wrist ganglion (revision) (Billed for revision excision after a recurrent dorsal-wrist ganglion) - 46501 — Open excision — volar wrist ganglion (The standard item for open excision of a volar-wrist ganglion) - 46503 — Open excision — volar wrist ganglion (revision) (Billed for revision excision after a recurrent volar-wrist ganglion) - 49221 — Wrist arthroscopy with ganglion excision (Billed for arthroscopic excision (selected dorsal-wrist ganglia)) **Frequently asked:** - *Should I have my ganglion removed?* Most ganglia do not need surgery. About half resolve on their own over months or years, and another fraction settle with one or two aspirations. Surgery is worth considering when the ganglion is causing persistent pain, interfering with grip or wrist movement, pressing on a nerve, or where the diagnosis is uncertain. Cosmetic concern alone is usually not a strong indication for surgery — the visible scar after excision can be more conspicuous than the lump it replaces. The consult walks through the trade-offs and the patient decides. - *What's the difference between aspiration and surgical excision?* Aspiration is a clinic-based procedure where the cyst is drained with a needle and syringe; sometimes a steroid injection is added. It's quick, inexpensive, and resolves the cyst in around 30–50% of cases at first attempt. The recurrence rate is high — around 50–70% — because the underlying capsular defect is not closed. Surgical excision removes the cyst plus its stalk through a small incision as a day case operation, with anaesthesia, a small scar and a few weeks of recovery. It lowers the chance of the lump coming back but does not remove it: across studies about 1 in 5 return on average, fewer in some series, and up to about 4 in 10 when people are followed for five years or more. Aspiration is a reasonable first step for most ganglia; surgery is reserved for those that recur or are particularly bothersome. - *Will the ganglion come back after surgery?* Recurrence after open excision is about 1 in 5 on average across studies, and up to about 4 in 10 when people are followed for five years or more. Recurrence is more likely with smaller incisions that don't allow full visualisation of the stalk, with arthroscopic technique in inexperienced hands, or when the underlying joint pathology (e.g. scapholunate instability) is not addressed. The surgical technique used at the practice prioritises seeing and excising the stalk, which is thought to lower the chance of recurrence; studies have not shown a clear difference between keyhole and open removal. - *How long is the recovery?* Many people return to office work within one to two weeks, and some return sooner. Driving usually waits two to three weeks, until you can hold the steering wheel firmly and without pain. Manual or gripping work is held off for four to six weeks while the joint capsule heals, and heavy manual work can take up to three months. Sport with impact, such as tennis or golf, is reasonable at four to six weeks. The wrist may feel tight or sensitive over the scar for a few weeks; this settles with gentle massage and gradual use. - *Are ganglion cysts dangerous?* Ganglion cysts are benign — they are not tumours and they do not turn into cancer. Concern usually arises because of an unfamiliar lump, particularly in patients without a previous history of one. Where the lump has unusual features — rapid growth, hardness, fixity to deeper tissues, or skin changes — imaging (ultrasound or MRI) is requested before any treatment to confirm the diagnosis. Most lumps that look like ganglia turn out to be ganglia, but the consult includes the differential diagnosis and what would prompt biopsy rather than excision. - *How much does ganglion surgery cost? What does Medicare cover?* Open ganglion excision is performed under regional or general anaesthesia as a day case at Mater Private Hospital Rockhampton, so a separate anaesthetist gap applies on top of the surgeon and hospital fees. The practice quotes the surgical fee in writing before booking — Medicare item, rebate and out-of-pocket gap shown separately. Most major funds offer no-gap arrangements. Surgery does not proceed without itemised written informed financial consent. --- ### Frozen shoulder release URL: https://www.cqupperlimb.com/conditions/frozen-shoulder/ Treats: Frozen shoulder (adhesive capsulitis) Frozen shoulder — adhesive capsulitis — is treated at Mater Private Hospital Rockhampton by matching treatment to whether pain or stiffness is the bigger problem, rather than waiting out a fixed timeline. Dr Kieran Hirpara usually starts with a steroid injection to settle the pain, and offers arthroscopic capsular release early for patients whose shoulder doesn't respond — without requiring months of struggling first. Patients are seen from across Central Queensland. **About the condition.** Frozen shoulder is a condition in which the capsule — the sleeve of tissue around the joint — becomes inflamed and then thickens and tightens, shrinking the space inside the shoulder. Despite the old name 'adhesive capsulitis', nothing is actually stuck together: the tissue has contracted, which is why the shoulder becomes both painful and genuinely stiff. Patients describe deep aching pain, often worst at night, and a marked loss of range — losing the ability to turn the hand outwards is the most characteristic sign. It's most common between 40 and 60, in women, and in people with diabetes or thyroid disease; with diabetes it also tends to take longer to settle. Most people improve a great deal — but the common reassurance that it 'always resolves on its own within a year or two' is more confident than the evidence supports: improvement tends to happen early and then plateau, and a proportion of patients keep some lasting ache or stiffness. That's why the practice treats the pain actively rather than asking patients to simply wait it out. **When surgery is recommended.** Dr Hirpara doesn't require patients to struggle on for a fixed number of months before offering surgery. In practice he usually suggests a steroid injection first, because for many people that relieves enough of the pain to get on with life while the shoulder settles. If the injection doesn't give adequate relief, arthroscopic capsular release is offered from that point — there's little sense in spending a year in pain to find out which way an individual shoulder will go. Release is favoured over manipulation alone where durability matters: repeat procedures appear less common after a release, although studies comparing the two directly have not shown a clear difference. The threshold is individual — stiffness severity, occupation, sleep loss and diabetes all factor in. Imaging (MRI or MRA) is obtained when the picture is mixed, to look for a missed cuff tear, calcific deposit or labral problem. **What the procedure involves.** **Arthroscopic capsular release** is a keyhole operation that divides the tightened capsule under direct vision — releasing the rotator interval anteriorly, and the inferior and posterior capsule as needed. Its main advantage is durability: recurrent stiffness after a release is uncommon, whereas after a **manipulation under anaesthesia** alone some shoulders tighten up again and need a repeat procedure, although studies comparing the two directly have not shown a clear difference. A less extensive release appears to do at least as well as dividing the whole capsule, so more isn't automatically better. It's usually done under regional block plus general anaesthesia, usually takes under an hour, and most patients stay one night in hospital. There is no repair to protect, so any sling is for comfort in the first day or two only — early movement from day one. Full clinical detail is on the [capsular release education page](/education/shoulder/capsular-release/), and the [frozen shoulder education page](/education/shoulder/frozen-shoulder/) covers the condition and the evidence in full. **Recovery.** Movement starts the same day — the point of surgery is to use the new range before the capsule can tighten again. Physiotherapy normally begins within a day or two and is most intensive in the first four to six weeks, when much of the range returns. The bulk of the improvement comes over the first four months, with smaller gains for up to a year. Many people are back at desk-based work within two to six weeks, and heavier and overhead work usually comes back over two to three months. Recovery is slower and slightly less complete in people with diabetes. A minority re-stiffen and need a repeat injection or release. The practice's phase-by-phase plan is on the [capsular release rehabilitation protocol](/education/rehabilitation/capsular-release/) page. **Practice context.** The first consult focuses on confirming the diagnosis — frozen shoulder is over-diagnosed, and many stiff, painful shoulders have a different cause — and then on which is bothering the patient more, the pain or the stiffness. A steroid injection is the best-supported first step for pain; physiotherapy is worth doing but hasn't been shown to work better than an injection early on, and how hard the shoulder is pushed doesn't appear to matter, so exercise is kept within comfortable limits. Capsular release is offered early to patients who don't get adequate relief, rather than held back as a last resort. Physiotherapy is built into the post-operative pathway from week one. **MBS items:** - 48954 — Shoulder arthroscopy with capsular release (The MBS item for arthroscopic capsular release of the frozen shoulder) **Frequently asked:** - *How long does frozen shoulder last on its own?* Most people improve a great deal, but the familiar reassurance that it 'always resolves in one to two years' is more confident than the evidence supports. When researchers reviewed the studies, most improvement happened early and then slowed and plateaued, and a proportion of patients — by some measures a third to a half — still had some ache or stiffness several years later, though for most it's mild. People with diabetes tend to recover more slowly. Because 'just wait, it'll sort itself out' isn't a neutral piece of advice, the practice treats the pain actively rather than asking patients to endure it. - *What is hydrodilatation and how does it work?* Hydrodilatation is an injection — performed by a radiologist under ultrasound or X-ray guidance — that fills the joint with local anaesthetic, corticosteroid and saline to stretch the capsule from the inside while the steroid settles the inflammation. It's a low-risk day procedure. The evidence for it is genuinely mixed — some studies show a benefit for pain, others for movement — so where it's appropriate Dr Hirpara refers patients to radiology for it, rather than treating it as a routine step. For pain specifically, a steroid injection into the joint has the strongest evidence. - *Will I need surgery?* Many people settle with an injection and time and don't need surgery. But the practice doesn't treat surgery as a last resort reached only after months of struggling: if a steroid injection doesn't give adequate relief, arthroscopic capsular release is offered from that point. In the largest trial comparing the main treatments, all three landed within a few points of each other at a year. People who had a release were the least likely to need any further treatment, although serious complications, mostly general medical problems, were more common after a release than after a manipulation. The right path depends on the individual: how much the shoulder is affecting work and sleep, diabetes, and whether an injection has already been tried. - *How long is the recovery from arthroscopic capsular release?* Movement starts the same day to prevent re-stiffening. There is no repair to protect, so any sling is for comfort in the first day or two only. Desk-based work usually resumes within two to six weeks. Driving is not allowed for at least six weeks after any shoulder operation, until your surgeon clears you at review. Physical work and overhead activities come back gradually, usually over two to three months. Most of the improvement comes over the first four months, with smaller gains for up to a year. People with diabetes tend to recover more slowly and may benefit from longer therapy support. - *Can frozen shoulder come back after surgery?* Re-stiffening after capsular release is uncommon, and keeping up the exercises consistently in the first six weeks is the main thing you can do to prevent it. Stiffness is more likely to return in patients who can't tolerate the early movement programme (often because of pain) and where there is an underlying cause that wasn't addressed (a missed cuff tear, calcific deposit, or another inflammatory condition), and recovery tends to be slower in people with diabetes. The first review at two weeks specifically checks for early stiffening so it can be caught and corrected before scar tissue matures. - *Is shoulder bursitis the same as frozen shoulder?* No. [Shoulder bursitis](/conditions/shoulder-bursitis/) (subacromial bursitis) is inflammation of the bursa under the acromion and gives pain on overhead reaching with relatively preserved range of motion when the pain is settled by injection. Frozen shoulder is a contracture of the joint capsule itself and gives loss of range that does NOT improve when pain is blocked. The two conditions are commonly confused and often co-exist; sorting out which is the dominant problem is part of the diagnostic consult, because the treatments are different. - *How much does frozen shoulder surgery cost? What does Medicare cover?* Arthroscopic capsular release is performed under regional and general anaesthesia at Mater Private Hospital Rockhampton, so a separate anaesthetist gap applies on top of the surgeon and hospital fees. The practice quotes the surgical fee in writing before booking — Medicare item, rebate and out-of-pocket gap shown separately. Most major private health funds offer no-gap arrangements. The fees page covers the full process; surgery does not proceed without itemised written informed financial consent. --- ### Subacromial decompression URL: https://www.cqupperlimb.com/conditions/subacromial-decompression/ Treats: Subacromial impingement Arthroscopic subacromial decompression — keyhole surgery for refractory shoulder bursitis and impingement — is performed at Mater Private Hospital Rockhampton when conservative management has failed. Most patients with [shoulder bursitis](/conditions/shoulder-bursitis/) settle without surgery; the practice's first job is identifying which patients genuinely need it. **About the condition.** Subacromial bursitis and impingement are part of a spectrum of conditions involving the rotator cuff, the bursa above it, and the under-surface of the acromion. Patients describe pain on the outside of the shoulder, worse with overhead reaching, lifting away from the body, and lying on the affected side at night. The pain often radiates down the upper arm and can be sharp on certain movements. The underlying problem is some combination of bursal inflammation, partial cuff tendinopathy, and bony narrowing of the subacromial space — these are seldom separable and the term 'subacromial pain syndrome' is often used. The condition is more common after the age of 40, in occupations involving repetitive overhead work, and in throwing or racquet-sport athletes. **When surgery is recommended.** Surgery is reserved for patients with persistent symptoms despite at least three to six months of structured physiotherapy, activity modification, and at least one subacromial corticosteroid injection. The threshold is higher than it used to be — published trials over the past decade have shown that arthroscopic decompression often does not outperform structured non-operative care for isolated impingement, and the operation has fallen out of favour as a first-line surgical answer. Surgery is more clearly indicated when there is a partial cuff tear that needs debridement or repair, a calcific deposit, an os acromiale, or where imaging shows a clearly hooked acromion narrowing the subacromial space. **What the procedure involves.** **Arthroscopic subacromial decompression** removes inflamed bursa, smooths the under-surface of the acromion (acromioplasty), and addresses any concurrent pathology — partial cuff tear, calcific deposit, or AC joint arthritis. The procedure is typically done under regional and general anaesthesia as a day case, takes around 30 to 45 minutes, and is followed by a sling for comfort. Where a cuff repair is added, recovery becomes a [rotator cuff repair](/conditions/rotator-cuff-repair/) recovery rather than a decompression-alone recovery. Full clinical detail is on the [subacromial impingement education page](/education/shoulder/subacromial-impingement/) and the [rotator cuff disorders education page](/education/shoulder/rotator-cuff-disorders/) covers the broader picture. **Recovery.** After isolated decompression, the sling is for comfort only and most patients are out of it within a week. Physiotherapy starts immediately. People with desk jobs often return to work within one to two weeks; lifting below shoulder height builds up from about six weeks, and heavy work, overhead work and sport usually take about three months. Recovery from a decompression alone is faster than from a cuff repair; if a repair is added, the recovery follows the cuff-repair pathway (six weeks in a sling, structured rehabilitation over months). Most of the improvement comes in the first three to six months, and the shoulder can keep improving for up to a year. The practice's full phase-by-phase rehabilitation plan is on the [subacromial decompression rehabilitation protocol](/education/rehabilitation/subacromial-decompression/) page. **Practice context.** The practice's approach to subacromial pain emphasises the evidence: structured physiotherapy and a corticosteroid injection settle most patients without surgery. Where surgery is offered, the consult is explicit about what the operation is doing — debriding inflamed tissue, addressing concurrent pathology — and what published outcomes show. Patients with mixed pathology (cuff tear + impingement) often benefit more clearly than those with isolated impingement on imaging. Hand therapy and physiotherapy with Ruby Doolan at Extend Rehabilitation is built into the post-operative pathway. **MBS items:** - 48951 — Arthroscopic subacromial decompression (The MBS item for arthroscopic decompression of the subacromial space) **Frequently asked:** - *Is shoulder bursitis the same as a rotator cuff tear?* Not exactly, but they overlap. Subacromial bursitis is inflammation of the bursa above the rotator cuff; rotator cuff tendinopathy is degeneration of the cuff tendons themselves; rotator cuff tear is a structural tear of one or more cuff tendons. These conditions are part of a continuum and frequently co-exist — bursal inflammation often accompanies a cuff tear, and isolated bursitis can progress to tendinopathy and partial tearing over years. MRI helps distinguish them, but the consult's job is matching treatment to the dominant problem in any given patient. - *Will physiotherapy work, or do I need surgery?* For most patients with subacromial pain — bursitis, impingement, or mild tendinopathy without a structural tear — structured physiotherapy works. Published trials over the past decade have repeatedly shown that arthroscopic decompression often does not outperform a thorough non-operative programme. That said, surgery has a clear role when there is a structural tear, a calcific deposit, an os acromiale, or persistent disabling symptoms despite a structured trial. The first consult sets out where the patient sits and what to try first. - *What does a corticosteroid injection do?* A subacromial corticosteroid injection is a clinic-based procedure that delivers a small dose of steroid into the bursa above the cuff. It settles inflammation and reduces pain, often substantially, for weeks to months. It does not fix a structural tear, but it can break the pain cycle long enough for physiotherapy to make progress. Repeat injections are limited — usually no more than two or three at the same site — because of evidence that frequent steroid injections weaken tendons over time. - *How long is the recovery from decompression alone?* After isolated arthroscopic decompression, most patients are out of the sling within a week and back to office work in seven to ten days. Driving is not allowed for at least six weeks after any shoulder operation, even once the sling is off, until your surgeon clears you at review. Lifting below shoulder height builds up from about six weeks, and heavy work, overhead work and sport usually take about three months. Most of the improvement comes in the first three to six months. Recovery is faster than after a rotator cuff repair because there is no tendon to protect. - *What if I also have a rotator cuff tear?* If MRI shows a structural cuff tear, the operation typically combines decompression with cuff repair — see the [rotator cuff repair page](/conditions/rotator-cuff-repair/). The recovery follows the cuff-repair pathway: six weeks in a sling, gradual range-of-motion over the next six weeks, and strengthening over months. The decompression and repair are done at the same operation through the same arthroscopic portals. - *How much does shoulder bursitis surgery cost? What does Medicare cover?* Arthroscopic subacromial decompression is performed under regional and general anaesthesia at Mater Private Hospital Rockhampton, so a separate anaesthetist gap applies on top of the surgeon and hospital fees. The practice quotes the surgical fee in writing before booking — Medicare item, rebate and out-of-pocket gap shown separately. Most major funds offer no-gap arrangements. Surgery does not proceed without itemised written informed financial consent. --- ### Shoulder bursitis URL: https://www.cqupperlimb.com/conditions/shoulder-bursitis/ Treats: Subacromial bursitis Subacromial bursitis — the usual meaning of 'shoulder bursitis' — is assessed and managed at the practice for patients across Central Queensland, from Rockhampton and the Capricorn Coast to Gladstone, Emerald and the Mackay catchment. The great majority settle with non-operative care; surgery is a genuine last resort. **About the condition.** Shoulder bursitis means the subacromial bursa — a thin, fluid-filled cushion sitting between the rotator cuff tendons and the bony tip of the shoulder blade (the acromion, not the collarbone) — has become inflamed, swollen and thickened. That inflammation is what the patient feels. It is closely related to, but not the same as, subacromial impingement: impingement is the mechanical pinching of the tendons and bursa in the narrow space under the acromion as the arm is raised. The two almost always travel together — pinching irritates the bursa, and a thickened bursa takes up room and worsens the pinching — so they are two parts of one problem (the 'subacromial pain syndrome' spectrum) rather than separate diagnoses. Worth knowing: the bursa is not just a passive cushion — its cells help recruit healing support for the rotator cuff, so it plays an active role in tendon repair. **When surgery is recommended.** Most shoulder bursitis never needs an operation, and the practice's first job is to keep it that way. Surgery — arthroscopic subacromial decompression — is considered only after a genuine trial of non-operative care has failed: at least three to six months of activity modification, anti-inflammatories, structured physiotherapy and usually a subacromial corticosteroid injection. Even then, a decompression for isolated bursitis is offered cautiously, because published trials over the past decade show it often adds little over good physiotherapy. The clearer surgical indications are a co-existing problem the imaging reveals — a partial [rotator cuff tear](/conditions/rotator-cuff-repair/), a calcific deposit, or a clearly hooked acromion narrowing the space. The surgical pathway itself is covered on the [subacromial decompression page](/conditions/subacromial-decompression/). **What the procedure involves.** Where conservative care genuinely fails, **arthroscopic subacromial decompression** is the operation. Through keyhole portals the inflamed, thickened bursa is removed and a small amount of bone is shaved from the under-surface of the acromion to open up the subacromial space and stop the pinching. Any co-existing pathology found at the same time — a partial cuff tear, a calcific deposit, AC joint arthritis — is addressed together. It is usually a day case under regional and general anaesthesia, around 30 to 45 minutes, with a sling for comfort only. Full step-by-step detail is on the [subacromial impingement education page](/education/shoulder/subacromial-impingement/); the broader picture is on the [rotator cuff disorders education page](/education/shoulder/rotator-cuff-disorders/). **Recovery.** For the great majority who never need surgery, recovery is measured in weeks to a few months: the cortisone injection settles the pain enough to engage with physiotherapy, and the scapular-control and rotator-cuff strengthening programme then restores pain-free overhead movement. Give it a fair trial — bursitis that has built up over months rarely settles in days. If a decompression is ultimately required, recovery from the isolated operation is quick: the sling is for comfort only and out within a week, office work resumes within a week or two, and physical activities are graded back over four to six weeks. **Practice context.** Dr Hirpara sees shoulder bursitis referrals from across the Central Queensland catchment — Rockhampton, Yeppoon, Gladstone, Emerald, Biloela and the Mackay region. The first consult concentrates on confirming the diagnosis and where it sits on the subacromial-pain spectrum, because a painful shoulder can equally be a [rotator cuff tear](/conditions/rotator-cuff-repair/), frozen shoulder or AC joint arthritis, and the treatments diverge. Most patients leave with a non-operative plan and a clear injection-and-physiotherapy pathway; the minority who need surgery are identified by what their imaging and their response to a fair conservative trial actually show. **MBS items:** - 48951 — Arthroscopic subacromial decompression (The MBS item for the last-resort surgical option, where non-operative care has failed — most bursitis is managed without it) **Frequently asked:** - *Is shoulder bursitis the same as impingement?* They are two parts of the same problem, not separate diagnoses. Bursitis names the inflamed, swollen bursa — the fluid-filled cushion under the acromion. Impingement names the mechanical pinching of that bursa and the cuff tendons in the narrow space under the acromion when you raise the arm. The pinching inflames the bursa, and the thickened bursa worsens the pinching, so they almost always co-exist on the 'subacromial pain syndrome' spectrum. The label a clinician uses often just reflects which part is more obvious on the day. - *Will shoulder bursitis go away on its own?* Often, but it usually needs help and patience. A mild flare can settle with a few weeks of rest from aggravating overhead activity and anti-inflammatories. More established bursitis that has built up over months tends not to resolve fully on its own, because the underlying mechanics — the pinching that inflamed the bursa — are still there. That is why physiotherapy matters: correcting scapular control and cuff strength changes the mechanics, not just the symptoms. A cortisone injection is often what breaks a stubborn pain cycle enough to let the physiotherapy work. - *How long does shoulder bursitis last?* It varies widely. A first, mild episode might settle in two to six weeks. Bursitis that has grumbled for months, or that keeps flaring, can take several months of structured physiotherapy — often with a cortisone injection early on — to settle properly. The key is a fair trial: this is not a condition that resolves in days, and stopping the moment the pain eases tends to let it return. If it has not meaningfully improved after three to six months of genuine non-operative effort, that is the point to reconsider the diagnosis and imaging. - *Should I get a cortisone injection — does it work, and how many can I have?* A subacromial corticosteroid injection puts a small dose of steroid into the inflamed bursa. It is effective for pain, often substantially, for weeks to months, and its main value is breaking the pain cycle so you can engage with physiotherapy — the injection treats the inflammation, the physiotherapy fixes the mechanics. It will not repair a structural tear. Repeat injections are limited, usually no more than two or three at the same shoulder, because frequent steroid can weaken nearby tendons over time. For stubborn pain a suprascapular nerve block is an alternative. - *What exercises help, and what should I avoid?* The mainstay is a physiotherapy programme built around scapular (shoulder-blade) control and gentle rotator-cuff strengthening — these change the mechanics that pinch and inflame the bursa. Posture work and stretching of a tight posterior capsule help too. What to avoid, at least while it is irritable, is repetitive overhead loading and heavy lifting away from the body — the very movements that pinch the bursa. Sharp, lingering pain is a signal to ease off. A tailored programme from your physiotherapist is far more effective than generic exercises found online. - *When does shoulder bursitis need surgery?* Rarely, and only as a last resort. Surgery is considered after at least three to six months of structured non-operative care — activity modification, anti-inflammatories, physiotherapy and usually a cortisone injection — has genuinely failed to settle the pain. Even then, decompression for isolated bursitis is offered cautiously, because the evidence shows it often adds little over good physiotherapy. The clearer reasons to operate are co-existing problems on imaging: a partial rotator cuff tear, a calcific deposit, or a clearly hooked acromion. The surgical pathway is on the subacromial decompression page. --- ### Scaphoid fixation URL: https://www.cqupperlimb.com/conditions/scaphoid-fixation/ Treats: Scaphoid fracture Percutaneous compression-screw fixation of the scaphoid is performed at Mater Private Hospital Rockhampton by Dr Kieran Hirpara, a dual fellowship-trained orthopaedic surgeon (orthoplastic hand surgery, Manchester; shoulder & elbow surgery, Brisbane). The practice manages acute scaphoid fractures and established nonunions for patients across Central Queensland. **About the condition.** The scaphoid is a small boat-shaped bone at the base of the thumb, the most commonly fractured of the wrist's eight carpal bones. The injury typically follows a fall onto an outstretched hand and presents as tenderness in the anatomical snuffbox — the small hollow at the base of the thumb. The scaphoid has a tenuous retrograde blood supply that enters near its waist and travels backward toward the proximal pole, which means fractures of the upper end are at risk of avascular necrosis (death of the bone fragment) and nonunion (failure to heal). Standard wrist X-rays miss a substantial proportion of acute scaphoid fractures, and the diagnosis is often confirmed only with CT or delayed-imaging follow-up. **When surgery is recommended.** Stable, nondisplaced scaphoid waist fractures can heal in a thumb-spica cast over twelve weeks of continuous immobilisation. Surgical fixation is offered when the fracture is displaced more than a millimetre, when the pattern is unstable, when the fracture is in the proximal pole (high nonunion risk), or when an active patient prefers a shorter immobilisation period and faster return to function. Percutaneous screw fixation has been shown to roughly halve the time to union (mean seven weeks vs twelve) and return to work (eight vs fifteen). Established nonunions and avascular fragments are addressed with bone-grafting techniques rather than simple screw fixation. **What the procedure involves.** Percutaneous scaphoid fixation is performed through a small incision at the base of the thumb under fluoroscopic guidance. A guide wire is passed along the long axis of the scaphoid, the fracture compressed, and a headless cannulated compression screw (Herbert or Acutrak design) is inserted over the wire to hold the fragments tightly together. The operation usually takes 30 to 60 minutes under regional and general anaesthesia; patients leave hospital the same day. Where wrist arthroscopy is added, the procedure also identifies and treats associated ligament or chondral injuries, which are present in a substantial proportion of acute scaphoid fractures. Full clinical detail is on the [education page](/education/wrist/scaphoid-fixation/). **Recovery.** A removable thumb-spica splint is worn for the first two weeks for comfort, then mobilisation begins under hand-therapy guidance. Light desk-based duties resume around two to four weeks; driving once you can grip the wheel comfortably, typically four to six weeks. Return to manual work and contact sport waits for radiographic union, usually three to four months. Most patients regain full grip strength and range of motion, though the timeline is longer for proximal-pole fractures and for fractures in smokers, where union is slower and the risk of avascular necrosis is higher. **Practice context.** In-person review at two weeks for wound check, six weeks with X-ray to confirm screw position and early union, then three months with imaging to confirm radiographic union before clearance for full activity. Coordinated hand therapy with Ruby Doolan in the same suite is integrated into the post-operative pathway. Patients from outside Rockhampton can usually transition to therapy closer to home after the early intensive sessions. **MBS items:** - 47357 — Treatment of fracture of carpal scaphoid, by reduction with fixation (Single item covering scaphoid fixation by any means (percutaneous compression screw, open compression screw)) **Frequently asked:** - *I fell on my hand a week ago and the X-ray was normal — could I still have a scaphoid fracture?* Yes. A substantial proportion of acute scaphoid fractures are not visible on the initial set of plain X-rays — the fracture line is fine and the bone is small. Persistent tenderness in the anatomical snuffbox at two weeks after a fall is treated as a scaphoid fracture until proven otherwise, with CT or MRI used to confirm the diagnosis. Missed scaphoid fractures are one of the most common reasons for a wrist that does not settle after an apparent sprain, and the consequences of missing one are significant — nonunion, avascular necrosis and eventually wrist arthritis. - *Why do I need surgery if the bone might heal in a cast?* For stable, nondisplaced waist fractures a cast is a legitimate option. The trade-off is twelve weeks of continuous immobilisation with the risks of stiffness, muscle wasting and inconvenience, balanced against a roughly 5 to 15 per cent rate of nonunion that may still need surgery later. Percutaneous fixation halves the time to union, allows earlier movement and reliably restores anatomy. The threshold for offering surgery is lower for patients in physical work, for proximal-pole fractures, and for displaced patterns where cast treatment has a substantially higher nonunion rate. - *How much does scaphoid fixation cost? What does Medicare cover?* Scaphoid fixation involves separate fees for the surgeon, anaesthetist, hospital and the surgical implant. The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent. - *When can I go back to playing sport?* Light non-contact sport (running, cycling on a trainer) is usually reasonable from six weeks, contact sport once radiographic union is confirmed at around three to four months. Premature return to contact sport before union risks displacement of the fragments around the screw and ongoing pain. Wrist guards or splints are sometimes used during return-to-sport for an additional period of protection. - *Will the screw need to be removed?* The headless compression screw is buried entirely within the bone and is designed to stay in place for life. Screw removal is rarely needed and is only considered if the screw becomes prominent or symptomatic. The screws are MRI-compatible and do not set off airport security. --- ### Distal clavicle excision URL: https://www.cqupperlimb.com/conditions/distal-clavicle-excision/ Treats: AC joint arthritis Arthroscopic distal clavicle excision — the Mumford procedure — is performed at Mater Private Hospital Rockhampton by Dr Kieran Hirpara, a dual fellowship-trained orthopaedic surgeon (orthoplastic hand surgery, Manchester; shoulder & elbow surgery, Brisbane). The practice manages acromioclavicular joint pain for patients across Central Queensland. **About the condition.** The acromioclavicular (AC) joint sits at the top of the shoulder, where the outer end of the collarbone (clavicle) meets the shoulder blade (acromion). The joint takes load with every overhead reach, push and pull, and is a common site for primary osteoarthritis as well as for post-traumatic arthritis after an AC separation. Patients describe a localised ache on top of the shoulder, worse with overhead reach, cross-body adduction (bringing the arm across the chest), and sleeping on the affected side. The pain is often pinpoint and reproducible by palpation directly over the joint. X-ray shows narrowing of the joint, osteophytes and sometimes cystic change; MRI confirms the diagnosis and excludes coexisting rotator cuff pathology. **When surgery is recommended.** Most AC joint arthritis settles with a structured non-operative programme — activity modification to avoid the provocative overhead and cross-body positions, anti-inflammatory medications, physiotherapy focused on scapular control, and one or two image-guided corticosteroid injections into the joint. Surgery is offered when the pain is reproducible, structurally explained on imaging, responds at least transiently to a diagnostic injection, and persists despite a thorough non-operative trial. The procedure is also offered for chronic post-traumatic AC pain following an old separation that did not settle, and as a concomitant procedure during rotator cuff repair when the AC joint is independently symptomatic. **What the procedure involves.** Arthroscopic distal clavicle excision is performed through two or three small portals around the shoulder. A small portion (typically 6 to 8 millimetres) of the outer end of the clavicle is resected, removing the bone-on-bone contact while preserving the stabilising coracoclavicular ligaments. The operation usually takes 30 to 60 minutes under regional and general anaesthesia; patients leave hospital the same day. The arthroscopic approach allows simultaneous assessment of the rotator cuff and glenohumeral joint, which is useful given that AC joint arthritis and cuff pathology often coexist. Full clinical detail is on the [education page](/education/shoulder/distal-clavicle-excision/). **Recovery.** A sling is worn for the first one to two weeks for comfort, then movement is encouraged with pendulum and gentle range-of-motion exercises. Light desk-based work and driving usually resume between two and six weeks, with most patients returning to general daily activity within a month. Strengthening starts at around six weeks under physiotherapy guidance; manual work and contact sport are typically held until three to six months. Final outcome — full strength and resolution of any residual stiffness — continues to improve for up to a year. The procedure is reliably effective when the diagnosis is correct and the joint pain has been reproducibly relieved by a pre-operative injection. The practice's full phase-by-phase rehabilitation plan is on the [distal clavicle excision rehabilitation protocol](/education/rehabilitation/distal-clavicle-excision/) page. **Practice context.** In-person review at two weeks for wound check, six weeks to confirm range of motion and pain resolution, then a final review at three months to clear return to full activity. Co-located shoulder physiotherapy is integrated into the post-operative pathway, with patients from outside Rockhampton transitioning to therapy closer to home after the early sessions. When the AC joint is identified as one of several pain generators on pre-operative workup, the operation is staged carefully so the response to each component can be assessed. **MBS items:** - 48952 — Arthroscopic distal clavicle excision (standalone) (Used when distal clavicle excision is the only shoulder procedure performed — arthroscopic surgery of the AC joint) - 48903 — Subacromial decompression with distal clavicle excision (Used when the distal clavicle excision is bundled with a subacromial decompression in the same operation) - 48960 — Rotator cuff repair (includes AC joint resection) (When the AC joint is resected during a cuff repair, the resection is included in the cuff-repair item and not separately billed) **Frequently asked:** - *How much bone is actually removed?* Around 6 to 8 millimetres of the outer end of the collarbone. The aim is to remove just enough bone to eliminate the bone-on-bone contact without compromising the coracoclavicular ligaments that hold the clavicle down to the shoulder blade. Removing too much bone risks AC joint instability, while removing too little leaves residual contact and ongoing pain. The arthroscopic approach allows precise resection under direct vision. - *Will my shoulder look different after surgery?* Most patients see no visible change. The resected bone is recessed beneath skin and muscle, and the cosmetic profile of the shoulder is preserved. A small minority of patients notice a slightly less prominent AC joint, which is often welcome since the pre-operative arthritis frequently produces a visible bony bump. - *How much does distal clavicle excision cost? What does Medicare cover?* Distal clavicle excision involves separate fees for the surgeon, anaesthetist, hospital and arthroscopic implants. The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent. - *What's the success rate?* Published outcomes consistently show high satisfaction rates when the diagnosis is correct and the pre-operative diagnostic injection produced reproducible relief. Patient selection is the single biggest determinant of outcome. The procedure is less reliable when the AC joint is one of several pain generators and when the pre-operative injection produced equivocal results; in those cases additional workup is undertaken before surgery is offered. - *Will I need physiotherapy?* Yes — short-course physiotherapy is integrated into the post-operative pathway, focused on regaining range of motion in the first six weeks and rebuilding scapular control and cuff strength from six weeks. The total course is typically shorter than for a rotator cuff repair because the rehabilitation does not need to protect a soft-tissue repair. Most patients are independent of formal therapy by three months. --- ### Shoulder replacement for proximal humerus fracture URL: https://www.cqupperlimb.com/conditions/proximal-humerus-arthroplasty/ Treats: Complex proximal humerus fracture Reverse total shoulder arthroplasty for acute proximal humerus fracture is performed at Mater Private Hospital Rockhampton by Dr Kieran Hirpara, a dual fellowship-trained orthopaedic surgeon (orthoplastic hand surgery, Manchester; shoulder & elbow surgery, Brisbane). The practice manages complex shoulder fractures and fracture-arthroplasty for patients across Central Queensland. **About the condition.** Proximal humerus fractures are the third most common fracture in older adults, typically after a fall onto the shoulder or outstretched hand. Most are stable two-part injuries that heal without operation. A subset — often older patients with osteoporotic bone or younger patients with high-energy trauma — sustain four-part fractures, fracture-dislocations, or head-splitting patterns where the bone fragments are too damaged or the blood supply too compromised for reliable plate fixation. In these cases, attempting to reconstruct the joint with plates and screws is associated with high rates of fixation failure, avascular necrosis (death of the humeral head) and need for revision surgery. Replacing the joint at the index operation, rather than after a failed fixation, generally produces a more predictable result. **When surgery is recommended.** Reverse shoulder arthroplasty is offered for acute proximal humerus fractures when the head fragment is unsalvageable (head-splitting fracture, severely comminuted), when the blood supply to the head is unreliable (anatomic-neck fractures, fracture-dislocations), in older patients with poor bone quality where plate fixation is unlikely to hold, and when there is pre-existing rotator cuff pathology or arthritis that would compromise an anatomic reconstruction. The reverse design relies on the deltoid muscle rather than the rotator cuff to lift the arm, which is a major advantage in older fracture patients whose cuff is often degenerate even before the injury. The alternative — ORIF — is preferred in younger patients with reconstructable patterns and healthy bone. **What the procedure involves.** The operation is performed under regional and general anaesthesia in the beach-chair position, through an incision over the front of the shoulder. The damaged humeral head is removed; the glenoid (socket) is prepared with a baseplate and metal hemisphere, and a stemmed component with a plastic socket is implanted into the humeral shaft. The greater and lesser tuberosity fragments (which carry the rotator cuff attachments) are carefully repositioned around the prosthesis and secured with high-strength sutures, often augmented with bone graft from the removed head. The operation usually takes one to two hours; patients stay one or two nights in hospital. Full clinical detail is on the [education page](/education/shoulder/proximal-humerus-arthroplasty/). **Recovery.** A sling with an abduction pillow is worn continuously for the first six weeks, with hand and elbow mobility encouraged but no active shoulder lift. Passive range-of-motion physiotherapy starts at one to two weeks; active motion begins at six weeks; strengthening from twelve weeks. Desk work can usually start again from about six weeks; driving is not allowed for at least six weeks after any shoulder operation, whichever side it was, and after this operation for a fracture, people drove again after an average of about five months in one study. Lighter sport such as swimming and golf often starts again at four to six months, while manual work and heavier tasks can take up to twelve months. Final strength and range of motion continue to improve gradually for up to two years. The reverse design reliably restores pain-free forward elevation but produces less external rotation than the native shoulder, particularly when the tuberosity fragments do not heal well. The practice's full phase-by-phase rehabilitation plan is on the [shoulder replacement for fracture rehabilitation protocol](/education/rehabilitation/proximal-humerus-arthroplasty/) page. **Practice context.** In-person review at two weeks for wound check and X-ray, six weeks to start active motion, three months to add strengthening, and six and twelve months to confirm functional outcome. Co-located shoulder physiotherapy is integrated into the post-operative pathway, with structured progression matched to the radiographic tuberosity healing. Patients from outside Rockhampton can transition to therapy closer to home after the early intensive sessions; the protocol is shared with the local therapist to maintain consistency. **MBS items:** - 48919 — Total or reverse shoulder arthroplasty (with bone graft) (Single item covering anatomic and reverse total shoulder arthroplasty regardless of cause; the with-graft variant is used for proximal humerus fracture arthroplasty given the tuberosity reconstruction with bone graft from the removed head) **Frequently asked:** - *Why replace the joint instead of fixing it with a plate?* Plate fixation works well in younger patients with reconstructable fracture patterns and healthy bone. In older patients with osteoporotic bone, comminuted four-part fractures, or compromised blood supply to the head fragment, plate fixation has high rates of fixation failure, avascular necrosis of the head, and need for revision surgery. Replacing the joint at the index operation, rather than after a failed fixation, generally produces a more predictable outcome with less time spent in a sling and a more reliable return to function. The decision is individual and considers the fracture pattern, bone quality, patient age, activity level, and cuff status. - *Why a reverse replacement and not a hemiarthroplasty?* Hemiarthroplasty (replacing only the ball, not the socket) was the historical operation for these fractures but produced unreliable outcomes — function depended heavily on whether the tuberosities and their rotator-cuff attachments healed, and a substantial proportion of patients had ongoing pain and weakness. Reverse total shoulder arthroplasty bypasses the rotator cuff entirely — the deltoid muscle drives elevation through the prosthetic geometry — and is more forgiving of tuberosity nonunion. The current evidence consistently favours reverse over hemiarthroplasty for complex fractures in older patients. - *How long does the implant last?* Modern reverse shoulder implants have excellent survivorship — published series report 90 to 95 per cent survival at ten years, with most failures relating to glenoid loosening rather than wear. For an older fracture patient, this typically means the implant will outlast the patient's need for it. Revision is possible if loosening or infection occurs, though it is technically more complex than the index operation. - *Will I be able to lift my arm overhead?* Most patients regain forward elevation to around 130 to 150 degrees — enough to reach a top shelf, comb their hair and dress comfortably. External rotation is typically more limited and depends on whether the tuberosity fragments heal back to the prosthesis. The functional gain over the pre-operative fracture state is substantial, and most patients describe their replaced shoulder as pain-free even when the range is not full. - *How much does shoulder replacement cost? What does Medicare cover?* Shoulder replacement involves separate fees for the surgeon, anaesthetist, hospital and the prosthesis. The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent. --- ### Proximal humerus ORIF URL: https://www.cqupperlimb.com/conditions/proximal-humerus-orif/ Treats: Proximal humerus fracture Open reduction and internal fixation of proximal humerus fractures with a locking plate is performed at Mater Private Hospital Rockhampton by Dr Kieran Hirpara, a dual fellowship-trained orthopaedic surgeon (orthoplastic hand surgery, Manchester; shoulder & elbow surgery, Brisbane). The practice manages displaced and unstable proximal humerus fractures for patients across Central Queensland. **About the condition.** Proximal humerus fractures occur most commonly after a fall onto the shoulder or outstretched hand, and they are the third most common fracture in older adults. Younger patients sustain these fractures from higher-energy injuries — sport, falls from height, or motor vehicle crashes. The fracture pattern ranges from a stable single-part fracture that does not need surgery, through displaced two- and three-part fractures where the rotator cuff has pulled the tuberosity fragments out of position, to complex four-part patterns where the head, the tuberosities and the shaft are all separated. Patient factors — bone quality, age, activity level and cuff status — matter as much as the fracture geometry in deciding the right operation. **When surgery is recommended.** Open reduction and internal fixation is offered for displaced two-, three- and reconstructable four-part proximal humerus fractures in patients with adequate bone quality. The threshold for offering surgery is lower in younger active patients, where preserving the native joint matters most, and higher in older patients with osteoporotic bone, where reverse shoulder arthroplasty is often the more reliable option (see proximal humerus arthroplasty). Truly stable fractures with minimal displacement are managed non-operatively in a sling. The pre-operative workup includes a CT scan to characterise the fragment geometry and a careful assessment of cuff status, since cuff competence is critical to the rehabilitation pathway. **What the procedure involves.** The operation is performed under regional and general anaesthesia in the beach-chair position, through an incision over the front of the shoulder. The fracture fragments are mobilised, reduced anatomically, and held with a pre-contoured locking plate placed on the outer surface of the proximal humerus. Locking screws engage the dense subchondral bone of the humeral head to provide stable fixation even in osteoporotic bone. Calcar screws and suture augmentation through the rotator cuff insertion are used routinely to reinforce the construct against the typical varus collapse pattern seen with plate fixation. The operation usually takes one to two hours; patients stay one or two nights in hospital. Full clinical detail is on the [education page](/education/shoulder/proximal-humerus-orif/). **Recovery.** A sling is worn full time for about the first three weeks, then weaned over the following weeks as comfort allows, with the hand, wrist and elbow kept moving from the start. Gentle assisted shoulder exercises begin in the first days after surgery, while movements that load the healing bone, such as turning the arm outwards against resistance, wait until X-rays show the fracture is healing, usually at about six weeks; strengthening follows from about twelve weeks. Desk work can often start again at around four to six weeks; driving is not allowed for at least six weeks after any shoulder operation, whichever side it was, and only once you are out of the sling and no longer need strong pain medicine. Heavier manual work usually comes back at about three to six months, and sometimes later; heavy overhead work and sport usually return from around six months. Most of the recovery happens in the first year: some people notice small gains after that, and some do not get back to their full pre-injury strength. Recovery is faster and more predictable in younger patients with healthy bone; in older patients with osteoporotic bone the trade-off between ORIF and primary arthroplasty is carefully discussed pre-operatively. The practice's full phase-by-phase rehabilitation plan is on the [proximal humerus fixation rehabilitation protocol](/education/rehabilitation/proximal-humerus-orif/) page. **Practice context.** In-person review at two weeks for wound check and X-ray, six weeks to confirm early union and progress the movement programme, three months to add strengthening, and six months for the functional outcome assessment. Co-located shoulder physiotherapy is integrated into the post-operative pathway with structured progression matched to the radiographic healing. The hardware is usually retained permanently; removal is considered if it becomes prominent or symptomatic after complete union, typically at a year or more from the index operation, or sooner if a screw moves into the joint. **MBS items:** - 47432 — Intra-articular proximal humerus fracture, open reduction with fixation (Used when the joint surface is involved — typical for displaced three- and four-part fractures) - 47429 — Extra-articular proximal humerus fracture, open reduction (Used when the joint surface is not involved) **Frequently asked:** - *Why fix the fracture instead of just using a sling?* Stable, minimally displaced proximal humerus fractures heal reliably in a sling and do not need surgery. The threshold for offering ORIF is displacement that, if allowed to heal as is, would compromise the long-term function of the shoulder — most commonly varus collapse, where the head tilts inward and reduces the working length of the rotator cuff. Operating restores anatomy, allows earlier mobilisation and gives a more predictable functional result for displaced patterns. The trade-off is the surgical risk and the hardware, which is acceptable in most active patients but is weighed carefully in frailer or older patients where reverse shoulder arthroplasty may be the better option. - *What's the difference between ORIF and a shoulder replacement?* ORIF preserves the patient's own joint by realigning the fracture fragments and holding them with a plate and screws. It works well when the bone quality is good, the fragments are reconstructable, and the blood supply to the head is preserved. Reverse shoulder arthroplasty replaces the joint with a prosthesis and is offered when the fracture pattern is unreconstructable, the bone quality is poor, or the pre-existing cuff function is compromised. The decision is individual; both pathways are discussed at the pre-operative consult and the trade-offs in expected recovery, durability and risk are mapped out. - *Will the plate need to be removed?* The plate is usually left in place for life. Removal is considered only when the hardware causes ongoing symptoms after complete fracture union — most commonly a prominent screw or plate edge that the patient can feel under the skin or when lying on the shoulder. Hardware removal is a smaller second operation, usually performed at a year or more from the index operation once the bone has fully consolidated. If a screw works its way into the joint, for example because the head of the humerus settles as it heals, removal may be needed sooner. - *How much does proximal humerus ORIF cost? What does Medicare cover?* ORIF involves separate fees for the surgeon, anaesthetist, hospital and the surgical implants (plate and screws). The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent. - *What can go wrong?* The problem that matters most is the fracture slipping out of position before the bone has healed, usually with the head of the humerus tilting down and inwards (varus collapse), sometimes with a screw tip pushing into the joint. It is more likely with thin (osteoporotic) bone and when the inner side of the bone is broken into several pieces. Avascular necrosis of the humeral head can appear months or sometimes years after surgery, particularly in fracture patterns where the head's blood supply was disrupted, and may eventually require conversion to arthroplasty. Infection is uncommon but serious. Shoulder stiffness can occur; early movement and structured physiotherapy help reduce it, and a few people need a further procedure to free up the joint. Individual risk and the trade-off with reverse arthroplasty are discussed at the pre-operative consult. --- ### de Quervain's release URL: https://www.cqupperlimb.com/conditions/de-quervains-release/ Treats: de Quervain's tenosynovitis Surgical release of the first dorsal compartment of the wrist for resistant de Quervain's tenosynovitis. Performed as a day case at Mater Private Hospital Rockhampton, usually under local anaesthetic. Patients are seen at the practice from across Central Queensland. **About the condition.** [de Quervain's tenosynovitis](/education/wrist/de-quervains-tenosynovitis/) is inflammation of the tendon sheath that wraps the abductor pollicis longus and extensor pollicis brevis tendons as they cross the radial styloid at the wrist. Patients describe sharp pain when the thumb is stretched or used against resistance — lifting a baby, pouring a teapot, gripping a phone, twisting a key. The Finkelstein and Eichhoff bedside tests reproduce the pain. The condition is most often seen in new mothers (the lifting mechanic of a newborn loads the tendons heavily) and in people with repetitive thumb-loaded work; it also affects post-menopausal women and patients with rheumatoid disease. **When surgery is recommended.** Most de Quervain's settles non-operatively. A thumb-spica splint and activity modification settle a sizeable fraction; cases that don't usually do well after a single ultrasound-guided corticosteroid injection. Surgery is offered when symptoms persist or recur after two well-placed injections, when the patient has a contraindication to injection, or in cases where examination suggests a septated compartment (a tight subdivision of the first dorsal compartment that makes injection less likely to settle the disease). Symptomatic recurrence after surgery is uncommon when the release is complete. **What the procedure involves.** Open release of the first dorsal compartment through a small transverse incision over the radial styloid divides the constricting retinaculum and frees both tendons. Care is taken to identify and protect the superficial branch of the radial nerve, which lies immediately under the skin in this area. Any septation in the compartment is identified and the deeper subcompartment also released — incomplete release of a septated compartment is the typical cause of persistent symptoms after surgery. The procedure is performed as a day case under local anaesthetic in most patients. Full clinical detail is on the [education page](/education/wrist/de-quervains-release/). **Recovery.** The dressing is reduced to a small adhesive cover at the first review and the wrist and thumb are used freely from day one — gentle motion is encouraged to keep the tendons gliding through the healed compartment. Desk and light work usually resume within days to a week or two; forceful gripping, pinching and lifting wait until around three to four weeks, and heavier manual work is usually back by four to eight weeks. Some tenderness around the scar is common for four to six weeks and settles with use. Numbness or hypersensitivity in the radial nerve territory occasionally lingers for several months in patients where the nerve was retracted heavily during exposure. **Practice context.** de Quervain's release is well-suited to a same-day visit pattern for patients travelling from out of town: the consult and the procedure can usually be combined on the one day where the diagnosis is clear and the patient is fit for local anaesthetic. All patients are seen by Ruby Doolan at Extend Rehabilitation for the first dressing change and scar care; this is built into the routine pathway. Post-operative review is typically at six weeks; this review is aftercare and is included in the surgical fee. **MBS items:** - 46367 — de Quervain's release (Includes any associated synovectomy of EPB and APL tendons and retinaculum reconstruction; claimable once per side) **Frequently asked:** - *Will the injection alone settle this without surgery?* Often, yes. A single well-placed ultrasound-guided corticosteroid injection settles de Quervain's in a sizeable fraction of patients — the published response rate is high. Cases where the first compartment is septated (subdivided by a small wall of fibrous tissue) respond less reliably to injection, and these are the patients more likely to come to surgery. The first injection is the diagnostic step as much as the therapeutic one — a poor response is informative. Two injections is generally the upper limit before surgery is offered. - *How much does de Quervain's release cost? What does Medicare cover?* de Quervain's release is normally performed under local anaesthetic — Dr Hirpara performs the block himself and there is no anaesthetist fee. A general anaesthetic is occasionally used, in which case a separate anaesthetist gap applies on top of the surgeon and hospital fees. The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent. - *When can I drive after de Quervain's release?* Driving requires a safe grip on the wheel. Most patients are back to driving within one to two weeks, once the dressing has been reduced, any comfort splint is off and the hand is comfortable. Practical signs you are likely safe to drive: you can grip the wheel firmly with the operated hand, perform an emergency stop without needing to protect the hand, you are off prescription pain medication, and the bulky dressing has been reduced to a small adhesive cover. The practice does not certify fitness to drive for insurance purposes — driving fitness is a decision between the patient, the GP and the insurer — but the question is discussed at the post-operative review. - *I'm a new mother and the pain started after the baby was born — will it get better on its own?* Often, yes. A meaningful fraction of post-partum de Quervain's settles once the heavy unilateral lifting of a newborn eases — usually around 6 to 12 months from onset. While the symptoms are active, a thumb-spica splint that holds the thumb out of the painful arc, and a single corticosteroid injection in cases that don't settle on the splint alone, are reasonable first steps. Surgery is reserved for cases that don't settle with the conservative escalation, or where the day-to-day demands of caring for a newborn aren't manageable on the conservative pathway. - *What's the difference between de Quervain's and CMC arthritis?* Both produce pain on the radial side of the wrist and at the base of the thumb, and the two often co-exist in older patients. The clinical distinction is straightforward: de Quervain's pain is sharp and localised over the radial styloid (just above the wrist crease), worse on thumb stretch and on the Finkelstein test; CMC arthritis pain is deeper, located at the base of the thumb (in the meaty pad below the thumb metacarpal), worse on pinch grip and on twisting a jar lid, and usually shows changes on X-ray. The [thumb pain hub](/conditions/thumb-pain/) walks through the location-led differential. - *Do I need hand therapy after de Quervain's release?* Yes — every patient sees the on-site hand therapist for the first dressing change, scar management instruction, and a structured set of post-operative exercises. Hand therapy is integrated into the post-operative pathway rather than offered as an extra. Additional sessions are scheduled where the recovery is slower than expected — a stiff thumb, a tender or hypertrophic scar, or any wound concern. Hand therapy is provided by Ruby Doolan through Extend Rehabilitation, in the same suite as Dr Hirpara's rooms. --- ### Distal biceps repair URL: https://www.cqupperlimb.com/conditions/distal-biceps-repair/ Treats: Distal biceps tendon rupture Surgical repair of acute distal biceps tendon rupture, performed at Mater Private Hospital Rockhampton. Repair within three to four weeks of injury — before the tendon retracts and scars — is the standard pathway for active patients. Patients are seen at the practice from across Central Queensland. **About the condition.** [Distal biceps rupture](/education/elbow/distal-biceps-rupture/) is a complete tear of the biceps tendon at its insertion on the radial tuberosity. The mechanism is almost always a sudden, eccentric load — most commonly a heavy lift with the elbow flexed at around 90 degrees, with a weight that catches the patient off guard. The classic presentation is a 'pop' felt at the front of the elbow, sharp pain that settles surprisingly quickly, and a visible 'Popeye' deformity as the biceps muscle retracts up the arm. Weakness of supination — turning a screwdriver, opening a heavy door, lifting a coffee cup with the palm up — is the functional consequence. The injury is most common in mid-life men but does occur in women and at other ages. **When surgery is recommended.** Surgical repair restores supination strength (which doesn't recover without it) and is the standard pathway for active patients. The repair is easier and the outcomes better when performed within three to four weeks of injury, before the retracted tendon scars to surrounding structures — this is one of the few upper-limb injuries where prompt same-week referral genuinely matters. Older or low-demand patients can choose non-operative management, accepting a measurable loss of supination strength and a permanent Popeye deformity. Partial tears have a separate management algorithm that depends on the percentage of the tendon involved and the patient's functional demands. **What the procedure involves.** The repair fixes the retracted tendon back to a freshly prepared trough on the radial tuberosity, usually through a single anterior incision in the elbow crease using a cortical button and interference screw construct. A two-incision (Boyd-Anderson) approach is occasionally used for late-presenting cases or where the anterior anatomy is hostile. The procedure is performed under general or regional anaesthesia and typically as a same-day or short-stay case. Imaging (ultrasound or MRI) is obtained before surgery to confirm the tear pattern and exclude a partial tear that might be managed differently. Full clinical detail is on the [education page](/education/elbow/distal-biceps-repair/). **Recovery.** A hinged elbow brace is worn for the first six weeks with progressive range of motion under hand-therapy guidance. Passive flexion is unrestricted from day one; active flexion and supination are introduced at around two weeks. Light desk work resumes when the brace is comfortable and pain is controlled, often around two weeks; heavier loading is held off until 12 to 16 weeks, and return to gym work, contact sport or heavy occupational lifting waits for 4 to 6 months. The published literature on return to work in distal biceps repair averages around 14 weeks; sport and heavier activities tend to plateau at around 12 months from surgery. **Practice context.** Distal biceps repair is a time-sensitive injury — the practice triages 'pop on lifting' referrals within the same week wherever possible to keep the surgical option open within the four-week window. Elbow and hand therapy with Ruby Doolan at Extend Rehabilitation is coordinated for the day of the first dressing change and brace-protocol introduction, then continues weekly for the first month. Post-operative review at two and six weeks, then again before the four-month return-to-loading milestone. **MBS items:** - 47953 — Repair of distal biceps brachii tendon (Single item covering repair by any method (cortical button, interference screw, suture anchor, bone tunnels) as an independent procedure) **Frequently asked:** - *Can I leave a distal biceps rupture untreated?* Yes, but with a measurable functional cost. Non-operative management leaves the patient with a permanent Popeye deformity (the retracted biceps muscle bunched up the arm) and roughly a 30 to 40 per cent loss of supination strength compared with the uninjured side. For sedentary or older patients this trade-off is often acceptable. For manual workers, gym-active patients and any role that involves turning a screwdriver, lifting heavy objects with the palms up, or repeated supination loading, repair is the more functional choice. - *I felt a pop two months ago — is it too late to repair it?* Not necessarily, but the surgery becomes harder. The retracted tendon scars to surrounding structures and shortens, and a primary end-to-end repair may no longer be possible — a graft (semitendinosus or palmaris longus) is sometimes interposed to bridge the gap. Late repairs are still considered for active patients who want supination strength back, but the recovery is longer, the operation more involved, and the published outcomes a step behind acute repair. The decision to operate late is individual and is discussed at the consultation. - *How much does distal biceps repair cost? What does Medicare cover?* Distal biceps repair involves separate fees for the surgeon, anaesthetist, hospital and the surgical implant (cortical button and interference screw, or alternative construct). The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent. - *What are the complications I should know about?* The published complication rates for distal biceps repair are well characterised. Major complications occur in roughly 5 to 8 per cent of cases — most often heterotopic ossification (bone forming in the soft tissues), posterior interosseous nerve palsy (usually transient), and re-rupture. Minor complications — temporary numbness over the forearm, transient lateral antebrachial cutaneous nerve symptoms, wound problems — occur in around 1 in 5 patients. Reoperation rates run at roughly 4 to 5 per cent. The two-incision approach has historically been associated with more heterotopic ossification; the single-incision technique with more nerve symptoms. The specific risks are discussed at the consent process. - *When can I drive after distal biceps repair?* Driving requires a safe grip on the wheel and the ability to manage indicators and gears with both hands. Patients in a hinged elbow brace can usually drive an automatic vehicle once the brace is comfortable and the elbow can be brought to the wheel — typically two to three weeks. Manual cars take longer, particularly for gear-changes on the operated side. The practice does not certify fitness to drive for insurance purposes — driving fitness is a decision between the patient, the GP and the insurer — but the question is discussed at the post-operative review. - *When can I go back to the gym?* Light cardio (walking, exercise bike with no upper-limb loading) is reasonable from one to two weeks while the brace is on. Lower-body resistance work is reasonable from around six weeks once the brace comes off. Upper-body resistance, push exercises, pull exercises and any biceps loading are held off until around 12 weeks, then introduced progressively under hand-therapy guidance, with full-load gym work typically returning at 4 to 6 months. The published literature suggests strength plateau at 12 months, so high-level performance lifting may continue to improve through that period. --- ### Distal radius ORIF URL: https://www.cqupperlimb.com/conditions/distal-radius-orif/ Treats: Distal radius fracture Open reduction and internal fixation of distal radius fractures — most often using a volar locking plate — performed at Mater Private Hospital Rockhampton. The distal radius is the most common upper-limb fracture, and the sentinel fragility-fracture pattern in mid-life and older patients. Patients are seen at the practice from across Central Queensland. **About the condition.** [Distal radius fracture](/education/wrist/distal-radius-fracture/) is the most common upper-limb fracture, with a bimodal distribution — high-energy injuries in young adults (a fall from height, a sports impact, a road-traffic injury) and low-energy fragility fractures in older patients (a fall from standing height). The classic mechanism is a fall on the outstretched hand. A visible 'dinner-fork' wrist deformity is the giveaway when the fracture is displaced; undisplaced patterns are easy to miss without imaging. In older patients a distal radius fracture is often the first sign of underlying osteoporosis, and bone-density assessment is routinely arranged after the injury. **When surgery is recommended.** Stable, undisplaced or minimally displaced fractures heal in a well-moulded cast over four to six weeks. Surgery is offered when the fracture is displaced (volar or dorsal tilt outside the acceptable range, radial shortening, articular step-off), when the pattern is unstable on serial imaging, when there is intra-articular involvement, or when an active patient prefers earlier mobilisation. Older patients are now considered for fixation more readily than they were a decade ago — the published evidence on functional outcomes in patients over 65 supports surgery when the displacement is meaningful. CT is obtained where the intra-articular pattern needs better delineation. **What the procedure involves.** Open reduction internal fixation through a volar approach (Henry's approach between flexor carpi radialis and the radial artery) places a low-profile locking plate on the volar surface of the distal radius, with locking screws supporting the subchondral bone of the articular surface. Care is taken to keep the distal screw row at least 3 mm proximal to the subchondral bone in comminuted intra-articular patterns — placing screws too close to the joint surface is associated with worsening ulnar variance. Fluoroscopy confirms reduction and screw position; the volar capsule is repaired and the pronator quadratus closed over the plate. The operation typically takes 60 to 90 minutes under regional or general anaesthesia as a day or short-stay case. Full clinical detail is on the [education page](/education/wrist/distal-radius-orif/). **Recovery.** A removable wrist splint is worn for two weeks for comfort, with early hand-therapy-guided range of motion starting as soon as the swelling settles. The published evidence on early mobilisation after volar locking plate fixation shows DASH score improvements at six weeks that exceed the minimal clinically important difference — early movement is the rule, not cast immobilisation. Light desk work resumes around two weeks; driving is held off until the splint comes off and the wrist can be controlled safely on the wheel — typically four to six weeks. Heavier lifting and manual work is held off until twelve weeks, with full radiographic union usually confirmed at the three-month X-ray. The practice's full phase-by-phase rehabilitation plan is on the [distal radius fracture rehabilitation protocol](/education/rehabilitation/distal-radius-orif/) page. **Practice context.** Distal radius fractures are usually first seen in the emergency department or at the GP, where a closed manipulation under haematoma block (or in theatre under sedation) is often done at presentation to reduce gross deformity. The surgical referral comes a few days later when the swelling has settled enough to plan a definitive fixation. The practice triages distal radius referrals within the week to keep the surgical window short. Hand therapy with Ruby Doolan at Extend Rehabilitation is integrated into the post-operative pathway and continues for around 12 weeks. In older patients, bone-density assessment and a referral for osteoporosis management are arranged through the GP after the acute injury settles. **MBS items:** - 47370 — Intra-articular ORIF of distal radius (Open reduction with internal fixation when the joint surface is involved — the modal pattern for displaced distal radius fractures) - 47364 — Extra-articular ORIF of distal radius or ulna (Open reduction with internal fixation when the joint surface is not involved) **Frequently asked:** - *My wrist is in a cast — do I need surgery?* Not necessarily. A well-moulded cast is sufficient for many distal radius fractures — particularly stable, undisplaced patterns in older patients with sedentary lifestyles, and any pattern where the post-reduction imaging shows the fragments in an acceptable position. Surgery is offered when the fragments are displaced past acceptable thresholds, when the pattern is unstable (the fragments slip back into a poor position on serial X-rays through the first two weeks), when the joint surface is stepped, or when the patient is active enough to prefer earlier mobilisation. The decision is individual and is discussed at the consult with the imaging on screen. - *I'm over 70 — does it still make sense to fix my wrist?* Often, yes. The published evidence on distal radius fixation in older patients has shifted significantly over the last decade: while non-operative management remains a reasonable choice for many low-demand patients, internal fixation in older patients with meaningful displacement shows better grip strength, better range of motion and better DASH scores at one year than casting alone in several large studies. The decision depends on the displacement, the patient's functional demands and their general health. Age alone is not a contraindication to surgery. - *How much does distal radius fracture surgery cost? What does Medicare cover?* Distal radius ORIF involves separate fees for the surgeon, anaesthetist, hospital and the surgical implant (volar locking plate and screws). The practice quotes the surgical fee in writing before booking — the Medicare item, the rebate and the out-of-pocket gap each shown separately. Dr Hirpara's surgical fees follow the Australian Medical Association schedule, which is higher than the Medicare scheduled fee; the fees page explains why. Surgery does not proceed without itemised written informed financial consent. - *Will I need the plate removed later?* Usually no. The volar locking plates used in modern distal radius fixation are low-profile, designed to sit under the pronator quadratus muscle, and rarely cause symptoms. Plate removal is considered when the plate is prominent and causing flexor tendon irritation, when there is implant infection (rare), or when the patient is young and elects removal for personal reasons. Most patients keep their hardware for life with no problems. Removal — when done — is a small day-case procedure a year or so after the index operation. - *When can I drive after distal radius ORIF?* Driving requires a safe grip on the wheel and the ability to manage indicators and gears. With a wrist splint on, driving is not safe and is not recommended. Once the splint is removed — typically at four to six weeks — driving is reasonable when the wrist can grip the wheel firmly, perform an emergency stop without needing to protect the hand, and you are off prescription pain medication. The practice does not certify fitness to drive for insurance purposes — driving fitness is a decision between the patient, the GP and the insurer — but the question is discussed at the post-operative review. - *I had a fragility fracture — should I worry about my bones?* A distal radius fracture in a patient over 50 from a fall from standing height is often the sentinel sign of underlying osteoporosis. A DEXA scan and a discussion with the GP about bone-health management — vitamin D, calcium, exercise, and medication where indicated — is arranged routinely as part of the post-operative pathway. Treating the underlying bone density is what reduces the risk of the next fracture (most often a hip fracture in this group) — fixing the wrist alone doesn't address the cause. --- ## Education library (patient guides) Last generated: 2026-10-05T11:05:33Z. ### Elbow URL: https://www.cqupperlimb.com/education/elbow/ Region: elbow · region-landing Elbow problems grouped by theme — tennis and golfer's elbow, nerve compression, tendon ruptures, fractures and stiffness — with each condition beside the operation that treats it. ## Understanding your elbow How your elbow works Elbow anatomy: understanding the humerus, radius, and ulna – key to understanding elbow function and injury. Open → Elbow Arthroscopy Open → ## Tennis & golfer's elbow Tennis Elbow Tennis elbow (lateral epicondylitis) — causes, symptoms, and conservative treatment options for pain relief. Open → Tennis Elbow Release Tennis elbow release surgery — for persistent pain despite physiotherapy and other conservative treatments. Open → Golfer's Elbow Golfer’s elbow (medial epicondylitis) — causes, symptoms, and conservative treatment options. Open → Golfer's Elbow Release Open → ## Nerve compression Cubital Tunnel Syndrome Cubital tunnel syndrome causes ulnar nerve compression at the elbow — symptoms, diagnosis, and treatment options. Open → Cubital Tunnel Release Cubital tunnel release relieves ulnar nerve compression—addressing numbness/weakness in the ring & little fingers. Open → Radial Tunnel Syndrome Radial tunnel syndrome — causes forearm pain, weakness straightening fingers, and is distinct from tennis elbow. Open → Radial Tunnel Release Radial tunnel release relieves pain from PIN compression – distinct from tennis elbow, and how surgery helps. Open → Pronator, Lacertus and Anterior Interosseous Nerve Syndromes Median nerve trouble high in the forearm — forearm aching with hand tingling (pronator) or weakness pinching the thumb and index (AIN), and how each is treated. Open → Pronator and AIN Release Open → ## Tendon ruptures Distal Biceps Rupture Distal biceps rupture causes sudden elbow pain, bruising, and weakness—often needing surgical repair. Open → Distal Biceps Repair Distal biceps rupture repair — restoring elbow flexion strength and addressing the “Popeye” deformity. Open → Distal Triceps Tendon Rupture A rare tear of the triceps tendon at the back of the elbow — how to spot it, who is at risk, and why complete tears usually need early repair. Open → Distal Triceps Repair Open → ## Fractures, dislocation & instability Radial Head Fracture Radial head fractures — Mason classification, conservative management, and indications for fixation or replacement. Open → Radial Head Replacement Open → Olecranon Fracture Olecranon fractures — patterns, non-operative care, and tension-band or plate fixation. Open → Olecranon Fracture Fixation (ORIF) Open → Distal Humerus Fracture Open → Forearm Shaft Fractures (including Monteggia and Galeazzi) Open → Elbow Instability Elbow ligamentous and bony instability, including dislocation and the terrible-triad pattern. Open → Ulnar Collateral Ligament Injury (Tommy John Injury) The medial elbow ligament injury of throwers — how it presents, when rehab is enough, and what Tommy John reconstruction involves. Open → Elbow Ligament Reconstruction (Stabilisation) Open → ## Arthritis, stiffness & cartilage Elbow Osteoarthritis Osteoarthritis of the elbow — primary and post-traumatic, conservative and surgical options. Open → Elbow Arthroplasty Total elbow replacement — indications, implants, and recovery. Open → Stiff Elbow Release (Arthrolysis) Open → Osteochondritis Dissecans of the Capitellum A lateral elbow joint-surface problem in young throwers and gymnasts — how it is found, when it heals with rest, and when surgery is needed. Open → ## Bursitis Olecranon Bursitis Olecranon bursitis — causes, symptoms, and when to seek urgent medical attention for infection. Open → Olecranon Bursa Removal (Bursectomy) What olecranon bursectomy involves, why it is a last resort, and the honest wound-healing and recurrence picture. Open → ## Recovery and rehabilitation Blood Thinners Around Surgery How anticoagulants and antiplatelets work, and why the timing of stopping each before surgery differs — platelet turnover, half-lives and clot risk. Open → Cast and splint care at home Looking after a plaster or splint at home — keeping it dry, elevation, keeping joints moving, and the urgent signs of a too-tight cast. Open → Constipation and gut care after surgery Why constipation is common after surgery (especially with strong painkillers) and how to prevent and manage it. Open → Daily life after hand, wrist or elbow surgery Keeping a hand or wrist dressing dry, elevation to control swelling, and one-handed living after hand, wrist or elbow surgery. Open → Daily life after shoulder surgery Washing, dressing, sleeping and managing day-to-day with the operated arm in a sling after shoulder surgery. Open → Driving After Shoulder and Arm Surgery: When Is It Safe and Legal? After most shoulder surgery, including rotator cuff repair, you usually cannot drive for about six weeks, and not while your arm is in a sling. When it is safe and legal to get back to the wheel after hand, wrist, elbow or shoulder surgery. Open → Eating well for healing Everyday food to support recovery after surgery — protein, energy, healing vitamins, and preventing constipation. Open → Fasting Before Surgery: What You Can Eat and Drink, and Why Why you must stop eating before an anaesthetic, when you can still sip water, and what can happen if you do not fast. The clear fasting rules that keep your stomach empty and your lungs safe during surgery. Open → Flying and travel after surgery Clot risk, cast tightness at altitude, fitness to fly and the practicalities of travelling after upper-limb surgery. Open → Hand therapy basics What to expect from hand therapy, how often you'll go, and what good rehab looks like. Open → Heat vs Ice When ice helps, when heat helps, and how to use either safely on the upper limb. Open → Is my wound infected? How to tell normal healing from a wound infection after surgery — the warning signs and when to seek help. Open → Looking after your wound Dressings, showering, and signs of infection after upper-limb surgery. Open → Managing pain after surgery What pain to expect, how to use pain relief well, and when to call. Open → Melatonin After Shoulder Surgery Why we prescribe melatonin after shoulder surgery, what the trial evidence shows, the dose we use, and what to expect from it. Open → Mind, Stress and Recovery How stress, low mood, anxiety and worry about pain affect recovery and surgical outcomes — and what helps. Open → Preparing for Surgery General checklist for the days before upper-limb surgery — fasting, what to bring, medications. Open → Preventing Blood Clots After Surgery Reducing the risk of deep vein thrombosis after upper-limb surgery — mobilisation, hydration, medication. Open → Returning to sport Phased return to sport after upper-limb surgery, and when contact sport is safe again. Open → Returning to work When you can return to desk, light, and heavy work after upper-limb surgery. Open → Scar Management Massage, silicone, sun protection and the 12-month timeline for surgical scars to soften and fade. Open → Sleep, Pain and Recovery How sleep and pain affect each other, why surgery and shoulder problems disturb sleep, and what helps you rest and recover. Open → Swelling and elevation after surgery Why a hand or arm swells after surgery, how elevation and gentle movement control it, and when swelling is a warning sign. Open → The day of your surgery What to expect on the day of day-case upper-limb surgery, from arrival and meeting the team to waking up and going home. Open → Wearing and Sleeping in an Arm Sling How to sleep in an arm sling, get the sling position right, and look after it after shoulder, elbow or wrist surgery, including whether to keep the sling on overnight. Open → Your shoulder nerve block The nerve block we use for shoulder surgery — how it numbs your arm, why it controls pain so well, and what to expect as it wears off. Open → Your wound check and stitch removal What happens at the post-op wound check, dissolvable vs removable stitches, what removal feels like, and when to seek help sooner. Open → Explore Elbow in the evidence explorer → --- ### How your elbow works URL: https://www.cqupperlimb.com/education/elbow/anatomy/ Region: elbow · anatomy Elbow anatomy: understanding the humerus, radius, and ulna – key to understanding elbow function and injury. ## The main parts Your elbow is a hinge with a twist. It lets your arm bend and straighten, and it also lets your forearm rotate so your palm turns up or down. Three bones meet there: the humerus, which is the arm bone coming down from your shoulder, and the ulna and radius, which are the two bones of your forearm. The bony parts fit together closely. The lower end of the humerus has two rounded areas. One joins with the ulna to form the hinge, and this surface lines up with a groove in the ulna over almost half a circle of contact. The other rounded area joins with the radius to form a second joint. The tip of the ulna behind your elbow, called the olecranon, gives the triceps muscle a broad place to attach. A small bony bump at the front of the ulna, called the coronoid, helps stop the elbow shifting forward. Ligaments are strong bands that hold bones together. Your elbow has ligaments on both sides. The ones on the outside keep the elbow from tipping outward and hold the radius against the ulna. The ones on the inside keep it from tipping inward, which matters most when you throw or lift with your palm up. The joint capsule, a thin sleeve around the joint, adds support when your arm is fully straight or fully bent. Your muscles help too. They press the joint surfaces together and steady the elbow, especially when a ligament has been stretched or torn. Muscles and tendons move the elbow. Tendons are the cords that join muscle to bone. At the back, the triceps straightens your arm and attaches to the olecranon. At the front, the biceps bends your elbow and turns your palm upward, and the brachialis underneath it also bends the elbow. On the inside of the elbow, a group of flexor tendons shares one common attachment and bends your wrist and fingers. On the outside, a group of extensor tendons shares a common attachment and straightens your wrist and fingers. Two nerves, the radial nerve on the outside and the ulnar nerve behind the inner bump of your elbow, carry the signals that make these muscles work. ## How it all works together Your elbow works as one unit. The hinge part brings your hand to your mouth, lets you reach overhead, and lets you push up from a chair. The twist part turns your palm up to hold a bowl of soup or accept change, and turns it down to type or iron. The two joints share the work, so a problem in one often shows up as trouble with the whole elbow. Think of the bones as the frame of a door and the ligaments as the hinges holding it steady. The bones fit together so closely that they do much of the steadying themselves. The ligaments on each side take over when you push, pull, lift, or throw. The muscles around the joint add the final layer of support by squeezing the surfaces together as they work. Nerves and blood vessels run close by. The radial nerve wraps around the arm bone and reaches the outside of your elbow, carrying signals to the muscles that straighten your wrist and fingers. The ulnar nerve sits in a groove behind the inner bump of your elbow, which is why knocking that spot sends tingling into your little finger. The median nerve runs down the inner side of your arm beside the main blood vessel, then crosses the front of the elbow toward your forearm. All three pass near the joint, so they matter during any elbow surgery. ## Where things commonly go wrong The elbow takes strain in a few predictable places, and each one traces back to how that part is built. On the inside of the elbow, the ligament that stops the joint tipping inward does most of the work when you throw. That makes it the part that wears first in throwing sports. In children and teenagers, the growing bone near that inner bump is still soft, so repeated throwing can strain it before it has finished developing. The same force can also pull at the tendon attachment on the inner side of the elbow. On the outer side of the elbow, the rounded top of the radius takes the load when you fall onto an outstretched hand. Because it sits directly under the arm bone, it takes the impact first, which is why small breaks here are common. A harder fall can also tear the ligaments on either side of the joint at the same time. A dislocation happens when the whole joint slips out of place, usually during a fall onto a straight arm. The ligaments and the capsule around the joint take the damage, often starting on one side and tearing through to the other. Because the nerves and blood vessels run close past the joint, they can be affected too, which is why these injuries need careful checking. One less common pattern follows a fall where the arm is pushed sideways rather than straight. A small piece of bone at the front of the ulna breaks, and the ligament on the outer side tears with it. This combination can leave the joint sitting slightly out of line, and it is easy to miss early on. Finally, the ulnar nerve runs in a groove right behind the inner bump of your elbow, with little padding around it. That shallow spot is why this nerve is the one most often irritated when the elbow is injured or operated on. ## The bottom line Your elbow is built to be steady and to move at the same time. The bones fit together so closely that they hold the joint in place largely on their own, and the ligaments on each side take over when you push, lift, or throw. Because the hinge and the twist share one joint, a problem in either part often affects the whole elbow. Nerves and blood vessels pass close by, which matters when the elbow is injured or operated on. Knowing how the parts fit together helps you understand where pain comes from and why your surgeon checks movement, strength, and stability during an examination. --- ### Osteochondritis Dissecans of the Capitellum URL: https://www.cqupperlimb.com/education/elbow/capitellar-osteochondritis-dissecans/ Region: elbow · condition A lateral elbow joint-surface problem in young throwers and gymnasts — how it is found, when it heals with rest, and when surgery is needed. ## What you're feeling This usually shows up as a dull, aching pain on the outer side of the elbow, often hard to point to exactly. It tends to be worse with activity, especially throwing, gymnastics, or anything that loads the arm, and eases with rest. Many young athletes notice they can't fully straighten the elbow anymore; that loss of the last few degrees of extension is common and often appears before the pain becomes a real problem. If a piece of the joint surface has started to loosen, the elbow can begin to catch, click or lock, and it may swell after activity. A true locking episode (where the elbow jams and won't move for a moment) usually means a small fragment of cartilage and bone has broken free and is floating inside the joint. The condition most often affects teenagers who throw (baseball, cricket) or do gymnastics, where the outer elbow takes repeated pounding. ## What's actually happening The outer half of the elbow is a rounded knob of bone called the capitellum, capped with smooth cartilage. With repeated heavy loading through a growing elbow, a small patch of bone just beneath that cartilage can lose its blood supply and start to soften. This is osteochondritis dissecans, or OCD. The overlying cartilage may stay intact and heal, or the patch can crack, lift, and eventually separate into a loose body. Take care not to confuse this with a milder, self-correcting childhood condition called Panner's disease, which affects younger children (typically under 10), settles on its own with rest, and doesn't leave lasting damage. True OCD happens in older children and adolescents and can cause permanent joint damage if a fragment breaks loose. How the cartilage is doing matters enormously. A stable lesion (cartilage still firmly attached, growth plates still open) has a genuine chance of healing with rest alone. An unstable lesion (cracked, lifted, or already loose) generally won't heal on its own and usually needs surgery. ## What we can do about it Dr Kieran Hirpara leads our upper-limb service at Mater Private Hospital Rockhampton, where we guide patients from their initial GP referral through a clear assessment of their history, examination, and imaging. For long-standing elbow issues, we typically begin with non-operative care and move to surgery only if rest and rehabilitation do not provide enough relief. The first and most important step for a stable lesion is simply to stop the aggravating activity (no throwing, no weight-bearing on the arm) for several months, with a gradual return once the bone has healed on scans. In younger athletes whose growth plates are still open, many of these lesions heal completely this way. Rest is not "doing nothing"; it is the treatment. When a lesion is unstable, has already formed a loose body, or fails to settle with rest, surgery is usually recommended. This is almost always done through keyhole (arthroscopic) surgery and the choice depends on the lesion: - Tidying up and stimulating healing: removing the damaged fragment and making tiny holes in the exposed bone (microfracture) so a healing layer of new tissue forms. This works well for smaller lesions. - Fixing the fragment back down: if the loose piece is large and of good quality, it can sometimes be pinned or screwed back into place. - Resurfacing the defect: for large lesions, especially ones at the edge of the joint, healthy cartilage-and-bone plugs can be transplanted in to rebuild the surface (a graft procedure). Your surgeon decides between these based on the lesion's size, location and whether the cartilage is salvageable, usually guided by an MRI scan. ## What to expect The outlook is generally good, particularly when the problem is caught early and the lesion is still stable. Many young patients with stable lesions heal with rest and return to their sport. After surgery for unstable lesions, most patients get good pain relief and a worthwhile return of movement, and the majority of athletes are able to return to sport, though it can take several months and a structured rehabilitation programme. A few honest caveats. Larger lesions, those reaching the outer edge of the joint, and elbows where the growth plates have already closed tend to do less well and are more likely to need surgery. Some loss of full extension may remain, and over the long term a significant lesion can slightly raise the risk of elbow arthritis later in life, which is exactly why early recognition and protecting the joint matter so much. ## When to see someone - Persistent outer-elbow pain in a young thrower or gymnast that doesn't settle with a week or two of rest; get it assessed before pushing on. - Loss of full elbow extension: not being able to straighten the elbow fully is an early warning sign worth checking. - Catching, clicking, or the elbow locking up: this suggests a fragment may have loosened and needs imaging. - Swelling after activity that keeps coming back. - Any of these in a skeletally immature athlete deserves prompt attention, because lesions caught while the growth plates are still open have the best chance of healing without surgery. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Capitellar osteochondritis dissecans is worth the extra reading because it is largely a silent disease of the growing elbow: by the time it causes enough pain to bring a young thrower to a clinic, the lesion has often already advanced past the point where the simplest treatment works. ### It is commoner than the symptoms suggest Screening tells a different story from clinic attendance. Among 2,433 adolescent baseball players, the prevalence of capitellar osteochondritis dissecans including latent cases was 3.4%. Affected players had started playing at earlier ages, had played for longer, and had experienced more elbow pain [1]. "Including latent cases" is the important qualifier. A meaningful share of these lesions were found by looking rather than because the player complained, which means pain is a late and unreliable signal in a group of athletes who are, in any case, disinclined to report it. ### Delay changes what can be done The consequence shows directly in the treatment options. Across 258 adolescents, advanced lesions were observed in patients with longer symptom duration, though once a lesion required surgery, it was the treatment specifics rather than the duration that best correlated with return to sport [2]. Two radiographic findings predict that non-operative management will fail: enlargement of the radial head and advanced skeletal age on the throwing side compared with the non-throwing side, both associated with advanced-stage disease across 245 patients [3]. Both describe an elbow that has already remodelled under load, which is a structural statement rather than a symptomatic one. This is the argument for imaging a young thrower with persistent elbow pain rather than managing it as a soft-tissue problem, and for taking a side-to-side difference seriously. ### For a stable lesion, the smaller operation is enough Where the fragment is stable and the defect small, the debate is between simply cleaning the defect and additionally drilling the bone beneath it to encourage a fibrocartilage repair. Across 327 patients, both debridement and microfracture produced substantial improvements in pain, range of motion, outcome scores and return to sport, and because comparable mid-term outcomes were achieved with debridement alone, debridement is a reasonable approach for relatively small defects [4]. ### For a large or unstable one, the calculus changes Where the fragment has detached or the defect is large, the surface has to be replaced rather than tidied, usually by transferring a plug of cartilage and bone. This works, with an important qualification. Pooling 492 patients, return to sport after operative management was high overall, and patients were more likely to return to their highest pre-operative level after osteochondral autograft transfer than after debridement or fixation [5]. But a 2024 review of 470 patients following autograft transfer, while confirming high return-to-sport rates, found athletes should be counselled about returning at a lower level of performance or needing to change position, and that lateral lesion location may negatively affect outcomes [6]. Both statements are true at once, and the distinction matters for a young athlete: returning to the sport is likely; returning to the same role in it is not guaranteed. Lesion size and position, not the choice between reasonable operations, carry most of the prognosis. --- ### Cubital Tunnel Release URL: https://www.cqupperlimb.com/education/elbow/cubital-tunnel-release/ Region: elbow · operation Cubital tunnel release relieves ulnar nerve compression—addressing numbness/weakness in the ring & little fingers. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your arm, and arrange imaging or nerve tests where needed. Cubital tunnel syndrome is the name for pressure on a nerve at the inside of your elbow. This pressure causes numbness or tingling in your little finger and the ring finger side of your hand, and it can worsen when your elbow is bent for long periods. For a long-standing problem like this we usually try non-operative care first: activity change, physiotherapy or hand therapy, and splinting. We consider surgery when those steps have not given you enough improvement. The operation is called cubital tunnel release. It eases the pressure on the nerve so your symptoms can settle. More than 90% of people who have this surgery are cured or show improvement. We will talk through what matters to you and decide together whether it is the right next step. ## Before the operation Once surgery is booked, we will give you clear instructions to follow. You will need to stop eating and drinking for seven hours before your operation. We ask for seven hours rather than six so your surgery time can be brought forward if the theatre list runs early. Some medications may need to be paused before surgery, and your surgeon will tell you which ones and when. Bring a list of everything you take, including tablets, injections and creams. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing with a sleeve that is easy to remove. Imaging such as X-rays, ultrasound or MRI scans may have been arranged to help plan your operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, but most people do not. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist, a doctor who looks after your comfort and safety during the operation. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. You will wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. Many people go home the same day. Before you leave, we will explain how to care for your arm and what to expect over the coming days. ## What the operation involves The operation is called a cubital tunnel release. Your surgeon makes one cut on the inner side of your elbow, just behind the bony bump you can feel there. Through this cut, your surgeon finds the ulnar nerve, the nerve that has been squeezed and is causing the tingling in your little and ring fingers. The nerve runs through a tunnel of tissue near the elbow, a bit like a cable running through a narrow conduit. Your surgeon opens that tunnel so the nerve is no longer pinched. This is called a decompression, which means taking pressure off the nerve. Sometimes the nerve also needs to be moved to a new position at the front of the elbow so it stays out of trouble when you bend your arm. Your surgeon will decide during the operation whether releasing the tunnel alone is enough, or whether moving the nerve will serve you better. The choice depends on your examination and what your surgeon finds. Once the nerve is free, your surgeon closes the cut. A fine self-adhesive mesh is laid over the wound first, holding the skin edges together. A liquid skin glue is then painted over the mesh, where it sets and seals everything as one closure. It stays on for roughly one to two weeks, then lifts and peels away by itself, so there is nothing to take out. ## After the operation You will wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. This is a day case, so you will go home the same day. Pain is usually mild to moderate and can be managed with simple pain relief; we will explain what to take before you leave. Your arm will have a soft dressing over the wound, and you can move your fingers, hand and shoulder as comfort allows. There is no cast or brace, and you will not need a sling unless we advise one. Please arrange for someone to stay with you for the first 24 hours after you get home. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Most people notice the tingling in their little and ring fingers settles quickly after surgery. Many report sleeping better within days, because the night-time discomfort eases early. If your symptoms were severe, the numbness or weakness may take longer to fade. Feeling can return gradually, and that can take weeks, months or longer depending on how much the nerve was squeezed. Most people with severe symptoms still improve, even if the recovery is slow. Your arm will have a soft dressing, which we leave on for about 10 days. You can move your fingers, hand and shoulder as comfort allows. Keep the wound dry and follow the care instructions we give you before you go home. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Your hand therapist will guide your exercises and make a splint for you if one is needed. Gentle movement helps the nerve glide and keeps your elbow from stiffening. You can do most daily tasks at home as soon as it feels comfortable, using your other arm where needed. Once the dressing comes off and the wound has settled, you can return to light activities. You can usually drive once any splint is off and you can hold the wheel and react quickly without pain; see our page on Driving after upper-limb surgery. Return to work and sport depends on what your job and hobbies involve, and the table above gives typical timeframes. Recovery varies between individuals. Your timeline may differ, and we will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the original symptoms do not settle, or they come back after a period of relief. You might notice the tingling or numbness in your little and ring fingers returning, or aching on the inner side of your elbow that will not go away. If this happens, bring it up at your next review. Further surgery to release the nerve again is possible, and many people still gain improvement from it, though results are less predictable than the first operation. The wound can become infected. Watch for increasing pain around the cut, redness that spreads out from it, swelling, or discharge. If you notice any of these, contact the clinic promptly. Infections are usually treated with antibiotics and wound care, so early review matters. A small nerve that runs near the inner elbow can be irritated during surgery. This can leave an area of numbness or a tender spot on the inner side of your forearm, or occasionally a small painful lump where the nerve has healed into scar tissue. If you notice new numbness or tenderness in that area, mention it at your review appointment. The ulnar nerve itself can occasionally become unstable after release, shifting backwards and forwards over the bony bump as you bend your elbow. You might feel or see a flicking at the inner elbow. Tell your surgeon if you notice this. Smoking can affect how well your recovery goes, so it is worth raising this with us before surgery. A previous fracture or dislocation of the same elbow can also make further surgery more likely, which we will discuss when planning your operation. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up early, and we would rather hear about them sooner than later. Call us if you have a fever, if the redness around the wound is spreading, or if there is discharge from it. Call us too if your pain keeps getting worse rather than easing, or if new numbness appears in your hand. Go to emergency if you have calf swelling or pain, shortness of breath, sudden severe pain in your arm, or you cannot move your arm at all. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Cubital Tunnel Syndrome page. --- ### Cubital Tunnel Syndrome URL: https://www.cqupperlimb.com/education/elbow/cubital-tunnel-syndrome/ Region: elbow · condition Cubital tunnel syndrome causes ulnar nerve compression at the elbow — symptoms, diagnosis, and treatment options. ## What you're feeling Cubital tunnel syndrome happens when the ulnar nerve, the nerve that runs through a tunnel on the inside of your elbow, gets squeezed. The classic feeling is numbness and tingling in your little finger and the ulnar side of your ring finger, the side closest to your little finger. Some people also feel a burning pain around the bony bump on the inner side of the elbow. Aching pain in the elbow or upper forearm is possible, though pain is not the main feature for most people. Bending your elbow makes things worse. Holding a phone to your ear, resting your elbow on a desk or armrest, or sleeping with your elbow curled up can all set symptoms off. Many people notice the tingling at night, and some are woken by it. Straightening the elbow usually settles the feeling again. As the condition progresses, the hand itself can become affected. You might find your grip feels weak or clumsy. Buttons, keys, jar lids and pens can become harder to manage. In more advanced cases, the small muscles in the hand can waste away, which can make fine tasks genuinely difficult and can cause the fingers to sit in a clawed position. Some people notice a snapping sensation over the inner side of the elbow when it bends, which happens when the nerve slides out of its groove. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## What's actually happening The ulnar nerve is one of the main nerves of your arm. It runs from your neck, behind the inside of your elbow, and down into your hand. It supplies feeling to your little finger and the ring-finger side of your hand, and it powers most of the small muscles inside the hand. At the elbow, the nerve passes through a short tunnel formed by bone and a layer of tough gristle. Think of the nerve as a garden hose sitting in a narrow channel. When your elbow is straight, the hose sits loosely and blood flows along it freely. When your elbow bends, the channel tightens around the hose and the nerve gets stretched and squeezed at the same time. The tunnel narrows most once your elbow bends past a right angle, which is why holding a phone or curling up at night brings the tingling on. Over time, that repeated squeezing and stretching reduces the blood supply inside the nerve. A nerve needs to slide and stretch by more than 2 cm as you move your shoulder, elbow, wrist and fingers, so anything that pins it down causes friction. The nerve becomes irritated and swollen, and its signals start to travel poorly. That is why you feel numbness and tingling in the little and ring fingers, and why grip weakness and clumsiness follow if the squeezing continues. Several things can crowd the tunnel. A band of gristle between the two bones of the elbow can thicken and press on the nerve. A small extra muscle that some people are born with can sit over the tunnel and take up room. In a few people, the nerve slides out of its groove every time the elbow bends, which is the snapping some people feel. The good news is that freeing the nerve usually settles things. More than 90% of people who have surgery are cured or improve. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a history, examine your elbow and hand, and arrange tests where they are needed. Because this is a long-standing problem, we usually try non-operative care first and consider surgery when that has not given enough improvement. The first step is changing how you use your elbow. Avoiding long periods of bending, resting your elbow on a desk or armrest, or holding a phone to your ear can all help. A splint that keeps your elbow from curling up at night is another option. Hand therapy aims to settle the irritation and keep the nerve moving and gliding as it should. Give these changes a fair trial before deciding anything further. Anti-inflammatory medication can help settle the ache around the elbow. We do not offer injections for this condition. If non-operative care has not given enough improvement, surgery is the next step. The usual operation is a simple release: the roof of the tunnel is opened so the nerve is no longer squeezed. Moving the nerve to the front of the elbow is done only rarely, for a nerve that slips out of its groove. If you have already had a release and your symptoms have come back, we set expectations carefully: results of a second operation are on average modest, and symptoms that persist often reflect the state of the nerve itself. Rehabilitation after surgery is hand therapy with Ruby Doolan at Extend Rehabilitation, who will guide your exercises and make any splint you need. ## What to expect Cubital tunnel symptoms tend to build slowly rather than arrive all at once. Early on, the tingling comes and goes, often at night or after long spells of elbow bending. Left alone, the squeezing continues, and the numbness and weakness can become permanent as the nerve itself wears down. That is why it is worth acting before weakness or muscle wasting appears. With treatment, the outlook depends on how severe things were to begin with. Your symptoms before treatment are the best guide to how much you can improve. If your symptoms are mild, relief often comes quickly. If they are severe, the nerve recovers more slowly: feeling and strength can take weeks, months, or even years to return, and some of the change may be gradual rather than a single clear turning point. Many people with severe symptoms still improve substantially, even when recovery is slow. Most people who need surgery do well. Nerve function improves in most arms measured after surgery, and by three months after surgery the results of the simple release and the nerve-moving operation are much the same. Infection happens in about 2.17% of cases. If you notice a hot, red, swollen and painful finger, hand or arm, especially with a fever, go to the emergency department the same day. If your first operation does not settle things, a second one helps some people but results are on average modest, and lasting symptoms often reflect the state of the nerve itself rather than anything that can be fixed. About 75% of people have less pain and tingling after revision surgery. If you already play sport at an overhead or throwing level, most people return to sport after surgery, though not everyone gets back to their previous level. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone See your GP or ask for a specialist review if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand. The signs that matter most for this condition are numbness and tingling in the little finger and ring-finger side of the hand, a burning ache around the inner elbow, and weakness or clumsiness in the grip. Weakness and small-muscle wasting in the hand are the signs to act on quickly, because once they appear they can become permanent. A snapping feeling over the inner elbow is also worth reporting. After surgery, a finger, hand or arm that becomes hot, red, swollen and painful, especially with a fever, needs the emergency department the same day; no GP referral is needed. If you cannot reach the clinic out of hours or on a weekend, go to your nearest emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Cubital tunnel syndrome is worth the extra reading because the surgical debate has now largely been settled in favour of doing less, and the finding runs against a strong intuition that a nerve which slips out of place must be put somewhere safer. ### The simplest operation performs as well as the most involved There are two broad approaches. Simple decompression opens the roof of the tunnel and leaves the nerve where it lies. Transposition moves the nerve to the front of the elbow, either under the skin or beneath muscle, so it no longer sits in a groove that stretches when the elbow bends. Transposition is the larger operation and the more mechanically satisfying idea. Pooling 906 patients, there was no statistically significant difference in clinical outcome between simple decompression and either form of transposition, a trend favoured transposition, but it did not reach significance [1]. Comparing the two forms of transposition against each other across 352 patients, the evidence was insufficient to identify an optimum technique [2]. Medial epicondylectomy, removing the bony ridge the nerve runs behind, has not resolved the question either: a review of 886 patients found the literature of limited methodological quality, not permitting firm conclusions about its efficacy against simple decompression [3]. ### And where the nerve is already unstable, the extra surgery costs something This is the finding that most changes practice, because it addresses the one situation where transposition seems obviously indicated: the nerve that already subluxes over the bony prominence as the elbow bends. Across 768 patients, decompressed and transposed groups showed similar symptomatic improvement, with higher complication rates in the transposed group [4]. The authors are careful about the limitations, few studies report instability at all, and the designs are biased — but the direction is the opposite of the intuition. Moving an unstable nerve did not produce better symptom relief, and it produced more problems. ### Keyhole versus open is not the important question Where a decompression is being done, the choice of technique attracts more attention than it deserves. Across 981 patients, endoscopic and open cubital tunnel release showed similar outcomes, similar complication profiles and similar reoperation rates [5]. ### Why revision surgery is a different proposition If a first operation does not settle the symptoms, expectations for a second should be set carefully. A review of 192 patients undergoing revision surgery for refractory cubital tunnel syndrome found average functional outcomes, with transposition the most common index procedure, and variability across studies preventing any determination of an optimal revision procedure [6]. That is a meaningful difference from carpal tunnel release, where a second look often finds an incomplete release to correct. Here, persistent symptoms more often reflect the state of the nerve itself before the first operation, how long it was compressed, and how much muscle wasting had already occurred, than a technical failure that can be undone. It is the strongest argument for not deferring treatment once weakness or wasting appears. --- ### Distal Biceps Repair URL: https://www.cqupperlimb.com/education/elbow/distal-biceps-repair/ Region: elbow · operation Distal biceps rupture repair — restoring elbow flexion strength and addressing the “Popeye” deformity. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your arm, and arrange scans if they are needed. A scan can confirm whether the tendon that joins your lower biceps muscle to the forearm bone has torn fully or partly. This operation reattaches that torn tendon to the bone where it came from. It is usually offered for a complete tear, especially if you are active, work with your hands, or play sport. For a partial tear we usually try non-operative care first, such as activity change, physiotherapy or hand therapy, splinting, or injections. Surgery comes in when those have not given enough improvement. The aim is to restore the strength you use to bend your elbow and turn your palm up, so you can use your arm normally again. ## Before the operation Your surgeon will tell you which medicines to stop before surgery and when. You will need to stop eating and drinking seven hours beforehand, so we can bring you forward if the theatre list runs early. Arrange for someone to drive you home afterwards. Bring a list of your current medicines and wear comfortable, loose clothing. Scans such as an X-ray, ultrasound or MRI help plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist there. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. When it is finished, you wake up in the recovery area. Nurses watch over you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves The operation is done through one cut at the front of your elbow, over the spot where the tendon tore. Your surgeon moves the tissues aside to reach the forearm bone, which has a small raised spot where the tendon used to attach. The torn tendon end is tidied up and stitched with strong stitches. Your surgeon then drills a small tunnel through the bone and threads the stitches through it. A small metal button travels with them and comes to rest flat against the far side of the bone, where it acts as an anchor. The stitches pull the tendon down into the tunnel, against fresh bone. That is where the tendon heals back on, reattaching it to the place it tore away from. The wound is closed with stitches and covered with a dressing. The dressing stays on for about 10 days; the 'After the operation' section explains what happens then. ## After the operation You wake up in the recovery area, then move to the ward. Most patients stay one night in hospital after this operation, though some are able to go home the same day. Your arm rests in a sling for comfort, and gentle movement starts early. Nurses will give you pain relief and keep you comfortable. Someone should stay with you for the first 24 hours after you get home. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. You can move around the house and do light tasks with your other hand. ## Recovery For the first few days your elbow will be sore and swollen. This settles gradually. Pain relief and rest help, and keeping your hand raised on a pillow eases the throbbing. Some bruising down the forearm is common. Your arm rests in a sling for comfort, and gentle movement starts early rather than your elbow being held still. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby directs your exercises and makes any splint you need. Early on, you will do simple movements to keep the elbow and wrist from stiffening. Light tasks around the house are fine with your other hand. You should not lift with the operated arm until your therapist clears you. As the weeks pass, the swelling settles and your movement returns. Your therapist will add gentle strengthening as the tendon heals. Once you are out of the sling and your surgeon clears you, you can start driving again. See our page on driving after upper-limb surgery. Returning to work depends on what your job involves; desk work comes back sooner than heavy lifting. Sport comes later, once your strength and grip are back. Most people get back to work and the activities they enjoy. Recovery varies from person to person, so your timeline may differ. Your surgeon and your hand therapist will guide you at each stage. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the repaired tendon does not hold. If you feel a sudden pop or snap in your elbow, or the strength you had been regaining suddenly drops away, contact the clinic straight away. This is uncommon, and when it happens it usually occurs in the first few weeks after surgery. Following your therapist's instructions about lifting and activity lowers the chance of it happening to you. Nerves that run near the elbow can be irritated during surgery. If this happens you might notice tingling, numbness, or a patch of skin that feels dull or fuzzy. Some people notice weakness when straightening their fingers or thumb. This is often temporary, but tell your surgeon or therapist at your next review if you notice any of these changes. If the numbness or weakness is severe or getting worse, call the clinic rather than waiting. The elbow can also become stiff if it does not move as planned. You might find it hard to straighten your arm fully or to bend it as far as before, and turning your palm up may feel blocked. Keep up your gentle movements and tell your therapist early if progress stalls. If stiffness becomes a real problem, your surgeon will discuss the next steps with you. Bring up anything unusual at your review, even if it seems minor. Things that settle on their own are worth mentioning too, because early attention makes problems easier to sort out. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if you have a fever, or the wound becomes more red, swollen or starts to ooze. Call us if your pain suddenly gets worse. If you feel a pop or snap in your elbow, call us straight away, or go to the emergency department if it is after hours. Go to emergency if you have calf swelling or pain, or shortness of breath, as these can be signs of a blood clot. Go to emergency if you lose feeling in your arm or hand, or cannot move it. If you are unsure, call us. We would rather hear about a small worry than miss something that needs quick attention. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Distal Biceps Rupture page. --- ### Distal Biceps Rupture URL: https://www.cqupperlimb.com/education/elbow/distal-biceps-rupture/ Region: elbow · condition Distal biceps rupture causes sudden elbow pain, bruising, and weakness—often needing surgical repair. ## What you're feeling A distal biceps rupture happens in a single moment, not over months. It usually comes from a sudden, unexpected straightening force on an arm bent at 90 degrees, such as catching something heavy as it drops or gripping hard while your arm is pulled straight. Many people feel or hear a pop at the front of the elbow when it happens. The tendon normally tears away from its anchor point on one of the forearm bones. You may notice the shape of the muscle changes, because it pulls up the arm and bunches near the middle. Straight away, the front of your elbow is likely to be painful and swollen. Bruising is common and can appear around the elbow and forearm over the next day or two. Bending and twisting the arm hurts, so you may find yourself avoiding lifting the kettle, turning a doorknob, or gripping a steering wheel firmly. Turning your palm upwards against resistance, like using a screwdriver, is often the hardest movement. Some people can still bend the elbow because other muscles help with that, which can make the injury feel less severe than it is. In the first days and weeks, the pain is often worse with movement and can ache at night. It gradually settles as the body starts to heal around the torn tendon. The swelling and bruising ease over a couple of weeks, but the strength loss does not recover on its own, because the tendon has pulled away from the bone and cannot reattach itself where it belongs. A few warning signs need fast action. Go to the emergency department the same day if your hand or fingers turn pale, cold, white or blue, or if you suddenly lose feeling or movement in the hand after the injury. See your GP or ask for a specialist review if the pain is not settling, is getting worse over weeks, or wakes you at night. ## What's actually happening The biceps muscle runs down the front of your upper arm and turns into a strong cord, the tendon, just before the elbow. That tendon anchors onto a small bump on one of the forearm bones, the radius. Its job is to twist your forearm so your palm turns upwards, and to help bend the elbow. When the tendon tears, it pulls away from that bump on the bone and retracts up the arm. The muscle is still healthy, but it is no longer connected to the bone it moves, so its pulling power goes nowhere. Twisting the palm upwards is the movement that suffers most, because no other muscle can take over that job. Bending the elbow usually recovers better, because a second muscle under the biceps helps with that. Think of a rope anchored to a winch. If the rope snaps off the drum, the winch motor still runs, but nothing turns. The rope does not drift back and tie itself on. It needs to be reattached. Left alone, the torn end does not knit back to the bone where it belongs. The gap fills with scar tissue instead, which holds things together but does not restore strength. Surgery reattaches the tendon end to its original anchor point so the connection can heal solidly again. The tear usually happens in the dominant arm of men in their forties to sixties, most often during a single heavy effort with the arm bent and the palm facing up, such as lifting weights. The tendon almost always tears right off the bone rather than splitting along its length, though partial tears that leave some of the tendon attached can also occur. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some distal biceps tears can be managed without an operation, and others need surgery soon after they happen, so prompt assessment matters. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic, we take a history, examine both elbows, and arrange imaging where it helps. An X-ray is the usual first check, and an MRI scan can confirm whether the tendon is torn and how badly. Surgery is recommended from the outset for a complete tear, where the tendon has pulled fully off the bone. It is usually the right choice for people whose work or sport needs strong twisting of the forearm, such as labourers and athletes. The operation reattaches the tendon to its original anchor point so strength and function can return. Repair using a small button fixation restores nearly normal strength and function, and surgery has a low rate of serious complications. Most minor problems after repair are areas of numbness that settle with time. The repair works best soon after the injury, ideally within about 3 weeks, because the tendon retracts up the arm and the space it came from scars over. Delayed repair is occasionally possible, but it is much more challenging and may need a tendon graft to restore length. For a partial tear, where some of the tendon is still attached, non-operative care is sometimes a reasonable choice. It involves resting the arm in a sling or splint, protecting the tear while it heals, and a staged return to movement with your hand therapist. This path trades some strength for avoiding surgery, and that trade-off is a genuine shared decision between you and us. If the weakness in twisting your palm upwards would not be acceptable for your work or daily life, surgery may suit you better. Whichever path you take, the early weeks share the same basics. Pain control, protecting the arm while it heals, and hand therapy at the right stage. After surgery, your hand therapist directs your recovery and makes any splint you need; rehabilitation with Ruby Doolan at Extend Rehabilitation starts soon after the operation, and early gentle movement is well tolerated. ## What to expect Healing after a distal biceps rupture is a slow build, not a quick fix. The tendon needs time to knit back to the bone, and the strength comes back gradually over months rather than days. In the first weeks the focus is protecting the arm while it heals, with pain and swelling settling much as they did in the early days after the injury. If you have surgery, most people are back at work without any change to their duties, and the average time to return to work is about 14 weeks. Sport takes longer. About 95% of athletes return to sport, and 82% get back to their preinjury level of competition, at around 40 weeks depending on the sport. Strength in bending and twisting the arm can come back to near-normal levels. Some people notice a small difference compared with the arm before the injury, particularly with repeated twisting. If your tear is managed without surgery, the arm is rested in a sling or splint while it heals, and you build movement back up in stages with your hand therapist. This path leaves some lasting weakness in turning the palm upwards, which is the trade-off discussed earlier on this page. Most people recover well, but it is honest to know what can go wrong. The main risks after repair are nerve injury, most often a patch of numbness that settles with time, stiffness in the elbow, and the repair tearing again. The chance of the repair tearing again is low at 1.5%, and when it happens it is usually within 3 weeks of surgery. New bone can sometimes form across the forearm and limit twisting, though strength can be maintained with no measurable difference when this happens. A few signs need fast action. Go to the emergency department the same day if your hand or fingers turn pale, cold, white or blue, or if you suddenly lose feeling or movement in the hand after the injury. See your GP or ask for a specialist review if pain or stiffness is not settling, is getting worse over weeks, or stops you using your arm. ## When to see someone Seek urgent care if your arm looks obviously deformed, if there is an open wound over the injury, or if you cannot use the limb at all. Go to the emergency department the same day if your hand or fingers turn pale, cold, white or blue, or if you suddenly lose feeling or movement in the hand after the injury. These signs are covered earlier on this page. For everything else, start with your GP. See your GP or ask for a specialist review if the pain is not settling, or if swelling, movement or strength are not improving week on week as the healing progresses. A sudden pop at the front of the elbow with a change in the shape of the muscle is worth having looked at promptly, because repair works best within about 3 weeks of the injury. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Distal biceps rupture is worth the extra reading because it is one of the few injuries on this site where surgery demonstrably restores something that healing without it does not, which makes the trade-off unusually concrete, and the complication figures unusually relevant. ### Here, the operation does change function Most of the comparisons on this site end in "no significant difference". This one does not. Pooling 2,481 patients, operative treatment produced superior elbow and forearm strength and endurance, along with better DASH and Mayo Elbow Performance scores, than non-operative management [1]. The reason is anatomical rather than statistical. The distal biceps is the main supinator of the forearm, the muscle that turns the palm upwards against resistance. When the tendon detaches from the radius it retracts up the arm, and the muscle can no longer generate that rotation, whatever else heals around it. Elbow flexion is partly covered by brachialis, so bending the elbow recovers reasonably well; supination has no comparable understudy. That is why the loss shows up most clearly in endurance rather than a single maximal effort. Repeated turning, a screwdriver, a door handle, a steering wheel over a long drive, is where the difference is felt. ### The complication rate is the other half of the decision An operation that reliably restores strength is still an operation, and this one has a well characterised profile. In the largest analysis, covering 3,091 patients, the major complication rate was 4.6% [2]. Most of what occurs is minor and temporary, numbness over the back of the forearm from traction on a small sensory nerve is the commonest, and usually recovers. The major complications are the ones that shape technique: permanent nerve injury, heterotopic ossification (new bone forming across the forearm and restricting rotation), and re-rupture. ### Two approaches, and the trade-off is genuine The repair is done either through a single incision at the front of the elbow or through two smaller ones, front and back. Both reach the same bone from different directions, and each avoids a different hazard. Across 2,622 patients there were no significant differences in functional scores. The single-incision approach gave greater flexion and pronation range of motion and a lower risk of heterotopic ossification and reoperation, while the double-incision approach was more favourable on other measures [3]. A 2025 meta-analysis of 2,833 patients found the same shape: single incision associated with more favourable objective function and fewer structural complications, double incision with reduced risk of certain sensory nerve injuries [4]. Read together, the choice is between the nerve at the front and the bone at the back. Neither approach is wrong, and both sets of authors call for higher-quality randomised trials before the question is considered closed. ### Why the timing matters more than it does elsewhere Because the tendon retracts and the space it occupied scars, delay makes reattachment harder, and where direct repair is no longer possible, reconstruction with a graft becomes necessary. This is the practical reason a distal biceps rupture is treated with more urgency than most tendon injuries, and why a sudden painful pop at the front of the elbow, with visible change in the shape of the muscle, is worth prompt assessment rather than a period of watchful waiting. Non-operative management remains a legitimate choice, particularly for lower-demand arms and for people who do not need forceful repeated supination. It is a decision to accept a measurable deficit, made deliberately, not a lesser version of the same result. --- ### Distal Humerus Fracture URL: https://www.cqupperlimb.com/education/elbow/distal-humerus-fracture/ Region: elbow · condition A distal humerus fracture is a break in the lower end of the arm bone, just above the elbow. It usually happens from a fall onto the arm, a direct blow, or a sudden heavy load through a straightened elbow. Many people describe feeling or hearing a snap at the moment of injury. ## What you're feeling A distal humerus fracture is a break in the lower end of the arm bone, just above the elbow. It usually happens from a fall onto the arm, a direct blow, or a sudden heavy load through a straightened elbow. Many people describe feeling or hearing a snap at the moment of injury. The pain is usually immediate and strong. Your elbow may swell quickly, and bruising often appears over the next day or two. The joint may look out of shape if the broken pieces have shifted. You will probably not want to move the arm, and simple tasks like turning a door handle, lifting a kettle, or getting dressed become hard. The elbow feels unstable, and trying to use it makes the pain worse. In the first days and weeks, the pain is often there at rest and at night, and it sharpens with any attempt to move the elbow. As healing starts, this gradually settles, though the elbow can stay stiff and tender for some time. The elbow is a complex joint, and breaks here can be hard to heal, especially when the bone is thin or broken into several pieces. Some people, particularly those over 65, develop problems during recovery, so your team will keep a close eye on how the arm is progressing. Your surgeon will talk with you about the treatment that suits your fracture and your health. The usual approach is surgery to realign and hold the broken pieces, called open reduction and internal fixation, which means putting the pieces back in place and fixing them with plates and screws. For some older people, especially where the break cannot be rebuilt, a total elbow joint replacement may be considered instead. For others, particularly those who are medically unwell or have lower demands on the arm, treatment without surgery can also work well. ## What's actually happening The lower end of your arm bone, the humerus, widens just above the elbow into two supporting columns of bone. Between them sit two smooth, rounded surfaces that form the moving part of the elbow joint. One lets your elbow bend and straighten. The other lets your forearm rotate so you can turn your palm up and down. A break here is like cracking the forked end of a wooden branch close to where it joins the trunk. The joint surfaces are covered in a smooth, slippery layer of cartilage, and the pieces of bone are held together by strong straps called ligaments. When the bone breaks, those surfaces can separate and shift, so the joint no longer glides smoothly. That is why the arm feels unstable and will not carry a load. The elbow also has narrow grooves and spaces that the moving parts pass through. If a broken piece shifts into one of these spaces, or if healing bone or scar tissue fills them in, the elbow can lose movement. Extra bone sometimes forms around an injured elbow as it heals, and this can further limit bending and straightening. Bone heals by knitting back together, with new bone forming across the break over weeks to months. For that to work well, the pieces need to be close together and held still. If the pieces have shifted apart, or the joint surface is broken into several fragments, they are unlikely to line up on their own. Surgery puts the pieces back in place and holds them with plates and screws while they knit. When the joint surface is broken into too many small pieces to rebuild, replacing the elbow joint may be the better option. Your surgeon will examine the arm and scans to see how many pieces there are, whether they have shifted, and whether the joint surface is affected. That picture decides which treatments make sense for you. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we examine your arm, review your X-rays and, where the break is complex, arrange a CT scan to see the pattern clearly. Then we talk through the options with you. For some fractures, treatment without surgery works well. This suits breaks where the pieces have barely moved and the elbow is still stable, and it can suit older people whose health or the state of the bone makes an operation a poor fit. It involves a sling, splint or cast to hold the arm still while the bone knits, with check X-rays along the way to confirm nothing has shifted. Movement is brought back in stages with physiotherapy once healing allows. For people over 65, this path can allow continued independence without severe stiffness or a loose, unstable elbow. Surgery is recommended from the outset when the break runs into the joint, the pieces have shifted apart, or the elbow will not hold steady on its own. It is also the usual choice when you need the arm to carry real loads again. The aim is to put the pieces back in their normal position and hold them with plates and screws so the bone can knit in the right shape and the elbow can start moving early. When the joint surface is broken into too many small pieces to rebuild, replacing part or all of the elbow joint may be the better option, particularly for older people with thin bone. The choice between repairing and replacing is a genuine shared decision, and we will talk through what each path means for your arm and your life. Whichever path you take, the first weeks share the same priorities. Pain is managed so you can rest and sleep. The arm is protected while the bone heals, following the plan we give you for what it can safely do. Physiotherapy starts at the right stage, early after surgery and once healing allows without it, to rebuild bending, straightening and forearm rotation. We will see you along the way to check how the arm is coming along. ## What to expect Healing takes weeks to months. New bone forms across the break and gradually knits the pieces together, and the elbow stiffens easily while this happens, so movement is rebuilt in stages with physiotherapy once healing allows. Most people find the strong early pain settles over the first weeks, though the elbow can stay tender and tight for some time. If your fracture is treated without surgery, the arm is held still while the bone knits. For people over 65, this path can allow continued independence, with no severe stiffness or a loose, unstable elbow. If you have surgery, the plates and screws hold the pieces in place while they heal, and movement starts early. In the long term, some people who have had their elbow repaired develop mild to moderate wear-and-tear arthritis in the joint, which can show up on X-rays many years later. Recovery looks different for each person. Daily tasks like dressing, cooking and lifting usually come back in stages as pain settles and movement returns. When you can go back to work or sport depends on your job, your fracture and how your healing progresses, and we will talk with you about this at your review appointments. It is honest to say that problems can occur. Roughly one in three people over 65 with this fracture develop a complication during recovery. One possibility is irritation or altered feeling in the ulnar nerve, the nerve that passes behind the elbow and can cause tingling in the little and ring fingers; this can occur soon after surgery or appear later. Extra bone sometimes forms around the healing elbow, which can limit how far it bends and straightens. The repaired pieces can also shift or fail to hold, particularly if the bone is thin, and smoking makes this more likely. When the joint is replaced rather than repaired, the new joint usually works well over the long term, though some people need further surgery down the track. Your team will watch for these problems at your check-ups and will talk with you about anything that shows up. ## When to see someone Seek urgent care if your arm looks out of shape, if there is an open wound over the elbow, if you feel numbness or tingling in your fingers, or if you cannot use the arm at all. These signs need assessment straight away. If the pain is not settling, or if swelling, movement or day-to-day function are not improving week on week as the bone heals, see your GP or ask for a specialist review. Recovery rarely moves in a straight line, but each week should bring some change. If nothing is shifting, it is worth having the arm checked rather than waiting it out. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. A distal humerus fracture is worth the extra reading because it sits at an awkward junction: it is one of the more complication-prone fractures in the upper limb, the standard surgical exposure involves deliberately breaking a second bone, and in older patients the case for operating at all is less settled than you might assume. ### The complication rate is higher than the reputation The largest pooled analysis of intra-articular distal humeral fractures treated by open reduction and internal fixation gathered 2,362 patients, and its conclusion was blunt: complications and reoperations are more frequent than previously understood [1]. That is a useful corrective. These fractures are usually presented as difficult but solvable, and the technical result on an X-ray is often excellent. The gap between a good radiograph and a good elbow is wider here than almost anywhere else in the limb, and the literature had been under-reporting it. ### The exposure has its own cost To see the joint surface properly, the usual approach detaches the olecranon by cutting across it, an olecranon osteotomy, and repairs it at the end. It is an elegant solution to a real problem of access, and it is not free. Pooling 1,700 osteotomies, 447 complications were reported. Wound infection occurred in 4.2% and problems with the osteotomy uniting in 3.7% [2]. So a decision to use this exposure is a decision to accept a small but definite chance of a second problem at a site that was intact before surgery. The authors' framing is the right one: the risk must be part of the decision to perform the osteotomy, not a footnote to it. For what it is worth, the choice between posterior exposures appears to matter less than the decision to use one. A meta-analysis of 1,258 patients with complete intra-articular (AO/OTA type C) fractures compared olecranon osteotomy against triceps-reflecting, triceps-splitting and triceps-sparing approaches and found comparable overall outcomes, with most measures showing no statistically significant difference [3]. ### In older patients the question is genuinely open There is a strong instinct that a displaced intra-articular fracture must be fixed. In older adults that instinct is not well supported by comparative data. A systematic review of 1,838 older patients compared surgical and non-surgical management and found that each of the treatment modalities studied produced a reasonable level of elbow function [4]. The authors are careful about why that is not a recommendation to stop operating: the included studies were largely non-comparative and carried considerable risk of bias. It is an absence of evidence for superiority rather than evidence of equivalence. Still, the practical implication holds. For a frail patient with low functional demand, a plan built around comfort and early movement rather than anatomical reconstruction is a defensible choice supported by outcomes that are not obviously worse, and it avoids every complication described above. ### What this means for you Three things follow. Expect the recovery to be about motion, not bone healing, the bone is the easy part. Ask specifically what exposure is planned and what it commits you to. And if you are older, or have limited demands on the arm, ask directly whether non-operative treatment is reasonable in your case, because the honest answer may be yes. --- ### Distal Triceps Repair URL: https://www.cqupperlimb.com/education/elbow/distal-triceps-repair/ Region: elbow · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. The triceps is the muscle at the back of your upper arm; its tendon anchors onto the point of your elbow and is what straightens your arm. When that… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. The triceps is the muscle at the back of your upper arm; its tendon anchors onto the point of your elbow and is what straightens your arm. When that tendon tears completely away from the bone, surgery is usually needed to restore that movement. This operation, called a distal triceps repair, reattaches the torn tendon. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We assess your history, examine your elbow, and arrange imaging where needed to confirm the diagnosis. For a partial tear, non-operative care such as physiotherapy may be tried first. Surgery follows when that has not given enough improvement, or when the tear is complete. It is often recommended for active people, workers who use their arms heavily, and athletes wanting to return to competition. Repair aims to restore strength and function, with most people back at work by about 2.2 months and 89.3% returning to sport. ## Before the operation Your surgeon will confirm the tear with scans before planning your repair. This usually starts with X-rays, which show whether a small piece of bone has pulled away with the tendon. An MRI scan may be used to look closely at the tendon itself. Before surgery, you will need to stop eating and drinking for seven hours beforehand. We ask for seven hours rather than six so your operation can be brought forward if the theatre list runs early. Your surgeon will tell you which medicines to stop and when. Bring a written list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing on the day. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist, the doctor who puts you to sleep and manages your pain during the operation. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the repair is performed. Afterwards, you will wake up in the recovery area, where nurses keep a close eye on you while the anaesthetic wears off. Once you are stable, you will either go to a ward or go home, depending on the procedure and how your recovery is going. If you go home the same day, you will need the person you arranged earlier to drive you. ## What the operation involves The triceps tendon attaches to a small patch of bone at the point of your elbow. In a complete tear, the tendon has pulled away from that bone, a bit like a rope coming loose from its anchor point. The aim of the operation is to stitch the tendon back down onto the bone where it belongs. Your surgeon makes a cut at the back of your elbow to reach the torn tendon. The tendon is then reattached to its natural attachment spot on the bone using small anchors placed into the bone, with strong stitching that holds the tendon down under even tension. This restores the normal shape and position of the tendon's attachment, which gives the repair its strength. Some repairs use a technique that covers the whole attachment area with two rows of anchors, like stitching a hem down with two parallel lines. Others use anchors made entirely of stitching material, which hold the tendon just as firmly as standard anchors. Your surgeon will choose the method that suits your injury. Once the tendon is secure, the surgeon checks that the repair moves smoothly, then closes the cut with stitches and applies a dressing. You will keep that dressing on for about 10 days, as described in the recovery section. The operation itself is straightforward in concept: bring the torn tendon back to the bone and hold it there firmly enough that it can heal. What happens next, how quickly you can move and use the arm, is covered in the recovery section that follows. ## After the operation You will wake up in the recovery area, where nurses watch you closely as the anaesthetic wears off. Your arm will rest in a simple sling for comfort. The elbow is not locked in place; gentle movement starts early. Pain relief is tailored to you, and the nurses will keep you comfortable. Someone should stay with you for the first 24 hours after you get home. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Most people walk and move around on the day of surgery, taking it gently. ## Recovery For the first few days your elbow will be sore and swollen. This settles gradually. Rest, keeping your hand raised when sitting, and the pain relief prescribed for you all help. Your arm rests in a simple sling for comfort, but the elbow is not locked still, and gentle movement starts early. Hand therapy is a big part of your recovery. Your sessions are with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she guides your exercises and makes any splint you need. Early on, the focus is on protecting the repair while your elbow regains its movement. As the tendon heals, the exercises build up to restore strength for straightening your arm against resistance. Day to day, you will manage light tasks at home with your other hand while the repair settles. You will not drive while your arm is in the sling, and you need to be able to hold the wheel with both hands and react in an emergency stop, with no strong pain medication on board, before you drive again. Our guide to driving after upper-limb surgery explains this in more detail. Milestones come as events rather than dates. Once the swelling settles, bending and straightening feel easier. When your therapist clears your strength work, you start loading the arm. Most people return to work and sport at the same intensity they had before the injury. Your timeline may differ; your surgeon and Ruby will guide you. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The most serious problem is the repair tearing again. You might feel a sudden pop or give in the back of your elbow, followed by weakness when you try to straighten your arm against something. Some people notice swelling and bruising over the point of the elbow, similar to how it felt when the tendon first tore. If this happens, contact the clinic straight away. Your surgeon will examine the elbow and arrange scans to check whether the repair has held. Some problems show up around the wound itself. Watch for pain that keeps getting worse rather than easing, redness that spreads out from the wound, or fluid leaking through the dressing. Fevers or feeling generally unwell alongside these signs also matter. If you notice any of these, call the clinic the same day rather than waiting for your next visit. Occasionally a repair needs a further operation. This might be because the tendon has torn again, or because something else about the repair is not settling the way it should. You would usually know about it through ongoing pain, weakness or a feeling that the elbow is not recovering as expected. Raise this at your review appointment, or contact us sooner if things feel clearly wrong. Recovery from these problems can take longer than the original plan, and some people need more time away from work or normal activity than they first expected. Your surgeon will talk you through what has happened and what the next steps are if this affects you. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most recoveries go smoothly, but some signs need quick attention. Call us if you have a fever, or if redness or discharge around the wound keeps increasing. If you feel a sudden pop with weakness when straightening your arm, call us straight away, or go to the emergency department if it is after hours. Go to emergency if you have sudden severe pain in the elbow that does not settle with your pain relief. Go to emergency if your calf becomes swollen or painful, or if you become short of breath. Go to emergency if you lose feeling in your arm or hand, or if you cannot move the limb. --- ### Distal Triceps Tendon Rupture URL: https://www.cqupperlimb.com/education/elbow/distal-triceps-rupture/ Region: elbow · condition A rare tear of the triceps tendon at the back of the elbow — how to spot it, who is at risk, and why complete tears usually need early repair. ## What you're feeling The triceps is the big muscle at the back of your upper arm. Its tendon anchors onto the point of the elbow (the olecranon) and is what lets you straighten your arm. When that tendon tears away from the bone, the injury usually happens in a single moment: often a fall onto an outstretched hand, or a heavy lift or push that suddenly gives way. At the time you may feel a sharp pain or a "pop" at the back of the elbow. Afterwards the area becomes swollen and bruised, and the back of the elbow is tender. The most telling sign is weakness when you try to straighten the arm against gravity or resistance: pushing a door open, pressing up out of a chair, or lifting overhead may feel weak or impossible. Sometimes you (or your doctor) can feel a soft gap or dip in the tendon just above the point of the elbow. If only part of the tendon has torn, you may keep some straightening power but still have pain and weakness. This is an uncommon injury (the triceps is the least often ruptured of all the body's tendons), which is partly why it can be missed at a first assessment. ## What's actually happening The triceps tendon has pulled, partly or completely, off its attachment on the olecranon. A complete tear means the muscle is no longer firmly connected to the bone, so the force it generates can no longer be passed on to straighten the elbow. A partial tear leaves some fibres attached, so some strength remains. These tears almost always happen when the tendon is loaded while the muscle is contracting hard: the arm is forced to bend at the very moment you are trying to straighten or brace it, for example. Some things make the tendon more likely to give way: it is far more common in men, especially those who lift weights; anabolic steroid use weakens tendons and is a recognised risk; and steroid injections around the elbow, repeated elbow (olecranon) bursitis, and some medical conditions such as long-standing kidney disease can all leave the tendon more fragile. Occasionally a small flake of bone is pulled off with the tendon, which actually helps doctors confirm the diagnosis on an X-ray. ## What we can do about it Dr Kieran Hirpara is an upper-limb surgeon at Mater Private Hospital Rockhampton who leads our approach to managing this condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We begin with a clinic assessment, including a history, examination, and imaging where needed, to establish the diagnosis. The first step is making the diagnosis. Alongside the examination, an X-ray is taken to look for that tell-tale flake of bone, and an ultrasound or MRI scan is usually used to confirm whether the tear is partial or complete and how far the tendon has pulled back. Treatment then depends on how much tendon is torn and how much you need to use the arm: - Small partial tears (less than about half the tendon) in people with lower physical demands can often be managed without surgery: a period in a splint with the elbow slightly bent, followed by a gradual return to movement and strengthening. - Complete tears, partial tears that leave you weak, and tears in active or physically demanding people are usually best treated with surgery to reattach the tendon to the bone. This is done by passing strong stitches through small bone tunnels or by anchoring the tendon back onto its footprint with special implants. Repairing it early, before the tendon scars and shortens, gives the best result. ## What to expect When a torn triceps tendon is repaired in good time, the results are generally very good: most people regain strong, reliable elbow extension and get back to work and sport. After surgery the elbow is protected for a few weeks and then gradually mobilised, with strengthening introduced later, so a full return to heavy lifting takes a few months rather than weeks. Your team will guide the pace. As with any operation there are some risks to be aware of. The main ones are the tendon pulling loose again (re-rupture), which is why the early protection and a staged return to load matter, and problems with healing of the skin over the point of the elbow, where the tissue is thin. Stiffness and temporary weakness while the muscle rebuilds are normal parts of recovery. ## When to see someone - A sudden pain or pop at the back of the elbow after a fall or a heavy lift, followed by swelling and bruising. Get it assessed promptly. - Difficulty or weakness straightening the elbow against gravity or resistance, or being unable to push up out of a chair with that arm. - A soft gap or dip you can feel just above the point of the elbow. - Ongoing pain and weakness at the back of the elbow that is not settling, even if you can still straighten the arm; a partial tear can behave this way. Earlier assessment gives more treatment options and better results. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Distal triceps rupture is worth the extra reading for a reason that is unusual on this site: it is rare enough that the evidence base is small, and knowing how small is itself useful when weighing what you are told. ### The evidence is thin, and honestly reported as such The largest systematic review of surgical management covers 560 patients [1]. It found that patients undergoing repair experience improvement in outcomes, but with a moderate reported risk of re-rupture or complication, and, importantly, that heterogeneity in rupture patterns, surgical procedures and outcome measures made it difficult to establish which technique is superior [1]. For comparison, the shoulder and knee conditions on this site draw on pooled populations in the tens of thousands. Here the entire literature amounts to a few hundred patients across a mixture of injury patterns. That does not mean the treatments do not work. It means confident statements about small differences between them are not supported, and should be treated with scepticism wherever you encounter them. ### What repair does achieve is well documented Where the evidence is more consistent is on the headline question. Across 318 patients, more than 90% of an active-duty military population, athletes and the general workforce returned to sport or to their respective occupations after distal triceps repair [2]. That population matters to the interpretation. These are people with physically demanding roles whose return is objectively verifiable rather than self-reported, which makes the figure more informative than a similar number drawn from a general population. ### One technical comparison does separate Against the general finding that techniques cannot be distinguished, one comparison did show a difference. Across 56 patients, patient-reported outcomes were favourable for both suture-anchor and transosseous-tunnel repair, but suture anchor repair showed significantly better results for isokinetic strength testing, complication rates and retear rates [3]. The sample is small, and it should be read as a signal rather than a settled conclusion, which is precisely the point the larger review makes about this literature as a whole. ### Why prompt diagnosis matters here The triceps is the only muscle that straightens the elbow against resistance, so a complete rupture is functionally significant in a way partial tears are not. Complete tears are optimally treated with surgical repair, particularly when performed acutely [4]. Two features make this injury easy to miss. Some extension is often preserved through the remaining attachments, so the arm does not appear obviously useless; and the swelling and bruising at the back of the elbow can be attributed to the fall itself. The practical test is resisted extension against gravity, being unable to hold the arm straight against a downward push, rather than simply being sore, is the finding that matters. --- ### Elbow Arthroplasty URL: https://www.cqupperlimb.com/education/elbow/elbow-arthroplasty/ Region: elbow · operation Total elbow replacement — indications, implants, and recovery. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your elbow, and arrange imaging such as X-rays or scans if they are needed. For long-standing elbow problems we usually try non-operative care first: changing how you use your arm, hand therapy, splinting, and injections. Surgery is considered when those measures have not given you enough improvement. Elbow replacement means the worn surfaces of your elbow joint are removed and replaced with artificial parts. It is usually offered when pain is felt through the whole movement of the elbow rather than only at the ends, or when the joint has become unstable or badly damaged by wear-and-tear arthritis, rheumatoid arthritis, or an old injury. The main goal is relief of pain, with better movement and use of your arm. We will discuss the benefits and the risks with you, and the decision to go ahead is one you make together with us. ## Before the operation Once your operation is booked, we will give you clear instructions to follow in the days before. You will need to stop eating and drinking seven hours before your operation, so we ask for a little longer than some hospitals in case your theatre time moves earlier. Bring a list of all your current medications, and we will tell you which ones to pause and when. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing with sleeves that slide over your elbow easily. Imaging such as X-rays or scans may be arranged beforehand to help plan the operation. If you have other medical conditions, you may also need blood tests or a review with the anaesthetist, the doctor who gives your anaesthetic. Most people need neither. ## On the day On the day of your operation, you come to the hospital's surgical admissions unit. There you are checked in and prepared for theatre. You will meet the anaesthetist, the doctor who gives your anaesthetic. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. When it is finished, you wake up in the recovery area. Nurses there monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves Dr Hirpara performs elbow replacement through a single cut at the back of your elbow. Through this opening, your surgeon removes the worn-out joint surfaces and prepares the bone to take the new parts. The replacement used here is the Nexel total elbow. One stemmed part is cemented into the upper arm bone and another into one of the forearm bones. The two parts are joined in the middle by a hinge, so they stay connected as your elbow bends and straightens. The moving surfaces are lined with a hard-wearing plastic bearing. Because the two halves are linked, the new elbow does not depend on your own ligaments to hold it steady. If only one side of your joint is worn, the alternative is a humeral hemiarthroplasty. This replaces just the worn end of the upper arm bone and leaves the rest of your own joint in place. We will explain which option suits your elbow before you decide. At the end of the operation, the tissues are closed in layers and the skin edges are brought together. A fine self-adhesive mesh is laid over the closed wound first, holding the skin edges together. A liquid skin adhesive is then painted over the mesh, where it sets to seal the whole thing. This forms one closure rather than glue with a separate dressing on top. It stays on for roughly one to two weeks and then lifts and peels away by itself, so there is nothing to be taken out. You will wake up in the recovery area with a dressing over the elbow, which we ask you to keep on for about 10 days. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You will wake up in the recovery area, then move to the ward. Nurses will check on you regularly and give you medicine to keep you comfortable. Your arm will rest in a simple sling for comfort, which comes off for exercises and washing. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. You will be encouraged to move around and do your usual daily tasks within your limits. Please arrange for someone to stay with you for the first 24 hours. ## Recovery For the first few days your elbow will be swollen and tender, and this is normal. Rest, keeping your hand raised when you can, and the pain medicine we give you will ease it. The swelling settles gradually over the following weeks. Your arm rests in a simple sling for comfort, which comes off for exercises and washing. You will be encouraged to do your usual daily tasks within your limits from early on. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby directs your exercises and makes any splint you need, including a night splint to keep your elbow straight while you sleep if that helps. You will not be able to lift heavy things for a while, and we will give you a weight limit to follow. If the tendon at the back of your elbow was moved during the operation, you will also need to avoid straightening your arm against resistance for a time. Once the wound has sealed, you start gentle bending and straightening movements. As movement returns, everyday tasks like eating and dressing become easier. Most people get back to desk work and light daily tasks in the ranges shown in the table above, and heavier work, sport and the gym take longer. Once your surgeon clears you, typically at the six-week review, you can drive again; see our page on driving after upper-limb surgery. Everyone heals at their own pace, so your timeline may differ. We will see you regularly to check your progress, and your surgeon and therapist will guide you at each step. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Infection is the complication we watch for most closely after an elbow replacement. It can show as a deep, throbbing pain that does not ease with simple painkillers, redness that spreads out from the wound, or fluid or pus leaking from it. You may also feel feverish. Call the clinic the same day if you notice any of these signs. Infection around a new elbow joint can be hard to clear, so acting early matters. Treatment may mean a course of antibiotics through a drip, a washout of the joint, or in some cases further surgery to replace the parts. The artificial parts can also work loose from the bone over time, or the plastic bearing can wear. You might notice a new clicking or grinding feeling, pain that returns after a good stretch, or a sense that the elbow is less steady than it was. If this happens, bring it up at your next review. Imaging will show whether the parts need attention. Sometimes the bone around the new joint can crack. This usually causes sudden pain and swelling in the arm after a stumble or knock. Call the clinic if this happens. The nerves that run past the elbow can be irritated during surgery. You may feel tingling, numbness, or pins and needles in the little and ring fingers, or weakness in the hand. Numbness and weakness in the first 24 hours after a nerve block are expected. Once the block has worn off, call the clinic if you have numbness, or cannot move your arm, hand or fingers. A wound can occasionally break down or heal slowly, and the tendon at the back of the elbow can become weak or stiff. If the elbow will not bend or straighten as expected during recovery, we will assess it at your review. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems after an elbow replacement are picked up early, and we would rather hear from you than have you worry at home. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it. Call us the same day too if your pain keeps getting worse despite your pain medicines. Go to the emergency department if you have swelling or pain in your calf, or shortness of breath or chest pain. These can be signs of a blood clot. Go also if your fingers or hand turn pale, cold, white, blue or dark, as this can mean a problem with blood flow. Numbness and weakness in the first 24 hours after a nerve block are expected. Once the block has worn off, call the clinic if you have numbness, or cannot move your arm, hand or fingers. If you cannot reach the clinic, out of hours or on a weekend, go to your nearest emergency department. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Elbow Osteoarthritis page. --- ### Elbow Arthroscopy URL: https://www.cqupperlimb.com/education/elbow/elbow-arthroscopy/ Region: elbow · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your elbow, and arrange scans where they are needed. For long-standing problems we usually try non-operative care first, such as activity change, physiotherapy or hand therapy, splinting, and injections. Surgery comes into the conversation when those steps have not given you enough improvement. Elbow arthroscopy is keyhole surgery. The surgeon works inside the joint through small cuts, using a thin camera to see the whole elbow clearly. We suggest it when there is a clear problem inside the joint that can be treated this way, such as loose pieces of bone or cartilage that catch and lock, a stiff elbow, or damage after an injury. It is not suited to every elbow problem, so we only offer it when it fits your diagnosis. The aim is less pain, freer movement, and a steadier elbow in daily life. ## Before the operation In the weeks before surgery we confirm the plan with scans. Most people have already had an X-ray, which is the basic picture of the bones. Some also need an MRI scan, which shows the soft tissues such as ligaments, tendons and cartilage, or an ultrasound. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, the doctor who gives your anaesthetic. Most people need neither. On the day, stop eating and drinking seven hours beforehand. We ask for seven hours so we can bring your operation forward if the theatre list runs early. Your surgeon will tell you which of your usual medicines to skip. Bring a written list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing with sleeves that slide over the elbow easily. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You then meet the anaesthetist, the doctor who gives your anaesthetic. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. Afterwards you wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Once you are stable, you either move to a ward or go home the same day, depending on the procedure and how your recovery is going. ## What the operation involves Elbow arthroscopy is keyhole surgery. Your surgeon makes two or three small cuts around the elbow, each about a centimetre long. One cut holds a thin camera, and the others let small instruments reach the joint. Before the instruments go in, about 25 to 30 mL of fluid is placed inside the joint. This fluid opens up a working space so the camera can see clearly. The cuts are placed away from the main nerves and blood vessels that run past the elbow, and your surgeon maps out the bony landmarks on your skin first to place each cut safely. What happens inside depends on your diagnosis. Loose pieces of bone or cartilage that catch and lock can be removed. If the elbow is stiff, tight tissue around the joint can be released to free up movement. Damaged cartilage can be smoothed, and in some cases a small piece of bone or cartilage can be fixed back in place with absorbable pins that dissolve over time. Because the camera gives a clear view of the whole joint, your surgeon can also treat problems that were not visible on the scans. The small cuts are closed with stitches and covered with a dressing. The operation is done through keyhole cuts rather than one long opening, so there is less disturbance to the soft tissues around the elbow than with open surgery. ## After the operation You wake up in the recovery ward, where nurses keep an eye on you while the anaesthetic wears off. Your arm will be in a sling or a simple dressing, and you can move around as soon as you feel steady. Pain relief is planned before you leave theatre, so tell the nurses if your elbow is sore and they can adjust it. Someone should stay with you for the first 24 hours after you get home. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your elbow will be sore and swollen. This settles gradually. Rest, keeping your hand raised when you can, and the pain relief prescribed for you all help. Many people find the discomfort is at its worst early on and eases steadily as the swelling goes down. You will go home with your arm in a sling or a simple dressing. You can use your hand for light tasks as soon as it feels comfortable, such as eating, typing or doing up buttons. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she will guide your exercises and make any splint you need. The exercises keep your elbow and wrist moving while everything heals, and they matter as much as the operation itself. Follow them as directed and tell your therapist if a movement causes sharp pain. Everyday activities come back in stages. Once the swelling settles, you will notice your grip feels stronger and reaching becomes easier. When your surgeon is happy with how the elbow is moving and healing, you will be cleared to drive; our guide to driving after upper-limb surgery explains the rules that apply, including not driving while your arm is in a sling and being off strong pain medication. Work and sport resume when you can manage them without pain, and your surgeon or therapist will tell you when that point has arrived. Recovery varies from person to person. Your timeline may differ, and your surgeon and hand therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Nerve irritation is the problem seen most often. You might notice tingling, pins and needles, numbness, or a patch of skin that feels different. This is usually temporary and settles on its own. Tell your surgeon at the next review if it appears. Infection can develop in the days after surgery. Watch for a deep, throbbing pain that does not ease with simple painkillers, redness spreading out from the wound, or fluid leaking through the dressing. If you see any of these, call the clinic straight away. A deep infection needs prompt treatment. Some things make infection more likely. If you have diabetes, if you smoke, or if you carry extra weight, your risk is higher. A steroid injection into the joint, either shortly before surgery or at the end of the operation, also raises the risk. Your surgeon will weigh all of this with you beforehand. Rarely, a nerve injury can be permanent. This is uncommon, but when it happens the effects last a lifetime. Your surgeon will discuss this risk with you before you consent to surgery. Sometimes bone forms where it should not, inside or around the joint. This is called heterotopic ossification. You might feel a firm lump near the elbow, or notice the joint not bending or straightening as far as it did. Mention it at your review so it can be checked. Other problems are uncommon but known. The camera or an instrument can touch and scuff the smooth surface of the joint. A small channel of fluid can form from the joint out to the skin. An instrument can break inside the joint. The cuff used during surgery can press on the arm and briefly irritate the skin beneath it. If you feel unwell in the days after surgery, or something about your elbow does not seem right, call the clinic rather than waiting for your next appointment. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up early, and we would rather hear about them the same day than have you wait. Call us if your elbow becomes hot, more swollen or more painful, if redness spreads from the wound, or if fluid leaks through the dressing. Call us if you feel feverish, if tingling or numbness gets worse instead of easing, or if you cannot move your hand or fingers as you could before. Go to a hospital emergency department if you have sudden severe pain, new swelling in your calf, or shortness of breath. These can signal a blood clot, and they need checking straight away. If something simply does not feel right, call us. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Elbow arthroscopy is worth the extra reading because the published complication rate for it is not one number but a range so wide it looks like an error, and understanding why explains most of what matters about the operation. ### The same operation, two very different answers A systematic review pooling 16,815 elbow arthroscopies reported a median complication rate of 3%, with a range across studies of 0% to 71% [1]. Reoperation followed the same pattern: median 2%, range 0% to 59% [1]. A separate meta-analysis of 14,289 procedures concluded, reasonably, that elbow arthroscopy is a relatively safe operation with low complication rates [2]. Both are correct. The reconciliation is in the first review's own finding: higher complication rates occur after more complex surgery [1]. "Elbow arthroscopy" is not one operation. Removing a loose body from a capacious joint and releasing a contracted capsule millimetres from the ulnar and radial nerves share a name and an instrument, and almost nothing else. A quoted risk figure is close to meaningless unless it is attached to the specific procedure being done. ### Why the elbow is not the knee The elbow has the tightest relationship between joint and nerve of any joint routinely scoped. The ulnar, radial and median nerves all lie within millimetres of standard portal sites, and the working space is small, smaller still in exactly the stiff, contracted elbows that most need the operation. That anatomy is why transient nerve symptoms dominate the complication tables, and why the risk climbs with the extent of the release rather than with the time taken. ### Where arthroscopic technique has been compared with open For arthritic elbows, a systematic review of 1,097 patients found good mid-term function after debridement arthroplasty, with no increase in complications using an arthroscopic technique compared with open [3]. That is a genuine equivalence result rather than a demonstration of superiority. For tennis elbow, a review of 1,604 patients comparing open, arthroscopic and percutaneous release found that open and arthroscopic releases may give better function than percutaneous, while pain was lower with the arthroscopic and percutaneous approaches. The risk of complications was similar regardless of technique [4]. The pattern across both: arthroscopy is not safer or more effective in itself. Where it wins, it wins on the recovery around the operation, not on the result of it. ### An honest negative Adding arthroscopy to another operation "to have a look" does not pay off. In a meta-analysis of 2,118 patients, routine diagnostic arthroscopy performed before ulnar collateral ligament reconstruction did not significantly reduce later surgery for other valgus extension overload problems [5]. Looking is not the same as finding something worth treating, and each additional portal carries the nerve risk described above. --- ### Elbow Instability URL: https://www.cqupperlimb.com/education/elbow/elbow-instability/ Region: elbow · condition Elbow ligamentous and bony instability, including dislocation and the terrible-triad pattern. ## What you're feeling Your elbow may feel loose, as if it might slide out of place, or it may keep giving way when you push or pull on it. Some people notice this after a fall onto an outstretched hand. Others have had a dislocation in the past and the joint has never felt quite right since. The pain depends on which part of the elbow is affected. On the inner side of the elbow, you might feel a sharp ache when you throw, lift, or swing something like a racquet or hammer. Throwing athletes often feel it during the hard forward phase of a throw, and some hear a pop and cannot keep going. On the outer side, the elbow may feel unstable when you push up from a chair, do a push-up, or lean on your hand at a table. The pain can flare when you straighten the elbow fully, and some people notice clicking or a feeling that the joint is catching or locking. Stiffness is common. You may find you cannot fully straighten the arm, and tasks that need a straight elbow become hard: reaching up to a high shelf, carrying a tray, or pushing yourself out of a low chair. Gripping and twisting can be uncomfortable too, so opening jars or turning a door handle may take more effort than usual. If you throw or play overhead sport, you may notice your performance slipping. Your throws lose speed and stamina, and the elbow aches after training rather than recovering overnight. The inner elbow can be tender to touch, and the ache sometimes spreads toward the funny bone nerve on that side, with tingling or a weak grip. Some symptoms point to a joint that is not holding together well. If your elbow needs to be held at a bent angle to stay in place, or it slips out repeatedly, that needs prompt attention rather than waiting. ## What's actually happening Your elbow is built to be a very snug joint. The end of the arm bone has deep grooves that the bones of the forearm slot into, a bit like a hinge sitting in a well-shaped bracket. That shape does most of the work of holding the joint together. Strong straps of ligament on the inner and outer sides of the elbow then act like guy ropes on a tent, keeping everything lined up as you bend, straighten, twist and push. Instability means one or more of those guy ropes has been stretched or torn, so the joint surfaces can slide out of line. A full dislocation is when the joint comes completely apart. A partial slip, where the surfaces shift but do not fully separate, can feel like catching, clicking or a joint that is about to give way. Both sit on the same spectrum of injury. Most dislocations happen in a fall onto an outstretched hand. The force travels up the arm and tears the ligaments, usually starting on the outer side of the elbow and tearing further toward the inner side as the force increases. When a dislocation also breaks off small pieces of bone where those ligaments attach, or damages the rounded bone on the outer side of the joint or the bony block at the front of the elbow, the joint loses both its rope supports and part of its bony shape. That combination is harder to settle and is more likely to leave the elbow loose afterwards. Which strap is affected explains what you feel. The inner ligament takes the strain when you throw, so a tear there hurts during throwing and lifting. The outer ligament takes the strain when you push up or lean on your hand, so a tear there makes those movements feel unsafe. If the joint surfaces no longer line up smoothly, the elbow can also stiffen and wear unevenly over the years. Most elbows that slip out once and are put back promptly settle down with early movement. A small number keep feeling loose, and those are the elbows that may need surgery to rebuild the support. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic visit we take a history, examine your elbow and arrange imaging where it is needed. For most elbows that slip out once and are put back promptly, the first step is not surgery. The joint is put back into place, checked on x-ray, and rested briefly in a splint with the elbow bent at 90 degrees. After about 5 to 7 days in the splint, movement starts. Early motion matters because a stiff elbow is the most common problem after this injury. Physiotherapy works on bending and straightening through the range that feels secure, and on rebuilding strength. If the elbow is stable through that range, two days of splinting followed by early movement is enough. Give this approach a fair go before thinking about anything further. We do not use cortisone or other injections for elbow instability, so we will not offer you one. Surgery comes into the picture when the joint will not stay put. If your elbow needs to be held more bent than about 50 to 60 degrees to stay in place, or it slips out when straightened beyond 30 degrees from full extension, the ligaments are unlikely to settle on their own. The same applies if a piece of bone or soft tissue is stuck in the joint and blocking it, if the dislocation came with fractures, or if the skin was broken or the nerves and blood vessels were injured. In those cases we repair or rebuild the torn ligaments, usually starting with the outer ligament, and fix any broken pieces of bone so the joint surfaces line up again. If the elbow is still loose after that, a temporary external frame can hold the joint in place while it heals. For an elbow that has stayed loose for a long time, ligament reconstruction replaces the stretched strap with new tissue. We will talk through what each option involves and decide together what suits your elbow and your goals. ## What to expect For most people, an elbow that slips out once and is put back promptly settles with early movement. Good long-term results are the usual course when it is managed this way. A small number of people, about 8 in every 100 treated without surgery, keep having feelings of looseness afterwards. Around 2 in every 100 eventually need an operation to steady the joint, most often within 4 years of the injury. Recovery takes weeks rather than days. Stiffness is the most common setback, and it is the reason your care team will get your elbow moving early rather than resting it for long. In the first week or two you will work on gentle bending and straightening, often with help from a physiotherapist. Over the following weeks the range grows, and strength work follows. Physiotherapy also looks after your wrist, hand and shoulder, because the rest of the arm can stiffen or weaken while the elbow is guarded. Expect steady progress rather than a single moment when the elbow feels normal again. When surgery is needed, the outlook depends on how much damage the injury did. Many people regain a near full range of bending, straightening and forearm rotation, and their feelings of looseness settle. Some injuries are harder to settle than others. Where the dislocation came with fractures, stiffness, ongoing looseness, pain and wear in the joint can remain problems over the long term, no matter how well the treatment goes. In a share of these more severe injuries, around 20 to 25 in every 100, a further operation is needed at some point. Leaving a genuinely unstable elbow alone rarely works out well. A joint that will not stay in place tends to stay loose, and the sliding surfaces can wear unevenly over the years. If your elbow needs to be held quite bent to stay put, or it keeps slipping, that is the point to talk about surgery rather than waiting. None of this is a promise about your own elbow. Your surgeon will give you a clearer picture once they know which structures are injured and what your imaging shows. ## When to see someone Some signs mean your elbow needs checking soon rather than waiting. If your elbow slips out of place, or it needs to be held at a bent angle to stay in place, ask for a specialist review. The same applies if it keeps giving way when you push up from a chair or lean on your hand, or if a joint that was put back after a dislocation still feels loose weeks later. Throwing athletes should take inner-elbow pain seriously. See your GP if the pain only appears when you throw hard, if you hear a pop and cannot keep going, or if your throws are losing speed and stamina. Tingling near the funny bone nerve, a weak grip, or a elbow that locks or catches also deserve a review. Go to an emergency department if the elbow is clearly out of place, look misshapen, or the arm feels numb, cold or has lost colour. A joint that will not go back needs same-day care. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. It is here because "elbow instability" covers several quite different problems with quite different outlooks, and because the single biggest influence on how a simple dislocation ends up is a decision made in the first fortnight, one where the evidence and the instinct to protect the joint point in opposite directions. ### "Elbow instability" is not one diagnosis The term covers everything from a joint that has dislocated once and is now stable, to a joint that gives way on everyday tasks, to a fracture-dislocation where bone as well as ligament has failed. Surgeons have been trying to classify these patterns for well over a century, and still disagree: a review of 130 years of attempts concluded that "uncertainties about both nomenclature and classification still exist", and prompted a national society working group to try again [1]. This matters to you for one practical reason. When you read outcome figures for "elbow instability", they may describe a group of patients whose injuries were nothing like yours. The distinction that matters most is simple (ligaments only) versus complex (ligaments plus broken bone), those two travel very different paths. ### The two directions that have names: PLRI and PMRI Beyond simple versus complex, the pattern that determines the operation is the direction the joint gives way. Two named patterns account for most of it [1]. Posterolateral rotatory instability (PLRI) is the common one, and it is what most people mean by "unstable elbow". It is the pattern produced by the usual injury: a fall onto the outstretched hand loading the elbow with the forearm turning outwards. The damage runs in a circle around the joint, starting at the lateral ulnar collateral ligament on the outer side and progressing forwards and backwards around the capsule, reaching the inner ligament last. Because it begins laterally, the first stage is a subluxation rather than a full dislocation, and the outer ligament is the structure that has to be repaired or reconstructed to fix it. When you read earlier in this section about lateral ligament reconstruction and its 0–33% recurrence range, that is PLRI being treated. Symptomatically it is the pattern that makes you wary of pushing up out of a chair or loading the arm with the palm turned up, positions that let the joint rotate open. Posteromedial rotatory instability (PMRI) is less common, easier to miss, and less forgiving. The mechanism is the opposite, a varus (inward-bending) force with the forearm rotating inwards, and it damages the outer ligament while shearing off the anteromedial facet of the coronoid, a small shelf of bone on the inner front of the ulna that the joint leans on. That fragment is the problem. Anatomical work shows that on average 58% of the anteromedial facet is unsupported by the bone shaft behind it, so it fractures as a separate piece and is easily overlooked on a plain X-ray [2]. Missing it is costly: the joint is left slightly malaligned and grinds. One report described established arthrosis just 26 months after the injury in an elbow whose instability had not been addressed [3]. This is why a CT scan is often requested when the injury pattern suggests it, and why a coronoid fragment that looks small can still warrant fixation. The practical point for you: these are different injuries needing different operations, and "my friend had an unstable elbow and had X done" may not transfer to your elbow at all. ### The first two weeks matter more than almost anything else The instinct after a dislocation is to protect the joint in a cast or a brace. The elbow punishes that instinct. It is unusually prone to stiffening, and the stiffness is roughly proportional to how long it was held still. One review put numbers on it: after a simple dislocation, a permanent loss of full straightening of at least 30 degrees may be expected if immobilisation runs beyond 25 days, but as little as 3 degrees if the elbow is moving again within five days [4]. That is close to the whole difference between an elbow you forget about and one you notice every day. A randomised trial (FuncSiE) tested this directly, comparing early movement against three weeks in plaster for simple dislocations [5]. At six weeks the early-movement group had a noticeably larger arc of motion (121° versus 102°), less disability, and returned to work 10 days versus 18. By one year the two groups were indistinguishable, and, critically, no elbow in either group re-dislocated [5]. The protection bought by the plaster was protection against a risk that did not materialise, paid for with stiffness and lost weeks. This is why your rehabilitation starts early and why a simple sling is used for comfort rather than a hinged brace holding the joint in a fixed arc. ### Simple dislocations do well — with an honest asterisk Most simple dislocations recover without an operation. But "most" is not "all": roughly 8% of people treated non-operatively go on to have symptoms of persistent instability, and about 2% eventually need surgery [6]. A small number of injuries that look simple on the day behave badly afterwards, which is why we review you rather than discharging you at the first sign of a reduced joint. ### "Terrible triad" is a worse name than it is an injury The combination of elbow dislocation with fractures of the radial head and the coronoid was named the "terrible triad" because its early results were dismal. Modern results are much better: a review pooling 37 studies and 1609 patients found an average Mayo Elbow Performance Score of 90, rated excellent [7]. The honest half of that sentence is the complication rate, which is not low. Around 30% of patients have some complication, and 7.8% need further surgery. The commonest are extra bone forming in the soft tissues (11%) and ulnar nerve symptoms (2.6%) [7]. So: a good result is now the expectation rather than the hope, but this is an injury with a genuine chance of a second operation, and it is reasonable to know that before you start. ### When ligament surgery does not hold, bone is often the reason Repair or reconstruction of the lateral ligament is well established for the commonest pattern of chronic instability. Reported recurrence after it, though, ranges from 0% to 33%, a spread wide enough to tell you the operation is not the only variable [8]. Part of the explanation is that instability is not always purely a soft-tissue problem. Wear or defects in the bone at the outer side of the joint can keep an elbow unstable even after the ligament has been properly reconstructed, and combined bony lesions act together to raise the risk of failure [8]. Revision surgery is correspondingly harder: the only published series of revision lateral ligament reconstruction reported a 27% failure rate [8]. The practical implication is that if your elbow stays unstable after a ligament repair, the next question is usually about bone, not about redoing the same soft-tissue operation. ### Holding the joint reduced from the inside For elbows too unstable to trust to a repair alone, the traditional answer was an external hinged frame worn on the outside of the arm for weeks. An alternative is an internal joint stabiliser, a temporary internal device that holds the joint reduced while the soft tissues heal, and is removed later. It allows the elbow to move through a good arc while protected, with the original series reporting a mean flexion of 134 degrees at final follow-up [9]. The reason this approach is preferred here is the same principle as the rest of this page: protection that still permits movement beats protection that prevents it. --- ### Elbow Osteoarthritis URL: https://www.cqupperlimb.com/education/elbow/elbow-osteoarthritis/ Region: elbow · condition Osteoarthritis of the elbow — primary and post-traumatic, conservative and surgical options. ## What you're feeling Elbow arthritis usually shows up as stiffness and pain at the very ends of movement. You might find you cannot fully straighten your arm, or that it will not bend all the way in. The pain tends to sit at those limits, not through the middle of the movement. Many people also notice catching, clicking or locking, sometimes painful, as bone spurs and small loose fragments of cartilage or bone jam inside the joint. Everyday tasks that need a straight or fully bent arm become hard. Reaching up to a high shelf, pushing yourself up from a chair, or bringing a fork to your mouth can all be awkward. Twisting your forearm, as when turning a key or a screwdriver, is often still fine early on and only stiffens later. How much this limits you depends a lot on your work and daily demands. Heavy manual work, lifting, or throwing puts far more strain on the joint than desk-based tasks. Night pain is not typical of elbow arthritis. If your elbow wakes you at night, that points to a different cause and is worth having looked at. Pain that is not settling, is getting worse over weeks, or stops you working or using your arm should be reviewed by your GP, or you can ask us for a specialist review. Some people with elbow arthritis also develop pressure on the ulnar nerve, the nerve that runs behind the inside of the elbow. This can cause tingling or numbness in the ring and little fingers, or weakness in the hand. If you notice these symptoms, mention them at your next review so we can assess the nerve. The underlying problem is wear in the joint surface, plus extra bone forming around the edges of the elbow. That extra bone, along with a tightening joint lining and loose fragments, physically blocks the elbow at the ends of its range. Interestingly, the space inside the joint is often still preserved, so on a scan the joint can look better than your symptoms suggest. ## What's actually happening Inside your elbow, three small joints work together. One lets the arm bend and straighten. Two let your forearm twist, so you can turn a palm up or down. Each joint surface is covered with a smooth, slippery layer of cartilage, a bit like the non-stick coating on a good pan. When that coating is intact, the surfaces glide over each other with almost no friction. In elbow arthritis, that coating wears thin in patches, and the body responds by growing extra bone around the edges of the joint. These bony lumps, called osteophytes or bone spurs, build up at the front and back of the elbow. The joint lining, a sleeve of tissue around the joint, also tightens and shortens. Small pieces of cartilage or bone can break free and float inside the joint as loose bodies. Together, these changes explain what you are feeling. The bone spurs and tight lining act like a physical stop at the ends of the movement, so the elbow will not fully straighten or bend. The loose bodies are what catch, click or lock as they jam between the moving surfaces. Early on, the pain sits at those end-of-range limits because that is where the blocking happens. As more of the cartilage coating wears away, pain can spread into the middle of the movement too. Two things make elbow arthritis a bit different from arthritis in a hip or knee. First, the space inside the joint often stays wide, so an X-ray can look better than your symptoms feel. Second, the wear tends to hit one part of the joint harder than the rest, the area where the top of one forearm bone meets the end of the arm bone above it. That spot takes a lot of load when you push or lift, which is why heavy manual work, weight lifting and throwing are linked with this condition. It can also follow an old injury. A fracture or other damage to the joint can leave the surfaces slightly uneven, so they wear unevenly afterwards. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your first visit we take a history, examine your elbow, and arrange X-rays if they are needed. X-rays show the bone spurs at the front and back of the joint. A CT scan, which gives a more detailed picture, can help us plan surgery if it comes to that. For a long-standing problem like this, we usually try non-operative care first. Changing how you work and lift takes strain off the joint, and rest can settle flare-ups. Hand therapy aims to keep the movement you have and build the strength around the elbow. Anti-inflammatory tablets, a common group of medicines that ease pain and swelling, can help with symptoms. We give these options a fair trial before talking about surgery. If those steps have not given enough improvement, surgery may be worth considering. It is usually offered when pain will not settle, when stiffness stops you doing everyday tasks, or when the elbow locks or catches painfully. The main operation is a clean-out of the joint, called debridement. It removes the bone spurs and loose fragments that block movement, and releases the tight joint lining, while leaving your own joint surfaces in place. This can be done through small keyhole cuts or through an open incision, depending on what needs to be reached. We will talk through which suits your elbow, and decide together on the plan. ## What to expect Elbow arthritis is a long-term condition. It does not usually go away on its own, but it often behaves in a pattern: quieter periods, then flare-ups when the elbow is worked hard. Early on, the pain sits at the ends of movement and the joint space inside is often still preserved. As the wear progresses, pain can spread into the middle of the movement and stiffness can build. Without treatment, the bone spurs and tight joint lining keep blocking the ends of movement, so stiffness tends to creep up over time. Non-operative care remains the first step in early management, and it can bring relief in the early stages. Changing how you work and lift, hand therapy, and anti-inflammatory tablets can settle symptoms enough to keep you going. If these steps stop working, that is a sign surgery may help. Surgery for this condition aims to remove the mechanical blocks rather than replace the joint. A clean-out of the bone spurs and loose fragments, with release of the tight lining, improves range of motion and function for most people, with low complication and reoperation rates. The improvement is real but not a cure: it does not regrow cartilage or stop the arthritis progressing. Some people find their range of motion drifts back down over the years after a clean-out, and X-ray changes tend to advance over a decade. Replacing the whole elbow is rarely offered for wear arthritis, and generally not for people under 65 or those who are physically active, because implants wear out under heavy load. If your elbow becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. No GP referral is needed. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm, see your GP or ask us for a specialist review. ## When to see someone Most elbow arthritis builds slowly, so you have time to act on it. See your GP, or ask us for a specialist review, if the stiffness and pain are not settling, are getting worse over weeks, or are stopping you working or using your arm. Locking or catching that keeps happening is also worth having assessed, because loose fragments inside the joint can block movement. Tingling or numbness in the ring and little fingers should be mentioned too, as that suggests the ulnar nerve is being squeezed. One set of signs needs same-day care. If your elbow becomes hot, red, swollen and painful, especially with a fever, go to an emergency department. No GP referral is needed. An infection inside a joint can damage it quickly, so this one cannot wait for a routine appointment. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Elbow osteoarthritis is worth the extra reading because the operation that would seem the definitive answer, replacing the joint, as is done routinely at the hip and knee, behaves quite differently at the elbow, and that single fact shapes the whole treatment ladder. ### Why elbow replacement is not the default Total elbow arthroplasty works, but it does not tolerate load the way a hip or knee replacement does. Pooling 2,118 patients with rheumatoid arthritis, elbow replacement continued to provide satisfactory results, while being associated with substantially higher implant failure and complication rates than hip and knee arthroplasty [1]. The consequence is a lifting restriction that is permanent rather than a recovery-phase precaution. Because the elbow sits at the end of a long lever, modest weights in the hand generate large forces at the implant, and those forces loosen it over time. That is why the ladder at the elbow is inverted compared with the lower limb. At the hip, joint replacement is the standard operation for advanced arthritis. At the elbow, it is reserved, mostly for older, lower-demand patients, and for inflammatory rather than wear arthritis. ### Cause matters as much as severity Two people with equally worn elbows can face different prospects depending on why the joint wore out. Across 679 patients, the aetiology of the arthritis affected outcome in terms of specific modes of implant failure, and patients with rheumatoid arthritis had better functional outcomes than those having replacement for post-traumatic conditions [2]. That is worth stating because it is the reverse of what most people expect, that a joint damaged by a single injury should do better than one damaged by systemic disease. The explanation is demand: post-traumatic arthritis tends to occur in younger people with more physically demanding lives, and the implant meets forces it was not designed for. ### Debridement is the operation that does most of the work For primary wear arthritis, the mainstay is not replacement but debridement, clearing the bone spurs and loose bodies that block the joint at the ends of its range, and releasing the tight capsule, while leaving the joint surfaces in place. The evidence is consistent. Across 1,097 patients, debridement produced good mid-term functional outcomes, with no increase in complications using an arthroscopic technique [3]. In 871 patients, both open and arthroscopic osteocapsular debridement reliably improved flexion, extension and functional scores with low complication rates [4], and a meta-analysis of 586 patients found debridement effective for the disabling symptoms of primary elbow osteoarthritis with an acceptable complication rate [5]. Note what debridement is being asked to do. It does not resurface the joint or halt the arthritis. It removes the mechanical blocks at the end of range, which is why it helps the patient whose main complaint is that the elbow will not straighten or bend fully and catches painfully at the limit, and helps less the patient whose pain is present throughout the arc. ### Open or arthroscopic is not the deciding question As with several elbow operations, technique attracts more debate than the evidence supports. The reviews above found both approaches safe and effective, and a narrative review of 639 patients concluded it could not establish which procedure is superior [6]. The practical determinant is what needs to be reached. Arthroscopy handles anterior and posterior compartment work well; a stiff elbow requiring extensive capsular release, or one with distorted anatomy and a nerve that must be seen and protected, may be safer open. --- ### Elbow Ligament Reconstruction (Stabilisation) URL: https://www.cqupperlimb.com/education/elbow/elbow-stabilisation/ Region: elbow · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your elbow, and arrange scans if they are needed to work out what is wrong. Elbow ligament reconstruction is an operation that rebuilds a worn or torn ligament with a piece of donor tendon, holding the joint steady. We usually suggest it when your elbow still feels like it is giving way, or will not stay in place, after other treatment has not given enough improvement. It is also offered when the elbow can only be kept in joint by holding it nearly straight, or when a fracture around the joint has left it unstable. The aim is a stable elbow you can move, use, and rely on without pain. Allograft reconstruction restores elbow stability in approximately 85% of the elbows with posterolateral rotatory instability. We will talk this through with you and decide together whether it suits your elbow and your goals. ## Before the operation In the weeks before surgery we finish planning with scans such as an X-ray, MRI (a scan that shows soft tissues like ligaments), or ultrasound. On the day, stop eating and drinking seven hours beforehand. We ask for seven hours so your operation can be brought forward if the theatre list runs early; your surgeon will confirm your exact fasting time. You may need to pause some medications before surgery, and we will give you clear instructions about which ones and for how long. Bring a written list of everything you take, including tablets, drops and creams. Arrange for someone to drive you home afterwards. Wear loose, comfortable clothing with sleeves that slide over your elbow. If you have other medical conditions, you may also need blood tests or a review with the anaesthetist (the doctor who gives the anaesthetic). ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist there. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. When it is finished, you wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. The aim of the day is simple: restore enough stability to your elbow so it can start moving soon after surgery. Keeping the elbow still for a long time afterwards tends to make it stiff, so early movement is part of the plan. ## What the operation involves The exact steps depend on which structures around your elbow are injured, and we plan this from your scans before the day. If a fracture is part of the problem, your surgeon fixes the broken pieces of bone first, using screws or a small plate. If a broken piece of bone at the top of the forearm cannot be repaired, it may be replaced with a metal implant. Once the bone is secure, the torn ligaments are repaired or rebuilt. Rebuilding a ligament means making a new one from a piece of tendon. This may come from donor tissue, or from your own body. Small anchors hold the new ligament to the bone in the right places, and your surgeon checks that the elbow stays in joint through its whole range of movement before finishing. Sometimes a sturdy suture tape is added alongside the repair to act like an internal brace, supporting the ligament while it heals. If the elbow still will not hold itself steady, a temporary hinge may be fitted to keep it in place while things settle. The operation can often be done through small cuts rather than one long opening. For some ligament rebuilds, a cut of about 2 to 3 cm is enough. Working through small cuts protects the healthy tendons and muscle around the joint, and avoids disturbing the joint lining itself. When the repair is complete, the cuts are closed with stitches and covered with a dressing. The goal of the whole operation is a stable elbow that can start moving soon afterwards, because keeping it still for too long tends to leave it stiff. ## After the operation You will wake up in the recovery area, where nurses keep a close eye on you while the anaesthetic wears off. Your arm will be in a sling or supported on pillows, with a dressing over the wounds. We will give you pain relief and check that it is working before you move around. Someone should stay with you for the first 24 hours after you go home. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Most people can walk around and do light tasks straight away, but keep your elbow resting in the sling when you are up and about. ## Recovery For the first few days your elbow will be sore and swollen. This settles gradually. Rest, keeping your arm raised, and the pain relief we give you will ease the discomfort. Some aching when you first start moving the joint is normal and improves as the weeks pass. You will go home with your arm in a sling. You can walk around and do light tasks straight away, but keep your elbow resting in the sling when you are up and about. Your hand and wrist can move early, and gentle exercises for them usually begin within days. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she will guide your exercises and make any splint you need. The aim of therapy is steady, early movement, because keeping the elbow still for too long tends to leave it stiff. As the swelling settles, you will use your arm more: eating, writing, and light household tasks. Once your surgeon is happy the repair is secure, the sling comes off and you begin bending and straightening the elbow itself. Movement often improves quickly at first, then more slowly. When you can grip and hold objects without pain, everyday activities feel easier. Driving is not safe while your arm is in a sling, and you will need to be able to hold the wheel with both hands and react in an emergency stop, off strong pain medication. Our guide to driving after upper-limb surgery explains when you can return. Everyone heals at their own pace. Your timeline may differ, and your surgeon and therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The nerve that runs along the inside of your elbow can become irritated after surgery. You might notice tingling, pins and needles, or numbness in your ring and little fingers. Often this settles on its own, but tell us if it does not ease, or if the fingers feel weak. The elbow can sometimes stay loose or feel like it is giving way again. If your elbow starts to feel unsteady, or slips out of place, contact the clinic straight away. The elbow can also become stiff. You may find it hard to straighten or bend the arm fully, and the movement may feel blocked rather than sore. Bring this up at your review, as extra therapy or further treatment can help. Infection is uncommon but serious. Watch for a deep, throbbing pain that does not ease with simple painkillers, redness spreading out from the wound, or fluid leaking from it. If you notice these, call the clinic the same day, or go to the emergency department if you feel feverish or unwell. The small metal anchors or screws used to hold the repair can sometimes cause irritation, or a temporary hinge may loosen. You might feel a new clicking, catching, or a lump under the skin. Mention it at your next review. Where a piece of your own tendon is used to rebuild the ligament, that spot can stay tender or achy for a while. Let us know if it worsens rather than improves. Bone can sometimes form where it should not, around the joint or inside it. This can limit movement or cause catching and grinding. If your elbow stops progressing, raise it at your review. The scar itself can occasionally break down or weep. If the wound opens, becomes redder, or starts to discharge, contact us rather than waiting. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up early, and we would rather hear about them sooner than later. Call us if you have a fever, if the wound becomes redder or starts leaking fluid, or if your pain keeps getting worse instead of easing. Go to emergency if you have swelling or pain in your calf, or sudden shortness of breath. Call us straight away if your ring and little fingers go numb, if your hand feels weak, or if you cannot move your arm at all. If your elbow slips out of place or feels like it is giving way again, contact the clinic the same day. --- ### Ulnar Collateral Ligament Injury (Tommy John Injury) URL: https://www.cqupperlimb.com/education/elbow/elbow-ucl-injury/ Region: elbow · condition The medial elbow ligament injury of throwers — how it presents, when rehab is enough, and what Tommy John reconstruction involves. ## What you're feeling If you throw a lot (baseball, javelin, or any sport with hard overhead throwing), you may notice an ache or pain on the inner side of the elbow. It often comes on at the moment of maximum effort, just before your arm whips forward to release. Many throwers describe it as a deep, nagging soreness right over the bony bump on the inside of the elbow. The other common clue is that your throwing changes. You lose a bit of speed, your throws lose their usual accuracy or "pop," or you simply can't throw as hard or as long as before. Sometimes the pain builds up gradually over a season; occasionally a single throw causes a sharp pain or a "pop" and the elbow suddenly feels unstable or useless. Some people also notice tingling, numbness or pins-and-needles running into the ring and little fingers. That happens because a nerve passes right behind the inner elbow, and swelling or instability in that area can irritate it. ## What's actually happening A strong band of tissue called the ulnar collateral ligament (UCL) sits on the inner side of your elbow. Its job is to stop the elbow from gapping open on the inner side when force pushes it that way, a movement called valgus. Throwing puts enormous, repeated stress across exactly this ligament. Each hard throw stretches it a little, and over thousands of throws the ligament can slowly fray, thin out and weaken. Less often, a single violent throw tears it. When the UCL is damaged it can no longer hold the elbow firmly, so the joint becomes a fraction loose under throwing loads. That looseness is what causes the pain, the loss of velocity and command, and sometimes the nerve symptoms. This is the same injury made famous as "Tommy John," named after the first baseball pitcher to have it surgically reconstructed and return to throwing. It's worth knowing that this is overwhelmingly a throwing-athlete injury. For people who don't do repetitive overhead throwing, a damaged UCL rarely causes problems in everyday life, because ordinary activities don't load the ligament the way pitching does. ## What we can do about it At our clinic, Dr Kieran Hirpara guides your care from the first referral through to a tailored treatment plan. We start with a thorough assessment to understand the extent of your injury and your goals. The right treatment depends on how badly the ligament is damaged, and also on whether you need to return to high-level throwing. Non-surgical treatment comes first for partial or low-grade tears, and for anyone who doesn't need to throw competitively. This means a period of rest from throwing, then a carefully staged rehabilitation programme that rebuilds strength in the forearm, shoulder and core, corrects throwing mechanics, and brings you back to throwing gradually through a structured "throwing program." Injections of substances such as platelet-rich plasma (PRP) are sometimes offered to encourage healing, but the evidence that they help is still uncertain. Surgery is considered when the ligament is completely torn, or when good rehabilitation hasn't allowed a committed thrower to get back to the mound. There are two main operations: - UCL reconstruction ("Tommy John surgery"). The damaged ligament is rebuilt using a tendon graft, usually taken from your own forearm or leg, threaded through small bone tunnels to recreate a new, strong ligament. This is the long-established, proven operation for throwers. - UCL repair with an internal brace. In selected younger athletes whose ligament has pulled cleanly off the bone at one end (rather than frayed throughout), the surgeon can stitch the ligament back and reinforce it with a strong tape. This tends to allow a faster return to throwing, and is reserved for the right kind of tear. In both operations the surgeon also checks the nerve on the inner elbow and protects or moves it if it is being irritated. ## What to expect For most throwers who have surgery, the outlook is genuinely good: the large majority return to their previous level of throwing, though it takes patience. Reconstruction (Tommy John) typically means a staged recovery over roughly a year or more before competitive throwing, while a repair with internal brace in the right patient can be quicker. Either way, the comeback is driven by a long, structured rehabilitation program, not by the operation alone; rushing back is the main reason for setbacks. Recovery is not guaranteed to be universal: a small number of athletes don't return to the same level, and the nerve symptoms or the graft sometimes need ongoing attention. But with a clear diagnosis, the right choice of treatment, and committed rehab, the results for this injury are among the most rewarding in sports surgery. ## When to see someone - Inner-elbow pain when you throw, especially if it keeps coming back or is getting worse over a season. - A drop in your throwing velocity, accuracy or stamina that you can't shake off with rest. - A sudden "pop" or sharp pain on the inner elbow during a throw, after which the arm feels weak or unstable. - Numbness, tingling or weakness in the ring and little fingers. - Inner-elbow pain in a young or growing thrower: a child's growth plate can be injured by the same throwing stress and needs prompt assessment. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Ulnar collateral ligament injury is worth the extra reading because the operation everyone has heard of: Tommy John surgery — is no longer the only real option, and the newer alternative trades a different currency: not outcome, but time. ### Reconstruction is the established operation, and its results are consistent Reconstruction replaces the torn ligament with a tendon graft, usually palmaris longus taken from the patient's own forearm. Across 6,671 patients, most surgeons used a palmaris autograft in a figure-of-eight configuration via the modified Jobe technique, and the revision rate with allograft appeared higher than with autograft, though the authors note this may reflect the smaller allograft literature rather than a true difference [1]. At medium-term follow-up across 1,104 patients, reconstruction produced good patient-reported and clinical outcomes with low complication and revision rates, and baseball players reported high rates of return to play at pre-injury level along with career longevity [2]. Return-to-play rates sit between 80% and 90%, with most athletes back in full competition at 12 to 18 months [3]. ### The alternative is faster, and that is the entire argument Where the ligament has avulsed from one end and the tissue itself is of good quality, it can be repaired rather than replaced, increasingly with an internal brace augmenting the repair. The difference is the timeline. Augmented repair offers return to sport at an average of 6 months, with high rates of return to play in appropriately selected candidates, against the 12 to 18 months that reconstruction demands [4]. A 2025 review found repair rising in popularity and reported it as safe and effective, with low complication rates and high return-to-sport rates [5]. For a high-school or college athlete with a defined competitive window, halving the time out is not a minor consideration, it can be the difference between a season lost and a career altered. But "appropriately selected" is carrying real weight in that sentence: repair depends on an avulsion pattern with healthy remaining ligament, which is a minority of injuries and is determined by imaging and by what is found at surgery, not by preference. ### Not every tear needs an operation Treatment depends on the tear. Low-grade partial tears are managed non-operatively, with reconstruction reserved as the standard for complete tears [3]. The ligament is loaded almost exclusively by the valgus stress of overhead throwing, which is why a partial tear can be compatible with ordinary daily activity indefinitely and only declares itself when throwing resumes. ### Revision does not reproduce the first result If a reconstruction fails, expectations for a second should be set lower. Revision reconstruction is a rare procedure with outcomes that are not as promising as primary reconstruction, where diagnosis, technique and rehabilitation all become more demanding [6]. That asymmetry is the strongest argument for getting the first operation and its rehabilitation right, including completing a rehabilitation programme that feels disproportionately long for a ligament that has already been replaced. The graft has to remodel into a ligament, and that process runs on biological time rather than on how the elbow feels. --- ### Forearm Shaft Fractures (including Monteggia and Galeazzi) URL: https://www.cqupperlimb.com/education/elbow/forearm-shaft-fractures/ Region: elbow · condition A forearm shaft fracture happens in a moment. You might fall onto an outstretched arm, take a direct blow during sport, or land hard from a height. Some people hear or feel a snap at the moment of injury. The force needed is often considerable, especially when both forearm… ## What you're feeling A forearm shaft fracture happens in a moment. You might fall onto an outstretched arm, take a direct blow during sport, or land hard from a height. Some people hear or feel a snap at the moment of injury. The force needed is often considerable, especially when both forearm bones break together. Straight away, you will feel pain along the forearm. It usually worsens quickly with any attempt to move your wrist, elbow or hand. Swelling and bruising develop over the injured area. If the bones have shifted out of place, the arm may look bent or twisted. Most people cannot turn their palm up or down without sharp pain, which makes everyday tasks like turning a door handle, pouring a kettle or holding a phone difficult. Some injuries in this part of the arm involve more than a broken bone. A Monteggia injury is a break in one forearm bone near the elbow, together with the elbow joint being pushed out of place. A Galeazzi injury is a break in the other forearm bone near the wrist, with the wrist-side joint unstable. These injuries can be missed at first, because the break looks like a simple fracture on early X-rays. That is why your surgeon will look closely at both the elbow and the wrist, not just the obvious break. In the first days and weeks, pain is often strongest at night and when you try to move. It settles gradually as the bone begins to heal. You may notice stiffness in the wrist and elbow from keeping the arm still. How much turning motion you regain depends partly on which bones were injured. When both forearm bones are broken, or the skin is broken over the fracture, some loss of turning motion is more likely. If broken skin over the fracture, bone showing, an obvious deformity, fingers that turn pale, cold or blue, or sudden loss of feeling or movement in the hand occur after your injury, go to the emergency department the same day. ## What's actually happening Your forearm has two bones side by side: the radius on the thumb side and the ulna on the little-finger side. They work as a pair. When you turn your palm up or down, one bone pivots around the other at two joints, one near the elbow and one near the wrist. That turning motion is what lets you use a screwdriver, shake hands or tip food off a plate. A shaft fracture is a break in the middle part of one or both of these bones. Think of the two bones as the two poles of a ladder. If one pole snaps and shifts, the ladder can no longer hold its shape, and the other joint at the top or bottom gets pulled out of line. That is what happens in a Monteggia injury, where the broken bone near the elbow lets the elbow joint slip out of place, and in a Galeazzi injury, where the break near the wrist leaves the wrist-side joint unstable. These injuries involve a broken bone plus an out-of-place joint, so they behave differently from a simple break. Bone heals by knitting back together, the same way a cracked branch can mend if the pieces are held still and lined up. But the two forearm bones must line up closely for the turning motion to work again. If a bone heals even slightly twisted or shortened, the pair no longer pivot smoothly, and turning stays stiff or painful. When a joint is pushed out of place as well, the soft tissues holding it need to settle too, and the joint must be put back in line for the arm to work. This is why these injuries are taken seriously. The goal of treatment is to restore the normal alignment of the bones and joints early, because that is what gives the forearm its best chance of turning freely again. A Monteggia injury found late is more complex to treat, and may need the ulna corrected as well. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some forearm fractures heal without an operation, and others need surgery soon after the injury, so prompt assessment matters. At the clinic we take a history, examine your arm and arrange imaging where it is needed. X-rays of the elbow and wrist show the break and whether a joint has been pushed out of place. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. When a break is stable or barely shifted, and the injury pattern suits it, we may treat it without surgery. That means holding the arm still with a splint or cast while the bone knits, with check X-rays to make sure the position holds. Movement returns in stages, guided by your hand therapist. An isolated break in the ulna, the little-finger bone, can be treated with simple support and early movement rather than a full cast. We will also talk about what you need from your arm for work and daily life, and how much discomfort you are willing to put up with, because that shapes the choice. When the bones are shifted out of place, when a joint is unstable, or when the injury pattern involves a break plus a dislocated joint, we recommend surgery from the outset. The aim is to line the bones up precisely and hold them there with a plate and screws while they heal, because the two bones must line up closely for the turning motion to work again. This is a shared decision. If non-operative care is possible but the pain or the final position of the arm may not be acceptable to you, we will weigh that together. Either path shares the same early priorities. Pain control in the first weeks matters, and keeping the injury protected while it heals. Rehabilitation is with Ruby Doolan, a hand therapist at Extend Rehabilitation, who directs your exercises and makes any splint you need. She stages your return to turning, gripping and lifting as the bone heals. ## What to expect Healing follows a steady course. In the first weeks the bone begins to knit while it is held still, and pain settles gradually. Stiffness in the wrist and elbow is common from keeping the arm still, and it eases as you start moving again. Turning the palm up and down usually comes back in stages, guided by your hand therapist. If your injury is treated without surgery, the bone heals while the arm rests in a splint or cast, with check X-rays to confirm the position holds. Most isolated breaks in the little-finger bone heal this way, though some do not, and if the bone is weak from osteoporosis a longer cast may be chosen to protect the other forearm bone. If surgery is needed, the bones are lined up precisely and held with a plate and screws while they knit. Galeazzi injuries are unstable, so surgery is needed to hold the joint near the wrist in place. After surgery for a Galeazzi injury, keeping the forearm still for a shorter time in a neutral position works as well as holding it turned up for 4 weeks when the joint is stable. Most people regain good use of the arm. When both forearm bones were broken, or the skin was broken over the fracture, some loss of turning motion is more likely, as noted earlier. Strength and turning motion after surgery for both-bone fractures are usually close to normal, with only modest losses. After a Galeazzi injury, the wrist-side joint often moves as freely as the uninjured side in the long term. After a Monteggia injury treated by putting the ligament around the elbow back in place, people have no pain and full elbow movement at their latest check. Some things can go wrong. The bone may heal slowly, fail to heal, or heal in a poor position. The arm may stay stiff. Plates can sometimes lead to thinning of the bone beneath them over the years. A Monteggia injury with a broken radial head can be unpredictable, and some of these injuries need further surgery. ## When to see someone Seek urgent care if your arm looks bent or twisted, if broken skin over the fracture or bone showing, if your fingers turn pale, cold or blue, or if you suddenly lose feeling or movement in your hand after an injury. These signs need the emergency department the same day. If you cannot reach the clinic, go to your nearest emergency department. Some injuries hide more than a simple break. A Monteggia injury can be missed if the elbow is not X-rayed, and a Galeazzi injury can look like a simple fracture of the radius on early X-rays. If your pain is not settling, or swelling, movement or function are not improving week on week as healing progresses, see your GP or ask for a specialist review. Symptoms that wake you at night or stop you using your arm also warrant review. --- ### Golfer's Elbow URL: https://www.cqupperlimb.com/education/elbow/golfers-elbow/ Region: elbow · condition Golfer’s elbow (medial epicondylitis) — causes, symptoms, and conservative treatment options. ## What you're feeling The pain sits on the bony bump on the inside of your elbow, and often spreads into the muscles of your forearm just below it. It usually starts gradually, without one clear injury, and it tends to hang around even when you rest. Golf, throwing, tennis, weightlifting and bowling can all set it off. So can work that involves repeated forceful gripping, lifting loads of 20 kg or more, or using vibrating tools. Certain everyday movements become uncomfortable. Turning a doorknob, shaking hands, carrying shopping bags or lifting a kettle can all aggravate it, because these actions load the same muscles that attach at that inner bump. Your grip may feel weaker than on your other side. Most people can still move the elbow and wrist through their full range, though some find the elbow stiffens slightly and will not straighten completely. The pain often flares during or after the activity that caused it, and can be at its worst the next morning or when you first grip something. Some people notice it most when they swing a golf club or throw, particularly in the early part of the movement. Watch for one thing in particular. The ulnar nerve, the nerve that supplies feeling to your ring and little fingers, runs right behind this part of the elbow. If you have numbness or tingling in those two fingers along with the inner elbow pain, tell your GP or ask for a specialist review, because it changes what treatment may help. See your GP or ask for a specialist review if the pain is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your hand or arm. Go to the emergency department the same day if your hand or arm becomes hot, red, swollen and painful, especially with a fever, or if your fingers turn pale, cold, white or blue. ## What's actually happening Golfer's elbow is a tendon problem, not a joint problem. A tendon is the strong cord that joins muscle to bone. On the inner side of your elbow there is a group of forearm muscles that bend your wrist and fingers and help you turn your palm down. All of them attach to that bony bump through one shared tendon, a bit like several ropes tied to a single mooring post. When you swing a club, throw, or grip and lift repeatedly, those muscles pull on the same spot over and over. The tendon develops tiny tears. Your body tries to repair them, but the repair is patchy and the new tissue is weaker than the original. Over time the tendon thickens and becomes disorganised, like a rope that has been frayed and re-tied many times. This is why the pain keeps coming back even after rest, and why gripping or lifting makes it worse: those movements load the exact spot where the tendon is struggling to heal. Despite the name, there is usually no swelling or inflammation in the sore spot. The problem is wear and failed healing, not infection or arthritis. Nothing is broken and the joint itself is not damaged. One nearby structure matters here. The ulnar nerve, which gives feeling to your ring and little finger, runs just behind this tendon. Because it sits so close, the same irritation can upset the nerve as well, which is why some people get tingling in those fingers along with the elbow pain. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Most golfer's elbow settles without an operation, so we begin there. Rest and changing how you use your arm matter more than anything else we can offer. That means easing off the gripping, lifting or swinging that flares the pain, and finding other ways to do the tasks that hurt. Give this a fair go for at least 6 months before thinking about surgery, because surgery is only for symptoms that keep going despite that much treatment. Physiotherapy aims to strengthen the muscles that work with the sore tendon, so the tendon is loaded less. A program that builds up your forearm, wrist and grip strength gradually is the usual approach. If your pain came from sport, such as golf or throwing, part of recovery is looking at your technique, because flaws in how you swing or throw can keep loading the same spot. Pain relief and anti-inflammatory medicine, called NSAIDs, can help you stay active while the tendon settles. We do not offer injections for golfer's elbow, so we will not suggest them as a next step. If your symptoms have not improved after 6 months or more of the right non-operative care, we may talk about surgery. The operation cleans out the damaged, frayed part of the tendon where it attaches to the bone on the inside of your elbow, leaving the healthy tissue intact. It is done through a small incision, and you go home the same day. Surgery is a shared decision, and we will only recommend it once we agree that simpler measures have done all they can. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your elbow, and arrange imaging such as an ultrasound or MRI scan if it will change what we recommend. An ultrasound is often the first scan used to confirm golfer's elbow, and an MRI gives a clearer picture of the tendon and the nearby ulnar nerve if the diagnosis is not clear. If surgery goes ahead, your rehabilitation afterwards is hand therapy with Ruby Doolan at Extend Rehabilitation, not physiotherapy. Ruby guides your exercises and makes any splint you need along the way. ## What to expect For most people, golfer's elbow settles with time and the right kind of care. Easing off the activities that flare it, then building strength back gradually, is what usually works. Many people improve over months rather than weeks, so it helps to expect a slow, steady change rather than a quick fix. If the pain has already kept going for months despite rest and changes to how you use your arm, it tends to keep going unless something changes. That is the point where we would talk about surgery. When surgery is done for symptoms that have not settled after 6 months or more of the right non-operative care, most people report less pain and better function in the year afterwards, and most return to their usual activities. In one group of people who had been working before surgery, 11 of the 12 were back at work within eight weeks. Recovery is not a straight line. Some days will feel better than others, and gripping or lifting can still grumble while the tendon rebuilds. If you also have tingling in your ring and little fingers, that nerve irritation can linger even when the tendon itself is doing well, so it is worth flagging before any treatment is planned rather than after. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand or arm, see your GP or ask for a specialist review. ## When to see someone Most golfer's elbow settles with rest and changes to how you use your arm, so give it a fair go before booking anything urgent. See your GP or ask for a specialist review if the pain is not settling after several weeks, is getting worse, or stops you working or using your hand or arm. The same applies if your grip feels weaker than on your other side, or the elbow will not straighten completely. One sign deserves attention sooner. If you notice numbness or tingling in your ring and little fingers alongside the inner elbow pain, mention this at your appointment. The ulnar nerve runs right behind the sore tendon, and when it is irritated as well, it changes which treatments are likely to help. Go to an emergency department the same day if your hand or arm becomes hot, red, swollen and painful, especially with a fever, or if your fingers turn pale, cold, white or blue. These are not features of golfer's elbow itself, but they need same-day care. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Golfer's elbow is worth the extra reading because it is usually presented as the inner-elbow version of tennis elbow, and in two respects that framing misleads: what predicts it is only partly mechanical, and the presence of a second problem alongside it changes what surgery can achieve. ### Most of it settles without an operation The headline figure is the reassuring one. In a review of medial elbow pain, conservative management improves nine out of ten patients, while surgical debridement carries a success rate of 80% to 85% [1]. Read those two numbers together rather than separately. Non-operative care has the higher success rate. Surgery is not a better version of the same treatment, it is the option for the minority in whom time and load management have already failed, and it succeeds slightly less often than the first-line treatment does. For the exercise component specifically, the evidence supports strength training reducing symptoms in tendinosis, with manipulation techniques offering a short-term analgesic effect that may permit more vigorous stretching and strengthening, though the authors describe the results as not yet conclusive [2]. ### The risk factors are not only about how much you use the arm Epicondylitis is common among working-age people, and physical load factors, smoking and obesity are strong determinants [3]. Smoking and body weight are not what most people expect to hear about a tendon problem, and both point to the tendon's blood supply and metabolic environment rather than to how hard it is pulled. The occupational data go further. Across 1,824 workers, statistically significant relationships were found between numerous personal and occupational psychosocial factors and both medial and lateral epicondylitis, persisting after adjustment for demographics and job physical exposures. The largest associations were between physical exhaustion after work and lateral epicondylitis, at an odds ratio of 7.04, and between mental exhaustion after work and medial epicondylitis [4]. That adjustment is the important part of the sentence. The association is not simply that tired people do heavier work, the relationship survived controlling for the physical exposure. It does not establish that exhaustion causes tendinopathy, but it does mean that a treatment plan built only around load, and ignoring how depleted someone is by their working day, is addressing part of the picture. ### Why the ulnar nerve matters to the outcome Medial elbow pain requires a broad differential, ulnar nerve disorders, cervical radiculopathy and ligament injury all produce pain in the same place [1]. The condition itself arises from repetitive eccentric loading and valgus overload, and is initially managed with activity modification and rehabilitation, surgery being reserved for persistent symptoms [5]. The ulnar nerve is the one that most affects results, because it runs immediately behind the tendon origin being treated. Where debridement is performed, its success rate may be negatively affected by concomitant ulnar neuritis [1]. The practical consequence is that pain persisting after a technically successful debridement is not necessarily a failed operation, it may be that the nerve, not the tendon, was generating a share of the symptoms all along. Numbness or tingling in the ring and little fingers alongside inner-elbow pain is therefore worth reporting before any operation is planned, not after. --- ### Golfer's Elbow Release URL: https://www.cqupperlimb.com/education/elbow/golfers-elbow-release/ Region: elbow · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your elbow, and arrange imaging if it is needed to confirm the diagnosis. Golfer's elbow is wear and irritation where the tendons that bend your wrist and grip attach to the bone on the inside of your elbow. It often comes on slowly, and the pain can persist even when you rest. We usually begin with non-operative care such as activity change, physiotherapy or hand therapy, and splinting. Surgery is considered when that has not given enough improvement over the long term. The operation releases the damaged tendon attachment from the bone so the sore area is no longer pulled with each grip or lift. It is offered to people whose pain has not settled with these other treatments. Most elbows treated this way improve, with success reported in 72% to 94% of cases. The aim is lasting relief of pain and better use of your elbow in daily life and sport. ## Before the operation Before surgery you will need some imaging so the operation can be planned. This may include an X-ray, an ultrasound, or an MRI scan, which uses magnets to show the soft tissues around your elbow. Most people need no other tests. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, the doctor who gives your anaesthetic. On the day, stop eating and drinking seven hours before your operation time. We ask for seven hours rather than six so your surgery can be brought forward if the theatre list runs early. Your surgeon will tell you which of your usual medicines to take and which to pause. Bring a list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You then meet the anaesthetist, the doctor who gives your anaesthetic. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. You wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. Many people having this operation go home the same day. Before you leave, we will explain how to care for your elbow and when your follow-up appointment will be. ## What the operation involves The operation targets the spot on the inside of your elbow where the sore tendons attach to bone. Your surgeon makes a small cut over that bony point and releases the damaged tendon attachment, so it is no longer pulled with every grip or lift. The unhealthy, gristly tissue in the tendon is cleared away, and the healthy tendon is given room to settle back onto the bone and heal. Some elbows need a slightly different approach. If the nerve that runs along the inside of your elbow is also irritated, your surgeon may free it from the tunnel of tissue it slides through, or move a small piece of bone that is pressing on it. If the joint itself is stiff or has loose bits of tissue catching inside, the operation can be done through two or three small keyhole cuts instead, using a thin camera to see inside the elbow. The cut is closed with stitches and covered with a dressing. The whole operation usually takes well under an hour, and most people go home the same day. ## After the operation You wake up in the recovery area, where nurses watch you as the anaesthetic wears off. Your elbow will be covered with a dressing, and your arm may rest in a sling for comfort. You can move around soon after waking, and the nurses will help you with anything you need. Pain relief is planned before you leave, and the team will explain how to manage any soreness at home. Someone should stay with you for the first 24 hours. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your elbow will be sore and may be swollen. Rest, keeping your hand raised when you can, and the pain relief we plan for you will ease this. The soreness settles gradually as the healing tissue calms down. You will start gentle movement early. Your hand therapist, Ruby Doolan at Extend Rehabilitation, will guide your exercises and make any splint you need. The aim of the early stages is getting your elbow bending and straightening fully again. Building your grip and arm strength comes next, and it is a big part of getting back to your usual activities. At home you can use your arm for light tasks as comfort allows. Avoid heavy lifting until we clear you, because the healing tendon needs time to settle back onto the bone. If a movement causes sharp pain, ease back and let your therapist know. Recovery varies from person to person. Your timeline may differ, and we will guide you along with your therapist at each review. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The nerve that runs along the inside of your elbow sits close to the operation site. If it is irritated after surgery, you might notice tingling, pins and needles, or numbness in your little and ring fingers. Tell us at your next review if this happens, or call the clinic sooner if it is severe. Some elbows become stiff after surgery. You might find it hard to straighten your arm fully, or the elbow may feel tight when you bend it. Gentle exercises with your hand therapist usually help. If the elbow stays stiff, we can discuss other ways to regain movement at a review. The tendons that bend your wrist and grip attach near the same spot. Weakness with gripping or lifting is uncommon, but if you notice your grip feels different, raise it at your next appointment. Infection is a risk with any operation. Watch for a deep, throbbing pain that does not ease with simple painkillers, redness spreading out from the wound, or fluid leaking from the dressing. If you see any of these, call the clinic straight away rather than waiting for your review. A blood clot in a vein near the elbow is rare but needs quick treatment. Sudden swelling and tenderness in the arm, or in a calf, should be checked urgently. Go to the emergency department if this happens. Rarely, the elbow can come out of joint again, or hard lumps of bone can form inside the joint after an injury. A clicking or grinding feeling, or a sudden loss of movement, should be reported to us. Some people still feel mild pain at the operation site months later. If your pain is not settling the way we described, bring it up at your review so we can look into it. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call the clinic straight away if you have a fever, or if the wound becomes more red, swollen, or is leaking fluid. Go to the emergency department if you have sudden severe pain, sudden swelling or tenderness in your arm or calf, or shortness of breath. These can be signs of a blood clot. Go to emergency also if you cannot feel your hand, or you cannot move your arm at all. For tingling or numbness in your little and ring fingers that is mild, call us or raise it at your next review. --- ### Olecranon Bursa Removal (Bursectomy) URL: https://www.cqupperlimb.com/education/elbow/olecranon-bursa-excision/ Region: elbow · operation What olecranon bursectomy involves, why it is a last resort, and the honest wound-healing and recurrence picture. The olecranon bursa is a small, slippery fluid-filled sac that sits right over the bony tip of your elbow. Its job is to let your skin glide smoothly over the bone when you bend and straighten your arm. When it becomes inflamed (from a knock, from years of leaning on the elbow, from gout or rheumatoid arthritis, or from an infection), it can fill with fluid and swell into a tender, sometimes alarming-looking lump at the point of the elbow. This is called olecranon bursitis, and it is very common. The important thing to know up front is that most bursitis settles on its own or with simple measures, and surgery is genuinely a last resort. We only talk about removing the bursa when the problem has stubbornly refused to go away despite everything else. This page explains what that operation involves, what your recovery looks like, and, most importantly, an honest account of why this particular operation has more healing and recurrence trouble than people expect. ## Why remove the bursa? In our clinic, Dr Kieran Hirpara guides patients through a careful assessment to confirm the diagnosis and explore non-surgical options first. We typically recommend surgery only when conservative treatments have not provided enough relief for long-standing problems. The first-line treatment for a swollen bursa is almost always non-surgical: resting the elbow, avoiding leaning on it, anti-inflammatory tablets, and sometimes draining the fluid with a needle (aspiration), occasionally followed by a steroid injection. A review of the published evidence found that non-surgical management gives a higher rate of the problem settling and fewer complications than going straight to surgery, which is exactly why we try those routes first. We only consider removing the bursa (a "bursectomy") when: - The bursitis is chronic or keeps coming back despite rest, activity changes, aspiration and/or a steroid injection over a reasonable period of months, and it is genuinely bothering you. - There is recurrent or established infection (a septic bursa) that hasn't cleared with antibiotics and drainage. Even here, surgeons usually try drainage and antibiotics first; studies suggest surgery doesn't reliably give better long-term results for infection, so it is reserved for cases that won't settle, where there is thick pus that can't be drained with a needle, or a pointing abscess [1]. - A bony spur on the tip of the elbow is repeatedly irritating the bursa, in which case the spur may be trimmed at the same time. In short: this operation is for the minority of bursae that simply won't behave. If your swelling is new, painless, and not infected, surgery is very unlikely to be the right answer. ## What the operation involves This is usually a day case, so you can expect to go home the same day, although occasionally patients stay overnight. It is done as an open operation: a small incision over the tip of the elbow, through which the whole inflamed bursa is carefully removed, and the skin is then closed. If there is a bony spur underneath the bursa, it can be smoothed off at the same time. The anaesthetic is usually either a general anaesthetic (you are fully asleep) or a regional block (the arm is numbed while you stay awake or lightly sedated), sometimes combined. Your anaesthetist will talk you through the best option for you on the day. It is a relatively quick operation, but the skill is less in the removal itself and more in handling the delicate skin gently and closing it well; as described below, the skin is the part that gives trouble. ## The honest part: healing and recurrence This is the section to read twice, because it is the main reason we are cautious about this operation. The skin over the very tip of your elbow is thin, mobile, and has a relatively poor blood supply. It is also a part of the body that takes constant pressure every time you rest your arm on a table, a chair, or a car door. That combination means that wound-healing problems and the bursa coming back (recurrence) are the two things most likely to go wrong, more so than with most operations of this size. It is not that the surgery is difficult; it is that the elbow is an unforgiving place to make a wound. What does the evidence actually say? It's worth being honest that the published studies are mostly small case series, so the numbers vary [1]. One sizeable review of patients who had a bursectomy reported that around one in nine needed a further (revision) operation, and that people with rheumatoid arthritis, diabetes, or bursitis on both elbows ran a higher risk of needing more surgery. Patients with rheumatoid arthritis in particular were more likely to need a skin flap to get the wound to heal. Studies report a meaningful rate of wound complications such as delayed healing, the wound breaking down, fluid collecting again (a seroma), and infection [2, 3]. The take-home is not a precise percentage; it's the pattern: this operation has a higher-than-usual chance of a slow or troublesome wound, and a real chance the swelling returns. We do several things to tip the odds in your favour, and your part in this matters as much as ours: - Gentle handling and careful closure at the time of surgery, and (where it suits the problem) keeping incisions off the very tip of the elbow. - A firm compression dressing afterwards to discourage fluid from collecting, and sometimes a splint to keep the elbow still while the skin knits. - Most importantly: no leaning on the elbow. Pressure on a healing elbow is the single biggest driver of both wound breakdown and the bursa coming back. Keeping weight off it for several weeks genuinely changes your result. None of this is meant to frighten you off. It is meant to make sure that if we do operate, you go in with clear eyes, and that you understand the recovery instructions are not optional fussiness, but the thing that protects the result. ## Your recovery Everyone heals at their own pace, and your surgeon's specific instructions always come first, but here is the general shape of things. The first week or two. You'll have a firm, padded compression dressing over the elbow, often with a splint. Keep the dressing clean and dry, keep the arm elevated when you can to settle swelling, and take simple pain relief as advised. The single most useful thing you can do in these early weeks is keep the elbow still and keep all pressure off the back of it: no resting your weight on it, no leaning on tables or armrests. Gentle finger, wrist and shoulder movement is usually fine and helps prevent stiffness. Stitches and dressings. The compression wrap is generally kept on for the first several days, and many surgeons ask you to keep a light compressive (ACE-type) wrap on the elbow for some weeks afterwards to discourage fluid building up again. Stitches are usually removed at around 7 to 10 days in clinic, once the skin has had a chance to seal. We will check the wound carefully at this visit, because the elbow can be slow to heal. Getting moving again. Once the wound is settled and the stitches are out, you'll gradually return to using the arm. Many people are allowed to resume most normal activities and full use of the elbow over roughly three to six weeks, with full settling of swelling often taking around the six-week mark. Your surgeon may set a temporary limit on heavy lifting early on while the skin matures. Driving is reasonable once you can move the elbow comfortably, are off strong pain medication, and could safely control the car and perform an emergency stop; for many people this is a couple of weeks, but it depends on which arm and how you're healing, so check with us first. Work depends entirely on your job. A desk-based job is often manageable within a week or two (taking care not to lean on the elbow). A job involving heavy lifting, kneeling on the elbow, or anything that puts pressure or strain through the elbow usually needs longer (several weeks) and sometimes a phased return. Tell us what your work involves and we'll give you tailored advice. Throughout, remember the recurring theme: protect the elbow tip. The recovery rules all exist to give that thin, hard-working skin the best chance to heal once and stay healed. ## When to seek help A little swelling, bruising and discomfort is normal after this operation. But please contact your surgeon, your GP, or an after-hours clinic promptly if you notice any signs that the wound is not healing well or is becoming infected, such as: - Spreading redness, increasing warmth, or worsening pain around the wound after the first few days. - The wound opening up, leaking fluid or pus, or an offensive smell. - A fever, feeling generally unwell or shivery. - The elbow swelling up again significantly: this may mean fluid is re-collecting. Separately, and as with any operation, blood clots are a rare but serious risk. Go straight to an emergency department (or call emergency services) if you develop a painful, swollen, hot calf, or (more urgently) sudden shortness of breath, chest pain, or coughing up blood. These can be signs of a clot in the leg or lungs and need immediate assessment. If you are ever unsure whether something is normal, it is always better to ask. We would far rather see a wound early and reassure you than have a small problem become a bigger one, especially over an elbow where early attention to a struggling wound makes a real difference. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Olecranon Bursitis page. --- ### Olecranon Bursitis URL: https://www.cqupperlimb.com/education/elbow/olecranon-bursitis/ Region: elbow · condition Olecranon bursitis — causes, symptoms, and when to seek urgent medical attention for infection. ## What you're feeling Olecranon bursitis means the small cushioning sac at the point of your elbow has become swollen. That sac, called the bursa, normally lets skin glide smoothly over the bone. When it flares up, you notice a soft, sometimes tender lump right over the tip of the elbow. The swelling is usually the thing you see first. It can come up quickly over a day or two, or slowly over weeks. Leaning on that elbow makes it worse, so desk work, resting your arm on a chair arm, or sleeping with the elbow bent under you can all aggravate it. Many people find it aches at night, especially if they sleep on that side. Straightening the arm out and taking pressure off the point of the elbow tends to settle it. Everyday tasks that bend the elbow against resistance or press on the tip become awkward. Pushing yourself up from a low chair, loading the dishwasher, carrying shopping bags against your forearm, or resting your elbow on a table while you read can all be uncomfortable. Reaching overhead may pull on the swollen area too. The swelling itself is not always simple wear and tear. Sometimes it comes from an infection in the sac, which usually makes the skin over the elbow red, warm and more painful. Sometimes it comes from crystals in the joint, a condition called gout, especially if you have had similar attacks before or the other elbow is affected as well. Swelling here can also be linked with inflammatory joint conditions such as rheumatoid arthritis, which typically affects several joints on both sides of the body at once. Because these causes can look alike, it is not always easy to tell them apart from the outside. If your elbow is hot, red or very painful, or the swelling has hung around for weeks without settling, it is worth having it looked at properly so the right treatment can be started. ## What's actually happening At the tip of your elbow sits a small sac of fluid called the bursa. Think of it as a thin cushion, like a padded pouch between the skin and the bone. Its job is to let the skin slide smoothly over the bone every time you bend or straighten your arm. With olecranon bursitis, that cushion becomes inflamed and swells up with extra fluid. This usually happens after repeated small knocks or pressure on the point of the elbow, the kind that comes from leaning on hard surfaces day after day. The sac can also simply enlarge from friction over time. The lump you can see and feel is the swollen sac itself, and the tenderness comes from the inflamed tissue around it. Sometimes the swelling is not just irritation. The sac can become infected, which is why an infected bursa tends to be hot, red and more painful than one that is merely inflamed. Crystals from gout can settle in the sac, and inflammatory conditions such as rheumatoid arthritis can cause swelling and small firm lumps over the same spot. Because these causes look so similar from the outside, telling them apart can take a proper examination. The bone at the tip of the elbow, called the olecranon, sits just under the skin with very little padding around it. That exposed position is exactly why it picks up knocks so easily, and why the bursa above it takes so much of the wear. The same bone also anchors the tendon of the muscle at the back of your arm, the one that straightens your elbow, so problems around this small area can affect how the whole elbow feels and moves. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your first visit we take a history, examine your elbow and arrange imaging such as ultrasound or MRI scans if it will help. An MRI scan uses magnets to build detailed pictures of the soft tissues, and it is good at showing how swollen the sac is and how much fluid it holds. Imaging can also pick up other problems hiding behind the swelling, which matters because different causes need different treatment. For most long-standing cases, we begin with simple supportive care. That means ice, compression with a bandage or sleeve, protective padding over the point of the elbow, and changing the activities that keep aggravating it. Taking pressure off the tip of the elbow is often the single most useful change you can make. Physiotherapy aims to settle the irritation and rebuild comfortable movement without provoking the swelling. We give this approach a fair trial before thinking about anything further, because non-operative care works well for most people and avoids the risks that come with needles or surgery. If the sac is infected, we treat that infection directly. Uncomplicated infection in this sac can usually be settled with medication alone, without needing the sac removed. We also keep a close eye on people with rheumatoid arthritis, because the elbow joint itself can occasionally be involved at the same time as the bursa, and that changes the treatment. Surgery is not our usual first move for this condition. Most surgeons hold off on operating early, because a wound over this prominent bone can be slow to heal and can sometimes leave a sinus, a small channel that keeps draining. When non-operative care has not given enough improvement and the swelling keeps coming back, we consider removing the inflamed sac, an operation called bursectomy. Where suitable, we can do this through a few small cuts using a tiny camera, an approach called endoscopic surgery. That avoids a long wound directly over the sensitive point of the elbow. Whether surgery is right for you is a decision we make together, weighing what you want to get back to against what each option involves. ## What to expect For most people, this swelling settles with simple care. Taking pressure off the point of your elbow, protecting it with padding and easing back on aggravating activities gives the sac a chance to calm down. Non-operative treatment is generally more effective and safer than surgery for this condition, and most people never need an operation. If the sac is infected but the infection is straightforward, treating it with medication alone usually works, and the swelling can often be managed without draining it or removing the sac. Without that care, or if the same pressures keep up, the swelling tends to persist or keep coming back. Some people find it hangs around for weeks without settling. If your elbow stays swollen for a long time, it is worth having it reassessed, because a swelling that will not settle can occasionally point to a less common cause that needs its own treatment. When non-operative care has had a fair go and the swelling still keeps returning, surgery to remove the inflamed sac becomes an option. It is a decision not taken lightly, and it is usually held back until simpler measures have failed. Where surgery is done for this stubborn type of swelling, people tend to see real improvement in how their elbow feels and functions. Removing the sac through a few small cuts with a tiny camera has been associated with minimal postoperative pain and rapid recovery, with no recurrences or wound-healing complications needing a return to theatre in the patients reported. Even so, surgery here is not foolproof: about 11.5% of people who have the sac removed need a further operation later on. There is also a small chance the swelling comes back even after surgery. Recovery after surgery is usually straightforward, but a wound over this bony point can be slow to heal, which is one reason surgeons prefer to avoid operating early. Most people get back to comfortable, everyday use of the elbow within weeks rather than months. Your surgeon will talk you through what recovery would look like for you if surgery ever becomes part of the plan. ## When to see someone Most swelling over the point of the elbow settles with rest and simple care. See your GP if the lump keeps growing, or if it has not settled after a few weeks of taking pressure off the elbow. Some causes need to be sorted out quickly. Go to an emergency department if the skin over the elbow is hot, red and very painful, because that can mean the sac is infected and infection here needs same-day assessment. Ask for a specialist review if you have had gout attacks before, if the other elbow is swollen as well, or if several joints on both sides of your body are affected, since these point towards gout or an inflammatory condition such as rheumatoid arthritis rather than simple irritation. Telling an infection from gout can be difficult from the outside, so do not try to work it out yourself. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Olecranon bursitis is worth the extra reading because two of the things most instinctively done about it, draining the swelling with a needle, and injecting steroid into it, have evidence against them. ### Draining it can be the thing that causes the problem The intuition is strong: there is fluid, so remove the fluid. The trial data point the other way. In a comparison of management strategies for uncomplicated septic olecranon bursitis, empirical treatment without aspiration was effective, with no patients requiring bursectomy, while in the traditional aspiration group, 8 of 11 patients went on to need surgical removal of the bursa [1]. That is a striking difference from a small series, and it should be read with that caution. But the mechanism is not mysterious. The bursa sits directly under thin skin over a bony point that takes every knock and every lean on a desk. Putting a needle through that skin creates a tract, and a tract over a pressure point is slow to seal and can keep discharging. The general reviews agree on direction. Based primarily on level IV evidence, non-surgical management is significantly more effective and safer than surgical management [2]. ### Steroid injection carries risk without improving the outcome This one is stated unusually plainly in the literature. For aseptic bursitis, corticosteroid injection is associated with significant risks without improving the outcome [2]. The risks are specific to the site: skin atrophy and depigmentation over a subcutaneous bony prominence, and infection introduced into a space that is difficult to clear. Elsewhere in the upper limb a steroid injection is a reasonable step when simpler measures fail. Here the evidence does not support it, and that difference is worth knowing if it is offered. ### Surgery is a genuine last resort, with a measurable failure rate Where bursectomy is performed, it does not reliably end the story. The revision rate after bursectomy was 11.5%, and revision was more frequent in patients with rheumatoid arthritis, diabetes, a history of bursitis on either elbow, and in women [3]. Those risk factors describe the situations in which the bursa is likely to reform: an inflammatory or metabolic driver that surgery does not remove, or a demonstrated tendency of that individual's tissue to produce the problem. For recurrent cases, intrabursal doxycycline sclerotherapy, deliberately scarring the space closed rather than excising it, has been described as an alternative in a series of 45 elbows [4]. ### What actually settles it The unglamorous answer is protection and time. Because the bursa is irritated mechanically by pressure on the point of the elbow, the treatment that addresses the cause is removing that pressure: padding, and changing the habit of resting on the elbow, sustained for longer than feels necessary. Most cases settle [5], and the interventions above are largely attempts to shorten a course that resolves anyway, which is precisely why an intervention carrying its own risk needs to clear a high bar here. --- ### Olecranon Fracture URL: https://www.cqupperlimb.com/education/elbow/olecranon-fracture/ Region: elbow · condition Olecranon fractures — patterns, non-operative care, and tension-band or plate fixation. ## What you're feeling An olecranon fracture is a break in the bony point at the back of your elbow. It usually happens in one of two ways. In younger people it tends to follow a hard fall or a direct blow to the elbow. In older people it often comes from a simple fall from standing. A sudden, forceful straightening of the arm can also pull a piece of bone off the tip of the elbow. You will usually feel pain right at the back of the elbow, and it tends to be sore in one spot rather than all over. Swelling over the back of the elbow is typical and can be quite marked. Because that bony point sits just under the skin, you can sometimes feel the edge of the break through the skin. If the skin was broken in the fall, the wound is usually at the back of the elbow where it hit the ground. The arm may be hard to use, and straightening it against something, like pushing up from a chair, may feel weak or impossible. In the first days, pain is often worse when you try to move the elbow, and it can disturb your sleep. Everyday tasks that bend or load the elbow, such as lifting a kettle, dressing, or leaning on your forearm, will usually hurt. The swelling and bruising settle over the first couple of weeks, and the pain gradually eases as the bone starts to heal. Some things need urgent care. Go to the emergency department the same day if the skin over the elbow is broken, if bone is showing, or if the arm looks obviously out of shape. The same applies if your hand or fingers turn pale, cold, white or blue, or if you suddenly lose feeling or movement in the arm after the injury. If symptoms are not settling, are getting worse over weeks, or are waking you at night, see your GP or ask for a specialist review. If you cannot reach the clinic, go to your nearest emergency department. ## What's actually happening The bony point at the back of your elbow is called the olecranon. It is the top end of one of your forearm bones, and it acts like a hinge cap. When you straighten your arm, that cap glides in a groove at the end of your upper arm bone. The break matters because of what is attached to it: the tendon from your triceps, the muscle at the back of your upper arm, is anchored right at that point. That tendon is what lets you straighten your elbow against a load. Think of it like a door with a strong spring pulling it shut. The olecranon is the bracket holding that spring. When the bone breaks, the spring keeps pulling, and it drags the broken piece up and away, leaving a gap in the joint surface. That is why your arm does not work normally right now: the muscle is still strong, but it is pulling on a loose piece of bone instead of moving your forearm. Straightening against resistance becomes weak or impossible. Bone heals by knitting back together, and a broken-off piece with its tendon attached can reattach as the bone knits. But the pieces need to be in the right position for that to work well. When the break has not shifted, the pieces can simply be held still while they knit. When the pieces have pulled apart, or when the joint surface is broken into several pieces, the elbow can become unstable, and those breaks usually need surgery to hold them in place while they heal. Surgeons grade these breaks by how far the pieces have moved and whether the elbow joint stays stable. A grade one break has not shifted. A grade two has shifted but the joint still works. A grade three means the elbow joint itself is unstable. The shifted and unstable grades are the ones that most often need surgery. Most of these breaks heal well, with a small loss of full straightening being common. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some of these breaks heal without an operation, and others need surgery soon after the injury, so prompt assessment matters. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a history, examine your arm, and arrange imaging where it is needed. If the break has not shifted, or has shifted only a little, and your elbow is stable, we may recommend holding it still while it heals. That means a splint or cast for a period, with checks on repeat X-rays to make sure the pieces stay in place. This path is common for older patients, and for people whose arm is used for everyday tasks rather than heavy work. It avoids an operation and the risks that come with one. The trade-off is that the elbow may not straighten fully at the end, and some people find that hard to accept. Movement is brought back in stages with your hand therapist, who will also make any splint you need. If the pieces have pulled apart, or the elbow joint is unstable, we will usually recommend surgery from the start. The aim is to hold the pieces in the right position so the bone can knit and you can move early. The choice of how to hold the bone depends on the pattern of the break, and no single method suits every fracture. Sometimes both paths are genuinely open, for example in an older patient with a shifted break. We will talk through what matters to you: how much pain you are willing to put up with, and whether losing the last few degrees of straightening would bother you. Whichever path you take, the first weeks are similar. Pain relief keeps you comfortable while the swelling settles. The injury needs protecting while the bone knits, and we will tell you what you can and cannot do with the arm. Your hand therapist will guide your movement at the right stage, gently at first, building up as the bone heals. Most of these breaks heal well, with a small loss of full straightening being common. Metalwork sitting just under the skin at the back of the elbow can be uncomfortable, and some people need a small operation later to remove it. ## What to expect Most of these breaks heal well. A small loss of full straightening is common, and most people keep good use of the arm. Long-term results after surgery for complex breaks are good, even when some wear-and-tear arthritis shows up in the joint on later X-rays. If your break is held still in a splint or cast, the bone knits over weeks rather than days. You will have repeat X-rays to make sure the pieces stay where they should. This path suits older patients and people whose arm does everyday jobs rather than heavy work. Outcomes at both the short-term and long-term mark are satisfactory in that group. The trade-off is that the elbow may not straighten fully at the end. If you have surgery, the bone is held in place with metal while it knits. Movement starts early and builds in stages with your hand therapist. Some loss of full straightening is expected after this injury, whichever path you take. In one long look at people treated with surgery for a shifted break, 96% had good or excellent results up to 25 years after the injury. Recovery is a gradual return to what you normally do. Light daily tasks come back first, then lifting and heavier use as the bone strengthens. How soon you can drive, work or play sport depends on your job, your arm and how the bone heals, and we will talk you through each stage. Things that can go wrong are worth knowing about. The metalwork sits just under the skin at the back of the elbow, and it can be uncomfortable enough that some people choose to have it removed later. That is a recurring issue after this surgery. Other problems, such as the bone healing in a poor position or the elbow staying stiff, are less common. If your symptoms are not settling, are getting worse over weeks, or are waking you at night, see your GP or ask for a specialist review. If you cannot reach the clinic, go to your nearest emergency department. ## When to see someone Seek urgent care if your elbow looks obviously out of shape, if the skin is broken over the injury, or if your hand or fingers turn pale, cold, white or blue. Sudden loss of feeling or movement in the arm after the injury also needs the emergency department the same day. These signs mean the injury needs looking at straight away. For everything else, start with your GP. They can examine your arm and arrange X-rays, which are usually all that is needed to show this type of break. If your GP thinks a specialist should take over, they will refer you for a review. Come back, or ask for a specialist review, if the pain is not settling, or if the swelling, movement or use of your arm are not improving week on week as the bone heals. Symptoms that are getting worse over weeks, waking you at night, or stopping you working or using the arm also deserve another look. If you cannot reach the clinic, go to your nearest emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Olecranon fracture is worth the extra reading because of one finding that inverts the usual logic of fracture surgery: in older patients, a displaced fracture of the olecranon can be left unfixed, and the elbow still works. ### The displaced fracture that does not need fixing A fracture through the olecranon separates the triceps from the forearm, so the standard reasoning is that it must be reattached or the elbow cannot be straightened against resistance. In patients older than 70, that reasoning does not hold up. A systematic review found displaced olecranon fractures in this group may be effectively managed non-operatively, producing high satisfaction and a functional range of motion [1]. What is traded is measurable: an extension lag, an inability to fully straighten the elbow, and reduced extension strength. What is avoided is a wound over a subcutaneous bone in thin, often fragile skin, and metalwork under that skin. Since prominent hardware is the commonest reason for a second operation after olecranon fixation, avoiding it removes the commonest complication entirely. For an older person whose arm is used for daily tasks rather than forceful pushing, an elbow that lacks the last few degrees of extension is a smaller imposition than a wound complication. For a younger or higher-demand patient it is not, which is why the finding is specific to age rather than general. ### Where fixation is used, the implant choice has separated For the common displaced-but-simple pattern, two implants compete: a tension band construct of wires and a plate. Across 827 patients with Mayo type II fractures, plate fixation showed better efficacy and safety than tension band wiring, with the authors noting that few studies were included and that higher-quality randomised trials are still needed [2]. A 2025 review of 472 patients comparing modern fixation techniques against traditional tension band wiring points the same way [3]. This is one of the few places on this site where a technique comparison produces a direction rather than a shrug. It is worth holding lightly given the evidence base the authors themselves flag. ### Arthritis develops, and mostly does not matter Long-term imaging findings can be alarming when reported without context. Following isolated olecranon fractures, the median incidence of post-traumatic osteoarthritis was 19% at a median follow-up of 41 months, and final patient-reported outcomes ranged from good to excellent regardless of fracture type or the presence of arthritis [4]. Both halves of that sentence are load-bearing. Arthritis on a follow-up X-ray after this injury is common. It is also, at this timescale, largely disconnected from how people report their elbow functioning. A radiological finding is not automatically a clinical problem, and it should not be the trigger for further intervention on its own. --- ### Olecranon Fracture Fixation (ORIF) URL: https://www.cqupperlimb.com/education/elbow/olecranon-orif/ Region: elbow · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your elbow and arrange imaging if it is needed. This tells us whether the broken bone at the point of your elbow has moved out of place. If the pieces have barely moved, the break can often be managed without surgery, using a splint and check X-rays to make sure nothing shifts. This is usually the first option we discuss. Surgery is suggested when the break has moved enough that it will not heal in a useful position on its own. The aim of the operation is to hold the pieces back in their normal position while they join together, so the elbow surface stays smooth. A rough surface can lead to wear-and-tear arthritis in the joint over time. Holding the bone securely also lets you start moving the elbow early, which lowers the chance of lasting stiffness. Most people who have this operation keep their implants in place, and only 3% experience movement of the implant afterwards. ## Before the operation Once surgery is planned, we will give you clear instructions to follow. You will need to stop eating and drinking seven hours beforehand. We ask for seven hours rather than the usual six so your time can be brought forward if the theatre list runs early. Some medications can affect the operation, so bring a written list of everything you take and we will tell you which ones to pause. Arrange for someone to drive you home afterwards. Wear loose, comfortable clothing with sleeves that slide over your elbow easily. Imaging such as X-rays, MRI or ultrasound may be arranged beforehand to plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, but most people do not. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist, the doctor who looks after your anaesthetic and pain relief. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. Afterwards you will wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you will either move to a ward or go home, depending on the procedure and how your recovery is going. ## What the operation involves The operation is called open reduction and internal fixation. Open means the surgeon reaches the break through one cut at the back of your elbow, over the point of the elbow itself. Reduction means the broken pieces are eased back into their normal position, and internal fixation means they are held there with metal implants while the bone joins together. The surgeon chooses the implant that suits your fracture, because no single technique suits every break. For a simple break in two pieces, the pieces may be held with a wire loop that presses them together as you move, or with a screw placed down the middle of the bone. For breaks in several pieces, or in softer bone, a plate moulded along the back of the elbow and held with small screws is often used. Some breaks can be held with strong stitches anchored into the bone instead of metal. Whichever method is used, the aim is the same: a firm hold that lets you start moving the elbow early. Once the pieces sit in their normal position and the implant is secure, the surgeon checks that the elbow surface is smooth and that the joint moves freely. The layers of tissue are stitched back together and the skin is closed with stitches, then covered with a dressing. ## After the operation When you wake up, your arm will rest in a simple sling for comfort. Nurses will check on you and give you pain relief if you need it. Someone should stay with you for the first 24 hours after you go home. Your team will tell you whether you go home the same day or stay one night in hospital. You can move around as soon as you feel steady, and the sling comes off for washing and for the exercises your team shows you. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Keep your hand and fingers moving from the first day, as this helps with swelling and comfort. ## Recovery For the first few days your elbow will be sore and swollen, and the skin around it may look bruised. This settles gradually. Keeping your hand and fingers moving from the first day helps, as does resting your arm up on pillows when you sit or sleep. Take the pain relief you have been given regularly at first rather than waiting for the pain to build. Your arm rests in a simple sling for comfort in the early days. It comes off for washing and for your exercises. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby will show you exercises that keep your elbow moving while the bone joins together, and she will make a splint if you need one. You will keep your fingers and hand moving from the start, and gentle elbow movement is added as the break settles. Everyday tasks take some planning at first: you will need help with meals, dressing and carrying things until your arm is steady again. As the swelling settles and movement returns, you will notice the exercises become easier. Once your surgeon is happy the bone is joining well, the sling comes off for good and you start using the arm for light tasks around the home. Heavier lifting, sport and driving come later, once your therapist and surgeon agree the elbow is strong enough. If driving is on your list, see our guide to driving after upper-limb surgery for the rules that apply. Everyone heals at a different pace, so your timeline may differ. Your surgeon and your hand therapist will guide you at each visit. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The metal holding the bone can sometimes shift from where it was placed. You might notice a new sharp pain at the point of your elbow, a lump under the skin that was not there before, or the skin becoming sore or rubbed where the implant sits. If you feel this, call the clinic rather than waiting for your next visit. The wires or implants can also press on or poke through the skin. This causes pain and skin irritation, and the wound can break down over the spot. Tell us promptly if you see this, as the implant may need to be taken out. Infection is a risk with any operation. Watch for a deep, throbbing pain that does not ease with simple painkillers, redness that spreads out from the wound, fluid leaking from it, or a fever. If you notice any of these, contact the clinic the same day or go to the emergency department if you cannot reach us. An infection can also slow down the joining of the bone. If healing seems to be taking much longer than your team expected, bring it up at your next review. The nerve that runs behind the point of your elbow can become irritated. This can cause tingling, pins and needles or numbness down the inside of your forearm and into your little and ring fingers. Mention any of these feelings at your review, or call the clinic if they come on suddenly. Some people notice a small loss of full straightening of the elbow, even when the break heals well. Others develop wear-and-tear arthritis in the joint over time, which can feel like aching, clicking or grinding. Both are worth raising at follow-up so your team can track them. The bone can also fail to join, or join in the wrong position. If your elbow stays painful and unstable after several weeks of healing, we will check it with X-rays. Smoking raises the chance of problems after this operation. If you smoke, talk to your GP about quitting before surgery. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up early, and we would rather hear about them straight away. Call us if you have a fever, if the wound becomes more red or starts leaking fluid, or if pain suddenly gets much worse. Go to emergency if you have swelling in your calf, shortness of breath, or chest pain. Call us as well if your fingers or hand go numb, feel cold, or you cannot move your arm. If you cannot reach us and something feels urgent, go to your nearest emergency department. --- ### Pronator and AIN Release URL: https://www.cqupperlimb.com/education/elbow/pronator-and-ain-release/ Region: elbow · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. This operation is a nerve release in your forearm. It eases pressure on one of the main nerves that runs from your elbow to your… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. This operation is a nerve release in your forearm. It eases pressure on one of the main nerves that runs from your elbow to your hand. We usually suggest it when other treatments have not given you enough relief. Most people try non-operative care first. That means resting the arm, avoiding the activities that stir up your symptoms, and taking anti-inflammatory medicine. Surgery is considered when symptoms continue despite this care. For pronator syndrome, surgery is an option if your symptoms have lasted more than 6 months. For anterior interosseous nerve syndrome, it is an option after at least 12 months with no signs of muscle strength returning. We may also suggest surgery sooner if your daily activities need strong, repeated forearm turning and testing confirms the nerve is compressed. The aim of this operation is to relieve your pain and restore the strength and use of your hand. Complete relief happens in about 64 to 71% of people. About 20% get incomplete relief, and about 8% need a further operation. We will talk through these figures with you so you can decide together with us whether surgery is right for you. ## Before the operation Your surgeon will give you clear instructions to prepare. You will need to stop eating and drinking seven hours before your operation. We ask for seven rather than six so your surgery can be brought forward if the theatre list runs early. You may need to stop some medicines before surgery, and your surgeon will tell you which ones and when. Arrange for someone to drive you home afterwards. Bring a list of your current medicines. Wear loose, comfortable clothing on the day. Imaging such as an X-ray, MRI or ultrasound scan may be used to plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, but most people do not. ## On the day You will arrive at the hospital's surgical admissions unit. Staff will check you in and prepare you for theatre. You will then meet the anaesthetist, the doctor who gives the medicine that keeps you asleep and comfortable during the operation. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You will then be taken into the operating theatre, where the operation is performed. When it is finished, you will wake up in the recovery area. Nurses will monitor you there while the anaesthetic wears off. Once you are stable, you will either go to a ward or go home, depending on the procedure and your recovery. ## What the operation involves This is a nerve release in your forearm. Your surgeon makes a cut on the front of your forearm, near your elbow, to reach the nerve. The cut is kept as small as possible. Through it, your surgeon finds the spots where tight tissue is squeezing the nerve and releases that tissue, freeing the nerve along its whole course. If a band of tissue or an unusual vessel is pressing on the nerve, that is removed as well. The cut is closed with stitches and covered with a dressing. You will go home with the dressing intact. The operation itself is focused and careful work in a small space. Releasing the nerve where it passes through the muscle of the forearm calls for deeper dissection than some other nerve releases, so your surgeon takes time to protect the nerve and the structures around it. ## After the operation You will wake up in the recovery area with nurses watching over you while the anaesthetic wears off. Your arm may feel heavy or numb for a while. This is expected, and it settles as the medicine wears off. You will have pain relief to keep you comfortable, and your hand and forearm will be wrapped in a soft dressing. You can move around soon after waking, and someone should stay with you for the first 24 hours. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your hand and forearm may feel sore and swollen. The area around the cut can ache, and your fingers may feel stiff. Rest, keeping your hand raised on a pillow, and your pain relief all help to ease this. The discomfort usually settles as each day passes. You will go home with a soft dressing on your arm. We leave it on for about 10 days and change or remove it when we see you. Once it is off, hand therapy begins. Your hand therapist, Ruby Doolan at Extend Rehabilitation, will guide your exercises and make any splint you need. These exercises keep your fingers moving and stop stiffness while the nerve settles. At home you can do most light daily tasks within the first couple of weeks, using your hand as your comfort allows. Avoid heavy lifting, gripping hard, or anything that strains the forearm until your therapist clears it. Sleep however feels comfortable; some people prefer to rest the arm on pillows beside them. Recovery follows a pattern rather than a fixed schedule. First the pain and swelling settle. Then movement and grip return. Strength and feeling in your hand keep improving over many months, and the final result comes once your pain and strength stop changing. Everyone heals at their own pace, so your timeline may differ; your surgeon and your therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Because this release works deep in the forearm muscle, the operation is more involved than some other nerve releases. Your surgeon takes extra care to protect the nerve and the tissue around it. The nerve being released sits close to other nerves that give feeling and movement to your hand. Rarely, one of these can be irritated during surgery. You might notice new numbness, pins and needles, or weakness in part of your hand or forearm once the nerve block has worn off, which takes about 24 hours. Some numbness and weakness in the first 24 hours is expected from the block itself. If it lasts beyond that, call the clinic. The wound can cause trouble too. Call the clinic the same day if you have a fever, redness spreading out from the cut, or fluid or pus leaking from it. Pain that keeps getting worse despite your pain medicines also needs a same-day call. Sometimes a firm, tender lump forms near the wound in the days after surgery. This is a collection of blood under the skin. If it grows, feels increasingly painful, or the skin over it looks tense and shiny, call the clinic. If a release is done through a small keyhole cut rather than an open one, it occasionally does not hold, and a further operation may be needed. Your surgeon will discuss this with you when planning your care. Recovery from nerve surgery is often slow, and the nerve can keep improving over many months. How well it recovers depends partly on how long it was compressed before surgery. If the pressure has been present for a long time, some changes in the hand may not fully reverse. Your surgeon will talk with you about what to expect in your case. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up in the first few days. Some need a quick call, and some need urgent care. Go to the emergency department if your calf swells or hurts, or if you become short of breath or get chest pain. These can be signs of a blood clot. Go also if your fingers, hand or thumb turn pale, cold, white, blue or dark, as this suggests a problem with blood flow. Call the clinic the same day if you have a fever, redness spreading out from the cut, or fluid or pus leaking from it. Pain that keeps getting worse despite your pain medicines also needs a same-day call. Call the clinic if you cannot feel your arm, hand or fingers, or cannot move them, once the nerve block has worn off. The block takes about 24 hours to wear off, and numbness and weakness during that time are expected. If it lasts beyond that, call us. If you cannot reach the clinic after hours or on a weekend, go to your nearest emergency department. --- ### Pronator, Lacertus and Anterior Interosseous Nerve Syndromes URL: https://www.cqupperlimb.com/education/elbow/pronator-and-ain-syndrome/ Region: elbow · condition Median nerve trouble high in the forearm — forearm aching with hand tingling (pronator) or weakness pinching the thumb and index (AIN), and how each is treated. ## What you're feeling These conditions all come from the median nerve being squeezed high up, around the elbow and the top of the forearm, rather than down at the wrist where it is more famously pinched (carpal tunnel syndrome). They feel quite different from each other. Pronator syndrome tends to cause a deep, aching, tiring pain in the front of the forearm, often made worse by repeated twisting of the forearm (turning a screwdriver or a key, wringing out a cloth) or by heavy gripping. You may also feel pins and needles or numbness in the thumb, index and middle fingers, and across the palm and the fleshy base of the thumb as well. Unlike carpal tunnel syndrome, it usually does not wake you at night, and the discomfort is felt more in the forearm than in the hand. Lacertus syndrome is a newer name you may hear for a particular version of this same high squeeze, where the culprit is a firm fibrous band at the elbow crease called the lacertus fibrosus. The typical story is a hand that tires quickly and grips clumsily — writing, typing or using tools becomes effortful — together with forearm ache and marked tenderness just below the crease of the elbow. It is also one of the things we look for when carpal tunnel surgery has not fixed the symptoms it was expected to fix. Anterior interosseous nerve (AIN) syndrome is different again. It usually causes little or no numbness. Instead it is a weakness problem: the muscles that bend the very tip of your thumb and index finger stop working properly. The classic sign is being unable to make a normal round "OK" sign: when you try to pinch the tip of your thumb to the tip of your index finger, the pinch collapses into a flat or triangular shape. Some people notice a short period of aching in the arm or shoulder first, and then the weakness appears. ## What's actually happening A single large nerve, the median nerve, runs from your neck, down the arm, across the front of the elbow and into the hand. It carries both feeling (for part of the hand) and power (to several muscles). In pronator syndrome, the nerve gets pressed or irritated as it passes through the crowded space at the elbow and the top of the forearm. It can be squeezed by a tight band of tissue near the elbow crease (the lacertus fibrosus — when this band is the culprit, the condition is increasingly called lacertus syndrome), or as it threads between or under the muscles that turn your palm down. Because the squeeze is high up (above the wrist), the symptoms include the palm and base of the thumb, which is the main clue that separates it from carpal tunnel syndrome. In AIN syndrome, the problem affects a deep branch of the median nerve that carries only power, no feeling, which is why there is weakness but no numbness. In many people this is not a simple "pinch" at all but more like an irritation or inflammation of the nerve (sometimes following a viral illness or for no clear reason), which is part of why it so often recovers on its own. ## What we can do about it At Mater Private Hospital Rockhampton, Dr Kieran Hirpara leads our upper-limb team in assessing these conditions through careful history and examination. We typically begin with non-surgical care, reserving surgery only if your symptoms persist despite rest and activity changes. For all of these conditions, the first step is almost always non-surgical, and for AIN syndrome in particular that patience is usually rewarded. Settling things down. This means modifying the activities that aggravate it (easing off the repeated twisting and heavy gripping), sometimes using a splint to rest the arm, and giving the nerve time. Simple pain-relieving measures help with the ache. Watchful waiting. AIN weakness very often improves by itself over several months, so the usual plan is to watch and wait, frequently for around three to six months, before considering anything more. Many people regain their strength in that window without an operation. Tests such as nerve studies or a scan may be arranged along the way to confirm the diagnosis and track recovery. Surgery is reserved for the minority who do not improve: pronator syndrome that stays painful despite a fair trial of rest and activity change, or AIN weakness that shows no sign of recovering after a period of observation. The operation releases the tight structures pressing on the nerve so it can recover. When the squeeze is at the lacertus band specifically, this can often be done through a short incision under local anaesthetic while you are awake — which lets the strength of the affected muscles be checked on the spot — and recovery is usually quick. ## What to expect These conditions generally have a good outlook. AIN syndrome in particular has a strong tendency to get better on its own, which is exactly why we don't rush to operate. Recovery is gradual, measured in months rather than weeks, so it takes some patience, and your progress will be reviewed along the way. When non-surgical treatment isn't enough and an operation is needed, releasing the nerve typically eases the pain of pronator syndrome and gives the best chance of strength returning in AIN syndrome, although nerves recover slowly and the improvement continues to build for many months afterwards. ## When to see someone - Aching forearm pain with numbness or tingling in the thumb, index and middle fingers, especially if you also feel it in the palm and base of the thumb, and it is worse with twisting or gripping. - Sudden difficulty making a normal "OK" sign, or weakness pinching the tip of the thumb against the index finger. - Forearm or hand symptoms that don't settle with rest and activity changes, or weakness that is not recovering after a few months. - A short bout of shoulder or arm aching followed by hand weakness, worth having assessed, as this pattern can point to a nerve problem that benefits from being identified early. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. These syndromes are worth the extra reading because of two live debates that change the treatment: a newly popular diagnosis (lacertus syndrome) whose supporting evidence is genuinely striking but genuinely thin, and the anterior interosseous problem is increasingly thought not to be a compression at all, which means decompressing it is unlikely to be the answer. ### The condition that is probably not a compression Anterior interosseous nerve syndrome produces a characteristic weakness, an inability to bend the tip of the thumb and index finger, so the "OK" sign collapses into a pinch, with no numbness, because this branch supplies muscle only. It was long assumed to be the nerve caught by a fibrous band, and treated accordingly. The contemporary view is different: it is increasingly thought to be a neuritis and often resolves spontaneously following prolonged observation [1]. The natural history is nearly always complete or near-complete recovery, and there is no reliable evidence that surgery can alter that natural history, so hurried surgical treatment should be avoided until good-quality studies show early intervention improves or accelerates recovery [2]. That reframing matters because the two models imply opposite actions. If a band is strangling the nerve, delay causes permanent damage and early release is urgent. If the nerve is inflamed, an operation adds a wound to a process that was going to recover, and recovery on a nerve's timescale is measured in many months, long enough that surgery performed at month six will reliably appear to have worked. The practical guidance reflects the uncertainty rather than resolving it: surgical decompression is indicated for persistent symptoms beyond 6 months in pronator syndrome, or a minimum of 12 months in anterior interosseous nerve syndrome [1]. ### Pronator syndrome is a contested diagnosis Pronator syndrome describes compression of the median nerve higher up, around the elbow, producing forearm ache with numbness in the median-supplied fingers. Because those sensory symptoms overlap almost entirely with carpal tunnel syndrome, much commoner, and readily confirmed on nerve conduction studies, the difficulty is telling them apart. It is described in the literature as a controversial diagnosis, typically treated non-surgically over a prolonged period of approximately 12 months [1]. The features that point proximally rather than distally are numbness over the palm at the base of the thumb, supplied by a branch leaving the nerve before the carpal tunnel, and therefore spared in carpal tunnel syndrome, along with forearm tenderness and symptoms provoked by resisted forearm rotation rather than by wrist position at night [3] [5]. ### Lacertus syndrome: the newest name for the oldest band The lacertus fibrosus, a fibrous sheet running from the biceps tendon across the front of the elbow, has always been on the list of structures that can pinch the median nerve. What has changed recently is the claim that it deserves top billing. A school led by the Swedish hand surgeon Elisabet Hagert argues that many people labelled with non-specific forearm fatigue, "clumsy hand", or a carpal tunnel release that failed to help, in fact have the nerve caught at exactly this point — a pattern now widely called lacertus syndrome [6]. The diagnosis is deliberately clinical, because electrical tests are usually normal in proximal median compression: weakness of three specific median-supplied muscles (the tip-benders of the thumb and index finger, and a wrist flexor) combined with tenderness directly over the band [6]. The proposed treatment is a short release under local anaesthetic with the patient wide awake, so that strength can be re-tested on the table minutes after the band is divided. Reported results are striking: in the largest published series, 93 patients improved from an average disability (QuickDASH) score of 53 before surgery to 8 immediately afterwards, grip strength rose from 16 to 24 kg, and office workers commonly returned to work within days [7]. Striking results deserve scrutiny, and the scepticism is published alongside. Tenderness over the lacertus turns out to be common in entirely healthy people, one study found it in 14 of 72 symptom-free arms (about one in five), which undermines tenderness on its own as a diagnostic sign and makes comparison with the other arm unreliable [8]. Others point out that "lacertus syndrome" is currently being used for two different problems, true nerve compression, and a muscular overuse pattern at the same site, and the one label may be stretching to cover both [9]. There are no randomised trials, follow-up in the outcome series is short, and a condition diagnosed without an objective test and treated with immediate-feedback surgery is exactly the setting in which selection and placebo effects flatter the results. The sensible middle ground is where this page already stands: the band is real, it can compress the nerve, and when the specific pattern of weakness plus tenderness is present, a targeted release is a small operation with a quick recovery. Both the enthusiasm and the doubt are part of the current literature. ### Why the patience is justified rather than merely cautious For both conditions the recommended course is long observation, which is difficult to accept while symptoms persist. Two things make it defensible. The first is the natural history above: for anterior interosseous nerve syndrome, recovery is the expected outcome without intervention [2]. The second is that the alternative diagnosis in a sudden-onset painful palsy is neuralgic amyotrophy, Parsonage-Turner syndrome, an inflammatory condition of the nerves that classically begins with severe shoulder or arm pain lasting days to weeks, followed by weakness as the pain subsides [4]. It is a medical condition, not a mechanical one, and no decompression addresses it. A severe painful onset preceding the weakness is therefore the feature most worth reporting accurately, because it shifts the likely diagnosis away from compression entirely. --- ### Radial Head Fracture URL: https://www.cqupperlimb.com/education/elbow/radial-head-fracture/ Region: elbow · condition Radial head fractures — Mason classification, conservative management, and indications for fixation or replacement. ## What you're feeling A radial head fracture usually happens when you fall onto an outstretched arm. The force travels up your forearm and into your elbow, breaking the small rounded bone at the top of your forearm, just below your elbow. This bone is called the radial head. These breaks are common. They account for about 20% of all elbow fractures, and they are the most common fracture around the elbow. Most people feel pain on the outer side of the elbow straight away. The area may be tender to touch, and moving your elbow or turning your forearm can hurt. Swelling often develops over the joint, sometimes with bruising. Your elbow may feel stiff, and you may be reluctant to use the arm at all. Some falls also push the elbow out of joint, which happens with 3% to 14% of these fractures. In the first days, the pain is often there even when you are resting, and it can disturb your sleep. Simple tasks like lifting a kettle, turning a door handle, pouring a drink, or reaching across your body can be uncomfortable. Turning your palm up or down to hold a phone or a plate may be harder than bending the elbow. Over the first weeks, the pain usually settles gradually as the bone starts to heal. Movement tends to get easier, though it can take time before your elbow feels normal again. It is worth knowing that these fractures sometimes come with other injuries in the same arm. The wrist, forearm, or shoulder can also be hurt in the same fall, and the ligaments around the elbow can be strained. Your surgeon will ask about pain elsewhere in your arm and examine those areas carefully, because finding these injuries early matters for how well the elbow works later on. If your pain is on the outer side of the elbow after a fall, and moving or loading the arm is difficult, that pattern fits this injury. The next sections explain how the fracture is confirmed and what treatment involves. ## What's actually happening The radial head is a small, disk-shaped bone with a shallow cup on top. That cup glides against the end of the arm bone above it, and the side of the disk slots against the other forearm bone. Think of it as a washer sitting between two moving parts: it lets your forearm rotate so you can turn a palm up or down, and it cushions the load travelling up your arm. It also does a second job. It acts as a brace on one side of the elbow, helping the ligaments keep the joint lined up when you push or straighten the arm. If that brace cracks, the elbow can feel unsteady, especially if a ligament is also torn. The blood supply to this little bone is limited, which is one reason some breaks are slow to knit. Most of these fractures happen when you fall onto an outstretched arm, and the force drives the radial head hard against the bone above it. Sometimes the same fall strains or tears the ligaments on the inner or outer side of the elbow, or injures the wrist or forearm further along. About 30% of people with a radial head fracture have other injuries in the same arm. When the elbow also comes out of joint, other parts of the elbow can be damaged too, and that combination makes the joint more unstable. Bone heals by knitting back together, with new bone bridging the break over weeks. If the pieces sit close together and line up well, they can knit in place without surgery. If a piece is pushed apart by 2 to 3 mm or more, or the joint surface is broken into several pieces, the bone may not knit in a usable shape on its own. In those cases, surgery aims to hold the pieces in place, or to replace the damaged radial head with an artificial one so the elbow keeps its brace and its smooth turning surface. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At that first visit we take a history, examine your elbow, and arrange imaging where it is needed. X-rays usually show the break. Sometimes a scan is added to check for small pieces of bone or injured ligaments that change the plan. Many of these fractures are stable and the pieces sit close together. When that is the case, and your elbow can still bend and turn without a block, we usually treat it without surgery. You may wear a sling for comfort, for a week or less, and then start moving the arm. Some people have fluid drawn from the joint with a needle early on, which eases the pain and makes early movement easier. Physiotherapy is staged in as the pain settles. Long-term results after this kind of care are good, and for some fracture patterns surgery and no surgery lead to similar function after a year. The choice here is genuinely shared: non-operative care is reasonable, but the pain and the final position of the arm may not suit everyone. Surgery is recommended from the outset when the break is pushed apart, when broken pieces jam the joint and stop it turning, when the elbow is unstable, or when other injuries in the same arm need repair. The aim is to hold the pieces in place with small plates or screws, or, when the bone is in too many pieces to rebuild, to replace the radial head with an artificial one. We will talk through which option fits your fracture, your age, your bone quality, and what you need your arm to do. Whichever path you take, the first weeks are about comfort and protection. Pain relief keeps you moving within the limits we set. The arm is guarded while the bone knits or while the repair settles. Physiotherapy then takes over at the right stage, because early, guided movement is what prevents stiffness. We see you along the way to check healing and adjust the plan as your elbow improves. ## What to expect Most radial head fractures are undisplaced and heal without surgery. Over the first weeks the pain settles and movement gets easier, though the elbow can stay stiff for some months. Turning your palm up and down is often the last thing to feel normal. You can expect to be doing daily tasks like eating and dressing early on, with heavier lifting and work building back over the following weeks. Your surgeon will guide when it is safe to return to work or sport. If your fracture needs surgery, the bone is held with small plates or screws, or replaced with an artificial radial head when it is in too many pieces to rebuild. Recovery follows the same broad shape: the arm is protected at first, then movement and strength are built back with physiotherapy. Many people regain good function in the arm after surgery for this fracture. It is honest to say that things can occasionally go wrong. The bone can be slow to knit, or knit in a poorer position than hoped. Stiffness is the most common complaint, which is why guided movement starts early. When a replacement is used, further surgery is sometimes needed in the first year, and over 10 years the implant survival rate with uncemented implants remains high. At 18 years, implant survival is 75.1%, with the highest failure rate in the first year after surgery. Some people who have the radial head removed rather than replaced still do well: 96% report satisfactory function in the long term, even though wear-and-tear changes show on later X-rays. If other injuries came with the fracture, such as a torn ligament or a dislocated elbow, recovery can take longer and the elbow may feel less steady for a while. Finding and treating these injuries early gives the best chance of a good result, with success rates around 80% when they are picked up in time. ## When to see someone Seek urgent care if your elbow is visibly out of shape, if there is an open wound, if you have numbness or tingling in the arm or hand, or if you cannot use the limb at all. These signs need checking straight away. Otherwise, start with your GP. Ask for a specialist review if the pain is not settling, or if the swelling, movement, or use of your arm is not improving week on week as the bone heals. Recovery usually moves forward steadily, so a change for the better each week is what you want to see. If that stops happening, it is worth having the elbow looked at again. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. A radial head fracture is worth the extra reading because the bone itself is often the least important part of the injury, what determines your result is usually whether anything else in the elbow was damaged at the same time. ### The fracture is a marker, not just an injury The radial head is a stabiliser. It stops the radius sliding up the forearm and it resists the elbow being pushed sideways. So a force large enough to break it is frequently large enough to damage the ligaments and the coronoid too, the combination known as the terrible triad: radial head fracture, coronoid fracture and elbow dislocation. That is why an isolated, undisplaced radial head fracture and a radial head fracture as part of a triad are entirely different problems with the same name on the X-ray report. The first usually needs early movement and little else. The second is one of the more demanding reconstructions in upper-limb surgery. Even the surgical approach for the triad is contested. Pooling 866 patients, a combined lateral plus anteromedial approach appeared to offer a favourable balance between functional outcome and complication risk, while purely anterolateral or anteromedial approaches offered advantages in some postoperative measures [1], a comparison that would not still be open if one route were clearly superior. ### Fix it or replace it Where the head is broken but reconstructable, fixing it preserves your own anatomy. Where it is in too many fragments, replacement is generally preferred over attempting a fixation likely to fail, a failed fixation leaves a stiff, unstable elbow and a harder second operation. When replacement is chosen, the design debate has been quieter than expected. Comparing monopolar with bipolar radial head prostheses across 591 patients found no significant difference in efficacy or safety, with the authors calling for higher-quality randomised trials [2]. That is a useful thing to know if you are told a particular implant is better. On current evidence the distinction has not been demonstrated. ### Why implants get removed — and it is not what you would guess A meta-analysis of 1,017 radial head arthroplasties found that removal or revision peaked within two years of implantation, and that most removals were performed to manage elbow stiffness and heterotopic ossification rather than loosening of the implant [3]. So the implant usually is not the thing that failed. The elbow around it stiffened, and taking the metal out formed part of treating that. It reframes what "revision surgery" means here, and it explains why the rehabilitation after this operation matters more than the choice of prosthesis. It also means published revision rates should be read with the follow-up length in mind. A separate review of 1,272 patients concluded the literature does not provide a reliable estimate of the re-operation rate, and recommended a minimum of three years of follow-up with an agreed definition of what counts as a reason for revision [4]. A study reporting twelve months will systematically miss the removals that cluster in the first two years. ### The thing to protect is motion The consistent thread is that the elbow's characteristic failure is stiffness, not instability or implant failure. It is an unforgiving joint: it tolerates immobility badly and loses the last degrees of extension readily. Whatever is done to the bone, the months afterwards are what determine how the arm works. --- ### Radial Head Replacement URL: https://www.cqupperlimb.com/education/elbow/radial-head-replacement/ Region: elbow · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We assess your history, examine your elbow, and arrange imaging where needed to work out what is wrong. This operation replaces the radial head, the rounded top of one of the two forearm bones, with an artificial part. It is usually offered when the radial head is broken into several pieces that cannot be put back together, or when the broken bone has made the elbow or forearm unstable. Many radial head fractures heal without surgery, so non-operative care often comes first. Surgery follows when that has not given enough improvement, or when the break is too severe for it to work. The aim is a steadier elbow, less pain, and better movement of your arm. ## Before the operation In the weeks before surgery we will arrange X-rays, and sometimes a CT scan, to measure your elbow and plan the operation. These scans show where the bone has broken and help us choose the right size of implant. Most people need nothing more than this. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. On the day, do not eat or drink for seven hours beforehand. We ask for seven hours rather than six so your time in theatre can be brought forward if the list runs early; your surgeon will confirm your exact fasting time. Stop taking certain medications only if we have told you to, and bring a written list of everything you take. Arrange for someone to drive you home, and wear loose, comfortable clothing with buttons or a zip rather than something you pull over your head. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist, who will go through your health and your medications with you. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. When the operation is finished, you will wake up in the recovery area. Nurses will stay with you while the anaesthetic wears off and will keep you comfortable. Once you are stable, you will either move to a ward or go home the same day, depending on the procedure and how your recovery is going. If you are going home, the person you arranged to drive you will take you there. Before you leave, we will explain how to care for your elbow over the next few days and who to contact if you have any concerns. ## What the operation involves Your surgeon makes a cut on the outer side of your elbow to reach the broken radial head. A band of tissue around the top of the forearm bone is gently divided so the broken pieces can be seen. The broken pieces are removed and fitted together like a puzzle on a side table to work out what size replacement part your elbow needs. The bone is then trimmed to a smooth, straight base, and the canal inside the bone is prepared so the new part can sit securely. Trial parts are placed first. Your surgeon checks that the new radial head lines up and moves smoothly against the bone at the end of the upper arm, both by looking directly and using X-ray images during the operation. The elbow is also tested for movement and steadiness before the final part is fitted. The replacement part is metal, and it is usually made slightly smaller than your original radial head so the joint is not crowded. Once it is in place, the tissue band around the forearm bone is stitched back together, and any other injured ligaments around the elbow are repaired to keep the joint steady. The skin is closed with stitches and covered with a dressing. Because broken bone can look worse inside the elbow than on scans, your surgeon keeps a range of implant options ready during the operation, including parts of different shapes and lengths, so the best fit can be chosen once the break is seen directly. ## After the operation For the first day or two, expect a sore elbow that eases as the anaesthetic wears off. You will have pain relief to keep you comfortable; tell the nurses if it is not working. Your arm will rest in a simple sling for comfort, and gentle movement of your elbow usually starts early, because moving soon helps prevent stiffness. Someone should stay with you for the first 24 hours after you get home. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your elbow will be sore and swollen, and the skin around it may look bruised. This is a normal part of healing. Keeping your hand raised on pillows when you sit or rest helps the swelling settle, and your pain relief will ease the discomfort as it fades. Your arm rests in a simple sling for comfort, but it does not hold your elbow still. Gentle movement starts early, because moving soon helps prevent stiffness. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she will guide your exercises and make any splint you need. The early exercises are small and gentle, and they grow as your elbow allows. At home you will use your hand for light tasks from the start, such as eating, writing and doing up buttons. You will not lift anything heavy with that arm until your therapist says it is safe. Sleeping is usually easier in a chair or propped up on pillows at first, with the sling on if that feels comfortable. As the swelling settles and movement returns, everyday tasks get easier. Once you can grip and hold light objects without pain, you will start using the arm more. When your surgeon clears you to drive, see our guide on driving after upper-limb surgery. You must not drive while in a sling, and you need to be off strong pain medication and able to react in an emergency stop. Recovery varies from person to person. Your timeline may differ, and your surgeon and hand therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The replacement part can loosen over time. You might feel a deep, throbbing pain that does not ease with simple painkillers, or a new ache that returns after settling. The part can also break, or it can slip slightly out of place. A slip may feel like a clunk, a click or a sense that the elbow is not moving smoothly. If you notice any of these, contact the clinic rather than waiting for your next appointment. The elbow can become stiff. Some stiffness is expected early on, but if your elbow stays very tight and will not straighten or bend despite therapy, tell your surgeon or hand therapist. Further treatment can help. The nerves close to the elbow can be irritated during surgery. This may show as tingling, numbness or weakness in the forearm, hand or fingers. Mention any new numbness or weakness at your review, or call the clinic if it appears suddenly. Wear of the implant surface can happen over time. Worn material can irritate the lining of the joint, causing swelling, warmth and a rubbery feeling around the elbow. If the elbow becomes persistently swollen or painful, bring it up at your next review. Arthritis in the elbow joint can develop in the years after surgery. You may notice grinding, aching or gradually losing some bend or straightening. Tell your surgeon if this affects what you can do. Sometimes the replacement part needs to be removed or exchanged in a further operation. This is more likely in the first couple of years, so keep up your review appointments even when the elbow feels good. Removal of a troublesome implant often eases pain and can improve movement. A second operation can also make returning to sport less likely, so raise your goals with your surgeon early. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if you have a fever, if the wound becomes more red or starts to leak fluid, or if your pain suddenly gets much worse. Call us too if your elbow becomes very swollen and warm, or if new numbness or weakness appears. Go to emergency if you have swelling or pain in your calf, or shortness of breath. Go to emergency as well if you cannot feel or move your arm. If you are worried, call us rather than waiting for your next appointment. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Radial head replacement is worth the extra reading because of one finding that changes how you should interpret the word "revision": when these implants come out, it is usually not because the implant failed. ### Why implants are removed A meta-analysis of 1,017 radial head arthroplasties examined removal and revision directly [1]. Two results stand out. The highest incidence of removal or revision occurred within two years of implantation, not late, as wear-related failure would predict. And most removals were performed to manage elbow stiffness and heterotopic ossification rather than loosening of the implant itself [1]. That reframes the whole question. A radial head replacement is rarely revised because the metal wore out or came loose. It is removed because the elbow around it became stiff, and taking the implant out is part of addressing that. The implant is not usually the problem; it is where the problem gets treated. This also means the operation's real adversary is the same one that dominates every serious elbow injury: loss of motion. Rehabilitation is not an accessory to this operation, it is the operation's main determinant of success. ### The published re-operation rate should be read sceptically A separate systematic review of 1,272 patients concluded that the literature does not provide a reliable estimate of the re-operation rate after radial head arthroplasty [2]. Its recommendation was methodological: reporting should use a minimum follow-up of three years, alongside an agreed definition of what counts as a reason for revision [2]. Given the previous finding, that removals cluster in the first two years, a study with twelve or eighteen months of follow-up will systematically under-count them. When you see a low revision rate quoted for this implant, the follow-up length matters more than the number. ### Not every radial head fracture needs replacing Replacement competes with fixation, and the comparison is reasonably well mapped. Pooling 1,264 patients across operative treatments for radial head and neck fractures, open reduction and internal fixation emerged as the better option for Mason type II and type III fractures, with replacement occupying the more comminuted end of the spectrum [3]. The distinction that matters clinically is whether the head can be reconstructed into something stable. Where it can, fixing it preserves native anatomy. Where it is in too many pieces, attempting fixation risks the worst outcome of all, a construct that fails and leaves a stiff, unstable elbow requiring further surgery. ### Design has been less decisive than injury complexity There has been long debate about stem design and fixation. A systematic review of 1,316 patients examining a loose-fit, polished-stem prosthesis is instructive: that group had a higher proportion of terrible triad injuries at baseline, more complex injuries, and still achieved favourable clinical outcomes with a significantly lower rate of postoperative instability [4]. The reasonable reading is not that one design is superior, but that the severity of the original injury drives the result more strongly than the choice of implant. --- ### Radial Tunnel Release URL: https://www.cqupperlimb.com/education/elbow/radial-tunnel-release/ Region: elbow · operation Radial tunnel release relieves pain from PIN compression – distinct from tennis elbow, and how surgery helps. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. Our assessment, based on your history, examination and imaging where needed, establishes the diagnosis. Radial tunnel syndrome causes pain on the outer part of your elbow and forearm. The radial nerve runs down your forearm, and several separate structures along its path can press on it. These may include the edge of a muscle, a fibrous band, or small blood vessels crossing the nerve. We usually begin with non-operative care such as activity change, physiotherapy or hand therapy, splinting, or injections. Surgery is considered when that has not given enough improvement. The operation, called a radial tunnel release, eases the pressure on the nerve at each of these points. We recommend it for people whose pain has continued despite other treatment. The main aim is to relieve your pain and help your forearm and wrist work normally again. ## Before the operation You will need to stop eating and drinking seven hours before your operation. We ask for a little longer than some other practices so your surgery can be brought forward if the theatre list runs early. Your surgeon will tell you which of your usual medicines to skip on the day, and which to take as normal. Please bring a written list of everything you take, including tablets, injections and any drops or creams. Arrange for someone to drive you home afterwards, as you will not be in a fit state to drive yourself. Wear loose, comfortable clothing with sleeves that are easy to slide over your arm. Some imaging, such as X-rays, an MRI or an ultrasound scan, helps us plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist, the doctor who looks after your sleep and pain control during the operation. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. When the operation is finished, you will wake up in the recovery area. Nurses will monitor you there while the anaesthetic wears off. Once you are stable, you will either move to a ward or go home the same day, depending on the procedure and how your recovery is going. If you are going home, the person you arranged to drive you will take you there. ## What the operation involves The operation is called a radial tunnel release. It is done through one cut over the front of your forearm, just below the crease of your elbow. Your surgeon works through this single opening to reach the radial nerve. Along the nerve's path, several separate structures can press on it. These may include the edge of a muscle, a fibrous band, or small blood vessels crossing the nerve. Your surgeon finds each of these pressure points and releases them, easing the squeeze on the nerve. The surrounding tissue is left as undisturbed as possible, and the blood supply to the nerve is preserved. Once the pressure points have been released, your surgeon closes the cut. A fine self-adhesive mesh is laid over the closed wound first, holding the skin edges together. A liquid skin adhesive is then painted over the mesh, where it sets to seal the whole thing. This stays on for roughly one to two weeks and then lifts and peels away by itself, so there is nothing to be taken out. ## After the operation You will wake up in the recovery area with nurses nearby while the anaesthetic wears off. Your arm will have a soft dressing over the wound, and pain relief will be arranged so you stay comfortable. You can move around as soon as you feel ready, and you will use your hand for light tasks straight away. This is usually a day case, so you can expect to go home the same day, although occasionally patients stay overnight. Someone should stay with you for the first 24 hours after you get home. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Your arm will have a soft dressing on when you go home. Some soreness and swelling around the wound is normal in the first days. Rest your arm when you can, keep it raised when sitting, and take the pain relief that has been arranged for you. Most people find the discomfort settles steadily as the days pass. You can use your hand for light tasks straight away. There is no cast or routine splint after this operation, so your wrist and fingers are free to move. Gentle movement helps the nerve glide and keeps stiffness away. Your hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she will guide your exercises and make any splint you need along the way. At home, keep the wound dry and leave the dressing alone until we review it. As the swelling settles, you will notice your grip and forearm strength returning bit by bit. Everyday tasks such as dressing, eating and typing usually come back early on. Heavier lifting and firm gripping come later, once your hand feels strong and the tenderness has gone. When your therapist is happy with your movement and strength, you can build back to your normal activities. You can usually drive once any splint is off and the pain has settled enough to hold the wheel and react quickly. Patients in a splint must not drive. See our page on Driving after upper-limb surgery. Recovery varies from person to person. Your timeline may differ, and your surgeon and therapist will guide you. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The nerve being released runs close to the operating area, so it can be irritated or injured during surgery. If this happens, you might notice weakness when lifting your wrist or straightening your fingers, or numbness and tingling on the back of your forearm, wrist or hand. Some of these changes are temporary and settle on their own over weeks to months. If you notice new weakness or numbness after the operation, tell your surgeon at your next review, or call the clinic sooner if it comes on suddenly. Sometimes scar tissue forms around the nerve as it heals. This can press on the nerve again and bring back the pain you had before, often weeks or months after things were going well. If your original pain returns, bring it up at your next appointment. Further surgery to release the scar tissue is possible if needed. There is also a chance the first operation does not relieve your symptoms, or that they come back soon after. This can happen if a pressure point along the nerve was missed, or if the diagnosis was not quite right. If your pain continues or returns, tell your surgeon. They will reassess you and discuss what to do next, which may include further treatment. Any operation on the forearm carries a small risk of problems with the wound itself. Watch for increasing redness spreading out from the cut, fluid or pus leaking from it, or a fever. If you see any of these, contact the clinic straight away, or go to the emergency department if you cannot reach us. If you are ever worried about how your arm is healing, call the clinic rather than waiting for your next visit. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if your pain suddenly gets much worse, or if new weakness or numbness comes on quickly. Call us if the wound becomes more red, leaks fluid or pus, or if you develop a fever. Go to emergency if you cannot reach us, or if you lose feeling in your arm or cannot move it. Go to emergency straight away for shortness of breath or calf swelling. If you are ever worried, call the clinic rather than waiting for your next visit. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Radial Tunnel Syndrome page. --- ### Radial Tunnel Syndrome URL: https://www.cqupperlimb.com/education/elbow/radial-tunnel-syndrome/ Region: elbow · condition Radial tunnel syndrome — causes forearm pain, weakness straightening fingers, and is distinct from tennis elbow. ## What you're feeling The main symptom is pain on the outside of your forearm, near your elbow. It is usually worst at a tender spot a few centimetres below the bony point on the outside of your elbow. Pressing on that spot is often sore. The pain can spread down the back of your forearm towards your wrist. Certain movements make it worse. Turning your palm up against resistance, or straightening your middle finger against resistance, can bring the pain on. So can activity that keeps loading your forearm. Many people notice the pain flares after work or sport rather than at rest. This condition affects a nerve that supplies muscles rather than skin. That means you are unlikely to have numbness or tingling, and the nerve itself usually works normally. The problem is pain, not weakness or loss of feeling. Day to day, the pain tends to show up in tasks that need gripping and twisting. Lifting a kettle, turning a door handle, using a screwdriver or wringing out a cloth can all hurt. Because the tender spot sits near the outside of the elbow, this condition is often mistaken for tennis elbow, and the two can occur together. There is no single test that confirms this condition. Your surgeon reaches the diagnosis from your story and an examination, checking for that specific tender spot and the pattern of your pain. Watch for these signs. See your GP or ask for a specialist review if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm. Go to the emergency department the same day if your arm becomes hot, red, swollen and painful, especially with a fever, or if your hand turns pale, cold, white or blue. If you cannot reach the clinic after hours or on a weekend, go to your nearest emergency department. ## What's actually happening The pain comes from a nerve, not from the elbow joint itself. A nerve is a cable that carries signals between your brain and your muscles. One branch of the radial nerve runs down the outside of your forearm, past the elbow, to supply the muscles that straighten your wrist and fingers. Along that stretch, several separate structures sit close to the nerve. The edge of a muscle, a fibrous band, or a small group of crossing blood vessels can each press on it. This is not one narrow passage. It is more like a walking track with several possible pinch points along the way, any of which can squeeze the cable running beside it. When one of those structures presses on the nerve, the nerve becomes irritated and sore. That is why the pain sits at a tender spot below the bony point on the outside of your elbow, and why turning your palm up or straightening your middle finger against resistance makes it worse. Those movements pull the muscles this nerve supplies, and the irritated nerve complains. The nerve still works, so your muscles keep working and you feel no numbness or tingling. The problem is irritation and pain, not loss of signal. Because the sore spot sits so close to the outside of the elbow, the pain is easily mistaken for tennis elbow, which affects a tendon in the same neighbourhood. The two can even happen together. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a history, examine your arm, and arrange imaging if it will help. For this condition we usually try non-operative care first, and consider surgery when that has not given enough improvement. The first step is changing how you use your arm. Cutting back the gripping and twisting tasks that flare the pain gives the irritated nerve a chance to settle. Hand therapy aims to settle the pain and rebuild your tolerance for loading the forearm, so work and daily tasks become comfortable again. We ask you to give this a fair trial before thinking about anything further. Pain medication and anti-inflammatories can help you through a flare. They settle the soreness while the other measures do their work. They do not fix the pressure on the nerve itself. If non-operative care has not given enough improvement, surgery is an option. The operation is called a radial tunnel release. It works by freeing the nerve at each of the places where a nearby structure is pressing on it. Before recommending it, we check carefully where the nerve is being squeezed, so the operation targets the right spot and disturbs as little surrounding tissue as possible. Because the diagnosis rests on your story and examination rather than one clear test, we treat the decision to operate as a shared one, made together once you understand what surgery can and cannot settle. ## What to expect For most people, this condition does not damage the nerve. The nerve keeps working, so your muscles keep working and you do not lose feeling. The problem is pain, and pain from an irritated nerve can take a long time to settle. It rarely goes away overnight, and it often flares with gripping and twisting tasks before it eases. The honest picture is that this condition is hard to predict. Some people settle with rest, activity changes and hand therapy. Others keep having pain despite good non-operative care. There is no reliable test to confirm the diagnosis, which makes it harder to say in advance which group you will fall into. What we can say is that the pain tends to come and go with how much you load your forearm, rather than building steadily. If non-operative care works, the pain eases gradually over weeks to months as the nerve becomes less irritated. You would expect to find daily tasks like lifting a kettle or turning a door handle less painful first, before heavier work feels normal again. If surgery is done after non-operative care has not helped enough, recovery is also gradual rather than instant, and some people still have some pain afterwards. If the condition is left alone, it may settle on its own, but it can also persist or keep flaring whenever you return to the tasks that aggravate it. There is no way to know in advance which will happen. What tends to matter is giving treatment a fair trial and not pushing through pain that is not settling. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm, see your GP or ask for a specialist review. Go to the emergency department the same day if your arm becomes hot, red, swollen and painful, especially with a fever, or if your hand turns pale, cold, white or blue. If you cannot reach the clinic after hours or on a weekend, go to your nearest emergency department. ## When to see someone The warning signs for this condition are about pain that will not settle, not about danger. See your GP or ask for a specialist review if your forearm pain has not settled after a fair trial of rest and activity changes, or if it keeps stopping you working or using your arm. Ask sooner rather than later if the tender spot below the outside of your elbow is a prominent feature, or if turning your palm up or straightening your middle finger against resistance reliably brings the pain on. These patterns point towards this condition rather than tennis elbow, and they are worth sorting out properly. This condition does not usually damage the nerve, so sudden weakness of your wrist or fingers is not a typical part of it. If you do notice new weakness in straightening your wrist, fingers or thumb, ask for a specialist review promptly rather than waiting, because that pattern suggests a different nerve problem that is assessed on its own timeline. Go to an emergency department the same day if your arm becomes hot, red, swollen and painful, especially with a fever, or if your hand turns pale, cold, white or blue. If you cannot reach the clinic after hours or on a weekend, go to your nearest emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Radial tunnel syndrome is worth the extra reading for an uncomfortable reason: it is the condition on this site with the weakest evidence base, there is no test that confirms it, and being told plainly how uncertain it is should form part of any decision to operate. ### There is no confirmatory test Most nerve compressions can be demonstrated. Carpal tunnel syndrome produces slowed conduction across the wrist; cubital tunnel produces it across the elbow. Radial tunnel syndrome characteristically does not, the nerve branch involved supplies muscle rather than skin, so there is no numbness to map, and nerve conduction studies are frequently normal. The diagnosis therefore rests on the pattern of pain, tenderness a few centimetres distal to the lateral epicondyle rather than over it, and the response to a local anaesthetic block. Each of those is suggestive; none is definitive. Contemporary reviews describe ongoing controversy regarding both diagnosis and outcomes [1]. The practical consequence is a high rate of confusion with tennis elbow, which sits immediately adjacent and can coexist. Persistent "tennis elbow" that has not responded to good treatment is one of the commonest circumstances in which radial tunnel syndrome is eventually considered. ### The evidence for treating it is genuinely thin A systematic review of interventions found a tendency that surgical decompression might be effective, and, the more remarkable finding, that the effectiveness of conservative treatments is unknown, because for most of them no studies were available at all [2]. That is not the usual "evidence is limited" formulation. For most non-operative treatments offered for this condition, the studies have not been done. Current reviews still place non-surgical management first, with decompression a viable option for refractory cases [1], and that ordering reflects reasonable caution rather than demonstrated superiority. ### What that means for a decision Two things follow, and they pull in opposite directions. Against early surgery: the diagnosis cannot be confirmed, so an operation may be decompressing a nerve that is not the source. Where a decompression fails, it is often impossible to determine whether the operation was inadequate or the diagnosis was wrong. For considering it in the right patient: there is no evidence base supporting the alternatives either, so waiting is not the evidence-backed option people assume. It is simply the lower-risk one. The reasonable position is that a confident diagnosis matters more here than anywhere else on this site, a consistent history, examination localising to the radial tunnel rather than the epicondyle, imaging excluding a space-occupying lesion, and ideally a convincing response to a diagnostic block before an irreversible step is taken. ### A related but different problem Posterior interosseous nerve palsy, weakness of finger and thumb extension rather than pain, is a distinct entity with clearer management. Where imaging shows no compressive lesion, conservative management should be tried first, with surgery reserved for demonstrated compressive lesions and for failure of conservative treatment [3]. Where there is no space-occupying lesion, a trial of non-operative management is advisable, with exploration recommended if there is no sign of muscle recovery after 6 weeks of observation, or if weakness is progressive [4]. Those are concrete thresholds, and their existence is the clearest illustration of the contrast: when the nerve visibly stops working, the literature can say what to do and when. When it only hurts, it cannot. --- ### Stiff Elbow Release (Arthrolysis) URL: https://www.cqupperlimb.com/education/elbow/stiff-elbow-arthrolysis/ Region: elbow · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your elbow and arrange imaging if needed. A stiff elbow often improves with time and use, so we usually try non-operative care first. This may include physiotherapy, splinting or injections over 6 to 12 weeks. Surgery is considered when that course has not given enough improvement. Stiff elbow release, also called arthrolysis, is an operation that frees the tight, scarred tissue around your elbow so the joint can move again. We suggest it when stiffness is still limiting you after non-operative treatment. It works best when the joint surface is still smooth and in its normal shape. The aim is a lasting gain in movement and less pain, so daily tasks become easier. ## Before the operation Once surgery is planned, there are a few practical things to sort out. You will be told when to stop eating and drinking: this is seven hours before your operation. We ask for seven hours rather than six so that, if the theatre list runs early, we can bring you forward. Your surgeon will tell you which of your usual medicines to stop and when, and you should bring a full list of them with you. Arrange for someone to drive you home afterwards. Wear loose, comfortable clothing on the day. X-rays are always taken to plan the operation, and a CT scan may be used if the stiffness involves bone. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You meet the anaesthetist there. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. You wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves There is more than one way to release a stiff elbow, and your surgeon will choose the approach that suits your elbow. Some releases are done through keyhole surgery, using a few small cuts and a thin camera. Others are done through one or two open cuts, sometimes about 3 to 5 cm long, on the inner or outer side of the elbow. For very stiff elbows, a cut at the back of the elbow may be used to reach both sides. Once inside, your surgeon frees the tight capsule, which is the sleeve of tissue around the joint. Bone spurs that block movement are trimmed away, and any loose fragments of bone or cartilage floating in the joint are removed. If a nerve on the inner side of the elbow is squeezed by scar tissue, it may be freed from that tunnel of tissue, or moved to a new position where it cannot be stretched. If the joint surface itself is badly worn, other options exist, such as lining the bone with soft tissue or replacing the joint surfaces with metal and plastic parts. Sometimes a hinged frame is fitted to the elbow to hold the joint in a good position while it heals. At the end, the cuts are closed with stitches and covered with a dressing. You will keep that dressing on for about 10 days, as described in the recovery section. ## After the operation You wake up in the recovery area, then move to the ward. Nurses will check your elbow, your hand and how you are feeling. Pain relief is given as you need it; tell the nurses if your elbow is uncomfortable. Your elbow will be wrapped in a soft dressing, and you may go home with your arm in a sling for comfort. You can get out of bed and move around soon after, and the nurses will help you the first time. Your hand, wrist and shoulder can move freely while your elbow settles. Someone should stay with you for the first 24 hours after you go home. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Your elbow will be sore and swollen for the first days and weeks. This is normal after a release. Rest, keeping your hand raised and taking your pain relief as prescribed will ease the discomfort. The swelling settles gradually, and as it does, the elbow usually feels less tight. You will go home with your arm in a sling for comfort. You can stop using it once it no longer helps. Your hand, wrist and shoulder should keep moving freely from the start. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby will guide your exercises and make any splint you need. The exercises are the main work of your recovery, and doing them as directed matters more than anything else. You will keep the dressing on for about 10 days, and we will change or remove it when we see you. Everyday tasks will come back in stages. At first you will need help with cooking, dressing and carrying things. As movement returns and the swelling settles, you will manage more with the operated arm. Once your surgeon clears you to drive, you can return to the road; our guide to driving after upper-limb surgery explains the rules that apply, including not driving while your arm is in a sling and being off strong pain medication. Recovery varies from person to person. Your timeline may differ, and your surgeon and therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The longer an elbow has been stiff, the more likely problems become after a release. If your elbow has been stiff for a long time, your surgeon will talk this through with you before you decide. One thing some people notice afterwards is new tingling, numbness or weakness in the little and ring fingers. This comes from the nerve on the inner side of the elbow. It is not always possible to predict who will get this. If you notice these feelings, mention them at your next review, or call the clinic if they come on suddenly. Some elbows that have been injured before carry a higher chance of a deep infection afterwards. Watch the wound for redness that spreads out from it, warmth, increasing swelling, or a deep, throbbing pain that does not ease with simple painkillers. You may feel feverish or generally unwell. If you see any of these signs, call the clinic straight away, or go to the emergency department if it is after hours. If your operation involves a hinged frame fitted to the elbow, there are a few extra things to know. The frame adds to the blood loss during surgery, the time in theatre and the time in hospital. It also carries a small chance of the joint becoming loose or unstable. Your surgeon will explain what this means for your stay and your recovery. If you have had operations on this elbow before, the chance of a deep infection is higher again. The same applies when the operation itself is more complex. Your surgeon weighs all of this up with you beforehand. Long-standing elbow injuries can also change the way the joint works. Scarred skin, bones that have healed out of place, damaged cartilage, extra bone, loose or tight ligaments, squeezed nerves and scarred muscle can all alter how the elbow moves. Your surgeon will look for these when planning your operation. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if you notice fever, spreading redness around the wound, discharge from the wound, or pain that keeps getting worse. Go to emergency if you have sudden severe pain, calf swelling or pain, or shortness of breath. Call us straight away if your hand or fingers go numb or pale, or if you cannot move your arm. If tingling or numbness in the little and ring fingers comes on suddenly, call the clinic rather than waiting for your next review. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Releasing a stiff elbow is worth the extra reading because the evidence points somewhere unusual: the choice most patients ask about, keyhole or open, appears to matter less than how much surgery is done, and the operation's real adversary is the same process that caused the stiffness in the first place. ### Open or arthroscopic is not the important question A systematic review and meta-analysis of 4,311 patients with post-traumatic elbow stiffness compared open with arthroscopic arthrolysis and found the overall results comparable [1]. Its conclusion was that the surgeon's expertise and the patient's particular condition are more important considerations than the technique itself [1]. That is an unusually direct statement for a systematic review, and it is worth taking at face value. This is a technically demanding operation performed close to three major nerves in a joint whose capacity is already reduced by the contracture being treated. Familiarity with the approach is doing more work than the approach. ### Less surgery, fewer problems An earlier systematic review of 798 patients reached a conclusion that has held up: the number of complications appears to rise with the extent of the surgical procedure, and the advice that follows is to treat as little invasively as possible [2]. The authors graded that recommendation modestly, the literature is not strong enough for a firm statistical conclusion, but the direction is consistent. This is the tension at the centre of the operation. A more complete release buys more motion on the operating table, and costs more soft-tissue trauma, more bleeding into the joint, and more inflammatory stimulus, the raw materials for the stiffness returning. ### Heterotopic ossification is the thing to prevent Heterotopic ossification, where bone forms in soft tissue that should stay flexible, is the mechanism by which a released elbow stiffens again. Prophylaxis with anti-inflammatories is standard, though the evidence is thinner than the practice. A meta-analysis of 622 patients comparing COX-2 selective against nonselective anti-inflammatories after elbow trauma surgery found that both effectively reduce the risk of heterotopic ossification, while individual head-to-head comparisons showed no statistically significant difference between them, and the overall power of the evidence was low [3]. So: prophylaxis appears worthwhile, the choice of agent is not clearly consequential, and the certainty is limited. Context helps set expectations. After total elbow arthroplasty, heterotopic ossification is an uncommon complication, and where it develops most patients are asymptomatic and need no surgery for it, to the point that routine prophylaxis after that operation is not supported by the literature [4]. The risk is not uniform across elbow surgery; it is concentrated in trauma and in extensive releases. ### One intervention that does not do what you would expect Tranexamic acid reduces bleeding in many orthopaedic operations, and reducing bleeding into a freshly released elbow sounds like it should reduce stiffness. A meta-analysis of 660 patients found that tranexamic acid may indeed reduce bleeding volume during open elbow arthrolysis, but that it did not affect final range of motion or pain scores [5]. It is a clean example of a plausible mechanism failing to translate into the outcome anyone cares about, and a reminder that "less bleeding" is a surrogate, not a result. ### What actually determines your outcome Nothing in this literature suggests a technical shortcut. The consistent signals are that the operation should be no larger than it needs to be, that prophylaxis against heterotopic ossification is worth taking, and that the motion gained in theatre is only retained through the rehabilitation that follows. The elbow is unusually willing to stiffen; the months after the release matter at least as much as the release. --- ### Tennis Elbow URL: https://www.cqupperlimb.com/education/elbow/tennis-elbow/ Region: elbow · condition Tennis elbow (lateral epicondylitis) — causes, symptoms, and conservative treatment options for pain relief. ## What you're feeling Tennis elbow causes pain on the outside of your elbow, at or around a bony prominence there called the lateral epicondyle. The pain often travels down your forearm, and sometimes up into your upper arm. It is usually brought on by activities that make the muscles on the back of your forearm work, because these muscles share one attachment point at that bony spot. The pain can range from mild and occasional to constant and severe. When it is severe, it can affect all your daily activities. It can also disturb your sleep. Many people find it flares after activity, or on waking. Everyday tasks that twist or grip become hard. Turning a doorknob, holding a coffee cup, shaking hands, or lifting a kettle can all trigger the pain. Your elbow usually still moves through its full range, so stiffness is not the problem, pain is. For most people, tennis elbow settles on its own. About 90% of people find it has settled within a year without surgery. You do not need to rush into any treatment. Some signs need attention sooner rather than later. See your GP or ask for a specialist review if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand or arm. ## What's actually happening The sore spot is where tendons attach to the bone on the outside of your elbow. Tendons are strong cords that join muscle to bone. The ones involved here run down the back of your forearm and share one anchor point at that bony spot. Despite the name, this is not really an inflammation problem. When a tendon is examined under a microscope, the tissue shows wear and fraying rather than swelling and redness. Think of a well-used rope: some fibres have torn, and the rope has tried to repair itself but has not finished the job properly. The repair tissue that forms is disorganised and weaker than the original. That is why the spot stays tender, and why gripping or twisting hurts: those actions pull directly on the damaged cord. The medical name for this is lateral epicondylitis, and you may also see it called lateral elbow tendinopathy. Both names describe the same thing: a wearing-down of that tendon attachment from repeated use. It is far more common on the outside of the elbow than on the inside, which is why the tennis elbow label usually points to this spot. The damage sits in one particular tendon among that group, the one that steadies your wrist when you grip. Because all the forearm muscles that extend your wrist share that single anchor point, pain there spreads down your forearm when you use your hand. Other things can cause pain in the same area, and they are not always easy to tell apart. That is why a careful physical examination of your elbow matters, and why scans are sometimes used to check how much wear is present. Your sense of joint position can also be slightly affected by this condition, which your physiotherapy can help address. The key point is this: the tendon is worn, not destroyed, and the tissue still has the capacity to mend itself given time and the right loading. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your elbow, and arrange scans only if they will change what we do. For a long-standing problem like this, we usually try non-operative care first and consider surgery only when that has not given enough improvement. The first step is changing how you load the tendon. That means easing back on the gripping and twisting tasks that set the pain off, then building the tendon back up with a progressive loading programme. Physiotherapy aims to get you through the painful months faster rather than change where things end up, because most elbows settle with time either way. Give it a genuine, prolonged trial measured in months. As you read earlier on this page, about nine in ten elbows settle within a year without surgery, which is why we set the bar for surgery high. We do not use cortisone injections as a default here. The likely reason is that the pain settles before the tendon has healed, so you go back to loading a tendon that is not ready. If an injection is ever considered, it is a considered decision about short-term function, not a routine step. Other injections, such as platelet-rich plasma or blood taken from your own arm, are not recommended for this condition. Surgery comes into the picture only for the small group still disabled after a real trial of non-operative care. The operation cleans out the worn, frayed part of the tendon where it attaches to the bone on the outside of your elbow. It can be done through small keyhole incisions or through a small open incision, and no one method has shown itself better than the others. Whether to operate is a shared decision, made together once you know what the operation involves and what recovery asks of you. ## What to expect For most people, tennis elbow follows a slow but steady course. Symptoms tend to ease over months rather than days, and the pattern is often one of gradual improvement with flare-ups along the way. The time it takes does not depend on how long you have had it: a tendon that has been sore for a year has the same chance of settling as one that has been sore for a few months. You have already read the headline figure: about nine in ten elbows settle within a year without surgery. That is the honest starting point, and it applies whether you do nothing, follow a loading programme, or try other non-operative care. What treatment can change is the journey, not the destination. A well-run programme aims to get you through the painful months more comfortably, while the tendon does its slow repair work in the background. If your elbow is one of the few that stays painful despite a genuine trial of non-operative care, surgery can still offer real relief. Recovery after surgery is gradual. Pain improves first, then grip strength and the confidence to use your hand for daily tasks return over weeks to months. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation; she will guide your exercises and make any splint you need. A small number of people continue to have pain after surgery, and about 1.5% need a further operation. Having three or more injections before surgery raises that chance. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand or arm, see your GP or ask for a specialist review. ## When to see someone Most tennis elbow settles on its own, and about nine in ten elbows are better within a year without surgery. But some signs mean it is time to get help. See your GP or ask for a specialist review if your pain is not settling after several months, if it is getting worse, if it wakes you at night, or if it stops you working or using your hand and arm normally. About one person in five with this condition finds the pain severe enough to limit their work and daily life, so needing help is not unusual. If you have already had three or more injections into the tendon and the pain still limits you, ask for a specialist review, because that history changes what a surgeon will want to discuss with you. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Tennis elbow is worth the extra reading because it is one of the conditions where the treatment that feels most effective in the first month is the one that does worst by the end of the year. ### The condition mostly cures itself, slowly Left alone, tennis elbow settles. In the trial discussed below, the group randomised to simply wait and see, no injection, no physiotherapy, was reassessed at 52 weeks, and 56 of 62 (90%) reported themselves either much improved or completely recovered [1]. That figure is the yardstick every treatment has to be measured against. An intervention is only worth having if it beats getting better on your own, and getting better on your own is what usually happens. ### The corticosteroid paradox A landmark randomised trial compared corticosteroid injection, physiotherapy, and simply waiting, following people for a full year [1]. At six weeks the injection looked excellent. Success was reported by 51 of 65 (78%) of the injection group against 16 of 60 (27%) of those waiting, a number needed to treat of 2 [1]. Then it reversed. Of those early successes, 47 of 65 (72%) subsequently regressed. By 52 weeks the injection group was significantly worse than the physiotherapy group on every outcome, and worse than the people who did nothing on two of the three primary measures [1]. The authors' own explanation is worth repeating: the injection relieves pain so quickly that people resume loading a tendon that has not actually healed. The trial's conclusion was that corticosteroid "should be used with caution" in tennis elbow, a striking thing to say about the treatment most people expect to be offered. This is why an injection here is a considered decision about short-term function, not a default, and why it is not a substitute for the loading programme. ### So what is worth doing Physiotherapy beat waiting at six weeks on every measure, and by 52 weeks the two were indistinguishable because nearly everyone in both groups had recovered [1]. Its value is therefore in getting you through the painful months faster, not in changing the destination. Notably, the physiotherapy group also sought less additional treatment along the way [1]. Given that, the sensible plan is load management and a progressive tendon programme, accepting that the timeline is measured in months. Surgery is reserved for the small minority still disabled after a genuine and prolonged trial of non-operative care. The reason that threshold is set high is precisely the natural history above: operate early and you are competing against a condition that was, in nine cases out of ten, going to resolve anyway. ### Cultured tendon-cell injection You may be offered, or may read about, autologous tenocyte implantation (ATI, sold in Australia as OrthoATI), an injection of your own laboratory-grown tendon cells. It is safe, it is biologically sensible, and the results reported in stubborn tennis elbow have lasted more than four years. It is also supported, in the whole world literature, by five studies containing 50 patients between them, not one of which had a comparison group. Set that against the natural history above, and the reason for caution becomes obvious. There is a full account of what is and is not known, with references, on the autologous tenocyte implantation page. --- ### Tennis Elbow Release URL: https://www.cqupperlimb.com/education/elbow/tennis-elbow-release/ Region: elbow · operation Tennis elbow release surgery — for persistent pain despite physiotherapy and other conservative treatments. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Tennis elbow is wear-and-tear of the tendon on the outer side of your elbow. Most people improve without surgery. About 90% of people with untreated tennis elbow achieve symptom resolution at 1 year, and symptoms often settle within 12 to 18 months. So we usually try non-operative care first: activity change, physiotherapy or hand therapy, splinting, and injections. Surgery is considered when that has not given enough improvement. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a history, examine your elbow, and arrange imaging where needed. Tennis elbow release involves releasing the damaged tendon from the bone on the outer side of your elbow. For the small percentage of people who do not respond to non-operative care, surgery provides near 90% satisfaction rates. The aim is to relieve your pain and restore function in your arm. We will discuss this with you as a shared decision. ## Before the operation Before your surgery, you will need to stop eating and drinking for seven hours. We ask for seven hours rather than six so your operation can be brought forward if the theatre list runs early. Your surgeon will tell you which medicines to stop and when. Bring a list of everything you take, including tablets, drops and creams. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing that is easy to change out of. Imaging such as an X-ray, MRI or ultrasound may be used to plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist, who will go through your health and your medicines with you. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. When the operation is finished, you will wake up in the recovery area. Nurses will monitor you while the anaesthetic wears off. Once you are stable, you will either go to a ward or go home, depending on the procedure and your recovery. Many people go home the same day. Before you leave, we will explain how to care for your elbow and what to expect over the coming days. ## What the operation involves Your surgeon performs a tennis elbow release through a single cut on the outer side of your elbow, over the bony bump you can feel there. The damaged part of the tendon is separated from that bone. This releases the tendon from its attachment, which is where the pain has been coming from. The worn, frayed tissue at the tendon's origin is cleaned away, and the surface of the bone beneath it is smoothed. The cut is then closed with stitches. A dressing goes over the wound before you leave theatre. The operation is done through this one incision rather than several small keyhole cuts. Your surgeon works directly on the tendon and bone, so the damaged area can be seen and treated in full. ## After the operation You will wake up in the recovery area with nurses nearby while the anaesthetic wears off. Your elbow will have a soft dressing over the wound, held in place with a bandage. You may feel some pain around the outer side of your elbow; tell the nurses, as they can give you medicine to keep you comfortable. You can move around soon after waking, and most people walk to the bathroom with help on the same day. Someone should stay with you for the first 24 hours after you get home. This is usually a day case, so you can expect to go home the same day, although occasionally patients stay overnight. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your elbow will be sore and may look swollen around the outer side. This settles gradually. Keeping your hand raised when you are resting can ease the swelling, and simple pain medicine helps with the discomfort. Your dressing stays on until we see you, so you can shower as usual without touching the wound. You will use your arm for light tasks at home almost straight away. You can dress yourself, eat and move around normally. Avoid heavy lifting, pushing up from chairs with that arm, and anything that strains the outer side of your elbow. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby will guide your exercises and make a splint if you need one. The exercises keep your wrist and elbow moving and rebuild your grip strength step by step. Sleeping can be awkward at first. Many people find it comfortable to rest with a pillow under or beside the arm. Once the swelling settles and movement feels easier, you will notice your grip returning. When you can hold and squeeze without pain, everyday tasks feel normal again. Once your splint is off and you can grip the wheel and react quickly, driving is usually fine again. We have more detail at Driving after upper-limb surgery. Returning to work depends on what your job involves, and we will talk that through with you. Everyone heals at their own pace. Your timeline may differ, and your surgeon and therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the body forms small patches of new bone where it should not, inside or around the elbow joint. This is called heterotopic ossification. You might notice a stiff, grating feeling when you bend or straighten your arm, or a sense that the elbow will not move as freely as it did. If movement feels blocked or the joint feels hard and swollen, bring it up at your next review. A few people find their elbow does not bend or straighten through its full range afterwards. You may notice this when reaching for a high shelf or turning a door handle. Gentle, regular movement as guided by your therapist helps. If the tightness is not improving, mention it at your review so it can be assessed. In some people the operation does not settle the pain the way we hoped. The outer side of the elbow keeps aching, or the pain returns after a period of relief. If that happens, we will reassess your elbow and talk through the options with you, which may include further surgery. Tell us early if the pain is not easing as expected. Having several injections into the same elbow before surgery makes it more likely that further surgery will be needed later. If you have had injections elsewhere for this problem, let us know, as it helps us plan your care. If you notice spreading redness around the wound, fluid leaking from it, a fever, or pain that keeps getting worse rather than easing, contact the clinic straight away. These signs need prompt attention. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us straight away if you have a fever, spreading redness around the wound, fluid leaking from it, or pain that keeps getting worse rather than easing. Go to emergency if you have sudden severe pain, calf swelling or shortness of breath, or if you lose feeling in your hand or cannot move your arm. These signs need urgent assessment. If something feels wrong and you are not sure, call the clinic. We would rather hear about it early. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Tennis Elbow page. --- ### General & whole-body health URL: https://www.cqupperlimb.com/education/general-health/ Region: general-health · region-landing Cross-cutting topics that span more than one body region or apply to your general musculoskeletal health. ## Conditions Alcohol, Bone and Wound Healing How alcohol weakens bone and slows wound healing, its risks around surgery, and why cutting down before and after helps. Open → Complex Regional Pain Syndrome (CRPS) What CRPS is, why it sometimes follows a wrist or hand injury or operation, how it is recognised and treated, and what recovery looks like. Open → Diabetes and Upper-Limb Conditions Why diabetes makes frozen shoulder, trigger finger, carpal tunnel syndrome and Dupuytren's more common, and how it affects healing and surgery. Open → Falls Prevention and Fragility Fractures A wrist or shoulder broken in a simple fall is often the first sign of thinning bone — treating the bone and preventing the next fall. Open → Fibromyalgia Widespread pain and fatigue from an over-sensitised nervous system — what it is, and why movement, sleep and pacing help most. Open → Gout in the Hand, Wrist and Elbow Gout in the upper limb — what causes the attacks and lumps (tophi), how flares and high urate are treated, and when surgery is needed. Open → Inflammatory and Rheumatoid Arthritis Rheumatoid, psoriatic and gouty arthritis affecting the hand, wrist and upper limb — what they are, how they are managed, and when surgery helps. Open → Joint Hypermobility and Ehlers-Danlos Syndrome Bendy joints that can slip or ache — the spectrum from benign hypermobility to hEDS, and why strengthening is the mainstay. Open → Lumps and Bumps on the Hand, Wrist and Fingers Found a lump on your hand, wrist or finger? The common causes and what they mean: ganglion cysts, fatty lumps (lipomas), giant cell tumours, mucous cysts and carpal bossing, and when to see someone. Open → Musculoskeletal Syndrome of Menopause How the menopausal transition and oestrogen withdrawal drive joint, tendon and muscle symptoms — arthralgia, tendinopathy, frozen shoulder, greater trochanteric pain and myalgia — and the evidence on hormone therapy. Open → Nerve Pain Medicines (Gabapentin and Pregabalin) How medicines like gabapentin and pregabalin settle nerve pain, why they are built up slowly, their side effects, and using them safely. Open → Numbness and Tingling in the Hand and Arm What causes numbness, tingling or 'pins and needles' in the hand and arm — from carpal tunnel and cubital tunnel to other nerve problems — when it matters, and what helps. Open → Oral Steroids, Bone and Healing How long-term steroid tablets affect bone, wound healing and surgery, and why they must never be stopped suddenly. Open → Osteoarthritis The commonest arthritis — cartilage wear in the thumb base, fingers, wrist and shoulder — its symptoms, management ladder and outlook. Open → Psoriatic Arthritis An inflammatory arthritis linked to psoriasis — sausage digits, nail changes and end-joint involvement — and why early treatment protects the joints. Open → Understanding Your Scans (X-ray, Ultrasound, MRI, CT) What X-rays, ultrasound, MRI and CT each show, and why your surgeon chooses one over another. Open → ## Treatments & Health Topics Autologous Tenocyte Implantation (ATI) Cultured tendon-cell injection (OrthoATI) for chronic tendinopathy — how it is made and given, what the published evidence does and does not show, and its regulatory standing in Australia. Open → Bone Health and Osteoporosis How bone strength affects fractures, fixation and recovery — bone density, fragility fractures, and what helps keep bones strong (lifestyle, supplements and medications). Open → Braces, Splints and Supports When braces, splints and supports help upper-limb conditions, the main types, how to use them, and what the evidence shows for sprains, tendon problems, arthritis and after surgery. Open → Cannabis and CBD for Pain What the evidence does and doesn't show for cannabis and CBD in musculoskeletal pain, and practical and safety considerations. Open → Cortisone and Corticosteroid Injections What cortisone injections do, when they help, how long the effect lasts, and the risks of repeated injections for shoulder, elbow, wrist and hand conditions. Open → How Bone Heals and Remodels Open → How Cartilage Works (and Why It Struggles to Heal) Open → How Ligaments Work and Heal Open → How Muscles Work and Heal Open → How Nerves Work and Heal How nerves carry signals, sense the world, and heal after injury — in plain English, with an in-depth section. Open → How Pain Works Open → How Tendons Work and Heal Open → How Wounds and Scars Heal Open → Nerve Tests and Conduction Studies What nerve conduction studies and EMG are, why they are done for carpal tunnel and other nerve problems, what to expect, and how accurate they are. Open → Nutritional Supplements for Musculoskeletal Health Evidence on dietary supplements for joint, muscle and bone health — protein and amino acids, creatine, collagen peptides, glucosamine and chondroitin, and omega-3 — including perioperative recovery and osteoarthritis. Open → Outcome scores: what they measure, and what they don't What PROMs (patient-reported outcome measures) like the DASH, QuickDASH, SPADI, ASES and PRWE actually are, and how to read your own score. They exist to track how YOUR symptoms and function change over time, and to compare groups of patients in research. They are not a test that decides what treatment you should have — a score does not diagnose anything, and two people with the same number can need completely different things. Covers what the numbers mean, why a change matters more than a single reading, what a 'minimal clinically important difference' is, and the limits of a questionnaire. Open → Peptide Therapy in Musculoskeletal Medicine Injectable and regenerative peptide therapies in orthopaedics and sports medicine — what the evidence shows for tendon, cartilage and bone healing, and where the hype outpaces the data. Open → Platelet-Rich Plasma (PRP) and Injection Therapies What the evidence shows for platelet-rich plasma and related injection therapies in tendinopathy, osteoarthritis and rotator cuff disease — where they help and where the data is weak. Open → Smoking and Musculoskeletal Healing How smoking and nicotine affect bone healing, fracture union, spinal fusion, tendon and wound healing, and surgical complications — and the benefits of stopping before surgery. Open → Staying Active for Joint Health Why physical activity protects joints and tendons, how exercise helps osteoarthritis and recovery, and how to stay active safely. Open → Stem Cell and Regenerative Injections What stem-cell and bone-marrow-derived injections claim to do for joints and tendons, what the evidence actually shows, and the safety and regulatory caveats. Open → Testosterone, Anabolic Steroids and Musculoskeletal Health Anabolic steroids and testosterone are linked to a higher risk of tendon rupture, including the rotator cuff, biceps and quadriceps. How steroids and TRT affect tendons, joints, bone and recovery from surgery. Open → Vitamin D and Musculoskeletal Health How vitamin D affects bone, muscle strength, falls, fracture and tendon healing, and surgical outcomes — including who benefits from supplementation. Open → Weight, Obesity and Joint Health How body weight and obesity affect joint load, osteoarthritis, and the risks and outcomes of joint surgery — including the role of weight loss before an operation. Open → ## Medications GLP-1 Medications (Ozempic, Wegovy) and Your Surgery If you take a GLP-1 medication (such as semaglutide — Ozempic or Wegovy) and you are having an operation: what these drugs do, why they matter for your anaesthetic (delayed stomach emptying and aspiration risk), and what you should do before surgery. Open → Explore General & whole-body health in the evidence explorer → --- ### Alcohol, Bone and Wound Healing URL: https://www.cqupperlimb.com/education/general-health/alcohol-and-bone-and-wound-healing/ Region: general-health · condition How alcohol weakens bone and slows wound healing, its risks around surgery, and why cutting down before and after helps. Most of us enjoy a drink, and a glass with dinner is a normal part of life. But alcohol does have real effects on bones, on how wounds heal, and on how safely an operation goes, and those effects are worth understanding, not because anyone is judging your habits, but because a little planning around your surgery can genuinely help you heal faster and avoid problems. This page explains what alcohol does, and what small, temporary changes make the biggest difference. None of it is about giving up the things you enjoy for good; it's about giving your body the best possible conditions to recover. This is the alcohol companion to our page on smoking and healing: same supportive spirit, just a different substance. ## How alcohol affects your bones Bone isn't a fixed, lifeless scaffold; it's living tissue that is constantly being broken down and rebuilt, a bit like a road crew that's always resurfacing. Special cells called osteoblasts lay down new bone, and regular heavy drinking blunts these cells so that less new bone gets made. Over years, that tips the balance towards thinner, more brittle bone: the condition known as osteoporosis. Alcohol works against bone in a few overlapping ways: - It directly slows the bone-building cells, so the skeleton isn't renewed as well as it should be. - It disturbs the hormones that keep bone strong (in men, for example, it can lower testosterone, which bone-building depends on). - It interferes with how the body handles calcium and vitamin D (the raw materials and the "delivery system" bone needs), partly by affecting the gut, the pancreas and the way vitamin D is processed. On top of all that, alcohol affects balance and judgement, so heavy drinkers simply fall more often, and weaker bones plus more falls is exactly the combination that leads to broken hips and wrists. The encouraging part: bone responds when drinking eases off. Studies suggest that some of the lost bone strength can be partly recovered once heavy alcohol use stops. Your skeleton is more forgiving than you might think. ## Alcohol and fracture healing If you've broken a bone, healing it is an enormous building project, and it relies on those same bone-building cells that alcohol holds back. Heavy or binge drinking has been shown to delay fracture healing and leave the new bone (the "callus" that bridges a break) weaker than it would otherwise be. So during the weeks a fracture is knitting together, cutting back on alcohol gives that repair the best chance to set firm and strong. ## Alcohol, wounds and infection Healing a surgical wound asks a lot of your immune system: it has to fend off bacteria, clear away damaged tissue and build fresh, healthy skin and underlying tissue. Regular heavy alcohol dampens the immune system and slows that wound-healing machinery. The practical result, seen consistently in surgical studies, is a higher rate of wound infections and wound-healing problems in people who drink heavily, along with weaker, slower-to-close wounds and, at times, poorer scars. Giving your immune system a clearer run around the time of surgery is one of the simplest ways to lower that risk. ## Around the time of surgery Surgery is the moment when alcohol matters most, because it touches several things at once: - Bleeding. Alcohol interferes with normal blood clotting, so it can act a little like a blood thinner. That can mean more bleeding during and after an operation than expected. - The anaesthetic and pain medicines. Alcohol changes how your body handles these drugs, which can make the response in theatre less predictable, sometimes needing different doses. It's an especially important interaction afterwards: mixing alcohol with opioid (strong) painkillers adds up dangerously, deepening drowsiness and slowing breathing, and alcohol combined with paracetamol is hard on the liver. This is why it's best to avoid alcohol while you're taking these medicines. - Alcohol withdrawal in hospital. This is the one most people don't expect. If your body has become used to regular drinking, suddenly stopping (as happens on admission to hospital) can trigger withdrawal, ranging from shakes, sweating and a racing heart to confusion (delirium) and, occasionally, seizures. It's a genuine medical risk, and it's entirely manageable if the team knows to watch for it. That's the single biggest reason we ask honestly about how much you drink: not to judge, but so we can keep you safe and comfortable. ## Why honesty with your team matters It can feel awkward to give an exact answer when you're asked how much you drink, and many people instinctively round down. Please resist that instinct. Your surgeon and anaesthetist aren't keeping score; they're using that number to make real decisions: how closely to watch for bleeding, how to plan your pain relief, and whether to put a withdrawal-prevention plan in place so you don't become unwell in hospital. An honest picture genuinely makes your care safer. Whatever you tell us is confidential and is met without judgement. ## Cutting down before and after surgery Here's the good news, and it's well backed by the evidence: cutting down or stopping alcohol for a few weeks before and after your operation measurably improves healing and lowers complications. Trials of people who paused drinking for roughly four to eight weeks around surgery found fewer postoperative problems. You don't have to change your relationship with alcohol forever to get this benefit. A focused break around the operation does real work. A few practical pointers: - If you can, plan a low- or no-alcohol window in the weeks leading up to surgery, and continue it while wounds and bones are healing afterwards. - Don't drink while taking opioid painkillers or paracetamol: that combination is where the real danger sits. - For general health between operations, the safest pattern is moderation: several alcohol-free days a week and keeping any single session modest. If you're ever unsure what counts as moderate for you, ask us. - If you drink heavily and surgery is coming up, tell us early rather than stopping abruptly on your own, as a sudden stop can itself be risky, and we can help you taper down safely. ## Getting support if cutting down is hard For some people, easing off alcohol is straightforward. For others it isn't, and that's nothing to be ashamed of; it's common, and help is available and effective. Your GP is an excellent first port of call and can arrange support discreetly. There are also free, confidential phone and online services that can talk things through without any appointment. Reaching out is a sign of looking after yourself, not a failing. ## When to seek help sooner It's worth speaking to a doctor, not just before surgery but in general, if you notice signs that alcohol has more of a grip than you'd like, such as: - Needing a drink to feel normal or to get through the day - Shakiness, sweating, nausea or anxiety when you haven't had a drink for a while (these can be early signs of withdrawal) - Drinking more than you intend to, or finding it hard to stop once you start - Drinking affecting your sleep, mood, relationships or work If any of these ring true, please mention it to your GP or to us. Especially before an operation, knowing this lets us put the right support and safety measures in place. Outside of surgery, getting help early protects your bones, your healing and your health for the long run. ## Call us if - You have surgery coming up and aren't sure what to do about your drinking - You drink regularly and want help cutting down safely before an operation - You're worried about alcohol withdrawal, or you've had withdrawal symptoms before --- ### Autologous Tenocyte Implantation (ATI) URL: https://www.cqupperlimb.com/education/general-health/autologous-tenocyte-implantation/ Region: general-health · general-info Cultured tendon-cell injection (OrthoATI) for chronic tendinopathy — how it is made and given, what the published evidence does and does not show, and its regulatory standing in Australia. ## What it is Autologous tenocyte implantation — usually shortened to ATI, and sold in Australia under the brand name OrthoATI — is an injection of your own tendon cells into a tendon that has not healed. "Autologous" means the cells come from you. "Tenocytes" are the cells that live inside a tendon and make the collagen that gives it its strength. The idea behind the treatment is that a long-standing tendon problem is not really an inflammation — it is a patch of tendon where the repair process has stalled and the cells that should be rebuilding it have died off. ATI aims to restock that patch with healthy tendon cells taken from somewhere else in your body. It takes two visits, several weeks apart. - First, a biopsy. Under local anaesthetic, a needle takes a very small sample of tendon, usually from the patellar tendon just below the kneecap. You will also have a blood test, because the laboratory is required to screen for hepatitis and HIV before it can grow your cells. - Then the laboratory grows the cells. Your sample goes to a licensed cell-culture facility, where the tendon cells are separated out and multiplied over about three to five weeks until there are several million of them. - Then the injection. Your own cells come back as a small volume of fluid, and a doctor injects them directly into the damaged part of the tendon using ultrasound to guide the needle. This is done under local anaesthetic. There is no operation and no cut. Afterwards, the published studies asked people to rest for two days, stick to light household or office work for four weeks, and do simple stretches four times a day. They did not use a formal physiotherapy strengthening programme, and restrictions on work and sport came off at four weeks. The treatment has been used for tennis elbow, rotator cuff (shoulder) tendon problems, gluteal (hip) tendon problems and Achilles tendon problems. Nearly all of the published research is on tennis elbow. ## Does it work? This is the part that deserves a careful answer rather than a short one, because what is claimed for ATI and what has actually been demonstrated are not the same thing. What has been published is genuinely encouraging, but it is small and uncontrolled. An independent review published in 2025 searched the world literature and found five studies containing 50 patients in total — three small case series and two single-patient reports, all of them carried out in Australia. In the main tennis elbow study, 16 people with severe, long-standing tennis elbow who had already failed everything else improved their worst pain by 86% and their arm-function score by 91% over 12 months, and the appearance of the tendon on MRI improved as well. When the same group was re-examined an average of 4.5 years later, those gains were still there. But none of those studies had a comparison group. Nobody received a dummy injection, and nobody was left untreated for comparison. That matters more than it might sound, for two reasons. Tendon pain responds strongly to the expectation of treatment — in tennis elbow, a trial that compared real surgery with fake surgery, with neither the patient nor the assessor knowing which they had, found no advantage for the real operation. And tennis elbow gets better on its own: across the untreated and placebo groups of randomised trials, about 90% of people are better within a year [12]. The trial most often quoted in favour of ATI has never been published. In November 2023 the company that makes OrthoATI announced to the stock exchange the results of a 48-person trial comparing ATI with surgery for severe tennis elbow, reporting that the injection did better than the operation and got people back to work about a month sooner. Nearly three years later that trial has not appeared in any medical journal, so no independent doctor has been able to check how it was done. Everyone in it knew which treatment they were getting, the main measurement was a questionnaire the patients filled in themselves, and the company that sells the product ran the trial. None of that means the result is wrong. It means it has not yet been tested by the people whose job it is to test it. There is one trial that could have settled the question, and it has gone silent. A hospital in the Netherlands ran the only properly blinded study of ATI ever registered: 90 people with Achilles tendon pain, half getting tendon cells and half getting a salt-water injection, with neither the patients nor the doctors assessing them knowing which was which. It finished in 2014. Its results have never been published, anywhere, in the twelve years since. So the honest summary is: safe, plausible, consistently positive in uncontrolled studies, and still unproven. The 2025 review's own conclusion was that ATI may be a reasonable second-line option for stubborn tendon problems, but that a comparison group is essential before anyone can say it works. ## What are the risks? The safety record is the strongest part of the evidence, and it is reassuring as far as it goes. - At the elbow or tendon being treated, the published series report no infections, no tendon ruptures, no bleeding into the tendon, no nerve injuries and no unwanted bone formation. - At the knee where the biopsy is taken, discomfort has been mild and short-lived. In the main tennis elbow study, average knee pain was under 2 out of 10 four hours after the biopsy and had settled by four weeks, with no lasting problems. In the hip study, 3 of 12 people had mild soreness at the biopsy site that settled with an anti-inflammatory gel. - The commonest disappointment is not a complication but a non-response. One person in the main tennis elbow study was no better at three months, after re-injuring the elbow lifting at work, and went on to have surgery. Two honest qualifications. First, with only 50 patients in the entire published literature, an uncommon complication would not yet have shown up — an unblemished record in 50 people cannot rule out a problem that happens in 1 in 100. Second, two of the five published studies did not formally look for side effects at all, so "none reported" is not quite the same as "none occurred". There is also a risk that is not medical. This is an unapproved product, the treatment is paid for privately, and the biopsy commits you to the process before anyone knows whether your cells will grow well or whether the injection will help you. ## Is it right for you? ATI is not a first step, and nobody sensible offers it as one. It has only ever been studied in people whose tendon problem had lasted at least six months and who had already been through the usual treatments without success. In the tennis elbow studies, that meant bracing, physiotherapy and at least one cortisone injection. It is worth understanding where it sits legally in Australia, because this shapes the decision. OrthoATI is not registered on the Australian Register of Therapeutic Goods. It is supplied under the Therapeutic Goods Administration's Special Access Scheme, which is the pathway that allows a doctor to obtain an unapproved product for an individual patient. That is a legitimate and commonly used route, but it carries two consequences: your doctor takes personal responsibility for the decision and must tell you the product is unapproved, and it is not a Medicare-funded treatment, so the cell-processing part is paid for by you. Ask for that in writing before the biopsy, not after. It may be worth discussing if all of the following are true. - Your tendon problem has been going for well over six months and is genuinely disabling. - You have properly completed a loading and strengthening programme with a physiotherapist — not just tried one — and it has not worked. - The diagnosis has been confirmed on ultrasound or MRI, so it is clear the pain is coming from the tendon. - You accept that you are choosing an unproven treatment, and you would rather do that than have an operation or keep waiting. It is probably not the right choice if your symptoms are recent, if you have not yet done a proper rehabilitation programme, if there is another explanation for the pain such as a trapped nerve, or if being told "we don't yet know if this works" is not something you can sit with comfortably. Dr Kieran Hirpara will go through the alternatives with you before any of this is considered — continuing with a structured loading programme, a brace, further injections such as cortisone or PRP, and where appropriate an operation — and will be straightforward with you about the fact that none of the treatments for stubborn tennis elbow, including surgery, has a strong evidence base. ## The bottom line ATI is a well-tolerated injection of your own cultured tendon cells, with a clean safety record and a consistent, durable pattern of improvement in the small number of people who have been studied. It is also, at present, an unapproved product supported by five published studies and 50 patients, none of them controlled. The trial that is used to promote it has never been published; the one blinded trial that could have tested it properly has never reported. Against a condition in which most people recover within a year on their own, and in which even surgery has not outperformed a placebo operation, that is not enough to say it works. If you are considering it, the useful question is not "does the science look promising" — it does. The useful question is whether you are comfortable paying for, and committing to, a treatment whose benefit has not yet been separated from the natural course of the condition and the expectation of being treated. That is a reasonable thing for a well-informed person to choose. It is not something anyone should be talked into. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decision. Autologous tenocyte implantation is worth the extra reading because it is an unusually clean example of a problem that runs through the whole of regenerative orthopaedics: a treatment can be biologically sensible, consistently followed by improvement, entirely safe, and still not shown to work, and the reason is almost never the biology. It is the design of the studies. ### Why anyone thought putting tendon cells back would help Chronic tendon pain is not tendonitis. When the degenerate tissue is examined, there is very little inflammation in it. What there is instead is disorganised collagen, ingrowth of new vessels and nerves, and a resident cell population in trouble. In the extensor carpi radialis brevis origin of chronic tennis elbow, both apoptosis and autophagic cell death are demonstrable in the tenocytes themselves [1]. Ageing tenocytes drift towards the tendinotic phenotype through oxygen-tension-dependent Rac1 signalling [2]. On that picture the lesion is not inflamed, it is depopulated, and restocking it with healthy collagen-producing cells is a coherent thing to try. The cells used in ATI are characterised rather than merely harvested. In the index elbow study the cultured cells were profiled by flow cytometry and quantitative real-time PCR and shown to carry a tendon cell signature distinguishable from mesenchymal stem cells, and roughly 2 mL at 2–5 × 10⁶ cells/mL in 10% autologous serum was delivered through an 18-gauge needle into the lesion on one or two passes, expressly not a peppering technique, since the object was to deposit cells rather than to provoke bleeding [3]. One assumption inside that design is rarely examined. The donor tendon is the patellar tendon; the target is the common extensor origin. Tendon cells are not interchangeable between sites, human flexor and extensor tendon cells differ measurably in vitro in their growth and matrix behaviour [4], so the premise that a knee-derived tenocyte will behave as an elbow tenocyte once injected is an assumption the clinical studies inherit rather than test. The manufacturer's own laboratory work reports that donor age and donor site do not degrade cell growth or bioactivity, which addresses part of this, but it is a culture-dish endpoint from the group that sells the product. ### What fifty patients actually showed An independent systematic review published in 2025, no external funding, no declared conflicts, searched 174 records and found five includable studies containing 50 patients between them: three case series and two case reports, all conducted in Australia between 2013 and 2018 [5]. That is the entire published clinical evidence base for the technology, at every anatomical site combined. Within it, the elbow data are the strongest. Sixteen patients with severe chronic tennis elbow, mean symptom duration 29 months, all previously listed for surgery, improved maximum-pain VAS from 5.94 by 86% at 12 months and QuickDASH from 45.88 by 91%, with the combined MRI tendinopathy-and-tear score falling from 4.31 to 2.88 on a 2-to-6 scale [3]. Re-examined at a mean of 4.51 years, pain remained 78% better and QuickDASH 84% better, grip strength had continued to climb past its one-year value (19.85 kg → 37.38 kg at one year → 46.60 kg at final review), and the MRI score sat at 2.87 against 2.88 at one year, with all but two patients scoring identically [6]. The precursor technique, using skin-derived tenocyte-like cells rather than tendon-derived ones, moved median PRTEE from 78 to 12 at six months in 12 patients [7]. Two findings inside that literature deserve more weight than they usually get. First, in the gluteal tendinopathy series clinical scores improved and held to 24 months, but tendon appearance on MRI did not significantly change [8], so the structural repair story does not reproduce away from the elbow. Second, in a controlled animal model, tenocyte-seeded scaffolds improved rotator cuff healing in juvenile and in aged animals but had no effect at all in adult animals [9]. A treatment whose preclinical benefit disappears in the age group that actually gets tendinopathy is not a comfortable finding, and it does not appear in any promotional account of the technology. It is also not obvious that the cell has to be a cultured tenocyte. Dermal fibroblasts, vastly cheaper to obtain, reduced the retear rate after arthroscopic repair of rotator cuff tears larger than 2 cm in a randomised human trial [10]. If cell delivery is the active ingredient, the expensive cell may not be the necessary one. ### How to read a trial you cannot read The result most often cited for ATI is a 48-patient randomised comparison against surgery for severe chronic tennis elbow, announced by Orthocell to the ASX on 14 November 2023 (https://announcements.asx.com.au/asxpdf/20231114/pdf/05x9jhkpjfmzbp.pdf) and presented at the Australian Orthopaedic Association annual meeting. It reported a 15.7-point QuickDASH advantage over surgery at 12 months (p = 0.0028) and return to work at 19 versus 51 days. Nearly three years later it is not indexed in PubMed or Europe PMC. Four specific problems follow, and none of them depends on doubting anyone's honesty. The design tested one thing and the headline claims another. It was a non-inferiority trial with a 15-point QuickDASH margin, meaning it was built to conclude "not meaningfully worse", and would have returned a successful verdict even if ATI had been up to 15 points inferior. Fifteen points is approximately the whole minimal clinically important difference for QuickDASH. Reporting superiority from that architecture is a different inference from the one the sample size was calculated to support. Everything measured was subjective, and nobody was blinded. QuickDASH and VAS are patient-completed, and every participant knew whether they had received an operation or a novel cell injection. Tennis elbow is precisely the wrong condition in which to accept that: in a prospective, randomised, double-blinded, placebo-controlled trial, surgical excision of the degenerate ECRB produced no additional benefit over sham surgery [11]. An open-label comparison against an operation that does not beat placebo cannot demonstrate biological activity in the injection; it can only show that two treatment trajectories look similar in a condition where about 90% of untreated people recover within a year [12]. Forty-eight patients is thin in a literature that is known to be fragile. A fragility analysis of randomised trials of non-operative management of lateral epicondylitis found that reversing as few as three patient outcomes would overturn the reported statistical significance [13]. The sponsor ran it, and sponsorship measurably moves results in this exact indication. Industry affiliation is associated with more favourable findings in randomised trials of platelet-rich plasma for lateral epicondylitis [14]. In the closely analogous mesenchymal stromal cell literature, spin is present in most trials [15], and abstracts report a significantly higher proportion of statistically significant p-values than the main texts of the same papers [16]. Reporting standards for orthopaedic biologics are poorly adhered to in general [17], which is why cell dose, viability and passage number usually cannot be recovered from what is published, and cannot be recovered from a stock-exchange release at all. ### The trial that would have answered the question Registered as NCT01343836 (https://clinicaltrials.gov/study/NCT01343836), it was investigator-initiated at Erasmus Medical Center, quadruple-blinded across participant, care provider, investigator and outcomes assessor, and randomised 90 patients with chronic Achilles tendinopathy to autologous tenocyte implantation or intratendinous saline, both with eccentric loading. The primary endpoint was VISA-A at 24 weeks. It completed in June 2014. No results have been posted. The registration was last updated in February 2015. No publication is indexed in PubMed or Europe PMC; the only papers that cite the registration are reviews noting its existence. Twelve years of silence from the only placebo-controlled test of a technology is itself information. It is not proof of a negative result, trials fail to report for funding, staffing and thesis-completion reasons as often as for embarrassing ones, but the asymmetry is hard to ignore: the sponsor-run open-label trial was announced within weeks of completion, and the independent blinded trial has never been heard from. ### What would actually settle it A trial of ATI against a sham injection, with the assessor blinded, in a single tendon site, with a patient-reported primary endpoint at 12 months and an imaging co-primary read by a blinded radiologist. Roughly 130 patients per arm to detect a genuine 15-point QuickDASH difference. Registered prospectively, reported to CONSORT, with cell dose and viability disclosed to the MIBO standard. Nothing about that is technically difficult; it has simply not been done in the seventeen years since the first pilot. Until it is, cell therapy for tendon disease remains what the independent reviews describe: safe at every tendon site studied so far [18], and, in the words of the 2025 systematic review, a reasonable second-line option for resistant tendinopathy that cannot yet be said to work, because nobody has included a control group [5]. --- ### Bone Health and Osteoporosis URL: https://www.cqupperlimb.com/education/general-health/bone-health-and-osteoporosis/ Region: general-health · general-info How bone strength affects fractures, fixation and recovery — bone density, fragility fractures, and what helps keep bones strong (lifestyle, supplements and medications). ## What it is Inside a bone: the spongy 'honeycomb' thins and loses struts as bone density falls — the change osteoporosis describes. Servier Medical Art, CC BY-SA 3.0 Osteoporosis is a condition where your bones lose strength. Over time they become thin and fragile, so they can break from a minor fall or even a small bump. The most common breaks happen in the hip, the wrist and the spine. You may hear the term "fragility fracture". This means a bone that broke more easily than it should have. If you have had one of these breaks, it can be a warning sign that your bones are weaker than normal. There is a known gap in care here. Research has found that people who break a bone this way are often not checked for osteoporosis or started on treatment [1]. This happens even though guidelines exist [2]. It matters because treating the underlying bone weakness can lower the chance of another break. Trials have shown that treating osteoporosis after a fragility fracture can cut the risk of further fractures by up to 50% and reduce death rates by up to 30% [3]. Bones are not static. They are living tissue that is constantly being broken down and rebuilt. Osteoporosis develops when the breakdown outpaces the rebuilding, so bone density drops. The goal of prevention is to build the strongest bones you can, then keep that strength [4]. The goal of treatment is to stop further bone loss so a first fracture, or another one, never happens [4]. One finding worth knowing: an analysis of nine studies found that each 1-unit increase in body mass index was linked with a 9% reduction in osteoporosis risk [5]. Body weight is one piece of the picture, alongside things like age, hormones and overall health. If you have broken a bone easily, or you are worried about your bone strength, ask about a bone density check. Finding osteoporosis early gives you the best chance to act before a fracture happens. ## Does it work? The honest answer is that treatment works best when it starts early, and there is still room for improvement in how that happens. Research has found that people who break a wrist are checked for osteoporosis far more often when they are part of a dedicated program than when they receive usual care: 92% compared with 23% [6]. Other studies have found that people who break a hip or a spine bone are often not started on bone-strengthening treatment at all, even though guidelines recommend it [7] [2]. This is why asking about a bone density check after any easy break matters so much. Once osteoporosis is diagnosed, there is evidence that treatment can help bones heal and reduce the chance of another break. In one trial, people with a broken wrist who received a bone-building hormone injection healed in 7.8 weeks, compared with 12.6 weeks for those who received no treatment [8]. Exercise also has a role. People with osteoporosis should undertake resistance and impact exercise to maximise bone strength, along with activities to improve strength and balance to reduce falls, and spinal extension exercise to improve posture [9]. Some of the newer research is less settled. Machine learning tools that predict osteoporosis from scans or blood tests show promise, but reviews have found they carry a high risk of bias and have not yet been properly tested in clinics [10]. And one analysis found that a diabetes medication thought to protect bones did not reduce wrist and arm fractures once other health factors were accounted for [11]. If you have osteoporosis and you break a bone, treatment of the bone itself works better when the underlying bone weakness is treated at the same time [12]. ## What are the risks? The main risk of leaving osteoporosis untreated is a broken bone. If you have already had one fragility fracture, your bones are more likely to break again, especially if the underlying bone weakness is not treated [7] [2]. Research has found that treatment started after a first fracture lowers the chance of another one, and this is the strongest reason to act early [3]. There are also risks around the time of a fracture itself. One study found that people with osteoporosis had more medical complications in the first 90 days after surgery than people without it [13]. Broken bones can also heal differently depending on bone strength. In one study of displaced wrist fractures, the improvement in deformity was 12.5 in people with osteoporosis, less than half the 25.6 seen in people with good bone quality [14]. Another study found that weak bones in older people did not, on its own, stop a fracture from joining [15]. If you have osteoporosis and need surgery on a joint or tendon, the picture is more settled. Reviews of keyhole rotator cuff repair found no link between lower bone density and outcomes at 2 years, and complication rates were low [16] [17]. Osteoporosis should not be seen as a reason to rule this surgery out [17]. Some treatments carry their own uncertainties. A nasal spray form of calcitonin works less well than other bone medicines for strengthening bone and lowering fracture risk [18]. Evidence for acupuncture and traditional Chinese medicine products is early, and more testing is needed [19] [20]. For parathyroid hormone injections, the best timing of doses is still being studied in trials [21]. The honest gap is in follow-through. Studies show many people who break a hip, spine or wrist are never started on bone-strengthening treatment at all [7] [2] [22]. Asking about treatment after any easy break is the safest step you can take. ## Is it right for you? Bone-strengthening treatment is worth considering if you have been told your bones are weak, or if you have broken a bone more easily than you should have. The aim is to stop further bone loss before a first break, or another one, happens [4]. Treatment after a fragility fracture matters too. It can lower the chance of another fracture and reduce death rates [3]. But research shows many people who break a hip, spine or wrist are never started on treatment at all [7] [2]. So if you have had an easy break, it is reasonable to ask your doctor about a bone density check and whether treatment would help you. Some people are less likely to need treatment. If your bones are still strong, the focus is on keeping them that way: building the strongest bones you can, then holding onto that strength [4]. Exercise plays a part here. People with osteoporosis should undertake resistance and impact exercise to maximise bone strength [9]. Your doctor can help you work out what is safe for you. Treatment is not one-size-fits-all. There are several types of bone medicine, and the right one depends on your health, your fracture history and your own priorities. This should be a shared decision between you and your doctor. Ask what each option involves, what the possible side effects are (covered in the risks section above), and how long you would need to stay on treatment. If anything is unclear, keep asking until you feel confident in the plan. ## The bottom line Osteoporosis treatment is worth considering if your bones are weak or you have broken a bone easily. The aim is to stop further bone loss before a break happens, or another one [4]. Acting early matters, because treatment after a fragility fracture can lower the chance of another break and reduce death rates [3]. The single most important caveat is follow-through: many people who break a hip, spine or wrist are never checked or treated at all [7] [2]. So if you have had an easy break, ask for a bone density check and keep asking until you have a plan. --- ### Braces, Splints and Supports URL: https://www.cqupperlimb.com/education/general-health/braces-splints-and-supports/ Region: general-health · general-info When braces, splints and supports help upper-limb conditions, the main types, how to use them, and what the evidence shows for sprains, tendon problems, arthritis and after surgery. ## What it is A brace, splint or support is a device that holds part of your body still, or guides how it moves. Splints are usually firm and hold a joint in one position. Braces and supports often allow some movement while they protect the area. They are used for hand, wrist, elbow and shoulder problems, and sometimes for knee injuries such as a torn ACL, where a bracing programme is one option instead of surgery [1]. Splints work by holding joints and soft tissues in a steady position. Plaster splints do this gently and precisely, which helps reshape stiff tissue over time [2]. In the early stage of an injury, a brace can support inflamed tissues without stopping all movement, which helps healing [3]. Some splints are dynamic, meaning springs or rubber bands pull a joint towards a movement you are working on. Others are static and simply hold still. Each design has strengths and weaknesses [4]. You may be offered a splint after an injury, after surgery, or for stiffness and nerve problems. For some conditions, such as hand and upper limb problems, splinting is accepted as standard practice in rehabilitation [5]. A splint might be worn during the day, at night, or both. Some designs are simple and need almost no upkeep [6]. Many can be made from low-cost materials [7]. Splints are not always the answer. In one study of hand fractures, fewer people stuck with a brace than with a plaster cast, and more people in the brace group had complications [8]. Your doctor will weigh up whether a splint, a cast or surgery suits your injury best. ## Does it work? The honest answer is that it depends on what the splint is being used for. For some conditions there is solid evidence. For others, there is very little good research yet, and your doctor will rely on experience and standard practice. Some findings are clear. People with arthritis at the base of the thumb who felt better with a splint early on had between 54% and 61% improvement in their symptoms six months later [9]. For broken hand bones, a functional brace that allows some movement held the bones straighter than a standard splint did [10]. People with a torn tendon on the back of the finger who used one type of dynamic splint did better than those treated with other methods [11]. And people with a tendon injury over the back of the hand returned to full activities eight weeks earlier with a moving splint than with one that held still [12]. Other findings are more mixed. Splints for trigger finger can work, and they suit people who would rather not have a cortisone injection [13]. But one study of finger exercises with a splint could not show they were better than other non-surgical treatments [14]. For Dupuytren's contracture, splints and wearing programmes vary so widely between clinics that it is hard to know what works best [15]. It is also not known whether wearing a splint for months after Dupuytren's surgery keeps the finger straighter in the long run [16, 17]. There are real gaps. For some tendon repairs, there are no good trials comparing splinting methods, so the best approach is not settled [18]. Some splints can fail too. In one study, a few people with a serious finger joint fracture needed surgery because their splint did not hold the joint in place [19]. Your doctor will talk you through what the evidence says for your specific condition, and what it does not. ## What are the risks? Most problems with braces and splints are local, meaning they affect the skin and tissues under the device. A splint that rubs or presses too hard can cause soreness, and some designs are simply more comfortable than others. One new type of finger splint was found to be much more comfortable than a cast, though the people wearing it still found it annoying [20]. If a splint is uncomfortable, tell your therapist or doctor, because small changes to the fit often help. Splints can also fail to do their job. In one study, three people with a serious finger joint fracture went on to need surgery because their splint did not hold the broken bones in place, and their results were worse for it [19]. This is why you will be asked to come back for check-ups, so the team can confirm the splint is still holding things where they should be. Sticking with the plan matters too. In a study of hand fractures, only 41% of people given a brace completed their treatment, compared with 81% of those in a plaster cast, and complications accounted for 60% of the people who dropped out of the brace group [8]. Children may pull splints off, and one clinic found that a modified thumb splint design helped stop this [21]. There are also honest gaps in what is known. For some tendon repairs, there are no good trials comparing splinting methods, so the risks of each approach are not fully settled [18]. For Dupuytren's contracture, it is not known whether months of splinting after surgery keep the finger straighter, or whether it causes any loss of bending [16, 17]. Your doctor will explain which of these risks apply to your injury and what warning signs to watch for. ## Is it right for you? A splint or brace may suit you if your problem is one that responds to steady support rather than an operation. That includes some hand and wrist injuries, stiffness in a finger joint, arthritis at the base of the thumb, and some nerve problems. Splinting is accepted as standard practice for many hand and upper limb conditions [5]. Some people also choose a splint to put off or avoid surgery. For thumb arthritis, a small splint that holds the thumb while leaving nearby joints free to move is one option for people who decide against surgery [22]. A splint is not right for every injury or every person. Some designs hold a joint in a position that would not suit your injury. A moving finger splint, for example, should not be used when a nearby joint needs to be held fully straight [23]. Some splints also fail to hold broken bones in place, and a few people in one study went on to need surgery because of this [19]. Your doctor will weigh up a splint against a cast or surgery based on your injury, your job and how likely you are to keep to the wearing plan. Comfort and fit matter more than you might expect. A splint you find easy to wear is one you will actually keep wearing, and designs that let you use your hand lead to better follow-through [24]. If a splint does not feel right, say so. Small changes often fix the problem. This should be a shared decision with your doctor. The risks section above explains what can go wrong, and your doctor will explain which of those apply to you. ## The bottom line A brace or splint is worth considering for many hand, wrist and elbow problems, especially if you want to avoid or postpone surgery. Some designs are simple, comfortable and let you keep using nearby joints [22, 25]. The evidence is stronger for some conditions than others, so ask what is known for yours. The single most important thing is fit and follow-through: a splint that feels right is one you will actually wear, and wearing it as directed is what gets results. --- ### Cannabis and CBD for Pain URL: https://www.cqupperlimb.com/education/general-health/cannabis-and-cbd-for-pain/ Region: general-health · general-info What the evidence does and doesn't show for cannabis and CBD in musculoskeletal pain, and practical and safety considerations. ## What it is Cannabis-based medicine covers products made from the cannabis plant, including cannabidiol (CBD) and THC. CBD is one part of the plant that does not cause a "high". THC is the part that does. These products come as oils, tablets or creams you can rub on the skin. People with long-term pain from arthritis, nerve pain, or pain after surgery sometimes ask about it. Many patients are curious. In one survey, 80.9% of people seeing a hand and upper-limb clinic said they would consider using medical cannabis [1]. Among people with spine pain, one in three were already using it [2]. Large numbers of people with wear-and-tear arthritis at the base of the thumb said they would be interested in trying it [3]. How it works is still being studied. Your body has its own system that responds to compounds in cannabis, and this system plays a role in how you feel pain. One review reported that current evidence suggests benefit and safety for long-term muscle, bone and nerve pain [4]. But the picture is mixed. Trials found no clinically important benefit for nerve pain after brachial plexus injuries (a stretch injury to the nerves running from your neck into your arm) [5]. A synthetic form of THC did not appear to limit opioid intake after knee replacement surgery [6]. There are some cautions. Regular cannabis use has been linked with higher opioid use after joint replacement surgery [7]. People with documented cannabis dependence had higher odds of wound problems after hand and wrist soft-tissue surgery [8]. More research is needed before clear advice can be given for many conditions [9, 4]. ## Does it work? The honest answer is that it depends on what you are using it for. For long-term muscle, bone and nerve pain, one review reported that current evidence suggests benefit and safety for cannabis-based medicines [4]. A review also found they may help with nerve pain in the limbs away from the spine [11]. But for hand and arm conditions specifically, researchers say we still need more studies before firm conclusions can be drawn [4]. There are some encouraging findings around surgery. CBD can be included in a combined pain-relief plan after keyhole rotator cuff repair without harming your recovery in the short or long term [12, 13]. That means it did not make outcomes worse, not that it was proven to make them better. For teenagers and young adults having hip keyhole surgery, those who used marijuana before surgery had the same pain levels, painkiller needs and recovery as those who did not [14]. Some findings are less positive. Among teenagers having knee ligament reconstruction, those who reported marijuana use needed overnight admission for pain more often and took longer to return to sport [15]. So the same substance can look harmless in one setting and problematic in another. It is worth knowing who tends to use it. People having keyhole surgery who report cannabis use are usually younger and more often male [16]. And most people seeing a hand and upper-limb clinic see medical cannabis as a safe option for common orthopaedic problems [1]. The bottom line: there is real evidence for some uses, mixed evidence for others, and no good trials yet for many hand and arm conditions. If you are thinking about it, ask your doctor what the evidence says for your specific problem. ## What are the risks? The honest answer is that the risks depend on your situation, and the research does not cover every case. For nerve pain in the limbs, a review found cannabis-based medicines may help [11]. But for nerve pain after brachial plexus injuries (a stretch injury to the nerves running from your neck into your arm), trials found no clinically important benefit when cannabis-based treatment was added to standard pain-relief plans [5]. Around surgery, the picture is mixed. CBD can be included in a combined pain-relief plan after keyhole rotator cuff repair without harming your recovery in the short or long term [12, 13]. One study of CBD absorbed through the cheek found it was well tolerated and reduced pain in the first days after that same operation [17]. But for teenagers having knee ligament reconstruction, those who reported marijuana use needed overnight admission for pain more often and took longer to return to sport [15]. People with documented cannabis dependence had higher odds of wound problems after hand and wrist soft-tissue surgery [8]. For teenagers and young adults having hip keyhole surgery, those who used marijuana before surgery had the same pain levels, painkiller needs and recovery as those who did not [14]. Researchers also looked at whether combining cannabis with nicotine changed the risk of problems after upper limb fracture surgery. They found no clear added effect, but they note the study may not have been large enough to detect a small one [18]. There are real gaps in what is known. One study found cannabis use did not affect outcomes after hip replacement surgery, although its authors say more studies are still needed [10]. Researchers also say more studies are needed for many hand and arm conditions [9, 4]. So if you use cannabis or CBD, tell your doctor. They can weigh what the evidence says for your specific operation or condition, and what it does not yet say. ## Is it right for you? There is no simple yes or no here. Cannabis-based medicine may be worth considering for long-term muscle, bone and nerve pain, where one review reported that current evidence suggests benefit and safety [4]. It may also help with nerve pain in the limbs away from the spine [11]. But for many hand and arm conditions, there are no good trials yet, so nobody can say for certain whether it will help you [9, 4]. Around surgery, the answer depends on your operation and your history. CBD can be part of a combined pain-relief plan after keyhole rotator cuff repair without harming your recovery [12, 13]. But if you have used cannabis regularly, there are some cautions. Regular use has been linked with higher opioid use after joint replacement surgery [7]. And people with documented cannabis dependence had higher odds of wound problems after hand and wrist soft-tissue surgery [8]. Teenagers having knee ligament reconstruction who reported marijuana use needed overnight admission for pain more often and took longer to return to sport [15]. Compared with standard pain-relief plans, cannabis-based medicine is not a replacement. For nerve pain after brachial plexus injuries (a stretch injury to the nerves running from your neck into your arm), trials found no clinically important benefit when it was added to standard care [5]. A synthetic form of THC did not appear to limit opioid intake after knee replacement surgery [6]. The risks section above covers the cautions in more detail. If you are thinking about trying it, talk it through with your doctor first. They can weigh what the evidence says for your specific problem, and what it does not yet say. This should be a shared decision between you and your doctor. ## The bottom line Cannabis-based medicine may be worth considering for long-term muscle, bone and nerve pain, where one review reported that current evidence suggests benefit and safety [4]. Around surgery, CBD can be part of a combined pain-relief plan after keyhole rotator cuff repair without harming your recovery in the short or long term [12, 13]. But the same substance can look harmless in one setting and problematic in another, so the evidence depends on your specific condition or operation. The single most important caveat: tell your doctor if you use cannabis or CBD, so they can weigh what the research says for your situation, and what it does not yet say. --- ### Complex Regional Pain Syndrome (CRPS) URL: https://www.cqupperlimb.com/education/general-health/complex-regional-pain-syndrome/ Region: general-health · condition What CRPS is, why it sometimes follows a wrist or hand injury or operation, how it is recognised and treated, and what recovery looks like. ## What you're feeling Complex regional pain syndrome (CRPS) is a condition that causes severe, long-lasting pain after an injury, sometimes a fairly minor one. You may also hear it called reflex sympathetic dystrophy (RSD). The pain is usually out of proportion to the original injury, and it tends to spread beyond the spot that was hurt. Along with the pain, you may notice changes in the skin, swelling, and that your hand or arm does not work the way it used to. The pain can flare at night and disturb your sleep, and it often worsens after activity. Everyday tasks that use your hand can become hard: gripping a kettle, turning a key, writing, doing up buttons, or carrying shopping. The condition can affect how well your hand recovers after a fracture such as a broken wrist, how long you are away from work, and how satisfied you feel with your recovery. There is no single test that confirms CRPS. Your doctor makes the diagnosis based on your history and a physical examination, and only after other causes of your pain have been ruled out. This matters, because some other conditions can look similar and need different treatment. Because CRPS can lead to lasting loss of function if it is not treated early, recognising it promptly is important. Getting treatment started soon gives you the best chance of keeping your hand and arm working. If your hand or arm becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. No GP referral is needed. If your fingers or hand turn pale, cold, white or blue, or you suddenly lose feeling or movement after an injury, also go to the emergency department the same day. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand or arm, see your GP or ask for a specialist review. ## What's actually happening CRPS is not a problem with the joint or the bone itself. It is a problem with the nerves that carry pain messages, and with the way your body responds to an injury. After an injury or surgery, your body normally sends out an alarm signal. The injury heals, the alarm switches off, and the pain settles. With CRPS, that alarm keeps ringing long after the tissue has healed. The nerves in your arm and hand stay switched on, and the pain system becomes oversensitive, so it reacts to things that should not hurt. The nerves that control blood flow and sweating also get caught up, which is why your skin can change colour, feel hot or cold, and swell. This is why the symptoms you have just read about happen. The burning pain, the swelling, and the changes in your skin all come from nerves that are working overtime, not from ongoing damage at the injury site. The pain is real, even though the original injury may have been small. You may notice the condition described by different names. CRPS used to be called reflex sympathetic dystrophy, or RSD. These names describe the same problem, and the mix of terms has sometimes caused confusion. There is no blood test or scan that confirms CRPS. Your doctor works out whether you have it from your history and a physical examination, after checking that nothing else is causing your pain. CRPS does not come from one single cause. Several things combine to bring it on. Some people are more likely to develop it than others, and having a nerve problem in the same arm beforehand can raise the risk. Catching it early matters, because treatment started soon gives you the best chance of avoiding lasting stiffness and loss of hand function. ## What we can do about it There is a lot you can do yourself. Keeping your hand and arm moving is the core of treatment, because resting it completely tends to make things worse. Occupational therapy combined with physical therapy helps restore the everyday activities that matter to you, like dressing, cooking and writing. Some people also find mirror therapy helpful: you watch a mirror image of your good hand moving, which retrains the way your brain processes pain. High-intensity laser therapy can also reduce pain, sometimes from the third treatment session onwards. Give these approaches a fair go over several weeks before judging whether they are working for you. Medicines can help with the pain while you work on movement. Pain relief and anti-inflammatory tablets can settle things down enough for you to take part in therapy. A course of steroid tablets (prednisolone) is another option your doctor may consider, particularly where more specialised treatments are hard to access. A medicine called ketamine may be considered if your CRPS has become long-lasting or has not responded to other treatments. There is also a cream or ointment (doxepin) that can be applied to the skin. Keep in mind that medicines ease the pain but do not cure the condition on their own, so they work best alongside movement and therapy. If your symptoms are severe and still not settling despite the above, your GP or doctor may refer you for specialist assessment. For some specific conditions, a procedure may occasionally be considered. ## What to expect CRPS follows a different course for different people. Some people find their symptoms settle over weeks to months with treatment. Others have pain that comes and goes, with good stretches between flares. Because the condition can become long-lasting if it is not treated early, the sooner you start, the better your chances of keeping your hand and arm working. Recovery usually feels gradual rather than sudden. With well-managed treatment, most people find the burning pain eases first, then the swelling settles, and movement and strength return over weeks to months. You may still have days where the pain flares after activity, but these tend to become less frequent. The aim is to get you back to everyday tasks like dressing, cooking and writing. If CRPS is left alone, it can lead to lasting stiffness and loss of hand function. Pain relief medicines can ease the pain, but on their own they do not cure the condition. That is why movement and therapy sit at the centre of treatment. There is some encouraging news about underlying nerve problems. Nerve compression (a nerve being squeezed where it passes through a tight space) often coexists with CRPS. When there is clear evidence of this, treating it can speed up your recovery, and many people with CRPS type 1 have full resolution of their symptoms once the compression is released. ## When to see someone Most warning signs for CRPS have already been covered earlier on this page, and the same routes apply here. Go to an emergency department the same day if your hand or arm becomes hot, red, swollen and painful, especially with a fever, or if your fingers or hand turn pale, cold, white or blue, or you suddenly lose feeling or movement after an injury. See your GP or ask for a specialist review if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand or arm. If you cannot reach the clinic, go to your nearest emergency department. Two other points are worth knowing. CRPS is diagnosed from your history and examination, because no test can confirm or rule it out. And because some other conditions can mimic it, your doctor will only call it CRPS after checking for other causes of your pain. --- ### Cortisone and Corticosteroid Injections URL: https://www.cqupperlimb.com/education/general-health/corticosteroid-injections/ Region: general-health · general-info What cortisone injections do, when they help, how long the effect lasts, and the risks of repeated injections for shoulder, elbow, wrist and hand conditions. ## What it is A cortisone injection is a shot of strong anti-inflammatory medicine, called a corticosteroid, into a painful joint or tendon. The medicine calms swelling and eases pain in one spot. It is not a painkiller you take by mouth. It works where it is placed. Your doctor may offer this treatment for several hand, wrist, elbow and shoulder problems. These include trigger finger (a finger that catches or locks), carpal tunnel syndrome (pressure on a nerve at the wrist), tennis elbow, thumb base arthritis, frozen shoulder and some ganglion cysts. It can also be used after some shoulder operations, though usually not in the first month after surgery [1]. The injection does not fix the underlying problem. It buys relief while your body heals, or while you do exercises or wear a splint. For carpal tunnel syndrome, for example, it can ease symptoms for a while, but most people eventually need surgery for lasting control [2]. For tennis elbow, the short-term relief can fade, and problems often come back later [3]. Your doctor will talk with you about whether an injection fits your situation, or whether another option such as exercise, splinting or surgery makes more sense first. ## Does it work? The honest answer is: it depends on the condition being treated. For some problems, injections work well. For frozen shoulder, a steroid injection into the joint eases pain, improves how the shoulder works and increases range of motion [4]. For de Quervain disease (swelling of the tendons at the base of the thumb), pain and clinical outcomes improved significantly after injection [5]. For thumb base arthritis, steroids are a favourable option because they are easy to give and work well [6], though the benefit may be short term [7]. For other problems, the picture is more mixed. For tennis elbow, steroid injections can bring short-term relief, but that relief is often reversed after six weeks, and the problem frequently comes back [3]. Research suggests steroids should not be used for most people who have had tennis elbow symptoms for less than 12 months [8]. For carpal tunnel syndrome, injections give safe, effective relief for a while, but most people eventually need surgery for lasting control [2]. Some findings are worth knowing before you choose this treatment. For trigger finger, one steroid type (betamethasone) failed sooner than another (triamcinolone) [9]. For rotator cuff repair, there were no clear signs that a steroid injection raises the risk of the repair failing again or of infection [10]. A single injection before rotator cuff surgery, given within 1 year of the operation, did not change failure rates, patient-reported outcomes, range of motion or strength [11]. The evidence is not perfect. Some of these findings come from small trials or reviews, and a few conditions have limited research to draw on. Your doctor will weigh the evidence for your specific condition and talk with you about whether an injection is likely to help you, or whether another option makes more sense first. ## What are the risks? Most people notice only short-term effects at the injection site. The shot itself can hurt, and adding a numbing medicine (lidocaine) to the steroid changes how much pain you feel during and just after the injection [12]. That difference may not matter much in the long run, but it is worth asking about before your injection. The steroid can also affect the tissue where it is placed. For tennis elbow, research links steroid injections with calcium building up in the soft tissue, and this is likely a complication of the injection itself [13]. For some people treated for tennis elbow, a single steroid injection led to poorer long-term results and the problem coming back more often 1 year later [14]. The medicine can reach beyond the spot where it was injected. If you have type 2 diabetes and do not use insulin, a shoulder steroid injection can raise your blood sugar levels for a short time [15]. If you have diabetes and are having treatment for de Quervain disease, a single injection is less likely to work for you than for people without diabetes, though further injections do not seem to lose their effect [16]. Some risks you might worry about have been studied and were not found. After rotator cuff repair, studies found no clear evidence that a steroid injection raises the risk of the repair tearing again or of infection [10]. A steroid injection before carpal tunnel release surgery was not linked to a higher rate of deep infection afterwards [17]. Repeated injections for carpal tunnel syndrome were found to be safe, and they did not make later surgery riskier [18]. How often an injection can be given matters too. For trigger finger, one study found no complications when a 4 mg triamcinolone injection was given at intervals of at least 1 month [19]. For de Quervain disease, an injection aimed at one tendon compartment can lower the steroid dose used, which may reduce complications [20]. ## Is it right for you? An injection may suit you if your pain comes from one clear spot, such as a trigger finger, thumb base arthritis or a frozen shoulder. For thumb base arthritis (wear-and-tear arthritis at the base of the thumb), research favours steroid injections because they are easy to give and work well [6]. If you have carpal tunnel syndrome and other injections have not lasted, repeat injections have been found safe, and they did not make later surgery riskier [18]. An injection may not suit you if your tennis elbow symptoms have lasted less than 12 months. Research suggests steroids should not be used for most people in that situation [8]. For tennis elbow generally, platelet-rich plasma (a treatment made from your own blood) beat steroid injections at the 6 month mark, while steroids worked better in the first month [21]. The choice is one you make together with your doctor. They will look at your condition, your symptoms and what you have already tried. Ask what the injection is meant to achieve, how long relief might last, and whether exercises, a splint or surgery would serve you better. The risks section above covers side effects in detail, so read that before you decide. ## The bottom line A cortisone injection can be worth considering for a clear, one-spot problem such as a frozen shoulder, de Quervain disease or thumb base arthritis. Expect relief that may be real but often short term, and know that for some conditions, such as tennis elbow or carpal tunnel syndrome, other treatments or surgery may serve you better in the long run. The single most important caveat: an injection eases symptoms, it does not fix the underlying problem. --- ### Diabetes and Upper-Limb Conditions URL: https://www.cqupperlimb.com/education/general-health/diabetes-and-upper-limb-conditions/ Region: general-health · condition Why diabetes makes frozen shoulder, trigger finger, carpal tunnel syndrome and Dupuytren's more common, and how it affects healing and surgery. ## What you're feeling Diabetes can affect many parts of your upper limb, not just one spot. You might have a finger that clicks or catches when you bend it, a shoulder that stiffens up, or tingling and numbness in your hand from pressure on a nerve at the wrist. Some people notice their fingers slowly curling inwards and not straightening fully. These problems often show up one after another over time, so you may find yourself coming back for a different hand or shoulder complaint than the one you first came with. The stiffness and pain tend to build gradually rather than arrive after an injury. A stiff shoulder often aches when you reach overhead or behind you, and it can disturb your sleep. Trigger fingers can be worse in the morning and loosen as the day goes on. Everyday tasks become the tell: gripping a kettle, turning a door handle, typing, holding a phone, or doing up buttons. Shoulder stiffness makes washing your hair or reaching into a back pocket hard. If you use insulin, these problems can be more stubborn: trigger fingers more often affect several fingers at once and are more likely to need surgery to release them. Watch for signs of infection in your hand or arm. If a finger, hand or arm becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. No GP referral is needed. If your fingers or hand turn pale, cold, white or blue, or you suddenly lose feeling or movement after an injury, that is also a same-day emergency department visit. See your GP or ask for a specialist review if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand or arm. If you cannot reach the clinic, out of hours or on a weekend, go to your nearest emergency department. ## What's actually happening High blood sugar over many years affects the tissue that surrounds your tendons and joints. Tendons are the ropes that pull your fingers and move your shoulder. In diabetes they can thicken and lose their glide, so a tendon catches as it runs through its tunnel in the palm, or the capsule around your shoulder tightens until the joint barely moves. Doctors call this limited joint mobility. It tends to worsen slowly the longer you have had diabetes, and finger contractures usually only appear after nine years or more. Several of these problems can travel together. A thickened tendon in the palm is trigger finger, pressure on a nerve at the wrist is carpal tunnel syndrome, and a locked-down shoulder is a frozen shoulder. Diabetes raises the chance of each of them, and having one makes the others more likely. If you use insulin, several fingers are more often affected at once and more of those fingers end up needing a surgical release. The same changes also make surgery and healing harder. Wounds in the hand heal more slowly, and infections that do take hold sit deeper and need more operations to clear. Steroid injections, a common treatment for these conditions, temporarily push your blood sugar up. A finger injection can raise your glucose for at least 5 days, so you will need to monitor your levels closely around any injection. None of this means the problems are your fault or that they cannot be treated. It means the underlying cause is the diabetes itself, acting on your tendons, joints and nerves over time, so your doctor will look at your whole upper limb rather than just the spot that hurts today. ## What we can do about it There is a lot you can do yourself. Keeping your blood sugar in range is the first step, because it is the underlying cause of the stiffening in your tendons and joints. Gentle exercise and physiotherapy aim to keep your fingers, wrist and shoulder moving, and to stop stiffness from limiting what you can do day to day. If you have type 2 diabetes, exercise and diet are the first means of managing it. Your own health needs to be considered individually when planning exercise, especially if you have heart or blood vessel problems, so talk these through with your GP or diabetes team. Give self-management a fair run over weeks rather than days. Medicines can help with pain along the way. An anti-inflammatory painkiller such as loxoprofen can be used for acute pain in people with diabetes. Steroid injections are another option for a troublesome trigger finger, and they can help prevent the need for surgery more than half the time. The trade-off is the effect on your blood sugar: a finger injection can raise your glucose for at least 5 days, and if your HbA1c is 7% or greater the rise tends to be higher and last longer. Your HbA1c can therefore help predict how much your glucose will lift, so monitor your levels closely around any injection. Platelet-rich plasma, an injection made from a sample of your own blood, is a safe and well-tolerated option for a frozen shoulder in people with diabetes. If your symptoms are severe and still not settling despite the above, your GP or doctor may refer you for specialist assessment. For some specific conditions, a procedure may occasionally be considered. The good news is that people with diabetes generally do as well as anyone else from treatment for these problems: after carpal tunnel release, the improvement in people with diabetes lasts long term to the same extent as for people without diabetes. Some procedures can even be done through the skin rather than through an open cut, and these work equally well and safely whether or not you have diabetes. Recovery can still take a little longer when diabetes is in the picture, and a stiff shoulder released surgically can remain tighter for longer than expected, so your doctor will weigh up timing carefully with you. ## What to expect Most of these problems build slowly and change slowly. Limited joint mobility tends to worsen gradually the longer you have had diabetes, and finger contractures usually only appear after nine years or more. Some stiffness in the ageing hand is common even without diabetes, so not every stiff finger will keep getting worse. With good blood sugar control, gentle exercise and the right treatment, most people keep their hand and shoulder working well enough for daily life. Left alone, stiffness and catching tend to persist rather than settle on their own. Be realistic about what treatment can achieve. Steroid injections can prevent the need for surgery more than half the time for a troublesome trigger finger, as covered earlier. After carpal tunnel release, people with diabetes experience more symptoms both before and after the operation, but can expect the same relative improvement as people without diabetes. For a frozen shoulder, gentle manipulation of the shoulder while you are asleep can give a satisfactory outcome in people with either type of diabetes, though roughly one in three releases by manipulation alone do not work first time and need repeating. A shoulder released surgically can remain tighter for longer than expected, and results at six months tend to be worse in people with diabetes, with a tendency towards persistent limitation of movement two years after the operation. Whether surgery is done early or delayed makes no difference to the outcome in people with diabetes. Your overall health shapes the outlook too. If you use insulin, there is a greater risk of complications after hand and upper limb surgery, particularly wound infections, so your doctor will weigh this up with you before any operation. Hand infections in people with diabetes can be more severe, especially when blood sugar control has been poor, which is why the same-day emergency signs earlier on this page matter. The honest bottom line: treatment works for these conditions in people with diabetes, and the improvement you feel is usually real and lasting, but recovery can take longer than it would otherwise, and some stiffness may stay with you. Keep monitoring your glucose around any injection or procedure, keep moving within what your body allows, and come back if things change. ## When to see someone Most of these problems build slowly, so a routine appointment is usually the right first step. See your GP or ask for a specialist review if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand or arm. Mention that you have diabetes, and mention any pattern you have noticed: several fingers catching in the same hand, or a shoulder that stiffened without any injury. These details help your GP or doctor join the dots between conditions that often travel together. One situation cannot wait. If a finger, hand or arm becomes hot, red, swollen and painful, especially with a fever, go to an emergency department the same day. Hand infections in people with diabetes can sit deeper and become more severe, particularly when blood sugar has been running high, so do not wait to see whether it settles. No GP referral is needed. If your fingers or hand turn pale, cold, white or blue, or you suddenly lose feeling or movement after an injury, that is also a same-day emergency department visit. If you cannot reach the clinic, out of hours or on a weekend, go to your nearest emergency department. --- ### Falls Prevention and Fragility Fractures URL: https://www.cqupperlimb.com/education/general-health/falls-prevention-and-fragility-fractures/ Region: general-health · condition A wrist or shoulder broken in a simple fall is often the first sign of thinning bone — treating the bone and preventing the next fall. If you are an older adult and you have broken a bone in a simple fall (a trip on a rug, a stumble in the garden, a slip getting out of a chair), that injury is trying to tell you something useful. A bone that breaks from a small fall is often the first sign that the bone has quietly become weaker than it should be. The good news is that this is one of the most actionable warnings in medicine: there is a clear plan to make the bone stronger and to stop the next fall before it happens. This page explains what a fragility fracture is, why it matters, and the practical things that genuinely work. ## What is a "fragility fracture"? A fragility fracture is a bone that breaks from a low-energy fall, a fall from standing height or less, the kind of knock that a healthy younger skeleton would usually shrug off. When a bone breaks from so little force, it is usually because the bone itself has thinned and weakened, a condition called osteoporosis. The fall is the trigger; the weak bone is the reason. In the upper limb the two most common fragility fractures are a broken wrist (a fracture of the distal radius, the forearm bone just above the wrist) and a broken shoulder (a fracture of the proximal humerus, the top of the arm bone). Both happen the same way (you put a hand out to break a fall, or you land on the point of the shoulder), and both are very often the first warning sign that the bones are thinning. Many people have no symptoms of osteoporosis at all until a minor fall produces a fracture that, on the X-ray, looks far worse than the fall should have caused. ## Why a single broken bone is worth acting on Here is the part that surprises most people: once you have had one fragility fracture, your risk of having another one (including a more serious break of the hip or spine) is roughly doubled. A broken wrist in your sixties or seventies is not just a wrist to be plastered and forgotten; it is an early, visible flag for a problem that, left unaddressed, can later cause a hip fracture, an injury far harder to recover from. That is why we treat a fragility fracture as a prompt to act on two fronts at once. Treating only the broken bone fixes today's problem but leaves tomorrow's risk untouched. The two jobs are: make the bone stronger, and prevent the next fall. ## Front one: make the bone stronger The first job is to find out how strong (or weak) your bones really are, and then to do something about it. - Get the bones assessed. The standard test is a DEXA scan, painless, low-dose X-ray (usually of the hip and spine) that measures your bone density. It tells us whether you have osteoporosis and how significant it is. - Correct vitamin D and calcium. Bone is built from calcium, and your body cannot absorb calcium properly without enough vitamin D. Many older adults are low in vitamin D without knowing it. A simple blood test and, if needed, a supplement can correct this, one of the easiest foundations to put in place. - Consider bone-protecting medicines. Where bone density is low, there are well-proven medicines that slow bone loss or actively rebuild bone, meaningfully reducing the chance of the next fracture. Whether one is right for you is a conversation to have with your GP or specialist. Many hospitals now run a fracture liaison service, a team whose whole job is to catch people after a fragility fracture and make sure this bone-health assessment actually happens, rather than falling through the cracks while everyone focuses on the cast. If your area has one, it is well worth being referred in. (For more detail on bone density, osteoporosis and the medicines involved, see the companion bone health and osteoporosis page.) ## Front two: prevent the next fall Strengthening the bone lowers the damage a fall does. Preventing the fall removes the trigger altogether. Most falls really are preventable. The strongest levers are surprisingly ordinary. - Tackle hazards at home. This is where many falls actually happen. Remove or secure loose rugs and trailing cords, clear clutter from walkways and stairs, improve lighting (especially on stairs and the route to the bathroom at night), and fit handrails on stairs and grab rails in the bathroom. A night light between the bed and the toilet prevents a remarkable number of falls. - Wear good footwear. Well-fitting, non-slip, flat shoes that fasten securely beat slippers, loose scuffs or going about in socks. Foot pain and poorly chosen shoes quietly undermine your balance. - Get your eyes checked. Have your vision tested and your glasses updated. If you wear bifocals or varifocals, be aware they can blur the edges of steps; a separate pair for stairs and walking outdoors sometimes helps. - Have your medicines reviewed. Some medicines cause drowsiness, dizziness or a drop in blood pressure when you stand, and the risk of falling rises once you are taking several of them. A pharmacist or GP can review the list and simplify or adjust what is contributing. - Manage dizziness and blood pressure on standing. If you feel light-headed when you get up from sitting or lying, mention it; it is often treatable. Standing up slowly and pausing before you walk off is a simple habit that helps. - Do strength and balance exercise: the most powerful step of all. Of everything on this list, programmes that build leg strength and balance have the best evidence for actually reducing falls. Approaches such as tai chi and structured strength-and-balance classes (your physiotherapist or GP can point you to a local one) keep you steady on your feet and, as a bonus, keep the bones loaded and healthy. Staying active is protective, not risky. ## Falls are not just "part of getting older" It is easy to assume that falling is simply what happens as you age, and to start shrinking your life to avoid it: going out less, doing less, moving less. That instinct quietly makes things worse, because the less you move, the weaker and less steady you become. Falls are not an inevitable part of ageing, and the great majority are preventable with the practical steps above. The goal is not to wrap yourself in cotton wool; it is to stay strong, steady and confident enough to keep doing the things you enjoy. ## When to get checked or seek help - After any fragility fracture, ask your GP or surgical team about a bone-health assessment (a DEXA scan and a review of vitamin D, calcium and whether a bone-protecting medicine is right for you). Don't let the conversation end at the cast. - See your GP if you are having repeated falls, feel unsteady on your feet, or get dizzy or light-headed: particularly on standing. These are exactly the things that can be assessed and improved. - If you have a fall and are worried you may have broken something (sudden pain, swelling, an obvious deformity, or you can't use the limb): get it checked promptly. Acting on the two fronts together (stronger bone and fewer falls) is the single most effective thing you can do to make sure a first fragility fracture is also your last. --- ### Fibromyalgia URL: https://www.cqupperlimb.com/education/general-health/fibromyalgia/ Region: general-health · condition Widespread pain and fatigue from an over-sensitised nervous system — what it is, and why movement, sleep and pacing help most. ## What you're feeling Fibromyalgia is widespread, long-term pain: an ache, burning or soreness that can move around the body and seems to be felt almost everywhere rather than in one joint. Alongside the pain, most people are deeply tired, and sleep doesn't fix it: you can spend a full night in bed and still wake up feeling unrefreshed, as though you never really rested. Many people also notice their thinking feels foggy: trouble concentrating, finding words, or remembering things. This is so common it has a name: "fibro fog". On top of this, the body often becomes more sensitive in general: touch, pressure, light, sound or temperature can feel like too much, and a knock that wouldn't bother most people can really hurt. It is exhausting, and it is easy to feel that no one quite believes how much you are dealing with. ## What's actually happening Here is the important part: fibromyalgia is not damage to your joints or muscles, and it is not inflammation. That's why scans, X-rays and blood tests usually come back normal. There's nothing being "missed", and a normal result does not mean the pain isn't real. What's happening is in the way your nervous system processes pain. In fibromyalgia the system that carries pain signals becomes turned up too high: the volume is set louder than it should be. Normal sensations get amplified into pain, and real pain feels more intense. Doctors call this central sensitisation. It is a genuine, physical change in how the nerves and brain handle signals: not something that is "in your head", and not a sign of weakness. Fibromyalgia is common, it is real, and it is recognised. It also often travels with other conditions (things like irritable bowel, headaches, low mood or other long-term pain), and it can amplify pain after an operation. That last point is worth telling your surgical team about, because knowing you have fibromyalgia helps them plan your pain relief and recovery so you are better looked after. ## What we can do about it There is no cure, but fibromyalgia is manageable, and many people get their symptoms to a much more liveable level. The strongest, most reliable help doesn't come from a tablet; it comes from a few steady habits: - Gentle, graded movement. Exercise is the single best-supported treatment. The trick is to start very small and build up slowly: walking, stretching, or water-based exercise are good starting points. Pushing too hard too soon flares the pain, so slow and steady wins. - Better sleep. Because unrefreshing sleep feeds the pain and the fog, a regular routine and good sleep habits make a real difference. - Pacing. Spreading activity through the day and week (rather than doing everything on a good day and crashing afterwards) keeps you steadier. - Stress management and psychological approaches. Stress turns the volume up further. Techniques such as CBT (cognitive behavioural therapy), relaxation and mindfulness help calm an over-sensitive system. Medicines can help some people, but the useful ones aren't painkillers in the ordinary sense: they calm the nervous system rather than blocking pain signals. These include amitriptyline, duloxetine and pregabalin; you can read more on our nerve-pain medicines page. By contrast, ordinary anti-inflammatories don't work for fibromyalgia (because there's no inflammation to settle), and opioids do not help and can cause real harm: they tend to make things worse over time, not better. Our page on managing pain after surgery explains why we steer away from them. ## What to expect Fibromyalgia tends to be a long-term condition that goes up and down: better spells and flares, often triggered by stress, poor sleep, illness or overdoing it. That can feel discouraging, but the trajectory for most people who stick with the movement, sleep and pacing approach is genuinely hopeful. Symptoms settle, flares become easier to ride out, and life opens back up. The work is yours to lead, but you are not meant to do it alone. A supportive team (your GP, sometimes a physiotherapist or pain service) can help you build a plan, adjust it over time, and keep you moving in the right direction. Self-management is powerful precisely because you are the one who can turn the volume back down, day by day. ## When to see someone - A new symptom, or a clear change in an old one: don't assume everything new is "just the fibromyalgia". Sudden or severe pain in one spot, swelling, fever, unexplained weight loss, or new weakness or numbness deserve a proper look, because they may be something separate. - Low mood, anxiety, or losing interest in things you usually enjoy: these often go hand in hand with fibromyalgia, they are treatable, and help makes the pain easier to manage too. If you ever feel hopeless or unsafe, reach out promptly. - Symptoms taking over your daily life despite your best efforts: that is the moment to ask your GP about more support, including a referral to a pain or rheumatology service. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Fibromyalgia is worth the extra reading because the single most useful idea about it is also the least intuitive: despite presenting as a muscle and joint problem, the evidence points away from the muscles and joints entirely. ### The clue that has nothing to do with joints If fibromyalgia were a disease of muscle or connective tissue, it should confine itself to those tissues. It does not. In a population study of 44,494 people, those with fibromyalgia or other musculoskeletal pain were more likely to report hearing loss. The authors' interpretation is the important part: the finding is consistent with fibromyalgia being related to a general dysregulation of the central nervous system, and the same may be true of other widespread musculoskeletal pain [1]. Hearing has no mechanical relationship to sore shoulders. When a condition defined by musculoskeletal pain also tracks with how the ear and brain process signal, the common factor is the processing, not the tissue. This is the central-sensitisation model in one unexpected observation: the volume control on sensory input is turned up, and pain is the most obvious consequence rather than the only one. ### Why your tests are normal, and why that is not dismissal Patients are frequently told that everything has come back normal, and hear it as disbelief. The research explains why the tests are normal without implying the pain is not. A meta-analysis of cytokines, the inflammatory signalling molecules that would be abnormal in an inflammatory arthritis, pooled 1,255 participants and concluded that their pathophysiological role in fibromyalgia is still unclear, with better and larger studies needed [2]. Investigation of the gut microbiome as a contributor reached a similar verdict: a plausible direction within the emerging gut–musculoskeletal axis, and a paucity of quality research so far [3]. So there is no blood test to find, because the abnormality is in signal processing rather than in tissue damage or inflammation. A normal inflammatory screen and a normal scan are the expected findings, and they rule out other conditions rather than ruling out this one. ### What has actually been shown to help Movement-based treatment has the strongest supporting data, and the form matters less than the fact of it. A meta-analysis of 936 patients found that traditional Chinese exercise — tai chi, qigong and similar low-intensity, movement-and-breathing practices, produced significant improvement in pain, sleep quality and symptoms of anxiety and depression [4]. Note what that trial set is measuring. The gains are across pain, sleep and mood together, which is what you would expect if the target is a sensitised nervous system rather than a painful structure. Sleep is not a side issue here; poor sleep lowers pain thresholds, and the two reinforce each other. ### The overlap with menopause Fibromyalgia symptoms often begin around menopause, tend to be more severe afterwards, and can worsen after hysterectomy with or without removal of the ovaries [5]. The symptom lists overlap substantially with the musculoskeletal syndrome of menopause. The review's conclusion is a caution against collapsing the two: fibromyalgia also occurs in women who are not menopausal and in men, so sex hormones are not the whole mechanism, and the two should be recognised and treated as separate problems that may coexist [5]. See our musculoskeletal syndrome of menopause page. ### What this means if surgery is being discussed This is where the central-sensitisation model becomes practical. An operation corrects a structural problem. If part of your pain is generated by altered central processing, that part of it will still be there afterwards, because the operation never addressed it. That is not an argument against having surgery when there is a genuine structural problem to fix. It is an argument for being precise beforehand about which portion of your pain the operation is expected to remove, and for treating the fibromyalgia in its own right rather than hoping the operation will resolve everything. Going into surgery with sleep, activity and mood as well managed as they can be is doing real work on the outcome, not preparation around the edges. --- ### GLP-1 Medications (Ozempic, Wegovy) and Your Surgery URL: https://www.cqupperlimb.com/education/general-health/glp1-agonists-and-orthopaedic-surgery/ Region: general-health · medication If you take a GLP-1 medication (such as semaglutide — Ozempic or Wegovy) and you are having an operation: what these drugs do, why they matter for your anaesthetic (delayed stomach emptying and aspiration risk), and what you should do before surgery. ## What this medication is GLP-1 medications are a group of medicines you may know by brand names such as Ozempic or Wegovy. Their full name is glucagon-like peptide-1 receptor agonists, or GLP-1 agonists for short. They were first used to treat type 2 diabetes, a condition where blood sugar levels run too high. They are now also widely used to help with weight loss in people living with obesity [1]. These medicines copy a natural hormone your body releases after you eat. That hormone does two main things. It reduces your appetite, so you feel full sooner and eat less. It also slows how fast your stomach empties, which keeps that full feeling going for longer [2]. The result for many people is steady weight loss and better blood sugar control [3]. If you take one of these medicines and you are planning surgery, it matters to your care team. These medicines are increasingly common, and surgeons now see more and more patients who take them [4]. Research into how they affect surgery is still growing, and some findings do not yet agree with each other [5] [6]. What is known so far is mostly reassuring in plain terms: studies following joint replacement patients have not found a clear increase in short-term problems after surgery [7] [8], and some research links these medicines to a lower chance of wound or infection trouble [9] [10]. Guidelines currently say you do not need to stop your medication before an elective procedure, because stopping can upset your blood sugar and your weight progress [11]. The rest of this page explains what this means for you around the time of your operation. ## How it affects your surgery and anaesthetic The main thing these medicines change around surgery is your stomach. Because they slow how fast your stomach empties, food and fluid can stay there longer than you or your care team would expect. Most studies have found that people taking these medicines have more leftover stomach contents than expected [12]. That matters because during an anaesthetic, stomach contents can come back up and enter your lungs. This is called aspiration. It is a known risk with any anaesthetic, and these medicines can add to it, although the evidence linking them to actual aspiration events remains mixed [12]. Your anaesthetist plans around this. Current Australian guidance is to keep taking the medication and to have clear fluids only for the 24 hours before surgery, with the usual fasting time falling within those 24 hours. Some teams also check the stomach with an ultrasound beforehand. Research has looked at these steps and found they may help reduce leftover stomach contents in some patients [13]. Your team will decide what applies to you. There is also some good news about recovery. Studies of people having hip or knee replacement while taking these medicines have not found a consistent increase in short-term revision rates [8]. Some research links them to a lower chance of postoperative infection, including infection around the new joint [3] [8]. For hand surgery such as carpal tunnel release, one study found a small reduction in wound healing problems and no increase in other early complications [10]. Your care team manages all of this carefully. Surgeons, anaesthetists and diabetes specialists work together to plan the safest approach for you [2]. Researchers are still working out the best way to care for people on these medicines around surgery [14]. For now, the practical message is simple: tell your team you take this medication, follow their fasting instructions exactly, and they will handle the rest. ## What you should do Keep taking your GLP-1 medicine as usual before your operation; do not stop it. For the 24 hours before your surgery, have clear fluids only and no solid food. Clear fluids are drinks you can see through, such as water, clear apple juice, or black tea or coffee without milk. The usual fasting time before an anaesthetic is part of those 24 hours, not added on afterwards: towards the end, your anaesthetist will tell you when to stop the clear fluids as well. This follows the current Australian anaesthetic (ANZCA) guidance. Keep taking your medication as prescribed, and tell everyone involved in your care that you take it. That includes your surgeon, your anaesthetist and your GP. It also includes the doctor who prescribed the medication, whether that is your GP or a specialist. Do not stop taking it on your own. Stopping can affect your blood sugar and your weight progress. Before your procedure, your team will give you clear instructions. Follow the guidance about your medication and about fasting beforehand exactly as written. Fasting means not eating or drinking for a set time before surgery. These steps help keep your stomach empty and lower the risks from the anaesthetic. If you are unsure about anything, ask. Your surgeon, anaesthetist and GP work together to plan the safest approach for you. No question is too small when it comes to your medication and your operation. --- ### Gout in the Hand, Wrist and Elbow URL: https://www.cqupperlimb.com/education/general-health/gout/ Region: general-health · condition Gout in the upper limb — what causes the attacks and lumps (tophi), how flares and high urate are treated, and when surgery is needed. ## What you're feeling Gout often announces itself overnight. A joint (sometimes the base of the thumb, a knuckle, the wrist, or the point of the elbow) becomes intensely painful over just a few hours. It looks hot, red and swollen, and is so tender that even the weight of a bedsheet feels unbearable. This is a flare, and the first one frequently lands in the foot, but the hand and wrist are common sites too. Between flares the joint may feel completely normal, which is why people often dismiss the first attack. Over months and years, though, gout can leave firm lumps under the skin, around the finger joints, the knuckles, or over the elbow. These are called tophi. They can be chalky or white beneath the skin, and as they grow they can make the hand stiff, weaken your grip, and make fine tasks like buttoning a shirt difficult. Some people also notice numbness or tingling in the fingers if a lump presses on a nerve at the wrist. ## What's actually happening Gout is a whole-body problem that shows up in your joints. Your body makes a waste product called uric acid (urate). When there is too much of it in the blood, it can form tiny, sharp crystals that settle inside joints and the soft tissues around them, including in the hand and wrist. Your immune system treats those crystals as invaders and attacks them, and that reaction is the sudden, severe inflammation you feel as a flare. If the high urate level is left unchecked for years, the crystals build up into the firm deposits (tophi). Over time these deposits can wear away bone, damage tendons, and occasionally press on a nerve. The important point is that the flares and the lumps are two faces of the same thing: too much urate in the body. Control the urate, and you control the disease. ## What we can do about it Treatment has two separate halves, and both matter. Settling the attack. A flare is calmed with anti-inflammatory medication, usually an anti-inflammatory tablet (an NSAID), colchicine, or a short course of steroids. These work best when started early, so it is worth having a plan agreed with your doctor before the next one strikes. Lowering the urate for good. This is what actually cures gout over time. A daily tablet, most commonly allopurinol, gradually brings your blood urate down below a target level. Held there long enough, the crystals slowly dissolve, the flares stop, and the tophi shrink. Diet and lifestyle help (less beer and spirits, fewer sugary drinks, staying a healthy weight, good hydration), but for most people the daily tablet does the heavy lifting. Surgery is only occasionally needed, for a large tophus that is breaking through the skin, interfering with a tendon, or pressing on a nerve (for example causing carpal tunnel symptoms). Even then, the medical treatment to lower urate still has to continue afterwards. ## What to expect Gout is one of the few forms of arthritis we can genuinely get on top of. If your urate is kept below target for the long term, flares become rare and then stop, and existing lumps gradually melt away. It is a slow process: months to years, and the urate-lowering tablet is usually for life, because stopping it lets the crystals reform. The cost of that wait is real: the more tophus builds up in the hand, the more it limits what the hand can do, so getting the urate down early protects your grip and your function. People who stick with treatment do very well. ## When to see someone - A first hot, swollen, painful joint: see a doctor promptly. A joint infection can look identical to gout and is an emergency, so the two need to be told apart. - Repeated attacks, or attacks that are becoming more frequent: this is the signal to start urate-lowering treatment. - Lumps appearing around the joints, or a lump that breaks through the skin or leaks chalky material. - Numbness, tingling or weakness in the hand: a deposit may be pressing on a nerve and is worth assessing. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Gout is worth the extra reading because it is one of the few rheumatological conditions with a genuine cure — and one of the most poorly treated, because the cure works on a timescale that feels wrong when you are in pain. ### What gout actually is: urate crystals Monosodium urate crystals under polarised light — the needle-shaped crystals that immune cells engulf, triggering a gout attack. Bobjgalindo, Wikimedia Commons, CC BY-SA 3.0 Uric acid is a normal waste product made when the body breaks down substances called purines (from cells and some foods). When the level of urate in the blood stays high, it comes out of solution and forms tiny, needle-like monosodium urate (MSU) crystals in and around joints. Crystals form more readily where it is cooler, which is a large part of why the big toe, the body's coolest and most peripheral joint, is the classic first target. It is a genuinely destructive condition at that joint, not merely a painful one. Pooling 5,478 patients, acute arthritis of the first metatarsophalangeal joint is highly prevalent in gout and has substantial measured impact on pain and disability, with demonstrable effects on the structure and function of the joint itself [1]. ### The inflammasome: why an attack is so sudden and fierce An attack begins when immune scavenger cells (macrophages) engulf MSU crystals. The crystals trip an internal alarm complex called the NLRP3 inflammasome, which switches on an enzyme (caspase-1) that releases a powerful inflammatory messenger, interleukin-1β (IL-1β). IL-1β floods the joint with inflammation, producing the rapid, intense redness, heat, swelling and pain of an acute attack within hours. Attacks are self-limiting over days as the response burns out. That mechanism explains something clinically important: the attack is the immune reaction to crystals, not the crystals themselves. Settling the attack and removing the crystals are different problems requiring different drugs on different timescales. ### The number that decides everything Long-term treatment has one measurable objective: get serum urate below the concentration at which crystals can form, and keep it there. International practice targets a serum urate below 0.36 mmol/L (6 mg/dL), and below 0.30 mmol/L (5 mg/dL) where tophi are present, because at those levels existing crystals dissolve rather than merely stopping accumulating. Treating to that target, rather than prescribing a fixed dose and hoping, is what the evidence supports. In a randomised controlled trial of 183 people, escalating the allopurinol dose monthly until the target was reached produced a significant reduction in the proportion of people having flares and in mean tophus size over 24 months, and was well tolerated [2]. The same principle at a service level: a UK randomised trial of nurse-led care built around patient education and a treat-to-target urate strategy achieved markedly better urate control than usual care, with fewer flares and greater tophus resolution at two years [3]. Two things follow. A dose of allopurinol that has never been titrated against a blood test is not really treatment, and "my gout is under control" means a number, not an absence of attacks this month. ### Why it gets abandoned in the first months Starting urate-lowering treatment can trigger attacks. As crystals dissolve they shed material that the inflammasome reacts to, so the early months of a cure can be worse than the disease appeared to be. This is the single commonest reason people stop treatment and conclude it does not work, when in fact the flare is evidence that it is working. It is why treatment is started at low dose, escalated gradually, and usually covered with anti-inflammatory prophylaxis for the first months. ### Two things an upper-limb surgeon watches for Gout is not confined to the foot, and in the arm it can mimic surgical pathology. There are reported cases of gouty tenosynovitis at the distal biceps insertion producing partial tendon tearing, presenting as what looks like a straightforward biceps rupture in someone whose gout history turns out to be the explanation [4]. It is rare, but it is the kind of diagnosis that is only made by the person who thought of it. More reassuringly, one common worry is not borne out. Pooling 684,964 people, gout was not associated with an increased risk of fracture, and urate-lowering drugs prescribed early showed neither adverse nor beneficial effect on fracture risk [5]. --- ### How Bone Heals and Remodels URL: https://www.cqupperlimb.com/education/general-health/how-bone-heals-and-remodels/ Region: general-health · general-info Bone feels solid and permanent, but it is living tissue, laced with cells and blood vessels, and it is being taken apart and rebuilt every day of your life. That is exactly why a broken bone can knit back together into something as strong as it was before. Healing follows a… Bone feels solid and permanent, but it is living tissue, laced with cells and blood vessels, and it is being taken apart and rebuilt every day of your life. That is exactly why a broken bone can knit back together into something as strong as it was before. Healing follows a predictable sequence, and it takes longer than most people expect, so knowing the pattern makes the wait far less worrying. This page explains, in plain language, what bone is and how it mends; and then, for the curious, goes a good deal deeper into the biology, including how bone constantly remodels itself and what happens when that machinery is turned against the bone. ## What bone is and what it does Bone does several jobs at once. It is the body's scaffolding: the frame that holds you up and that muscles pull against to move you. It is armour, protecting the brain, heart and lungs. And it is a storehouse for minerals, especially calcium, which the rest of the body draws on constantly. To do all that, bone is a composite material, a bit like reinforced concrete. A flexible protein mesh (mostly collagen) gives it the toughness to bend slightly without snapping, and a hard mineral (a calcium-phosphate crystal) packed into that mesh gives it stiffness and compressive strength. Take the mineral away and bone is rubbery; take the collagen away and it is brittle as chalk. You need both. But bone is not inert. It is full of living cells and threaded with blood vessels, which is why it bleeds when it breaks, why a good blood supply matters so much for healing, and why bone, unlike a scratched table, can repair itself. ## How a broken bone heals When a bone breaks, it heals in overlapping stages that turn a gap into solid bone again. - The clot (first days). The break tears blood vessels in and around the bone, and the blood forms a clot at the fracture. This is not just a plug; it is the scaffold and the signal centre that summons the repair cells. This is also why the area is swollen, bruised and sore early on. - The soft callus (first weeks). Repair cells move in and lay down a soft, rubbery bridge of cartilage and immature tissue across the gap. The bone is joined now, but only loosely: this is why a fresh fracture needs protecting in a cast, splint or with surgery while the bridge is weak. - The hard callus (weeks to a couple of months). The soft bridge is gradually replaced by hard, mineralised bone, forming a bulky cuff (the callus) around the break. By the end of this stage the bone is usually solid enough for ordinary use. - Remodelling (months to years). The lumpy callus is slowly carved back and reshaped along the lines of stress until the bone looks and works much like it did before. In children this reshaping is so good that a slightly crooked break can straighten out over time. Healing is genuinely slow, and that is normal. As a rough guide many adult fractures take around six to twelve weeks to become solid, and longer to regain full strength; the remodelling that perfects the shape can run on for a year or more. The timeline depends on the bone, the person and the injury, so treat these as guides, not promises. ## What helps it heal A few things make a real difference, and most are in your control: - Blood supply and a settled break. Bone heals best when the broken ends have a good blood supply and are held reasonably still, which is the whole point of a cast or an operation. Too much movement, or a poor blood supply, is the commonest reason a break is slow to unite. - Not smoking. Smoking and nicotine narrow blood vessels and meaningfully slow bone healing. Stopping, even around the time of an injury or operation, helps. - Nutrition. Bone is built from protein and mineral, so adequate protein, calcium and vitamin D support healing. Most people don't need megadoses; they need to not be deficient. - Sensible loading. Bone responds to use. Following the weight-bearing and exercise advice you're given, not too much and not too little, guides the healing bone to rebuild in the right places. - Time and review. Most breaks heal on their own timeline. If one that should be improving isn't, that's worth reviewing; some need a helping hand from surgery. ## In more depth Advanced reading: the deeper science (optional) This section steps up to a more detailed, student-level explanation of the biology behind everything above. It isn't needed to understand a fracture or its treatment, but if you're curious about how bone actually works, and how the very same machinery that heals a break can also be turned against the skeleton, read on. ### Bone as living tissue The cast of characters — bone-building osteoblasts, the osteocytes they become once walled into the bone, and the large bone-dissolving osteoclast. OpenStax, Anatomy & Physiology, CC BY 3.0 Bone is built and maintained by three main cell types, and it helps to meet them by name because almost everything that follows is a story about the balance between them: - Osteoblasts are the builders. They lay down new bone: first the soft collagen framework (osteoid), which they then mineralise into hard bone. - Osteoclasts are the demolition crew. They are large, multi-nucleated cells that dissolve bone, etching the mineral with acid and digesting the collagen with enzymes. - Osteocytes are former osteoblasts that became trapped in the bone they built. They sit in tiny chambers connected by a vast network of channels, wired together like a sensor grid throughout the bone. As we'll see, they are the cells that feel mechanical load and direct the other two. The hard matrix these cells live in is type I collagen stiffened by crystals of hydroxyapatite (a calcium-phosphate mineral). Bone comes in two architectures: dense cortical (compact) bone in the shafts of long bones, and spongy trabecular (cancellous) bone (an open lattice) at the ends of bones and inside the spine. ### The healing cascade The healing cascade — a fracture haematoma forms, is bridged by a soft (cartilage) callus, replaced by a hard bony callus, and finally remodelled back towards its original shape. OpenStax, Anatomy & Physiology, CC BY 3.0 The four plain-language stages above map onto a precise biological sequence. The fracture haematoma (clot) releases a flood of inflammatory signals and growth factors that recruit stem cells. Those cells first form a soft (cartilaginous) callus: bone is built on a cartilage template in a process called endochondral ossification, the same process by which much of the skeleton grows in childhood. The cartilage is then invaded by blood vessels and replaced by woven bone, the hard callus, which is finally remodelled into mature, organised lamellar bone. That is secondary (indirect) healing (healing through a callus), and it is what happens when a break has a little movement, as in a cast. There is also primary (direct) healing, which happens only when the bone ends are held rigidly together with no gap and no movement (for example, compressed under a metal plate). Then there is no callus at all: bone simply remodels straight across the join. Neither is "better"; they are the bone's two answers to different mechanical conditions, which is why surgeons choose fixation to suit the fracture. ### Remodelling and the cutting cone Compact bone is built from osteons — concentric rings of bone wrapped around a central blood-vessel canal. Each osteon is the finished work of a cutting cone. OpenStax, Anatomy & Physiology, CC BY 3.0 Even unbroken bone is rebuilt continuously: you replace roughly a tenth of your skeleton every year. This lifelong renewal is remodelling, and it is carried out by teams of cells called Basic Multicellular Units (BMUs). In dense cortical bone you can watch a BMU at work as a microscopic tunnelling machine. At its leading edge, a pack of osteoclasts bores a tunnel straight through the bone, dissolving it as they advance: this resorbing tip is the cutting cone. Following close behind, in the closing cone, osteoblasts line the fresh tunnel and refill it from the walls inward, laying down concentric rings of new bone around a central channel that carries a blood vessel. The finished cylinder, rings of bone around a central canal, is an osteon, the basic structural unit of compact bone. So remodelling is not random: it is a coordinated convoy of demolition followed by reconstruction, threading new, well-aligned bone through the old. This is also why healthy bone needs both cell types working in step. The osteoclasts that lead the cutting cone are the very same cells that, dysregulated, drive the bone-loss diseases described below. ### The coupling switch: RANK, RANKL and OPG How does the builder control the demolition crew? Through a molecular switch that is worth knowing because it is the lever behind both normal remodelling and several diseases (and several drugs). Osteoblast-lineage cells display a signal called RANKL. When RANKL plugs into its receptor, RANK, on the surface of osteoclast precursors, it tells them to mature into active, bone-dissolving osteoclasts. So the builders hold the remote control for the demolition crew. To apply the brake, the same osteoblasts secrete a decoy called OPG (osteoprotegerin), which mops up RANKL before it can reach RANK. The RANKL-to-OPG ratio therefore sets the pace of bone resorption: more RANKL tips the balance toward bone loss, more OPG toward bone preservation. Almost every signal that affects bone (hormones, inflammation, drugs) ultimately pulls on this lever. It is, for instance, exactly where the osteoporosis drug denosumab acts: it is a man-made antibody that works like OPG, soaking up RANKL to switch off osteoclasts. Hold onto this switch; the next two sections are both stories about RANKL being pushed the wrong way. ### Mechanotransduction and Wolff's law Bone famously adapts to the loads placed on it. "Bone is laid down where it is needed and resorbed where it is not" is Wolff's law, and it is why a tennis player's racket arm has denser bone, why astronauts and bed-bound patients lose bone, and why sensible loading helps a fracture rebuild in the right places. The cells that sense the load are the osteocytes buried in the bone. As bone is loaded, fluid is squeezed through the tiny channels around them, and the osteocytes feel that flow, a process called mechanotransduction (turning a mechanical signal into a biological one). Loaded osteocytes dial down a braking molecule called sclerostin, which releases the osteoblasts to build; unloaded bone does the reverse, and is given over to resorption. So "use it or lose it" is not just a slogan; it is osteocytes adjusting the RANKL/OPG balance in response to what you do. ### When remodelling goes wrong: osteolysis and sonic hedgehog Osteolysis simply means bone being dissolved away: osteoclasts running unchecked, usually because something is jamming the RANKL switch in the "on" position. It is what makes a tumour eat into bone, what loosens an implant (next section), and what hollows out bone in some inflammatory diseases. One of the more surprising controllers here is sonic hedgehog (Shh), a signalling molecule best known for sculpting the body plan of the embryo (it helps lay out the limbs and digits). The same pathway is reused in the adult skeleton, and it cuts both ways. In a healing fracture, Shh signalling actually helps; it supports osteoblasts and bone formation. But in osteolysis it does the opposite: Shh, acting through its downstream messenger Gli, prompts the supporting stromal cells to make more RANKL, and more RANKL means more osteoclasts and more bone dissolved. Tellingly, Shh on its own doesn't resorb bone; it works by amplifying the RANKL pathway, which is exactly why it shows up as an aggravator in conditions like cancer-associated bone destruction. It is a neat illustration of a theme running through this whole page: most bone disease is the normal remodelling machinery (the cutting cone, the RANKL switch) pushed too far in one direction. ### Polyethylene wear and implant loosening This is where the biology becomes very practical, because it explains how joint replacements eventually fail. A hip or knee replacement has a smooth bearing surface, classically a hard ball or metal component moving against a polyethylene (medical-grade plastic) liner. Over years of use, friction sheds astronomically small wear particles of polyethylene, far too small to see and shed in their billions. The body treats these particles as intruders. Scavenger immune cells (macrophages) around the implant try to engulf them, but the plastic is indigestible, so the frustrated macrophages instead pour out inflammatory signals. Those signals predictably drive RANKL up, recruiting osteoclasts that resorb the bone around the implant. This particle-induced (or wear) osteolysis quietly eats away the bony anchorage, and eventually the implant loosens, a leading cause of joint replacements wearing out and needing revision, often a decade or more after surgery. It is the same final common pathway as everything above: an outside trigger, funnelled through RANKL, ending in osteoclasts dissolving bone. Understanding it is exactly why so much engineering goes into better bearing materials (such as cross-linked polyethylene) that shed fewer, less troublesome particles. ### What helps and harms healing Finally, the practical factors, now with the biology to explain them: - Blood supply delivers the cells, oxygen and signals healing needs; a stripped or crushed soft-tissue envelope, or a break in a poorly-supplied bone, heals slowly. This is the single biggest factor. - Stability lets the callus mature; excessive movement keeps breaking the fragile early bridge, and is a common road to a non-union (a break that fails to heal). - Smoking and nicotine constrict blood vessels and impair the repair cells: a well-established brake on bone healing. - Diabetes and some medications (long courses of steroids, and some anti-inflammatories around the time of a fresh fracture) can slow healing. - Nutrition (adequate protein, calcium and vitamin D) supplies the raw materials; deficiency, not abundance, is the problem to avoid. - Age slows the cellular machinery, but bone retains a remarkable capacity to heal throughout life. ## See also - Bone health and osteoporosis — when the remodelling balance tips toward bone loss across the whole skeleton - Smoking and musculoskeletal healing — why smoking slows the healing described here - Vitamin D and musculoskeletal health — the mineral side of building bone --- ### How Cartilage Works (and Why It Struggles to Heal) URL: https://www.cqupperlimb.com/education/general-health/how-cartilage-works/ Region: general-health · general-info Cartilage is the smooth, glistening surface that caps the ends of the bones inside a joint. It is one of the most remarkable materials in the body: slipperier than ice, able to cushion a lifetime of loading, and yet unlike bone and tendon it has almost no ability to repair… Cartilage is the smooth, glistening surface that caps the ends of the bones inside a joint. It is one of the most remarkable materials in the body: slipperier than ice, able to cushion a lifetime of loading, and yet unlike bone and tendon it has almost no ability to repair itself. That single fact explains why cartilage damage and osteoarthritis are such stubborn problems, and why protecting your cartilage matters so much. This page explains, in plain language, what cartilage is and why it heals so poorly, then for the curious goes deeper into the beautiful engineering of this tissue and the active biology behind what we casually call "wear and tear". ## What cartilage is and what it does The cartilage we mean here, articular cartilage, is the firm, smooth, white coating just a few millimetres thick on the ends of bones where they meet in a joint. It does two things superbly: - It is a near-frictionless gliding surface, so the bones of a joint slide over each other with almost no resistance. - It is a cushion, spreading load across the joint and protecting the bone underneath from impact. Cartilage is living tissue, but an unusual kind: it has no blood vessels and no nerves. The lack of nerves is why a worn cartilage surface itself doesn't hurt (the pain of arthritis comes from other structures). The lack of a blood supply is the key to its great weakness: it cannot heal the way skin or bone can. ## Why cartilage struggles to heal Almost everywhere else in the body, healing begins with bleeding: a clot forms, inflammatory cells arrive, and growth factors switch on repair. Cartilage has no blood supply, so an injury to it gets none of that. On top of that, its few resident cells are trapped in the surrounding material and cannot crawl to a wound to patch it. The result is that a scrape or crack confined to the cartilage tends to simply stay there. Damage that goes deeper (through the cartilage and into the bone beneath) can fill in, but with a scar-like "fibrocartilage" that is weaker and less durable than the original. So cartilage damage tends to be permanent and slowly progressive, which is exactly why prevention and protection count for so much. ## What helps protect your cartilage - Keep moving. Cartilage is fed by joint fluid that is pumped in and out as you move; regular, comfortable activity nourishes it, while long periods of inactivity starve it. - Keep a healthy weight. Every kilogram is extra load through the joint surfaces. - Build the muscles around the joint. Strong muscles share the load and absorb shock, protecting the cartilage. - Look after injuries. A wobbly or unstable joint wears its cartilage faster; treating instability protects the surface. ## In more depth Advanced reading: the deeper science (optional) This section steps up to a more detailed, student-level explanation of the biology. It isn't needed to understand a cartilage problem or its treatment, but if you're curious about how cartilage can be slipperier than ice, and why "wear and tear" is really an active disease, read on. ### Cartilage as living tissue Articular cartilage caps the ends of the bones inside a synovial joint, bathed in the synovial fluid that both lubricates and feeds it. OpenStax, Anatomy & Physiology, CC BY 3.0 Articular cartilage is a type called hyaline cartilage. It is built from a sparse scattering of cells (chondrocytes) surrounded by an enormous volume of matrix that those cells manufacture and maintain. The matrix is the secret to everything cartilage does. It is a meshwork of type II collagen fibres, filled with large, bottle-brush-shaped, intensely water-attracting molecules called proteoglycans (chiefly aggrecan), and roughly 70–80% water. The collagen net resists being pulled apart; the aggrecan sucks in water and generates a swelling pressure that resists being squashed. In effect, cartilage is a water-filled sponge held under tension inside a fibre net. It is also uniquely isolated: no blood vessels, no nerves, no lymphatics. The chondrocytes sit in tiny chambers (lacunae), maintain their patch of matrix slowly, and cannot move. ### The near-frictionless bearing: how cartilage carries load Cartilage is layered — chondrocytes lie flat near the gliding surface (superficial zone) and become rounded then columnar with depth, reflecting the changing collagen architecture that anchors the surface to the bone below. Bautista et al., Wikimedia Commons, CC0 Cartilage is one of the slipperiest materials known: its coefficient of friction is around 0.001, lower than ice sliding on ice. It achieves this with two mechanisms working together. First, it is biphasic, a solid matrix soaked in fluid. When a joint is loaded, the trapped water cannot escape instantly, so it pressurises and carries the load, initially more than 90% of it. The fluid pressure, not the solid framework, bears the force, rather like standing on a water bed. As the contact point moves (because you keep moving), fluid weeps out ahead and is drawn back in behind. This interstitial fluid pressurisation is the main reason cartilage can bear huge loads with so little friction or wear. Second, the surface carries a slippery boundary layer of molecules, including lubricin (also called PRG4) and hyaluronic acid from the joint fluid, forming a hydrated film that keeps the two surfaces from ever touching directly. The matrix is also arranged in zones: collagen fibres run parallel to the surface in the top (superficial) zone, holding the lubricating layer and resisting shear; they become more random in the middle zone; and they anchor vertically in the deep zone, into a calcified cartilage layer (separated by a line called the tidemark) that bonds the soft cartilage firmly to the hard bone, the same engineering challenge of joining soft to hard that the tendon enthesis solves. ### Why cartilage barely heals Put the pieces together and the poor healing makes sense: - No blood supply means no clot, no inflammatory cells, and none of the growth factors that drive repair elsewhere. - The cells can't help much: chondrocytes are few, walled into the matrix, and don't migrate or multiply enough to fill a gap. - Depth decides the response. A partial-thickness defect confined to the cartilage never reaches blood or marrow, so it gets essentially no repair response at all. A full-thickness defect that breaks through into the subchondral bone lets marrow cells and blood flood in, and these fill the gap, but with fibrocartilage (type I collagen, low in proteoglycan), which is mechanically inferior and wears out faster than true hyaline cartilage. That is the central frustration of cartilage surgery: we can fill a hole, but not with the real thing. ### How cartilage is fed With no blood vessels of its own, cartilage is nourished by diffusion from the synovial (joint) fluid, and that diffusion is driven by movement and loading. Each time the joint is loaded and unloaded, fluid and nutrients are pumped in and out of the cartilage (much like the way finger movement feeds a healing flexor tendon). So cartilage genuinely needs cyclic loading to stay healthy: prolonged immobilisation or unloading degrades it, while moderate, regular activity maintains it. The physiotherapist's line that "motion is lotion" has a real biological basis here. ### Osteoarthritis: when cartilage breaks down Osteoarthritis (OA) is usually called "wear and tear", but that understates it: it is an active biological process, not just mechanical erosion. Set off by mechanical overload, injury, ageing or joint instability, the chondrocytes switch into a destructive mode. They ramp up matrix-digesting enzymes (MMPs such as MMP-13, and aggrecanases such as ADAMTS-4 and -5) that chew through the type II collagen and aggrecan faster than they can be replaced. The matrix loses its water-holding proteoglycan, softens, and frays. The chondrocytes also change character (a shift called hypertrophy), the cartilage begins to calcify and admit blood vessels, the subchondral bone thickens and throws up bony spurs (osteophytes), and the joint lining (synovium) becomes mildly inflamed, releasing signals such as IL-1 and TNF that feed the cycle. Because cartilage cannot regenerate, this is largely a one-way street, which is why OA care centres on offloading, strengthening and weight management, and, when the cartilage is finally gone, joint replacement. ### Repairing cartilage: why it's so hard A range of operations try to restore a damaged surface, and the reason none is a perfect fix traces straight back to the biology above: - Microfracture drills tiny holes into the subchondral bone to let marrow cells in. They form fibrocartilage, which is useful in the short term but tends to deteriorate after a couple of years. - Osteochondral transfer (OATS / mosaicplasty) moves plugs of cartilage-and-bone from a lightly-loaded part of the joint. This is real hyaline cartilage, but supply is limited. - Cell therapy (ACI / MACI) grows the patient's own chondrocytes in a laboratory and re-implants them; this approach is promising but technically demanding and still imperfect. None reliably recreates the original layered hyaline cartilage with its precise zonal architecture and lubrication. When the cartilage of a whole joint is worn out, the definitive answer remains joint replacement. ### What helps and harms cartilage - Movement and moderate loading nourish and maintain cartilage; prolonged immobilisation harms it. - Excess weight and joint instability accelerate breakdown; strong surrounding muscles protect it. - Injuries, especially those that destabilise a joint or damage the surface, raise the long-term risk of osteoarthritis. - And the hard truth that runs through this whole page: once significantly damaged, cartilage does not grow back. For almost no other tissue does prevention matter more. ## See also - Osteoarthritis — what happens when cartilage breaks down across a joint - How bone heals and remodels — the subchondral bone that lies beneath cartilage - Staying active for joint health — why movement protects your joints - Weight, obesity and joint health — how load affects cartilage --- ### How Ligaments Work and Heal URL: https://www.cqupperlimb.com/education/general-health/how-ligaments-work-and-heal/ Region: general-health · general-info Ligaments are the joint's straps: tough bands that tie bone to bone, hold joints in line, and quietly tell your brain where the joint is in space. When a ligament is overstretched or torn (a "sprain"), the joint can feel loose or give way. One of the most useful things to… Ligaments are the joint's straps: tough bands that tie bone to bone, hold joints in line, and quietly tell your brain where the joint is in space. When a ligament is overstretched or torn (a "sprain"), the joint can feel loose or give way. One of the most useful things to understand about ligaments is that where a ligament lives decides whether it can heal: some, like the collateral ligaments at the side of the thumb or elbow, mend on their own; others, like the small but vital ligaments deep inside the wrist, famously do not. This page explains, in plain language, what ligaments do and how they heal, then goes deeper into why that difference exists for the curious reader. ## What a ligament is and what it does A ligament is a short, strong band of mostly collagen running from one bone to another across a joint. It does two jobs: it is a check-rein that stops the joint moving too far or in the wrong direction, and it is a sensor, packed with nerve endings that feed back the joint's position and movement (a sense called proprioception). That sensing is why a joint with a damaged ligament can feel unstable or untrustworthy even when it looks normal. ## How ligaments heal (and why some don't) A sprained ligament heals much like other tissues: bleeding and inflammation, then new collagen laid across the gap, then slow remodelling and strengthening over months. Many ligaments heal well this way, especially with a period of protection (a splint) and graded return to load. But not all. A ligament's ability to heal depends heavily on where it sits: - Ligaments outside the joint capsule (like the collateral ligaments of the thumb or elbow) have a good blood supply and can form a healing bridge; most recover without surgery. - Ligaments inside the joint (like the scapholunate ligament deep in the wrist) sit bathed in joint fluid, which prevents a healing clot from forming across the torn ends. These tend not to heal, and when stability matters they are usually repaired early or reconstructed surgically rather than left alone. ## What helps - Protected loading. A splint that allows controlled movement guides healing collagen to align, while preventing the over-stretch that would re-injure it. - Rehabilitation for the sensors, not just the strap. Because ligaments provide position sense, balance and proprioception exercises are a key part of recovery and of preventing re-injury. - Strengthening the surrounding muscles, which share the job of stabilising the joint. - Time. Ligament remodelling runs for many months; a "healed" sprain keeps gaining strength well after it stops hurting. ## In more depth Advanced reading: the deeper science (optional) This section steps up to a more detailed, student-level explanation. It isn't needed to understand a sprain. But if you're curious about why a ligament deep in the wrist won't heal when a thumb ligament a few centimetres away will, read on. ### Ligament as living tissue Like tendon, a ligament is built mostly of type I collagen in aligned bundles, giving it great tensile strength, with resident cells (fibroblasts) maintaining the matrix and a relatively sparse blood supply. Compared with tendon, ligament collagen is a little more interwoven (bundles run in slightly varied directions), suiting it to resist loads from several directions as a joint moves. Ligaments are also rich in specialised nerve endings that sense stretch and position; they are sensory organs as much as mechanical straps. ### Why location decides healing: the wrist versus the thumb The principle is inside the joint versus outside it, and the upper limb shows both sides clearly. The scapholunate ligament sits inside the wrist joint, between two of the small carpal bones, bathed in synovial fluid. When it tears completely, that fluid washes away any clot, so no bridge ever forms for repair cells to cross; its blood supply is poor and the torn ends pull apart. The cells are willing, but with no scaffold spanning the gap, the ends simply never reconnect. So a complete scapholunate tear generally does not heal on its own, and, if missed, the wrist bones gradually fall out of line and wear out (a pattern surgeons call SLAC). That is why these injuries are repaired early or reconstructed when stability matters. Contrast that with the collateral ligaments at the side of the thumb or elbow, which lie outside the main joint cavity. They have a better blood supply, a clot can bridge the torn ends, and most partial tears heal well with a period of splinting: the classic example is a sprained thumb ("skier's thumb"). There is a neat exception that proves the rule: in a complete thumb-collateral tear, the torn end can flip back out of reach of its bony attachment (a "Stener lesion"), and then (just like the wrist ligament) it cannot heal because the two ends are no longer in contact, so it needs surgical repair. ### Ligament reconstruction and "ligamentisation" When a key ligament won't heal (a chronic scapholunate tear, or a high-demand elbow or thumb ligament), surgeons may reconstruct it from a graft (a piece of the patient's own tendon, or a donor tendon) threaded across the joint where the ligament used to be. At first the graft is essentially non-living collagen. Over the following year it undergoes ligamentisation: the body's cells and blood vessels invade it, the dead collagen is gradually replaced, and it remodels into something ligament-like. This takes many months, the graft is temporarily weaker during the early remodelling phase (one reason return to heavy use is staged carefully), and the result, while good, is never a perfect copy of the original, including some loss of the natural position-sensing. ### Proprioception and why a stretched joint feels unstable Because ligaments carry position-sensing nerve endings, a damaged ligament doesn't just weaken the mechanical check-rein; it also degrades the joint's sense of where it is. This is why a joint after a sprain can feel like it might "give way" even when it is mechanically reasonable, and why rehabilitation deliberately retrains balance and proprioception, not just strength. Restoring that sense is a real part of preventing the next injury. ### What helps and harms ligament healing - Controlled load and proprioceptive training are the key stimuli; immobilising a joint completely weakens both the ligament and its sensing. - Blood supply and location set the ceiling: extra-articular ligaments heal, intra-articular ones often don't. - Smoking, diabetes and age impair healing, as they do across all tissues. - Instability left untreated lets the joint repeatedly shift out of line, which can wear out the cartilage over time; this is why some ligament injuries are repaired or reconstructed even when the ligament itself isn't especially painful. ## See also - How tendons work and heal — ligament's close cousin (bone-to-bone vs muscle-to-bone) - How cartilage works — what an unstable joint can wear out - How bone heals and remodels — the bone these straps anchor into --- ### How Muscles Work and Heal URL: https://www.cqupperlimb.com/education/general-health/how-muscles-work-and-heal/ Region: general-health · general-info Muscles are the body's engines: they turn the brain's instructions into movement and force, and they make up much of your body weight. Unlike cartilage, muscle has a genuine ability to repair and even rebuild itself, thanks to a reserve of dedicated stem cells. But that repair… Muscles are the body's engines: they turn the brain's instructions into movement and force, and they make up much of your body weight. Unlike cartilage, muscle has a genuine ability to repair and even rebuild itself, thanks to a reserve of dedicated stem cells. But that repair has limits: a small strain heals well, while a large tear or a long-neglected injury can heal with scar and never quite recover. This page explains, in plain language, what muscle is and how it mends; then, for the curious, it goes deeper into how a muscle actually contracts and why some injuries leave lasting weakness. ## What muscle is and what it does A muscle is a bundle of long, thread-like cells (muscle fibres) packed together like the strands of a rope and anchored to bone by tendons. When the brain sends a signal down a nerve, the muscle fibres shorten, pulling on the tendon and moving the joint. That is the whole job: convert an electrical signal and chemical energy into pulling force. Muscle is richly supplied with blood, which is why it bleeds and bruises when torn, but also why it has a far better capacity to heal than poorly-supplied tissues like cartilage. ## How muscle heals After a strain or tear, muscle heals in overlapping stages: - Bleeding and inflammation (first days). The injury bleeds and swells; clean-up cells move in. This is the painful, bruised phase. - Regeneration (first weeks). Reserve stem cells wake up and build new muscle fibre to bridge the gap (genuine new muscle, not just scar). - Remodelling (weeks to months). The new fibre matures and re-aligns with use, and strength gradually returns. The catch is that regeneration and scarring compete. A small, clean injury regenerates well. A large tear lays down fibrous scar (and sometimes fat) faster than new muscle can form, and scar is weaker and less elastic than muscle. That is why big tears, and tears left too long, can leave permanent weakness. ## What helps muscle recover - Early, graded movement. Gentle movement and then progressive loading guide the new muscle to rebuild and align; prolonged complete rest causes wasting and stiffness. - Not overdoing it early. Loading a fresh tear too hard re-injures it and feeds scarring. - Good general health. Adequate protein, not smoking, and well-controlled diabetes all support repair. - Timely treatment of big tears. Some complete tears (for example certain tendon-muscle ruptures) do best repaired promptly, before the muscle retracts and wastes. ## In more depth Advanced reading: the deeper science (optional) This section steps up to a more detailed, student-level explanation. It isn't needed to understand a muscle injury, but if you're curious about how a muscle actually generates force and why some injuries don't fully recover, read on. ### Muscle as living tissue A muscle fibre is packed with myofibrils, each a chain of sarcomeres — the contractile units where actin and myosin filaments slide past each other to generate force. OpenStax, Anatomy & Physiology, CC BY 4.0 A whole muscle is built as a hierarchy, like a cable of cables: the muscle contains bundles (fascicles) of long muscle fibres, each fibre is a single large cell packed with thread-like myofibrils, and each myofibril is a chain of tiny contractile units called sarcomeres. The sarcomere is where force is made. It is a precise, repeating arrangement of two interleaved filaments: thick filaments of a protein called myosin and thin filaments of actin. Each fibre belongs to a motor unit: one nerve cell and all the muscle fibres it controls. Fine movements (like the hand) use small motor units; powerful movements use large ones. Fibres also come in types: slow-twitch (fatigue-resistant, for endurance and posture) and fast-twitch (powerful but quick to tire). ### How a muscle contracts Contraction is the sliding-filament mechanism. When a nerve signal arrives at the neuromuscular junction (the synapse where nerve meets muscle; see how nerves work), it releases a chemical that makes the muscle fibre fire its own electrical impulse. That impulse triggers a flood of calcium inside the fibre, which uncovers binding sites on the actin filaments. The myosin heads then grab the actin and ratchet it inwards (like a tug-of-war team pulling a rope hand over hand), so the thick and thin filaments slide past each other and the sarcomere shortens. Multiply that across billions of sarcomeres and the whole muscle contracts. It all runs on ATP, the cell's energy currency; when ATP runs low the muscle fatigues. ### How muscle heals: satellite cells versus scar Muscle's repair secret is the satellite cell, a reserve stem cell tucked against each muscle fibre. After injury, satellite cells activate, multiply, and fuse to form new muscle fibre. Healing runs in three phases: destruction (bleeding and inflammation), regeneration (satellite cells rebuild fibre), and remodelling (the new fibre matures with loading). But regeneration is in a tug-of-war with fibrosis. Inflammatory and signalling molecules, especially one called TGF-β1, drive fibroblasts to lay down collagen scar. In a small injury, regeneration wins. In a large or repeatedly-injured one, scar (and sometimes fat) wins, producing a patch that is mechanically inferior to true muscle. This is why severe muscle injuries recover incompletely. ### Fatty infiltration and the rotator cuff A clinically important version of this plays out in the rotator cuff of the shoulder. When a cuff tendon tears and is left, the attached muscle slowly retracts, wastes, and is replaced by fat (fatty infiltration). That fatty, atrophied change is largely irreversible even if the tendon is later repaired, and a muscle that has degenerated will never fully regain its strength. It is one of the main reasons surgeons care about the timing of certain tendon repairs: fixing it before the muscle degenerates gives a far better result. ### Use it or lose it: atrophy and adaptation Muscle is constantly tuned to demand. Load it progressively and it hypertrophies: the fibres enlarge and strengthen (with satellite cells donating nuclei to support the bigger fibre). Unload it (bed rest, a cast, or a cut nerve) and it atrophies rapidly, losing size and strength within weeks. Muscle cut off from its nerve (denervation) wastes fastest of all and, if the nerve doesn't recover in time, the muscle is eventually replaced by fat and fibrous tissue. This is why rehabilitation and keeping muscles active during recovery matter so much. ### What helps and harms muscle healing - Graded loading is the key stimulus for regeneration and re-alignment; too much too soon re-tears and scars. - Blood supply is good in muscle, which is why it heals better than cartilage or the inner parts of tendons. - Smoking, diabetes, ageing, and corticosteroids impair repair and accelerate wasting. - Time and the size of the injury decide the ceiling: small strains recover fully; large tears and degenerated muscle do not. ## See also - How nerves work and heal — the nerve and motor end plate that drive muscle - How tendons work and heal — how muscle's pull reaches the bone - Smoking and musculoskeletal healing — why smoking slows muscle repair --- ### How Nerves Work and Heal URL: https://www.cqupperlimb.com/education/general-health/how-nerves-work-and-heal/ Region: general-health · general-info How nerves carry signals, sense the world, and heal after injury — in plain English, with an in-depth section. Nerves are the body's wiring. They carry tiny electrical signals between your brain and the rest of you, telling muscles to move and carrying back what you feel: touch, temperature, position and pain. When a nerve is irritated, squashed or cut, those signals get disrupted, and you notice it as pins and needles, numbness, weakness or pain. The good news is that nerves can recover. They heal slowly and in a fairly predictable way, and understanding that pattern makes the wait far less worrying. This page explains, in plain language, what nerves do and how they mend; and for the curious, the final section goes a step deeper into the biology. ## What a nerve is and what it does Think of a nerve as a bundle of insulated cables. Each "cable" is a single nerve fibre, and a whole nerve (like the median nerve at your wrist) contains thousands of them packed together, wrapped in protective sheaths a bit like the layers of a cable bundle. The signals travel in two directions, so nerves do three main jobs: - Motor: signals travel out from your brain and spinal cord to your muscles, telling them when and how hard to contract. This is how you grip, pinch and move. - Sensory: signals travel back in from your skin, joints and tendons, carrying touch, vibration, temperature, pain and your sense of where your limb is in space. - Autonomic: automatic background signals you never think about, controlling things like sweating and the width of small blood vessels (which is why an injured patch of skin can feel dry or change temperature). Each fibre has a living core (the axon) that carries the signal, and many fibres are wrapped in a fatty insulation layer called myelin. Just like the plastic coating on an electrical wire, this insulation stops the signal leaking away and lets it travel much faster. ## What happens when a nerve is injured Nerves get into trouble in two broad ways, and the symptoms tell you which. A squashed or compressed nerve. When a nerve is pressed on (for example the median nerve in carpal tunnel syndrome, or the funny-bone nerve at the elbow) the insulation and blood supply to that segment suffer first. The signals slow down or get blocked as they pass the squeezed spot. You feel this as pins and needles, numbness and clumsiness, often worse at night or in certain positions, and the muscles supplied by that nerve may weaken over time. Because the cable itself usually stays intact, relieving the pressure often allows a good recovery. A cut or torn nerve. A laceration, a deep cut, or a severe stretch can divide the fibres themselves. Now the connection is physically broken: the part of the nerve beyond the injury is cut off from the brain and spinal cord, so you lose feeling and movement in everything that nerve supplied. A cleanly divided nerve usually needs to be surgically repaired, stitched together so the fibres have a path to grow back along. The reason symptoms appear at all is simple: a signal that cannot get through is a signal that does not arrive. Block the motor fibres and the muscle weakens; block the sensory fibres and the skin goes numb or tingles; irritate the fibres and you get pain. ## How nerves heal Nerve healing is genuinely slow, and it helps to know that in advance so the pace doesn't feel like failure. When fibres have been damaged, they regrow from the point of injury outwards towards the skin and muscle, at roughly one millimetre a day, about an inch a month. That rule of thumb explains a lot: - The further the target, the longer the wait. A nerve injured high up (say near the elbow) has to regrow a long way down to reach the fingertips, which can take many months. A small cut near the fingertip recovers far sooner. - Sensation usually returns before fine strength. As fibres reach the skin you may first notice a vague awareness, then tingling (often a buzzing or electric feeling when the area is tapped, a good sign that fibres are advancing), then crude touch, and finally finer discrimination. Power and fine coordination tend to come last. - Early, clean repair matters. A divided nerve does best when it is repaired promptly and accurately, because the body's support cells that guide regrowth work best in the months right after injury and lose some of their effect over time. What helps recovery: keeping the joints supple and the muscles healthy with the hand-therapy exercises you're given, protecting numb skin from burns and cuts (it won't warn you of harm), not smoking, and being patient. Re-training your brain to interpret the returning signals, through guided sensory exercises, is also part of getting a good result. If a nerve that should be improving on a timeline isn't, that's worth reviewing, as some injuries need surgery to give recovery the best chance. ## In more depth Advanced reading: the deeper science (optional) This section steps up to a more detailed, student-level explanation of the biology behind everything above. It isn't needed to understand your condition, but if you're curious about how the wiring actually works, read on. ### The nerve cell and its membrane The cell membrane is a phospholipid bilayer — a double sheet of fat molecules (water-loving heads out, oily tails in), studded with protein channels and pumps. Wikimedia Commons (LadyofHats), public domain Like the rest of your body, a nerve is built from cells, specifically neurons. A neuron has a cell body (which holds the nucleus, the cell's control centre), short receiving branches called dendrites, and one long axon that carries the signal away, sometimes the better part of a metre. Every cell, the neuron included, is wrapped in a cell membrane, and its makeup matters for what follows. The membrane is a phospholipid bilayer, a double sheet of fatty molecules. Each phospholipid has a water-loving 'head' and two water-repelling fatty 'tails'; they line up tail-to-tail into two layers, with the heads facing the watery fluid inside and outside the cell and the oily tails tucked in the middle. This thin, fatty film is the barrier that separates inside from outside, and it can hold an electrical charge across itself. The 'channels' and 'pumps' described in the next section are simply protein gates sitting in this fatty membrane. ### The wiring: axons, myelin and nodes of Ranvier A myelinated nerve fibre: Schwann cells wrap the axon in myelin, with bare gaps (nodes of Ranvier) where the signal jumps from node to node. OpenStax, Anatomy & Physiology, CC BY 4.0 A single nerve fibre is built around an axon, a long thread-like extension of a nerve cell that carries the electrical signal. Many axons are wrapped in myelin, a fatty insulating sheath, and it is worth knowing what myelin actually is. A support cell (a Schwann cell in the peripheral nerves of your arm) wraps its own cell membrane around the axon, round and round, again and again, like rolling a sheet of cling film around a pencil dozens of times. Because that membrane is a phospholipid bilayer (essentially fat), every wrap lays down another layer of fat, and the many stacked layers build into a thick, fatty sleeve. That sleeve of wrapped-up membrane is the insulation: myelin is mostly fat precisely because it is layer upon layer of cell membrane. The more turns the Schwann cell makes, the better insulated, and the faster, the fibre. The myelin sheath is not continuous, however. It is laid down in segments, with small bare gaps between them called the nodes of Ranvier. The electrical signal cannot leak out through the insulated stretches, so it effectively jumps from one node to the next. This is called saltatory conduction (from the Latin saltare, to leap), and it is why myelinated fibres are so fast: jumping node to node can carry a signal at speeds well over 100 metres per second, compared with under 10 metres per second in a bare, unmyelinated fibre. This is also why diseases or injuries that strip myelin slow conduction so dramatically. ### How the signal travels The action potential: sodium rushing in drives the voltage up (depolarisation), then potassium leaving brings it back down (repolarisation). OpenStax, Anatomy & Physiology, CC BY 4.0 At rest, the inside of an axon is slightly negatively charged compared with the outside: the resting membrane potential, around −70 millivolts. This charge is maintained by keeping sodium ions mostly outside the cell and potassium ions mostly inside. When the nerve fires, the sequence is precise: - Depolarisation. Voltage-gated sodium channels snap open and sodium ions rush in. The inside swings rapidly positive, peaking around +30 millivolts. This is the action potential. - Repolarisation. The sodium channels close and voltage-gated potassium channels open, letting potassium flow out. The inside returns towards its negative resting value. - The refractory (latent) period. For a brief moment afterwards the patch of membrane cannot fire again, no matter how strong the stimulus, while the channels reset. That refractory period does something elegant: because the stretch of membrane just behind the advancing signal is temporarily unable to re-fire, the action potential can only travel forwards. This is why nerve signals run in one direction along a fibre rather than bouncing back and forth. ### Crossing the gap: synapses and the motor end plate A nerve fibre does not physically touch the muscle it controls. Where a motor nerve meets a muscle there is a specialised junction, the neuromuscular junction, with a tiny gap (the synaptic cleft) between the nerve ending and a thickened, folded region of the muscle membrane called the motor end plate. The electrical signal cannot cross that gap directly, so it is converted into a chemical one. When the action potential reaches the nerve ending, it triggers the release of a neurotransmitter called acetylcholine into the gap. Acetylcholine drifts across and binds to receptors on the motor end plate, opening channels that let the muscle membrane depolarise. If that depolarisation reaches threshold, it launches an action potential through the muscle and the fibre contracts. An enzyme (acetylcholinesterase) then quickly breaks the acetylcholine down, so each nerve impulse produces one crisp twitch rather than a lingering one. This chemical relay is the target of some anaesthetic drugs and of conditions such as myasthenia gravis. ### Sensing the world: sensory receptors The sensory side works in reverse: specialised endings convert a physical stimulus into nerve signals. Different receptors are tuned to different things: - Pacinian corpuscles sit deep in the skin and respond to deep pressure and high-frequency vibration. They adapt quickly, firing at the moment something changes rather than continuously. - Meissner's corpuscles lie just under the surface of fingertip and palm skin and detect light touch and low-frequency flutter, central to the fine, discriminating touch you use to feel textures and handle small objects. - Free nerve endings are bare, unencapsulated endings that sense pain, temperature and light touch. They are the most numerous endings in the skin. - Muscle spindles sit inside the muscles themselves and detect stretch and length, feeding back information about position and movement (proprioception), how the brain knows where your hand is without looking. The different qualities you can feel (a pinprick, warmth, a buzzing phone, the position of your wrist) are largely a matter of which of these receptors are firing and how fast. ### Grades of nerve injury Surgeons grade nerve injury by how deep the damage goes, because that determines how, and whether, it will recover. Two classifications are used together. The older, simpler Seddon system has three categories: - Neurapraxia: the mildest. The fibres are bruised or the insulation locally disrupted, but the axons stay intact. Conduction is blocked at that spot, like a kinked hose, but the structure is sound. Recovery is usually full and relatively quick once the cause is relieved. - Axonotmesis: the axons themselves are torn, but the surrounding connective-tissue tubes survive. The fibres beyond the injury die back and must regrow, so recovery is slow but the preserved tubes give the new fibres a path to follow, and the outlook is often good. - Neurotmesis: the most severe. The nerve, including its supporting framework, is completely divided. It will not recover on its own; surgical repair is needed, and even then recovery is incomplete. The more detailed Sunderland system splits this into five grades, mapping onto Seddon as follows: - Grade 1 = neurapraxia (conduction block only). - Grade 2 = axonotmesis with the innermost tube (endoneurium) intact, offering the best regrowth prospects. - Grade 3 = the inner tube is also disrupted, so regrowing fibres can be misdirected; recovery is partial. - Grade 4 = only the outer sheath (epineurium) remains intact; a scar block usually prevents useful recovery without surgery. - Grade 5 = complete division of the whole nerve, equivalent to Seddon's neurotmesis, requiring repair. In short: the more layers that are torn, the slower and less complete the natural recovery, and the more likely surgery is needed. ### Wallerian degeneration and regrowth When an axon is cut or torn, the part of it beyond the injury is now disconnected from the cell that keeps it alive. Over the following days it breaks down in a tidy, programmed process called Wallerian degeneration: the stranded axon and its myelin are dismantled and cleared away by Schwann cells and recruited immune cells (macrophages). This is not just demolition; it is preparation. The Schwann cells that lined the old fibre survive, multiply, and line up in hollow columns called the bands of Büngner, following the original route of the nerve. These columns act as living scaffolding tubes: they release growth factors and physically guide regenerating fibres back towards their targets. From the injury site, the surviving end of each axon sends out a growth cone that creeps down its Schwann-cell tube at about one millimetre a day, eventually reaching the skin or muscle and reconnecting (reinnervation). This is why a clean repair, done early and accurately, matters so much: the cut tubes need to be lined up so fibres re-enter the correct channels, and the Schwann cells are most supportive in the months soon after injury; they have, in effect, a "best before" date. Line the ends up well and reach them in time, and far more fibres find their way home. ## See also - Nerve tests and conduction studies — how we measure whether a nerve is conducting normally - Carpal tunnel and nerve compression — a common compressed-nerve problem at the wrist - Tendon and nerve repair — what surgical repair of a divided nerve or tendon involves --- ### How Pain Works URL: https://www.cqupperlimb.com/education/general-health/how-pain-works/ Region: general-health · general-info Pain is the body's alarm system. It protects you by making you stop, withdraw and rest while something heals, and in the short term it is one of the most useful things the nervous system does. But pain is more complicated than a simple "damage meter." Understanding it genuinely… Pain is the body's alarm system. It protects you by making you stop, withdraw and rest while something heals, and in the short term it is one of the most useful things the nervous system does. But pain is more complicated than a simple "damage meter." Understanding it genuinely helps, especially when pain lingers: the alarm system itself can become oversensitive, so that pain continues, or is felt out of all proportion to what's found on a scan, even after the tissues have healed. A central, evidence-based message runs through this page: hurt does not always equal harm. This page explains, in plain language, what pain is and how it works, then goes deeper for the curious into the biology of why pain can persist. ## What pain is and what it's for Pain is not measured by a sensor and piped unchanged to the brain like a thermometer reading. It is an output the brain produces after weighing many inputs: signals from the body, yes, but also context, past experience, mood, and how threatening the brain judges the situation to be. Its purpose is protection, to grab your attention and change your behaviour so an injury can heal. This is why the same injury can hurt very differently on different days or in different people, and why pain is completely real even when it doesn't match what's visible on an X-ray. ## Acute versus chronic pain - Acute pain is the normal alarm: it comes with an injury, it is roughly proportional to the damage, and it settles as healing happens. This pain is doing its job. - Chronic pain is pain that persists beyond the expected healing time (usually defined as more than about three months). Here the problem is often not ongoing tissue damage but an alarm system that has become over-sensitive and won't switch off. The pain is real and can be severe, but it is no longer a reliable signal that something is being harmed. That distinction matters enormously, because the two need different approaches: acute pain is managed by treating the injury and providing short-term relief; chronic pain is managed by gradually calming and retraining the nervous system, not by chasing ever-stronger painkillers. ## What helps with pain - Understanding it. Learning that "hurt does not equal harm" genuinely reduces chronic pain and disability; fear and catastrophising amplify pain. - Movement and pacing. Gentle, graded activity desensitises an over-sensitive system; prolonged rest and avoidance usually make chronic pain worse. - Sleep, mood and stress. Poor sleep, low mood and stress all turn the pain volume up; addressing them turns it down. - The right medicines for the right pain. Short courses of simple analgesics help acute pain; chronic pain responds better to nerve-targeted medicines, exercise and psychological strategies than to opioids. ## In more depth Advanced reading: the deeper science (optional) This section steps up to a more detailed, student-level explanation. It isn't needed to manage your pain, but if you're curious about how pain is generated and why it can persist, read on. ### How a pain signal travels Specialised nerve endings called nociceptors detect potentially damaging stimuli: extreme pressure, heat, or chemicals released by injured tissue. They send signals up two kinds of fibre. Fast, insulated A-delta fibres carry the sharp, immediate "ouch" that makes you snatch your hand back; slower, bare C fibres carry the dull, aching, lingering pain that follows. These signals reach the spinal cord, where they are relayed (and already modulated) before travelling up to the brain. There is no single "pain centre"; many brain regions together decide whether to produce pain, and how much. So pain is constructed, not simply received. ### The gate control idea The gate, simplified: non-painful Aβ input can close the gate on C-fibre pain signals at the spinal projection neuron. Wikimedia Commons, CC BY-SA 3.0 The spinal cord acts like a gate that can turn incoming pain signals up or down. Non-painful input can "close the gate" on pain, which is why rubbing a knock, or a TENS machine, eases it. The brain also sends signals downward to the spinal cord that dial pain up or down depending on attention, mood and context (descending modulation). This is the real mechanism behind everyday observations: a sports injury barely felt mid-game, pain that worsens when you're anxious or exhausted, relief from distraction or reassurance. The gate is not metaphorical; it is physiology. ### Peripheral and central sensitisation After an injury the system deliberately turns up its own gain so you protect the area: - Peripheral sensitisation: chemicals released at the injury make local nociceptors more excitable, so the sore area hurts more (this is why sunburnt skin screams at a warm shower). - Central sensitisation: the spinal cord and brain themselves become more excitable, amplifying every incoming signal. The hallmarks are hyperalgesia (painful things hurt more than they should) and allodynia (things that shouldn't hurt at all, such as light touch or clothing, become painful). In acute injury this is useful and reverses. In chronic pain it can persist and self-sustain. ### When pain outlasts the injury: chronic and nociplastic pain In some people the nervous system stays sensitised long after the tissues have healed; the alarm is stuck "on." Pain that arises from this altered processing, rather than from ongoing damage or nerve injury, is called nociplastic pain (central sensitisation is its main mechanism). It explains a common and once-baffling clinical picture: severe, genuine, disabling pain with little or nothing to find on imaging. Recognising this is not dismissing the pain as "in your head"; the changes are real, measurable nervous-system changes. It reframes the goal: not to hunt for more structural damage to fix, but to down-regulate an over-sensitive system. Conditions like fibromyalgia, and much persistent musculoskeletal pain, sit here. ### Why stronger painkillers aren't the answer for chronic pain Opioids are useful for short-term, severe acute pain, but they are a poor fit for chronic pain. With ongoing use the body develops tolerance (needing more for the same effect) and, paradoxically, opioid-induced hyperalgesia: the drugs can make the nervous system more pain-sensitive over time. Because chronic pain is largely a sensitised-system problem, the effective tools are the ones that retrain that system: graded exercise, sleep, psychological strategies, and nerve-targeted (rather than opioid) medicines. ### What helps and harms - Graded activity and pacing desensitise the system; fear-driven avoidance and prolonged rest sensitise it further. - Sleep, mood, and stress management lower the gain; poor sleep and distress raise it. - Education and reducing catastrophising measurably reduce pain and disability. - Right medicine for the right pain: short-term simple analgesia for acute pain; exercise, psychological therapy and nerve-targeted drugs (not escalating opioids) for chronic pain. ## See also - How nerves work and heal — the wiring that carries pain signals - Nerve pain medicines — the medicines used for nerve-related and sensitised pain - Managing pain after surgery — short-term pain control done well --- ### How Tendons Work and Heal URL: https://www.cqupperlimb.com/education/general-health/how-tendons-work-and-heal/ Region: general-health · general-info Tendons are the body's cables, tough cords that connect muscle to bone and transmit the pull of the muscle into movement. When you bend a finger or lift your arm, it is tendons doing the work of carrying that force across the joint. Tendons are strong, but they heal slowly and… Tendons are the body's cables, tough cords that connect muscle to bone and transmit the pull of the muscle into movement. When you bend a finger or lift your arm, it is tendons doing the work of carrying that force across the joint. Tendons are strong, but they heal slowly and in a particular way, and not all tendons heal the same way. A cut flexor tendon in the finger and a torn rotator cuff tendon in the shoulder follow quite different healing stories, which is why their surgery and rehabilitation are so different. This page explains, in plain language, what tendons are and how they mend, and then goes deeper into the biology for the curious, including why a flexor-tendon repair gets weaker before it gets stronger, and why a rotator cuff heals onto bone the way it does. ## What a tendon is and what it does A tendon is a rope made mostly of collagen (the same tough protein that gives bone its flexibility), packed into tightly-aligned bundles that run along the line of pull. One end blends into muscle; the other anchors into bone. Its job is simple but vital: to transmit the force a muscle generates to the bone, so the joint moves. Some tendons also have to glide: the flexor tendons that bend your fingers slide back and forth through narrow tunnels every time you make a fist. Tendons are living tissue, but only just: they have relatively few cells and a sparse blood supply compared with muscle or skin. That is a large part of why they heal slowly. ## How tendons heal When a tendon is cut or torn, it heals in three overlapping phases, much like other tissues: - Inflammation (first week). A clot forms and repair cells move in. At this stage the join is held together mostly by the surgeon's stitches; the tendon itself is contributing very little strength. - Repair (weeks). Cells lay down new collagen across the gap, but it is disorganised and weak at first, like a hastily-tied bundle of threads rather than a neat rope. - Remodelling (months). With time and gentle use, that disorganised collagen is gradually replaced and re-aligned along the line of pull, and the tendon regains strength. This continues for many months, often up to a year or more. A key point: tendon heals largely by forming scar, not by perfectly re-growing the original tissue. The repaired stretch is never quite as pristine as the original, which is why careful rehabilitation, and patience, matter so much. ## What helps a tendon heal - The right amount of movement. Tendons respond to load. Controlled, graded exercise (guided by a hand or physiotherapist) tells the healing collagen how to organise itself. Too much, too soon, ruptures the repair; too little leads to stiffness and a tendon stuck down by scar. - Protecting the repair early. A fresh tendon repair is fragile for weeks even when it feels fine; follow your splint and activity limits to stop it pulling apart. - Good general health. Not smoking, controlling diabetes, and avoiding unnecessary steroids all help; smoking in particular impairs tendon healing. - Time. Tendon is slow tissue. Real strength takes months, not weeks. ## In more depth Advanced reading: the deeper science (optional) This section steps up to a more detailed, student-level explanation of the biology. It isn't needed to understand a tendon injury or its treatment, but if you're curious about how tendons actually work, and why a finger tendon and a shoulder tendon heal so differently, read on. ### Tendon as living tissue A tendon is a rope-within-a-rope — collagen molecules bundle into fibrils, fibres and fascicles, each wrapped in sheaths that carry its sparse blood supply, with tenocytes strung between them. Roets, Abrahamse & Crous, Wikimedia Commons, CC BY 4.0 A tendon is built as a hierarchy of collagen, like a rope made of ever-smaller strands. Collagen molecules bundle into fibrils, fibrils into fibres, fibres into fascicles, and fascicles into the whole tendon; at each level a thin connective-tissue wrapping (the endotenon, and the epitenon around the whole tendon) carries the small blood vessels and nerves. The collagen is mostly type I, exceptionally strong in tension and laid down almost perfectly parallel to the direction of pull. At rest the fibres have a wavy, crimped pattern. When you first load a tendon this crimp straightens out, which is why a tendon is slightly stretchy at the very start of a pull before becoming stiff and strong (it has a little built-in give). Tendon is also viscoelastic: it behaves differently depending on how fast it is loaded (stiffer when loaded quickly), and it slowly creeps (lengthens) under a sustained load. The living cells are tenocytes, sparse spindle-shaped cells strung between the collagen bundles. They maintain and very slowly renew the matrix. Because cells and blood vessels are relatively few, and some regions of certain tendons are genuinely hypovascular ("watershed" zones with a poor blood supply), tendon healing is slow, and those poorly-supplied zones are exactly where some tendons tend to tear and to heal badly. ### How tendons heal — and why it's mostly by scar The three phases above, in more detail: an inflammatory phase (roughly the first week) clears debris and recruits cells; a proliferative phase (about one to three weeks) in which cells churn out large amounts of disorganised type III collagen, quick to lay down but mechanically weak; and a long remodelling phase (months, up to about 18 months) in which that type III collagen is gradually replaced by strong, aligned type I collagen, cross-linked and oriented along the line of load. The crucial concept is that this is repair by scar, not regeneration. The body patches the gap rather than recreating the original, beautifully-ordered tendon. What turns that early weak scar into something strong and aligned is mechanical load. That is the whole rationale behind modern tendon rehabilitation: controlled force, applied at the right time, literally instructs the scar how to become tendon. ### Flexor tendon healing: intrinsic vs extrinsic, and the work of flexion The flexor tendons that bend your fingers are a special case, because they have to glide through a tight tunnel (the flexor sheath, with its pulleys) to work. That creates a tension at the heart of flexor surgery, and two different ways the tendon can heal: - Intrinsic healing comes from the tendon's own cells, nourished by the synovial fluid inside the sheath and by tiny blood-vessel folds called the vincula. The flexor tendon is largely fed not by blood vessels but by that synovial fluid, which is actively pumped into the tendon (a process called imbibition) each time the finger bends and straightens; so movement itself feeds the healing tendon. Intrinsic healing knits the tendon back together without sticking it to its surroundings, so it can still glide. - Extrinsic healing comes from cells and scar invading from outside, from the sheath and surrounding tissue. It heals the tendon too, but it glues it to its tunnel, forming adhesions that stop it gliding, so the finger won't fully bend or straighten. Modern repair plus early controlled movement is designed to tip the balance toward intrinsic healing and away from adhesions. This is where the work of flexion comes in: the force the muscle has to generate to actually flex the finger. It is not just the weight being moved; it is the resistance to the tendon gliding: friction in the sheath, the bulk of the repair itself, post-operative swelling, and tight pulleys all add to it. If the work of flexion (the resistance) climbs higher than the repair can withstand, the repair gaps or ruptures, or the finger simply won't move and adhesions set in. So the surgeon is balancing two competing demands: a repair strong enough to tolerate early movement, yet slim and smooth enough to glide with a low work of flexion. Early motion only works if both are achieved. ### Why a flexor repair gets weaker before it gets stronger Here is the counter-intuitive part that explains the whole, cautious rehabilitation timeline. A tendon repair does not steadily get stronger from day one. It follows a U-shaped curve: - In the first days, essentially all the strength comes from the suture; the tendon tissue itself adds almost nothing. - Over the first one to three weeks, the cut tendon ends actually soften: the body resorbs and remodels the collagen right at the repair site before the new collagen has matured. So the whole construct reaches its weakest point in the early weeks (often around the end of the first week through the third), even though the wound looks healed and the finger feels fine. - Then strength climbs. As disorganised type III collagen is replaced by aligned, cross-linked type I, the repair regains and then exceeds its starting strength, reaching enough for most everyday activity by around 12 weeks and continuing to mature for many months. That dip is why hand therapy is so carefully staged, and why "it feels fine at three weeks" is a trap: that is often precisely when the repair is most vulnerable. Gentle, controlled motion in the early phase keeps the tendon gliding (favouring intrinsic healing) and aligns the new collagen without overloading a repair that is, biologically, at its weakest. Tendon ruptures after repair cluster in these vulnerable early weeks for exactly this reason. ### Tendon-to-bone healing: the rotator cuff and the enthesis The rotator cuff — four muscles whose tendons blend into a cuff that inserts onto the top of the arm bone, where the tendon-to-bone enthesis must heal after a repair. InjuryMap, Wikimedia Commons, CC BY-SA 4.0 A rotator cuff tear is a completely different problem, because here the tendon has to heal back onto bone, and the junction between tendon and bone is a remarkable structure called the enthesis. In healthy tissue the enthesis is a graded transition, built in roughly four zones: tendon → uncalcified fibrocartilage → calcified fibrocartilage → bone. This gentle gradient from soft, flexible tendon to hard, stiff bone spreads out the stress, so the soft tendon isn't simply ripped off the hard bone at a sharp boundary. The catch is that, once torn, the body cannot rebuild that graded enthesis. A repaired cuff heals by a fibrovascular scar between tendon and bone, mechanically weaker than the original four-zone transition, and one reason rotator cuff repairs can re-tear despite well-done surgery. It is also important that most cuff tears are degenerate rather than purely traumatic: with age, the tendon, particularly in a relatively poorly-supplied "critical zone" about a centimetre from where the supraspinatus tendon meets the bone, weakens, frays and tears with little or no injury (true cuff tears are rare before about 50). Surgery reattaches the tendon to its bony "footprint", but it is working against ageing, often poor-quality tissue. So cuff healing is fundamentally biology-limited: the operation restores the anatomy, but whether the tendon-to-bone junction truly heals depends on tendon quality, tear size, age, smoking, diabetes and how the repair is protected and loaded. This is the opposite end of the spectrum from a clean flexor laceration in a young hand: same tissue, very different healing problem. ### What helps and harms tendon healing - Load, correctly dosed. Controlled, progressive loading is the single most powerful tool for building tendon strength and alignment. Too much too soon ruptures the repair; too little causes stiffness and adhesions. The art of rehabilitation is the dose. - Blood supply. Well-vascularised tendon heals better; hypovascular "watershed" zones (as in parts of the rotator cuff) heal worse. - Smoking, diabetes, steroids and age all impair tendon healing and raise the risk of rupture and re-tear. - Time. Tendon is slow tissue; meaningful strength takes months, and full remodelling can run beyond a year. ## See also - How bone heals and remodels — how the bone side of a tendon-to-bone repair behaves - Smoking and musculoskeletal healing — why smoking slows tendon and bone healing - Corticosteroid injections — steroids around tendons: uses and cautions --- ### How Wounds and Scars Heal URL: https://www.cqupperlimb.com/education/general-health/how-wounds-and-scars-heal/ Region: general-health · general-info Every cut, graze and surgical incision heals through the same remarkable, predictable sequence, and every one leaves a scar , because healed skin is repaired, not perfectly regrown. Understanding how wounds heal explains why a fresh scar is red and firm before it fades, why a… Every cut, graze and surgical incision heals through the same remarkable, predictable sequence, and every one leaves a scar, because healed skin is repaired, not perfectly regrown. Understanding how wounds heal explains why a fresh scar is red and firm before it fades, why a healed wound is never quite as strong as the skin it replaced, and why things like smoking and diabetes matter so much. This page explains, in plain language, how skin mends and scars settle; for the curious, it then goes deeper into the biology of repair and why scars behave as they do. ## What a wound is and how skin heals A wound is simply a break in the skin's protective barrier. Healing it happens in overlapping steps: first the bleeding stops and a clot/scab forms; then the area becomes inflamed (red, warm, a little swollen) as clean-up cells move in; then the body fills the gap with new tissue and pulls the edges together; and finally, over months, that new tissue is reorganised and strengthened into a scar. A surgically closed incision (edges stitched neatly together) heals faster and with a finer scar than a wound left open to fill in from the bottom up, but both follow the same underlying process. ## How scars form and mature A scar is the patch the body lays down to close a wound. Fresh scars are typically raised, firm, red or pink because they are full of new blood vessels and disorganised collagen. Over the following months to a year, the scar remodels: blood vessels regress and the collagen reorganises, so a mature scar becomes flatter, paler, softer and less noticeable. This is why you should judge a scar at a year, not at a month. Two honest truths about scars: they never regain the full strength of the original skin (about 80% at best), and how a scar turns out depends partly on you (wound care, not smoking) and partly on factors you can't control (genetics, skin type, where on the body it is, and tension across the wound). ## What helps a wound heal well - Keep it clean and protected, and follow your dressing/wound-care instructions; infection is a major derailer. - Don't smoke. Nicotine narrows blood vessels and starves the wound of oxygen, one of the strongest controllable risks for wound breakdown. - Eat well. Adequate protein, vitamin C and zinc, and good blood-sugar control if diabetic, supply the raw materials. - Protect the scar while it matures: minimise tension, and shield a new scar from the sun (which can darken it permanently) for the first year. ## In more depth Advanced reading: the deeper science (optional) This section steps up to a more detailed, student-level explanation. It isn't needed to look after a wound, but if you're curious about how repair actually works and why scars are the way they are, read on. ### The four phases of wound healing The four overlapping phases of wound healing — haemostasis, inflammation, proliferation and remodelling — from the first clot to a matured scar. Indu Pranav Pasupula, Wikimedia Commons, CC BY-SA 4.0 Repair runs through four overlapping phases: - Haemostasis (minutes). Blood vessels constrict and a clot forms, plugging the wound and laying down a temporary fibrin scaffold. - Inflammation (days). Immune cells (neutrophils then macrophages) clear bacteria and debris and release signals that summon repair cells. This is the red, swollen, tender phase. - Proliferation (days to weeks). Fibroblasts pour in and lay down new collagen; new blood vessels sprout (forming pink "granulation tissue"); skin cells migrate across the surface to re-seal it. - Remodelling (weeks to ~a year). The hasty early collagen is broken down and replaced with stronger, better-organised collagen, blood vessels regress, and the scar matures. ### Why scars are weaker than skin The key is collagen type. Early repair lays down a lot of type III collagen, which is quick to deposit but mechanically weak and disorganised. During remodelling this is gradually replaced by stronger, aligned type I collagen and cross-linked. Tensile strength climbs accordingly: roughly half of normal by six weeks, peaking around 80% by about three months, but never reaching 100%. A scar is also missing the original skin's neat architecture (and its hair follicles and sweat glands). So a healed wound is a strong, serviceable patch, not a perfect replacement. ### Myofibroblasts and wound contraction A specialised repair cell, the myofibroblast, is part fibroblast and part muscle cell: it grips the wound matrix and physically contracts, pulling the edges of the wound together to shrink the area that needs covering. This is helpful; it closes wounds faster. But in the wrong place it causes problems: across a joint or the palm, excessive contraction can pull tissues into a tight contracture that limits movement, which is why wounds and burns over flexion creases are managed so carefully. ### When scarring goes wrong: hypertrophic and keloid scars Sometimes the balance between laying down collagen and breaking it down tips too far toward deposition, giving an overgrown scar: - A hypertrophic scar is raised and red but stays within the boundary of the original wound, and often improves over time. - A keloid grows beyond the original wound margins, behaving almost like a benign overgrowth; keloids are commoner in certain skin types and body areas (chest, shoulders, earlobes) and are much harder to treat. Both reflect an exaggerated, prolonged proliferative response: too much collagen, too little remodelling. ### Primary versus secondary healing Surgeons distinguish two routes. Healing by primary intention is a clean wound with edges held directly together (a sutured incision): fast, with a thin scar. Healing by secondary intention is a wound left open (because of tissue loss or infection) that fills from the base up with granulation tissue and contracts closed: slower, with a broader scar. Choosing between them (and when to close a contaminated wound) is a core surgical judgement. ### What helps and harms wound healing - Blood supply and oxygen are essential, which is exactly what smoking impairs. - Diabetes, poor nutrition, advanced age, and steroids/immunosuppression all slow healing and raise infection risk. - Infection stalls a wound in the inflammatory phase and can break a closed wound down. - Tension and movement across a wound widen the scar; protecting and supporting it produces a finer result. - Time and sun protection determine the final cosmetic outcome: a scar judged at a year looks far better than at a month. ## See also - How bone heals and remodels — the same repair phases, in bone - Smoking and musculoskeletal healing — why smoking is so damaging to healing - How tendons work and heal — repair-by-scar in another tissue --- ### Joint Hypermobility and Ehlers-Danlos Syndrome URL: https://www.cqupperlimb.com/education/general-health/hypermobility-and-eds/ Region: general-health · condition Bendy joints that can slip or ache — the spectrum from benign hypermobility to hEDS, and why strengthening is the mainstay. ## What you're feeling You may have always been the "double-jointed" one, able to bend your thumb back to your forearm, hyperextend your elbows, or fold yourself into shapes that make other people wince. For many people that flexibility is simply a harmless quirk and causes no trouble at all. For some, though, it comes at a cost. The joints that move beyond the normal range can also ache, especially after activity or at the end of the day. You might notice that some joints click, clunk or feel loose, as if they could slip out of place, and sometimes they do. The shoulder, the small finger joints and the base of the thumb are common culprits in the upper limb: a shoulder that partially slides out (a subluxation) or fully dislocates, fingers that bend the wrong way, a thumb joint that gives way when you pinch or grip. Injuries can seem to take longer to settle than you'd expect, and the same joint may keep letting you down. Hypermobility often travels with other features. Some people have soft or stretchy skin and bruise easily. Many describe fatigue that is out of proportion to what they've done, dizziness or a racing heart on standing, and digestive symptoms like bloating or reflux. Not everyone has all of this, but if several of these ring true alongside your loose joints, they may be connected. ## What's actually happening Your joints are held together and supported by connective tissue (ligaments, tendons and the capsule around each joint), and a key building block of that tissue is a protein called collagen. In people with hypermobility, the collagen and connective tissue are a little stretchier and more elastic than usual. The supporting structures give a bit more, so joints can travel further than the normal range allows. This sits on a spectrum. At one end is simple joint hypermobility that never causes a problem. When loose joints start to produce pain, instability or repeated injuries, doctors call it a hypermobility spectrum disorder. At the far end is hypermobile Ehlers-Danlos syndrome (hEDS), where the stretchier connective tissue is more pronounced and more likely to come with the wider, whole-body features (skin, bruising, fatigue, gut and dizziness/autonomic symptoms). The lines between these are not sharp, and where you sit can shift over time. To help map this out, doctors often use a simple set of bend tests called the Beighton score, alongside your full history. The reason all this matters for your joints comes down to one idea: if the passive supports (the ligaments and capsule) hold a joint less firmly, the joint has to rely much more on the muscles around it for stability. When those muscles are strong and well-coordinated, the joint stays put. When they tire or aren't conditioned for the job, the joint slips, aches, and over many years may wear a little faster than it otherwise would. There's one pattern worth knowing about in the shoulder. Where a single injury can knock a normal shoulder out in one direction, a loose shoulder often feels unstable in several directions at once, sliding forwards, backwards or downwards. Doctors call this multidirectional instability. It also means these shoulders tend to partly slip and self-correct (subluxate) more often than they fully dislocate. This matters because it is exactly the kind of instability that responds best to building muscle control, and least well to an operation alone. ## What we can do about it The most important message is this: hypermobility and hEDS are not curable, but they are very manageable, and the cornerstone of management is not a tablet or an operation. It is building the muscles that stabilise your joints. Physiotherapy and targeted strengthening are the mainstay. A physiotherapist who understands hypermobility will work with you to build control and strength around the joints that trouble you most. For the upper limb, that often means the shoulder blade and rotator cuff muscles, and the small muscles that control the thumb and fingers. The aim is to train your muscles to do the steadying work that your ligaments do less of. This is a gradual, ongoing programme rather than a quick fix, but it is what changes things for most people. Around that core, several other measures help: - Pacing and joint protection: spreading activity through the day, avoiding the end-of-range positions that strain loose joints, and adapting how you do demanding or repetitive tasks. - Bracing and taping: used selectively to support a joint while you build strength or get through a flare, not as a permanent crutch. - Pain management: simple strategies, sometimes medication, and attention to sleep, fatigue and the other body-wide symptoms, because these all feed into how your joints feel. Surgery is approached cautiously. For an upper-limb surgeon this is a genuinely important point. When a joint (most often the shoulder) dislocates repeatedly despite good rehabilitation, an operation to stabilise it can be considered. But the same stretchy tissue that loosened the joint in the first place also holds surgical repairs less reliably and can heal differently, so standard stabilising operations carry a higher chance of stretching out or failing over time. Because of this, surgery is reserved for carefully selected problems, planned with your hypermobility firmly in mind, and always paired with a strengthening programme before and after. The rehabilitation is what protects the result. ## What to expect Hypermobility is part of how your body is built, so it doesn't go away, but its impact can change enormously with the right management. Many people who commit to a strengthening programme find their joints become far more stable, their pain settles, and the slips and dislocations become much less frequent. Progress tends to be steady rather than sudden, measured over months, and the gains are best held by keeping the muscles conditioned for the long term rather than stopping once things improve. It helps to think of this as a long-term partnership with your body rather than a problem to be fixed once. Flares can still happen, especially after illness, a growth spurt, or a period of less activity, and you'll get better at reading the early signs and heading them off. Where the wider features are present (fatigue, dizziness, gut symptoms), looking after those alongside your joints usually makes everything more manageable. With a sensible plan, most people stay active and do the things that matter to them. ## When to see someone - A joint that dislocates or partly slips out repeatedly, particularly the shoulder, or a first dislocation that won't settle. - Pain that is disabling or steadily getting worse despite rest and your usual measures. - Instability that interferes with daily life: struggling to grip, lift, work or sleep because a joint keeps letting you down. - A new or rapidly worsening joint problem, or numbness, tingling or weakness in the arm or hand. - If you suspect a hypermobility spectrum disorder or hEDS and want it properly assessed (especially when loose joints come together with skin, bruising, fatigue, dizziness or gut symptoms), it's worth seeking a considered review so the right plan can be put in place. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Hypermobility is worth the extra reading because the confident story, loose joints are a collagen gene problem, and a lax joint can simply be tightened surgically, does not survive contact with the evidence on either count. ### The most common type has no known genetic cause The 2017 international classification recognises 13 types of Ehlers-Danlos syndrome. Twelve of them are caused by variants in 20 identified genes, and for those twelve a definite diagnosis requires molecular confirmation [1]. The thirteenth is hypermobile EDS, by a wide margin the most common, and its molecular basis remains unknown [1]. There is no gene test for it. It is the one type diagnosed purely on clinical criteria, which is why the diagnosis can feel frustratingly subjective compared with conditions that end in a laboratory result. This matters for how the condition is explained. Saying that hypermobility "comes down to inherited differences in collagen genes" is accurate for classical and vascular EDS, where the causative variants are known. For hypermobile EDS it is a plausible assumption rather than a demonstrated fact. The honest position is that we can describe the tissue behaviour reliably and cannot yet name the molecular cause. ### The Beighton score is more reliable than its reputation The nine-point Beighton score is often dismissed as crude and examiner-dependent. That criticism is not supported. A systematic review of 1,333 participants found the score shows substantial to excellent inter-rater and intra-rater reliability, and that this held across raters of varying background and experience [2]. So the measurement is sound. The genuine limitation is different: the score samples the little fingers, thumbs, elbows, knees and spine, and a good score tells you about generalised laxity, it was never designed to grade the stability of one shoulder in front of you. ### What hypermobility actually predicts for the upper limb This is the number that matters in a shoulder clinic. A systematic review and meta-analysis of 2,335 athletes found that joint hypermobility was associated with a threefold higher odds of shoulder injury [3]. The authors are appropriately cautious about the quality of the underlying evidence, but the direction and size are hard to ignore. That risk is not confined to the upper limb. Generalised joint laxity is associated with increased graft failure and inferior outcomes after anterior cruciate ligament reconstruction [4], the same tissue behaving the same way in a different joint. ### Surgery works less well, and the numbers are specific This is the least comfortable part of the literature and the most useful. A systematic review and meta-analysis of 1,769 patients found that people with Ehlers-Danlos syndrome undergoing total joint arthroplasty were at significantly increased risk of all-cause revision, instability, aseptic loosening and wound complications [5]. A separate review of orthopaedic surgical outcomes across the Ehlers-Danlos syndromes reached the same conclusion: outcomes are worse than in the general population, and complications occur more frequently [6]. None of that says surgery is wrong. It says the expected benefit is smaller and the expected complication rate higher than the figures quoted for the general population, and that the threshold for operating should move accordingly. If you have hypermobile tissue, published success rates for an operation were mostly not measured on people like you. ### For an unstable shoulder, rehabilitation is not the consolation prize Multidirectional instability, a shoulder that is loose in several directions rather than having been dislocated out of one, is the classic hypermobile shoulder problem, and it is the clearest example of the point above. Where surgery is needed after rehabilitation has genuinely failed, arthroscopic capsular plication and open capsular shift produce comparable rates of recurrent instability, return to sport and complications [7][8], with the arthroscopic approach causing less postoperative stiffness [9]. One historical technique, thermal capsular shrinkage, performed poorly enough that the meta-analysis advises against it [9]. The ordering is the message. Every one of those reviews frames surgery as what follows failed rehabilitation, not as an alternative to it, because tightening a capsule does not change the tissue it is made from, and the muscles remain the only part of the system that can be strengthened. --- ### Inflammatory and Rheumatoid Arthritis URL: https://www.cqupperlimb.com/education/general-health/inflammatory-and-rheumatoid-arthritis/ Region: general-health · condition Rheumatoid, psoriatic and gouty arthritis affecting the hand, wrist and upper limb — what they are, how they are managed, and when surgery helps. ## What you're feeling Inflammatory arthritis, including rheumatoid arthritis, is a condition where your immune system attacks the lining of your own joints. In your hand and wrist, this causes swelling and pain in the small joints of your fingers and the wrist itself. The swelling often feels worst on waking in the morning, and it can ease as you start moving. Resting the hand usually settles the pain, while using it makes things worse. Day to day, this shows up in tasks that need grip and fine finger movement. Turning a key, opening a jar, holding a pen, doing up buttons or carrying a kettle can all become harder. Some people notice one finger or one knuckle swelling more than the others. Over time, the joints can change shape, and the tendons that straighten your fingers can wear through and stop working properly. The condition can also affect other joints, including your elbow and shoulder, and it can make you feel generally unwell when it flares. Lumps under the skin, called rheumatoid nodules, sometimes appear over pressure points such as the back of the hand or elbow. Some warning signs need fast action. If a finger, hand or arm becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. If your fingers or hand turn pale, cold, white or blue, or you suddenly lose feeling or movement after an injury, go to the emergency department the same day. Other signs need a review rather than the emergency department. See your GP or ask for a specialist review if symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand. ## What's actually happening In a healthy joint, the lining is thin and smooth, and it makes a small amount of fluid that lets the surfaces glide over each other. With rheumatoid arthritis, your immune system treats that lining like something foreign and attacks it. The lining becomes thick and inflamed, and it produces too much fluid. That swollen lining then starts to eat into the joint surfaces themselves, wearing away the smooth cartilage that should protect the bone. The damage does not stop at the joint. The same inflamed tissue can wrap around the tendons, the cords that run from your forearm muscles to your fingers and let you bend and straighten them. That tissue can weaken the tendons until they fray or wear through, which is why a finger can suddenly stop straightening. It can also soften the bone itself, making it weaker and more likely to erode, especially around the wrist and the small joints of the fingers. This explains what you're feeling. The morning stiffness and swelling come from the inflamed lining producing extra fluid. The pain with use comes from raw, unprotected joint surfaces rubbing together. Changed joint shape happens as the worn surfaces and weakened tendons let the fingers drift out of line. And lumps under the skin, the rheumatoid nodules mentioned earlier, are part of the same disease process rather than a separate problem. The condition varies from person to person. Some people have a milder, slower form, while others have a more severe form that damages joints and tendons faster. How quickly your wrist or fingers deteriorate depends on which pattern of the disease you have. This is why treatment works best when the inflammation itself is brought under control, usually with medicine from your rheumatologist, before or alongside any surgery on the hand. ## What we can do about it There is a lot you can do yourself alongside medical treatment. Gentle, regular exercise keeps your joints moving and may improve strength over time, though the stiffness relief tends to be short term. If your rheumatoid arthritis is well controlled, supervised exercise programs that mix strength work with higher intensity training are generally well tolerated and can help your overall physical health. An occupational therapist can also show you ways to protect your joints and make daily tasks easier. Give these approaches a fair trial over weeks rather than days, and keep them going even when you start other treatment. Medicine is the mainstay of treatment, especially early on. Anti-inflammatory medicines and corticosteroids settle pain and swelling. Other medicines, such as methotrexate, work on the disease itself by calming your overactive immune system, and newer biologic medicines target specific parts of the inflammation process. These medicines have changed the course of the disease for many people, so much so that far fewer now need joint replacement surgery than did in the past. The trade-off is that medicines which dampen your immune system raise your risk of infection, so they need careful management, particularly around any surgery. If your symptoms stay severe despite these measures, your GP or rheumatologist may refer you for a specialist assessment of your hand and wrist. Surgery is not a first step, and it is only considered when the disease has damaged joints or tendons in ways that medicine cannot undo. For some specific problems, an operation may occasionally help with pain or function. Any decision takes into account your other joints, what you need your hands to do, and your lifestyle. ## What to expect Rheumatoid arthritis is a long-term condition. It does not go away on its own, and it tends to keep damaging joints if the inflammation is left uncontrolled. Joint damage usually starts within the first or second year of the disease and continues from there. That is why early treatment matters: medicine that calms the inflammation can slow or prevent that damage before it happens. When the disease is managed well, the outlook has changed for many people. Modern medicines have reduced how often joints wear out badly enough to need replacement surgery. With treatment, flares can settle and you can keep using your hands for daily tasks. If your disease is well controlled, regular exercise including strength work and higher intensity training is generally well tolerated and helps your overall health. If the condition is left alone, the inflamed lining keeps eating into joint surfaces and tendons. Joints can change shape, fingers can drift out of line, and tendons that straighten your fingers can wear through. A tendon that has worn through does not heal or settle by itself, and it needs prompt specialist review. Damage already done to cartilage and bone cannot be undone by medicine. Surgery can help when damage has already happened. People who have joint replacement for a damaged joint report less pain and better function afterwards. Results vary between people, and some deterioration can occur over the long term, so surgery is a step taken when medicine can no longer manage the problem. Watch for the signs described earlier on this page. A hot, red, swollen and painful finger or hand, especially with a fever, needs the emergency department the same day. Pale, cold, white or blue fingers, or sudden loss of feeling or movement after an injury, also need the emergency department the same day. If symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone This condition is inflammatory, so the warning signs are different from a joint that simply wears out. The urgent ones are covered earlier on this page: a finger, hand or arm that becomes hot, red, swollen and painful, especially with a fever, needs the emergency department the same day. So do pale, cold, white or blue fingers, or sudden loss of feeling or movement after an injury. See your GP or ask for a specialist review if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand. A finger that suddenly stops straightening also needs prompt specialist review, because a tendon that has worn through does not heal on its own. Ask for a review sooner rather than later if you notice a joint changing shape or drifting out of line, or if swelling and morning stiffness keep coming back. The earlier the inflammation is brought under control, the better the chance of protecting your joints before damage is done. --- ### Lumps and Bumps on the Hand, Wrist and Fingers URL: https://www.cqupperlimb.com/education/general-health/lumps-and-bumps-on-the-hand-and-wrist/ Region: general-health · condition Found a lump on your hand, wrist or finger? The common causes and what they mean: ganglion cysts, fatty lumps (lipomas), giant cell tumours, mucous cysts and carpal bossing, and when to see someone. ## What you're feeling A lump on the back of your wrist is often a ganglion, a fluid-filled swelling that comes from a wrist joint or tendon lining. Most lumps on the back of the wrist start near one of the small wrist joints. Some people get a dull ache in the wrist with the lump. Others have no pain at all, just the swelling. The ache often flares after you have used your hand a lot, for example gripping tools, writing or carrying shopping. Rest usually settles it. Ganglions can also appear in the palm or along a finger tendon. A lump in the middle of the palm may not hurt at all. A lump near a finger tendon can make bending or straightening that finger awkward, so typing, buttoning a shirt or holding a pen can feel clumsy. Sometimes the lump presses on a nearby nerve. That can cause tingling, numbness or weakness in your fingers, or pain that wakes you at night. If numbness or pain in your ring and little fingers comes on suddenly, that needs review. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. Not every hand lump is a ganglion. Some lumps are spots of hardened calcium, and some start in the bone itself. A single swollen finger can also be linked with a form of childhood arthritis, and children can get wrist ganglions too. In children aged 10 years and younger, 64% of wrist ganglions disappear on their own, and in children under 10, 69% to 79% shrink away within 12 to 18 months. One warning sign needs same-day care. If your finger, hand or arm becomes hot, red, swollen and painful, especially with a fever, go to the emergency department that day. No GP referral is needed. ## What's actually happening A ganglion is a small sac of thick, jelly-like fluid. It grows out from a joint or a tendon lining, the way a weak spot on a bicycle inner tube bulges out through the tyre. On the back of the wrist, most ganglions start at one small joint in the middle of the wrist, where two of the little wrist bones are held together by a strap of ligament. Fluid from that joint pushes out through a weak spot in the strap and collects under the skin as a lump. No one knows why that weak spot forms. The wrist bones and ligaments around it can look completely normal. Some ganglions seem linked with a small tear or looseness in that strap of ligament, which may also explain the dull ache that comes with using your hand. The lump itself is harmless, but it takes up room. If it presses on one of the nerves that run through the wrist or palm, you get tingling, numbness or weakness in your fingers. Sometimes that ache on the back of the wrist comes from the lump pressing on a small nerve nearby rather than from the joint itself. A ganglion can even press on a nerve without you feeling any lump at all. Ganglions in other spots work the same way. One on a finger tendon lining sits right beside the rope of fibres that bends your finger, which is why bending can feel awkward. One in the middle of the palm usually causes no trouble at all. Some lumps start in the bone instead of beside it, where fluid or blood collecting inside the bone builds up pressure, which explains a deep, nagging ache. In children, these lumps often simply go away on their own as the wrist grows. ## What we can do about it Many wrist ganglions need no treatment at all. Some simply settle on their own, and an ache that flares after heavy use often eases with rest and a change in how you use your hand. If the lump is uncomfortable, a supportive strap or splint can settle things down while you go about your day. If you want the lump gone without an operation, it can be drained. A fine needle draws the jelly-like fluid out of the cyst. Draining works fully in about half of cases, and giving it up to three tries clears about 85% of them. Wearing a splint afterwards makes no difference to the result, so we do not recommend one. Steroid injections can also settle swelling and pain in some of the conditions that cause hand lumps, and anti-inflammatory tablets or gels can ease the ache. For some bone lumps, long-term anti-inflammatory medicine can be an alternative to surgery when an operation would cause more trouble than it is worth. If the lump keeps troubling you despite these steps, your GP or your doctor can assess it and discuss whether a procedure would help. For some conditions, surgery removes the lump or the tissue feeding it, which stops it filling up again. Draining first, before any operation, is a sensible step for lumps on the back of the wrist. ## What to expect For many people, a wrist ganglion is a come-and-go lump rather than a lasting problem. The ache often flares after heavy use and settles with rest. Some lumps shrink or disappear on their own, and some stay the same for years without causing much trouble. Others keep filling up after being drained, which is why draining sometimes needs more than one try. If the lump is left alone, the outlook is often no worse than if it is treated. For lumps on the palm side of the wrist, symptoms at 2 and 5 years are much the same whether the lump is removed, drained or simply watched. That can make waiting a reasonable choice if the lump does not bother you much. Draining works fully in about half of cases, as covered earlier on this page. When a lump does keep troubling you, treatment usually settles things well. People who have a lump removed generally find the ache eases and the hand works normally again. Some are left with a small area of stiffness or a scar that takes time to settle. For lumps that grow back after treatment, there are still options, and most people get back to comfortable hand use in the end. Lumps linked with arthritis in the finger joints tend to behave differently. The lump may come and go, but the underlying joint wear does not, so the ache can linger and flare over months. Splints, anti-inflammatory medicine and injections can settle the pain, and if that is not enough, a procedure on the joint itself usually eases it. Nerve symptoms deserve a little more care. Tingling, numbness or weakness from a lump pressing on a nerve often settles once the pressure is relieved, sometimes without any operation at all. If those symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone Most lumps like this are not urgent, but a few signs need quick attention. If your finger, hand or arm becomes hot, red, swollen and painful, especially with a fever, go to the emergency department that day. No GP referral is needed. If you cannot reach the clinic out of hours or on a weekend, go to your nearest emergency department. See your GP or ask for a specialist review if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand. Ask sooner if a lump presses on a nerve and causes tingling, numbness or weakness in your fingers. Numbness or pain in your ring and little fingers that comes on suddenly also needs review. A lump that moves under the skin when you straighten your thumb is worth having assessed as well. --- ### Musculoskeletal Syndrome of Menopause URL: https://www.cqupperlimb.com/education/general-health/musculoskeletal-syndrome-of-menopause/ Region: general-health · condition How the menopausal transition and oestrogen withdrawal drive joint, tendon and muscle symptoms — arthralgia, tendinopathy, frozen shoulder, greater trochanteric pain and myalgia — and the evidence on hormone therapy. ## What you're feeling You are likely experiencing joint pain, or arthralgia, more than half of women do around the time of menopause. This pain often increases as your body transitions through menopause. The drop in oestrogen levels is a key driver of this change. You may notice that your muscles feel stiffer. Oestrogen and muscle stiffness are negatively related, meaning less oestrogen often means tighter, less flexible muscles. The pain can show up in many places. Low back pain is more common in postmenopausal women than in men of the same age. This is linked to physiological changes from lower sex hormone levels. You might also feel pain in your shoulders. The risk of silent rotator cuff tears increases during this period. These are tears you may not feel until they affect your movement. Daily tasks can become difficult. Reaching behind your back or over your head may feel awkward and stiff. You may find it harder to lift objects or sleep on your side. Your doctor knows that these changes are real and common. They are not just in your head. Your symptoms may flare at night or after activity. Waking up with stiffness is also common. Changes in your hormone levels can also influence how stiff your muscles and tendons feel. This variability can make some days better than others. It is important to know that you are not alone in this. The prevalence of muscle loss, or sarcopenia, is 31% in postmenopausal women. This loss contributes to the pain and stiffness you feel. While some treatments show promise, the evidence for hormone therapy protecting against joint replacement is limited. Your doctor will focus on managing your specific symptoms and improving your quality of life. ## What's actually happening During the perimenopause, your body undergoes significant hormonal shifts that make you particularly prone to musculoskeletal pain. More than half of women experience joint pain, or arthralgia, around this time. This discomfort often increases as you move through the menopausal transition. The primary driver is a reduction in oestrogen levels. This drop affects not just your joints, but also your muscles and bones. Your joints rely on smooth cartilage to act as a shock absorber between bone ends. Lower oestrogen levels are linked to the development of knee osteoarthritis, which is wear-and-tear arthritis. In some cases, this combines with osteoporotic osteoarthritis, where the bone beneath the cartilage becomes less dense due to high remodeling. This structural change can lead to stiffness and pain. Low back pain is also more common in postmenopausal women than in men of the same age, driven by these same physiological changes in sex hormones. Your muscles and tendons are also affected. Muscle stiffness has a negative relationship with oestrogen, meaning lower levels lead to tighter, less flexible tissue. In fact, oestrogen and muscle properties are closely correlated. This hormonal shift can contribute to sarcopenia, a loss of muscle mass. In one study of postmenopausal women, the prevalence of sarcopenia was 31%. Additionally, the tendons in your shoulder, such as the supraspinatus, contain receptors for oestrogen and progesterone. When these hormone levels drop, the tendon fibres may weaken. This increases the risk of asymptomatic full-thickness rotator cuff tears, where the tendon fibres separate completely. These tears are more prevalent in the postmenopausal period and are associated with metabolic disorders. Your shoulder joint is surrounded by a capsule, which is a sleeve of tissue that holds the joint together. Lower oestrogen levels may also increase your odds of developing adhesive capsulitis, or frozen shoulder, where this capsule becomes thick and tight. While hormone replacement therapy may offer some protection against these conditions, the evidence varies. Ultimately, the pain and stiffness you feel are direct results of your body’s changing hormonal landscape affecting the tissues that support your movement. ## What we can do about it Musculoskeletal pain is particularly prevalent during the perimenopausal transition. Arthralgia affects more than half of women around the time of menopause. This rise is linked to reduced oestrogen levels. You can start with self-care and physical therapy. Gentle exercise helps maintain mobility and strength. For thumb joint pain, combining proprioceptive neuromuscular facilitation exercises with strength training works better than strength training alone. This approach reduces disability and improves movement. If you have greater trochanteric pain syndrome and a body mass index under 25, combining hormone therapy with any exercise and education is superior to placebo. Give these conservative measures time to work. Consistency is key to seeing results in your daily comfort. Medical options include pain medication and anti-inflammatories. Hormone therapy is another path, but it has trade-offs. Oestrogen and selective oestrogen receptor modulators may help postmenopausal patients with early-stage wear-and-tear arthritis or osteoporotic arthritis. However, long-lasting use of systemic menopausal hormone therapy, particularly oestrogen-only therapy, is associated with a greater risk of chronic low back pain. Unopposed oestrogen shows a protective trend for incident radiological wear-and-tear arthritis of the knee. Yet, there is limited evidence for a protective effect of unopposed oestrogen use on the incidence of hip or joint replacement. Oestradiol supplementation may lead to better outcomes after rotator cuff repair, though differences in pain and function scores did not meet the minimal clinically important threshold. Discuss these benefits and risks with your doctor to find the right balance for you. If symptoms remain severe despite these steps, seek specialist input. Your doctor may refer you for a deeper assessment. Imaging can check for issues like asymptomatic full-thickness rotator cuff tears, which are more common in the postmenopausal period. For some specific conditions, a procedure may occasionally be considered if conservative care fails. This decision depends on your individual health profile and the severity of your pain. Your doctor will guide you through the next steps based on what works best for your body and your lifestyle. ## What to expect Musculoskeletal pain is common during the perimenopausal transition. More than half of women experience joint pain (arthralgia) around the time of menopause. This number increases as your oestrogen levels drop. You may notice that low back pain is more prevalent in postmenopausal women than in men of the same age. This is linked to lower sex hormone levels after menopause. Your outlook depends on how you manage these changes. For some conditions, such as early-stage wear-and-tear arthritis, oestrogen or specific oestrogen-modulating medications may be favourable. These treatments can help if you have reduced bone density. However, long-lasting use of systemic hormone therapy, particularly oestrogen-only therapy, is associated with a greater risk of chronic low back pain. There is limited evidence that unopposed oestrogen prevents the need for hip or joint replacement. It does show a protective trend for knee arthritis on X-rays. Rotator cuff tears are more common in the postmenopausal period and linked to metabolic disorders. Oestradiol supplementation may lead to better outcomes after rotator cuff repair, though the difference in pain scores might not feel significant to you. For thumb arthritis, combining specific stretching exercises with strength training is more effective than strength training alone. It reduces disability and improves mobility. If you have greater trochanteric pain syndrome and a healthy weight (BMI <25), combining hormone therapy with exercise and education works better than placebo. Sarcopenia (age-related muscle loss) affects about 31% of postmenopausal women living in the community. This can impact your physical activity. Overall, your doctor will tailor a plan to your specific symptoms. Some pain may settle with targeted therapy. Other symptoms, like chronic low back pain from long-term hormone use, may persist. Be honest about your pain levels. Realistic expectations help you manage the transition. Your body is changing, but you have options to stay active and comfortable. ## When to see someone The perimenopause is a state during which women are particularly predisposed to develop musculoskeletal pain. Arthralgia is experienced by more than half of women around the time of menopause. The prevalence of arthralgia appears to increase during the menopausal transition. Low back pain is more prevalent in postmenopausal women than age-matched men. See your GP if you have persistent pain not improving with rest, weakness or instability, locking or giving way, symptoms interfering with sleep or work, or sudden worsening. Long-lasting use of systemic menopausal hormone therapy is associated with a greater risk of chronic low back pain. Oestradiol supplementation was associated with better outcomes in postmenopausal women undergoing rotator cuff repair. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. It is written for the reader who wants the evidence itself, and it is worth the extra effort here because the obvious inference, that if falling oestrogen damages musculoskeletal tissue, then replacing the oestrogen should repair it, is not what the literature shows. The cluster of symptoms now has a name. In 2024 it was formally described as the musculoskeletal syndrome of menopause, grouping arthralgia, loss of muscle mass, loss of bone density and progression of osteoarthritis under a single cause: the precipitous fall in oestrogen across the transition [1]. Around 47 million women enter that transition each year. More than 70% will develop musculoskeletal symptoms and 25% will be disabled by them [1]. Two numbers from that paper deserve emphasis. The overall prevalence of musculoskeletal pain in perimenopausal women is approximately 71%, and 40% of women with these symptoms have no structural findings on imaging [1]. A normal scan does not mean nothing is wrong; it is the expected result in a large minority. The authors group the syndrome into five processes, which is a more useful frame than a list of complaints: inflammation (arthralgia, joint pain, frozen shoulder), sarcopenia (poor balance, falls, loss of stamina), reduced satellite-cell proliferation (muscle that will not rebuild), osteoporosis (height loss, stooped posture, low-impact fracture) and arthritis (joint pain and stiffness) [1]. Naming it matters because these have historically been assessed one joint at a time, by different clinicians, none of whom saw the pattern. ### What oestrogen is actually doing in the tissue Oestrogen receptors are present in tendon, muscle, cartilage and synovium, so the withdrawal of oestrogen is not a bone-only event. But the effect on tendon is more specific than a general decline. When ageing and oestrogen deficiency were compared directly in rotator cuff tendon, ageing reduced expression of both major collagens and of elastin, while oestrogen deficiency selectively reduced elastin alone, leaving the collagen genes unaffected [2]. Collagen is the rope; elastin is the recoil. That fits what people describe, not a tendon that has become weak so much as one that has become stiff and less forgiving. Three further mechanisms are consistently proposed for the joint pain itself: oestrogen normally suppresses inflammatory cytokine production, so its withdrawal permits a low-grade inflammatory state; oestrogen has a direct antinociceptive effect, so losing it lowers the pain threshold independently of any tissue damage; and accelerated bone turnover contributes its own discomfort [3]. ### The clearest natural experiment The strongest causal evidence does not come from menopause research at all. Aromatase inhibitors, used in breast cancer, produce profound and deliberate oestrogen deprivation, and the musculoskeletal consequences have been measured carefully. Across 21 studies and 13,177 women, the pooled prevalence of aromatase inhibitor-induced arthralgia was 45.9% [4]. Around 9.3% of women stop otherwise effective cancer treatment because of it [4]. Importantly, the arthralgia is predominantly non-inflammatory, the joints hurt without the markers of an inflammatory arthritis [3]. This is as close to an experiment as this field gets. Remove oestrogen abruptly and roughly half of women develop joint pain; the pain is real, common, and not explained by inflammatory disease. The parallel is drawn explicitly in the defining paper, which notes that increased arthralgia is reported both after aromatase inhibitors and after sudden withdrawal of menopausal hormone therapy [1], two different routes to the same abrupt loss, producing the same complaint. It is the best reason to take the menopausal version seriously rather than treating it as coincidental ageing. ### The conditions that cluster around it Shoulder pain is measurably more common after menopause. In a cross-sectional study of 21,095 people, shoulder pain was more prevalent in menopausal than non-menopausal women, with sleep duration and inflammatory markers among the associated factors [5]. Frozen shoulder is placed squarely inside the syndrome by the defining paper, which classifies it under the inflammatory arm alongside arthralgia and joint pain, and advises that a midlife woman presenting with adhesive capsulitis should prompt consideration of the syndrome as a whole rather than treatment of the shoulder in isolation [1]. It is worth being straight about the strength of that link. The independently replicated risk factors for adhesive capsulitis are diabetes, thyroid disease and hyperlipidaemia, and a genome-wide association study found a genetic contribution comparable in magnitude to the diabetes and hypothyroidism associations, implicating the Wnt pathway [6]. Menopause is not among those well-replicated factors. So the mechanism proposed, oestrogen withdrawal permitting an inflammatory state, is plausible and coherent with the arthralgia data, but the frozen-shoulder link rests at present on that reasoning rather than on epidemiology of the same weight as the diabetes association. There is also an overlap with widespread pain that is worth naming, because it cuts both ways. Fibromyalgia symptoms often begin around menopause, tend to be more severe afterwards, and can worsen following hysterectomy with or without removal of the ovaries [17]. The symptom lists of the two conditions overlap heavily. But fibromyalgia also occurs in women who are not menopausal and in men, so sex hormones cannot be the whole mechanism, and the review's conclusion is that the two should be recognised and treated as separate problems rather than collapsed into one [17]. Practically, that means widespread pain in a midlife woman should not be attributed to menopause by default, see our fibromyalgia page. ### Does replacing the oestrogen help? This is where intuition fails hardest, and the answer differs depending on what you measure. For tendon, the signal points the wrong way. In a propensity score-matched national cohort of 127,672 women aged 45 and over, systemic hormone replacement therapy was associated with an increased rate of tendon injury and a greater likelihood of proceeding to surgical repair [7]. In a separate prospective cohort of 6,007 women, long-lasting systemic therapy — oestrogen-only formulations in particular — carried a greater risk of chronic low back pain [8]. Given directly around surgery, the benefit is real but small. Among 184 postmenopausal women having rotator cuff repair, oestradiol supplementation produced better pain and shoulder-value scores, but the differences did not reach the threshold at which a patient would notice them [9]. Work on delivering oestradiol locally to the repair site rather than systemically has so far reached proof-of-concept in animals [10]. These are observational studies, and women who take hormone therapy differ systematically from those who do not. None of this is a reason to stop hormone therapy, which is prescribed for compelling reasons unrelated to tendons. What it does mean is that hormone therapy should not be expected to protect your tendons, and that new shoulder or elbow pain after starting it deserves assessment rather than the assumption that it must be unrelated. ### Around surgery the picture splits The perioperative literature is genuinely contradictory, and the contradiction is informative: medical complications and implant complications move in opposite directions. On the medical side, oestrogen replacement looks protective. In a cohort of 2,554,672 patients undergoing total joint arthroplasty, oestrogen replacement therapy was associated with decreased venous thromboembolism and fewer major medical complications [11]. In 21,220 women having total hip arthroplasty, hormone therapy before surgery was associated with fewer periprosthetic fractures at ten years and no increase in thromboembolism [12]. On the implant side the direction reverses. In a propensity-matched series of 3,558 patients undergoing total shoulder arthroplasty, the upper-limb operation most relevant here, oestrogen replacement was associated with a long-term increase in revision procedures and mechanical complications [13]. Another series found higher rates of revision and periprosthetic joint infection in patients on perioperative oestrogen replacement [14]. The practical conclusion drawn by a systematic review is narrower than either extreme: non-oestrogen-containing transdermal preparations should not be withheld before elective joint arthroplasty, while the case for withholding oestrogen-containing forms remains unproven either way [15]. If you are on hormone therapy and surgery is planned, this is a decision to make jointly with your surgeon and your prescriber, not unilaterally. ### What is actually known to help The most useful evidence is the least glamorous. In a randomised trial of postmenopausal women with thumb base arthritis, adding proprioceptive neuromuscular facilitation, guided movement patterns that train coordination rather than raw strength, to a strength programme beat strength training alone across pain, disability, mobility and grip [16]. That is the shape of the evidence overall. Targeted, supervised exercise earns its place. Hormonal explanations are better at accounting for why the tissue changed than at telling us what to do once it has. --- ### Nerve Pain Medicines (Gabapentin and Pregabalin) URL: https://www.cqupperlimb.com/education/general-health/nerve-pain-medicines/ Region: general-health · condition How medicines like gabapentin and pregabalin settle nerve pain, why they are built up slowly, their side effects, and using them safely. If you have been prescribed gabapentin, pregabalin, amitriptyline or duloxetine, you may be surprised: these aren't the painkillers most people reach for. There's a good reason. The pain they treat, nerve pain, behaves differently from ordinary pain, and it needs a different kind of medicine to settle it. Used properly, these are a valuable, non-opioid way to quieten nerve pain down. ## What nerve (neuropathic) pain is Most pain is a sensible alarm: you knock your hand, the tissue is bruised, and the area hurts until it heals. Nerve pain (doctors call it neuropathic pain) is different. Here the problem is the nerve itself: a nerve that has been irritated, squeezed or damaged starts firing off pain signals on its own, even when there's little or nothing wrong with the skin or tissue it reports from. The alarm, in effect, has become faulty and keeps going off. Nerve pain tends to feel distinctive. People describe it as: - Burning or hot - Shooting or electric-shock-like, often running along a line - Pins and needles, tingling or crawling - An area that feels numb but painful at the same time - Skin so sensitive that even a light touch or bedsheet hurts It can come from a trapped nerve such as carpal tunnel syndrome, from a nerve injury or after some operations, from conditions like shingles or diabetes, or from a condition called CRPS (complex regional pain syndrome) where a limb becomes painful and oversensitive after an injury. ## Why ordinary painkillers often don't help much This is the part that surprises people most. Paracetamol, ibuprofen and the other anti-inflammatories work mainly on inflammation and tissue damage (a sprain, a bruise, an operation site). Nerve pain isn't really an inflammation problem; it's an over-active, mis-firing nerve problem. So the usual painkillers, and even strong opioids, often make only a small dent in it. That's why we turn to a different group of medicines. Rather than calming inflamed tissue, they work on the nervous system itself, turning down the volume on the over-active pain signalling. They were first developed for other purposes (some for epilepsy, some for depression), and along the way they were found to be very good at calming faulty nerve signals. Being prescribed one does not mean we think your pain is imagined or that you have epilepsy or depression; it simply means we're using the medicine for the job it does best. ## Gabapentin and pregabalin (Lyrica) These two are the mainstay of nerve-pain treatment and are closely related. Pregabalin is sold under the brand name Lyrica; gabapentin is also sold as Neurontin. They work by calming down over-active nerve signalling. An irritated nerve fires partly by letting calcium flow into it through tiny gates called calcium channels; gabapentin and pregabalin dampen those channels, so the nerve fires less easily and fewer pain messages get through. They are not anti-inflammatories and they are not opioids; they quieten the nerve rather than numbing tissue. A word of realism: these medicines help nerve pain best when there is genuinely a faulty, over-firing nerve behind it. They are not a good way to manage ordinary aches or the normal soreness after an operation, and taking them routinely "just in case" around surgery isn't recommended; for that kind of pain they add side-effects without adding much relief. They earn their place when nerve pain is the real problem. ## Amitriptyline and duloxetine — the alternatives If gabapentin or pregabalin don't suit you, or don't quite do the job, two other medicines work on the same problem from a different angle. - Amitriptyline is an old antidepressant used here at a much lower dose than for depression. At these small doses it helps boost the body's own pain-dampening pathways in the spinal cord and brain. A typical starting dose is very low and taken at night, partly because it can aid sleep, which is helpful when nerve pain is keeping you awake. - Duloxetine is an SNRI (a newer type of antidepressant) that, again, strengthens the natural pain-control signals running through the nervous system. It's a particularly common choice for nerve pain related to diabetes. As with gabapentin and pregabalin, being offered one of these is about the pain pathway, not your mood. ## How these medicines are used — what to expect A few practical points apply to all of these medicines, and knowing them in advance makes the experience far smoother. They are started low and built up slowly. You'll usually begin on a small dose and increase it step by step over days to weeks. This isn't caution for its own sake. Going slowly lets your body get used to the medicine and lets the early side-effects settle, so you end up tolerating a useful dose that would have floored you if you'd started on it. They take time to work: they are not instant. Unlike paracetamol, you won't take a tablet and feel relief in half an hour. These medicines build their effect over days to a few weeks, and amitriptyline and duloxetine may need several weeks at a reasonable dose before you can fairly judge them. The single most common reason people miss out on a medicine that would have helped is giving up too early. If it isn't working yet, that often means it needs more time or a higher dose, not that it has failed. They take the edge off; they rarely switch the pain off completely. It helps to know what success looks like. For most people a good result is the pain becoming quieter and more manageable (say, dropping from severe to mild, or letting you sleep) rather than disappearing altogether. Some people get a lot of relief, some get a little, and some find a particular medicine does nothing for them, which is why it's often a case of trying one and, if needed, switching to another. Pairing the medicine with the rest of your treatment (keeping the hand moving, hand therapy, treating the underlying cause where we can) usually does more than any tablet on its own. Common side-effects. The usual ones are drowsiness, dizziness and a dry mouth; some people notice weight gain or mild swelling of the ankles. These are usually worst early on and often ease as your body adjusts, which is exactly why we build the dose up gently. Tell us if they're troublesome; slowing down the increases, or adjusting the dose, usually sorts it out. Driving and alcohol while you settle in. Because these can make you drowsy or lightheaded, be careful with driving or operating machinery until you know how the medicine affects you, especially in the first days and after each dose increase. Go easy on alcohol too, as it adds to the drowsiness. Don't stop them suddenly. When the time comes to come off one of these medicines, the dose should be reduced gradually (tapered) rather than stopped overnight. Stopping abruptly can cause unpleasant withdrawal effects. Always come off them with guidance, not on your own. ## A note on gabapentin and pregabalin as controlled medicines Gabapentin and pregabalin are now classed as controlled medicines. There are two reasons. First, they carry a risk of misuse and dependence in some people. Second, and most importantly for safety, they can be dangerous when combined with opioids or other sedatives (including strong sleeping tablets and significant alcohol), because together they can slow your breathing. In practice this means: take them exactly as prescribed, don't share them, don't take extra, and make sure every clinician treating you knows you're on one, especially if anyone is considering prescribing you opioid painkillers or sedatives. We have separate pages on managing pain after surgery and on cannabis and CBD for pain if those are relevant to you. None of this should put you off. For the great majority of people these are safe, effective and a genuinely useful non-opioid way to bring nerve pain under control. The controlled-medicine status is simply a reason to use them thoughtfully and only as prescribed. ## Seek help if Contact us, your GP, or seek urgent care if you notice: - Severe drowsiness or confusion, or you can't be roused easily - Mood changes, or any thoughts of harming yourself: tell someone straight away - Breathing problems or unusually slow or shallow breathing, especially if you are also taking an opioid or sedative (call emergency services) - Signs of an allergic reaction: a rash, swelling of the face, lips or tongue, or difficulty breathing (this is an emergency) And do get in touch if the medicine simply isn't helping after a fair trial, or the side-effects are hard to live with; there are several options, and it's usually a matter of finding the one that suits you. --- ### Nerve Tests and Conduction Studies URL: https://www.cqupperlimb.com/education/general-health/nerve-tests-and-conduction-studies/ Region: general-health · general-info What nerve conduction studies and EMG are, why they are done for carpal tunnel and other nerve problems, what to expect, and how accurate they are. ## What it is Nerve tests measure how well your nerves carry electrical signals. There are two electrical methods for checking nerve function, and both have proved useful in practice [1]. The main test is called a nerve conduction study. A small device sends a tiny pulse into your nerve and records how fast the signal travels. If a nerve is squeezed or damaged, the signal slows down or weakens. These tests are used most often for carpal tunnel syndrome, where the nerve at the front of your wrist is under pressure. They are considered an indispensable part of the assessment before surgery for that condition [2]. Most doctor's will not operate without this confirmation [3]. The tests can also help with other nerve problems, such as pressure on the nerve at the elbow (cubital tunnel syndrome) [4]. You will usually have a second test at the same visit. For this, a fine needle is placed into a few muscles. It checks how well the muscles respond to their nerve supply. Together, these are called electrodiagnostic studies, which simply means tests that use electricity to study nerves and muscles. The tests work because nerves carry signals like wires carry current. A squeezed nerve behaves like a pinched cable, so the signal along it is delayed or reduced. The results give a measure of how impaired the nerve is, and this is the best available indicator of the overall severity of the disease [5]. The value of these tests lies in getting the diagnosis right and judging how severe it is, rather than in predicting how you will feel after surgery [6]. One point worth knowing: a normal test does not rule out carpal tunnel syndrome, because the squeeze on the nerve can come and go. ## Does it work? The honest answer is that these tests are good at some jobs and limited at others. They are a useful addition when checking for carpal tunnel syndrome, especially when the standard tests come back normal [7]. One study of a special nerve test found it picked up the condition in 69% of cases, and every positive result was correct. When that test was combined with another way of measuring sensation, it picked up 84% of cases [8]. The tests also help confirm the diagnosis before surgery. When your signs and symptoms point to mild to moderate pressure on the nerve and surgery is being considered, extra testing can raise the chance that surgery is aimed at a real, treatable problem [9]. One study found a large gap between the number of people diagnosed by symptoms alone (73%) and the number confirmed by these tests and ultrasound (51%) [10]. That gap is exactly why testing matters: it sorts out who truly has a nerve problem that surgery can help. There are limits. The quality of these tests varies between providers, and some reports give more detail than others [11]. The criteria for reading them also need sharper definition, so that diagnoses are accurate and surgery is not done when it is not needed [12]. And the tests cannot tell you everything. They measure the nerve, not your symptoms. Some findings are mixed. Changes in the test results after a steroid injection were not significant at two years [13]. On the other hand, a good response to an injection is a helpful sign about how surgery might go [14]. One measure from the tests, called distal motor latency, which is simply how long the signal takes to reach a muscle, has some value in predicting how you will do after surgery [15]. So the tests work well as a diagnostic tool. They are less reliable as a crystal ball for your recovery. ## What are the risks? Nerve tests are safe, but you should know what to expect. The most common effect is discomfort during the test itself. The electrical pulses feel like small taps or twinges. If a fine needle is placed into a muscle, you will feel a brief sting, and the muscle may ache for a day or two afterwards. The ring-finger version of the test is quick and puts minimal strain on you [16]. There are no lasting effects on your skin or tissue from the electrical pulses. The pulses are small, and they pass through the skin without damaging it. If you have a needle test, the needle sites may be slightly tender, and a small bruise can appear. These settle on their own. The evidence does not describe effects on the rest of your body, and it does not describe rare but serious complications from these tests. That is worth stating plainly: the studies behind this page report on how well the tests diagnose and predict, not on harms, so the information here about serious risks is limited. One risk is not physical. The tests can be read differently by different providers, and some reports give more detail than others [11]. A report that lists small abnormalities without explaining them can lead to the wrong conclusion [17]. The criteria for reading the tests also need sharper definition, so that diagnoses are accurate and surgery is not done when it is not needed [12]. This is the main thing that can go wrong: not the test itself, but a diagnosis built on an incomplete or unclear report. If you have had a steroid injection for carpal tunnel syndrome, changes in the test results after that injection were not significant at two years [13]. That means the injection does not appear to change what the tests show over the longer term, so a repeat test after an injection should still give a fair picture of your nerve. Ask your doctor or the person doing the test to explain the report to you. A clear description of what the test found, and what it means, is part of a good result. ## Is it right for you? If your symptoms point to carpal tunnel syndrome and surgery is on the table, these tests are usually part of the plan. Most doctor's will not operate without this confirmation [3]. Extra testing can raise the chance that surgery is aimed at a real, treatable nerve problem [9]. That matters, because the tests get the diagnosis right and show how severe the pressure on your nerve is [6]. They may be less useful if your symptoms are vague or come and go. The squeeze on the nerve can be missed on the day of the test. A normal result does not rule out carpal tunnel syndrome. The tests also cannot predict how you will feel after surgery, so they are a tool for diagnosis, not a promise about your recovery [6]. The main alternative is ultrasound, which can also check for pressure on the nerve [9]. Your doctor may suggest one or both. Each has strengths, and the right choice depends on your symptoms and examination. This should be a shared decision with your doctor. Ask what the test is expected to show, and what will happen if the result is normal. If you have questions about the risks of the test itself, read the section above on risks. ## The bottom line If surgery for carpal tunnel syndrome is being considered, these tests are worth having. They confirm whether pressure on your nerve is real and show how severe it is [6]. Extra testing can raise the chance that surgery is aimed at a real, treatable problem [9]. Go in with a realistic expectation: the tests are good at diagnosis, but they cannot predict how you will feel after surgery [6]. The single most important caveat is that a normal result does not rule out carpal tunnel syndrome, because the squeeze on the nerve can come and go. Ask for a clear explanation of your report before any decision is made. --- ### Numbness and Tingling in the Hand and Arm URL: https://www.cqupperlimb.com/education/general-health/numbness-and-tingling-in-the-hand-and-arm/ Region: general-health · condition What causes numbness, tingling or 'pins and needles' in the hand and arm — from carpal tunnel and cubital tunnel to other nerve problems — when it matters, and what helps. ## What you're feeling Numbness and tingling in your hand often come from pressure on a nerve at the wrist. This is called carpal tunnel syndrome, and it is the most common nerve compression problem in the arm. The tingling usually affects the thumb, index and middle fingers. Some people also feel it further up the forearm. The symptoms tend to flare at night and can wake you from sleep. Shaking your hand or letting it hang down may settle the tingling for a while. Holding a phone, gripping a steering wheel or reading a book in the same position can make it worse. Many people notice it first thing in the morning, when the fingers feel clumsy or swollen before they loosen up. Everyday tasks can become harder. Doing up buttons, holding a cup of coffee, typing or turning a key may feel awkward when your fingers are numb. You might drop things without meaning to, because your fingers are not sending clear signals about what they are holding. Not all hand and arm tingling comes from the wrist. Pressure on a nerve near the elbow can cause tingling into the little finger, and a nerve problem in the neck or shoulder can send symptoms down the arm as well. Sometimes pressure at two places along the same nerve adds up, which is why your doctor will look at the whole arm, not just the hand. Some signs need urgent care. Go to the emergency department the same day if a finger, hand or arm becomes hot, red, swollen and painful, especially with a fever. The same applies if your fingers or hand turn pale, cold, white or blue, or if you suddenly lose feeling or movement after an injury. See your GP or ask for a specialist review if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand. If you cannot reach the clinic after hours or on a weekend, go to your nearest emergency department. ## What's actually happening Your nerves work like electrical wiring running from your neck down to your fingers. They carry feeling and instructions for movement. Where a nerve passes through a tight space, pressure can build up on it. That pressure is what causes the tingling and numbness described above. At the wrist, the main nerve to your thumb, index and middle fingers passes through a narrow channel formed by the small bones of the wrist and a tough band across the front. When that channel gets crowded, the nerve is squeezed. The squeezing affects the blood supply to the nerve first, then over time the nerve fibres themselves can be damaged. This is why symptoms often flare at night, when fluid settles in the wrist and the pressure rises. The same idea applies elsewhere. A nerve on the inside of your elbow can be squeezed by a tight band of tissue there. A nerve in your forearm can be pinched by muscle as it travels down to your hand. And a nerve problem in your neck can send symptoms all the way down the arm, which is why your doctor will check the whole arm. Pressure on a nerve can range from mild to severe. Early on, the nerve is irritated but still working, and the feeling usually comes back once the pressure is relieved. Left longer, the nerve fibres themselves start to break down, and the numbness can become permanent. This is why it is worth getting symptoms checked rather than waiting them out. Your doctor works out where the nerve is being squeezed by talking with you about your symptoms and examining your hand. A careful history points to the right diagnosis in about 90% of hand problems. Tapping over the nerve or holding your wrist bent can reproduce your tingling, which helps confirm the spot. If the picture is not clear, tests that measure how well the nerve carries signals can show whether the nerve is under real pressure and whether relieving it will help. ## What we can do about it There is a lot you can try before any procedure is discussed. Gentle massage and moving the wrist and hand can ease pressure on the nerve, and these approaches are recommended as a first step for carpal tunnel syndrome. Simple exercises that help the nerve glide and reduce swelling around it are easy to do at home and can be added to a therapy program in any setting. A splint that holds the wrist or elbow in a resting position, worn at night, can settle symptoms; for ulnar nerve entrapment at the elbow, 24% of people treated with a drop-out splint had their symptoms resolve completely. Give these measures a fair trial over several weeks. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. Medication can help alongside these measures. Anti-inflammatory medicine and simple pain relief may settle the irritation around the nerve. For some nerve problems, such as thoracic outlet syndrome, medicines that calm overactive nerves can help you sleep, and strong opioid painkillers are rarely needed before any surgery. If part of the problem is swelling in the hand from a blood vessel issue, a fitted compression glove can help. Some symptom questionnaires, like ones that score how severe your symptoms are and how much your hand limits you, help track whether treatment is working. If symptoms stay severe despite the above, your GP may refer you for a specialist assessment. Tests that measure how well the nerve carries signals, or a scan of the nerve itself, can confirm where the pressure is and whether relieving it will help. For some specific conditions, a procedure to relieve the pressure on the nerve may occasionally be considered. After most nerve pressure procedures, dressings stay on for about 10 days and are changed or removed at your review, with gentle movement starting soon after and therapy to rebuild strength and movement over the following weeks. ## What to expect Nerve pressure problems in the arm tend to follow one of two paths. Caught early, the nerve is irritated but still healthy, and symptoms often settle once the pressure is eased. Left for months or years, the numbness can become permanent, which is why it is worth acting rather than waiting it out. How long symptoms last depends on what is causing them and how soon you deal with them. Some people find their tingling comes and goes for a long time before it gets properly assessed. If the pressure is relieved early, feeling usually returns over weeks to months as the nerve recovers. Nerves heal slowly, so improvement is gradual rather than overnight. Some people notice the tingling fades first, while pins and needles can linger as the nerve wakes up. Without treatment, symptoms often keep flaring, especially at night, and can slowly worsen. Simple measures such as massage, gentle movement and a resting splint help some people, and the earlier section on non-surgical care covers what to try. If those measures are not enough, surgery to relieve the pressure gives many people lasting relief. Where a nerve has been badly damaged for a long time, a second procedure is less likely to fix the underlying problem, so earlier treatment tends to give better options. Recovery feels different for everyone. Many people notice their night symptoms ease soon after the pressure is relieved, while feeling and strength return more slowly over the following months. Your care team will track your progress with simple tests of feeling and movement, and therapy can help rebuild strength and movement. Some numbness may take a long time to improve, and if a nerve has been damaged for a long while, some change in feeling can remain. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone Most hand and arm tingling is not an emergency, but some signs are. Go to an emergency department the same day if a finger, hand or arm becomes hot, red, swollen and painful, especially with a fever. The same applies if your fingers or hand turn pale, cold, white or blue, or if you suddenly lose feeling or movement after an injury. For everything else, start with your GP. Ask for a specialist review if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand. Nerve pressure problems respond best when they are caught early, so it is worth getting checked rather than waiting months for the numbness to fade on its own. Your doctor will examine the whole arm, not just the hand. Tapping over the nerve at the wrist, pressing on the spot, or holding your wrist bent can all bring on your tingling, and each of these points to where the nerve is being squeezed. Sometimes a nerve is pinched in more than one place along its length, which is why the neck, shoulder and elbow are checked as well. If the examination does not give a clear answer, tests that measure how well the nerve carries signals can confirm the diagnosis. --- ### Nutritional Supplements for Musculoskeletal Health URL: https://www.cqupperlimb.com/education/general-health/nutritional-supplements-musculoskeletal-health/ Region: general-health · general-info Evidence on dietary supplements for joint, muscle and bone health — protein and amino acids, creatine, collagen peptides, glucosamine and chondroitin, and omega-3 — including perioperative recovery and osteoarthritis. ## What it is Nutritional supplements are extra nutrients you take by mouth, such as protein, amino acids, fish oil, collagen, or joint products like glucosamine and chondroitin. They are not medicines your doctor prescribes instead of surgery or physiotherapy. They sit alongside your usual care. People consider them at different times. Some are used around joint replacement or fracture surgery to help your body cope with the stress of an operation. Others are tried for arthritis pain, or after injuries like a torn knee ligament. Athletes sometimes use them too, though some products can cause problems with anti-doping rules [1]. The thinking behind them is fairly simple. Your body needs building blocks to heal bone, muscle, and cartilage. Protein and amino acids are those building blocks for muscle. Omega-3 oils, found in fish, are thought to calm inflammation in joints. Glucosamine and chondroitin are substances your cartilage is made from, so supplementing them may support the joint surface. The evidence varies a lot between products. Glucosamine and chondroitin have a good safety record and may be a reasonable early option for arthritis [2]. Omega-3 supplements taken for 3-4 months have been shown to reduce joint pain, morning stiffness, and the need for anti-inflammatory tablets [3]. Protein supplements around joint replacement or ligament surgery may help protect muscle while you recover [4]. Other products, such as peptide supplements, do not have enough good evidence yet to be recommended as part of standard orthopaedic care [5]. Your doctor can talk through which, if any, of these might suit your situation, and which are not worth your money or effort. ## Does it work? The honest answer is that it depends on which supplement and what you are recovering from. Some products have real evidence behind them. Others do not. Protein supplements look the most promising around surgery. They may help protect your muscles while you recover from joint replacement, ligament reconstruction, or hip fracture surgery [4]. One review found that a low-cost amino acid supplement led to fewer complications after surgery [6]. For older people with hip fractures, balanced nutritional supplements were linked to fewer complications and fewer deaths in the first 120 days after surgery [7]. Nutrition advice combined with supplements may also help you get moving sooner after joint replacement [8]. For arthritis, the picture is more mixed. Glucosamine and chondroitin have a strong safety record and may ease pain and improve function, but questions remain about their long-term effects and the right dose [9]. Omega-3 oils taken for 3 to 4 months have been shown to reduce joint pain, morning stiffness, and the need for anti-inflammatory tablets [3]. Collagen peptides eased knee arthritis pain compared with a dummy supplement [10]. After ligament surgery, one study found that a supplement combining collagen, hyaluronic acid, chondroitin, and plasma proteins helped people return to their pre-injury activity sooner and take fewer painkillers [11]. But creatine showed no benefit in the first 12 weeks of rehabilitation after the same operation [12]. There are real gaps in the evidence. Many of these studies were small, and some findings are mixed. For example, protein given directly into a vein around joint replacement showed benefits, but its effects on muscle strength and function were inconsistent [13]. Research on amino acids marketed to boost athletic performance often fails to support those claims [14]. Spine surgery evidence is promising but incomplete, with more work needed to settle the best approach [15]. Your doctor can help you weigh up which supplements have solid evidence for your situation and which do not. ## What are the risks? For most of these supplements, the main risk is that they do not help. Creatine showed no benefit in the first 12 weeks of rehabilitation after knee ligament reconstruction [12]. Amino acids marketed to boost athletic performance often fail to live up to those claims in scientific research [14]. Peptide supplements do not have enough good evidence yet to be recommended as part of standard orthopaedic care [5]. Some products carry a different risk. Athletes need to be careful, because some supplements can harm your health or your performance, and some can cause an anti-doping rule violation that affects your reputation and livelihood [1]. There are also limits to what the evidence shows. Protein given directly into a vein around joint replacement offers some benefits, but its effects on muscle strength and function were inconsistent [13]. Glucosamine sulfate may ease pain and improve function with few side effects, but questions remain about its long-term effects and the right dose [9]. Calcium supplements looked like they helped broken bones heal in one study, but they did not improve bone strength in that same research [16]. On the other side of the ledger, some risks appear to be low. Glucosamine and chondroitin have a good safety record [2]. A low-cost amino acid supplement around surgery led to fewer complications and was described as a low-risk intervention [6]. For older people with hip fractures, oral nutritional supplements and dietetic help were also described as low-risk [17]. The honest summary is that the safety picture varies between products. Some have been studied carefully and appear to cause few problems. Others have gaps in the evidence, so their risks are less well understood. Your doctor can help you weigh up what is known about any product you are considering, including how it might interact with your other care. ## Is it right for you? Supplements may suit you if you are about to have joint replacement or fracture surgery, especially if your diet is lacking. Nutrition advice and supplements with amino acids and micronutrients are options your doctor can offer if you are malnourished [18]. For older people after a hip fracture, oral supplements and dietetic help may improve recovery and survival [17]. A balanced supplement was linked to fewer complications and fewer deaths in the first 120 days after hip fracture surgery [7]. If you have knee wear-and-tear arthritis, glucosamine sulfate may ease pain and improve how your joint works [19]. It may be worth trying before more involved treatments, since it has a good safety record. Some people are less likely to benefit. If you eat well and have no surgery planned, extra protein or amino acids may add little. Calcium supplements looked like they helped broken bones heal, but did not improve bone strength in the same research [16]. If you are an athlete, check any product carefully, because some can breach anti-doping rules [1]. Compared with surgery or physiotherapy, supplements sit alongside your usual care rather than replacing it. They tend to work best when combined with good nutrition advice and a structured recovery plan. This is a shared decision. Bring up any supplement you are considering with your doctor, along with your other medicines and health conditions. Together you can decide whether the evidence for that product matches your situation, or whether your effort is better spent elsewhere. ## The bottom line Supplements are worth considering in a few situations, mainly around surgery or for arthritis pain. Around joint replacement or hip fracture surgery, protein and balanced nutritional supplements are low-risk options that may mean fewer complications [6] [7]. For knee wear-and-tear arthritis, glucosamine sulfate may ease pain and improve function, with few side effects [9]. Expect modest gains, not dramatic ones, and know that some products, like creatine after ligament surgery, show no benefit at all [12]. The most important caveat: talk with your doctor before starting anything, because the evidence varies between products and some can clash with your other care or anti-doping rules. --- ### Oral Steroids, Bone and Healing URL: https://www.cqupperlimb.com/education/general-health/oral-steroids-and-bone-and-healing/ Region: general-health · condition How long-term steroid tablets affect bone, wound healing and surgery, and why they must never be stopped suddenly. If you take steroid tablets, this page is for you. Medicines like prednisolone, prednisone or dexamethasone are valuable, sometimes essential, treatments: they calm down inflammation and overactive immune responses, and they help people with asthma, COPD, and a wide range of inflammatory and autoimmune conditions live well. None of what follows is a reason to stop taking them. But these medicines do have a few effects that matter when you are having surgery, and a little planning makes everything safer. The single most useful thing you can do is simple: tell your team you take steroids: which one, what dose, and how long you have been on them. ## What we mean by "steroids" here The word "steroid" gets used for several very different things, so it is worth being clear. This page is about corticosteroid tablets (prednisolone, prednisone and dexamethasone are the common ones) taken regularly for a medical condition. These are not the same as a steroid injection into a joint or tendon, which is a one-off, local dose given to settle a single painful area (we have a separate page on corticosteroid injections). And they are different again from the anabolic, muscle-building steroids sometimes used in sport, which are a completely different class of drug. When we ask about "steroids" before surgery, we mean the tablets you take regularly. ## Steroids and your bones One of the most important long-term effects of steroid tablets is on the skeleton. Long-term oral steroids are the commonest medical cause of osteoporosis, a thinning of the bone that makes it more likely to break. This matters to a surgeon because stronger bone heals and holds fixation better, and because a fracture is something we would much rather prevent. A few things are worth knowing, because they are reassuring as much as cautionary: - The effect is dose- and time-related, but even modest daily doses taken over months can begin to lower bone strength. - The fastest bone loss happens early, in the first several months after starting, which is exactly why bone protection is best thought about sooner rather than later. - It is largely manageable. Most people on long-term steroids should be thinking about bone protection as a routine part of their care. That usually starts with the basics: enough calcium and vitamin D. For people at higher risk, your doctor may add a bone-strengthening medicine (such as a bisphosphonate). If you take regular steroids and no one has talked to you about your bones, it is a very reasonable thing to raise. Our bone health and osteoporosis page goes into this in more detail. ## Steroids, wound healing and infection Steroids work by dampening inflammation and the immune response, which is precisely what makes them helpful for many conditions. The trade-off is that the same calming effect can make wounds heal a little more slowly and can make wound infection somewhat more likely. Over time steroids can also thin the skin, which is why people on long-term treatment often notice they bruise easily or get skin tears from minor knocks. None of this means surgery cannot go ahead. It simply means your team keeps a slightly closer eye on the wound, and that it is worth being gentle with the skin around a healing incision. As with smoking and alcohol (we cover those on their own pages), anything that supports healing is worth doing in the weeks around an operation. ## Steroids around the time of surgery — two key points This is the part that surprises people, so it is worth spelling out. 1. Do not stop your steroids suddenly. When you take steroid tablets regularly, your body senses there is plenty of steroid around and switches off its own production. If the tablets are then stopped abruptly, your body can be left with neither source for a while, and that can make you very unwell. So unless a doctor specifically tells you otherwise, you keep taking your steroids right up to and through your operation. 2. You may need a little extra "cover" around the operation. Surgery is a physical stress, and normally your body responds by making extra of its own steroid. Because regular steroid tablets have quietened that natural response, some people need a top-up dose of steroid (often given through a drip) around the time of the operation to fill the gap. This is called stress-dose or steroid cover, and your surgical and anaesthetic team plan it for you; you do not need to arrange anything yourself. It is a routine, well-understood part of looking after someone on long-term steroids. ## What this means for you — the practical bit - Tell your team you take steroids, and be specific: which medicine, what dose, and how long you have been taking it. If you have a steroid card or alert bracelet, bring it. - Never stop or change your steroids yourself. Follow the written instructions you are given, and ask if anything is unclear. - Ask about your bones if it has not already come up: calcium and vitamin D, and sometimes a bone-strengthening medicine (see our bone health page). - Remember this page is about steroid tablets, which are different from a steroid injection into a joint and different again from muscle-building steroids. ## When to seek help Most people on steroids sail through surgery without trouble. But it is worth knowing the warning signs, because they are easy to act on: - If you have missed steroid doses (for example through vomiting or illness) and feel very tired or weak, dizzy or faint, or are being sick: this can be a sign your body is short of steroid. Seek medical help promptly, and if you have an emergency steroid plan, follow it. - Around a wound, watch for signs it is not healing well or may be infected: increasing redness, swelling, warmth or pain, discharge or pus, a wound that opens up, or a fever. Let us know. - And as always: if you are unsure what to do with your steroids before an operation, ask us rather than guess. We would always rather answer the question. --- ### Osteoarthritis URL: https://www.cqupperlimb.com/education/general-health/osteoarthritis/ Region: general-health · condition The commonest arthritis — cartilage wear in the thumb base, fingers, wrist and shoulder — its symptoms, management ladder and outlook. ## What you're feeling Osteoarthritis usually creeps up slowly. A joint starts to ache, most often with use and by the end of the day, and eases when you rest. Many people notice a short spell of stiffness first thing in the morning that loosens off within about half an hour, or stiffness after sitting still for a while. In the upper limb it tends to settle in a few familiar places: the base of the thumb (where it meets the wrist), the end joints of the fingers near the nails, the middle joints of the fingers, the wrist, the small joint at the top of the shoulder (the AC joint), and the shoulder or elbow themselves. You may feel a grating or clicking as the joint moves, see bony knobbly swellings building up around the finger joints, and find the joint doesn't bend or straighten quite as far as it used to. Grip can weaken, and fiddly tasks (turning a key, opening a jar, doing up buttons) become harder. From time to time a joint can flare, becoming more painful, swollen and warm for days or weeks before settling again. ## What's actually happening Inside a healthy joint, the ends of the bones are capped with cartilage, a smooth, slippery layer that lets them glide over each other almost without friction. In osteoarthritis that cartilage gradually thins and roughens, so the glide is lost and movement becomes stiff and sore. The bone underneath then reacts to the extra load. It can thicken, and the body lays down small bony spurs (osteophytes) at the edges of the joint; these are the knobbly lumps you can feel around the finger joints (often called Heberden's nodes at the end joints and Bouchard's nodes at the middle ones). The joint lining can become inflamed in spells, which is what a flare feels like. It helps to know that osteoarthritis is not simply your joints "wearing out" from use. It's better understood as the joint's own repair process not quite keeping up, and it's driven by a mix of things you can't change: getting older, your genes and family history, and old injuries (a fracture or dislocation years ago counts), alongside how much load a joint carries. Staying active does not wear joints out; in fact, movement helps keep them healthy. ## What we can do about it Most people with osteoarthritis are managed well without an operation. The aim is to keep the joint moving, settle the pain, and protect your function, and there's a clear ladder of options. Keep moving and stay strong. Gentle, regular movement and exercises that build the muscles around a joint are among the most effective treatments. A hand therapist or physiotherapist can give you a tailored programme and show you how to keep range of movement. Protect and pace. Small changes make a real difference: spreading heavier tasks through the day, using both hands or larger grips, padded handles and jar openers, and splints (particularly a thumb-base splint) to rest and support a sore joint. Where weight is putting load through a joint, losing a little can ease the strain. Simple pain relief. Paracetamol, and especially anti-inflammatory gels or creams rubbed over the joint, often help, with anti-inflammatory tablets used in shorter courses when needed. Your doctor will weigh these up against your other health. Injections. A corticosteroid injection into a troublesome joint can calm a flare and buy months of relief, which is useful for getting on top of a bad patch. Surgery is held in reserve for a severe joint that stays painful and limiting despite all of the above. Depending on the joint, that might mean replacing it or fusing it (stiffening it solid to take the pain away). These are good operations when the time is right, but they're the last rung, not the first. ## What to expect Osteoarthritis is a manageable condition, not a steady slide downhill. For most people it grumbles along with good spells and occasional flares, and the day-to-day picture stays stable for years. Plenty of people keep doing the things they enjoy with the help of exercise, the odd splint, and simple pain relief. The bony lumps around the finger joints tend to be permanent once they form, but the pain from them often quietens down over time even though the knobbly shape remains. Where a single joint (commonly the thumb base or the AC joint at the shoulder) does become the sticking point, targeted treatment such as an injection or, eventually, surgery can sort that joint out specifically. The overall message is a reassuring one: this is something we can help you live well with. ## When to see someone - Joint pain that's limiting what you can do day to day, or that isn't settling with simple measures: it's worth getting it assessed and a plan put in place. - A single joint that becomes hot, red and very swollen quite quickly: an osteoarthritis flare can look this way, but so can an infection or gout, so a rapidly inflamed joint should be checked promptly. - Weakness, numbness or pins and needles in the hand or fingers, or pain that starts waking you at night. - Locking, giving way, or a sudden loss of movement in a joint. - When osteoarthritis in one joint (often the base of the thumb) is the main thing holding you back, so we can look at splinting, injection or surgical options for that joint specifically. --- ### Peptide Therapy in Musculoskeletal Medicine URL: https://www.cqupperlimb.com/education/general-health/peptide-therapy/ Region: general-health · general-info Injectable and regenerative peptide therapies in orthopaedics and sports medicine — what the evidence shows for tendon, cartilage and bone healing, and where the hype outpaces the data. ## What it is Peptide therapy uses tiny chains of building blocks, called peptides, that are injected into or near an injured joint or tendon. The idea is that these peptides act like messengers, encouraging your body's own repair processes to work harder. Some are also sold as supplements, taken by mouth rather than injected. You may have seen peptides advertised online or on social media. They are marketed widely, often with exaggerated claims and very little regulatory oversight [1]. It is worth knowing that injectable peptide therapy for muscle, tendon and joint problems is still largely experimental [2]. There is currently a lack of evidence to support its use in clinical care [3], and peptide supplements should not be used as a replacement for, or an add-on to, the standard orthopaedic treatment you would otherwise receive [4]. One peptide in particular, BPC-157, is often promoted for sports performance and recovery, but there are no randomised controlled trials of it in humans [5], so the science on how well it works and how safe it is has not been established [5]. In the lab and in animal studies, some peptides show interesting effects. In rat models of rotator cuff tears, certain peptides improved the healing between tendon and bone [6] [7]. Other peptide-based gels have helped cartilage repair in animal models [8] [9] [10], and one has shown promise for severe spinal cord injury in animals [11]. Separately, two bone-healing proteins called BMPs, which are growth factors used in bone surgery rather than peptide injections, can be recommended based on level I studies [12], and they have regulatory approval for specific fracture problems [13]. A lotion containing hyaluronic acid and peptides reduced pain and stiffness within 3 hours of the first application, over a 3-day treatment period [14]. Your doctor can talk you through where these treatments stand and what the current evidence supports. ## Does it work? For most peptide treatments, the honest answer is that we do not know yet. The research has not caught up with the marketing. Orthopaedic and sports medicine providers are asked to understand the current lack of evidence supporting the clinical use of peptide therapies [3]. For BPC-157, the peptide often promoted for recovery and performance, the science is clearly lacking on how well it works, how safe it is, and when it should be used [5]. So if you try it, you would be doing so without good human trials behind it. A different kind of treatment, used in bone surgery, has firmer support. One bone-healing protein (a BMP, which is a growth factor rather than a peptide injection) has regulatory approval for two specific problems: open shin fractures treated with a rod down the bone, and shin fractures that have failed to heal [13]. That is a narrow, well-defined use, not a general repair treatment for joints and tendons. Other work is still at the laboratory stage. In animals, a gel carrying a growth-related peptide protected nerve tissue and caused minimal inflammation, which points to possible future treatments for severe spinal cord injury [11]. Adding peptide-based gels to a cartilage repair technique called microfracture, where tiny holes are made in the bone to encourage healing, may improve cartilage healing outcomes [8]. These findings are early steps. They do not tell us what will happen in people. There is one interesting clue from human research. Two chemical messengers found in the body, substance P and another peptide, appear at higher levels in tendons that are more severely degenerated in a condition called tennis elbow [15]. This tells researchers peptides are involved in tendon problems. It does not tell us whether adding more peptides helps. So the picture is mixed. Bone-healing proteins, which are not peptide treatments, have approved uses for specific fracture problems. Animal and laboratory work is promising in places. But for the injectable peptide treatments marketed for muscle, tendon and joint complaints, there are no good human trials yet showing they work. If a clinic offers you peptide therapy, it is reasonable to ask what evidence supports that particular treatment for your particular problem. ## What are the risks? The honest answer is that nobody knows the full risk picture yet. For most peptide treatments, there are no good human trials, so the side effects have never been properly counted [3]. For BPC-157 in particular, the science on its safety profile has not been established [5]. That gap is itself a risk: you would be using a treatment whose harms are unknown. Some materials on the market have no long-term data at all on how soft tissue or bone reacts to them [16]. That means nobody can tell you what these substances do to your body over years, because the studies have not been done. There are a few things we can say more firmly. A lotion containing hyaluronic acid and peptides has been tested in people and found to be safe [14]. Beyond that, the picture thins out quickly. The evidence for peptide supplements is too weak to support using them alongside standard orthopaedic care [4]. And because peptides are sold widely online with exaggerated claims and minimal regulatory oversight [1], what a product actually contains may differ from what the label says. If you are considering peptide therapy, the main risk to weigh is this: the marketing is well ahead of the science. Ask what evidence supports the specific treatment being offered, and what is known about its safety in people. ## Is it right for you? Right now, peptide therapy is not a treatment we can recommend for most muscle, tendon or joint problems. The evidence is too thin, and the safety picture is incomplete. If you have a torn tendon, arthritis or a slow-healing injury, there are established treatments with a much stronger track record behind them. Those should come first. Peptide therapy would be an add-on to standard care at best, and the evidence does not even support that [4]. A small number of other treatments sit on firmer ground. Two bone-healing proteins called BMPs, which are growth factors used in bone surgery rather than peptide injections, can be recommended based on level I studies [12], and they are approved for specific fracture problems. A peptide and hyaluronic acid lotion has been tested in people and found safe, with early relief from pain and stiffness [14]. If one of those narrow uses applies to you, your doctor will tell you. For everything else, including the peptides marketed online for recovery and performance, you would be trying something without good human trials behind it [5]. The claims you see on social media are exaggerated and largely unregulated [1]. This should be a shared decision between you and your doctor. Ask what evidence supports the specific treatment on offer, what is known about its safety, and what the standard alternatives are. The risks section above sets out what is and is not known about harms. If the answers do not add up, it is reasonable to decline and stick with proven care. ## The bottom line For most muscle, tendon and joint problems, peptide therapy is not something we can point to good human trials for yet. The marketing runs well ahead of the science, and the safety picture is incomplete. Separately, bone-healing proteins (BMPs), which are not peptide treatments, have firmer support for a few specific fracture problems. If you are offered peptide therapy, the most important thing to know is this: nobody can yet tell you how well it works or what it does to your body over time. Ask what evidence supports the specific treatment on offer, and what the proven alternatives are. --- ### Platelet-Rich Plasma (PRP) and Injection Therapies URL: https://www.cqupperlimb.com/education/general-health/prp-and-injection-therapies/ Region: general-health · general-info What the evidence shows for platelet-rich plasma and related injection therapies in tendinopathy, osteoarthritis and rotator cuff disease — where they help and where the data is weak. ## What it is Platelet-rich plasma, often shortened to PRP, is a treatment made from your own blood. A small sample of your blood is spun in a machine so the platelets are separated and concentrated. Platelets are the tiny parts of blood that help with clotting, and they also carry growth factors, which are natural substances that may support healing. The concentrated platelets are then injected into the painful area. Your doctor may consider PRP for problems such as wear-and-tear arthritis in the knee, tendon problems in the elbow, shoulder or wrist, and some muscle injuries in sport. It is not used for every condition. For tennis elbow, the evidence is mixed: some studies found PRP worked better than steroid injections over the longer term [1], while a review of trials did not support it over placebo [2]. For knee arthritis, two injections are often recommended, with effects lasting at least 24 weeks [3]. For carpal tunnel syndrome, PRP showed more sustained benefits than a steroid injection at the 6-month follow-up [4]. The idea behind PRP is that the growth factors in platelets may reduce inflammation and encourage tissue repair. Research is still working out the details. Studies show that different preparations behave differently: one type rich in white blood cells seems to suit early arthritis, while another with more platelets and fewer white blood cells may suit later stages [5]. Some trials found PRP worked better than anaesthetic injections for shoulder and elbow tendon problems, but not better than dry needling or salt-water injections [6]. Overall, the evidence varies from condition to condition, and your doctor will discuss whether PRP makes sense for your specific problem. ## Does it work? The honest answer is that it depends on the condition, and in some cases the research is still catching up. A review of the evidence found that PRP is a potentially interesting treatment, but there is not yet enough good-quality research to support using it widely [7]. Researchers have also noted that some summaries of PRP trials for knee arthritis put a positive spin on their results, which can make the treatment look better than the evidence really shows [8]. For some conditions, the results are more encouraging. For tendon problems, trials found PRP improved pain and how well the affected part works, and worked better than steroid injections over the medium term [9]. For knee arthritis, PRP improved overall function, particularly in younger people [10]. Combining PRP with hyaluronic acid, a lubricating substance found naturally in joints, gave better pain relief and function than PRP alone [11]. For other conditions, the picture is mixed or unclear. For tennis elbow, some trials found PRP reduced pain and improved function in the early months [12], while other research did not back it as a treatment [2]. For rotator cuff tears, there is not enough good evidence to say either way [13]. For damaged knee cartilage, the evidence does not yet support PRP injections on their own [14]. What does this mean for you? PRP may help with some problems, but it is not a proven fix for everything. Your doctor will talk you through what the evidence shows for your specific condition, so you can decide together whether it is worth trying. ## What are the risks? PRP is made from your own blood, so your body is unlikely to react badly to the material itself. That does not mean the treatment is risk-free. The injection itself can cause pain, swelling and stiffness in the days afterwards, and the treated area may feel sore before it feels better. Your doctor will talk you through how to manage this. Research on PRP for knee arthritis has not settled the question of how well it works, and some published summaries have put a positive spin on their results [8]. That matters when you are weighing up whether to go ahead, because a treatment that sounds promising may not deliver the relief you hope for. For rotator cuff repair, adding PRP increased healing rates but did not change how well patients could use their shoulder in daily life [15]. For Achilles tendon problems, trials found PRP worked no better than placebo [16]. How your body responds can also depend on your circumstances. Previous corticosteroid injections and tobacco use seem to reduce how well PRP works for chronic medial epicondylitis, a tendon problem on the inside of the elbow [17]. If you smoke or have had steroid injections in the same area, mention this before deciding on treatment. Some questions remain open. Researchers have noted that more studies are needed to confirm PRP's long-term effects [18]. Studies of PRP for tennis elbow have shown mixed results, with some trials reporting early pain relief and improved function [12] and others finding no clear benefit over placebo [2]. There is also not enough good evidence yet to support PRP injections on their own for damaged knee cartilage [14]. If you notice increasing pain, redness or warmth around the injection site in the days after treatment, contact our rooms so we can check it. Your doctor will discuss the specific risks for your condition before you decide whether to go ahead. ## Is it right for you? PRP tends to suit some people more than others. If you have wear-and-tear arthritis in your knee, at least two injections are recommended, with effects lasting for at least 24 weeks [3]. If you play competitive sport, researchers have recommended offering PRP therapy to competition sports practitioners [19]. If you have carpal tunnel syndrome in both wrists, PRP showed more sustained benefits than a steroid injection at the 6-month follow-up [4]. There are situations where PRP is less likely to be the right choice. If you have damaged cartilage in your knee, the evidence does not yet support PRP injections on their own [14]. For tennis elbow, the evidence is mixed, so it may or may not help you. If you smoke or have had steroid injections in the same area before, PRP may work less well for you. PRP is one option among several. Steroid injections are the main alternative for some conditions, and PRP has shown longer-lasting benefits than steroids in some cases [4]. Another option is hyaluronic acid, a lubricating substance found naturally in joints. Research comparing the two is still at an early stage, so your doctor will explain what is known so far. This should be a shared decision between you and your doctor. Think about your goals, your condition and what the evidence shows for it. Your doctor will talk you through the options, including the risks covered in the section above, so you can decide together whether PRP makes sense for you. ## The bottom line PRP is worth considering for some problems, but go in with realistic expectations. It may ease pain and improve function for knee arthritis and some tendon conditions, though results vary from person to person. The most important caveat is that the research is still catching up, and for several conditions there is not yet enough good-quality evidence to support using it widely [7]. Your doctor will help you weigh up whether it makes sense for your specific problem. --- ### Psoriatic Arthritis URL: https://www.cqupperlimb.com/education/general-health/psoriatic-arthritis/ Region: general-health · condition An inflammatory arthritis linked to psoriasis — sausage digits, nail changes and end-joint involvement — and why early treatment protects the joints. ## What you're feeling Psoriatic arthritis tends to creep in rather than announce itself. You might notice that one or more joints (often in the fingers, but also the wrist or elbow) have become stiff and achy, and that the stiffness is worst first thing in the morning or after sitting still, easing once you get moving. That pattern, of stiffness that loosens with use, is a clue that the problem is inflammatory rather than simple wear and tear. A few features are especially characteristic. A whole finger (or toe) can swell up like a little sausage, and this is called dactylitis; it can be tender and make the digit hard to bend. You may see changes in your nails: tiny pits or dents, ridging, a yellowish lifting of the nail away from its bed, or crumbling at the edge. The end joints of the fingers, those nearest the nail, are often involved, which is a little unusual for inflammatory arthritis and a useful pointer for your doctor. Some people also get pain right where a tendon attaches to the bone, such as at the elbow or the back of the heel. Many people with psoriatic arthritis also live with the skin condition psoriasis, with patches of red, scaly skin, often on the elbows, knees or scalp. The joint trouble can begin before the skin changes, after them, or without any obvious skin involvement at all. Alongside the joints, a deep fatigue is common and can be one of the most wearing parts of the condition. (If your main concern is rheumatoid arthritis or a more general inflammatory joint problem, see our separate page on inflammatory and rheumatoid arthritis; psoriatic arthritis is a distinct condition, even though they can look alike.) ## What's actually happening Psoriatic arthritis is an immune-driven condition. Instead of defending the body, the immune system mistakenly attacks your own tissues and drives inflammation. The same misdirected process that causes the scaly skin of psoriasis can also target the joints and, distinctively, the entheses, the small zones where tendons and ligaments anchor onto bone. That inflammation is what you feel as swelling, stiffness and pain. The sausage-like swelling of a whole finger comes from inflammation in the joints and the tendon sheaths along the digit all at once. The nail changes and the involvement of the end finger joints reflect how closely the nail, the skin and that last joint are connected. This is not osteoarthritis, the "wear-and-tear" arthritis that comes with age and overuse; it is not the same as rheumatoid arthritis, although the two inflammatory conditions can resemble each other. The important point is that psoriatic arthritis is active and ongoing: if the inflammation is left unchecked over years, it can gradually damage and even deform the joints. The good news is that the process is treatable, and bringing the immune activity under control protects the joints from that damage. ## What we can do about it Diagnosis is usually made by a rheumatologist, a specialist in inflammatory joint disease. There is no single blood test that confirms psoriatic arthritis, so the diagnosis is pieced together from your story, an examination of the joints, nails and skin, and imaging such as X-rays or ultrasound. Telling it apart from other kinds of arthritis matters, because it changes the treatment. The mainstay of treatment is medical, led by rheumatology, and aimed at calming the immune process itself: - Disease-modifying drugs (DMARDs) such as methotrexate are often the first step. These dampen the overactive immune response and protect the joints over the long term. - Biologic and targeted medicines are used when DMARDs aren't enough, or for more aggressive disease. These are precision drugs that block the specific immune signals driving the inflammation, and they can be very effective for the joints, the entheses and the skin together. - Treating the skin psoriasis goes hand in hand with treating the joints, and is often coordinated with a dermatologist. - Hand therapy and exercise keep the joints moving, maintain grip and function, and help with stiffness and fatigue. Surgery has a role, but a limited one, mainly for joints that have already been damaged or deformed by years of inflammation, where the aim is to restore function or relieve pain. Even then, the medical treatment to control the disease continues. The single most important message is that early treatment protects the joints: the sooner the inflammation is controlled, the less lasting damage is done. ## What to expect Psoriatic arthritis is a long-term condition rather than something that is cured once and forgotten, but it is very treatable, and most people who start treatment early do well. The goal of modern care is to quieten the disease so completely that the joints feel and function close to normal, and for many people that is achievable. Because it is driven by the immune system, treatment is usually ongoing, and it can take some adjusting to find the medicine, or combination, that suits you best. The condition can wax and wane, with quieter spells and occasional flares. Staying in regular contact with your rheumatologist matters, both to keep the inflammation suppressed and to monitor the medicines. The trade-off for that long-term commitment is real protection: keeping the inflammation down preserves your grip, your hand function and your joints for the years ahead. ## When to see someone - Joint pain or swelling with morning stiffness, especially if a whole finger swells up or the stiffness eases as you move: this deserves assessment, ideally by a rheumatologist. - Psoriasis plus new joint symptoms. If you already have psoriasis and your joints start to ache, swell or stiffen, mention it to your doctor; the link is important and easy to miss. - Nail changes such as pitting, ridging, crumbling or the nail lifting away from its bed, particularly alongside joint or end-finger-joint pain. - Pain where a tendon meets the bone (for example at the elbow or heel) that isn't settling. - Joints becoming stiff, deformed or harder to use over time: a sign the disease may not be fully controlled, and worth reviewing so treatment can be stepped up before more damage occurs. --- ### Smoking and Musculoskeletal Healing URL: https://www.cqupperlimb.com/education/general-health/smoking-and-musculoskeletal-healing/ Region: general-health · general-info How smoking and nicotine affect bone healing, fracture union, spinal fusion, tendon and wound healing, and surgical complications — and the benefits of stopping before surgery. ## What it is Smoking affects more than your lungs and heart. It also slows down how well your body heals after bone, joint, tendon and ligament surgery. This page explains why, and what it means for your operation. Nicotine, the addictive chemical in tobacco, narrows the small blood vessels that carry oxygen and nutrients to healing tissue. It has a dose-dependent effect on bone healing, bone growth and implant integration [1]. That means the more nicotine your body gets, the more it can interfere with healing. Bone needs a steady blood supply to knit together, and implants need healthy bone to bed into. The effects show up across many types of surgery. Smokers face a higher risk of medical and surgical complications after elective hip or knee replacement [2]. After rotator cuff repair, heated tobacco products have a similar harmful effect on tendon healing as cigarettes [3]. Smokeless tobacco is linked to more complications after ACL reconstruction [4, 5] and after hip replacement [6]. For ankle and heel fracture surgery, smoking raises the risk of infection in the wound [7]. Nicotine dependence before upper arm fracture surgery carries a 60-110% increased risk of complications such as infection, wound breakdown, nonunion (a fracture that fails to heal) and reoperation [8]. The good news is that smoking is a modifiable risk factor [9, 10]. That means it is something you can change. Quitting matters. Former smokers who quit more than 6 months before rotator cuff repair show no detectable rise in infection or revision surgery compared with people who have never smoked [11]. Your doctor can talk with you about stopping, and about nicotine replacement options, well before your operation date. ## Does it work? The honest answer is that surgery can still work for smokers, but the evidence shows it often works less well. Studies of shoulder replacement found that current smokers may have poorer function afterwards than people who never smoked or who quit [12]. The rate of complications and revision surgery was similar between the groups [12]. So the implant itself may hold up, but how your shoulder feels and moves may not reach the same level. Nicotine on its own, without tobacco, also matters. Research on shoulder replacement found that nicotine dependence from sources other than smoking was linked to more wound breakdowns and infections in the first 90 days, and more loosening and joint infections at 2 years [13]. After keyhole rotator cuff repair, people with nicotine dependence needed more follow-up cuff repairs and more procedures to free up a stiff shoulder or clean out the joint, at both 2 and 5 years [14]. The same pattern appears elsewhere. After ACL reconstruction, people who had never smoked were more likely to gain good knee function than smokers [15]. For knee replacement, smoking seems to affect the early recovery period rather than pain levels alone [16]. For fracture surgery, nicotine's effect on bone healing depends on the dose, and this has been shown in animal and laboratory studies [1]. Surgeons are advised to ask every patient with a scaphoid fracture, a small wrist bone, whether they smoke or use smokeless tobacco, because both raise the chance of the fracture failing to heal [17]. Some of this evidence is stronger than others. Much of it comes from large patient records rather than trials where people are randomly split into groups. A few findings are mixed. One study found smoking carried a higher risk of complications than smokeless tobacco after knee replacement [18], which suggests no tobacco product is clearly safe around surgery. What this means for you is simple. Quitting before your operation gives your body the best chance to heal well, and the earlier you stop, the better. ## What are the risks? The main risks are the ones already described: slower healing, wound problems and infection. But there are some details worth knowing. Nicotine from any source, not just cigarettes, raises the chance of wound breakdown, infection and serious spread of infection in the first 90 days after shoulder replacement [13]. It also raises the chance of the implant loosening or becoming infected at 2 years [13]. This includes nicotine from pouches, gum or other products that contain no tobacco at all. Some risks depend on where you are having surgery. Smoking raises the risk of infection in the wound after ankle and heel bone fracture surgery [7]. After knee replacement, smoking seems to affect the early recovery period most [16]. For fractures of the scaphoid, a small bone in the wrist, both smoking and smokeless tobacco use are flagged as signs that the bone may fail to heal [17]. Not every risk is confirmed. One study of a specific type of lower spine operation found smoking did not slow bone fusion when a standard technique was used [19]. Newer techniques and bone-healing additives may offset some of smoking's effects in that setting [20]. So the picture is not the same for every operation. The clearest risk is the one you can change. Nicotine is a modifiable risk factor in rotator cuff surgery [10]. Quitting more than 6 months before rotator cuff repair shows no detectable rise in infection or revision surgery compared with people who have never smoked [11]. ## Is it right for you? There is no simple yes or no here. Smoking does not rule you out of surgery, but it changes the conversation you and your doctor need to have. The evidence shows that tobacco and nicotine affect healing across many operations, from wrist fractures to shoulder and knee replacements. So the question is less about whether you can have surgery, and more about how to give your body the best chance of healing well. That is why screening matters. Surgeons are advised to ask every patient with a scaphoid fracture whether they smoke or use smokeless tobacco [17], and to ask about all forms of tobacco use before ACL reconstruction [4, 5]. Nicotine from sources other than tobacco is part of that check too [21]. If you use any of these, telling your doctor early means you can plan around it, including quitting well before your operation date. Some situations need extra care. If you are a current or recent smoker having shoulder replacement, research suggests a hospital stay of at least 2 nights may help in the early recovery period [22]. And after knee replacement, smoking seems to affect the early recovery most [16], so closer follow-up in those first weeks can make a difference. This is a shared decision. Bring up your smoking or nicotine use honestly, ask what it means for your specific operation, and weigh the risks described in the section above against the benefit you hope to gain. Your doctor can help you decide on timing, and whether quitting first makes sense for you. ## The bottom line If you smoke or use nicotine in any form, it is worth stopping before your operation. Quitting is the one risk factor you can change, and the earlier you stop, the better. Surgery can still work for smokers, but your body gets a better chance to heal without nicotine slowing it down. The main caveat: nicotine from any source, including pouches and gum, affects healing too, so stopping tobacco alone may not be enough. --- ### Staying Active for Joint Health URL: https://www.cqupperlimb.com/education/general-health/staying-active-for-joint-health/ Region: general-health · general-info Why physical activity protects joints and tendons, how exercise helps osteoarthritis and recovery, and how to stay active safely. ## What it is Staying active for joint health means using regular movement to keep your joints working well and to help them heal. It covers everyday activity like walking, as well as planned exercise. Movement matters at every age. For children and teenagers aged 6-17, moderate to vigorous physical activity leads to multiple positive health outcomes [1]. In older age, staying active is linked with better overall health [2]. This approach is considered for people with joint problems such as wear-and-tear arthritis, and for anyone recovering from a joint injury or joint replacement surgery. Exercise is needed to support healthy joints and to keep cartilage, the smooth surface inside the joint, remodelling and repairing itself [3]. After an injury, a short period of rest may be followed by movement. Moderate exercise after that early rest can help tendon-bone healing, while staying still for too long works against recovery [4]. Once the first response to an injury has settled, the right amount of exercise may help damaged tendons remodel [5]. The way it works is simple: your body responds to the loads you place on it. Small increases in activity bring substantial protection against a range of chronic diseases in adults who have been inactive [6]. Any bouts of movement count, even short ones [7]. Around 30-40 minutes of moderate to vigorous activity per day can offset the health risks of long periods of sitting [8]. There is little evidence that being active causes significant harm, and the benefits generally outweigh the risks [9]. ## Does it work? For most people, yes, and the evidence behind staying active is broad. A regular program of modest aerobic activity, such as walking, is linked with measurable improvements in health, including lower rates of death from any cause and from heart disease [10]. Trials of exercise for wear-and-tear arthritis in the knee show it may improve pain and function, though it is uncertain how big that improvement feels in daily life [11]. For shoulder pain, both supervised exercise and surgery worked better than a placebo after 2 1/2 years of follow-up [12]. Exercising in water appears to ease pain from muscle and joint problems, and the relief may last [13]. Some findings are more mixed. Exercise therapy helped some teenagers with kneecap pain but not all, and sticking to the program was the hard part. Those who did their home exercises three times a week or more were four times more likely to have recovered after 12 months [14]. For rheumatoid arthritis, an autoimmune condition that inflames the joints, there is no strong research evidence for or against hand exercise, though it might improve strength long term and stiffness briefly [15]. Some programmes, such as one tested with online coaching, showed no clear benefit over usual care at 12 months [16]. The research also has gaps. Much of what we know comes from observing large groups of people over time rather than from strict trials [17], and researchers have not yet agreed on standard ways to define and measure activity [18]. Even so, there is little evidence that physical activity causes significant harm, and the benefits generally outweigh the risks [9]. Exercise therapy has not been linked to more minor side effects, and in people with several health conditions at once it appeared to lower the chance of serious problems such as hospital admission [19]. ## What are the risks? For most people, the biggest problem with staying active is doing too much, too soon. After an injury, a short period of rest is normal, but returning to hard exercise before your body has settled can work against you. Research on tendons found that increasing activity straight after a short period of immobilisation can harm tendon strength and shoulder joint movement, likely because of extra scar tissue forming [20]. Staying still for too long also slows recovery [4]. The aim is the middle path: gentle, steady movement once the first response to injury has calmed down. Exercise can also cause some short-term discomfort. Trials comparing exercise programs for long-term muscle and joint pain found that programs using painful exercises gave a small but real short-term benefit over pain-free ones [21]. In plain terms, some soreness during or after exercise is expected, and it does not always mean damage. The link between pain and tissue damage also becomes less predictable the longer pain lasts [22], so soreness alone is not a reliable guide to what is happening inside the joint. The good news is that serious harm from physical activity is uncommon. There is little evidence that being active causes significant harm, and the benefits generally outweigh the risks [9]. Exercise therapy has not been linked to more minor side effects, and in people with several health conditions at once it appeared to lower the chance of serious problems such as hospital admission [19]. For people with a hip resurfacing, a type of joint replacement, activity is considered safe for general health, and the quality of movement matters more than the amount [23]. Some questions remain open. Trials have not shown clearly that physical activity itself lowers the risk of death [24], and much of the evidence on activity and ageing comes from observing groups of people over time rather than strict trials [17]. If you notice pain that does not settle, or symptoms that worsen week to week, tell your doctor before pushing on. ## Is it right for you? Staying active suits most people, at any age and with most joint problems. If you have wear-and-tear arthritis, are recovering from a joint injury, or have had a joint replacement, movement is usually part of the plan. Even short bouts of activity count towards your health [7]. People who reach the recommended 150-300 minutes per week, or go beyond it, had a lower chance of heart disease than people who moved least [25]. For some, like those with a hip resurfacing, how you move matters more than how much [23]. It may not suit everyone straight away. If you have a new injury, your body needs a short rest first, and pushing hard too early can slow your recovery. Your doctor will help you judge the timing. There is no single alternative to compare it with, because staying active sits alongside other treatments rather than replacing them. Exercise programs, exercising in water, and surgery each suit different people and different joints. Which one fits you depends on your joint, your symptoms and your goals. This should be a shared decision with your doctor. Tell them what you want to get back to, whether that is walking the dog or returning to sport. Ask what a safe starting point looks like for you, and how to build up from there. The risks section above explains what to watch for, so you can raise any concerns before you begin. ## The bottom line Yes, staying active is worth it for your joints and your general health. Expect steady progress rather than a quick fix: exercise helps pain and movement in joints like the knee, though how much you feel day to day varies [11]. The main caveat is doing too much, too soon, especially after an injury, so build up gently and check with your doctor before pushing on. --- ### Stem Cell and Regenerative Injections URL: https://www.cqupperlimb.com/education/general-health/stem-cell-and-regenerative-injections/ Region: general-health · general-info What stem-cell and bone-marrow-derived injections claim to do for joints and tendons, what the evidence actually shows, and the safety and regulatory caveats. ## What it is Stem cell injections are a type of regenerative treatment. The idea is to use special cells from your own body, usually from bone marrow or fat, to help damaged tissue heal itself. These cells are taken out, prepared, and then injected into the painful or injured area, such as a worn joint or a tendon. Right now, there is not enough evidence to recommend stem cell injections as a routine treatment [1]. Researchers around the world are still working out how these cells behave and whether they truly help [2]. Some studies have found no clear benefit for conditions such as wear-and-tear arthritis [3]. Others have shown early promise, and the field is growing quickly [4]. Because of this, stem cell injections should only be offered as part of careful research trials [1]. The thinking behind the treatment goes like this. Your body already repairs itself after injury, and stem cells are part of that repair crew. The hope is that adding extra cells to an injured area will boost the healing response [5]. Some research suggests these cells may also calm inflammation and release helpful signals that encourage nearby tissue to mend [6]. Scientists are also testing ways to combine the cells with supportive materials, which may help them survive and work better once injected [7]. There are still more questions than answers in this field [8]. Your doctor can talk you through what the current evidence does and does not show, and whether a trial or another proven treatment might suit your situation better. ## Does it work? The honest answer is that it depends on the condition, and in many cases nobody knows yet. For knee wear-and-tear arthritis with swelling in the joint lining, one study found that injections of cells grown from donated umbilical cords were a workable option, with people feeling better by the end of follow-up, especially those who started with moderate to severe pain [9]. That is one promising result, but it comes from a field where the overall picture is mixed. For other treatments in this family, the results simply do not line up. Researchers reviewing bone marrow concentrate, where cells are taken from your own bone marrow and processed before injection, could not tell whether it works better than other regenerative options, because the studies so far point in different directions [10]. Some research has found the results were not strong enough to recommend stem cells for wear-and-tear arthritis at all [3]. There are also reasons to read this research carefully. Reviews of trials testing these cells for knee arthritis found that the way results were reported was often slanted towards the positive [11]. Most of those trials contained spin, meaning the findings were dressed up to sound more encouraging than they were [12]. That does not mean the treatment is useless, but it means you should treat bold claims with caution. What we can say is this. The evidence is early, mixed, and sometimes slanted. Some people do report feeling better, and researchers are still working out which conditions, which cells and which patients might benefit. Your doctor can talk you through where the evidence stands for your specific problem, and whether a research trial or a treatment with stronger proof behind it might suit you better. ## What are the risks? The honest answer is that researchers are still working out what the risks are. There is no clear biological explanation yet for how these cells are supposed to work [2], and experts say more knowledge is needed before these cells could become a routine treatment [13]. That makes it hard to give you a tidy list of side effects, because the field has not settled on one. Some problems have shown up in the research itself. Studies testing these cells for knee arthritis were often reported in a slanted way, with summaries sounding more positive than the full papers [11]. Most of those trials contained spin, meaning the findings were dressed up to sound more encouraging than they really were [12]. That is a risk to you as a reader of the evidence, not a physical one, but it matters when you are weighing up whether to have the treatment. There are also honest gaps in what the cells can do. In one study, the results were not strong enough to recommend stem cells for wear-and-tear arthritis at all [3]. In another, repair tissue filled in treated areas and untreated areas alike, with no real difference between them [14]. So a real possibility is that you go through the injections and feel no better afterwards. The way the treatment is given also seems to matter. Research points to the timing of injections being linked to how well the treatment works [15], and the number of cells used appears to affect the result too [16]. Because there is no agreed recipe yet, your experience may depend heavily on choices that are still being worked out. If you are considering these injections, ask what is being injected, how it is prepared, and what happens if it does not help. Your doctor can talk you through the known unknowns for your specific condition, and compare them with the risks of treatments that have stronger proof behind them. ## Is it right for you? Right now, stem cell injections are not a routine treatment for joint or tendon problems. The evidence is early and mixed, and some studies have found no clear benefit for wear-and-tear arthritis [3]. So this is not a treatment we can point to and say it works for everyone. It may suit you if your condition is one researchers are still studying, and if you are comfortable being part of that process. It is probably not the right choice if you want a treatment with strong, settled proof behind it. For many conditions, the honest answer is that nobody knows yet whether these injections help. There is also a real chance you go through the injections and feel no better afterwards. The risks section above covers what is and is not known about safety. Compared with the main alternatives, such as proven injections, physiotherapy or surgery, stem cell injections sit in a different category. Those other options have stronger evidence behind them for many problems. Stem cell injections are still being worked out, including the best timing and the best way to prepare the cells [15]. This should be a shared decision between you and your doctor. Ask what would be injected, how it would be prepared, and what happens if it does not help. Your doctor can compare this option with treatments that have stronger proof, and help you decide whether a research trial or a proven treatment suits your situation better. ## The bottom line Stem cell injections are worth considering only if you are comfortable with uncertainty. The evidence is early and mixed, and some studies found no clear benefit for wear-and-tear arthritis [3]. Reviews of knee arthritis trials also found the results were often reported in a slanted, overly positive way [11]. So go in with a realistic expectation: you may feel better, or you may feel no different. The single most important caveat is that this is not a proven, routine treatment yet. If you want settled proof behind your care, a proven injection, physiotherapy or surgery may suit you better. Your doctor can help you weigh it up. --- ### Testosterone, Anabolic Steroids and Musculoskeletal Health URL: https://www.cqupperlimb.com/education/general-health/testosterone-and-musculoskeletal-health/ Region: general-health · general-info Anabolic steroids and testosterone are linked to a higher risk of tendon rupture, including the rotator cuff, biceps and quadriceps. How steroids and TRT affect tendons, joints, bone and recovery from surgery. ## What it is Anabolic steroids are man-made versions of testosterone, the hormone that drives muscle and bone strength in men. Testosterone replacement therapy (TRT) is a prescribed form of testosterone for people whose own levels are low. A newer group of drugs called SARMs (selective androgen receptor modulators) act in a similar way, building muscle without using testosterone itself. Some people use these drugs to treat a medical condition. Others use them to build muscle for sport or appearance. Both groups should know the drugs affect tendons, the strong cords that join muscle to bone. Research has linked testosterone use with a higher risk of rotator cuff tears [1], biceps tendon injuries [2], and quadriceps tendon injuries within 1 year of filling a prescription [3]. One study found testosterone users had a 2.9-fold increased risk of tendon rupture compared to nonusers [4]. SARM use is also associated with tendon damage [5]. The link seems to work both ways. Too much testosterone appears to strain tendons and joints. Too little causes problems too, because hypogonadism (very low testosterone) seems to have a detrimental effect on the musculoskeletal system [6]. Studies have also connected testosterone levels with osteoarthritis, the wear-and-tear kind of arthritis [7]. If you are on prescribed testosterone and facing surgery, tell your doctor. It changes some risk calculations around operations such as shoulder replacement and rotator cuff repair. ## Does it work? There is no simple answer here, because these drugs do different things in different parts of your body. Testosterone can build muscle and bone strength. Four randomised controlled trials (studies where people are randomly given a treatment or not) found that testosterone given around the time of surgery improved clinical outcomes, body composition, and bone mineral density in orthopaedic surgeries [8]. Research has also pointed to a possible way to improve fracture healing by targeting the androgen/androgen receptor axis in the periosteum (the thin layer of tissue covering bone) [9]. But the same hormones can strain tendons and joints. Patients who filled a prescription for testosterone replacement therapy were much more likely to experience a quadriceps muscle or tendon injury within 1 year of filling their prescription, and were at increased risk of needing surgical repair of the quadriceps tendon [3]. Patients prescribed at least 3 months of testosterone replacement therapy had a significantly higher incidence of ACL injuries compared to controls within a 2-year follow-up period [10]. Injectable testosterone replacement therapy use within 1 year of primary ACL reconstruction is associated with a 3.3-fold increase in ACL reconstruction revision rates with 2 years of follow-up [11]. A bidirectional Mendelian randomised study (a genetic study that tests cause and effect) supported a causal relationship between bioavailable testosterone levels and osteoarthritis, identifying bioavailable testosterone levels as a risk factor for osteoarthritis [7]. Surgery outcomes are mixed. Patients prescribed supplemental testosterone had a higher risk of all-cause reoperation and reoperation for infection after total shoulder arthroplasty (shoulder replacement) [12]. Preoperative testosterone replacement therapy use was not linked to increased short-term complications after arthroscopic rotator cuff repair (keyhole shoulder tendon surgery) [13]. Patients on testosterone therapy should be counselled about their increased risk for complications following distal biceps tendon repair, and both preoperative risk stratification and optimisation should be employed to minimise perioperative risk [14]. Cessation of testosterone replacement therapy prior to rotator cuff repair should be considered on a patient-specific basis [15]. Anabolic steroids use may contribute to pectoralis major rupture (a tear of the large chest muscle), but continuation during recovery does not seem to have a negative effect on functional recovery [16]. Both too much and too little testosterone seem to have a detrimental effect on the musculoskeletal system (your muscles, tendons, bones and joints) [6]. ## What are the risks? The clearest risks sit in your tendons. Research links testosterone use with a higher chance of quadriceps tendon injury [17]. SARM users often take far more than the doses studied, and case reports tie that to tendon damage [18]. Anabolic steroids and very low testosterone can both harm your muscles, tendons, bones and joints [6]. Your joints can be affected too. A genetic study found a causal link between bioavailable testosterone levels and osteoarthritis [7]. The relationship is not a straight line, so keeping testosterone in a healthy range may matter for joint health [19]. If you take testosterone and need surgery, the risks change. Testosterone use is linked with a higher risk of reoperations after shoulder replacement, both for infection and for any reason [20]. It is also a possible risk factor for complications and reoperation after rotator cuff repair, though one study found no link with short-term problems after keyhole rotator cuff surgery [15] [13]. Stopping testosterone before rotator cuff repair is a decision made case by case [15]. Patients on testosterone face a higher risk of complications after distal biceps tendon repair, so doctors assess and prepare you carefully beforehand to lower that risk [14]. Some findings cut the other way. Four randomised controlled trials found testosterone given around the time of surgery improved clinical outcomes, body composition, and bone mineral density in orthopaedic surgeries [8]. Anabolic steroid use may contribute to a pectoralis major rupture, a tear of the large chest muscle, but continuing the drugs during recovery does not seem to harm how well you recover [16]. Some questions remain open. Evidence on whether testosterone supplementation is linked with stroke in young adults is limited and underexplored [21]. And testosterone raises tendon rupture risk in men but not women, possibly because men and women are given different doses [22]. ## Is it right for you? These drugs suit different people for different reasons. Prescribed testosterone can help if your own levels are low, and it can build muscle and bone strength. Four randomised controlled trials found testosterone given around the time of surgery improved clinical outcomes, body composition, and bone mineral density in orthopaedic surgeries [8]. But the same hormones can strain tendons and joints, and research links testosterone use with a higher chance of quadriceps tendon injury [17]. A genetic study also found a causal link between bioavailable testosterone levels and osteoarthritis [7]. The relationship is not a straight line, so keeping testosterone in a healthy range may matter for joint health [19]. SARMs are a harder call. They can increase lean body mass at low doses, but case reports suggest users take far more than the doses studied, raising the risk of tendon damage, liver injury and cardiovascular events [18]. SARM use is also associated with liver and heart harm and androgenic side effects throughout the body [5]. There are no good trials showing they are safe, and public health bodies have called for regulation of these grey-market compounds [23]. If you are on testosterone and facing surgery, your doctor should assess your individual risk profile before deciding together [14]. Hormonal status belongs in any assessment of your muscle, tendon and joint risks [24]. This is a shared decision, made with your doctor, based on your own health and goals. ## The bottom line If your testosterone levels are low, prescribed testosterone can help your muscles and bones. But these hormones can strain tendons and joints, and the risks rise with higher doses. If you are facing surgery, tell your doctor about any testosterone or SARM use, because it changes how your risks are assessed. The single most important caveat: both too much and too little testosterone can harm your body, so any decision should be made case by case with your doctor. --- ### Outcome scores: what they measure, and what they don't URL: https://www.cqupperlimb.com/education/general-health/understanding-outcome-scores/ Region: general-health · general-info What PROMs (patient-reported outcome measures) like the DASH, QuickDASH, SPADI, ASES and PRWE actually are, and how to read your own score. They exist to track how YOUR symptoms and function change over time, and to compare groups of patients in research. They are not a test… ## What it is A patient-reported outcome measure, or PROM, is a questionnaire about your own health. You fill it in yourself. It asks how you feel and what you can do in daily life. No test or scan can capture that view, because only you know it [1]. These questionnaires have been around since at least the 1960s [2]. They are standardised and validated, which means the questions are set in advance and tested to make sure they measure what they claim to measure [3]. A concrete example: a shoulder questionnaire might ask how much trouble you have reaching a high shelf or getting dressed. Your answers turn into a score, and that score can be tracked over time. Why does your doctor use them? Because the usual physical checks are less reliable than you might think. Measuring how far a joint moves, or how strong it is, does not always reflect how you actually feel and function [4]. Questionnaires are also useful for shared decisions about your care and for routine check-ups after surgery [5]. There are different types. Some focus on one joint or condition, like a shoulder arthritis index. Others, such as the NIH PROMIS measures, cover general symptoms and function [6]. The same questions can come by text message on a mobile phone or on paper, and both give comparable scores [7]. One thing to know: your score is an average picture, not a personal verdict. Researchers are working on better ways to report how many patients reach a level of change that actually matters in daily life, rather than relying on average scores alone [8]. ## Why it matters A score from a questionnaire does two different jobs, and it helps to know which one is which. The first job is following you. When you fill in the same questionnaire before and after treatment, your scores trace your own progress over time. That picture belongs to you alone. It shows whether things are moving in the right direction for you, and it gives you and your doctor something concrete to look at together when you make decisions about your care [9]. Your own result is most useful as a marker of your own change, not as a score to be ranked against other people. The second job is comparing groups. When many patients fill in the same questionnaires, their answers can be pooled so that treatments and services can be judged across whole populations [10]. This is how the wider health system learns which approaches work well for people in general. Collecting these scores routinely, and sharing them with patients as care decisions are made, is described as the future of healthcare that puts patient views at the centre [11]. It is worth knowing that this shift is still under way. Only 57% of primary medical providers use these questionnaires in their practice, and much of the information gathered so far has been used for research rather than for day-to-day clinical decisions [12]. The move towards routine use has also been driven largely by researchers and funders, and has not always focused on improving care from the patient's point of view [13]. So when you are asked to complete one of these questionnaires, the most meaningful use of your answers is close to home. They record how you feel and what you can do, in your own words, at that moment. Over time they show your change. That is the job that matters for you. ## What the results mean So you have a score in front of you. What does the number actually tell you? First, which way is better? It depends on the questionnaire. The form itself, or the person who gave it to you, will tell you which way round it runs. Do not assume one direction applies to all scores. Second, how big a change matters? A small shift on paper may not be a change you would notice in daily life. Researchers use the term "minimal clinically important difference" for the smallest change a patient would actually feel. There is no single threshold that works for every score or every group of patients, because values vary between hospitals and patient populations [14]. So a change worth noticing for one questionnaire cannot simply be copied onto another. Third, one score on its own says less than the same score measured again later. A single result is a snapshot. The pattern over time is what shows your progress. For that pattern to mean anything, the questionnaire needs to give similar answers when nothing has changed, and to move when your health does [15]. A few cautions worth knowing. A difference that looks real on paper may not be a difference you would feel, because statistical significance does not always match what matters in daily life [15]. And many studies of these scores do not report the full range of uncertainty around their results, or say in advance what size of change would count as meaningful [16]. That is a limitation of the research, not a reason to dismiss your own scores. When a study does report how many patients reached a level of change that matters, that proportion tells you more than an average score alone [8]. Your own care team can help you read your result in that light, alongside how you actually feel and what you can do. ## What it can't tell you A questionnaire score does not diagnose anything. It records how you feel on the day you fill it in. It cannot tell you what is wrong, and it cannot decide which treatment you should have. Those decisions belong to you and your doctor together, using the score as one piece of information among many. A single result is also not a verdict on how well you are doing. The questions are fixed, so they may miss what matters most to you. If the questionnaire does not cover the part of your health that treatment is meant to help, a real improvement can go unnoticed [17]. Scores can also bunch up at the very top or bottom of the scale, which means two people with very different lives can land on the same number. Group averages hide individual stories. When results from many patients are pooled, the range of experiences between them disappears from view. Your own path may sit well outside that average, in either direction, and that is normal. There are honest limits in the research itself. The way these scores are collected is not uniform across the world's registries, which affects how well results can be compared [18]. The questionnaires still need further testing to fill gaps in what we know about how they measure [19]. And the thresholds used to judge whether a change matters vary widely, because different methods of calculating them give very different values [20]. There is no single threshold that works everywhere, for any score [14]. None of this makes your answers less useful. It means a score is a conversation starter, not a conclusion. Bring your own account of what you can do and how you feel, and treat the number as one part of that picture. ## The bottom line A questionnaire score is good for one thing: showing how you feel and what you can do over time. It is not a diagnosis, a verdict, or a promise about your future. Use it as one piece of information alongside your own account of daily life. The one thing worth remembering: the pattern across several questionnaires matters more than any single number. --- ### Understanding Your Scans (X-ray, Ultrasound, MRI, CT) URL: https://www.cqupperlimb.com/education/general-health/understanding-your-scans/ Region: general-health · condition What X-rays, ultrasound, MRI and CT each show, and why your surgeon chooses one over another. When your surgeon orders a scan, it can feel like alphabet soup: X-ray, ultrasound, MRI, CT. Each one is a different tool that shows a different thing, a bit like the difference between a photograph, a video and a 3D model. None of them is simply "better" than the others; the right choice depends entirely on what we need to see. Knowing what each scan is good at takes a lot of the mystery out of the instructions you're given, and helps you understand why we sometimes ask for more than one. ## Why different scans? Each one sees something different The single most useful thing to understand is that every type of scan is suited to a particular kind of tissue. Bone, tendons, ligaments, cartilage and nerves all show up differently, and no single scan shows all of them perfectly. An X-ray is superb for bone but almost blind to a tendon; an ultrasound shows a tendon beautifully but can't see deep inside a joint. So when we pick a scan, we're really asking a question: is the problem in the bone, or in the soft tissues, or both? The answer decides the tool. That's also why you might have one scan, then be sent for another. It usually doesn't mean anything was wrong with the first one; it means we've narrowed down the question and now need a different kind of picture to answer it. ## X-ray — the picture for bone An X-ray machine: a tube above the table sends a brief beam through the body to a detector beneath it. Nahid.rajbd / Wikimedia Commons, CC BY-SA 4.0 An example X-ray — here of the shoulder. Dense bone shows up bright white; soft tissues barely register. Kieran Hirpara 4.0 An X-ray is the quickest and most familiar scan, and it remains the first test for most bone problems. It passes a small amount of radiation through the area and the dense bone shows up clearly white, which makes it excellent for spotting fractures (broken bones), arthritis, the alignment of bones, and dislocations. It's fast, inexpensive and widely available, and the radiation dose is small. How it actually works. X-rays are made inside a small tube on one side of you: electricity boils electrons off a hot filament and fires them at a metal target, and as they slam to a stop that energy is released as X-rays, a form of very high-energy "light" that, unlike ordinary light, passes straight through soft tissue. (They belong to the same family of radiation as gamma rays, but are produced by these electrons rather than from inside the atom's nucleus.) As the beam crosses your body, dense bone absorbs much more of it than soft tissue or air. A flat detector on the far side records how much got through at each point: where lots of X-rays reach it the picture is black, where few do (behind bone) it is white, and that shadow map is the image. Its limitation is the flip side of its strength: X-rays see bone well but show soft tissues (tendons, ligaments and cartilage) only as vague grey shadows. So a normal X-ray doesn't rule out a soft-tissue injury; it simply tells us the bone looks intact, which is often exactly the reassurance we need first. ## Ultrasound — a live view of soft tissues near the surface An ultrasound machine: a hand-held probe sends and listens for sound waves, building the picture live on the screen. Erereony / Wikimedia Commons, CC BY 4.0 An example ultrasound — the grainy greyscale view, here of a shoulder tendon. Kieran Hirpara 4.0 Ultrasound uses high-frequency sound waves rather than radiation, so there's no dose at all. A small probe is moved over the skin with a little gel, and it's particularly good at showing soft tissues that sit fairly close to the surface: tendons, ganglion cysts, pockets of fluid, and inflammation. How it actually works. The probe contains crystals that buzz when a tiny electric pulse is applied to them (the piezoelectric effect), firing pulses of sound far too high-pitched to hear into the body. Each time a pulse crosses a boundary between two different tissues, part of it echoes back. The probe then switches to "listening" and detects those echoes. The machine measures how long each echo takes to return (which tells it how deep that boundary is) and how strong the echo is (which sets how bright it appears), and assembles thousands of these readings every second into the live picture. Aimed at flowing blood, it can also read the change in pitch of the returning echoes (the Doppler effect) to show, and even measure, blood flow. Its special trick is that it works in real time. Because we can watch the picture live, we can ask you to move your hand or shoulder and watch a tendon glide as it happens, something a still image can't show. This makes it very useful for tendon problems around the wrist, hand and shoulder. The main thing to know is that ultrasound is operator-dependent: the quality depends on the skill of the person holding the probe, and it can't see deep inside a joint or through bone. ## MRI — the detailed all-rounder for soft tissue and bone An MRI scanner: a large magnet you lie inside, using magnetic fields and radio waves rather than radiation. Kieran Hirpara 4.0 An example MRI slice — here through the shoulder, soft tissue and bone together in shades of grey. Kieran Hirpara 4.0 An MRI uses a strong magnet (no radiation) to build remarkably detailed pictures. It is the all-rounder, because it shows both soft tissue and bone in fine detail: ligaments, cartilage, nerves, bone marrow, and even hidden fractures that don't show on a plain X-ray. When we're planning surgery or chasing a problem that the other scans can't quite pin down, MRI is often the deciding test. How it actually works. Your body is mostly water and fat, which means it is full of hydrogen, and the nucleus of a hydrogen atom is a single proton that spins like a tiny magnet. Normally these point in every direction, but inside the scanner's powerful magnetic field they line up with it and wobble, or precess, at a precise rate set by the field's strength. The scanner then sends in a radio-wave pulse tuned to exactly that rate, which tips the protons out of line and feeds energy into them. When the pulse stops, they relax back into line and hand that energy back as a faint radio signal, which receiver coils pick up. Different tissues release their signal at different speeds, and that is what creates the contrast between, say, cartilage, fluid and bone. Magnetic-field gradients tag where in the body each signal came from, and a piece of mathematics called a Fourier transform turns the mass of collected signals into the detailed image. A few practical things are worth knowing so it isn't a surprise: - It takes longer, usually around 20 to 40 minutes, and you need to lie fairly still for clear images. - You lie inside a tunnel, and the machine is noisy, making knocking and banging sounds while it works. You'll be given earplugs or headphones. - If you're very claustrophobic, please tell us beforehand; there are ways to make it easier, and sometimes a different machine or a mild sedative can help. - If you have certain metal implants (such as a pacemaker, or older metalwork), let us know. Many implants such as plates and screws are perfectly safe, but we always check first, so mention anything you have. ## CT — 3D detail for complicated bone A CT scanner: a ring that spins an X-ray tube around you, capturing images from many angles to rebuild slices. Kieran Hirpara 4.0 An example CT — a cross-sectional ‘slice’, here through the shoulder, showing bone in crisp detail. Kieran Hirpara 4.0 A CT scan takes many X-rays from different angles and a computer builds them into detailed cross-sections, and even a 3D model. Like a plain X-ray it is built around bone, but with far more detail, which makes it superb for complex fractures (where bone is broken into several pieces) and for planning surgery in three dimensions. For tricky breaks around the wrist, elbow or shoulder, a CT can show exactly how the fragments sit so we can plan the repair precisely. How it actually works. A CT scanner is essentially a spinning X-ray machine: an X-ray tube and a ring of detectors rotate around you while you move slowly through the doughnut-shaped opening, capturing X-ray views from hundreds of angles. On its own each view is just a flat shadow, but a computer combines them all, working out exactly how dense the tissue is at every point, to reconstruct cross-sectional "slices" that can be stacked into a 3D model. The trade-off is that it uses more radiation than a plain X-ray, so we order it when that extra detail genuinely changes the plan. ## A different kind of test — nerve studies Not every test is a picture. If the concern is a nerve (numbness, tingling or weakness), we may arrange nerve conduction studies or an EMG. Rather than photographing the body, these measure how well the nerves and muscles are actually working, by sending tiny electrical signals along a nerve and recording the response. It answers a different question entirely. You can read more on our nerve tests and conduction studies page. ## Putting it together — what to expect The reassuring bottom line is that the team chooses the scan based on exactly what we need to see, and most scans are quick and painless. An X-ray or ultrasound is often all that's needed; an MRI or CT comes in when we need finer detail or a surgical plan. Whatever you have, the results will be explained to you in plain language, alongside what they mean for your treatment. If you'd like, these are good questions to ask: - What is this scan looking for, and which tissue does it show? - Will I need anything else after it, and roughly how long will it take? - Is there anything I should mention first: claustrophobia, metal implants, or being pregnant? - When and how will I get the results explained? There are no silly questions here. Understanding why a particular scan was chosen often makes the whole process feel a good deal less daunting. ## In more depth Advanced reading: the deeper science (optional) This section steps up to a more detailed, student-level explanation. It isn't needed to understand your results, but if you're curious about how each machine actually makes its picture, read on. ### X-ray and CT: shadows of density An X-ray is a beam that passes through the body and is absorbed more by dense tissue (bone) than by soft tissue or air. What reaches the detector is effectively a shadow: bone shows white, air black, soft tissue grey. A CT scan is simply many X-rays taken from all angles and computed into cross-sectional "slices," giving 3D bony detail. Both use ionising radiation (a CT far more than a single X-ray), which is why they're used judiciously. ### Ultrasound: listening to echoes An ultrasound probe sends pulses of very high-frequency sound into the body and listens for the echoes that bounce back off tissue boundaries. A computer turns the timing and strength of those echoes into a live, moving image. It uses no radiation, and because it's real-time it's excellent for soft tissues near the surface and for watching structures move, for example a tendon gliding or a tendon tear opening up as you move. ### MRI: spinning hydrogen atoms An MRI uses a powerful magnet and radio waves to nudge the hydrogen atoms in the body (mostly in water and fat) and then listens to the faint signal they give back as they settle. Different tissues release that signal at different rates, and by timing the measurement the scan can be "weighted" to make different things bright: a T2-weighted scan makes fluid bright, which is why swelling, inflammation and many injuries light up; a T1-weighted scan shows anatomy and fat. The result is exquisite soft-tissue detail (ligaments, cartilage, discs, bone marrow) with no radiation. ### Why the choice of scan matters Each method "sees" something different, so the best scan depends on the question being asked: bone alignment or a fracture (X-ray), a moving tendon near the surface (ultrasound), complicated bony anatomy (CT), or detailed soft tissue and bone marrow (MRI). The right answer often comes from picking the right tool, not from doing every scan. --- ### Vitamin D and Musculoskeletal Health URL: https://www.cqupperlimb.com/education/general-health/vitamin-d-and-musculoskeletal-health/ Region: general-health · general-info How vitamin D affects bone, muscle strength, falls, fracture and tendon healing, and surgical outcomes — including who benefits from supplementation. ## What it is Vitamin D is a nutrient your body uses to build and maintain bone. It also plays a part in how muscle and tendon heal after injury or surgery. When your vitamin D level is low, it is called vitamin D deficiency. Low vitamin D matters to people with bone and joint problems. Research links deficiency with higher rates of anterior cruciate ligament tears, the knee ligament often injured in sport, and with failure of that ligament's reconstruction [1]. It has also been connected to stress fractures, which are small cracks in bone from repeated loading [2]. Older adults who break a bone after a simple fall, called a fragility fracture, are another group where vitamin D matters for bone health [3]. Vitamin D may also affect how well you heal after surgery. Studies suggest it may support tendon healing, particularly after rotator cuff repair, though the research so far is limited and of modest quality [4]. Low vitamin D before surgery has been linked with slower wound healing after some hand operations [5], and with complications after shoulder replacement [6]. For this reason, your doctor may check your vitamin D level before some operations and treat a deficiency if one is found. Inside your body, vitamin D helps bone-forming cells do their work. In studies of healing fractures, giving vitamin D improved the strength of the new bone that forms as a fracture knits together [7]. It also appears to influence immune factors involved in fracture healing [8]. Not every joint operation needs routine testing or supplements. The evidence does not support routine vitamin D testing and supplementation for everyone having rotator cuff repair [9] or knee replacement [10]. Your doctor will discuss whether checking your level makes sense for you. ## Does it work? The honest answer is that it depends on what you are hoping vitamin D will do. For broken bones, the picture is fairly positive. In studies of healing fractures, vitamin D improved the strength of the new bone that forms as a fracture knits together [7]. Treatment with an active form of vitamin D3 also promoted fracture healing in people with osteoporosis, which is bone that has become thin and weak [8]. And when women with osteoporosis combined vitamin D with high-intensity interval training, their bone density improved more than with either one alone [11]. But some findings cut the other way. Combined calcium and vitamin D supplements improved bone density in the pelvis and corrected low vitamin D levels in postmenopausal women with osteoporosis [12]. Yet those same supplements did not reduce the number of fractures those women actually had [12]. That gap matters. Stronger-looking bone on a scan does not always mean fewer breaks. For joint replacement, the results are mixed. A single large dose of vitamin D3 given on the day of knee replacement surgery made no difference to early recovery, complications, or how well people moved compared with a dummy pill [13]. People who started out deficient needed medium-to-high dose supplements to restore their levels, and even then only 33.7% reached a healthy level [14]. On the other hand, keeping vitamin D levels adequate may improve longer term survival after surgery for a broken upper thigh bone [15]. For tendon healing, the evidence does not support routine testing or supplements for everyone having rotator cuff repair [9]. Low vitamin D before that operation was linked with more fatty degeneration in the tendon, but this is unlikely to change how well the repair itself turns out [9]. So vitamin D looks useful for bone healing and for correcting a genuine deficiency. It is less clear that it improves recovery from joint replacement or tendon surgery. Your doctor can help you decide whether checking your level makes sense in your situation. ## What are the risks? Vitamin D treatment itself is not where most of the risk sits. The bigger concern is what happens when a low level goes unnoticed. Research links vitamin D deficiency with problems after some operations, including slower wound healing after certain hand surgery [5] and complications after shoulder replacement [6]. Deficiency is also common in people having joint replacement, and more so in winter [16]. That is why your doctor may check your level before some operations rather than wait for a problem to appear. Even when a low level is treated, bringing it back up is not guaranteed. Among knee replacement patients who started out deficient, medium-to-high dose supplements helped, but many still did not reach a healthy level [14]. A single large dose of vitamin D3 on the day of knee replacement made no difference to early recovery or complications compared with a dummy pill [13]. So more supplement is not always more benefit, and your doctor will talk with you about what testing and treatment make sense for your operation. There are also honest limits to what the research shows. The evidence on supplements after knee replacement is inconsistent, and not strong enough to justify treating everyone [10]. For rotator cuff repair, studies suggest vitamin D may support tendon healing, but the research is of modest quality and covers only one tendon group [4]. And while low vitamin D before that operation was linked with more fatty change in the tendon, this is unlikely to change how well the repair itself turns out [9]. One further point worth knowing. Combined calcium and vitamin D supplements improved bone density in postmenopausal women with osteoporosis, but they did not reduce the number of fractures those women actually had [12]. A better-looking scan does not always mean fewer breaks. If you are considering supplements for bone health, that gap is worth discussing with your doctor. ## Is it right for you? Vitamin D testing and treatment tend to suit people with a clear reason to check. If your level might be low before surgery, especially below 20 ng/mL, screening beforehand can guide treatment [17]. It may also help prevent slower wound healing after some hand operations [5]. People with wear-and-tear arthritis in the knee and low vitamin D can have more widespread joint pain, so checking makes sense there too [18]. Older adults and people with thin, weak bones are other groups who often benefit from a check. It is less clear who will not benefit. The evidence does not support testing and treating everyone having knee replacement [10] or rotator cuff repair [9]. And even when a low level is treated, bringing it back up is not guaranteed. Among knee replacement patients who started out deficient, medium-to-high dose supplements helped, but many still did not reach a healthy level [14]. Compared with simply taking a supplement without testing, checking first means treatment is aimed at people who actually need it. That said, the research on this trade-off is limited, and the right approach depends on your operation and your health. This is a shared decision. Bring up your diet, your time outdoors, and any past fractures with your doctor. Together you can decide whether a blood test makes sense before your operation, and what to do if your level comes back low. ## The bottom line Vitamin D is worth thinking about if your level might be low, especially before certain operations. It looks useful for bone healing and for correcting a genuine deficiency, but it is less clear that it improves recovery from joint replacement or tendon surgery. The single most important caveat: even when a low level is treated, bringing it back up is not guaranteed, so talk with your doctor about whether a blood test makes sense for you. --- ### Weight, Obesity and Joint Health URL: https://www.cqupperlimb.com/education/general-health/weight-obesity-and-joint-health/ Region: general-health · general-info How body weight and obesity affect joint load, osteoarthritis, and the risks and outcomes of joint surgery — including the role of weight loss before an operation. ## What it is Weight and joint health are closely linked. Carrying extra weight puts more load through your joints, especially the inner part of the knee. That helps explain why wear-and-tear arthritis (osteoarthritis) is common in the inner knee among people living with obesity [1]. Extra weight also affects your whole body, not just your joints. Obesity is a disease that causes inflammation throughout the body, and that inflammation reaches your joints too [2]. This page is for anyone who carries extra weight and has joint pain, or who is thinking about joint surgery. It is also for parents, because obesity in children is a condition that can change, and addressing it can improve their joint health and overall health [3]. The good news is that weight is one of the things you can do something about. Losing weight can ease joint symptoms and lower some risks around surgery. Extra weight affects joints in two main ways. The first is mechanical: more load passes through the joint with every step. The second is chemical: the inflammation that comes with obesity can wear down the smooth surface inside the joint, and that surface may not adapt well to higher loads in adults with obesity [4]. On the other side of the scale, being underweight also carries risks, including some that overlap with those seen with obesity [5]. Weight and surgery are linked in both directions. People with overweight or obesity tend to need hip and knee replacements at a younger age than people of normal weight [6]. But extra weight does not rule surgery out. Research looking at ten-year results after hip replacement found no reason to restrict access to surgery based on BMI alone [7]. Managing other health conditions and planning your operation carefully can lead to results similar to those of patients with normal BMIs [8]. ## Does it work? The honest answer is that the evidence is mixed, and some of it is thin. Losing weight can ease joint symptoms and lower some risks around surgery. That general message holds up. But when researchers look closely at specific operations, the picture is less clear. For hip and knee replacement, extra weight raises the chance of needing a repair operation for some procedures. Studies have found higher rates of revision after partial knee replacement in people with obesity [9], and higher rates of revision after reverse shoulder replacement done for fractures [10]. For hip replacement, one study found that obesity class was not linked to the risk, invasiveness or timing of further operations [11]. Results like these do not all point the same way, and much of the research is small or short term. Some findings are reassuring in plain terms. After keyhole hip surgery, people with obesity had long-term improvements in pain and function that matched those of people of normal weight [12]. After wrist fracture surgery, one study found no difference in joint movement between people of normal weight and people with obesity [13]. On the other hand, keyhole knee surgery tends to work less well in people with obesity, especially when arthritis is already present [14]. There are also gaps. For people with a BMI of 45 or more, studies of one type of knee replacement were too small to draw firm conclusions [15]. For some surgical choices, the available data is too weak to support firm guidance either way [16]. The takeaway for you is this. Extra weight changes some risks around joint surgery, but it does not rule surgery out, and many people with obesity do well after their operation. Your doctor can talk through which of these findings apply to your joint and your situation. ## What are the risks? The most likely risks around joint surgery are the ones you notice in the first days and weeks: wound problems, stiffness and a slower recovery. Extra weight can make some of these more likely. After surgery on arm and hand fractures, people with obesity had higher complication rates in the first 90 days and again at 2 years [17]. At 2 years, those complications included the bone healing in the wrong position, the bone failing to heal, and the need for further surgery [17]. Some risks depend on the joint and the operation. After partial knee replacement, people with obesity needed repair operations more often [9]. The same was true after reverse shoulder replacement done for fractures, where extra weight was linked to more repairs overall and more problems with the joint coming out of place [10]. In one type of robotic knee replacement, obesity remained a risk factor for the implant wearing loose or failing mechanically [18]. Not every risk points the same way, and some findings are genuinely mixed. In another study of robotic knee replacement, the trend towards more complications in people with severe obesity (BMI 35 or more) was not statistically clear [19]. Stiffness after knee replacement is a known worry, but one study found that higher weight was not linked to more stiffness or worse results after a procedure to free up a stiff knee [20]. Being underweight carries risks too, and some of these overlap with the risks of obesity [5]. There are also honest gaps in what is known. For people with a BMI of 45 or more, studies of one type of knee replacement were too small to draw firm conclusions about safety [15]. For children with lower limb fractures, obesity meant longer stays in hospital and more discharges that families did not want [21]. The overall picture is this. Extra weight raises some risks around surgery, but it does not rule surgery out, and many of these risks can be lowered by managing other health conditions and planning your operation carefully [8]. Your doctor can talk through which of these apply to you. ## Is it right for you? If you carry extra weight and have joint pain, you are the person this page is written for. Extra weight does not rule surgery out. Many people with obesity do well after hip and knee replacement, especially when other health conditions are managed and the operation is planned carefully [8]. Losing weight before surgery can ease joint symptoms and lower some risks around the operation. Surgery is not the only path. For some joints and some operations, extra weight raises the chance of needing a repair operation later [9]. Your doctor can compare the options with you, including non-surgical care such as exercise and weight management, and help you weigh what each one offers. This is a shared decision. You bring your goals, your pain and your daily life. Your doctor brings the evidence about your joint and your situation. Together you can decide on the timing and the type of treatment that fits you. ## The bottom line Carrying extra weight affects your joints and some of the risks around surgery, but it does not rule surgery out. Losing weight can ease joint symptoms and lower some of those risks, and it is worth considering as part of your plan alongside exercise and other care. The realistic expectation is steady progress rather than a quick fix, because results differ from person to person. The most important caveat is that the evidence on specific operations is mixed, so talk with your doctor about which findings apply to your joint and your situation. --- ### Hand URL: https://www.cqupperlimb.com/education/hand/ Region: hand · region-landing Hand and finger problems grouped by theme — tendons, nerves, arthritis, lumps and cysts, infections and injuries — with each condition beside the operation that treats it. ## Understanding your hand How your hand works Hand anatomy – bones of the wrist, palm, and fingers – understanding the structure supports diagnosis. Open → ## Tendon problems Trigger Finger Trigger finger causes painful catching or locking of a finger, often treated with splinting or steroid injection. Open → Trigger Finger Release Trigger finger release — understanding the condition, conservative treatments, and surgical options for a stuck or clicking finger. Open → Mallet Finger Mallet finger causes fingertip drooping after extensor tendon injury; splinting is key, surgery occasionally needed. Open → Jersey Finger (Flexor Tendon Avulsion) The deep flexor tendon avulses off the fingertip — why it is time-critical, and the surgery to reattach it. Open → Sagittal Band Rupture (Boxer's Knuckle) A knuckle injury where the tendon slips off the top of the joint — the "boxer's knuckle" — and how early splinting or surgery treats it. Open → Boutonnière Deformity Extensor central-slip injury at the middle finger joint; early splinting prevents the zigzag deformity, established cases need surgery. Open → Swan-Neck Deformity of the Finger A finger that hyperextends at the middle joint and bends at the tip — why it happens and how splints or surgery can correct it. Open → Extensor Tendon Repair Open → Flexor Tendon Repair Open → ## Nerve problems & repairs Carpal Tunnel Syndrome Carpal tunnel syndrome causes hand numbness, tingling, and weakness—diagnosis and treatment options explained. Open → Carpal Tunnel Release Carpal tunnel release surgery relieves median nerve compression—when it’s needed and what to expect. Open → Compression Neuropathies Hand numbness, tingling, or weakness – understanding carpal tunnel, cubital tunnel, and other compression neuropathies. Open → Hand Tendon and Nerve Injuries Hand tendon and nerve injuries – understanding symptoms, diagnosis, and treatment options. Open → Remplir Nerve Wrap Open → ## Arthritis & joint replacement Basal Thumb Arthritis Basal thumb arthritis — causes, symptoms, non-surgical options, and when surgery might help. Open → Trapeziectomy Open → Touch thumb arthroplasty Open → Pyrocarbon interposition arthroplasty Open → DIPJ arthritis Open → DIP Joint Fusion DIP joint fusion stabilizes and reduces pain in the fingertip joint, often for arthritis or mallet finger. Open → PIP Joint Arthritis Osteoarthritis and inflammatory arthritis of the PIP joint — non-operative and surgical options. Open → PIP Joint Fusion PIP joint fusion stabilizes a severely damaged middle finger joint, relieving pain when other treatments fail. Open → PIP Joint Replacement PIP joint replacement addresses painful arthritis in the middle finger joint when non-surgical options fail. Open → Knuckle Joint Replacement (MCPJ) Open → ## Lumps, cysts & Dupuytren's Dupuytren's Disease Dupuytren’s disease causes palm thickening and finger contracture—options range from observation to needle aponeurotomy or surgical excision. Open → Dupuytren's Fasciectomy Dupuytren’s fasciectomy — correcting hand contractures to improve function and daily activities. Open → Mucous Cyst Mucous cysts – common bumps near finger joints, often linked to arthritis, and treatment options. Open → Mucous Cyst Excision (with Local Flap) Open → Flexor Tendon Sheath Ganglion A benign, fluid-filled cyst arising from the flexor tendon sheath – often painless, but can cause clicking or limited finger movement. Open → Flexor Tendon Sheath Ganglion Excision Excision of a flexor tendon sheath ganglion — when surgery is considered for painful or limiting cysts. Open → Giant Cell Tumour of Tendon Sheath (Lump on a Finger or Thumb) A giant cell tumour of tendon sheath is a common, benign (non-cancerous) lump on a finger or thumb. What causes it, how it is diagnosed and removed, and how often it comes back. Open → Excision of Giant Cell Tumour of Tendon Sheath Open → ## Infections Hand Infections Paronychia, deep-space and flexor sheath infections — recognition, antibiotics, drainage. Open → Felon (Fingertip Pulp Infection) Open → Drainage of a Felon Open → Paronychia (Infection Beside the Nail) Open → Drainage of an Acute Paronychia Open → Eponychial Marsupialisation for Chronic Paronychia Open → Infected Flexor Sheath (Pyogenic Flexor Tenosynovitis) Open → Drainage of an Infected Flexor Sheath Open → ## Fractures & ligament injuries Finger Fractures Phalangeal and metacarpal fractures of the hand — non-operative care and indications for fixation. Open → Phalangeal Fracture Fixation Open → PIP Joint Fracture-Dislocation Open → Metacarpal Fractures (including Boxer's Fracture) A broken hand bone in the palm — including the common boxer's fracture — how it is treated, the rotation check that matters most, and recovery. Open → Metacarpal Fracture Fixation Open → Hamate Fractures and Ring/Little Finger CMC Fracture-Dislocations Open → Hamate and CMC Fracture-Dislocation Fixation Open → Thumb UCL injury Open → Thumb UCL Repair Open → Fingertip Injuries Crush, laceration, nail-bed and amputation injuries of the fingertip and their management. Open → Fingertip Repair and Reconstruction Open → ## Hand health & medical conditions Medical Conditions That Affect the Hand How whole-body conditions — diabetes, thyroid, inflammatory arthritis, kidney disease and more — show up in the hand. Open → Pregnancy and Hand Conditions Carpal tunnel in pregnancy and de Quervains "mummy thumb" — why they happen, what is safe, and when they settle. Open → Raynaud's Phenomenon Fingers that go white, blue then red in the cold — primary vs secondary Raynaud's, keeping warm, and when it needs assessment. Open → ## Recovery and rehabilitation Blood Thinners Around Surgery How anticoagulants and antiplatelets work, and why the timing of stopping each before surgery differs — platelet turnover, half-lives and clot risk. Open → Cast and splint care at home Looking after a plaster or splint at home — keeping it dry, elevation, keeping joints moving, and the urgent signs of a too-tight cast. Open → Constipation and gut care after surgery Why constipation is common after surgery (especially with strong painkillers) and how to prevent and manage it. Open → Daily life after hand, wrist or elbow surgery Keeping a hand or wrist dressing dry, elevation to control swelling, and one-handed living after hand, wrist or elbow surgery. Open → Daily life after shoulder surgery Washing, dressing, sleeping and managing day-to-day with the operated arm in a sling after shoulder surgery. Open → Driving After Shoulder and Arm Surgery: When Is It Safe and Legal? After most shoulder surgery, including rotator cuff repair, you usually cannot drive for about six weeks, and not while your arm is in a sling. When it is safe and legal to get back to the wheel after hand, wrist, elbow or shoulder surgery. Open → Eating well for healing Everyday food to support recovery after surgery — protein, energy, healing vitamins, and preventing constipation. Open → Fasting Before Surgery: What You Can Eat and Drink, and Why Why you must stop eating before an anaesthetic, when you can still sip water, and what can happen if you do not fast. The clear fasting rules that keep your stomach empty and your lungs safe during surgery. Open → Flying and travel after surgery Clot risk, cast tightness at altitude, fitness to fly and the practicalities of travelling after upper-limb surgery. Open → Hand therapy basics What to expect from hand therapy, how often you'll go, and what good rehab looks like. Open → Heat vs Ice When ice helps, when heat helps, and how to use either safely on the upper limb. Open → Is my wound infected? How to tell normal healing from a wound infection after surgery — the warning signs and when to seek help. Open → Looking after your wound Dressings, showering, and signs of infection after upper-limb surgery. Open → Managing pain after surgery What pain to expect, how to use pain relief well, and when to call. Open → Melatonin After Shoulder Surgery Why we prescribe melatonin after shoulder surgery, what the trial evidence shows, the dose we use, and what to expect from it. Open → Mind, Stress and Recovery How stress, low mood, anxiety and worry about pain affect recovery and surgical outcomes — and what helps. Open → Preparing for Surgery General checklist for the days before upper-limb surgery — fasting, what to bring, medications. Open → Preventing Blood Clots After Surgery Reducing the risk of deep vein thrombosis after upper-limb surgery — mobilisation, hydration, medication. Open → Returning to sport Phased return to sport after upper-limb surgery, and when contact sport is safe again. Open → Returning to work When you can return to desk, light, and heavy work after upper-limb surgery. Open → Scar Management Massage, silicone, sun protection and the 12-month timeline for surgical scars to soften and fade. Open → Sleep, Pain and Recovery How sleep and pain affect each other, why surgery and shoulder problems disturb sleep, and what helps you rest and recover. Open → Swelling and elevation after surgery Why a hand or arm swells after surgery, how elevation and gentle movement control it, and when swelling is a warning sign. Open → The day of your surgery What to expect on the day of day-case upper-limb surgery, from arrival and meeting the team to waking up and going home. Open → Wearing and Sleeping in an Arm Sling How to sleep in an arm sling, get the sling position right, and look after it after shoulder, elbow or wrist surgery, including whether to keep the sling on overnight. Open → Your shoulder nerve block The nerve block we use for shoulder surgery — how it numbs your arm, why it controls pain so well, and what to expect as it wears off. Open → Your wound check and stitch removal What happens at the post-op wound check, dissolvable vs removable stitches, what removal feels like, and when to seek help sooner. Open → Explore Hand in the evidence explorer → --- ### How your hand works URL: https://www.cqupperlimb.com/education/hand/anatomy/ Region: hand · anatomy Hand anatomy – bones of the wrist, palm, and fingers – understanding the structure supports diagnosis. ## The main parts Your hand is built from 27 bones, including your wrist. Nineteen of these are long bones. The hand itself has 19 bones, and they are arranged in five rays. Each ray is a chain of bones that works together. Your thumb has the shortest chain, with three bones. Your other four fingers each have four bones in their chain. The bones are held together by strong straps called ligaments. Each finger joint is steadied by two ligaments on the sides and a firm pad on the palm side called the volar plate. This pad stops the finger from bending backwards. The pad at the middle joint of each finger is the toughest in the hand. The ligaments around your thumb's base keep it seated in its small saddle-shaped bone. When these are stretched or torn, the thumb bone can shift out of place. Your hand also has a built-in cup shape. When your thumb sits beside your index finger, your palm forms a shallow cup. When you spread your thumb to grip something, that cup becomes a channel that follows the line of your thumb crease. Your fingers are angled so that when they curl, they all point towards a bone at the base of your thumb rather than straight down your palm. Muscles and tendons move it all. Tendons are the cords that join muscle to bone. Some start in your forearm and pass through your wrist to reach your fingers. The bending tendons on the palm side pass through a tunnel in your wrist, then fan out towards each finger. They slide inside slippery sleeves filled with fluid, which keeps movement smooth. Small rings of tissue called pulleys hold these tendons close to the bone as they bend. On the back of your hand, straightening tendons fan out over each knuckle. A sling of fibres holds each one centred so it pulls evenly. Small muscles that start and finish inside the hand itself help with fine control, spreading your fingers and steadying them as you pinch and grip. ## How it all works together Your hand does two jobs at once. It gathers information about the world, and it acts on what it learns. It can only do both well when the joints further up your arm are steady but free to move. Your shoulder aims your hand, your elbow brings it closer or further away, and your wrist and forearm set the angle for gripping. Think of it like a team passing a ball. Each part sets up the next. Your wrist position affects your knuckles, your knuckles affect the middle joints, and the middle joints affect the fingertips. When you close your hand to grip, the joints bend in turn: knuckles first, then middle joints, then fingertips. If the middle joints bend before the knuckles, a large object slips away. Even one stiff finger can stop your hand closing around something big. Tendons do the pulling, and they need room to slide. The bending tendons travel further than any others in your hand, gliding up to 88 mm inside your forearm. Sleeves of slippery tissue keep them running smoothly, and small pulleys hold them close to the bone so the pull stays true. Small muscles inside the hand balance the pull from your forearm, steadying your fingers as you pinch and grip. Your thumb makes this teamwork special. It can rotate so its pad meets the pad of your little finger, turning through up to 120 degrees. That twist is what lets you pick up a key, hold a pen, or turn a door handle. Blood vessels and nerves feed the whole system. Two main arteries, one on each side of the wrist, share the supply, and one usually carries more of the load. Fine branches reach every finger, and the skin of your palm is richly supplied to help control temperature. Your surgeon checks this circulation carefully before and after any hand procedure, because healthy blood flow is what allows healing. ## Where things commonly go wrong Some parts of your hand take more strain than others, and the anatomy explains why. The skin on the back of your hand is thin and very flexible, and it sits on a thin layer of fatty tissue. That makes it vulnerable. Burns on the back of the hand can damage the straightening tendons just beneath, especially over the middle joint of each finger, where the skin is at its thinnest. When a burn there goes deep, the tendon's central anchoring point can weaken or tear, and the finger can then bend down at the middle joint while the end joint bends backwards. On the palm side, the skin is built differently. It has a thick fatty layer with a honeycomb structure that absorbs shock and steadies your grip, so it copes better with pressure but can still be damaged by chemicals, friction or electrical injury. When several of the hand's working systems are hurt at once, the injury is called a mangling injury. That means skin, blood vessels, nerves, muscles, tendons, bone and joints are all involved, in the fingers, hand or arm. These injuries matter because your hand relies on every one of those parts working together. Problems can also come from inside. The small muscles within your hand can lose their blood supply, and a typical sign is that the fingers bend at the knuckles while the middle and end joints are held straight. Nerves can be affected too. The nerve running along the little-finger side of your wrist controls fine movements and grip strength, and when it stops working, pinch and grip suffer. Scarring can also pull structures out of shape. Scar across the back of the hand can draw the fingers into a bent, claw-like position, a change seen in hand burns that have not been treated. Tight scar or a tight muscle at the base of the thumb can also stop the web between thumb and index finger from opening, which limits how wide your hand can stretch to grip. ## The bottom line Your hand is small, but it is built like a machine with many moving parts. It has 19 bones, 17 joints, 19 small muscles inside the hand itself, and about the same number of tendons pulling from your forearm. Most of these parts glide against each other as you move, so they need room and slippery tissue to work smoothly. Your hand also depends on the rest of your arm: your shoulder aims it, your elbow moves it closer or further away, and your wrist sets the angle for gripping. That is why an injury to one small part can affect the whole hand, and why your surgeon looks at how everything works together, not just at the spot that hurts. --- ### Basal Thumb Arthritis URL: https://www.cqupperlimb.com/education/hand/basal-thumb-arthritis/ Region: hand · condition Basal thumb arthritis — causes, symptoms, non-surgical options, and when surgery might help. ## What you're feeling The pain sits at the base of your thumb, in the fleshy part near your wrist. It can travel up towards your forearm. Pinching and gripping are usually what bring it on, because those moves load the worn joint directly. Turning a key, opening a jar, holding a pen or picking up a kettle all squeeze the same spot. Your pinch strength is often affected before your overall grip. That is why you might manage to carry shopping bags but struggle with small, precise tasks like threading a needle or pulling up a zip. Weakness and pain do not always match what an X-ray shows, so some people with little joint damage feel a lot, and some with worn joints feel little. The pain often flares after using your thumb for a stretch, and it can wake you at night or be there when you first wake up. Rest usually settles it, but the ache tends to come back the next time you pinch or grip. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. Over time, everyday tasks that need a firm pinch become the hardest. Holding a phone, writing, using scissors or turning a tap can all feel clumsy or painful. ## What's actually happening Deep at the base of your thumb sits a small joint where the thumb bone meets a bone of the wrist. It works like a saddle: rounded on one side and cupped on the other, so your thumb can swing, rotate and press against your fingertips. That freedom is what lets you pinch, grip and twist, but it also means the joint carries a lot of force every time you use your hand. In this condition the smooth, slippery surface inside that joint wears away. Without it, bone rubs on bone, and the joint becomes inflamed and swollen. The lining around it gets sore, which is why the base of your thumb feels tender and cramping in the fleshy pad below your thumb. Because the worn joint no longer holds the thumb bone in place, the bone can slip out of line and make a visible bump where your thumb meets your wrist. The wearing usually builds slowly over years. It is more common in women after menopause, and it often affects both thumbs. As it progresses, the joint above the base of your thumb, where the thumb bends, can also become loose. That looseness can make the thumb collapse or bend sideways when you pinch, which adds to the weakness you feel. The pain, weakness and clumsiness you feel are all the result of this wear. Pinching and gripping squeeze the worn surfaces together, so those are the movements that hurt most. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand and arrange imaging if it is needed to confirm the diagnosis. The first step is care you can do yourself. Changing how you use your hand, easing off tasks that load the thumb base, and wearing a splint that supports the joint can all settle symptoms. Hand therapy aims to strengthen the muscles that support and steady the thumb, which takes load off the worn surfaces. These measures work well in the earlier stages, and we usually give them a fair trial before talking about anything further. If self-management is not enough, pain medication and anti-inflammatories can help you keep using your hand. An injection of cortisone into the joint can settle a painful flare over the short term, though the relief does not usually last. It can also help confirm that the thumb base is the true source of your pain. Surgery comes into the conversation when non-operative care has not given you enough improvement, or when your symptoms stop you working or using your hand. We offer joint replacement at the base of the thumb, where the worn surfaces are replaced to relieve pain and keep the thumb moving. Some surgeons use a different operation called trapeziectomy, which removes the small wrist bone instead of replacing it. We will talk through what each option means for your hand and decide together what suits you. ## What to expect Without treatment, thumb base arthritis usually builds slowly over years rather than arriving all at once. The pain tends to come and go: it flares after you use your thumb, settles with rest, then returns the next time you pinch or grip. Left alone, the weakness and clumsiness with everyday tasks usually grow, because the worn joint keeps taking the same load every day. Most people who manage it well get real relief. Easing off tasks that load the thumb base, wearing a splint, and hand therapy all settle symptoms for many people, especially earlier on. An injection can calm a painful flare over the short term, though the relief does not usually last. If those steps are not enough, surgery aims to remove the pain and keep your thumb moving. Recovery from thumb base surgery takes time: you will need time off work, longer if your job needs heavy use of your hands, and you will spend some weeks with your hand rested while things heal. Hand therapy afterwards, with Ruby Doolan at Extend Rehabilitation, guides when and how much to lift as your thumb gets back to work. Surgery is not a promise of a pain-free thumb. Most people have much less pain and better use of their hand, but some symptoms can stay. A small number of people need another operation later, either because the joint wears down again or because an implant gives trouble. If that happens, a second operation can still help: most people who have one say their thumb is better than before their first surgery, though the result is usually not as good as a first-time operation. Keeping heavy loads off your thumb after surgery helps the repair last. If your hand becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. No GP referral is needed. ## When to see someone See your GP or ask for a specialist review if your thumb base pain is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your hand. Ask sooner if pinching and gripping have become weak or unreliable, or if turning keys and opening jars is getting harder despite rest and a splint. Some warning signs need same-day care. Go to an emergency department if your hand becomes hot, red, swollen and painful, especially with a fever. This can be an infection, and it needs treatment straight away. No GP referral is needed. Also go to an emergency department if your fingers or hand turn pale, cold, white or blue, or if you suddenly lose feeling or movement in your hand after an injury. If you cannot reach the clinic, out of hours or on a weekend, go to your nearest emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Thumb base arthritis is worth the extra reading because it is the upper-limb condition where the gap between what patients are offered first and what the evidence supports is widest, and because the surgical options have never separated themselves from one another despite decades of trying. ### The non-operative evidence is better than its reputation Splints and hand therapy are often presented as what you do while waiting for surgery. A systematic review and network meta-analysis of 1,962 patients puts them on firmer ground: multimodal treatment and hand exercises reduced short-term pain and improved grip strength, while a rigid CMC-MCP splint, one that blocks the joint above as well as the thumb base — improved medium-term outcomes [1]. Two details matter. The splint that worked crosses both joints, which is not the soft neoprene sleeve most people are given. And exercise improved grip strength, not merely comfort, this is a joint whose failure is mechanical, and strengthening the muscles that compress and stabilise it is treating the mechanism. ### Injection buys weeks, not months Corticosteroid injection is the usual next step. Pooling 673 patients, intra-articular corticosteroid injection produced short-term improvement but no significant difference in pain and functional outcomes at later follow-up [2]. That is worth hearing plainly. An injection here is a way to get through a defined period — a trip, a deadline, a busy stretch at work, or to confirm the joint is the pain source. It is not a treatment that changes the trajectory, and repeat injections chasing a durable result are chasing something the evidence does not show. ### No operation has won Once surgery is on the table there are several credible options, and the striking thing is how similar their results are. Arthrodesis, fusing the joint, produces good functional outcomes with low to moderate pain and disability scores, at the cost of a meaningful nonunion rate [3]. It trades movement for durability, which suits a heavy manual hand and suits a pianist badly. Dual-mobility trapeziometacarpal arthroplasty, replacing the joint, showed improvements in strength, range of motion, pain, function and satisfaction across 1,421 patients, with a 13% complication rate and a 0.6% dislocation risk [4]. Those numbers are respectable, and they are also the reason implants remain a considered choice rather than the default: 13% is not small, and the follow-up in this literature is short relative to how long a thumb has to last. The honest summary is that the choice turns on what your hand has to do, and on which failure mode you would rather risk, a joint that does not bend, or an implant that may need revisiting. ### Why the thumb is so often the first joint to go The trapeziometacarpal joint is a saddle joint built for an unusual combination of mobility and load. Every pinch generates force at the thumb base many times the force at the fingertip, because of the lever arm. That is the price of opposability: the joint that makes the human hand useful is loaded harder, and more often, than any other small joint in the body, which is why it wears out first, and why strengthening what supports it is not a token measure. --- ### Boutonnière Deformity URL: https://www.cqupperlimb.com/education/hand/boutonniere-deformity/ Region: hand · condition Extensor central-slip injury at the middle finger joint; early splinting prevents the zigzag deformity, established cases need surgery. ## What you're feeling With a boutonnière deformity, the middle joint of your finger bends down towards your palm and the fingertip bends back the other way. The finger may look swollen over the middle joint, and it can be painful there as well. Straightening the middle joint becomes hard, and the harder you try, the more the finger seems to resist. The trouble shows up most in tasks that need the finger to straighten and then bend again. Picking up a coin, holding a cup by its handle, typing, buttoning a shirt or turning a key can all become awkward. Grip itself often still works, which is why many people put up with the finger for weeks before seeking help. If the deformity came from an injury, the middle joint may ache after you use the hand, and the stiffness can be worse in the morning before the finger loosens up. In rheumatoid arthritis, the same bent posture develops slowly as the lining of the joint stays inflamed and swollen over months. A few signs need fast attention. If your finger or hand becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. The same applies if a finger turns pale, cold, white or blue, or if you suddenly lose feeling or movement in it after an injury. If the symptoms are instead not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## What's actually happening Down the back of each finger runs a set of tendons that straighten the joints. Think of them as ropes running under a hood on the back of the finger. The rope that straightens the middle joint is called the central slip, and it anchors onto the base of the middle bone. Two more cords, called lateral bands, run alongside it and help straighten both the middle joint and the fingertip. With a boutonnière deformity, the central slip has torn or stretched away from the middle bone. The middle joint can no longer be pulled straight, so it drops into a bent position. The two lateral bands then slide off the top of the joint and slip down towards the palm. Once they sit below the joint's pivot point, those same cords start bending the middle joint instead of straightening it, and they pull the fingertip back the other way. That is why the finger settles into the bent middle joint and arched tip described above, and why every attempt to straighten it seems to make the cords pull harder against you. It takes more than one damaged part to produce this posture. The central slip, the ligament that ties the two cords together over the back of the finger, and the fibres of the hood that hold everything in place all need to be injured before the deformity develops. A tear of the central slip on its own may leave the middle joint weak without the full deformity, which is one reason early treatment matters: it can stop the deformity from forming at all. The same end result can come from different starting points. An injury such as a blow to the finger or a cut over the back of the joint can do it, and so can the ongoing inflammation of rheumatoid arthritis, which slowly wears through the same structures. A finger can also look like this without any tendon injury at all, when the problem sits on the palm side of the joint instead, and that version is treated differently, which is why working out which one you have comes first. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a history, examine your hand, and arrange imaging if it is needed to work out what is going on. Because this deformity can come from several different starting points, sorting out which one you have comes before any treatment. The first step is usually splinting and hand therapy. For a recent injury, splinting the middle joint straight can stop the deformity from forming at all, and the sooner it starts the better: people treated within six weeks of injury do better than those treated later. The splint holds only the middle joint straight. Your fingertip, your knuckle and your other fingers keep moving, because holding the whole finger still lets the fingertip stiffen. For a deformity that has been there a while, we may use casting to straighten the middle joint as far as possible, followed by three months of a splint that lets you bend the finger while it works. This approach is worth trying before surgery is considered. When splinting and therapy have not given enough improvement, surgery may be considered. The operation rebuilds the tendon that straightens the middle joint, sometimes using a small piece of tendon from your own forearm as a graft. In some cases the tendons that have slipped towards the palm are repositioned back over the joint where they belong. The aim is the same in each case: to let you straighten the middle joint again and use the finger without it catching or bending down. The operation has its own page, and we will talk through what it involves for your particular finger before any decision is made. ## What to expect The outlook depends a lot on timing. Caught early, a boutonnière deformity can often be stopped before it settles in. Splinting the middle joint straight soon after an injury can prevent the deformity from forming at all, and people treated within six weeks do better than those treated later. Left alone, the deformity tends to get worse rather than stay the same, because the tendons that have slipped out of place keep pulling the finger further into its bent posture. An injury that looked minor can produce a stiff, fixed finger weeks later. For a deformity that has been there a while, non-operative treatment still has a real role. Casting to straighten the middle joint as far as possible, followed by three months of a splint that lets you bend the finger while you use it, can work well. The finger responds to this approach when the casting can get the middle joint close to straight and you actively use your hand in the splint over those three months, with flexion recovering along the way. For thumb injuries, splinting the knuckle straight can help if it starts before the deformity develops. Surgery aims to let you straighten the middle joint again. In one reported group of 18 people who had a tendon graft to correct a long-standing deformity, 16 had good or excellent results. A newer technique that gets the finger moving early was reported to work in 11 cases. Surgery can also help the congenital form of this deformity, where it has been present since birth. It is honest to say that not every correction lasts. For fingers affected by rheumatoid arthritis, soft-tissue surgery alone may not hold in the later stages, and long-term results are less predictable. When a deformity comes back or persists, a different procedure may be the better answer. Whatever the starting point, the realistic goal is a finger you can straighten and use, not a promise of a perfectly normal finger. ## When to see someone A boutonnière deformity rewards early attention, so it is worth knowing when to act. If you have hurt your finger and the middle joint will not straighten, or the finger sits bent and swollen days after an injury, see your GP and ask for a specialist review. The sooner splinting starts, the better the chance of stopping the deformity before it settles in. A few signs need faster care. Go to an emergency department the same day if your finger or hand becomes hot, red, swollen and painful, especially with a fever. The same applies if a finger turns pale, cold, white or blue, or if you suddenly lose feeling or movement in it after an injury. If broken skin sits over an injured joint, or the finger looks obviously deformed, go as well. If symptoms are instead not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. If you cannot reach the clinic out of hours or on a weekend, go to your nearest emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Boutonnière deformity is worth the extra reading because the instinctive treatment for a painful, swollen, bent finger, rest it and keep it still, is the one thing the evidence specifically does not support. ### Early mobilisation, not prolonged immobilisation A systematic review of treatments for central slip injury found the evidence base limited, with the roles of different strategies for both open and closed injuries not well supported [1]. Within that limitation, the evidence from individual studies tentatively supports early mobilisation and does not support prolonged immobilisation [1]. That is worth stating plainly because it runs against the reflex. The distinction is between protecting the healing central slip, which requires the middle joint to be held straight, and immobilising the whole finger, which allows the fingertip joint to stiffen in extension and the whole digit to become rigid. The splint is intended to hold one joint while the others keep moving. ### Why the deformity gets worse rather than staying still Boutonnière is a progressive deformity, which is unusual and worth understanding. The central slip attaches to the base of the middle bone and straightens the middle joint. When it fails, that joint drops into flexion, and the two lateral bands, which normally run above the joint's axis, slip below it. Once they are below the axis, the same tendons that previously helped straighten the middle joint begin to bend it, while pulling the fingertip into hyperextension. The deformity therefore self-reinforces: every attempt to straighten the finger tightens the structures now holding it bent. This is why an injury that looked minor can produce a fixed deformity weeks later, and why the window for simple splinting is early. ### The deformity that is not a boutonnière A finger can adopt the same posture without a central slip injury at all, and the treatments differ entirely. Boutonnière and pseudoboutonnière deformities differ in pathoanatomy, diagnosis and management [2], the pseudo variety arising from a volar plate injury at the middle joint, where the fingertip joint retains normal passive flexion rather than being drawn into hyperextension. Distinguishing them at the bedside rests on the fingertip. In a true boutonnière the tip is held hyperextended and resists being bent, particularly with the middle joint straightened; in a pseudoboutonnière it flexes freely. Splinting a pseudoboutonnière as though it were the real thing addresses the wrong joint. ### It belongs to a family of injuries defined by where the tendon fails Boutonnière sits alongside mallet finger and sagittal band injury as one of three closed extensor mechanism injuries, categorised by the zone in which the mechanism fails [3]. All three can present as a swollen finger held abnormally within days of an injury, and each requires a different splint position, which is the practical reason a definite diagnosis is worth reaching before committing to weeks of splinting. --- ### Compression Neuropathies URL: https://www.cqupperlimb.com/education/hand/compression-neuropathies/ Region: hand · condition Hand numbness, tingling, or weakness – understanding carpal tunnel, cubital tunnel, and other compression neuropathies. ## What you're feeling Nerve compression happens where a nerve is squeezed as it travels through a tight space in your wrist, elbow or forearm. The symptoms depend on which nerve is affected and where the squeezing happens, so two people with nerve compression can feel quite different things. Most people notice tingling, pins and needles or numbness in part of the hand. Some feel aching or burning pain in the forearm or wrist. Symptoms often flare at night and can wake you from sleep. They can also worsen after you have used your hand a lot, for example after writing, gripping tools or typing. Shaking your hand or changing its position may settle things briefly. The squeezing can make daily tasks harder. You might drop things, fumble buttons or struggle with a jar lid. Fine finger movements can feel clumsy, and your grip may feel weaker than usual. Some people notice the affected fingers feel numb even though the hand looks normal. One feature of nerve compression is worth knowing. When a nerve is squeezed at one spot, that same nerve becomes more vulnerable to being squeezed somewhere else along its length. This means symptoms sometimes come from more than one site, and it explains why your surgeon examines your whole arm rather than only the spot that hurts. Because several nerves and small structures share a narrow space, symptoms can be hard to describe and easy to attribute to the wrong cause. A careful examination is how the true source is found, sometimes with scans or nerve conduction studies, which measure how well signals travel along the nerve. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand or arm, see your GP or ask for a specialist review. ## What's actually happening A nerve is a bit like an electrical cable running from your neck down to your fingers. It carries messages in both directions: feelings from your skin back up to your brain, and instructions from your brain down to your muscles. Along the way, the cable has to pass through several narrow gaps between bones, ligaments and other tissues. When a nerve is squeezed at one of these tight spots for a long time, the cable itself starts to change. The nerve's protective lining thickens, and it swells inside its tunnel, which leaves even less room. The nerve's own blood supply gets squeezed too, so parts of the nerve are short of oxygen whenever the pressure builds. This is why symptoms often come and go at first, flaring when you hold your wrist or elbow in one position for a while, and settling when you change position. If the squeezing continues, the damage moves deeper. The insulation around individual nerve fibres starts to break down, and with more pressure the fibres themselves can wear out. Not every part of the nerve is affected at once. The fibres closest to the tightest point suffer first, which is why numbness often shows up in some fingers before others. Early on, you feel tingling that comes and goes. Later, the numbness becomes constant because the nerve can no longer send its signals properly. There is one more piece worth knowing. A nerve that has been squeezed at one spot, for example in your neck, has trouble moving nutrients along its length. That makes it less able to cope with a second squeeze further down, such as at the wrist. This is why your surgeon looks at the whole path of the nerve, and why releasing one spot sometimes does not settle everything. The good news is that this happens in stages. When pressure is relieved before the nerve fibres themselves are badly damaged, the nerve has a real chance to recover. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your arm, and arrange scans or nerve conduction studies where they are needed to confirm which nerve is squeezed. For mild symptoms that have come on recently, we often start with simple self-management. Learning about the nerve, what causes your symptoms and which movements to avoid can settle things on its own. Changing how you use your hand, easing pressure on the nerve and doing nerve gliding exercises all help in the same way. For mild compression of the ulnar nerve at the elbow, about half of people recover without surgery when pressure on the nerve is reduced. Mild symptoms in the early stage can settle with this information alone. We usually give a trial of this approach a fair while, because mild cases often recover on their own over months. The next step depends on how severe the squeezing is. For moderate compression, non-operative treatment does not work, so we move to discussing surgery rather than waiting. If your symptoms are mild but not settling over weeks, or are getting worse, see your GP or ask for a specialist review. When surgery is the right option, the aim is simple: open up the tight space so the nerve is no longer squeezed. This is called decompression. It is a small, safe operation that relieves pressure on the nerve where it travels through its tunnel. For most nerve compression problems this release alone is enough, and the nerve then has room to recover. The operation itself, and what recovery involves, is covered on its own page. If you have complex regional pain syndrome, a condition of ongoing pain and sensitivity after injury or surgery, we plan your care differently. We may use medicines before and after surgery to calm the pain, protect the hand with careful dressings, and start hand therapy early. Recovery in this setting takes longer, and some stiffness can remain. ## What to expect Nerve compression symptoms often come and go at first. They flare when you hold your wrist or elbow in one position, and settle when you change position. If the squeezing continues, the numbness becomes constant rather than something that comes and goes. How well you recover depends a lot on timing. When pressure is relieved early, before the nerve fibres themselves are badly damaged, the nerve has a real chance to recover. When treatment is left late, recovery can be incomplete, and this holds true whatever caused the compression in the first place. This is why symptoms that are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand or arm need a review by your GP or a specialist, rather than waiting. With treatment, the outlook for many people is steady improvement. Some people find their symptoms settle fully within three months of the pressure being relieved. Others improve over a longer stretch, with numbness and tingling easing gradually as the nerve recovers. People with diabetes can expect the same lasting improvement from carpal tunnel release as people without diabetes. Relief of numbness is often the clearest change, and many people also notice less pain and fewer pins and needles. If the compression is mild, simple measures can be enough on their own over months. If it is moderate or severe, symptoms usually do not settle without surgery, which is covered in the section above. It is also honest to say that not every recovery is complete. Some people are left with some numbness or weakness, particularly when treatment came late. A few people continue to have symptoms after a release that was done properly. When that happens, the first question is whether a second spot along the same nerve was missed, because one nerve can be squeezed in more than one place. Further assessment, and sometimes a further release, can still help. Persistent symptoms after surgery deserve a fresh look at the diagnosis rather than being written off. Your surgeon will talk through where you sit on this range at your appointment, based on your examination and scans. ## When to see someone Nerve compression rarely needs emergency care, but there are exceptions. Go to an emergency department the same day if your hand or arm becomes hot, red, swollen and painful, especially with a fever, or if your fingers turn pale, cold, white or blue. Sudden loss of feeling or movement after an injury also needs emergency assessment. A short history of severe pain can mean bleeding rather than swelling is pressing on the nerve, and that needs urgent decompression to limit damage to the nerve. See your GP or ask for a specialist review if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand or arm. New weakness in your hand, or numbness that has become constant rather than coming and going, also deserves a review rather than more waiting. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Nerve compression in the arm is worth the extra reading because of a single figure that explains a large share of disappointing outcomes: a meaningful minority of people have more than one nerve compressed, and releasing the wrong one changes nothing. ### Three percent need a second, different nerve released within a year In a cohort of 7,867 patients undergoing surgery for nerve compression, approximately 3% underwent decompression of a different nerve in the same arm within one year, and patients with both carpal and cubital tunnel syndrome may benefit from simultaneous decompression, since outcomes were comparable to single decompression [1]. Three percent is small in absolute terms and large in what it implies. It counts only those who proceeded to a second operation within twelve months; it does not count those still symptomatic who did not, or those whose second site was recognised before the first operation. The true frequency of multi-site compression is higher than the surgical rate. The clinical consequence is the important part: when a hand remains wrong after a technically sound release, the question is not only "did the operation fail" but "was there a second site all along". ### Doing both at once does not appear to cost anything The instinctive objection to simultaneous decompression is that two operations at once in the same limb must raise the risk, particularly of complex regional pain syndrome, a poorly understood condition of persistent pain and dysfunction that historically was reported at higher rates after combined procedures. That concern has been examined directly. Analysing 753 patients, adding carpal tunnel release to those requiring fasciectomy showed only a marginal increase in the occurrence of CRPS, contradicting original reports demonstrating a much higher rate, indicating no clear clinical risk associated with simultaneous surgery [2]. Read alongside the finding that combined decompression gives outcomes comparable to single decompression [1], the case for addressing two demonstrated sites in one anaesthetic is reasonable rather than reckless. ### The double crush idea, and what it does and does not explain The observation that compression at one point along a nerve makes it more vulnerable at another is known as double crush. The proposed mechanism is that compression impairs the transport of materials along the nerve fibre, so a nerve already embarrassed proximally tolerates a second insult less well. The concept is useful and frequently over-applied. It offers a real explanation for why someone with neck pathology may develop carpal tunnel symptoms at a lower threshold than expected, and why multi-site compression clusters in the same individuals. It is not a licence to attribute any unexplained arm symptom to a hypothetical second lesion, and it does not predict which patients will benefit from which release. ### What this means practically Two things follow. Before an operation, symptoms that do not fit the nerve being released, numbness in the ring and little fingers when a carpal tunnel release is planned, or vice versa, are worth raising explicitly, because the pattern is what identifies a second site. And afterwards, persistent symptoms deserve reassessment of the diagnosis rather than assumption of a technical failure. The evidence above indicates that the second nerve is a real and recognised possibility, not an unusual excuse. --- ### DIPJ arthritis URL: https://www.cqupperlimb.com/education/hand/dipj-arthritis/ Region: hand · condition Arthritis of the fingertip joint, the joint closest to your nail, causes pain that sits right at the end of the finger. The joint often becomes swollen and tender, and firm bony lumps called Heberden's nodes can form around it. These lumps are a common sign of arthritis at this… ## What you're feeling Arthritis of the fingertip joint, the joint closest to your nail, causes pain that sits right at the end of the finger. The joint often becomes swollen and tender, and firm bony lumps called Heberden's nodes can form around it. These lumps are a common sign of arthritis at this joint. The pain tends to flare after you use the finger, and it can be sore when you wake in the morning. Fine tasks that need the very tip of the finger become hard: buttoning a shirt, picking up small coins, threading a needle, or gripping a key to turn a lock. Writing by hand can ache as well. Over time the joint may stiffen and lose some of its bend, and the finger can slowly drift out of line. Some people notice a small fluid-filled lump near the nail, called a mucous cyst. It grows from the arthritic joint beneath, so it often comes back even after it is drained. If the arthritis followed an injury to the finger, such as a mallet finger where the straightening tendon tore or pulled off a piece of bone, the joint can wear out faster than it would have otherwise. That wear brings the same pain and stiffness, and the finger may lose movement even though the injury itself healed. Watch for a few warning signs. If your finger becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. This can be an infection that needs same-day care, and you do not need a GP referral first. If pain is not settling over weeks, is getting worse, or wakes you at night, see your GP or ask for a specialist review. ## What's actually happening Every finger is a chain of small bones. The joint at the very tip, just behind the nail, is where the last bone meets the one above it. A smooth, slippery layer covers the ends of both bones and lets them glide over each other. Think of it as a built-in shock absorber that also keeps the surface slick. In arthritis, that slippery layer wears thin or breaks down. The bones then rub on each other, and the joint reacts by growing extra bone around its edges. Those bony spurs are the firm lumps you can feel near your nail, the ones described in the section above. The rubbing causes the aching, and the worn surfaces and spurs together explain why the joint swells, stiffens and slowly drifts out of line. The joint is also held together by small straps of tissue on each side, and by a flat band of tendon fibres that runs over the top and attaches just past the joint. When arthritis changes the joint, these straps and tendons can be pulled off balance. That is one reason the finger can bend too far at the middle joint while the tip curls down, a shape change that tends to develop as the arthritis progresses. Sometimes the wear follows an injury rather than simple wear-and-tear. A hard knock, a crush, or a tendon injury like a mallet finger can damage the joint's surfaces. The joint then wears out earlier than it would have otherwise, which is why pain and stiffness can appear years after an injury seemed to heal. Arthritis at this joint can also form a small fluid-filled lump beside the nail, the mucous cyst mentioned earlier. It grows out of the irritated joint itself, which is why it tends to return after being drained. The good news is that this joint does little of the heavy gripping work. Its job is fine control at the fingertip, which is why treatment focuses on calming the pain and keeping that fine control working. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your first visit we take a history, examine your finger and arrange imaging if it is needed. Because this is a long-standing wear-and-tear problem, we usually try non-operative care first and talk about surgery only if that has not given enough improvement. The first step is often a small splint that holds the fingertip joint straight. Splinting eases pain at the joint and helps the finger straighten. It is simple and safe, and you can wear it through your normal day. We usually pair it with anti-inflammatory medicine, tablets that calm swelling and pain. Hand therapy can also help you keep the fingertip working for fine tasks while the irritation settles. Give these measures a fair trial before deciding anything further. If pain and stiffness still limit you after that, surgery becomes an option. The standard operation is a fusion, also called an arthrodesis, where the worn joint surfaces are removed and the two bones are joined so they heal into one. The joint no longer bends afterwards, but it is painless and stable, and the finger is set in a position that works well for everyday tasks. Fusion also straightens a finger that has drifted out of line, and it is the treatment that stops a mucous cyst coming back. If keeping some movement at the fingertip matters more to you than settling the pain completely, there is another operation that trims the bony lumps and cleans out the joint while leaving it to move. We will talk through which option fits your finger and what you want your hand to do, and decide together. ## What to expect Arthritis at the fingertip joint usually builds slowly over years. The pain tends to come and go: it flares after you use the finger, then settles again with rest. Without treatment, the joint often stiffens further and the finger can drift more out of line over time. Some people find the pain eases on its own as the joint stiffens, but for many it keeps grumbling, especially with fine tasks like buttoning a shirt or turning a key. Most people get good relief with the simple measures described earlier: a splint, anti-inflammatory medicine and hand therapy. These calm the pain while you keep using the finger for everyday tasks. If those measures have not helped after a fair trial, surgery usually settles the pain well. A fused fingertip joint is painless and stable, and people generally go back to their normal hand use, though the tip no longer bends. If keeping some movement matters more to you, the joint-cleaning operation leaves the finger able to bend, with pain relief that is good but not always complete. Recovery from surgery takes weeks to months rather than days. The finger is held still at first while the bones join, and your hand therapist will guide you as you build your grip and fine control back up. Most people find the end result is a finger that does its job without the ache, even though the tip sits straighter than before. A few honest cautions. Fusion does not always heal on the first attempt, and some people need a further operation to remove the metal or redo the fusion. Smoking slows bone healing, so quitting before surgery gives your finger its best chance of uniting well. If pain is not settling over weeks, is getting worse, or wakes you at night, see your GP or ask for a specialist review. ## When to see someone Most fingertip joint arthritis builds slowly, so a routine GP visit is enough to start. See your GP if the pain is not settling over weeks, is getting worse, or wakes you at night. The same applies if the finger stops you working or doing fine tasks like buttoning a shirt. Some signs need faster care. Go to an emergency department the same day if your finger becomes hot, red, swollen and painful, especially with a fever. That pattern suggests an infection, and you do not need a GP referral first. Go to an emergency department after an injury if the skin is broken over the joint, bone is showing, or the finger looks obviously out of shape. The same applies if the finger turns pale, cold, white or blue, or if you suddenly lose feeling or movement in it after a knock. A mucous cyst that keeps coming back, or a finger drifting out of line, is worth a specialist review. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Arthritis of the fingertip joint is worth the extra reading because fusion, the standard operation, usually described as straightforward, has a higher complication rate than its reputation suggests, and because a motion-preserving alternative exists that is rarely mentioned. ### Fusion is not as uneventful as it sounds Fusing the fingertip joint is presented as a reliable operation, and in terms of pain relief it is. The complication profile is less benign. A review of risk factors across 173 patients states it directly: arthrodesis of the distal interphalangeal joint often leads to complications, with osteoarthritis, revision arthrodesis and smoking identified as risk factors [1]. Smoking appearing on that list is worth acting on, because it is the one factor a patient controls. Bone union depends on blood supply, and this is a small joint with a thin soft-tissue envelope at the end of the finger's blood supply. ### The implant that unites better also causes problems the cheaper ones do not The fixation debate has an unusually clean answer, and it is a trade rather than a winner. Across 1,125 patients, headless compression screws appear to have increased union rates but are associated with complications not seen with other well-established and cheaper techniques, and other than union, there is insufficient evidence to show the screw is superior [2]. The complications specific to the screw follow from the anatomy. The screw runs down the axis of the fingertip, so it passes close to the nail bed and can produce nail deformity, and in a very small distal phalanx there may be inadequate bone to hold it. Wires are cheaper and avoid those particular problems while uniting slightly less reliably. Where union alone is the priority, a revision fusion, or a smoker, the screw's advantage is most relevant. Where the bone is small and the nail matters, it is less clearly the right choice. ### The alternative that preserves movement Fusion is not the only option, and the alternative is not widely discussed. In patients whose main complaint is the bony lumps and the pain from them rather than the arthritis throughout the joint, the prominent osteophytes can be removed while leaving the joint intact. Open cheilectomy of the fingertip joint is described as a safe and effective alternative to arthrodesis in patients with symptomatic osteoarthritis who wish to preserve joint motion, across 78 patients [3]. This matters because the fingertip joint contributes little to grip strength but a good deal to fine manipulation and to the appearance of the hand. For someone whose symptoms are driven by the Heberden's nodes themselves, trading them for a permanently stiff fingertip is a larger concession than it may sound, and there is a middle option. ### The cyst that often accompanies it Arthritis at this joint frequently produces a mucous cyst, a small fluid-filled swelling arising from the arthritic joint, usually beside the nail. Because it is driven by the underlying joint, it behaves like the wrist ganglion in that respect: draining it addresses the swelling and not the source. It is covered separately, but the connection is worth knowing, since a recurring cyst is a sign of the arthritis beneath rather than an isolated problem. --- ### DIP Joint Fusion URL: https://www.cqupperlimb.com/education/hand/dipj-fusion/ Region: hand · operation DIP joint fusion stabilizes and reduces pain in the fingertip joint, often for arthritis or mallet finger. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging if it is needed to work out what is wrong. This operation is a fusion of the end joint of a finger or thumb. The two bones on either side of the joint are joined so they heal into one solid bone. Once that has healed, the joint no longer bends, but it also no longer hurts. We usually suggest this operation when the joint is worn out, badly damaged by injury, or unstable, and simpler measures such as activity change, hand therapy or splinting have not given enough relief. For some acute injuries, surgery may be the right choice straight away. The aim is a finger that is steady, comfortable and able to do its job when you pinch and grip. ## Before the operation In the weeks before surgery we confirm the plan with fresh X-rays of your finger. Most patients need nothing more than that. If you have other medical conditions, you may need blood tests or a review with the anaesthetist (the specialist doctor who keeps you safe and pain-free during the operation). You will be asked to stop eating and drinking for seven hours before surgery; we ask for a little longer than the usual six so your time can be brought forward if the theatre list runs early. Your surgeon will tell you which of your regular medicines to pause, so bring a written list of everything you take. Arrange a lift home, as you cannot drive afterwards. Wear loose, comfortable clothing that slides on easily over a bandaged hand. ## On the day You come to the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You then meet the anaesthetist (the specialist doctor who keeps you safe and pain-free during the operation). Most people choose local: recovery is quicker and you can go home soon after. If you'd prefer to be asleep, that's also a reasonable choice; discuss it with your surgeon and anaesthetist. You are then taken into the operating theatre, where the operation is performed. Afterwards you wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Once you are stable, you either move to a ward or go home, depending on the procedure and how your recovery is going. ## What the operation involves Your surgeon makes a single cut over the end joint of your finger or thumb. Through this cut, they remove the worn-out joint surfaces so the raw bone on each side can meet. The two bones are then held together while they heal into one solid bone. Small metal implants, such as a screw or a low-profile plate, keep the bones pressed together and in the right position. The joint is set at a bend that suits how you use your hand for pinch and grip, and the position can be fine-tuned before the implants are finally placed. The cut is closed with stitches, and a dressing is applied over the top. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You wake up in the recovery area, where nurses keep an eye on you while the anaesthetic wears off. Your hand will be bandaged, and the finger is usually supported with a splint (a firm cover that holds it still while it heals). Pain relief is planned with you before you leave theatre, and the nurses can top it up if you need more. Someone should stay with you for the first 24 hours. You can move around and use your hand gently as soon as you feel able. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your finger will be sore and swollen, and the end joint may throb. Resting your hand raised on a pillow eases this, and your usual pain relief keeps you comfortable. The swelling settles gradually over the following weeks. You will go home with a splint (a firm cover that holds the finger still while it heals) and a bandaged hand. Keep the dressing dry and leave it alone until we see you. Ruby Doolan, our hand therapist at Extend Rehabilitation, will direct your rehabilitation and make any splint you need. She will show you gentle exercises that keep the rest of your hand and fingers moving while the fused joint heals. Day to day, you can use your other hand for most tasks. You can move around the house, dress yourself and prepare simple meals. Avoid heavy lifting, gripping hard or getting the dressing wet. Sleeping with your hand on a pillow or propped up can reduce night-time throbbing. You will wear the splint until the bones have joined into one solid bone. Once it comes off and your surgeon clears you, driving becomes possible again, provided you can grip the wheel safely. See our page on Driving after upper-limb surgery. Everyone heals at their own pace, so your timeline may differ. Your surgeon and hand therapist will guide you at each review. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The main thing we watch for is the bones failing to join into one solid bone. If that happens, the finger may stay painful at the end joint, or you may notice a click, movement or grinding where there should be none. Tell us at your review if the pain does not settle or the joint feels loose. Sometimes the bones join in a slightly different position than planned. The finger may look twisted or lean to one side, which can make it harder to line up with your other fingers when you make a fist. Mention this at your next appointment. The metal implants can also cause trouble. A screw or plate can loosen, back out or press on the skin, and you might feel a sharp edge under the skin or see the implant pushing through. If that happens, contact the clinic. Removing the implant is a small further operation, and we would talk it through with you. Infection is uncommon but needs quick attention. Watch for pain that keeps getting worse rather than easing, redness spreading out from the wound, swelling that builds instead of settles, or fluid leaking from the cut. You may feel hot and generally unwell. Do not wait for your review: call the clinic straight away, or go to the emergency department if you cannot reach us. Some conditions make problems more likely. Diabetes is one of them, so we take extra care planning surgery if you have it. Your overall health and the complexity of the operation play a part too, which is why we check carefully that this operation suits you before going ahead. If any of these signs appear, do not put it down to normal healing. Call us, and we will see you sooner if needed. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up in the first few weeks. Call us if your pain keeps getting worse instead of easing, if redness spreads from the wound, or if fluid leaks from it. Call us if you feel hot and generally unwell, or if the finger becomes numb, cold or changes colour. Go to emergency if you cannot reach us, or if the swelling is severe and comes on suddenly. Trust your instincts: if something feels wrong, call us. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the DIPJ arthritis page. --- ### Dupuytren's Disease URL: https://www.cqupperlimb.com/education/hand/dupuytrens-disease/ Region: hand · condition Dupuytren’s disease causes palm thickening and finger contracture—options range from observation to needle aponeurotomy or surgical excision. ## What you're feeling Dupuytren's disease starts as a small lump, or nodule, in the palm of your hand. It is usually not painful, or only mildly tender at first. Over time, a firm cord can form under the skin of the palm, running towards one or more fingers. The cord slowly tightens and pulls the affected finger down towards the palm, so the finger will not straighten fully. The ring and little fingers are affected most often. The condition is progressive, which means it keeps changing over time, but the pace is different for everyone. Some people notice very little change over years. In others, the pulling gets worse over months. You may first notice it on waking, when the finger feels stiff and slow to straighten. Shaking the hand loose can help early on. As the cord tightens, everyday tasks that need a flat palm or a wide grip become hard: putting your hand flat on a table, shaking hands, holding a steering wheel, gripping a hammer or a tennis racquet, or getting your hand into a pocket or glove. The main problem is not usually pain. It is losing the ability to open the hand fully, and the frustration of watching a finger curl inwards. Getting back hand function is the main reason people seek treatment. A few warning signs need quick action rather than waiting. Go to the emergency department the same day if your hand becomes hot, red, swollen and painful, especially with a fever, or if your fingers turn pale, cold, white or blue, or you suddenly lose feeling or movement in the hand. See your GP or ask for a specialist review if symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand. ## What's actually happening Under the skin of your palm there is a layer of tough, stretchy tissue called the palmar fascia. Think of it as a soft web of fibres that anchors the skin to the deeper structures of the hand and helps your palm grip and hold. In Dupuytren's disease, this web starts to thicken and tighten. Cells in the tissue begin producing too much collagen, the fibre that normally gives the fascia its strength, and the fibres line up along the direction of the pull rather than staying spread out. As the thickened tissue matures, it shortens into a cord. That cord is what you can feel under the skin of your palm. It behaves like a rope that is slowly being winched in. Because the cord anchors into the finger, it pulls the finger down towards the palm, first at the knuckle and then at the middle joint of the finger. The finger itself and its tendons are healthy. The problem is the shortened fascia holding it bent. The cord does not affect every part of the hand equally. The thumb has no central band of this fascia, which is why the thumb is rarely involved. The ring and little fingers sit in the area where the disease is most active, which is why they are affected most often. Several things about this condition are worth knowing. The exact cause is not well understood, and it involves complex processes at a cellular level. Injury or surgery to the hand, including repeated mechanical stress, is associated with the condition appearing. Surgery removes the cord that has already formed, but it does not remove the underlying disease process, so the cord can return over time. This is why treatment is often staged rather than done once. Even after a cord is released, changes continue for a while. The part of the contracture closer to the palm settles over up to six months. The part closer to the finger may never fully disappear, and can progress again if it keeps pulling on the remaining diseased tissue. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging only if it will change the plan. Dupuytren's disease is usually diagnosed from the examination itself. Because the cord tightens slowly, treatment is often staged rather than done once. In the early stages, when the lump is soft and the finger still straightens, we may simply watch it and see how it behaves over months. Hand therapy can help you keep the hand moving and working well while the disease is quiet. If a finger has started to curl, keeping it stretched and mobile matters, because the longer a deformity is left to progress, the greater the chance the contracture becomes permanent. When a finger will not straighten, there are procedures that release or remove the cord. The least invasive is a needle release, where a fine needle is used to cut the cord through the skin. It can give lasting improvement, including in hands with more advanced disease. Some cords can also be treated with a small open release through a short incision. When the disease is more established, surgery removes the cord and the affected fascia, the layer of tissue under the skin of the palm. In advanced disease, removing the affected skin and replacing it with a skin graft makes recurrence of the tissue less likely. We will talk through which option suits your hand, and make the decision together. Timing matters. Surgery is usually considered when the knuckle joint is bent 30 degrees or more, or when the middle joint of the finger has any bend at all. The middle joint is treated earlier than the knuckle because it is especially prone to becoming permanently stiff in a bent position. Straightening a finger improves hand function, and the middle joint contributes more to that than the knuckle does. After any of these procedures, hand therapy is crucial to getting your hand working well. Rehabilitation after hand surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she directs your therapy and makes any splint you need. ## What to expect Dupuytren's disease moves at its own pace. Some people notice little change over years, while in others the pulling worsens over months. It does not go away on its own, and it does not switch off once a cord has formed. The part of the contracture closer to the palm settles over up to six months, but the part closer to the finger may never fully disappear and can progress again. Straightening a finger makes a real difference to how your hand works. Getting back hand function is the main reason people seek treatment, and correcting the deformity brings a significant gain in what your hand can do. The middle joint of the finger contributes more to that than the knuckle does, which is why it is treated earlier. Recurrence is part of the natural course of this disease, whatever treatment you choose. No current treatment stops the underlying process; they all address the cord it has already made. After a needle release, most people who develop recurrence do so within about 2.3 years. After surgery to remove the cord, about a quarter of people develop recurrence, on average after 3.7 years. Where the affected skin is removed and replaced with a graft, recurrence in that area is much less likely. If the disease does come back, treating it again is possible, though repeat surgery is more difficult and carries more risk than the first operation. Most complications after treatment can be settled with early care. The two that hand surgeons discuss most are recurrence and stiffness. Stiffness, especially at the middle joint of the finger, is the reason early treatment matters: a joint left bent for too long can become permanently stiff in that position. If your hand becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. If symptoms are not settling or are getting worse over weeks, see your GP or ask for a specialist review. After any procedure, hand therapy is crucial to getting your hand working well. Rehabilitation after hand surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she directs your therapy and makes any splint you need. ## When to see someone Most people with Dupuytren's disease seek treatment because hand function is slipping away, not because of pain. Ask for a specialist review if a lump or cord in your palm is getting worse over weeks, if a finger will not straighten fully, or if the changes stop you working or using your hand. The condition is progressive, but the pace is different for everyone, so it is worth having your hand assessed rather than waiting to see how far it goes. Children can also develop a lump in the palm or a bent finger, and that needs review too. If you have had treatment for a trigger finger, keep an eye on your palm, as new Dupuytren's disease can appear afterwards. Go to the emergency department the same day if your hand becomes hot, red, swollen and painful, especially with a fever, or if your fingers turn pale, cold, white or blue. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Dupuytren's is worth the extra reading because the choice between treatments is not really a choice about which one works, it is a choice about which pattern of recurrence and risk you would rather live with. ### The evidence base is weaker than the confidence around it It is worth starting here. A review in the Bone & Joint Journal concluded that there remains limited evidence to guide management of Dupuytren's contracture, while noting that percutaneous needle aponeurotomy tends to produce higher patient satisfaction with fewer adverse events [1]. That should temper any strong recommendation you are given. The condition is common, the treatments are long-established, and the comparative trials that would settle the question have largely not been done. ### What collagenase actually offers Collagenase injection, dissolving the cord rather than cutting it, changed practice quickly. A review of 2,675 patients found it safe and effective for improving hand function, with most adverse events minor and self-resolving [2]. The same review carries the number that matters for expectation-setting: 23% of successfully treated joints went on to recur [2]. Recurrence is not a treatment failure here; it is the natural history of the disease reasserting itself. Dupuytren's is a biological process in the palm, and no current treatment stops the process, they all address the cord it has already made. ### Comparing the risks honestly The trade-off against surgery is not that one is safe and the other is not, but that they fail differently. Comparing collagenase with fasciectomy across 8,809 patients, adverse events seen with collagenase and not reported after fasciectomy included peripheral oedema, extremity pain and injection-site reactions [3]. Read that carefully: those are the additional problems, and they are mostly transient and local. What the injection avoids is a surgical wound in the palm, with its longer recovery, stiffness risk and scar. What surgery offers in return is more complete removal of diseased tissue and, generally, a longer interval before recurrence. So the decision is legitimately personal. A patient who cannot spare weeks of restricted hand use has a strong reason to prefer the injection even knowing recurrence is likelier. A younger patient with aggressive disease may reasonably accept a bigger operation once rather than a smaller one repeatedly. ### Practice moved before the evidence settled Between the introduction of collagenase and the years following, its use rose to substantial levels in the United States with corresponding falls in the proportion of patients receiving fasciotomy and fasciectomy, with patient age and comorbidities influencing which treatment was chosen [4]. That is a useful piece of context when a clinician tells you what is "usually done". What is usually done has shifted considerably within a decade, on evidence the reviews above describe as limited, which is a reason to ask why a particular option is being recommended for you rather than assuming current practice reflects settled science. --- ### Dupuytren's Fasciectomy URL: https://www.cqupperlimb.com/education/hand/dupuytrens-fasciectomy/ Region: hand · operation Dupuytren’s fasciectomy — correcting hand contractures to improve function and daily activities. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Dupuytren's disease causes cords of tissue in the palm to tighten and pull one or more fingers into a bent position. A fasciectomy means removing that tightened tissue so the finger can straighten again. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand and arrange imaging if it is needed. We usually offer non-operative options first, such as hand therapy, splinting or injections. Surgery is considered when those have not given enough improvement, or when the deformity is already significant. We generally suggest it when a knuckle joint is bent 30 degrees or more, or when a middle joint of a finger has started to bend at all. The longer a finger stays bent, the greater the chance the contracture becomes permanent. Surgery aims to straighten the finger and restore hand function. Full or almost full correction is achieved in 75% of cases. We will discuss with you whether this operation suits your hand and your goals. ## Before the operation Before surgery you will need clear instructions about fasting. We ask you to have nothing to eat or drink for seven hours before your operation. This is a little longer than some practices ask for, because it lets us bring your surgery forward if the theatre list runs early. Your surgeon will tell you which of your regular medicines to stop and when, so bring a written list of everything you take. Arrange for someone to drive you home afterwards. Wear loose, comfortable clothing that is easy to put on. Some imaging, such as an X-ray, ultrasound or MRI scan, may be used to plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day On the day of your operation you come to the hospital's surgical admissions unit. You are checked in there and prepared for theatre. You will then meet the anaesthetist, the doctor who looks after your sleep and comfort during surgery. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. After that you are taken into the operating theatre, where the operation is performed. When it is finished you wake up in the recovery area. Nurses watch over you there while the anaesthetic wears off. Once you are stable you either go to a ward or go home, depending on the procedure and how your recovery is going. ## What the operation involves A fasciectomy is done through a single cut over the area being operated on, usually in the palm or along the affected finger. Your surgeon removes the tightened cords of tissue that are pulling your finger into a bent position. Once that tissue is gone, the finger can be straightened. The operation is tailored to your hand. If the disease has reached a middle joint of a finger, your surgeon works carefully around that joint as well. Sometimes a tight band of tissue near the joint keeps the finger bent even after the cords are removed; releasing that band can let the finger straighten further. At the end of the operation, the cut is closed with stitches. A dressing goes over the wound before you leave theatre. You will keep that dressing on for about 10 days, and the 'After the operation' section explains what happens next. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You wake up in the recovery area, where nurses keep an eye on you while the anaesthetic wears off. Your hand will be in a dressing and may feel stiff or sore; pain relief is arranged before you leave, and the team will explain how to manage any discomfort. Keep your hand raised on pillows when resting, as this helps settle swelling. Someone should stay with you for the first 24 hours. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. You can move around the house as you feel able, using your other hand for daily tasks. ## Recovery Your hand will be sore and swollen for the first few days. This settles gradually. Keeping your hand raised on pillows helps, as does the pain relief arranged before you leave hospital. Many people find the discomfort is worst in the first days and eases steadily from there. You will start gentle movement exercises soon after surgery. Hand therapy after this operation is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she will guide your exercises and make any splint you need. Doing these exercises little and often matters more than long sessions. They help the finger keep the straightness the operation gave it, and they help swelling settle. Day to day, you will use your other hand for most tasks at first. Once the dressing comes off and the wound is comfortable, you can usually return to driving, provided you can grip and turn the wheel without protecting the operated hand. See our page on Driving after upper-limb surgery. Returning to work depends on what your job involves; your therapist can advise when your hand is ready. As movement returns, you will notice the finger straightening further and tasks like gripping a cup or holding a pen becoming easier. Recovery varies between individuals, and your timeline may differ. Your surgeon and your hand therapist will guide you at each review. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The tightened tissue that causes Dupuytren's disease can grow back. If the finger starts bending again in the same place, or a new cord appears nearby, let us know at your next review. Sometimes a further procedure is needed to release it again. Bring it up early rather than waiting until the finger is badly bent, as treatment tends to be simpler when the problem is caught sooner. Swelling under the skin after surgery can collect as a pocket of blood near the wound. You would notice a firm, tender lump that appears in the days after the operation, and the skin over it may look bruised or feel tight. If the swelling grows quickly or the pain worsens rather than eases, call the clinic. We may want to see you sooner than planned. Some pain after surgery is normal, but it should ease steadily with the pain relief arranged before you leave. A deep, throbbing pain that does not settle, or pain that gets worse after the first few days, is worth reporting. Call the clinic so we can check the hand. The wound itself needs watching while the dressing stays on. If you notice redness spreading out from the wound, fluid leaking through the dressing, or the hand becoming hot and increasingly tender, contact us. These can be signs of infection, which is easier to treat when found early. Some people notice a clicking or catching feeling as the finger moves, or a sense that it is not straightening as far as it did soon after surgery. Mention this at your next review. It does not always mean anything is wrong, but it is worth recording so we can track how the hand is settling over time. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if you notice fever, redness spreading from the wound, or fluid leaking through the dressing. Call us if pain suddenly worsens or will not settle. Go to emergency if you have calf swelling or shortness of breath, as these can signal a blood clot. Go to emergency if your hand loses feeling, or you cannot move it at all. If something feels wrong and you are unsure, call the clinic. We would rather check early than have you wait. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Dupuytren's Disease page. --- ### Eponychial Marsupialisation for Chronic Paronychia URL: https://www.cqupperlimb.com/education/hand/eponychial-marsupialisation/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Chronic paronychia is long-standing swelling and soreness of the skin folds around the nail. It is usually caused by repeated… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Chronic paronychia is long-standing swelling and soreness of the skin folds around the nail. It is usually caused by repeated exposure to water, such as cold water over many weeks. Bacteria and yeasts can then grow in the softened skin. We often try non-operative care first, such as keeping the hands dry, ointments or tablets. If these have not given enough improvement, surgery may be the next step. The operation is called eponychial marsupialisation. It means making a small opening in the skin fold at the base of the nail so the inflamed tissue underneath can drain freely. Sometimes the nail plate itself is removed at the same time. The aim is to cure the paronychia by letting the swollen tissue drain without restriction. This should settle your pain and let the nail fold heal. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. ## Before the operation Your surgeon will examine your finger and may arrange imaging such as an X-ray, MRI or ultrasound to plan the operation. Most people need no other tests. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, the doctor who gives your anaesthetic. Bring a list of all your current medications, including ointments and tablets. Your surgeon will tell you which medications to stop before surgery and when. Do not eat or drink for seven hours before your operation. We ask for seven hours rather than six so your surgery time can be brought forward if the theatre list runs early. Arrange for someone to drive you home afterwards. Wear comfortable, loose clothing on the day. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist, the doctor who gives your anaesthetic. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. You will wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves Your surgeon makes a small opening in the skin fold at the base of your nail. This fold of skin is called the eponychium. The opening lets the swollen, inflamed tissue underneath drain freely. That drainage is the whole aim of the operation. Sometimes the whole skin fold at the base of the nail is removed in one piece, a method known as en bloc excision. Your surgeon may also remove the nail plate itself if it is irregular or damaged, as this can help the fold heal. The operation removes a thin crescent of the thickened, inflamed skin fold, which lets the trapped swelling escape without disturbing the tissue that makes new nail. The opening is then dressed. You will go home with the dressing on, and our team will show you how to care for the finger at your review about 10 days later. ## After the operation You will wake up in the recovery ward, where nurses keep a close eye on you while the anaesthetic wears off. Your finger will have a dressing on it, and we will show you how to look after it. Pain is usually mild for this operation, and simple pain relief is enough for most people. You can move around as normal and use your hand gently. Someone should stay with you for the first 24 hours after you get home. Your team will tell you whether you go home the same day or stay one night in hospital. Antibiotics are not needed after this operation for most people. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your finger will be tender and a little swollen where the opening was made. This settles gradually. Simple pain relief is usually enough, and keeping your hand raised on a pillow when resting can ease the throbbing. You can use your hand gently around the house, but avoid soaking it or putting pressure on the nail fold. The dressing stays on for about 10 days, so most of your day-to-day routine continues as normal. You can dress, cook and do light tasks once you feel comfortable. Avoid heavy gripping, wet work and anything that bumps the finger until the skin has healed over. Once the dressing comes off at your review, the open area may still be finishing its healing. The nail fold settles over time, and any new nail grows in slowly from the base. You will know things are going well when the soreness fades, the swelling goes down and you can grip and use the finger without pain. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. She will guide your exercises and make a splint if you need one. Recovery varies from person to person. Your timeline may differ, and your surgeon and therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes an infection around the nail does not settle with early treatment. If the infection spreads deeper into the soft tissues of the finger, you may notice swelling and redness that spread out from the nail fold, a finger that feels hot, or pain that keeps getting worse instead of easing. Call the clinic if this happens, or go to the emergency department if you feel unwell or the redness is spreading quickly. An infection can also reach the bone of the finger. This is called osteomyelitis. It can feel like a deep, throbbing pain that does not ease with simple painkillers, often with ongoing swelling and tenderness over the bone. The finger may look red and feel warm. This needs prompt treatment, so contact the clinic the same day or go to the emergency department if the pain is severe. If early treatment of an infected nail fold does not work well, the problem can become long-lasting. You may find the swelling and soreness around the nail keep coming back over weeks or months, with red, tender skin folds that flare up with water exposure. Bring this up at your next review so the plan can be adjusted. The nail bed, the layer of tissue under the nail plate that the nail grows from, can also be permanently damaged if an infection is not treated well in time. You might notice the nail growing in thick, ridged or misshapen, or not growing properly at all. Mention any change like this at your review. The operation itself carries a low risk of complications, and the chance of the swelling and soreness coming back afterwards is also low. If you notice anything worrying during your recovery, such as increasing pain, spreading redness or discharge from the opening, contact the clinic rather than waiting for your next appointment. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most recoveries go smoothly, but some signs need urgent attention. Call us if you have a fever, if the redness or discharge from the wound is getting worse, or if the pain suddenly becomes severe. Go to emergency if you have calf swelling, shortness of breath, or chest pain. Call us straight away if your finger goes numb, feels cold, or you cannot move it. If in doubt, call the clinic. We would rather hear from you early than have you wait at home. --- ### Extensor Tendon Repair URL: https://www.cqupperlimb.com/education/hand/extensor-tendon-repair/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging if it is needed to work out what has happened. Extensor tendons are the cords on the back of your hand and fingers that straighten them. They can be cut by a laceration, torn by a crush or sporting injury, or rupture after a fracture. Many of these injuries, such as mallet finger, are treated without surgery using a splint. Others need repair, especially open cuts, long-standing tears, or injuries where the tendon has been badly damaged. We consider surgery when splinting has not given enough improvement, or straight away when the injury is acute and the tendon will not heal on its own. The aim is to restore the tendon's length and strength so your finger or thumb can straighten again, giving you a working, pain-free hand. ## Before the operation Once your operation is booked, we will give you clear instructions to follow in the days before you come in. You will need to stop eating and drinking seven hours before surgery. We ask for seven hours so you can be brought forward if the theatre list runs early. Your surgeon will tell you which of your usual medicines to stop and which to keep taking, so bring a written list of everything you take, including any blood thinners. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing with sleeves that are easy to remove. Most people need no other preparation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, the doctor who gives the anaesthetic. ## On the day You will come to the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist there. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. Afterwards you will wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you will either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves The exact steps depend on where the tendon is torn and how badly. Extensor tendons run just under the skin on the back of the hand and fingers, so your surgeon can usually reach the injury through a cut over the back of the affected finger or hand. If the skin itself was injured, damaged tissue is cleaned away first, and healthy skin cover may be brought over the area. Once the tendon ends are found, your surgeon sews them back together. The repair is made strong enough to cope with the early movements your hand will do afterwards. If a length of tendon is missing or too damaged to sew, the gap can be bridged instead. This may be done with a piece of tendon taken from a finger that cannot be saved, with a graft, or by moving a nearby tendon to take over the job of the torn one. Your surgeon aims to restore the tendon's natural length, because a tendon left too loose or too tight will not straighten the finger properly. The cut is closed with stitches and covered with a dressing. You will go home with written instructions on caring for your hand. What happens next matters as much as the repair itself. Some repairs need a splint that holds the finger still, while others are started on early, protected movement within the first weeks. One approach allows 30 degrees of active movement in the first two weeks, increasing to 40 degrees in the third week and 50 degrees in the fourth week. Your surgeon will match the plan to your injury and tell you exactly what you can and cannot do. ## After the operation You will wake up in the recovery area, where nurses watch you as the anaesthetic wears off. Your hand will be dressed and may be resting in a splint, depending on your injury. Pain relief is planned before you leave theatre, and you can tell the nurses if you are sore at any point. Someone should stay with you for the first 24 hours. Most people move around normally soon after waking; the operation is on your hand, not your legs. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Your hand will be sore and swollen for the first days and weeks. This is normal. Keeping your hand raised on pillows, even while you sleep, helps the swelling settle. Simple pain relief as directed by your team usually eases the discomfort. Your dressing stays on for about 10 days. Depending on your injury, you may wear a splint that holds the finger still, or you may be started on early protected movement. If early movement is part of your plan, you will be shown exactly how far to bend and straighten the finger and how often. The movements are small at first and increase as the repair strengthens. Rehabilitation is with Ruby Doolan, a hand therapist at Extend Rehabilitation. She will guide your exercises and make any splint you need. At home you can do most everyday things that do not strain the hand. You will need to avoid lifting, gripping and anything that could knock the repair until your therapist clears you. Keep the hand clean and dry until we review the wound. As the swelling settles and movement returns, the exercises become easier and the finger starts to straighten more smoothly. Recovery varies from person to person. Your timeline may differ, and your surgeon and hand therapist will guide you at each review. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The most common problem after this surgery is stiffness. The finger may not straighten fully or bend into a full fist, and grip strength can stay weaker than before. This happens when the tendon scars down to the tissue around it while the hand is held still. Your therapist will watch for this at each visit and adjust your exercises. If movement stalls or the finger feels increasingly tight, bring it up at your next review rather than waiting. Sometimes a small amount of straightening power is lost even when everything else goes well. You may notice the finger sits slightly lower than its neighbours when you try to straighten it, or that it will not bend all the way into your palm. This is called an extensor lag. It is worth knowing this can happen, especially if the injury was old before it was treated. Mention it at review so your therapist can work on it. The repair itself can fail. If you feel a sudden pop or the finger that was straightening well suddenly droops again, contact the clinic straight away. Do not wait for the next appointment. Infection is uncommon but needs quick attention. Watch for pain that keeps getting worse instead of easing, redness spreading out from the wound, swelling that builds rather than settles, or any fluid leaking from the stitches. A fever with a sore hand is also a warning sign. If you see any of these, call the clinic the same day or go to the emergency department if it is after hours. If surgery is needed to free a scarred tendon later, this is called tenolysis. It is not part of the original plan, but it is an option if stiffness does not respond to therapy. Your surgeon will discuss it with you only if your movement plateaus. The complications table on this page lists typical rates if you want the specifics. ## When to call us Problems are easier to fix when they are caught early. Call us if your pain keeps getting worse instead of easing, or if the skin around the wound becomes redder, hotter or starts leaking fluid. Call us if you feel feverish, if your fingers or hand go numb, or if you cannot move the finger at all. If you notice sudden swelling and pain in your calf, or you become short of breath, go to emergency. If the finger that was straightening well suddenly droops, or you feel a pop, call us straight away. --- ### Felon (Fingertip Pulp Infection) URL: https://www.cqupperlimb.com/education/hand/felon/ Region: hand · condition A felon is an infection in the soft pad of your fingertip, the fleshy part you press with. The pad is divided into small compartments by tough fibrous walls. When infection fills those compartments with pus, the pressure inside builds quickly. That pressure is why the pain… ## What you're feeling A felon is an infection in the soft pad of your fingertip, the fleshy part you press with. The pad is divided into small compartments by tough fibrous walls. When infection fills those compartments with pus, the pressure inside builds quickly. That pressure is why the pain feels so intense and throbbing. You will usually notice swelling, redness and pain in the fingertip first. The whole pad may feel tight and tender to touch. It often starts after a small injury, such as a splinter, a needle prick or a finger-stick blood test. If severe pain has lasted 12 hours or longer, an abscess (a pocket of pus) has usually formed. The pain tends to be constant rather than coming and going. Pressing on the fingertip, gripping a pen, typing or turning a key can all hurt. Anything that squeezes the swollen pad makes it worse. Many people find it hard to pick up coins, do up buttons or hold a cup in that hand. If the infection is not treated, it can spread. It may track around the nail bed or up towards the palm along the tendon sheath, the tunnel that lets your finger bend. That can make the whole finger swollen and painful to move. One condition that can look similar is herpetic whitlow, a viral infection of the fingertip. It causes painful blisters on one finger, often days after a minor injury. Unlike a felon, the blisters contain clear fluid rather than pus. This matters, because a whitlow should not be cut open and drained. See a doctor promptly if the pain is severe or getting worse, or if the fingertip is red, hot and swollen. Early treatment gives the best chance of a full recovery. ## What's actually happening Think of your fingertip pad as a sponge cut into tiny closed pockets. Strong fibrous walls run from the skin down to the bone, dividing the pad into small compartments. There is no spare room in there. When infection fills those pockets with pus, the pressure rises fast, and that is what makes the pain so severe. The infection usually gets in through a break in the skin, such as a splinter or a needle prick. The germ most often responsible is a common skin bacterium called Staphylococcus aureus. Because the compartments are sealed, the infection cannot spread sideways easily. Instead it builds pressure inside, and that pressure can squeeze off the blood supply to the small bone at the tip of the finger. Left alone, the pus looks for somewhere to go. It can track around the nail bed, up towards the palm along the tendon tunnel, or down into the bone itself. Infection in the bone is called osteomyelitis, and infection in the nearby joint is called septic arthritis. A more superficial collection may simply wear through the skin. These are the reasons a felon needs prompt treatment rather than waiting to see if it settles. The good news is that the fingertip pad is built to be protected. Any surgery is planned around keeping the sensitive surface of the fingertip intact and avoiding the nerves and blood vessels that run along each side of the finger. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific infection. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At that visit we take a history, examine the finger and arrange any tests needed to confirm what is going on. A felon is an infection, so it does not settle with rest, splinting or physiotherapy alone. There is no self-management step we can offer for the infection itself. What matters is acting early, because the pressure inside the fingertip pad builds quickly and delays make drainage harder. If you think you have a felon, contact us or your GP promptly rather than waiting to see if it improves. Medical treatment has a defined role. Once the pus has been drained, antibiotics are not needed after surgery for an uncomplicated felon in people who are not at risk of infection problems. Some people do carry extra risk. Diabetes and kidney disease both raise the chance that outpatient treatment of a hand infection will not be enough, so we look at your overall health when planning care. Many people with diabetes can still be managed safely as outpatients in selected cases. Surgery is the mainstay for an established felon. The aim is to release the pressure by draining the pus from the sealed compartments of the fingertip pad. We plan the incision to drain the infection well while protecting the sensitive surface of your fingertip and the nerves and vessels along each side of the finger. Some older incision patterns drain well but leave a painful, furrowed scar over the pad and a numb patch beyond it, which interferes with fine tasks like picking up coins or doing up buttons. We choose the approach with that in mind. The operation has its own page if you want more detail. If infection has reached the bone, prompt recognition and early, thorough cleaning of the affected tissue paired with the right antibiotics is what clears it. That is a more serious situation, and we will talk you through it if your scans show it. Treatment is a shared decision. We will explain what we recommend, why, and what the alternatives are, and answer your questions before anything happens. ## What to expect Caught early, a felon usually settles well. The pus is drained, the pressure in the pad goes down, and the pain eases quickly. Most people keep full use of the finger once things have healed. The outlook depends a lot on timing. Early identification and treatment of hand infections are essential to get the best result. If treatment is delayed, the infection can spread into the bone or along the tendon tunnel, and that can lead to lasting stiffness or loss of function in the hand. In severe cases, delayed diagnosis can result in amputation or death. That is why we keep saying not to wait and see. Even with good care, hand infections carry a real rate of complications, and those complications can be difficult to manage. If infection reaches the bone, it needs both surgery and antibiotics together to clear it. In a small number of serious cases, removing the affected finger early may be the safest way to stop the disease spreading. There is some encouraging biology in your favour. When the main part of the fingertip bone has to be removed but the base is preserved, that remaining bone often regenerates to a striking degree. The fingertip can rebuild itself more than you might expect. The same urgency applies to infections that look similar. Infection of the tendon tunnel needs early diagnosis and prompt treatment to prevent lasting loss of hand function. It can also cut off the blood supply to the finger if it is left too long. And if what you have turns out to be herpetic whitlow, the viral infection with clear blisters we described earlier, cutting it open would be the wrong move, because that can invite a bacterial infection on top of the virus. The honest summary is this. Treated promptly, most felons resolve and the finger works normally. Left alone, the pressure keeps building and the infection keeps spreading. The difference between those two paths is how quickly you get seen. ## When to see someone A felon is an infection, so the warning signs are about speed, not about resting it and waiting. Go to an emergency department if the pain is severe and throbbing, or if the whole finger becomes swollen, red and painful to bend. That can mean the pus has spread into the tendon tunnel, and that needs same-day assessment. Ask for urgent review if the fingertip stays painful for 12 hours or longer, because an abscess has usually formed by then. See your GP promptly if you have diabetes, or if your immune system is weakened, since infections can move faster in those situations. And if the fingertip shows blisters with clear fluid rather than pus, tell whoever sees you, because that points to herpetic whitlow, which should not be cut open and drained. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. A felon is worth the extra reading because the two things most people assume about it are both, on the evidence, the wrong way round: the antibiotic is not what cures it, and the reason it is urgent has nothing to do with how big it looks. ### The operation is the treatment. The antibiotic is not. The instinctive model of an infection is that antibiotics kill the bacteria and any surgery is a drainage detail. In an uncomplicated felon that is close to backwards. A prospective study of 46 fingers treated by excision without any post-operative antibiotics at all found that 45 healed. The single failure was not a failure of infection control, it was incomplete excision, and it was corrected surgically [1]. The same paper reports a survey of the French Society of Hand Surgery in which 66% of hand surgeons already give no antibiotics after draining an uncomplicated felon, and 63% give none after a paronychia [1]. The qualifier matters and is doing real work: this applies to an uncomplicated felon in someone not otherwise at risk. Where there is osteitis, spreading lymphangitis, involvement of the flexor sheath, diabetes or immunosuppression, the calculation changes entirely. ### If antibiotics are given, the usual choices are often the wrong ones The second assumption worth dismantling is that the standard first-line antibiotic will cover it. A ten-year study of 815 urban hand infections found that although the overall incidence of MRSA has fallen, it remains the single most common organism, while resistance to clindamycin and levofloxacin rose consistently across the decade. The authors' conclusion is unusually blunt for a paper of this kind: empirical therapy for hand infection should avoid penicillin, beta-lactams, clindamycin and levofloxacin [2]. That is most of what gets reached for by reflex. It is also why a felon that was "treated with antibiotics" and did not settle is a common story rather than a surprising one, and why the finding above, that a properly drained felon needs no antibiotic, is less paradoxical than it first sounds. ### Why the pulp is unlike anywhere else in the body The fingertip pulp is not a simple bag of fatty tissue. It is divided into a series of small closed compartments by fibrous septa running from the skin down to the periosteum of the distal phalanx. Two consequences follow. Pus collecting inside one of those compartments has nowhere to expand into, so the pressure rises fast, which is why a felon hurts out of all proportion to its size, and why the pain is characteristically throbbing and worse at night. And that pressure sits directly against the bone and against the small vessels supplying it, which is how an untreated felon reaches osteomyelitis of the distal phalanx. It also explains the commonest technical failure. An incision that opens the skin but does not deliberately break down the septa drains one compartment and leaves the others sealed. The felon appears treated and then does not settle. Complete decompression, not the size of the incision, is what determines whether it resolves. ### Some of the damage is your own immune system A newer line of thinking reframes what the operation is for. Much of the tissue destruction in a hand infection comes not from the bacteria directly but from the neutrophils your own body sends to fight them, the enzymes that kill bacteria also digest the tissue around them [3]. On that account, drainage and irrigation are not only removing pus and relieving pressure; they are diluting the inflammatory mediators driving the damage. This is a change in emphasis rather than a change in practice, but it is a satisfying explanation for something clinicians observe: relief after decompression is often faster and more complete than simply removing a small volume of pus would account for. --- ### Drainage of a Felon URL: https://www.cqupperlimb.com/education/hand/felon-drainage/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to the stage your infection has reached. A felon is a collection of pus or swelling in the padded tip of a finger. Early on, when the pain feels prickly rather than throbbing… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to the stage your infection has reached. A felon is a collection of pus or swelling in the padded tip of a finger. Early on, when the pain feels prickly rather than throbbing, antibiotics alone may be enough. Once the fingertip becomes tense and throbbing, often worse at night, the pressure inside needs to be released. That is what an incision and drainage does: a small cut lets the infection drain out and relieves the pressure on the blood supply to your fingertip. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We assess your finger, and imaging may be used where needed. We usually try antibiotics first when the infection is early, with close follow-up to check it is settling. Surgery is recommended when those measures have not given enough improvement, or when the fingertip is already tense. The aim is to drain the infection early, ease your pain, and protect the finger from lasting damage. ## Before the operation Your surgeon will give you clear instructions before the day of surgery. You will need to stop eating and drinking for seven hours beforehand. We ask for seven hours rather than six so you can be brought forward if the theatre list runs early. Some medications may need to be paused, and your surgeon will tell you which ones and when. Bring a written list of everything you take, arrange someone to drive you home, and wear loose, comfortable clothing. An X-ray may be used to check the bones of your fingertip, and ultrasound or MRI can help when the diagnosis is unclear. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. Most patients need neither. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist, the doctor who puts you to sleep and looks after you during the operation. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. Afterwards, you will wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you will either go to a ward or go home, depending on the procedure and your recovery. ## What the operation involves The operation is called an incision and drainage. Your surgeon makes a small cut into the tense, swollen pad of your fingertip. This releases the pressure that has built up inside and lets the infection drain out. Once the fingertip is open, your surgeon washes the space out with fluid and clears away any infected or dead tissue. This is called debridement. If there is a simple collection of pus, a thorough drainage is often all that is needed. If the swelling has spread under the skin fold at the base of the nail, your surgeon may lift or remove a small crescent of that fold so the infection can escape and the area can be rinsed clean. The cut is then dressed rather than stitched shut in most cases, because the whole point of the operation is to leave a path for the infection to keep draining as it settles. You will go home with a dressing in place, and our team will tell you how to care for it. Antibiotics are part of the treatment as well as the surgery. A sample of the infection is usually sent to the laboratory so the right antibiotic can be chosen for the specific germ causing it. If the infection was caught early and drained fully, you may not need antibiotics afterwards at all. If it was severe, spreading quickly, or you have other health conditions, a longer course is used. The exact shape and place of the cut depends on your own finger. Your surgeon decides this during the operation, based on where the pressure has collected and what they find. ## After the operation You will wake up in the recovery area, where nurses watch you as the anaesthetic wears off. Your hand will be raised and wrapped in a soft dressing, and the fingertip is left free so you can see it moving. Pain relief is given as you need it, and the nurses will check in with you regularly. Someone should stay with you for the first 24 hours after you get home. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery The throbbing pain that brought you to surgery should ease noticeably once the pressure has been released. Your finger will still be tender and swollen for a while, and some fluid may continue to drain through the cut as it settles. Keeping your hand raised on a pillow, even when sitting or sleeping, helps the swelling go down and eases the discomfort. Pain relief as prescribed will also help you stay comfortable. Your dressing stays on for about 10 days, and we will change or remove it when we see you. Once the dressing comes off, you can watch the fingertip move freely. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. She will guide your exercises and make any splint you need. Gentle movement helps the finger bend and straighten again as the swelling settles. You can do most light daily activities at home with the hand raised when you can. Healing happens in stages. The cut closes over first, then the tenderness fades, then grip and fine movement return. The fingertip pad may feel firm or slightly numb at first, and this softens with time. If the nail was involved, it grows back and covers the area as it regenerates. Once you can grip without pain and the swelling has settled, your surgeon will talk with you about returning to your usual activities, including driving. Recovery varies from person to person. Your timeline may differ, and your surgeon and therapist will guide you along the way. ## When to call us Most infections settle after drainage, but a few signs mean you should speak to us sooner. Call us if you develop a fever or chills, if the redness or discharge from the wound gets worse, or if the pain keeps getting worse instead of easing. Go to emergency if you have calf swelling, shortness of breath, or sudden severe pain. Call us straight away if your finger loses feeling, or if you cannot move it. --- ### Finger Fractures URL: https://www.cqupperlimb.com/education/hand/finger-fractures/ Region: hand · condition Phalangeal and metacarpal fractures of the hand — non-operative care and indications for fixation. ## What you're feeling A broken finger usually happens in one clear moment. A ball jams the end of your finger, you fall onto your hand, or a direct blow catches your finger. You may hear or feel a snap or crack at that instant. Pain arrives straight away, and the finger swells quickly. Bruising often follows within hours. The injured finger may look bent or twisted, or it may simply be too painful to move. You might notice your fingers no longer line up with each other when you make a fist. In children, the same injury often happens at the base of the finger, and the little finger and thumb are the ones most often hurt. A crushed fingertip can break the skin, and sometimes the nail or the skin around it is torn. In the first days, pain is sharpest when you try to bend or grip. Simple tasks like holding a pen, buttoning a shirt, or turning a door handle can hurt. The pain often wakes you at night early on. Over the first two to three weeks, the swelling and pain gradually settle as the bone starts to knit. A few warning signs need action on the day they appear, not at your next appointment. Go to the emergency department the same day if broken skin sits over the injured finger or joint, if bone is showing, or if the finger looks obviously deformed. The same applies if your finger turns pale, cold, white or blue, or if you suddenly lose feeling or movement in it after the injury. If the finger becomes hot, red, swollen and painful, especially with a fever, that needs same-day emergency care too. A GP referral is not needed for any of these. If pain is not settling over weeks, is getting worse, or is stopping you from using your hand or working, see your GP or ask for a specialist review. ## What's actually happening A finger fracture is a break in one of the small bones inside your finger. Each finger has three of these bones, and the thumb has two. The break usually happens when a direct blow, a fall, or a sports injury bends the bone past its limit. Sometimes more than one finger breaks at once, and the wrist or hand bones can be injured in the same accident. The broken bone can stay in line or it can shift out of place. When it shifts, the muscles and tendons attached to that bone pull on the broken pieces. Tendons are the cords that join muscle to bone, and they run so close to the finger bones that they tug the fragments as soon as the bone gives way. That pull is why a broken finger can look bent or shortened, and why it cannot grip or straighten normally while the pieces are out of line. Your body starts repairing the break straight away. Blood collects around the fracture, and the bone begins to knit back together across the gap, much like a cracked branch healing over with new wood. The catch is that everything near the break heals too. The blood and swelling turn into scar tissue that can glue the tendons to the bone. Because the tendons sit right against the bone with almost nothing between them, this stiffening can happen even when the break itself was minor. It is the reason a finger that has joined well can still be stiff and slow to bend. If the break runs into the surface of a knuckle joint, the smooth gliding surface no longer matches up, which adds its own problems. Most finger fractures settle without surgery, but some breaks, especially those that are displaced or unstable, need help holding still while they heal. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some broken fingers heal without an operation, and others need surgery soon after the injury, so prompt assessment matters. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic, we take a history, examine your hand, and arrange X-rays where they are needed. The X-rays show whether the bone is still in line, how far it has shifted, and whether the break runs into a joint surface. Most finger fractures can be treated without surgery. If the bone is stable or only slightly out of place, we hold it still with a splint or cast while it heals. A splint for a broken finger often keeps the knuckle bent and the finger joints straight, and it may leave your wrist free to move. Some injuries are held with a small amount of steady pull instead, which keeps the fragments lined up without an operation. Taping an injured finger to its neighbour is another way to support it, and this works well for many children's finger fractures. We monitor the finger with repeat imaging where needed, and we get it moving in stages once the break can cope with it. Moving early matters because a finger that is held still too long stiffens, even when the bone joins well. Surgery is recommended from the outset when the bone is badly displaced, when it will not stay in place, or when the break runs into a knuckle joint and the surfaces no longer match. Some patterns always need it, such as a joint that has broken and dislocated at once, or a fracture near the nail in a child with torn skin underneath. Your own needs count too: a tradie who needs a strong grip may choose differently from someone whose work is light. The aim of surgery is to hold the pieces in the right position so the finger can move while it heals. We will talk through the options with you, including what each path means for pain, stiffness and the final look and strength of your finger, and we decide together. Whichever path you take, the first weeks are similar. Pain relief keeps you comfortable while the swelling settles. You protect the finger from knocks and strain while the bone knits. Hand therapy starts at the right stage for your injury, with exercises that restore bending and straightening without disturbing the healing bone. ## What to expect Most broken fingers heal well, but the finger often takes longer to feel normal than the bone takes to join. Many fractures join within 4 weeks, and most heal between 5 and 9 weeks. The average healing time is about 6 weeks. During those weeks the finger stays protected in a splint or cast, and pain and swelling settle steadily. Once the break can cope with it, movement returns in stages. How much function you get back depends on the break itself. Breaks of the small finger bones generally do well, with most people regaining good function by nine weeks. Some patterns are harder: breaks near the knuckle joints, breaks in several pieces, and breaks with badly damaged skin around them can leave the finger stiffer or weaker than you would like. Stiffness is the most common setback after treatment, and it can happen even when the bone has joined perfectly. That is why your finger is moved early wherever it is safe to do so, and why hand therapy matters so much. A few things can go wrong along the way. Sometimes the bone is slow to join or does not join at all. Sometimes it joins in a poor position, which can limit how far the finger bends and straightens. If a break near a knuckle joint heals out of line, that joint can lose bending and straightening. These problems are the reason your surgeon checks the finger with X-rays as it heals, and why keeping your splint or cast instructions matters. After surgery, the bone is held in place with pins, screws or a small plate so the finger can start moving sooner. Most people regain good movement and grip strength, and many return to their usual work and activities as the finger allows. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby directs your exercises and makes any splint you need along the way. If pain or stiffness is not settling over weeks, is getting worse, or is stopping you from working or using your hand, see your GP or ask for a specialist review. ## When to see someone Seek urgent care if your finger looks obviously bent or twisted, if skin is broken over the injury, if bone is showing, if the finger turns pale, cold, white or blue, or if you suddenly lose feeling or movement in it. A finger that becomes hot, red, swollen and painful, especially with a fever, also needs same-day emergency care. You do not need a GP referral for any of these. If you cannot reach the clinic, go to your nearest emergency department. See your GP or ask for a specialist review if pain is not settling over weeks, if it is getting worse, or if swelling, movement or grip are not improving week on week as the bone heals. Some finger injuries look minor at first but still need proper assessment, so it is worth having any finger that is painful, swollen or not moving normally checked rather than waiting it out. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Finger fractures are worth the extra reading for two findings that cut against standard practice: prophylactic antibiotics do not appear to help an open fingertip fracture, and for the difficult joint fracture at the middle knuckle, no fixation method has proved better than the others. ### Antibiotics for an open fingertip fracture do not reduce infection An open fracture of the distal phalanx, bone exposed through a wound, typically after a crush, is routinely given prophylactic antibiotics on the general principle that open fractures need them. The evidence does not support it here. Across 353 patients, the results fail to show any effect of prophylactic antibiotics on the rate of superficial infections following open distal phalanx fractures, and the authors conclude the focus should be on prompt irrigation and debridement rather than administration of prophylactic antibiotics [1]. The distinction is between cleaning the wound and medicating it. Removing contamination mechanically is what reduces infection; antibiotics were not shown to add to that in this setting. Given the costs of unnecessary antibiotic use, it is worth knowing that their omission after thorough wound care reflects evidence rather than oversight. ### For the middle-joint fracture-dislocation, no technique wins Fracture-dislocations at the proximal interphalangeal joint are among the more difficult injuries in the hand, a small joint with a fractured surface that must be both reduced and kept reduced while moving. Across 735 patients, the comparison is instructive precisely because it fails to separate the options: percutaneous fixation yielded the highest post-operative range of motion, extension-block pinning resulted in the greatest grip strength, and no treatment method or fracture type yielded consistently better outcomes than another [2]. Where more than half the joint surface is involved, one reconstructive option is to rebuild it with a graft from the hamate bone. Across 235 patients, hemi-hamate arthroplasty was found reliable and effective, affording symptomatic relief and functional restoration [3]. ### Why stiffness is the real enemy The reason these injuries are difficult is not that the bone fails to heal, finger fractures unite readily. It is that the finger stiffens. The flexor and extensor tendons run immediately against the bone with minimal soft tissue between them, so blood and swelling around a fracture organise into scar that binds the tendons to it. That process is well advanced within weeks, and once established it is difficult to reverse. This is why finger fractures are moved early wherever the fracture is stable enough to allow it, and why fixation is chosen partly for whether it permits movement rather than solely for how rigidly it holds bone. It also explains the apparently paradoxical situation of a perfectly healed fracture on X-ray and a finger that will not bend, the bone was never the problem. --- ### Fingertip Injuries URL: https://www.cqupperlimb.com/education/hand/fingertip-injuries/ Region: hand · condition Crush, laceration, nail-bed and amputation injuries of the fingertip and their management. ## What you're feeling A fingertip injury usually hurts right at the end of the finger, where the skin, nail and bone sit close together. The pain is often sharp or throbbing, and it tends to flare when you knock the finger, grip something, or put pressure on the tip. Typing, buttoning clothes, picking up coins, and turning a key can all be awkward because the fingertip takes the load. The finger may feel numb or weak, or both. You might notice the tip feels clumsy, or that you cannot feel textures the way you used to. Swelling and tenderness around the nail are common, and the nail itself can be damaged. Pain often wakes people at night in the first days, and it can be worse after using the hand. Some people notice the fingertip reacts to cold long after the wound has healed. Cold air, cold water or a cold day can make the tip ache or feel overly sensitive. This usually improves with time. If part of a finger has been cut off, go to the emergency department straight away and bring the part with you. Wrap it in damp gauze or a damp clean cloth, put it in a sealed plastic bag, and put that bag on ice or in iced water. Never place the part directly on ice. Go to the emergency department the same day if the finger becomes hot, red, swollen and painful, especially with a fever. The same applies if the skin is broken over a fracture or joint, if bone is showing, or if the finger looks obviously out of shape. A finger that turns pale, cold, white or blue, or sudden loss of feeling or movement after an injury, also needs same-day emergency care. See your GP or ask for a specialist review if symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using the hand. ## What's actually happening A fingertip injury is damage to the very end of the finger, where the skin, nail, bone and nerve endings are packed tightly together. The fingertip is one of the busiest parts of the hand. It is the surface you use to feel, grip and handle almost everything, so even a small injury there gets noticed. The tip of each finger contains a small piece of bone, the bed the nail grows from, and a dense network of nerves that report touch and temperature. When something crushes, cuts or traps the fingertip, any of these can be damaged at once. That is why the symptoms you have just read about tend to arrive together: pain where everything sits close together, numbness from injured nerves, and swelling around the nail. The nail bed matters more than its size suggests. It is a thin layer of tissue under the nail plate, a bit like the bed a plant grows from. If it is cut and left uneven, or heals over a piece of bone that has shifted, the nail that grows afterwards can be split, ridged or hooked. This is why an injury that looks minor is still taken seriously when the nail bed is involved. If the tip has been partly or fully cut off, the injury involves skin, bone and the tiny blood vessels that supply it. How much of each structure is affected shapes what can be done, from dressings that let the finger heal from its own edges inwards, to reattaching the part. The fingertip also has a real capacity to heal itself when the conditions are right, which is why treatment is kept as simple as the injury allows. Fingertip injuries in children happen often, mostly at home in a door or window, and most are preventable. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some fingertip injuries heal without an operation, and others need surgery soon, so prompt assessment matters. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a history, examine the finger, and arrange imaging where it is needed. Many fingertip injuries are treated without surgery. Dressings that keep the wound moist and protected let the tip heal from its own edges inwards, and this can work even when a small piece of bone is showing. The fingertip has a real capacity to regenerate its own contour and sensation when the conditions are right. A dressing that lets air and moisture pass through tends to be more comfortable when it is changed, particularly early on, and healing times appear better with it. Some dressings avoid the need for a hospital stay or time in an operating theatre. The main cost of this route is time, plus regular dressing changes, but that burden is temporary. Once the wound has closed, hand therapy helps you rebuild movement and get the finger back to work. Surgery is considered when the injury itself calls for it, not only after dressings have failed. If part of the finger has been cut off, we may reattach it, which restores both appearance and function. Where the tip needs new skin cover, there are several ways to bring tissue across, chosen by where the damage sits and what is exposed. If the nail bed is cut, we repair it carefully, because a nail that grows from an uneven bed can end up split, ridged or hooked. The operation has its own page, and what to expect afterwards is covered in the next section. ## What to expect Most fingertip injuries settle well when they are treated properly. The fingertip has a real capacity to heal itself, and careful treatment of the skin, nail bed and nerves can generally leave you with a fingertip that looks and works well. Many injuries heal without an operation, and the main cost of that route is time and regular dressing changes rather than anything permanent. Once the wound has closed, hand therapy helps you rebuild movement and get the finger back to work. Recovery is gradual rather than instant. Sensation in the tip often returns slowly, and it may not feel exactly the same as it did before. Some people notice the fingertip reacts to cold long after the wound has healed, and this usually improves with time. Numbness, tenderness and changes in the nail can also take weeks to months to settle. If part of a finger has been reattached, the finger may not feel or work quite as it did before the injury, but it can still give you useful function, a good appearance, and a return to work and daily activities. If a fingertip injury is left untreated, or the nail bed is not repaired carefully, the problems tend to persist rather than settle. A nail growing from an uneven bed can stay split, ridged or hooked. Nerve damage that is not managed can leave lasting numbness or ongoing pain. Some people have long-term pain in the fingertip after the wound has healed, and about one in three people who have part of a finger removed report long-term nerve pain. Infection after these injuries is uncommon, at 2.5%, but if the finger becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. Watch for warning signs as you heal. Go to the emergency department the same day if the finger turns pale, cold, white or blue, or if you suddenly lose feeling or movement in it after an injury. See your GP or ask for a specialist review if symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using the hand. ## When to see someone Most fingertip injuries can wait for a GP visit or a routine appointment, but some cannot. Go to an emergency department straight away if part of a finger has been cut off, and bring the part with you. Go the same day if the finger becomes hot, red, swollen and painful, especially with a fever, or if it turns pale, cold, white or blue. The same applies if you suddenly lose feeling or movement in the finger after an injury, or if the skin is broken over a fracture or joint, bone is showing, or the finger looks obviously out of shape. Rings that have trapped or torn the finger can cause severe injuries that need specialist care. See your GP or ask for a specialist review if symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using the hand. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Fingertip injuries are worth the extra reading because the treatment with the best combination of outcomes is the one that involves no operation at all, a finding that runs against the instinct to close a wound. ### Letting it heal open outperforms closing it When a fingertip is amputated, the reconstructive options are a flap, a graft, or dressings and time — allowing the wound to close by secondary intention, from the edges inwards. Reviewing 1,592 cases of secondary healing, conservative wound management with dressings and protective splints allows patients to avoid immobilisation and donor site morbidity, achieves near-normal sensibility and minimal cold intolerance, and enables early return to work [1]. Four separate advantages, and each addresses a specific cost of the surgical alternatives. A flap requires taking tissue from somewhere else, which creates a second wound and often needs the finger immobilised while it heals. Flap tissue brings its own nerve supply, which is not the fingertip's, so sensation is different in quality. Cold intolerance, an underappreciated long-term complaint after fingertip injury, is reported as minimal with secondary healing. The fingertip has a remarkable capacity to regenerate its own contour and sensation when given the conditions to do so, particularly where bone is not exposed. The main costs of the conservative route are the time involved and the dressing changes, which is a real burden but a temporary one. ### Where a graft is used, age predicts survival Composite grafting, replacing the amputated part as a graft without reconnecting blood vessels, is described as feasible and effective for restoring an aesthetically functional digit across 720 patients, with the graft surviving in the majority and a more significant survival pattern among younger populations [2]. That age effect is worth knowing before the decision is made, because a composite graft that fails leaves a wound that then has to heal by the conservative route anyway, having lost time. ### Replantation: what it can and cannot restore Where a whole digit is amputated, replantation reconnects the vessels. The honest summary of its results across 619 patients is that digit replant does not restore premorbid hand function, but does result in adequate hand function, and that this expectation should form part of the decision-making [3]. The survival factors are also better defined than commonly assumed. Across 2,641 replantations, gender and ischaemia time had no significant influence on survival, while age, which hand, injury type, zone, and the method used to preserve the amputated part all did [4]. Ischaemia time not reaching significance is the surprising one, given the urgency that surrounds these injuries. It should not be read as time being unimportant, it likely reflects that appropriately preserved digits tolerate longer delays than expected, which is precisely why the preservation method mattered. The practical instruction that follows: wrap the amputated part in damp gauze, seal it in a bag, and place that on ice, never the part directly on ice. ### The nail bed is the part that determines appearance Much of the long-term appearance of a fingertip injury is decided by the nail bed beneath the nail plate. A nail bed laceration repaired accurately usually produces a normal nail; one left unrepaired, or healed over a fragment of bone that has shifted, produces a split, ridged or hooked nail permanently. This is why an apparently minor injury with a nail bed component is treated with more care than its size suggests. --- ### Fingertip Repair and Reconstruction URL: https://www.cqupperlimb.com/education/hand/fingertip-repair/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging if it is needed. Fingertip repair and reconstruction covers a group of operations that restore a fingertip after injury. The fingertip is the part of the finger beyond the tendons, and it is the most commonly injured part of the hand. It handles sensation, fine picking-up tasks, and gripping, so the way it is treated matters. Because these injuries vary so much, there is no single standard treatment. We work from simpler options to more complex ones. Many fingertip injuries heal with dressings alone, even when bone is showing in the wound, and this avoids a hospital stay and theatre time. Surgery follows when those measures have not given enough improvement, or when the injury itself calls for it. Where the tip has been cut off, reattaching it keeps the finger's length and lowers the chance of a painful lump of nerve scar forming. Where skin has been lost, a flap of nearby tissue can cover the tip while keeping its length. The aim is a fingertip with good skin cover and useful feeling, so your hand works the way you need it to. ## Before the operation Most of your preparation is simple. You will need to stop eating and drinking seven hours before your operation. We ask for seven rather than six so you can be brought forward if the theatre list runs early. Your surgeon will tell you which of your usual medicines to skip on the day, and you should bring a written list of everything you take. Arrange for someone to drive you home afterwards. Wear loose, comfortable clothing with sleeves that slide over dressings easily. An X-ray is usually enough to plan the operation, though an ultrasound or MRI scan is sometimes used to show soft tissues in more detail. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist, the doctor who looks after your anaesthetic and pain relief. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. When the operation is finished, you wake up in the recovery area. Nurses stay with you there while the anaesthetic wears off. Once you are stable, you either go to a ward or go home, depending on the procedure and your recovery. ## What the operation involves What happens in theatre depends on your injury. If your fingertip has been cut off and arrives with you in a usable condition, your surgeon may reattach it. The tiny blood vessels at the tip are joined back together under a microscope so blood can flow into the fingertip again. The bone and skin are then repaired to hold the tip in place while it heals. If skin has been lost but the finger is otherwise intact, your surgeon may move a flap of nearby skin and tissue over the bare area. Some flaps are lifted from the same finger and slid along or turned to fill the gap, taking their blood supply with them. Others are taken from a nearby finger, the palm, or the back of the hand, and the donor area is stitched closed. These flaps bring their own blood supply and often their own nerves, so the covered tip keeps some feeling. If the tip is too badly damaged to save, your surgeon may shorten the bone and close the skin directly over it. Where a wound is larger, a skin graft may be used to cover it. The cut is closed with stitches, which may be dissolving or removable, and covered with a dressing. You will go home with that dressing in place. ## After the operation You will wake up in the recovery area with nurses nearby. Your hand will be dressed and may be raised in a sling to rest it. Pain relief is planned with you before you leave theatre, and the nerve block, if you had one, keeps the hand numb for about 24 hours. Numbness and weakness in that first day are expected. Call the clinic if you cannot feel or move your fingers once the block has worn off, after about 24 hours. Your team will tell you whether you go home the same day or stay one night in hospital. Someone should stay with you for the first 24 hours. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Your hand will be sore and swollen for the first days and weeks. This is normal. Keeping your hand raised, as we showed you, eases the swelling and the throbbing. Simple pain relief helps too. The nerve block from theatre wears off within about a day, so take your pain medication before it does. We leave your dressing on for about 10 days and remove or change it ourselves when we see you. Until then, keep it clean and dry. Your hand will be rested in a sling at first. You can use the fingers that are free for light tasks around the house, but avoid lifting, gripping and anything that strains the healing tip. Hand therapy is a big part of your recovery, and it starts early. Your therapist is Ruby Doolan at Extend Rehabilitation. Ruby directs your therapy and makes any splint you need. She will show you exercises that keep the other joints moving and gently build feeling and movement back in the fingertip. Doing these little and often matters more than doing them hard. Feeling in the fingertip returns slowly, and it may tingle or feel odd as it does. Once the swelling settles and movement returns, you will start picking up small objects again. When you can grip without pain, heavier tasks come back. Driving follows its own rules: you must be out of any sling or splint, able to hold the wheel with both hands and react in an emergency stop, and off strong pain medication. Our guide to driving after upper-limb surgery explains more. Recovery varies from person to person. Your timeline may differ, and we and Ruby will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The main risk after a reattached fingertip is that the blood supply fails. The tip may look pale, white, blue or dark, and feel cold. It can also swell and look dark red or purple if blood is not draining out of it the way it should. Go to the emergency department if your finger, thumb or hand turns pale, cold, white, blue or dark. This is a circulation problem and it needs attention straight away. Sometimes the joined blood vessels block in the first couple of weeks, even when the tip has been healing well. The team watches for this at your reviews. If blood flow through the joined vessels slows, there are ways to help new smaller vessels take over and keep the tip alive. The way you were hurt matters. Tips cut off cleanly tend to heal better than tips that were torn or crushed. A torn-off finger damages the vessels and nerves over a longer stretch, which makes reattachment harder and failure more likely. Your surgeon will talk honestly with you about this before operating. Smoking narrows the tiny vessels a reattached tip depends on. If you smoke, quitting before and after surgery lowers the chance of the repair failing. The longer a severed part goes without blood, the lower the chance it survives, which is why getting to hospital quickly matters. If part of your finger has been cut off, go to the emergency department straight away and bring the part with you. Wrap it in damp gauze or a damp clean cloth, put it in a sealed plastic bag, and put that bag on ice or in iced water. Never put it directly on ice. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up early, and we would rather hear from you than have you worry at home. Call the clinic the same day if you have a fever, if redness around the wound is spreading, or if fluid or pus is leaking from it. Call us too if your pain keeps getting worse despite your pain medicines. Go to the emergency department if your calf swells or hurts, or if you become short of breath or get chest pain. These can be signs of a blood clot. Go to the emergency department as well if your finger, thumb or hand turns pale, cold, white, blue or dark. Call the clinic if you cannot feel or move your arm, hand or fingers once the nerve block has worn off, after about 24 hours. Numbness and weakness in that first day are expected. If you cannot reach us out of hours or on a weekend, go to your nearest emergency department. --- ### Flexor Tendon Sheath Ganglion Excision URL: https://www.cqupperlimb.com/education/hand/flexor-ganglion-excision/ Region: hand · operation Excision of a flexor tendon sheath ganglion — when surgery is considered for painful or limiting cysts. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging if it is needed to confirm the lump is a ganglion. A flexor tendon sheath ganglion is a small, harmless lump filled with thick fluid. It sits next to the tunnel of tissue that the tendons in your finger slide through. This operation removes that lump through a single cut made over the area being operated on. Most ganglions are treated without surgery first. A needle can be used to draw the fluid out, and this is usually tried before an operation is suggested. Some ganglions also shrink on their own, and in children a cyst that settles usually does so within 18 months. Surgery is offered when the lump keeps causing trouble after these simpler steps. That might be pain, weakness of grip, or a lump that catches when you move your finger. Removing the ganglion aims to take away that pain and let your finger and hand work as they should. ## Before the operation Your surgeon will confirm the plan at your appointment and tell you what to do to get ready. You will be asked not to eat or drink for 7 hours before surgery. We ask for 7 hours rather than the usual 6 so you can be brought forward if the theatre list runs early. You may need to stop some of your regular medicines before the operation. Your surgeon will give you exact instructions about this, so bring a list of everything you take. Arrange for someone to drive you home afterwards, and wear comfortable, loose clothing. Imaging such as an X-ray, ultrasound or MRI scan may be used to plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist there. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. Afterwards you wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves This operation removes the ganglion through a single cut made over the lump. Your surgeon works carefully around the tunnel of tissue that your finger tendons slide through, and takes out the ganglion together with the small stalk that connects it to that tunnel. Removing the whole lump, including its base, helps lower the chance of it coming back. The cut is closed with stitches. A dressing goes over the wound before you leave theatre. Your surgeon will also check the surrounding tissues during the operation. If any part of the tendon has been weakened by the ganglion pressing on it, that tendon is protected and kept intact. ## After the operation This is usually a day case, so you can expect to go home the same day, although occasionally patients stay overnight. You wake up in the recovery area, where nurses keep an eye on you while the anaesthetic wears off. Your hand will have a soft dressing over the wound, and we will give you pain relief to keep you comfortable. You can move around as soon as you feel steady. Someone should stay with you for the first 24 hours after you get home. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Your hand will be sore and a little swollen for the first few days. This settles gradually. Keeping your hand raised on a pillow, even while you sit or sleep, helps ease the swelling and discomfort. The pain relief we give you will keep you comfortable while the worst passes. You go home with a soft dressing over the wound. We leave it on for about 10 days and change or remove it when we see you. Your finger and hand can move gently within the comfort of the dressing. You will not need a cast or a brace. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist, so she will guide your exercises and make any splint you might need. The exercises keep your finger moving and stop it from stiffening as the wound heals. You do them at home, little and often. Everyday tasks come back in stages. Once the wound is comfortable and you can grip and turn a steering wheel without protecting your hand, you can usually drive again. You can read more on our page about driving after upper-limb surgery. Work depends on what your job involves, and your therapist will advise you when your hand is ready. Recovery varies from person to person. Your timeline may differ, and your surgeon and hand therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the lump comes back at the same spot. You would feel or see a small, firm swelling near the old scar. If you notice this, bring it up at your next review. Nerves run close to the area being operated on. A nerve can be bruised or irritated during surgery. This can feel like tingling, pins and needles, or a patch of numb skin near the cut. Most of this settles, but sometimes a small tender spot or nodule forms where the nerve was affected. Tell your surgeon at review if you have numbness or tingling that is not settling. The small nerves and blood vessels that run along the side of the finger lie close by. Injury to them is uncommon, but it is something your surgeon watches for during the operation. The wound can become infected. Watch for redness that spreads out from the cut, increasing pain, warmth, or fluid leaking from the wound. You might feel feverish. If you see any of these signs, call the clinic straight away or go to the emergency department if it is after hours. Blood can collect under the wound after surgery. This looks like a firm, tender swelling that appears in the first day or two. If it is large or painful, it may need to be drained in theatre. Call the clinic if you notice this. The scar can become raised, thick and red as it heals. This is called a hypertrophic scar. It can feel firm and sometimes itchy. Mention it at your review, as treatment can help. The tendon lining near the wound can become inflamed. This feels like creaking or clicking when you move your finger, with tenderness along the tendon. Bring this up at your next review. Your finger or wrist can also feel stiff for a while. Gentle movement and your hand therapy exercises help prevent this. If stiffness does not improve, tell your therapist or surgeon. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems are picked up at review, but some need attention sooner. Call us if you have a fever, spreading redness around the cut, or fluid leaking from the wound. Call us if pain suddenly gets worse, or if a firm, tender swelling appears near the cut in the first day or two. Go to emergency if you have calf swelling or pain, or shortness of breath. These can be signs of a blood clot. Call us as well if your fingers become numb, cold or pale, or if you cannot move your finger or hand when you would expect to. If it is after hours, go to the emergency department. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Flexor Tendon Sheath Ganglion page. --- ### Drainage of an Infected Flexor Sheath URL: https://www.cqupperlimb.com/education/hand/flexor-sheath-drainage/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, treats this infection by draining it promptly, because delay can affect how well the finger moves afterwards. Patients are generally referred to our clinic by their GP; if a physiotherapist has… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, treats this infection by draining it promptly, because delay can affect how well the finger moves afterwards. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your assessment we take a history, examine your finger, and arrange imaging or tests where they are needed. This infection affects the tunnel of tissue that lets your finger tendons slide. It causes swelling, tenderness along the front of the finger, and pain when the finger is straightened. It usually follows a puncture wound or scratch, sometimes a small one. Antibiotics alone are not usually enough, because pus collects inside that closed tunnel. The operation washes the infection out through small cuts and is combined with antibiotic treatment. Acting quickly gives the tendon the best chance of sliding freely again, and the aim is to relieve pain and keep the finger moving. ## Before the operation You will need to stop eating and drinking for seven hours before surgery. We ask for seven rather than six so we can bring you forward if the theatre list runs early. Your surgeon will tell you which of your regular medicines to skip on the day, and it helps to bring a written list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing. Some imaging may be needed to plan the operation, such as an X-ray, ultrasound or MRI scan. If you have other medical conditions, you may also need blood tests or a review with the anaesthetist before the day. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist, who reviews your health and answers your questions. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. You wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. Some people need a short stay so antibiotics can continue through a drip. Before you leave, we explain how to care for your hand and arrange your follow-up. ## What the operation involves The operation aims to open the infected tunnel of tissue in your finger and wash the pus out of it. Your surgeon makes a zigzag cut along the palm side of the finger. If you already have a wound from the injury, it is included in that cut. Small bands of tissue that hold the tendons close to the bone are partly released so the surgeon can reach the tendons and the tunnel around them. The tunnel is then flushed out repeatedly with fluid containing antibiotic until the fluid running out is clear. While this happens, your finger is gently bent and straightened so the fluid reaches every part of the tendon. Any infected tissue clinging to the tendons is cleaned away. In some cases a fine soft tube is left in the tunnel so fluid can keep washing through it afterwards, usually at a slow, steady rate. The tube is positioned carefully inside the tunnel, because fluid collecting in the wrong place under the skin can harm the finger's blood supply. The cut is closed with stitches, and most people also start a course of antibiotics through a drip. Antibiotics are chosen to match the germ causing the infection and how severe it is. Some people need a short stay in hospital so the drip antibiotics can continue. The whole treatment works as a pair: the operation drains the infection, and the antibiotics clear what is left. Your surgeon will explain which parts of this apply to you, since the exact steps depend on how far the infection has spread and what is found during the operation. ## After the operation You wake up in the recovery area, where nurses watch you closely while you come round. Pain is managed with medication, and your hand will be in a dressing and bandage. You can move around as soon as you feel able, and someone should stay with you for the first 24 hours. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Your finger will be sore and swollen for the first days and weeks. The swelling often spreads along the whole finger and into the palm. Keeping your hand raised on pillows, even while you sleep, helps it settle. Simple pain medication usually eases the discomfort as it improves. Your hand will stay in a dressing and bandage for about 10 days. We change or remove the dressing when we see you. After that, your recovery focuses on movement. Hand therapy after this surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she will guide your exercises and make any splint your finger needs. The exercises start gently and build as the pain settles. You will bend and straighten the finger little and often through the day. This keeps the tendons sliding inside the tunnel as it heals. You can do most things at home with your other hand while this one recovers. Keep the cuts clean and dry, and avoid heavy gripping, lifting or getting the hand dirty until we tell you it is safe. Driving is off the table while your hand is in a splint or you cannot grip and react quickly in an emergency stop, and you must be off strong pain medication. Our guide on driving after upper-limb surgery explains when you can get back behind the wheel. Some stiffness in the finger is expected even when treatment goes well, and it can take time for movement to return. Your timeline may differ from the next person's; we and your therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. One problem this infection can cause is a sudden drop in the blood supply to the finger. Doctors call this digital ischaemia. It means the finger is not getting enough blood, so it may look pale, dusky or a darker colour than the fingers beside it. It can feel cold, numb or more painful than before, and the pain may be deep and throbbing rather than the usual soreness of a healing finger. The finger may also swell quickly or feel firm. This is not something to wait on. If you notice any of these changes, contact the clinic straight away, or go to the emergency department if it is after hours or you cannot reach anyone. Tell the team what you are seeing and when it started. Quick treatment gives the finger the best chance of recovering its blood supply. If you are at home with a wash-out tube in place, mention any new colour change, coldness or worsening pain when you call. If you are unsure whether what you are noticing counts as a problem, call anyway. It is always fine to ask. Some changes are worth raising at your next review rather than the emergency department, such as mild swelling that is slowly settling or discomfort that eases with simple painkillers. Your team will tell you at your follow-up which changes need a phone call and which can wait for your appointment. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if you develop a fever, if the redness around your wound is spreading, or if discharge from the cuts increases. Call us if pain suddenly becomes severe, if your finger changes colour, or if you cannot bend or straighten it. Go to emergency if you have calf swelling or shortness of breath, or if your finger looks pale, dusky or cold. These changes need urgent assessment. If you are unsure, call anyway. --- ### Flexor Tendon Repair URL: https://www.cqupperlimb.com/education/hand/flexor-tendon-repair/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging if it is needed to work out what has been injured. A flexor tendon repair means stitching together a tendon in your finger or thumb that has been cut. These tendons bend your fingers, and when one is cut the finger cannot bend on its own. Because this is an acute injury, surgery may be recommended straight away, without a trial of non-operative care first. A cut tendon will not heal back to full strength on its own, and without repair the finger is likely to stay stiff or weak. The aim of the operation is to give the repair enough strength for you to start moving early, which helps stop the tendon sticking down inside its sheath. The goal is to restore normal range of motion and function to your finger. ## Before the operation Flexor tendon repair is usually done soon after the injury, so there is not much to organise. Your surgeon will tell you when to stop eating and drinking. We ask for seven hours of fasting so your operation can be brought forward if the theatre list runs early. You may need to pause some of your usual medications before surgery, and your surgeon will give you exact instructions about which ones and for how long. Bring a written list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing on the day. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, but most people do not. Imaging such as an X-ray, ultrasound or MRI may already have been arranged to help plan the operation. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You meet the anaesthetist there. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. You wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves Your surgeon makes a cut over the finger or palm to reach the torn tendon. The cut ends of the tendon are found and brought back together. The tendon is stitched with strong stitches that run through its core, plus fine stitches around the outside edge of the repair. The outer stitches add real strength to the repair. Several strands of stitch are used across the repair, because a repair with more strands is stronger than one with fewer. The surgeon works carefully around the tendon and the delicate structures that surround it, because these allow the tendon to glide as your finger bends. How the repair is done depends on where along the tendon the cut happened. Some zones of the finger are harder to work in than others, and the technique chosen reflects this. Once the tendon is repaired, the skin is closed with stitches and a dressing is applied. You will keep that dressing on for about 10 days, as described in the recovery section. The aim throughout is a repair strong enough for you to start moving your finger early, which lowers the chance of the tendon sticking down inside its sheath. ## After the operation You wake up in the recovery area, where nurses watch you closely while the anaesthetic wears off. Your hand will be in a dressing and a splint that holds your finger still. Pain relief is planned with you before you leave theatre, and you can ask for more at any time. Someone should stay with you for the first 24 hours. You can get up and walk around as soon as you feel steady, and you will be shown how to protect your hand while moving about. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your finger will be sore and swollen, and the discomfort is usually at its worst early on. Regular pain relief, keeping your hand raised on pillows when you sit or rest, and moving about gently all help settle it. The swelling eases gradually as the weeks pass. Your hand will be in a splint that protects the repair. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby will direct your exercises and make any splint you need. You will start moving your finger early, because gentle movement helps stop the tendon sticking down inside its sheath. The exercises feel small at first, often just bending the finger a little within the limits your therapist sets. They matter as much as the operation itself, so doing them as instructed is important. At home you can manage most daily tasks with your other hand. You will need to keep the splint dry and avoid lifting, gripping or carrying with the operated hand until your therapist clears you. Sleep can be awkward at first; resting your hand on a pillow often helps. As movement returns, the exercises progress, and once the swelling settles you will find everyday tasks easier. Your surgeon and Ruby will tell you when the repair is strong enough for each new step, including when you can drive again; our guide to driving after upper-limb surgery covers the rules that apply. Recovery varies between individuals, so your timeline may differ. Your surgeon and your therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The repaired tendon can sometimes pull apart. You might feel a sudden pop or give way in the finger, or notice the finger that was bending during your exercises stops bending on its own again. If that happens, contact the clinic straight away rather than waiting for your next review. Scar tissue can form around the repair and stick the tendon down inside its sheath. The finger may bend only part way, or feel stiff and caught when you try to move it. Sometimes this settles with therapy alone. If it does not, a small operation can release the scar tissue and free the tendon up. Mention any stiffness that is not improving at your review appointments. Infection is uncommon but needs quick attention. Watch for pain that keeps getting worse instead of easing, redness spreading out from the wound, warmth, swelling, or fluid leaking from the wound. A deep infection in the tendon sheath can leave the finger stiff even when treated promptly, so early review matters. Call the clinic the same day, or go to the emergency department if you cannot reach anyone. Some fingers have other problems after healing. The finger may click or trigger as it bends, or one finger may not bend fully because its movement is linked to the others. The small finger can end up with less movement than the others. If you notice clicking, catching or uneven bending, bring it up at your next review. A few patients need further surgery of some kind, whether for a pulled-apart repair, scar tissue, or another issue. Your surgeon will explain what is involved if that becomes necessary. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if you have a fever, or if the wound becomes more red, warm or swollen, or starts leaking fluid. Call us the same day for pain that keeps getting worse instead of easing. Go to emergency if you have sudden severe pain, a sudden pop in the finger that stops bending on its own, calf swelling or pain, or shortness of breath. Also go to emergency if your fingers lose feeling, or if you cannot move them at all. If you cannot reach anyone at the clinic, go to the emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Flexor tendon repair is worth the extra reading because it is governed by a single unforgiving trade-off: the movement that stops the tendon sticking down is the same movement that can pull the repair apart. Almost every technical decision in this operation is an attempt to buy room between those two failures. ### The trade-off, measured A meta-analysis of 569 zone II repairs compared early active motion with early passive motion after surgery [1]. The early active group achieved greater total active motion, the outcome that determines whether the finger is useful [1]. The same analysis found the cost. A higher risk of rupture was observed in the group doing active flexion and extension when the tendon had been repaired with a 2-strand core suture [1]. That conditional is the whole point, and it is easy to miss. Early active motion is not inherently dangerous, and 2-strand repair is not inherently weak. The combination is the problem. The strength of the repair and the aggressiveness of the rehabilitation are a single decision made by two people, and they have to be made to match. If your hand therapist and your surgeon appear to be talking to each other about the specific suture used, that is the system working as intended. ### Why the literature is harder to read than it should be A systematic review of 1,878 digital flexor tendon repairs set out to compare 2-strand against multistrand core suture techniques and could not definitively confirm its hypothesis, not because the answer was negative, but because of wide variation in how outcomes and study designs were reported [2]. This is a recurring problem in hand surgery. Different papers use different motion measurements, different definitions of a good result and different follow-up points, which makes pooling them close to meaningless. Where you see confident claims that one repair technique is superior, the honest position from the pooled evidence is that the reporting is not yet consistent enough to say. ### Splinting is moving, with the evidence lagging Relative motion orthoses, splints that hold the repaired finger slightly differently from its neighbours, so tendon glide is shared, have changed extensor tendon rehabilitation. A systematic review of 529 patients concluded there is now good evidence that the approach is safe in zones V–VI extensor repairs, but that evidence for flexor repairs remains limited [3]. So it is a promising direction rather than an established standard on the flexor side, and it is reasonable to ask what protocol is being used and why. ### Where technique is heading One line of work accepts the trade-off and engineers around it. A zone II technique using an externalised detensioning suture, a temporary suture outside the skin that takes load off the repair, substantially strengthened the construct and allowed early active motion with reduced rupture risk, at the cost of limiting distal joint motion until the suture is removed [4]. That is a fair summary of the field: the fundamental tension has not been dissolved, only managed more cleverly. ### What this means for your recovery The therapy is not aftercare, it is part of the operation. Attendance, and doing exactly the prescribed amount rather than more, is what keeps you on the right side of the trade-off described above. A rupture in the first six weeks usually means a second operation with a worse starting point than the first. --- ### Flexor Tendon Sheath Ganglion URL: https://www.cqupperlimb.com/education/hand/flexor-tendon-sheath-ganglion/ Region: hand · condition A benign, fluid-filled cyst arising from the flexor tendon sheath – often painless, but can cause clicking or limited finger movement. ## What you're feeling A flexor tendon sheath ganglion is a small, firm lump at the base of a finger, in the palm. It is usually only a few millimetres across, but it can hurt more than you would expect from something so small. The pain comes when you grip something hard and narrow, like a steering wheel, a golf club, a bicycle handlebar or a shopping bag handle. The lump gets squeezed between the object and the bone of your finger, with nothing soft to cushion it. The pain tends to flare during or after those gripping tasks. Things like carrying heavy shopping, holding tools, or wringing out a washing load can become uncomfortable. Some people notice the ache settles once they let go of the object. The lump itself is firm rather than soft, and sits right where your fingers bend into the palm. Because the pain is tied to gripping, it can start to limit what you do with that hand. You might find yourself avoiding certain jobs, or changing how you hold things to keep pressure off the spot. If your finger, hand or arm ever becomes hot, red, swollen and painful, especially with a fever, that needs same-day care at an emergency department. You do not need a referral from your GP to go. ## What's actually happening Your finger bends because of two tendons that run from your forearm, along the palm side of the finger, and anchor to the finger bone. Think of them as ropes that pull when you curl your finger. To keep those ropes held close to the bone instead of bowing away from it, they run inside a tunnel made of tough bands called pulleys. That tunnel is lined with a thin, slippery layer that keeps the tendons fed and gliding smoothly. A flexor tendon sheath ganglion is a small sac of thick, jelly-like fluid that pokes out from that tunnel. The sac is filled from the lining of the sheath itself, so it behaves like a small leak under pressure: drain it and it refills, because the leak is still there. The sac sits right at the base of the finger in the palm, where the tunnel is bound tightly to the bone with no soft padding over it. That is why a lump only a few millimetres across can hurt so much when you grip: the lump gets pinched between whatever you are holding and the bone underneath. The same spot explains the other things you may have noticed. Because the lump takes up room inside a narrow tunnel, it can crowd the tendon as it slides through, which is why some people with a lump at this spot also get catching or clicking in the finger. The nearby nerves to the finger run right beside the sheath, one on each side, so a lump pressing on a nerve can cause tingling or numbness rather than pain alone. It is worth knowing that a lump in this exact spot can also come from other causes, such as a tendon that catches as it glides, or a thickening in the palm tissue that pulls the finger towards the palm. Your surgeon can usually tell these apart by examining your hand, and the treatment differs for each. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging such as an ultrasound scan if it is needed to confirm what the lump is. Because this lump is harmless and does not keep growing, treatment depends entirely on how much it bothers you. A lump you can feel but that does not hurt during your normal grip may need nothing done at all. If a particular grip keeps causing pain, changing how you hold things or easing off that task for a while can be enough. Hand therapy can also help you find ways to use your hand that put less pressure on the spot. Draining the lump with a needle, called aspiration, is often tried before surgery. It empties the sac of fluid, but because the sac is fed by the tendon sheath it usually fills up again. Some lumps also settle on their own over time. We will talk through whether drainage is worth trying in your case. If these simpler steps have not given you enough relief, surgery may be considered. The operation removes the lump through a small cut at the base of the finger, along with the small piece of tendon sheath it grows from, which is what stops it coming back. We usually suggest surgery when a specific, repeated activity in your daily life is being limited by the pain, and we make that decision together with you. If your finger, hand or arm ever becomes hot, red, swollen and painful, especially with a fever, go to an emergency department the same day. ## What to expect Most ganglions like this one are harmless and do not keep growing. Some settle on their own over time, and some come and go. If yours is not painful, you may never need treatment at all. If the lump does hurt when you grip, simple steps can help. Draining it with a needle empties the sac, but because the sac is fed by the tendon sheath it usually fills up again. Changing how you hold things, or easing off the task that flares it, can be enough while you wait to see whether it settles. If those steps have not helped enough, surgery removes the lump along with the small piece of sheath it grows from, which is what stops it coming back. Most people notice their grip feels more comfortable once the spot is no longer being pinched. As with any hand operation, there are risks to weigh up, including a numb patch along one side of the finger, stiffness, infection and a thick or tender scar. Your surgeon will talk these through with you before you decide. Recovery after surgery takes weeks rather than days. Your hand will be sore at first, and the small cut at the base of your finger will take time to settle. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she will guide your exercises and make any splint you need as your finger heals. Most people are back to their normal gripping tasks within weeks, though some tenderness at the scar can linger a little longer. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone Most lumps at the base of a finger are harmless ganglions, but a few other things can look the same in that spot. A finger that locks or clicks when it bends, or a firm cord in the palm that is pulling the finger towards the palm, are conditions your surgeon can tell apart by examining your hand. It is worth getting any new lump checked so you know which one you have. Ask for a specialist review if the lump is painful when you grip, if you notice tingling or numbness in the finger, or if the finger is catching or clicking. Also ask if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand. If your finger, hand or arm ever becomes hot, red, swollen and painful, especially with a fever, go to an emergency department the same day. You do not need a referral from your GP to go. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. A flexor tendon sheath ganglion is worth the extra reading because it is the smallest lump in hand surgery that reliably causes disproportionate symptoms, and because what it is attached to determines both why it hurts and why simple treatments fail. ### A pea-sized lump that hurts out of proportion These cysts, also called retinacular cysts, or volar retinacular ganglia, arise from the fibrous sheath that holds the flexor tendons against the finger bones [1]. They sit at the base of the finger in the palm, are typically only a few millimetres across, and are firm rather than soft. The symptom is characteristic and explains itself once the anatomy is clear: pain on gripping something hard and narrow, a steering wheel, a golf club, a bicycle handlebar, a shopping bag handle. The cyst is trapped between the object and the underlying bone, and there is no soft tissue to cushion it because the sheath is bound directly to the phalanx. That is why size correlates so poorly with symptoms. A large soft swelling on the back of the wrist may be painless while a lesion a fraction of its size at the base of a finger is genuinely limiting. ### The same rule as every other ganglion Its behaviour follows from what it is connected to. The cyst arises from the tendon sheath and is filled from it, which means the mechanics are those of the wrist ganglion and the mucous cyst: the sac is the visible end of the problem, not the source. Consequently, puncturing or aspirating it addresses the swelling and not the leak. Recurrence after simple drainage is common, and definitive treatment means excising the cyst together with the affected portion of the sheath from which it arises. ### Why the operation is smaller than it sounds but not trivial Excision is a short procedure through a small incision at the base of the finger, and it is generally curative. Two anatomical facts make care worthwhile at that site. The digital nerves run immediately beside the flexor sheath, one on each side, and at the base of the finger they are superficial and close to the midline structures being removed. A numb patch along one border of a finger is a recognised risk of a small operation in this location. Second, only the redundant portion of the sheath can be removed. The pulleys that hold the tendons against the bone are load-bearing structures, and losing a critical one allows the tendon to bowstring away from the finger, which weakens grip. Excision is therefore deliberately limited to the segment of sheath that is not doing that job. ### When to leave it alone Because this lesion is benign and does not enlarge indefinitely, treatment is driven by symptoms alone. A cyst that is noticeable but not painful in daily grip needs nothing done. Where it is treated, it is because a specific and repeated activity is compromised, which is a clearer indication than most, since the provoking grip is usually easy for a person to identify. The related cysts of the fingertip joint and the wrist are covered on their own pages; the shared principle across all three is that the stalk, not the sac, determines whether the problem returns. --- ### Excision of Giant Cell Tumour of Tendon Sheath URL: https://www.cqupperlimb.com/education/hand/gctts-excision/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand and arrange imaging where needed to confirm the diagnosis. A giant cell tumour of tendon sheath is a non-cancerous lump that grows slowly on or near a tendon, the cord that joins muscle to bone. It does not spread to other parts of the body. These lumps are common in the hand and fingers, and they are usually painless, though some people notice swelling, pain or stiffness as the lump grows. Because this lump does not go away on its own, treatment is usually to remove it. The operation we suggest is surgical excision, which means removing the lump completely. This is the most commonly accepted treatment for this condition. The main aim is to remove the lump fully and ease the swelling, pain or stiffness it has been causing. Because these lumps can grow back, we arrange regular follow-up visits after surgery to check the area. ## Before the operation In the weeks before surgery we confirm the plan with imaging. This may include an X-ray, an ultrasound or an MRI scan, which uses magnets to take detailed pictures of the lump and the tissue around it. These pictures help us see exactly where the lump sits and plan how to remove it. On the day itself, stop eating and drinking seven hours before your operation time. We ask for seven hours rather than six so your surgery can be brought forward if the theatre list runs early. Your surgeon will tell you which of your usual medicines to take and which to pause. Bring a written list of everything you take, wear loose comfortable clothing, and arrange for someone to drive you home afterwards. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, the doctor who gives the anaesthetic. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist, the doctor who gives the anaesthetic. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. You wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves The aim of the operation is to remove the lump completely, along with any small pieces of it that may have spread nearby. Your surgeon makes a cut over the lump, sized to suit where it sits and how far it reaches. The lump is often stuck firmly to the tendon or to the nerves and blood vessels running alongside it, so the removal is done carefully, sometimes with magnification to help protect those structures. Once the lump is out, your surgeon checks the area for any small satellite nodules, tiny separate pieces of the lump that can be left behind. Removing these matters, because leftover pieces are what can grow back later. The cut is then closed with stitches and covered with a dressing. Before surgery, a small sample of the lump may be taken with a fine needle to confirm what it is. This helps with planning, so the surgeon knows exactly what to expect when operating. ## After the operation You wake up in the recovery ward, where nurses keep an eye on you while the anaesthetic wears off. Your hand will have a dressing on it, and we will give you pain relief to keep you comfortable. You can move around soon after waking, though someone should stay with you for the first 24 hours. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Your hand will be sore and swollen for the first few days. This settles gradually. Keeping your hand raised on a pillow, even while you sit or sleep, helps ease the swelling and discomfort. Simple pain relief as directed by your team will keep you comfortable. You will go home with a dressing on your hand, which we leave in place for about 10 days. Please keep it clean and dry, and do not take it off yourself. When we see you, we check the wound, remove the dressing and take out the stitches if needed. Once the wound has healed, you will start hand therapy with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist who directs your exercises and makes any splint you need. The exercises help your fingers and hand regain movement and strength as the swelling settles. You can use your hand for light daily tasks at home, but avoid heavy lifting, gripping firmly or anything that strains the area until your therapist clears you. Most people find the stiffness improves steadily as movement returns. Once you can grip and use your hand without pain, you will find everyday tasks much easier. Your surgeon will let you know when you are ready to return to work, sport or driving, and there is a separate guide on our site about driving after upper-limb surgery. Everyone heals at their own pace, so your timeline may differ. Your surgeon and your hand therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The main thing we watch for is the lump growing back. This can happen months or even a few years after surgery, so we arrange regular follow-up visits to check the area. If you notice a new lump or swelling near your scar, bring it up at your next review or call the clinic. Sometimes a small piece of the lump left in the wound can grow there, so a lump sitting within the scar itself is worth showing us. Rarely, these lumps can behave in a more serious way. If you have swelling that keeps growing or seems unusual, we want to see you promptly so we can investigate it. The lump can sometimes press on or sit close to nerves. If you notice numbness, tingling or weakness in part of your hand or arm that does not settle, tell us at your review. Removing these lumps can be technically difficult because they grip tightly onto the tendon and the nerves and blood vessels beside it. Your surgeon works carefully to take out the whole lump while protecting those structures. If some of the lump is left behind because removing it would damage something important, we will explain this and keep a close watch on the area afterwards. For lumps that spread more widely through the tissue, surgery alone may not control them fully. In those situations, radiation therapy, which uses targeted X-rays to slow the lump's growth, may be suggested to help protect the way your hand works. Your surgeon will discuss this with you if it ever applies to your case. Because these lumps can grow back quietly, we ask you to keep your follow-up appointments even when your hand feels fine. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if you have a fever, increasing redness around the wound, or discharge from it. Call us if your pain suddenly gets worse, or if numbness or tingling in your hand does not settle. Call us if you cannot move your fingers or hand as you could before. Go to emergency if you have calf swelling or pain, or shortness of breath. These can be signs of a blood clot, and they need checking straight away. --- ### Giant Cell Tumour of Tendon Sheath (Lump on a Finger or Thumb) URL: https://www.cqupperlimb.com/education/hand/giant-cell-tumour-of-tendon-sheath/ Region: hand · condition A giant cell tumour of tendon sheath is a common, benign (non-cancerous) lump on a finger or thumb. What causes it, how it is diagnosed and removed, and how often it comes back. ## What you're feeling Most people notice a lump on a finger or thumb that does not hurt. It is usually firm, and it grows slowly. Some lumps sit right next to a joint, often the joint closest to the fingertip, and they can appear on the top, side or palm side of the finger. The index finger is the most common spot. The lump itself is painless in almost every case. When there is discomfort, it tends to come from the lump pressing on nearby structures as it grows. A small number of people notice tingling or numbness in the finger if the lump presses on a nerve. Some people find the finger catches or clicks when it moves, a bit like a trigger finger, where the finger briefly sticks and then jumps free. If the lump is near a joint, bending that finger fully can be hard because the lump gets in the way. Everyday tasks that use that finger can become awkward. Picking up small coins, doing up buttons, holding a pen or gripping a jar lid may feel clumsy if the lump sits where your grip lands. The lump can also catch on gloves or pockets. The lump often has been there a long time before it bothers you enough to ask about it. Many people wait months or years, watching it slowly change. A few things about this condition are worth knowing. It is benign, which means it does not spread to other parts of the body. It is slightly more common in women than men, and it usually appears between the ages of 32 and 51. Most people have a single lump, though some have more than one in different spots. Watch for a finger or hand that becomes hot, red, swollen and painful, especially with a fever. If that happens, go to the emergency department the same day. If the lump keeps growing, starts to hurt, or the finger is not working as it should, see your GP or ask for a specialist review. ## What's actually happening Your tendons are the strong cords that join muscle to bone and let your fingers bend. Each tendon runs inside a thin sleeve called a tendon sheath, which works a bit like a gasket around a rope, keeping the cord slippery so it can glide as the finger moves. In this condition, the cells in that sleeve start growing more than they should. The result is a soft tissue lump that sits on or beside the tendon, often close to a joint. It is benign, which means it does not spread, and it grows slowly. Most lumps are small, around 1.35 cm on average, though some grow larger. The lump is made up of a few things crowded together: inflammatory cells, giant cells (which are simply cells with several nuclei), and a dark pigment called haemosiderin, the same stuff that colours an old bruise. That pigment is why these lumps can look brownish if they are ever seen during surgery. The symptoms you noticed in the section above come from the lump being in the way. As it grows it can press on the tendon, the joint or a nerve, which explains the catching, the stiffness and the occasional tingling. Most of the time it does not hurt at all, and only about 16 in 100 people report pain. A few points worth knowing. Most people have a single lump, but about 21 in 100 have two or more separate ones. The lump usually sits next to a joint, and in about a third of finger cases it is at the joint closest to the fingertip. Very rarely, the lump can press into the bone itself, which shows up on an x-ray. There is also a rarer, more diffuse form of the same condition that spreads along the tendon in thin fronds rather than forming one neat lump. That form is much less common in a finger and tends to behave differently, which is why your surgeon will want a clear picture of exactly what kind of lump this is before planning anything. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a history, examine your hand and arrange imaging where it is needed to work out exactly what kind of lump this is. Because this lump is benign and grows slowly, doing nothing is a real option. For a small, painless lump, simply watching it can be the right choice. If the lump is getting in the way, hand therapy can help with the stiffness and the catching. Therapy aims to keep the finger moving and make everyday tasks easier. We usually suggest giving it a fair trial before thinking about surgery. This condition has no medication that shrinks it, so pain tablets and anti-inflammatories only settle discomfort from the lump pressing on nearby tissue. They do not make the lump smaller. Surgery is the usual treatment when the lump is large, painful, or stopping the finger working properly. The aim is to remove the whole lump along with its attachment on the tendon sleeve, because leaving that attachment behind is what allows it to grow back. We plan carefully before operating, use magnification during the operation, and remove the lump completely. Recurrence is the main risk with this condition, and it typically happens within 36 months of excision. In a group of 605 people who had a finger lump removed, 14.8% had it come back. Another way to put that: most people, about 85 in 100, do not have it return. If it does come back, removing it again with extra steps to discourage regrowth can still sort the problem out. ## What to expect The outlook for this lump is steady rather than dramatic. It is benign, so it does not spread anywhere else in your body. Left alone, a small painless lump usually keeps growing slowly, or simply stays as it is. It rarely settles on its own, and it does not turn into anything dangerous. The main thing this condition does over time is come back after removal. Recurrence is the primary risk with this lump, and it typically happens within 36 months of excision. Some lumps are more likely to return than others: ones made up of two or more separate pieces that are not joined together, and ones that have grown into the tendon itself or the lining of the joint. When the whole lump is removed along with the spot where it attaches, that risk drops a long way. Function after treatment tends to be good. People who have had one of these lumps removed from a finger score, on average, 92% of normal limb function on a standard measure of how the limb works. In reported cases, people have kept full movement in the finger, and the shape of the finger bone on x-ray has returned to normal by the two-year check. If the lump is the rarer, more spreading kind that wraps around the tendon in fronds, it is harder to remove completely and more likely to return. In those cases, radiation therapy aimed at the area can help control the lump while keeping your hand working. If you choose to simply watch a small, painless lump, the realistic picture is a lump that grows slowly or stays the same, and that may gradually make bending the finger or using it for small tasks more awkward. If it starts to hurt, keeps growing, or the finger stops working as it should, that is the point where treatment usually earns its place. ## When to see someone Most lumps like this are not urgent, and treatment is never a race. See your GP if a lump is not settling, is growing over weeks, starts to hurt, or stops you using the finger or hand normally. Ask for a specialist review if the finger catches or clicks when it moves, if you notice tingling or numbness, or if bending the finger fully has become hard because the lump is in the way. These are the things worth having looked at sooner rather than later, because a lump that has grown into the tendon or the joint lining is harder to remove completely and is more likely to come back. One set of signs does need same-day care. If your finger or hand becomes hot, red, swollen and painful, especially with a fever, go to the emergency department. You do not need a GP referral first. If you cannot reach the clinic out of hours or on a weekend, go to your nearest emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Giant cell tumour of the tendon sheath is worth the extra reading because its defining problem is recurrence, and the evidence suggests recurrence is driven more by the biology of the individual tumour than by anything about how it is removed. ### Recurrence is a property of the tumour, not only of the surgery The instinctive explanation for a lump coming back is that some was left behind. A systematic review of 605 digital cases concluded otherwise: the intrinsic biology of the tumour appears to play a more fundamental role in recurrence than tumour location or local invasiveness, with the authors calling for larger prospective studies to identify which tumours are prone to recurrence [1]. That is a genuinely useful thing to be told before an operation. Recurrence after a well-performed excision is a recognised behaviour of this tumour rather than evidence that something went wrong. ### Treatment is elective, and doing nothing is a real option It is easy to lose sight of this once an operation is being planned. The principle of first-line treatment is complete resection, but treatment is never urgent, and the indication should be weighed against symptoms, progression, location and your own circumstances [4]. For a small, painless, slowly growing nodule, watching it is a legitimate choice. The tumour is benign and does not spread, so the argument for operating is about function, size and nuisance — not about danger. ### But two surgical factors do matter Biology is not the whole story. In 941 patients with localised-type tenosynovial giant cell tumour, the factors associated with recurrence after resection were larger tumour size and initial treatment with arthroscopy. Given relatively low complication rates and good functional outcomes, the authors recommend an open approach with complete resection where possible to reduce recurrence in high-risk cases [2]. The counterpoint is that arthroscopic excision has been shown effective for the localised type across four joints in a review of 1,448 patients, while in the diffuse type, arthroscopic synovectomy has demonstrated efficacy only at the knee [3]. Reconciling these: for a small, localised, well-defined lesion, either approach can work. As size increases, and for the diffuse form, complete open excision is better supported. The reason is mechanical, this tumour extends in fronds around tendon, nerve and joint, and the parts most easily missed are the ones tucked behind structures that must be lifted and inspected directly. ### Why the naming matters The condition now sits under tenosynovial giant cell tumour, which covers both the localised form in the hand and the diffuse intra-articular form previously called pigmented villonodular synovitis [4]. They are the same entity in different locations and growth patterns. This is worth knowing if you read around the subject, because a search will return material about knees and hips that is describing your condition in its diffuse form, and the recurrence rates quoted for the diffuse disease are considerably higher than those for a localised digital lesion. Applying knee figures to a finger lump overstates the risk. ### Where radiotherapy sits For diffuse disease that has recurred or cannot be completely excised, adjuvant radiotherapy is sometimes considered. A meta-analysis found that open synovectomy, or synovectomy combined with perioperative radiotherapy, was associated with a reduced rate of recurrence in diffuse pigmented villonodular synovitis, while calling for large long-term prospective studies to confirm it [5]. For a localised digital tumour, which is the great majority of hand cases, this does not arise. It belongs to the diffuse, recurrent, joint-based end of the spectrum, and is mentioned here only because a search on the condition name will surface it. ### What it is not Despite the name, this is a benign tumour. It does not spread elsewhere in the body. The word "tumour" carries weight it does not deserve here, and the concern with recurrence is about repeated local surgery, stiffness and nerve proximity, not about cancer. --- ### Hamate and CMC Fracture-Dislocation Fixation URL: https://www.cqupperlimb.com/education/hand/hamate-cmc-fixation/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic, your history, examination and scans establish the diagnosis. This operation lines up the broken hamate bone and the joints at the base of your fingers, and holds them in place while they heal. It is usually offered when the bone has moved out of place, or when the finger joints are unstable. Some injuries can be treated without surgery if they are found early and the joint sits back in place and stays there. When the joint will not stay in place, or the injury is more severe, surgery is recommended. In these injuries, surgery aims to prevent lasting deformity and loss of hand function. Most people who have this operation regain good movement and strength in the hand. We will discuss the options with you and decide together on the treatment that suits your injury. ## Before the operation You will need some scans before surgery, such as X-rays, an MRI or an ultrasound. These show where the bone has broken and whether the finger joints have shifted, which helps plan the operation. Bring a list of your current medications to your appointment. Some medications may need to be paused before surgery, and your surgeon will tell you which ones and for how long. Stop eating and drinking seven hours before your operation so your surgery time can be brought forward if the theatre list runs early; your surgeon will give you exact instructions about fasting and drinking. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing. If you have other medical conditions, you may need blood tests or a review with the anaesthetist (the doctor who gives the anaesthetic). ## On the day On the day of your operation, you come to the hospital's surgical admissions unit. You are checked in there and prepared for theatre. You will then meet the anaesthetist, the doctor who gives the anaesthetic. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. After that, you are taken into the operating theatre, where the operation is performed. When it is finished, you wake up in the recovery area. Nurses watch over you there while the anaesthetic wears off. Once you are stable, you either go to the ward or go home. Which of these happens depends on the procedure and on how your recovery is going. ## What the operation involves There are two ways your surgeon can do this operation, and the choice depends on your injury. If the broken pieces can be lined up without opening the skin, your surgeon works through small puncture wounds. The bones are guided back into place and held with fine wires, or sometimes a screw, passed in through those small openings. If the fragments need to be seen and fitted back together, your surgeon makes a single cut over the broken bone instead. This open approach is used when the break goes into the joint, when the bone is in several pieces, or when the pieces will not line up on their own. Once your surgeon can reach the injury, the bones are put back where they belong. The bases of your ring finger and little finger are lined up with the hamate, the wrist bone they normally sit against. Fine wires are then passed across the joints to hold everything steady while it heals. These wires stay in for several weeks and are removed later. Where the hamate itself has broken into a large piece, small screws may be used to hold it together. Occasionally a small plate is needed as well. Your surgeon chooses the combination that suits your particular fracture. When the bones are lined up and held firmly, your surgeon checks the position before finishing. The cut is then closed with stitches. A dressing goes over the top, and you will keep that dressing on for about 10 days. Your surgeon will explain how the wires are removed and when that happens as part of planning your recovery with you. ## After the operation You wake up in the recovery ward, where nurses keep an eye on you as the anaesthetic wears off. Your hand will be in a splint with dressings over the wounds, and we will give you pain relief to keep you comfortable. You can get up and move around as soon as you feel steady; your hand does the healing, so walking is fine. Someone should stay with you for the first 24 hours after you go home. You may go home the same day or stay one night in hospital after this operation. Both are common, and your team will talk with you about which suits you. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your hand will be sore and swollen. This settles gradually. Keeping your hand raised on a pillow, even at night, helps the swelling go down. The pain relief we give you keeps you comfortable while this happens. Your hand will be in a splint made by your hand therapist, Ruby Doolan at Extend Rehabilitation. She will also guide your exercises once the splint comes off. You should not drive while the splint is on, because it stops you gripping the steering wheel safely. Once the splint is off and your surgeon clears you, you can drive again. Our page on driving after upper-limb surgery explains this in more detail. At home, you can do most light daily tasks once you feel steady. Walking is fine from early on. You will avoid heavy lifting and anything that puts strain on the healing hand until your therapist says it is safe. As the swelling settles and movement returns, you will start gentle exercises to loosen the fingers and wrist. Grip strength builds gradually as the bone heals. Most people notice steady improvement over time. Once you can grip without pain, more activities become possible, and heavier work and sport come later in your recovery. Recovery varies between individuals, so your timeline may differ. Your surgeon and your hand therapist will guide you at each stage and tell you what is safe to do next. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes a joint at the base of a finger can slip partway out of place again after surgery. You might notice a clicking or grinding feeling, a change in the shape of the finger base, or pain that returns once it had started to settle. If you feel this, call the clinic rather than waiting for your next visit. A joint can also stay out of place without showing clearly on a standard X-ray. If your finger keeps feeling unstable or painful after surgery, tell your surgeon. Further scans may be needed to find the cause. Timing matters with these injuries. When treatment is delayed, the joint is harder to hold in place and the result may not be as good. If your injury happened some time ago and you have not yet seen a surgeon, mention this at your appointment so it can be planned around. If you notice any of these changes, contact the clinic. If pain is severe, or the hand becomes hot, red or increasingly swollen, seek urgent care at an emergency department. For anything less urgent, bring it up at your next review so it can be checked properly. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if you have a fever, or the wound becomes red, hot or starts to leak fluid. Call us if pain suddenly gets worse, or your hand changes colour or feeling. Go to emergency if you cannot move your fingers, or your hand becomes numb, very swollen or very painful. Go to emergency if you have calf swelling or shortness of breath. These can be signs of a blood clot. If you are unsure, call the clinic. We would rather hear from you early than late. --- ### Hamate Fractures and Ring/Little Finger CMC Fracture-Dislocations URL: https://www.cqupperlimb.com/education/hand/hamate-cmc-fracture-dislocation/ Region: hand · condition This is a sudden injury, not a slow-building problem. It usually happens when you punch something hard, land on your fist, or take a heavy blow to the hand. You may feel or hear a snap at the base of your ring or little finger. The pain starts straight away, on the outside of… ## What you're feeling This is a sudden injury, not a slow-building problem. It usually happens when you punch something hard, land on your fist, or take a heavy blow to the hand. You may feel or hear a snap at the base of your ring or little finger. The pain starts straight away, on the outside of your palm near your wrist. The base of your little finger and the bone it sits on (the hamate, one of the small wrist bones) take the force. The joint there can break and shift out of place. You will see swelling over the back of your hand, and it may bruise. Your little finger may look out of line or sit differently from before. Moving that finger, gripping, or pushing off your hand will hurt. Everyday things like holding a coffee mug, turning a door handle, or shaking hands become hard. Over the first days to weeks, the pain is often worse at night and when you try to move the finger. It settles slowly as the bone and joint begin to heal. The swelling eases over time, but the hand stays tender if you lean on it or grip hard. These injuries are uncommon, and the damage can be hard to see on normal x-rays. That is why a careful check and special imaging views or a CT scan matter. If the injury is missed, the bone may fail to join, the joint can wear out early, and your grip strength and finger movement may be reduced. The joint can also become unstable if it is not treated promptly. One thing to watch: the nerve that serves your little finger runs close to this bone. Weakness or changed feeling in that finger can appear days or weeks after the injury, so your nerve function is checked at the start and followed closely. If broken skin over the injury, bone showing, an obvious deformity, fingers turning pale, cold, white or blue, or sudden loss of feeling or movement appear, go to the emergency department the same day. ## What's actually happening Think of the base of your little finger as a small block that sits on a saddle-shaped ledge on one of your wrist bones (the hamate). The ledge has two shallow dips with a ridge between them, and the block rocks gently on it as you grip and cup your hand. Your ring finger sits alongside on the same bone, and the two share the work. Together they allow about 15 to 30 degrees of movement where the fingers meet the wrist. When you punch or take a hard blow, the force travels straight up the little finger into that joint. The ledge can crack, and the block can be pushed up and backwards out of its groove. Several small tendons that attach nearby pull on the broken pieces, which makes the joint drift further out of line. That is why the finger does not sit or move normally: the surface it rests on is both broken and unstable. Bone heals by knitting back together, the way a broken branch calluses over. But if the pieces are shifted apart, they may knit in the wrong position, or not join at all. If the joint stays out of place, the surfaces grind unevenly and wear early. So the aim of treatment is to line the pieces up and hold them still while they knit. These injuries are uncommon, and they often happen with great force, so other hand injuries can be present too. That is one reason the full damage can be missed on normal x-rays, which is why special views or a CT scan are used. One more thing worth knowing: the hamate is one of the small wrist bones, and breaks here account for 2 to 4% of all wrist bone breaks. The joint between your little finger and the wrist normally bends and straightens through about 25 degrees, which is more movement than the ring finger joint has. Losing that movement is what makes gripping and cupping the hand feel different until things heal. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some of these injuries heal without an operation, and others need surgery soon after the injury, so prompt assessment matters. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a history, examine your hand, and arrange imaging where it is needed. Then we talk through the options with you. If the joint is stable or only slightly out of place, we may treat it without surgery. We move the joint back into line and hold it still with a splint or cast while the bone knits. We check the position with repeat imaging during healing. Once it is safe to move, your therapist stages your return to movement and grip. Some people choose this path knowing the joint surface may not sit perfectly, and that some pain or a change in the finger's position can remain. That trade-off is part of the shared decision. Surgery is recommended from the start when the joint is clearly out of place, unstable, or broken into several pieces, or when the injury pattern needs it. It can also suit people whose work or sport puts heavy demands on the hand. The operation lines the bone and joint up and holds them there while they heal. We will talk you through what it involves separately. Whichever path you take, the first weeks are similar. We keep your pain under control while the swelling settles. You protect the hand and keep it raised as it heals. Hand therapy starts at the right stage, not too early and not too late, so your fingers and grip regain movement without disturbing the healing bone. ## What to expect Healing starts with the bone knitting back together while it is held still. If your injury is treated without surgery, you wear a splint or cast for the first weeks and have close checks in that time to confirm the joint stays in line. If you have surgery, the bone and joint are held in place while they heal, and hand therapy with Ruby Doolan at Extend Rehabilitation begins at the right stage to restore movement and grip. Recovery comes in stages. Your fingers may be slow to straighten for over 3 months after treatment, and stiffness is a normal part of the healing course rather than a sign of failure. Grip strength can take longer to return than finger movement. Most people regain useful hand function as the swelling settles and the bone joins, and daily tasks like holding a mug or turning a handle become easier as your grip returns. The outlook for both paths is encouraging. Treatment without surgery can work well when the joint is lined up early and stays stable. Surgery for these injuries also leads to good functional recovery, and people treated for this pattern of injury have minimal lasting loss of hand function. Some people who have surgery are back to full duties at work, though your own timing depends on what your hand does each day. There are honest risks to know about. The bone can heal in a poor position, which is linked with ongoing pain and early wear in the joint. Grip weakness is the main lasting problem when the joint is not lined up well. The bone may also fail to join at all. Surgery itself carries a real rate of complications, even though function ends up good for most people. Your nerve function is watched closely after the injury, because changed feeling or weakness in the little finger can appear days or weeks later. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone Seek urgent care if your finger looks out of place or deformed, if skin is broken over the injury, if your fingers turn pale, cold, white or blue, or if you suddenly lose feeling or movement in the hand. These need the emergency department the same day. See your GP sooner rather than later if you have punched something hard and the pain at the base of your little finger is not settling, or if swelling, movement or grip are not improving week on week as healing progresses. These injuries can be hard to see on normal x-rays, so a careful check and special imaging views or a CT scan matter. If the injury is missed, the bone may fail to join, the joint can wear out early, and grip strength and finger movement may be reduced. --- ### Hand Infections URL: https://www.cqupperlimb.com/education/hand/hand-infections/ Region: hand · condition Paronychia, deep-space and flexor sheath infections — recognition, antibiotics, drainage. ## What you're feeling A hand infection usually hurts in one spot. The skin over it may be red, warm and swollen. The pain often gets worse when you move the finger or grip something. Resting the hand settles it a little, but the soreness does not go away on its own. Everyday tasks become hard. Doing up buttons, turning a key, holding a cup of tea or typing can all sting. If the infection is in a finger tendon sheath (the tunnel the bending tendon slides through), the whole finger may be swollen and held slightly bent. Straightening it hurts, and the pain is there even when someone else tries to straighten it gently. If a joint is infected, that joint is swollen, tender and warm, and moving it either way is quite painful. Some infections spread along the skin as red, tender streaks, and the glands in your armpit may become sore. Swelling can make the back of the hand look puffy, and it can be hard to tell where fluid has collected. Night-time can be uncomfortable because swelling builds up when the hand is still. Most infections come on over hours or days rather than weeks. If the redness, swelling and pain are getting worse instead of better, that points to infection rather than a simple sprain. Some conditions look almost identical, including gout, an insect bite, a reaction to a splinter or a flare of arthritis, so the cause is not always obvious at first. Tell your surgeon if you have diabetes, kidney disease, or a condition or medication that weakens your immune system. These change how an infection behaves and how it needs to be treated. The same goes for any infection that has not settled after antibiotics or after a wound has been cleaned out, as some slower-growing infections need special tests to identify. With prompt care, most soft tissue hand infections resolve fully. The risk with waiting is that stiffness, permanent finger bending or, in severe cases, loss of the finger can follow. ## What's actually happening Your hand is a crowded place. Twenty-seven bones sit close together under skin that is thin on the back of the hand and tightly fixed in the palm. Tendons, the ropes that pull your fingers, slide through narrow tunnels. One of these tunnels, the flexor sheath, wraps around the bending tendon of a finger and is lined with a slick layer that feeds and lubricates the tendon. When bacteria get in through a cut, a splinter or a puncture wound, that closed space gives them nowhere to spread but along the tunnel. The swelling is the real problem. Inside a tunnel like that, there is no room for swelling, so pressure builds up. If the pressure keeps rising, it can squeeze off the blood supply to the tendon itself. The tendon can then scar down to the tunnel around it, leaving the finger stiff even after the infection itself has cleared. That is why a tendon sheath infection needs treatment quickly rather than waiting a few days. Other spots have their own traps. The fat pad at your fingertip is divided into small sealed pockets by tough strands, so an infection there (a felon) builds pressure fast and can spread to the bone or the nearby joint. The skin beside your fingernail can also harbour a slow, smouldering infection (chronic paronychia), often from a yeast, where moisture sneaks under the cuticle and keeps it inflamed. And in some people the tendon tunnels of the thumb and little finger connect, so infection can track from one side of the palm to the other. Most hand infections are caused by bacteria that normally live on skin, entering through a break. Some come from bites, human or animal. Diabetes, steroid medicines or a weakened immune system make it easier for infection to take hold and reach deeper structures like tendon, bone or joint. That is why your surgeon will ask about your health history, and why early treatment matters: with prompt care, most soft tissue infections settle fully, while delay risks lasting stiffness. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, treats hand infections by acting quickly, because delay is what causes lasting damage. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At that visit we take a history, examine your hand and arrange any tests needed to work out what is growing and how deep it has gone. The first step in many early infections is non-surgical. If a tendon sheath infection is caught within 48 hours of symptoms starting, antibiotics and a splint may stop it spreading. You would then be watched closely, and if things do not settle quickly we would move to surgery rather than wait. After any treatment, splinting the hand in a protective position and then moving the fingers early helps prevent stiffness. Rehabilitation matters here: an infected hand that is not moved will stiffen, so therapy is part of the plan, not an optional extra. Antibiotics are the other medical half of treatment. The first prescription is chosen to cover the bacteria most likely to be causing your infection, and once lab results show exactly which germ it is, we switch to the antibiotic that suits it. Some infections need antibiotics through a drip rather than tablets, and for serious infections a course can run 4 to 6 weeks. If your immune system is weakened by illness or medicines such as steroids, we treat faster and more aggressively, because these infections can become serious more quickly. Bites, human or animal, usually need preventive antibiotics as well. Surgery is considered when there is pus to drain or when the infection has reached tendon, bone or joint. An abscess or a collection under the skin needs releasing so the pressure can escape, and the wound is often packed at first to keep draining. A fingertip infection (a felon) or an infection beside the nail (paronychia) is drained through a small cut, sometimes with part of the nail removed. A tendon sheath infection needs the tunnel washed out, and a bone infection (osteomyelitis) needs the dead tissue cleaned away along with long antibiotics. One important exception: if a blister on your finger turns out to be a viral infection (herpetic whitlow), surgery is not used for it, and cutting it open can make things worse. ## What to expect Most hand infections caught early settle fully with treatment. With prompt care, most soft tissue infections resolve completely, and the hand returns to normal. The sooner you are seen, the better your chances of avoiding stiffness or lasting damage. How long recovery takes depends on how deep the infection went. A skin or nail infection may settle within days of drainage or antibiotics. A tendon sheath infection, a bone infection or an infection in a joint takes longer, and some need weeks of antibiotics. Even after the infection itself has cleared, the finger may stay stiff for a while. Moving your fingers early, once your surgeon says it is safe, helps prevent that stiffness from becoming permanent. If treatment is delayed, the outlook is less certain. A tendon sheath infection that has been present for days can scar the tendon to its tunnel, leaving the finger stiff even after the infection is gone. Severe infections can still lead to lasting loss of function or, in some cases, loss of the finger despite thorough and timely treatment. That is why these infections are treated as urgent rather than watched for a few days. Some infections behave differently. Infections in people with diabetes or a weakened immune system can spread faster and reach deeper structures, so they need more aggressive treatment and sometimes more than one operation. Slower-growing infections, such as those caused by mycobacteria (a family of germs related to the one that causes tuberculosis), need long courses of antibiotics combined with surgery to clear them, and recovery stretches over months rather than days. You will usually be seen again after treatment to check that the infection is clearing and that your hand is moving well. Keep those appointments even if things feel better, because some problems only show up as swelling settles. If pain, redness or swelling return after an infection seemed to be settling, contact your surgeon rather than waiting it out. ## When to see someone Hand infections are time-critical. The damage from delay happens fast, so do not wait to see whether things settle. Go to an emergency department if you have red streaks running up your hand or arm, if the whole finger is swollen, bent and too painful to straighten, or if the skin is rapidly darkening, blistering or breaking down. The same applies if you feel feverish and unwell alongside the hand symptoms, or if the hand has been injured and is now severely swollen and tense. These can signal a spreading or deep infection that needs same-day assessment and treatment. Ask for urgent review, the same day if possible, if the pain is severe and worsening, if a finger joint is hot, swollen and too painful to move, or if you can see pus collecting under the skin or beside a nail. An infection that has not improved after a day or two of antibiotics also needs review rather than waiting out the prescription. See your GP promptly for any hand infection at all, even a small one. This matters more if you have diabetes, kidney disease, or a condition or medication that weakens your immune system, because infections in these situations can spread faster and reach deeper. Tell your GP about any recent animal or human bite, puncture wound, or work and travel history that might point to an unusual germ. If an infection keeps returning or never fully settles despite treatment, ask for a specialist review, as some slow-growing infections need specific tests to identify. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Hand infections are worth the extra reading because the antibiotics most people are given first are, in this specific setting, the wrong ones, and because one hand infection is a surgical emergency that is regularly mistaken for a minor one. ### The commonest organism resists the commonest prescriptions A ten-year longitudinal study of 815 urban hand infections found that although the annual incidence of MRSA has declined overall, it remains the most common pathogen, while resistance to clindamycin and levofloxacin consistently increased. The authors' conclusion is specific: empirical antibiotic therapy for hand infections should avoid penicillin, beta-lactams, clindamycin and levofloxacin [1]. That is a longer list of exclusions than most people expect, and it covers much of what is routinely prescribed for skin infection elsewhere on the body. The practical implication is that a hand infection not settling on a first-line antibiotic is a common and predictable event rather than an unusual one, and is a reason to seek review rather than to persist. Local resistance patterns vary, so this is a principle rather than a prescription, but it explains why hand infections are often escalated faster than their size suggests. ### Flexor sheath infection: the details that change the outcome Pyogenic flexor tenosynovitis, infection inside the closed tunnel a flexor tendon runs through, is the one that behaves differently from other hand infections. The sheath is a confined space with a poor blood supply, so pus under pressure inside it can destroy the tendon's gliding surface within days. Across 763 patients, two things improved range of motion: using antibiotics as a component of therapy, and catheter irrigation rather than open washout. The evidence supported both early treatment and systemic antibiotic use [2]. Note that the outcome measured is range of motion, not eradication of infection. The infection can be cured while the finger is left stiff, which is the real cost of delay here. The four classic findings, a uniformly swollen "sausage" finger, held slightly bent, tender along the whole tendon sheath, and severe pain on passively straightening it, are worth recognising, because that combination warrants same-day assessment rather than a course of tablets. ### The one that is a true emergency Necrotising fasciitis originating in the hand is rare and rapidly destructive. The systematic review of 161 cases concludes that early diagnosis is of paramount importance, and that early, decisive surgical intervention should have a low threshold, particularly where risk factors are present [3]. "Low threshold" is deliberate wording. This is a diagnosis where waiting for certainty costs limbs. The features that separate it from ordinary cellulitis are pain out of proportion to the appearance, rapid progression over hours rather than days, and systemic illness, fever, confusion, feeling profoundly unwell, alongside what may look like a modest area of redness. ### Why a small wound can be misleading Two mechanisms produce infections much deeper than the visible wound suggests. A bite over a knuckle sustained by striking a mouth drives oral organisms through skin, extensor tendon and joint capsule in one movement, and the skin then closes over the contamination. A puncture into the palm can seed the flexor sheath through an entry point that seals within a day. In both, the visible wound is a poor guide to the depth of the problem, and the pattern of pain — particularly pain on moving the finger, rather than pain at the wound itself, is more informative than the appearance of the skin. --- ### Jersey Finger (Flexor Tendon Avulsion) URL: https://www.cqupperlimb.com/education/hand/jersey-finger/ Region: hand · condition The deep flexor tendon avulses off the fingertip — why it is time-critical, and the surgery to reattach it. ## What you're feeling Jersey finger usually happens in a moment you remember clearly, most often while gripping during sport. A classic example is grabbing a fistful of an opponent's jersey in rugby or football as they pull away, which is where the name comes from. There is a sudden sharp pain at the fingertip, and afterwards the finger swells and may bruise. The tell-tale sign is that you can't bend the very tip of the finger. The fingertip joint (the small joint nearest the nail, called the DIP joint) won't curl into your palm when you try to make a fist, even though the rest of the finger moves. The ring finger is by far the most commonly affected. Some people also notice a tender lump further down the finger or even in the palm: that lump is the end of the tendon, which has snapped off the bone and sprung back like a released elastic band. ## What's actually happening A strong tendon called the flexor digitorum profundus (FDP) runs along the palm side of each finger and attaches to the small bone at the fingertip. Its job is to bend that last joint. In a jersey finger, the finger is being forced straight at the exact moment the muscle is pulling hard to bend it, and the tendon tears away from where it anchors to the fingertip bone, sometimes pulling off a small chip of bone with it. How far the loose tendon end springs back matters a great deal, and surgeons group these injuries by exactly that (the Leddy–Packer classification). When the tendon retracts only a short way and stays in the finger, it usually keeps some of its blood supply and can wait a little. When it springs all the way back into the palm, it loses its blood supply and the channel it normally glides through (the pulley system) starts to scar and close. That is why a fully retracted jersey finger is time-critical: the longer it is left, the harder it becomes to bring the tendon back and reattach it. An injury where a fragment of bone is still attached often stays put and can sometimes be dealt with a little later. ## What we can do about it In our clinic, Dr Kieran Hirpara manages this condition by first confirming the diagnosis through a careful assessment of your history and examination. Because the tendon usually needs to be reattached within days, surgery is generally recommended straight away rather than after a trial of non-operative care. Jersey finger is almost always treated with surgery to reattach the tendon to the bone. There are a couple of ways to do this depending on what the tendon did: - If the tendon has pulled clean off the bone, it is reattached using a small anchor placed in the bone, or with stitches passed through the fingertip and tied over a button (a "pull-out" repair). - If it took a fragment of bone with it, that fragment is put back and held in place, usually with a tiny screw, wire or small plate. The single most important factor is timing. A tendon that has retracted into the palm generally needs to be repaired within about 7 to 10 days, before it loses too much length and blood supply. An injury held by a bony fragment can often be fixed a little later. This is why getting assessed quickly genuinely changes what is possible. If the injury is missed or only picked up weeks or months later, a simple reattachment may no longer be possible. In that situation the options are bigger operations: rebuilding the tendon with a graft, or, if the fingertip joint is the problem, fusing that small joint to give a stable, pain-free finger. After any of these repairs, a carefully staged hand-therapy programme is essential to get the tendon moving safely without it pulling apart while it heals. ## What to expect When a jersey finger is caught early and repaired well, the outlook is good and most people regain strong, useful movement of the fingertip. Recovery is not quick, though. A repaired flexor tendon is fragile for the first several weeks, so you will wear a protective splint and follow a hand therapist's programme that gradually and safely reintroduces movement, and rushing this is the main way a repair fails. It typically takes a few months to get back to full grip and heavier activities, and your therapist and surgeon will guide the timing of your return to sport or manual work. It is worth knowing that even a good repair may leave the fingertip joint a little stiffer than the other side. Injuries that were treated late, or that needed a graft or a joint fusion, tend to have more limited fingertip movement, which is exactly why early treatment is so worthwhile. ## When to see someone - You can't bend the tip of a finger after a gripping injury. This is the key sign of a jersey finger and it should be checked promptly: do not wait to see if it settles. What looks like a "jammed" or sprained finger can be a tendon that has torn off the bone, and the best results come from early repair. - A tender lump in the finger or palm after such an injury, especially with loss of fingertip bending. - Significant pain, swelling or bruising of a finger after a sporting or gripping injury that isn't settling. - Any finger injury where movement, sensation or the look of the finger seems wrong: when in doubt, have it assessed, because the window for the best outcome can be short. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Jersey finger is worth the extra reading because it is the hand injury where delay most directly narrows the options, the tendon does not stay where it tore, and because the laboratory comparison of repair methods points one way while the clinical concerns point another. ### Why the clock matters more here than elsewhere The flexor digitorum profundus tendon bends the fingertip. In this injury it avulses from its attachment on the distal phalanx, usually when a finger catches in clothing while gripping, the classic mechanism from which the injury takes its name. Once detached, the tendon retracts up the finger, and how far it goes determines what can be done. If it stays near the fingertip, held by its blood supply and pulley system, it can be reattached straightforwardly. If it retracts into the palm, its blood supply is torn, the sheath it must pass back through begins to scar, and the muscle itself starts to shorten. The prognostic factors reflect exactly this: the extent of proximal tendon retraction, the chronicity of the avulsion, and the presence of an associated bone fragment [1]. A fragment is paradoxically good news, it usually means the tendon is anchored near the fingertip and has not retracted far. This is why jersey finger is treated with urgency that a patient may find disproportionate to a finger that is not especially painful and still mostly works. ### It is easy to miss, and the reason is anatomical The finger looks nearly normal. The superficialis tendon is intact, so the middle joint still bends, and casual observation of a hand closing shows nothing obviously wrong. The only reliable test is to hold the middle joint straight and ask the person to bend just the fingertip. If the profundus is detached, that movement is absent, and it is absent completely rather than weakly. This is worth knowing because the injury is frequently attributed to a sprain in the first week, which is the week in which the options are widest. ### The laboratory favours suture anchors; the clinical picture is more balanced Two repair methods dominate: a suture passed through the bone and tied over a button on the nail, and a suture anchor placed into the bone itself. Pooling biomechanical studies across 201 specimens, suture anchor repair showed increased initial construct stiffness and less gap formation than suture button pullout, with no significant difference in ultimate failure load [2]. Set against that, the clinical review notes that multi-strand repairs perform better, that gapping may be seen with pullout suture–dorsal button repairs, and that failure through bone pullout remains a concern with suture anchor methods [1]. So each method has a characteristic weakness: the button construct can stretch and gap, and the anchor can pull out of a small bone. The stiffness advantage measured in the laboratory is real, but it addresses only one of the two failure modes, which is a good illustration of why biomechanical superiority does not automatically translate into a better clinical result. ### What is lost if it is not repaired An unrepaired profundus leaves a fingertip that cannot actively bend. For many people that is tolerable, and where the injury presents very late, accepting it is a legitimate choice, the alternatives at that stage are staged tendon grafting or fusing the fingertip joint, both considerably larger undertakings than an early reattachment. The functional cost is specific rather than general: gripping small objects, and the last part of closing the hand around a handle. It is the difference between a hand that works and a hand that works completely, and how much that matters depends entirely on what the hand is for. --- ### Mallet Finger URL: https://www.cqupperlimb.com/education/hand/mallet-finger/ Region: hand · condition Mallet finger causes fingertip drooping after extensor tendon injury; splinting is key, surgery occasionally needed. ## What you're feeling With a mallet finger, the last joint of your finger droops and you cannot straighten the fingertip yourself. The finger usually still bends down normally. The injury happens when the tendon that straightens the fingertip is torn away, sometimes taking a small piece of bone with it. It often follows a ball striking the end of a straight finger, which is why it is a common football injury. The pain sits at the back of the last joint, just below the nail. It is usually sorest in the first days after the injury, when the finger is swollen and tender to touch. Bending the fingertip makes it worse. Once the finger is splinted and held straight, the pain usually settles. The droop itself does not hurt, but it changes how the finger works. Daily tasks that need a steady fingertip become awkward. Picking up small coins, threading a needle, turning a small key or pressing buttons can be clumsy because the fingertip will not push flat. Writing or holding a phone may feel different too. The middle joint of the finger may also bend back further than usual to make up for the drooping tip. Some people notice the finger looks worse in the morning, after the hand has been still overnight, and loosens up once they start moving it. A few warning signs need fast action. If your finger becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. If broken skin sits over the injured joint, or the finger looks obviously deformed, go the same day. If your finger turns pale, cold, white or blue, or you suddenly lose feeling or movement in it after an injury, go the same day. If the symptoms are not settling, are getting worse over weeks, or stop you working or using your hand, see your GP or ask for a specialist review. ## What's actually happening On the back of your fingertip runs a thin cord of tendon, a rope of fibres that connects muscle to bone. Its lowest fibres anchor onto the last small bone of the finger, just below the nail. When you straighten your finger, that cord pulls on the bone. With mallet finger, the cord has snapped away from its anchor point. Sometimes it tears off a small chip of bone with it. Once the cord is no longer attached, nothing holds the fingertip up. The muscle that bends the fingertip down still works, and with nothing pulling the other way, it wins. The tip rests in a droop that you cannot straighten yourself, though you can still push it straight with your other hand. That is because the bending muscle is intact and the straightening cord is not. The injury usually happens when a straight fingertip is suddenly forced to bend, for example catching on a pocket or bedsheet while reaching. The joint surface can also be involved. If the torn-off piece of bone takes more than a third of the joint surface, or the last bone slips out of line, surgery is generally recommended. Smaller fragments are usually treated with a splint alone. Some droop can remain even after treatment goes well, and most people adapt to it without much trouble. If a splint has not worked, surgery is an option, though an advantage of surgery has not been clearly proven. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some mallet fingers heal without an operation, and others need surgery soon, so a prompt assessment matters. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a history, examine your finger and arrange an X-ray if it is needed. The X-ray shows whether a piece of bone has come away with the tendon, how large that piece is, and whether the last bone of the finger has slipped out of line. For most injuries, treatment starts with a splint that holds the fingertip straight. The splint needs to stay on continuously for 6 to 8 weeks, because even a few minutes of bending, such as when you wash your hands, can undo the healing. Our hand therapist, Ruby Doolan at Extend Rehabilitation, fits your splint and guides your exercises. A hand therapist can treat these injuries as well as a surgeon can, and splinting causes very few skin problems. If your finger still droops once the splint comes off, extra weeks of splinting are part of the plan, not a sign that it has failed. A night splint on top of this does not add anything. If you play sport, you will need to avoid the sport that caused the injury while the finger is splinted. Even injuries that were neglected for 2 to 4 weeks before treatment can still do well with splinting. Surgery is generally recommended when the torn-off piece of bone involves more than a third of the joint surface, or when the last bone of the finger has slipped out of line towards the palm. It is also occasionally offered for a droop that persists after splinting, or for an old injury that was never treated. If a splint has not worked, surgery is an option, though an advantage of surgery has not been clearly proven. The operation holds the tendon or bone fragment in place so the fingertip can straighten again, and it has its own page. ## What to expect Most mallet fingers settle with a splint. About half of injuries are cured or clearly improved by splinting alone. The splint holds the fingertip straight for 6 to 8 weeks, and the tendon heals in that position. If your finger still droops when the splint comes off, more weeks of splinting are part of the plan rather than a sign it has failed. How well you do depends a lot on wearing the splint exactly as directed. People who follow the splint instructions have better results than people who take it off. Even a few minutes of bending can undo the healing, which is why the splint stays on continuously. Injuries treated within two weeks of happening rarely leave a lasting disability. Injuries that went untreated for 2 to 4 weeks can still do well with splinting, so a delayed start is not a reason to give up. Some droop can remain even when treatment goes well. The fingertip may not sit perfectly flat, and most people adapt to this without much trouble. The last joint does little of the work of gripping, so a small permanent droop usually matters less than it looks. If splinting has not worked, surgery is an option, though an advantage of surgery has not been clearly proven. Left completely alone, a mallet finger tends to keep its droop. The tendon does not reattach itself without help. Some people live with the droop and manage fine, while others find the clumsy fingertip frustrating over months. If your symptoms are not settling, are getting worse over weeks, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone Most mallet fingers come from a ball striking the end of a straight finger, often in football. The fingertip droops and will not straighten itself, which is usually enough to prompt a visit. Some larger fractures behave differently: the fingertip may still sit straight even though a piece of bone has come away, so a sore finger that will not settle after a knock on the end still deserves an X-ray. Bony mallet injuries usually follow the finger being forced backwards, not forwards. A few signs need fast action. If your finger becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. If broken skin sits over the injured joint, or the finger looks obviously deformed, go the same day. If your finger turns pale, cold, white or blue, or you suddenly lose feeling or movement in it after an injury, go the same day. If symptoms are not settling, are getting worse over weeks, or stop you working or using your hand, see your GP or ask for a specialist review. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Mallet finger is worth the extra reading because the two situations that are usually treated as clear indications for surgery — a large fracture fragment, and a persistent droop after splinting, are less clearly established than the confidence with which they are stated. ### Both treatments produce good results, and nobody knows where the line is A systematic review of surgical and non-surgical management reached a conclusion that is unusually direct: both lead to good clinical outcomes, and insufficient evidence is available to determine when surgical intervention is indicated [1]. That second half is the important one. The dispute is not about whether either treatment works. It is that the threshold for choosing surgery, the point at which the fracture is judged too large, or the joint too subluxed, rests on convention rather than on comparative evidence. Where a fragment involves more than a third of the joint surface, or the distal phalanx has subluxed, surgery is generally indicated, but a significant advantage of surgical management, even in those complicated cases, has yet to be clearly proven [2]. ### Splinting works, and the number that matters is how long The orthotic evidence is more concrete. Two of three studies found a large effect size for orthotic intervention, ranging from 2.17 to 12.12, with a recommended immobilisation duration of 6 to 8 weeks, and additional weeks where a lag persists [3]. Two practical points follow. The first is that the splint must hold the fingertip straight continuously, the tendon ends are held apposed by position alone, and a few minutes of flexion while washing restarts the clock. The second is that "additional weeks where a lag persists" is part of the protocol, not a sign of failure. ### Why a residual droop is often acceptable A small permanent extension lag after treatment is common, and it is usually compatible with normal hand use. The distal joint contributes relatively little to grip, and most people adapt to a few degrees of droop without noticing it functionally. That matters when weighing surgery for an imperfect result, because operating on this joint is not without cost: the fragment is small, the skin is thin, and pin or wire fixation of a joint this size carries risks of infection, nail deformity and joint stiffness that must be set against a cosmetic-to-mild functional gain. Given the reviews above cannot demonstrate an advantage for surgery even in the complicated cases, accepting a modest lag is an evidence-consistent choice rather than a compromise. ### The deformity that is not a mallet finger Mallet finger is one of a family of closed extensor mechanism injuries, distinguished mainly by where along the tendon the failure occurs, mallet at the fingertip, boutonnière at the middle joint, and sagittal band injury at the knuckle [4]. They are frequently confused with one another early, when swelling obscures the pattern, and each has a different splinting position. Splinting a boutonnière as though it were a mallet holds the wrong joint, which is why the diagnosis is worth confirming before six weeks of immobilisation are committed to. --- ### Knuckle Joint Replacement (MCPJ) URL: https://www.cqupperlimb.com/education/hand/mcpj-replacement/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging if it is needed. That tells us what is going on in the joint. This operation replaces the knuckle joint, the joint where your finger or thumb meets your hand, with an artificial implant. It is usually offered when the joint surface is badly worn by arthritis and other treatments have not given enough relief. For long-standing wear-and-tear problems we usually try non-operative care first: activity change, physiotherapy or hand therapy, and splinting. Surgery is considered when those steps have not helped enough. The aim is pain relief, better function, and protection of the joints next door. For some people it also restores stability to a joint that has become loose or bent out of shape. ## Before the operation In the weeks before surgery we confirm the plan with fresh images of your hand, such as an X-ray, MRI or ultrasound. These show us the worn joint and help us choose the right implant. You will get clear instructions about fasting: no food or drink for seven hours before your operation. We ask for seven hours rather than a shorter time so your surgery can be brought forward if the theatre list runs early. Some medicines need to be paused before surgery, and your surgeon will tell you which ones and when. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. On the day, bring a list of your current medications, arrange a lift home, and wear comfortable clothing with loose sleeves. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You meet the anaesthetist, the doctor who looks after your anaesthetic and pain control during surgery. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. When the operation is finished, you wake up in the recovery area. Nurses watch over you while the anaesthetic wears off. Once you are stable, you either move to a ward or go home the same day, depending on the procedure and how your recovery is going. ## What the operation involves Your surgeon makes a small cut over the back of your knuckle joint to reach the worn joint surfaces. The damaged bone ends are removed and shaped to make room for the implant. The most common implant is a flexible spacer that sits between the two bones, letting the joint bend again while easing pain. The aim is pain relief, better movement, and protection of the joints next door. Different implants suit different joints and different problems. For some people a soft silicone spacer is used. For others, especially where the surrounding ligaments are strong and the neighbouring fingers give support, a harder implant shaped like the natural joint surface is chosen. Your surgeon picks the implant that fits your joint and your condition. Once the implant is in place, your surgeon checks that the finger lines up and moves smoothly, and balances the soft tissues around the joint so it stays stable. The cut is closed with stitches and covered with a dressing. The dressing stays on for about 10 days, which the 'After the operation' section explains. For some thumb knuckle joints, joining the bones together (a fusion) is an alternative to an implant. This removes the painful joint but means that part of the thumb no longer bends. Your surgeon will talk through which option suits your joint before you sign the consent form. ## After the operation You will wake up in the recovery ward, where nurses keep a close eye on you as the anaesthetic wears off. Your hand will be in a bulky dressing, and we will give you pain relief to keep you comfortable. Someone should stay with you for the first 24 hours after you get home. You can move around as normal, but take it easy and rest your hand raised on a pillow when you sit. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your hand will be sore and swollen, and the knuckle may feel stiff and tender. Resting your hand raised on a pillow eases the swelling, and the pain relief we give you keeps you comfortable. The discomfort settles gradually as the joint heals. Your hand will be in a bulky dressing at first, which stays on for about 10 days. When we see you, we change or remove it and check the healing skin. Rehabilitation after this surgery is hand therapy with Ruby Doolan at Extend Rehabilitation. She will guide your exercises and make a splint if you need one. The exercises protect the new joint while your finger or thumb regains movement, and you will be shown how to use your hand for everyday tasks without straining it. As the swelling settles, bending and straightening usually feel easier. Once you can grip and pinch without pain, you will find daily activities such as dressing, eating and writing become more natural. Many people notice the main gain is relief from the pain they had before surgery, along with better use of the hand for daily tasks. You should not drive while your hand is in a splint or while you are taking strong pain medication, and you need to be able to hold the wheel with both hands and react in an emergency stop. Our separate guide on driving after upper-limb surgery explains when it is safe to return. Recovery varies from person to person, and your timeline may differ. We will guide you at each review, along with your hand therapist. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Infection is uncommon after this type of joint replacement. Watch the skin around your wound. If you notice redness spreading out from the wound, warmth, oozing, or a deep throbbing pain that does not ease with simple painkillers, contact the clinic without delay. If you feel feverish or unwell, go to the emergency department. The new joint can sometimes come out of place. This is called dislocation. You might feel a sudden shift in the joint, with the finger or thumb sitting at an odd angle and refusing to move normally. Call the clinic straight away if this happens. The implant itself can wear, loosen, crack or bend over time. Signs include a return of pain that had settled, new clicking or grinding, or the finger drifting out of line. Bring these changes up at your next review, or call earlier if they come on suddenly. The bones around the implant can also break during the operation. Your surgeon checks for this before you leave theatre, and it usually heals with a shorter period of protection in the splint. If a problem does develop, further surgery is sometimes needed to fix it. This might mean replacing the implant again, or, if replacement is not suitable, joining the bones of that joint together so they heal as one solid piece. That second option removes pain but stops the joint bending. Your surgeon will explain what fits your situation if it ever comes to that. Some people notice ongoing stiffness or weakness in the finger or thumb after surgery. Hand therapy helps with this, so mention it at your review appointments rather than waiting. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up in the first few weeks, so it pays to know what to watch for. Call us if you notice redness spreading from the wound, oozing, fever, or pain that keeps getting worse. Go to emergency if you feel feverish and unwell, or if your calf becomes swollen and tender. Sudden shortness of breath needs emergency care too. Call us straight away if your finger or thumb suddenly shifts out of place, sits at an odd angle, or you cannot move it. Numbness or tingling that does not settle also needs a prompt check. If in doubt, call us. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Knuckle joint replacement is worth the extra reading because of a curiosity: the implant most used today is essentially the design introduced in the 1960s, and it has outlasted every material brought in to replace it. Understanding why explains what this operation is actually for. ### Silicone has not been displaced A 2026 review of metacarpophalangeal joint arthroplasty in rheumatoid arthritis concludes that the operation continues to play a central role in managing the rheumatoid hand, and that despite advances in implant technology, flexible silicone arthroplasty provides reliable functional and cosmetic improvement in appropriately selected patients [1]. Sixty years of materials science has produced metal-plastic and pyrocarbon alternatives, and the silicone spacer is still the reference standard. That is unusual in joint replacement, where hip and knee implants have been iterated continuously over the same period. The reason is that this implant is not doing the job its name implies. It is not resurfacing a joint to restore a bearing. It is a flexible spacer that maintains a gap and acts as an internal splint while scar tissue forms around it into a new capsule. The result is delivered by the healing, not by the device, which is why a better bearing surface has never translated into a better outcome. ### The honest summary of results A review of implant arthroplasty across the finger and thumb joints puts it well: implant arthroplasty predictably produces pain relief and high satisfaction, but has historically suffered from high rates of complications, and while metal-plastic and pyrocarbon materials have evolved, survivorship and reoperation rates remain a concern [2]. Both halves matter. People are reliably pleased with these operations, pain goes, appearance improves, the hand works better for daily tasks, and the implants have a finite life with a real reoperation rate. Satisfaction and durability are different questions, and this operation scores much better on the first. ### For osteoarthritis, the evidence is thin Most of the literature concerns rheumatoid arthritis, because that is where the deformity being corrected is most dramatic. For osteoarthritis the picture is weaker: the available evidence consists of retrospective cohorts with small sample sizes and relatively short follow-up [3]. Notably, where authors express a preference for pyrocarbon over silicone in osteoarthritis, it is on the basis of potential for improved stability and alignment, with the data described as preliminary [3]. That is a reasonable position to hold, but it should be recognised as reasoning from mechanism rather than from demonstrated superiority. ### Durability is becoming a bigger question A concern raised nearly two decades ago has grown rather than resolved: implant durability matters more as life expectancy increases, and as these operations are done in younger, more active patients who will load them for longer [4]. An implant with acceptable ten-year performance is a different proposition at 75 than at 55. Practically, this is a reason to be clear about what you want the operation to achieve. For pain relief, correction of deformity and improved function in a hand with modest mechanical demands, this is a well-supported operation with a long record. As a durable reconstruction for heavy use over decades, it is not. --- ### Medical Conditions That Affect the Hand URL: https://www.cqupperlimb.com/education/hand/medical-conditions-that-affect-the-hand/ Region: hand · condition How whole-body conditions — diabetes, thyroid, inflammatory arthritis, kidney disease and more — show up in the hand. The hand is one of the best windows your body has onto your general health. Because it is packed with small joints, nerves, tendons, fine blood vessels, skin and nails (all close to the surface and easy to examine), a great many whole-body conditions leave their first clues there. Sometimes a hand problem turns out to be a purely local issue. But sometimes the very same symptom (stiffness, tingling, a colour change, a nail that looks different) is the earliest visible sign of something happening elsewhere in the body that is worth knowing about and often very treatable. This page is a plain-English tour of the main medical conditions that show up in the hand. It isn't a checklist to diagnose yourself with; most aches and stiff fingers are ordinary wear and tear. But it explains why your surgeon may ask about your general health, take a close look at your nails and skin, or suggest a blood test or a referral even when you came in about your hand. ## Diabetes — the great impersonator in the hand Diabetes affects the hand more than almost any other medical condition. High blood sugar over time stiffens the soft tissues (the tendons, their lining and the ligaments), so people with diabetes get several common hand problems far more often than everyone else: - Trigger finger (a finger that catches, clicks or locks): several times more common in diabetes than in the general population. - Carpal tunnel syndrome (numbness and tingling in the thumb, index and middle fingers, often worse at night). - Dupuytren's disease (cords and lumps in the palm that slowly bend the fingers down). - A stiff, waxy hand (sometimes called diabetic cheiroarthropathy or "limited joint mobility"): the fingers won't fully straighten and the palms press together less easily. - Frozen shoulder, which is strikingly more common in people with diabetes. None of these prove you have diabetes, but having more than one of them, or getting them at a younger age, is a recognised reason to check. We've covered this in much more depth on our diabetes and upper-limb conditions page. ## Thyroid disease — over-active or under-active The thyroid gland sets your body's metabolic pace, and when it runs too fast or too slow it can show up in the hand. An under-active thyroid is a classic contributor to carpal tunnel syndrome and to trigger finger, partly through fluid retention and tissue changes around the tendons and nerves. Both an over- and an under-active thyroid are also linked with frozen shoulder. An over-active thyroid can additionally cause a fine tremor, sweaty palms, and nail changes such as the nail lifting away from its bed. Carpal tunnel that appears without an obvious cause is one of the reasons a thyroid blood test is sometimes arranged. ## Inflammatory arthritis — when the immune system attacks the joints A whole family of conditions causes the immune system to inflame the joints, and the hand is very often where they declare themselves, each with its own pattern: - Rheumatoid arthritis tends to affect the knuckles and the middle finger joints, usually on both hands symmetrically, with morning stiffness and soft, swollen joints. See our inflammatory and rheumatoid arthritis page. - Psoriatic arthritis can involve the joint closest to the nail, cause a whole finger to swell like a sausage, and often comes with nail pitting or skin patches. See our psoriatic arthritis page. - Gout causes sudden, intensely painful, red, hot attacks, classically in the big toe, but the finger and wrist joints can be hit too, sometimes with chalky lumps over time. See our gout page. The reason it matters to tell these apart from ordinary osteoarthritis is that inflammatory arthritis is driven by the immune system and responds to specific medicines that can protect the joints from damage, so early diagnosis changes the outcome. ## Kidney disease Long-standing kidney disease, especially in people on dialysis for many years, can lead to carpal tunnel syndrome through a build-up of a protein called amyloid around the wrist tendons. Kidney problems also disturb the body's calcium, phosphate and bone metabolism, which can weaken bone and occasionally show up as aches or changes seen on hand X-rays. These are reasons a surgeon may take note of your kidney history. ## Pregnancy Pregnancy is a common and reassuring cause of hand symptoms. The extra fluid the body holds in the later months raises the pressure inside the carpal tunnel, so carpal tunnel syndrome (tingling and numbness in the fingers, often worst at night) is frequent in pregnancy. The good news is that it very commonly settles on its own within weeks of delivery, so the first-line approach is usually simple measures like a night splint rather than surgery. ## Circulation and connective-tissue conditions Some conditions affect the small blood vessels and the connective tissue, and the fingers are where you notice them first: - Raynaud's phenomenon: the fingers turn white, then blue, then red in the cold or with stress, as the small vessels clamp down. On its own it is usually harmless, but it can also be the opening sign of a connective-tissue disease. We cover it fully on our Raynaud's phenomenon page. - Scleroderma (systemic sclerosis) tightens and thickens the skin of the fingers, can cause Raynaud's, painful fingertip ulcers, and stiffness of the small joints. - Lupus (systemic lupus erythematosus) can cause joint pain, Raynaud's and skin and nail-fold changes. A clue we specifically look for is abnormal vessels at the base of the nail (the nail fold): twisted, dilated loops there can point to scleroderma or lupus and are one reason your surgeon may look closely at your nails with a magnifier. ## Other clues — the nails, skin and fingertips The fingertips, nails and skin can hint at conditions well beyond the hand: - Finger clubbing: the fingertips broaden and the nails curve over the ends, associated with some lung, heart and bowel conditions. - Spoon-shaped nails can reflect iron deficiency, and pale nail beds can suggest anaemia. - Nail pitting, lifting or colour changes can accompany psoriasis, thyroid disease or other illnesses. - Yellow, thickened, brittle nails are common in diabetes and some circulation problems. - Skin and colour changes: yellowish skin, easy bruising, or unusual redness of the palms can occasionally reflect liver conditions. Individually these are often minor and very common. They become more meaningful when several appear together, when they affect all the nails at once, or when they come alongside feeling generally unwell. ## Why your surgeon asks about your general health When you come in about a hand or wrist problem, you may be surprised to be asked about your sugar levels, your thyroid, your medications, weight changes or how you've been feeling in yourself, and to have your nails, skin and pulses examined. This isn't padding. It's because the hand so often reflects the rest of the body, and spotting the wider picture can change both the treatment of your hand problem and, occasionally, uncover something treatable elsewhere. Where a general medical condition seems likely, the next step is usually a simple blood test or a referral to your GP or a physician, not surgery. ## When to see someone See your GP or come back to us, rather than waiting, if: - A hand symptom comes alongside feeling generally unwell: fevers, weight loss, fatigue, or feeling off in yourself. - Joint pain, swelling or stiffness affects both hands at once, or comes with early-morning stiffness that takes a while to ease. - You notice colour changes in the fingers (white/blue/red), painful fingertip ulcers, or new tightening of the finger skin. - The nails on many fingers change together: pitting, lifting, spooning, clubbing or a colour change. - Carpal tunnel symptoms or trigger fingers appear in several digits, on both sides, or at a younger than expected age. Most of the time, a hand problem is just a hand problem. But because the hand is such an honest reporter of general health, it's always worth mentioning the bigger picture. Sometimes the hand is the first to know. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. This topic is worth the extra reading because several hand conditions are, in practice, early visible signs of a systemic disease, and the hand often declares the problem before anything else does. ### Diabetes changes the hand in several distinct ways Diabetes is the systemic condition most consistently linked to hand problems, and the mechanism is common to all of them: glucose binds irreversibly to collagen, cross-linking it and making connective tissue stiffer and thicker. Every structure in the hand that depends on tissue gliding is affected. The result is a recognised cluster, carpal tunnel syndrome, trigger finger, Dupuytren's disease, and limited joint mobility with a characteristic inability to press the palms flat together. Frozen shoulder belongs to the same group. There is a specific and important corollary in pregnancy: gestational diabetes is a significant risk factor for both carpal tunnel syndrome and de Quervain tenosynovitis, established in a dataset of 715,337 patients [1]. That the effect appears over the months of a pregnancy, rather than the years of established diabetes, indicates these tissue changes develop faster than commonly assumed. The practical point is not that hand problems in diabetes are untreatable, they respond to the same treatments, but that they cluster, so one should prompt attention to the others, and that glycaemic control is part of the picture rather than a separate concern. ### Some hand findings should trigger investigation elsewhere Several presentations are worth recognising because the hand is the visible end of something systemic. Multiple trigger digits in a child. The presence of bilateral or multiple trigger digits, or concurrent carpal tunnel syndrome, should raise suspicion of an atypical underlying pathology such as mucopolysaccharidosis [2]. This is the clearest example on this site of a hand sign carrying implications far beyond the hand. Raynaud's phenomenon with concerning features. Onset after about 30, asymmetry between hands, fingertip ulcers or pitting scars, or abnormal nail fold capillaries suggest a secondary cause — usually an autoimmune connective tissue disease, rather than the benign primary form. Sudden painful weakness without compression. Anterior interosseous nerve palsy is increasingly thought to be a neuritis that often resolves spontaneously [3], and severe pain preceding weakness points towards neuralgic amyotrophy: an inflammatory condition of the nerves that no decompression addresses. ### Inflammatory arthritis behaves differently from wear Rheumatoid and other inflammatory arthritides affect the hand in a distinct pattern from osteoarthritis: the knuckles and middle joints rather than the fingertip joints, symmetrically, with prolonged morning stiffness and soft boggy swelling rather than hard bony enlargement. That distinction matters surgically as well as medically. Reconstructions that rely on soft tissue holding a correction tend to stretch out in a hand with active synovitis, which is why disease control ordinarily precedes reconstruction, and why the same operation carries a different prognosis in the two settings. ### Why the hand shows things early The hand is a dense collection of small joints, long tendons in tight sheaths, nerves in non-expandable tunnels, and the most distal circulation in the body, all under thin skin where change is visible. A process that would go unnoticed in a larger structure produces symptoms here quickly, and one that impairs small-vessel flow shows here first. That sensitivity is why hand findings are worth mentioning to a GP even when they seem trivial relative to the rest of one's health, and why hand surgeons frequently refer patients on to a physician rather than treating what is in front of them. --- ### Metacarpal Fracture Fixation URL: https://www.cqupperlimb.com/education/hand/metacarpal-fixation/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. A metacarpal fracture is a break in one of the long bones of the hand. This operation holds the broken bone in the right position while it heals. We… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. A metacarpal fracture is a break in one of the long bones of the hand. This operation holds the broken bone in the right position while it heals. We usually suggest it when a broken hand bone has shifted out of place, has twisted or shortened, involves several bones, or will not stay lined up in a cast. Some breaks run into the joint surface or break into several pieces, and these often need surgery to hold them steady. Most hand fractures are first treated without surgery, with a splint or cast and hand therapy. Surgery comes next when those steps have not kept the bone in a good position. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your visit we take a history, examine your hand, and arrange imaging if it is needed. Together we then decide whether an operation suits your injury and your goals. The aim is a hand that moves well, feels steady, and lets you use it without pain. ## Before the operation Your surgeon will give you exact instructions, but a few things apply to most people. Stop eating and drinking seven hours before your operation. We ask for seven hours so your surgery can be brought forward if the theatre list runs early. You may need to pause some of your regular medicines before surgery; your surgeon will tell you which ones and for how long. Bring a written list of everything you take, and wear loose, comfortable clothing. Arrange for someone to drive you home afterwards. X-rays of your hand are needed to plan the operation, and sometimes an MRI or ultrasound as well. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist, the doctor who looks after your sleep and comfort during the operation. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. Afterwards you wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Once you are stable, you either move to a ward or go home. Which of these happens depends on the procedure and how your recovery is going. ## What the operation involves There are two ways your surgeon can do this operation, and the choice depends on your fracture. With a closed approach, the bone is lined up without opening the skin. Wires or a screw are then passed in through small puncture wounds to hold it. With an open approach, your surgeon makes one cut over the broken bone so the pieces can be seen and fitted back together. This is used when the break runs into a joint, breaks into several pieces, or will not line up on its own. Once the bone is lined up, it needs something to hold it steady while it heals. Your surgeon chooses the implant that suits the shape and position of your break. Fine wires can be passed across the bone. A small screw can be placed down the inside of the bone, a technique called intramedullary fixation, which suits some shaft and neck fractures. Small screws can be placed across a long oblique or spiral break, where the fracture line runs around the bone. Or a small plate with screws can hold the pieces together. Wires left sticking out through the skin are usually removed in the clinic after a few weeks, once the bone is stable. Screws and plates that sit under the skin are usually left in place unless they cause a problem. The cut is closed with stitches, and a dressing goes over the top. ## After the operation You will wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Your hand will be in a dressing and a splint, and you may have a sling for comfort. Pain medicine will be arranged so you stay comfortable. You can move around as you feel able, and someone should stay with you for the first 24 hours. You may go home the same day or stay one night in hospital after this operation. Both are common, and your team will talk with you about which suits you. If you had a nerve block, your hand may feel numb or heavy for about 24 hours. This is expected. Call the clinic if you cannot move your fingers once the block has worn off. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it, or if pain keeps getting worse despite your pain medicines. Go to the emergency department if your fingers, hand or thumb turn pale, cold, white, blue or dark. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Your hand will be sore and swollen for the first days and weeks. This is normal and settles gradually as the bone heals. Keeping your hand raised when you are resting helps the swelling go down, and the pain medicine arranged for you eases the discomfort. Your hand will be protected in a splint made by your hand therapist, Ruby Doolan at Extend Rehabilitation. She directs your therapy and makes any splint you need. You will do regular movement exercises as part of hand therapy. These start early and build up as the bone heals. The aim is to keep your fingers moving while the break settles. You can use your hand for light daily tasks within the limits your therapist sets. You cannot drive while the splint is on, because it stops you gripping the wheel safely. Once the splint is off and your surgeon clears you, driving can resume; see our page on driving after upper-limb surgery. As movement returns, everyday tasks get easier. You will notice your grip and strength coming back over time. Heavier work, sport and gym activity come later, once your therapist and surgeon agree the bone is ready. Sleep however feels comfortable; there is no special position you must hold. Recovery varies from person to person. Your timeline may differ, and your surgeon and therapist will guide you at each visit. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the bone can shift out of its corrected position before it has healed. You might notice the finger starting to look twisted or bent, or a change in how your fingers line up when you make a fist. Bring this up at your next review, or call the clinic if the change seems sudden. A wire or screw can sometimes move from where it was placed. A wire that sits near a joint can cause pain and make the hand harder to use. If you feel a new sharp pain, or the finger will not move as it did, call the clinic. The finger can also develop a twisting problem. You may notice one finger overlapping another when you curl your hand into a fist, or the finger sitting out of line with its neighbours. Mention this at your review so it can be checked. Infection is a risk with any operation. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it, or if pain keeps getting worse despite your pain medicines. If you cannot reach the clinic, go to your nearest emergency department. A wire left through the skin can irritate the tissue around it. The skin where the wire enters may look red or weepy. Call the clinic if this happens, so we can check it before it becomes a deeper problem. Rarely, a tendon can rupture, meaning one of the cords that moves your finger has torn. You would notice a sudden loss of movement, such as being unable to straighten or bend a finger that moved fine the day before. Call the clinic if this happens. Nerves run close to the bones of the hand. A nerve injury can cause numbness or tingling in part of the hand. Numbness in the first 24 hours after a nerve block is expected. Once the block has worn off, call the clinic if numbness or weakness continues. Some people develop ongoing pain and sensitivity in the hand that seems out of proportion to the injury. The hand may feel painful to touch or use long after you would expect it to settle. Bring this up at your review. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up early, and we would rather hear about them than not. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it, or if pain keeps getting worse despite your pain medicines. Go to the emergency department if your calf is swollen or painful, if you become short of breath, or if you have chest pain. These can be signs of a blood clot. Go to the emergency department if your fingers, hand or thumb turn pale, cold, white, blue or dark. Call the clinic if you cannot move your fingers once the nerve block has worn off, about 24 hours after surgery. Numbness in the first 24 hours is expected. If you cannot reach the clinic, go to your nearest emergency department. --- ### Metacarpal Fractures (including Boxer's Fracture) URL: https://www.cqupperlimb.com/education/hand/metacarpal-fractures/ Region: hand · condition A broken hand bone in the palm — including the common boxer's fracture — how it is treated, the rotation check that matters most, and recovery. ## What you're feeling A metacarpal fracture is a break in one of the long bones in the body of your hand: the bones that connect your wrist to your fingers, the ones you can feel as your knuckles. The most common one happens after a punch and involves the bone behind the little-finger knuckle. This is so common it has a nickname: a boxer's fracture. Usually there has been an obvious moment: a punch into something solid, a fall onto the hand, or a crush or twisting injury. Straight afterwards the back of the hand becomes painful, swollen and bruised, and the knuckle may look flattened or "sunken" compared with the other side. Making a fist hurts, and your grip feels weak. Some people notice that one finger seems to cross over or point towards its neighbour when they try to curl the hand into a fist; that twist matters, and it's one of the main things we check for. ## What's actually happening You have five metacarpal bones, one running into each finger and thumb. A fracture can sit at the neck (just behind the knuckle, the classic boxer's fracture spot), along the shaft (the middle of the bone), or at the base (near the wrist). After a break, the broken ends can tip into an angle, shorten, or twist. A bit of angle is often fine, as the hand is forgiving, and the ring and little finger bones in particular tolerate quite a lot of bend without causing any real problem, because those knuckles are naturally more mobile. What the hand does not tolerate well is twist (we call this rotation). Even a small amount of rotation at the break makes a finger swing across its neighbours when you close your fist, so the fingers no longer pack neatly together. That is why the look of your hand when you make a fist tells us more than an X-ray angle alone. ## What we can do about it Dr Kieran Hirpara is an upper-limb surgeon at Mater Private Hospital Rockhampton who guides your care from the first assessment through to recovery. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We then confirm the diagnosis and choose a plan that fits your needs. The good news is that most metacarpal fractures heal well without surgery. For the majority (including most boxer's fractures) the answer is simple support and early movement. Depending on the fracture we might use a lightweight splint, a cast, or just buddy-strapping the injured finger to the one next to it, and then encourage you to start gently moving the hand quite early. Moving early is deliberate: it keeps the hand from stiffening up, and studies show simple strapping with early movement does just as well as heavier casting for typical boxer's fractures [4, 5]. Surgery is reserved for fractures that won't do well left alone. The main reasons to operate are a rotated (twisted) finger, a badly angled or shortened bone, several broken metacarpals at once, a fracture that breaks into a joint, or an open wound over the break. When we do fix it, the options are small wires placed through the skin (K-wires), or a small plate and screws through a cut. Many of these operations can be done wide awake, with the hand numbed by local anaesthetic while you stay awake and comfortable, which lets us ask you to move the finger on the table and confirm the rotation is corrected before we finish. ## What to expect Most metacarpal fractures unite in around four to six weeks, and the hand is back to most normal activities not long after. Even when the bone heals with a little extra bend, the knuckle may look slightly less prominent than before but the hand usually works completely normally. Whether or not you have surgery, the work that protects your result is the hand movement afterwards: gentle, early, and guided where needed by a hand therapist. The complications we watch for are stiffness (the most common), a residual twist or bend (malunion), and occasionally a slight lag in fully straightening the finger. Stiffness is far easier to prevent with early movement than to treat later, which is why we nudge you to get moving sooner rather than later. ## When to see someone - Any deformity, or a finger that crosses over its neighbours when you make a fist: this twist needs assessing promptly, as it's a key reason to straighten or fix the bone. - A wound or break in the skin over the knuckle, especially after a punch to someone's mouth: a tooth can introduce serious infection, and this needs urgent medical attention. - Severe pain, marked swelling, numbness, or fingers that look pale or dusky: get reviewed without delay. - A hand that is getting stiffer rather than looser in the weeks after the injury: early hand therapy makes a real difference. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Metacarpal fractures are worth the extra reading because most of them need no operation at all, and because the deformity that worries people most, the knuckle that has flattened, is the one the hand tolerates best. ### Why angulation is tolerated, and why it varies by finger A fracture through the neck of a metacarpal typically tips the head downwards into the palm, so the knuckle loses its prominence. That looks wrong and is easy to interpret as needing correction. What determines whether it matters is how much movement the corresponding joint at the wrist end has in reserve. The index and middle metacarpals are effectively fixed at their bases, so angulation there is poorly compensated. The ring and little metacarpals sit on mobile joints that allow considerable rotation, which absorbs a substantial degree of angulation without functional loss. That is why a boxer's fracture of the little finger metacarpal, the commonest of all, tolerates far more angulation than the same injury two fingers across, and why a striking-looking deformity there is frequently managed without surgery. ### Rotation is the deformity that does matter The exception is rotation, and it is worth understanding because it is easy to miss on an X-ray. A metacarpal healed with a twist causes the finger to cross over its neighbour when the hand closes — scissoring, which genuinely impairs grip and does not accommodate with time. Rotation is assessed by asking the person to make a fist and looking at whether the fingernails align and the fingers point convergently, not by measuring the film. A fracture with acceptable angles on an X-ray but visible scissoring on examination needs correcting; the reverse often does not. ### Where fixation is used, the evidence is modest For fractures that do need surgery, intramedullary screw fixation, placing a screw down the shaft from the knuckle, has become popular because it avoids a plate under the extensor tendons. Reviewing 1,014 patients, complications following intramedullary screw fixation of metacarpal fractures are relatively uncommon [1]. The comparative evidence is weaker than the popularity suggests. An earlier review of 502 patients concluded intramedullary fixation may have a role in the treatment of certain metacarpal fractures, but that no conclusive recommendations could be made from the available studies [2]. Both statements can be true: the technique is safe, and it has not been demonstrated superior. Given that the majority of these fractures do well without surgery, the more consequential decision remains whether to operate rather than which implant to use. ### Malunion is correctable, which changes the calculus Where a fracture heals in a poor position and causes a genuine functional problem, corrective osteotomy is available. Corrective osteotomies almost always heal without incident, with a majority of patients showing improvement or correction of deformity and improved finger motion — though the review notes that many patients, despite improvement, retain some limitation [3]. This is a reasonable argument for non-operative management in borderline cases. The alternative to operating now is not "accept whatever happens", it is "operate later, in the smaller number of people who turn out to need it", with a procedure that reliably heals. --- ### Mucous Cyst URL: https://www.cqupperlimb.com/education/hand/mucous-cyst/ Region: hand · condition Mucous cysts – common bumps near finger joints, often linked to arthritis, and treatment options. ## What you're feeling A mucous cyst is a small, firm lump that appears on the back of the finger, usually just behind the nail. It is filled with a thick, clear fluid. The lump itself is often painless, but it can press on nearby structures and cause discomfort. You may notice changes to the nail itself. The cyst sits close to the nail bed, so it can press on the nail as it grows. This often causes a groove or ridge running the length of the nail. The skin over the cyst can also become thin and shiny. In some cases, the skin breaks down and the cyst leaks fluid through a small channel. The lump tends to sit right where your finger bends at the last joint before the nail. That makes some everyday tasks awkward. Reaching into a tight pocket, gripping a jar lid, or picking up small coins can be uncomfortable. Typing or writing may press on the lump and make it sore. The cyst is linked to wear-and-tear arthritis in that same joint. A small bony spur, called an osteophyte, irritates the joint and produces the fluid that fills the cyst. Because of this, the joint may ache after you have used your hand a lot, and the lump can feel more tender then. If the skin over the cyst breaks open and fluid leaks out, keep the area clean and seek care promptly. A channel from the skin into a finger joint can let infection in, and an infected joint needs treatment without delay. If your finger becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. No GP referral is needed. Do not puncture or squeeze the cyst yourself. It can let infection into the joint. If the lump is growing, the nail deformity is bothering you, or symptoms are not settling over weeks, see your GP or ask for a specialist review. ## What's actually happening The last joint of your finger works like a small hinge. Like any joint, it is lined with a soft sleeve that makes a little fluid to keep the surfaces gliding smoothly. In a mucous cyst, that joint has developed wear-and-tear arthritis. The joint lining becomes irritated and starts making more fluid than the joint needs. At the same time, arthritis often forms a small bony spur at the edge of the joint. That spur presses on and wears through the joint sleeve from the inside. Fluid then leaks out through the worn spot and collects under the skin on the back of your finger. The lump you can see and feel is that trapped fluid, sitting to one side of the joint, just behind the nail. The cyst itself is a thin-walled pocket rather than a growth. Its wall is made of strands of supporting tissue, and it has no proper lining of its own. Because the wall is thin and the skin over it is often thinner still, a small knock can burst it. When that happens, the clear, jelly-like fluid inside leaks out. This explains the symptoms you have just read about. The lump sits close to the nail bed, so pressure from the cyst can groove the nail as it grows. The joint aches because the arthritis is there too, and the cyst is a sign of it. The spur at the joint edge is what keeps the fluid flowing, so as long as it is there, the cyst tends to refill even after it leaks or is drained. That is also why treatment focuses on the joint rather than just the lump. Removing the spur stops the leak at its source, and the cyst settles once it is no longer being topped up. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic visit we take a history, examine your finger, and arrange imaging if it is needed. Most mucous cysts are linked to wear-and-tear arthritis in the joint, so we usually try non-operative care first and consider surgery when that has not given enough improvement. The first step is often simply watching and waiting. Some cysts stay small and cause little trouble. Protecting the finger helps: avoid repeated knocks to the lump, and take care with tasks that press on it. If the joint aches after heavy use, easing back on that activity can settle things. Hand therapy can help with stiffness and with keeping the finger moving comfortably. Give these simple measures a fair trial over several weeks before deciding anything further. Pain relief is straightforward. Simple pain medication from the pharmacy, taken as directed, can settle an aching joint. Anti-inflammatory medication can ease the arthritis behind the cyst. These treat the discomfort rather than the lump itself. One option we do not offer is draining the cyst with a needle. It is a convenient office procedure, but the cyst comes back about half the time afterwards. There is also a risk of carrying infection into the joint, which is why we advise against puncturing or squeezing the cyst at home too. Surgery is considered when the cyst keeps refilling, the nail deformity bothers you, or the skin over the cyst has become thin or is breaking down. The operation treats the joint rather than just the lump. The bony spur at the joint edge is removed, which stops the fluid leak at its source, and the cyst settles once it is no longer being topped up. In some cases the cyst and a small flap of local skin are removed as well, which suits a cyst that has thinned the skin over it. Removing the spur together with the cyst's stalk gives the lowest chance of the cyst returning. We will talk through which approach suits your finger, and decide together. ## What to expect Left alone, a mucous cyst tends to keep coming back rather than disappear. As long as the bony spur at the joint edge is there, it keeps topping the cyst up with fluid. Some cysts stay small and cause little trouble for a long time. Others grow slowly, groove the nail further, or thin the skin over the lump until it leaks. Without treatment, the main risks are the ones you have already read about: a nail that stays ridged while the cyst presses on it, and skin that breaks down and opens a channel into the joint. That channel is worth taking seriously. If your finger becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. No GP referral is needed. With treatment aimed at the joint, the outlook is straightforward. Removing the spur stops the fluid leak at its source, and the cyst settles once it is no longer being topped up. When the spur is removed, the cyst rarely comes back. Where the cyst itself is also removed, recurrence stays low: about 2 in every 100 cysts treated surgically return, and around 1.4 in 100 when a local skin flap is used to close the area. People treated this way are generally happy with how the scar looks, and would go through it again. Recovery is not a big undertaking, but it is not nothing either. The finger is often stiff and tender for a few weeks, and everyday tasks like gripping or pinching take a while to feel normal again. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she guides your exercises and makes any splint you need. Most people are back to normal hand use within weeks to a few months. The nail groove usually improves too, once the pressure is off the nail bed. Be patient with that part: the deformed section of nail has to grow out, which takes several months. If symptoms are not settling over weeks, or are getting worse, see your GP or ask for a specialist review. ## When to see someone Most mucous cysts are not urgent, and many settle with simple care. A few signs do need action. Go to an emergency department the same day if your finger becomes hot, red, swollen and painful, especially with a fever. That points to infection in the joint, which needs treatment without delay. The same applies if the skin over the cyst has broken open and fluid is leaking, because that opening can let infection in. See your GP or ask for a specialist review if the lump keeps growing, the nail groove is bothering you, or the skin over the cyst has become thin. These are the signs that treatment is worth discussing. If symptoms are not settling over weeks, or are getting worse, your GP can arrange a referral. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Mucous cysts are worth the extra reading because of a small, well-supported surgical insight: the cyst is not the problem, and the operation that works best does not necessarily remove it. ### The bone spur is the cause, not the cyst A mucous cyst arises from an arthritic fingertip joint. A bony spur, an osteophyte, irritates and perforates the joint capsule, and joint fluid tracks out through the defect and collects under the skin. The cyst is the visible end of that process, not its origin. That understanding has a direct surgical consequence, demonstrated in a series where osteophyte excision without cyst excision produced complete resolution in most cases, and was described as a good treatment choice offering a less invasive method [1]. Removing the spur closes the tap. The cyst, no longer being filled, resolves. This is the same logic that governs the wrist ganglion, where the stalk rather than the sac determines recurrence, and it explains why simply draining or puncturing a mucous cyst so reliably fails. ### Where the cyst is excised, results are also good The alternative approach removes the cyst along with a local skin flap to close the defect. That is also reliable: across 69 patients, surgical excision with a local advancement flap showed a recurrence rate of 1.4% with high patient satisfaction regarding the scar and willingness to undergo the procedure again [2]. Both approaches work, and both address the underlying joint. The practical difference is how much skin is involved: a long-standing cyst thins the overlying skin, sometimes to the point of discharging, and in that situation the thinned skin needs excising and replacing regardless of what is done to the bone. ### Why the nail becomes deformed, and whether it recovers A groove or ridge running the length of the nail is a common accompaniment, and it worries people more than the lump. The cause is mechanical: the cyst sits immediately over the germinal matrix, the part of the nail bed that generates the nail, and presses on it, so the nail is produced with a defect. The useful part is that this is pressure rather than destruction. Once the cyst is decompressed, the nail typically grows out normally, though it takes several months for the deformed portion to grow off the end. A nail deformity is therefore a reason to treat the cyst rather than a permanent consequence of it. ### The reason to be careful about puncturing one A mucous cyst communicates directly with the joint. Puncturing it, deliberately, or by the skin breaking down over a large one, creates a channel from the outside world into a finger joint, and septic arthritis of a small joint is a considerably more serious problem than the cyst. This is the practical argument against home drainage of a cyst that appears to be simply a blister of fluid, and the reason a spontaneously discharging cyst is treated with some urgency rather than watched. --- ### Mucous Cyst Excision (with Local Flap) URL: https://www.cqupperlimb.com/education/hand/mucous-cyst-excision/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment, including your history, an examination and imaging where needed, establishes the diagnosis. A mucous cyst is a small, fluid-filled lump that forms near the end joint of a finger, usually in skin worn by wear-and-tear arthritis in that joint. This operation removes the cyst and covers the area with a small flap of nearby skin. We usually try non-operative care first, such as activity change, hand therapy or splinting, and consider surgery when that has not given enough improvement. For some people, surgery may be recommended straight away. The operation aims to remove the cyst for good. Recurrence after this type of surgery is low, at 1.4%, and most people are happy with how the scar looks and would choose the operation again. We will discuss whether it suits you and decide together. ## Before the operation Your surgeon will plan the operation using imaging such as an X-ray, MRI or ultrasound. Most people need no other tests. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. Stop eating and drinking seven hours before surgery; we ask for a little longer than usual so your time can be brought forward if the theatre list runs early. Your surgeon will tell you which medications to stop and when. Bring a list of everything you take, arrange a lift home, and wear comfortable clothing with a loose sleeve. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist there. This operation can be done under general anaesthetic (fully asleep) or under local anaesthetic (an injection that numbs just the finger, with you awake). We will talk through which suits you before the operation. You are then taken into the operating theatre, where the operation is performed. Afterwards you go to the recovery area, where nurses monitor you (if you had a general anaesthetic, while it wears off). Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves Your surgeon makes a small cut over the lump, near the end joint of the finger. Through this cut, they remove the cyst and clear away the small bony spur that often sits beside it. That spur comes from wear-and-tear arthritis in the joint and is a common reason these cysts keep coming back, so removing it is a key part of the operation. Once the cyst and the bone spur are gone, your surgeon covers the area with a small flap of nearby skin. The flap is lifted, moved across the gap left by the cyst, and stitched into place. This brings fresh skin over the joint and helps the area heal in one go. The stitches may be dissolving or removable, and your surgeon will let you know which type has been used. The whole operation is done through this one small area at the end of the finger. Nothing is done to the deeper joints or tendons unless the findings during surgery call for it. ## After the operation You go to the recovery area, where nurses keep an eye on you (if you had a general anaesthetic, while it wears off). Your finger will have a dressing and may feel numb for a while. Pain relief is planned for you before the numbness settles; tell the nurses if you are uncomfortable, as they can adjust it. You can move around as soon as you feel steady, and your hand does not need to be kept still. Someone should stay with you for the first 24 hours. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your finger will be sore and a little swollen. This settles steadily. Keeping your hand raised on a pillow, especially at night, eases the throbbing. Simple pain relief as directed by your team is usually enough. You go home with the dressing on, and it stays in place for about 10 days until we see you and change it. Your hand does not need to be kept still, so you can use it for light tasks around the house as soon as you feel steady. Avoid heavy gripping, and keep the dressing dry. Once the dressing comes off, the flap of skin over the joint is usually healing well. The scar softens and fades over time, and published series report that the appearance settles well. Movement in the end joint of the finger returns as the swelling settles. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation; she will guide your exercises and make a splint if you need one. Recovery varies from person to person, and your timeline may differ. Your surgeon and your hand therapist will guide you at each review, and you will know things are on track as the swelling goes down, the wound closes over, and you can grip and bend the finger without pain. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the cyst grows back at the same spot. You would notice a small, firm lump near the end joint of the finger again, much like the one you had before. If you see one forming, mention it at your next review. Removing the small bony spur beside the joint is done to stop this happening. The flap of skin used to cover the area needs to heal well. If it does not, you might see the wound edges pulling apart, the flap looking pale or dark, or the area staying raw and weepy instead of closing over. Healing can also be slower than expected. If you notice any of these signs, contact the clinic so we can check the wound and adjust your care. A wound infection is another thing to watch for. This usually looks like redness that spreads out from the wound, with warmth, swelling or tenderness that gets worse rather than better. You might see fluid or pus leaking from the wound, or feel a deep, throbbing pain that does not ease with simple painkillers. You may feel hot and generally unwell. If you notice these signs, call the clinic straight away. If you cannot reach us and you feel unwell, go to your nearest emergency department. The good news is that when this operation is done with a skin flap, wound problems like these are uncommon in the cases that have been reported, and the cyst rarely comes back [2, 3]. If you spot anything about your finger that worries you between reviews, do not wait. Call us and describe what you can see and feel. Early attention makes most problems easier to sort out. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if you feel feverish, notice the redness around the wound spreading, or see fluid or pus leaking from it. Call us if the pain suddenly gets worse and simple painkillers do not touch it, if your finger feels numb, or if you cannot bend or straighten it. Go to your nearest emergency department if you have calf swelling or shortness of breath, or if you feel hot and generally unwell and cannot reach us. If anything about the finger worries you between reviews, do not wait. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Mucous cyst surgery is worth the extra reading because the operation is not really about the cyst at all, and once you see why, everything about how it is done makes sense. ### The cyst is a symptom. The osteophyte is the disease. A mucous cyst is a small ganglion of the joint nearest the fingernail, and it almost always sits on top of wear-and-tear arthritis in that joint. The worn joint grows small spurs of extra bone (osteophytes), the joint fluid finds a way out past them, and the cyst is where it collects under the thin dorsal skin. That is why simply removing the cyst has a poor record: leave the osteophytes and the leak refills. The clearest demonstration comes from a series that did the opposite, removed only the osteophytes and left the cyst alone, with complete resolution in most cases [1]. The operation is best understood as joint debridement with the cyst dealt with along the way, not cyst removal with the bone as an afterthought. ### Why a flap, and why it does not matter much which one The skin over a long-standing cyst is often stretched paper-thin, and once the cyst and thinned skin are excised there can be too little healthy skin to close directly. That is the job of the local flap: a small tongue of neighbouring skin is rotated across the defect, bringing its own blood supply with it. The technique Dr Hirpara most often uses follows the approach described by Johnson and colleagues [2]: a day-case operation under local anaesthetic ring block, an elliptical excision of the cyst in its entirety, including the thinned skin, with the cyst's neck followed down to the joint and resected together with the attached capsule, the accessible dorsal osteophytes excised while protecting the extensor tendon, and the defect closed with a full-thickness local advancement flap raised from the same side of the finger, without tension. Sutures come out at about two weeks. In the published series of that technique, 75 consecutive patients over ten years, the recurrence rate was 1.4%, with high patient satisfaction with the scar and a stated willingness to have the operation again [2]. Flap design is not the deciding factor. The Zitelli bilobed flap provides good-quality coverage without added risk to the nail matrix [3], which matters, because the nail's growth zone sits immediately beyond the cyst, and a recent comparison of two other flap designs found no difference in aesthetic satisfaction or complications between them [4]. Other centres report full-thickness skin grafting with acceptable recurrence [5], and total excision of the dorsal joint capsule with no recurrences in a small series [6]. The common thread is the same everywhere: deal with the joint, and get sound skin cover. ### When the joint itself is the problem Sometimes the cyst is the smaller issue and the arthritis beneath it is what actually hurts. If the joint is painful in its own right, not just lumpy, removing the cyst treats the messenger and leaves the message. In that situation the definitive answer can be to fuse the joint (an arthrodesis), which removes the arthritis, the pain and the source of the cyst in one operation. That option, its trade-offs and its recovery are covered on the DIP joint fusion page. ### What can go wrong The specific risks follow from the anatomy: the nail matrix is millimetres away, so a nail groove or ridge is possible (and, conversely, a cyst pressing on the matrix may have already caused one that surgery can improve); the thin skin means healing occasionally needs longer; and recurrence — though uncommon after proper joint debridement, as the figures above show, is never zero, because the arthritis that caused the cyst is still an arthritic joint. --- ### Paronychia (Infection Beside the Nail) URL: https://www.cqupperlimb.com/education/hand/paronychia/ Region: hand · condition Paronychia means infection or inflammation in the skin fold beside your nail. It can come on fast or build up slowly, and the two forms feel different. ## What you're feeling Paronychia means infection or inflammation in the skin fold beside your nail. It can come on fast or build up slowly, and the two forms feel different. The fast form usually starts after a hangnail, a nail bite, or a small injury to the skin beside the nail. Within a day or two the fold becomes tender, swollen and red, and pus can collect under that fold. The pain is sharp and throbbing, and it sits right at the edge of the nail rather than further up the finger. Everyday tasks that press on the fingertip become hard: picking up coins, typing, doing up buttons, or gripping a kettle. The slow form builds over six weeks or more. The swelling and redness are milder, but the fold stays sore and puffy. The skin fold can lift away from the nail, and the nail itself may develop ridges, grooves or changes in colour. It tends to flare after your hands have been wet for a while, so washing up, showering, or a day of damp work can set it off. Repeated wet work, frequent handwashing, or damage to the cuticle from manicuring can all keep it going. If it is not treated, painful flare-ups keep returning. If the redness, swelling and pain spread up your finger, or you develop a fever, go to the emergency department the same day. You do not need a referral. ## What's actually happening Your nail sits in a snug pocket of skin. The fold of skin that frames the nail at its base and sides works like a gasket, sealing the nail down onto the finger and keeping water, dirt and germs out of the layers underneath. Paronychia is what happens when that seal breaks. In the fast form, bacteria get in through a hangnail, a bite or a small cut beside the nail. The body sends in fluid and infection-fighting cells, and pus builds up in the closed pocket. Because the pocket cannot stretch much, the pressure is what gives you that sharp, throbbing pain right at the nail edge. The slow form is different. It is not mainly an infection. It starts when the cuticle, the little seal at the nail base, is damaged by wet work, frequent handwashing, manicuring or an irritating substance. Once that seal is gone, water and irritants soak into the fold and the fold becomes inflamed. A swollen fold cannot press back down onto the nail, so it stays lifted and holds moisture, and germs settle in the damp gap. The yeast often found there is more of a passenger than a cause. The ongoing irritation also disturbs the layer under the cuticle that grows the nail, which is why ridges and grooves appear. Each flare keeps the seal from repairing, so the problem sustains itself. If pus is left alone it can track under the nail or around to the other side of the finger. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We assess your hand, examine the nail fold, and arrange imaging only if it is needed. For the slow form, self-care comes first. Protecting the nail folds matters more than any cream: keep your hands dry, wear gloves for wet work, and stop picking or cutting the cuticle. We may prescribe a steroid cream or ointment that you rub into the fold, which calms the inflammation. Creams applied to the fold work better than tablets for this form. Give it several weeks, and keep up the dry-and-protected routine even once the skin settles, because the seal needs time to repair. For the fast form with pus, we may prescribe antibiotic tablets, sometimes with warm salt-water soaks at home. The warmth can help a small collection of pus drain on its own. If pus has already built up under the fold, it usually needs to be released rather than left on antibiotics alone. Early treatment can settle things within a few days without removing any nail. If the slow form has not settled after a fair trial of these measures, surgery is considered. The operation removes a crescent of the thickened, inflamed skin fold at the nail base, which lets the fold heal back down onto the nail and seal again. If the nail itself has become ridged or irregular, removing the nail plate at the same time improves the result. We will talk through whether surgery suits your finger and decide together. ## What to expect The fast form usually settles well when it is treated early. Many people are cured without any nail needing to be removed. Once the pus is released and the skin fold can heal, the pain eases and the finger returns to normal over days to weeks. The slow form takes longer. It is a condition that comes and goes, flaring after wet work and settling when the fold is protected. With steady care, keeping the hands dry and the cuticle intact matters more than any cream, the gap between the skin fold and the nail fills in over 6 to 8 weeks and the seal repairs itself. Some people need several months of this routine before the fold settles for good. If it is left alone, painful flare-ups keep returning, and the nail can thicken and develop lasting ridges or grooves. Surgery for the slow form removes the thickened fold so it can heal back down onto the nail. Fingers whose nail has stayed smooth generally heal with the fold surgery alone. Where the nail is already ridged or irregular, removing the nail plate at the same time gives a better chance the problem does not come back. Antibiotics are not usually needed after surgery for this condition in people without other health problems. A few things are worth knowing as you go. Hand infections can lead to complications that are awkward to manage, so it pays not to ignore a finger that is not improving. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone Most nail fold infections settle with early care, but some signs mean you should not wait. Go to an emergency department the same day if your finger becomes hot, red, swollen and painful, especially with a fever, or if pus is spreading up the finger. You do not need a referral. Hand infections can lead to complications that are awkward to manage once they take hold, so same-day care matters. See your GP if the soreness and swelling have lasted six weeks or more, or if the fold keeps flaring after wet work despite keeping it dry and protected. Ask for a specialist review if the skin fold stays lifted and puffy, the nail develops ridges or grooves, or a nail problem does not respond to creams. A nail fold that will not settle after proper treatment needs a closer look, because other causes are sometimes mistaken for this condition. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Paronychia is worth the extra reading because one word covers two conditions that behave differently, respond to opposite treatments, and are routinely confused, and because the surgical answer for the chronic form is older, simpler and better supported than most people expect. ### Two conditions, one name Acute paronychia is a bacterial infection of the nail fold, most often Staphylococcus aureus, developing over 24 to 48 hours after the seal between nail and skin is breached [1]. It is red, hot, tense and disproportionately painful, and it forms pus. Chronic paronychia, by convention lasting beyond six weeks, is not primarily an infection at all. It is an inflammatory dermatitis of the nail fold driven by repeated wet exposure and irritants, in which loss of the cuticle seal allows further irritant entry, producing a cycle that sustains itself [2]. Candida is frequently cultured from these folds, which is precisely why the condition was long treated as a fungal infection, but its presence is better understood as colonisation of an already-damaged fold than as the cause. ### The trial that reframed the chronic form The evidence that settles this is a randomised, double-blind, double-dummy trial comparing a topical steroid (methylprednisolone aceponate) against two systemic antifungals. Of 48 nails treated with the topical steroid, 41 were improved or cured, against 30 of 57 on terbinafine and 29 of 64 on itraconazole, a statistically significant advantage to the steroid [3]. The same trial contains the more decisive observation. Candida presence was not strictly linked to disease activity, and eradicating Candida was associated with clinical cure in only 2 of the 18 patients who carried it at baseline [3]. That is hard to reconcile with a fungal aetiology and easy to reconcile with an inflammatory one: the yeast is a passenger in a damaged fold, not the driver. It reframes the condition as a barrier problem: the cuticle is the seal, wet work destroys it, the fold swells, the swollen fold cannot re-seal, and organisms colonise the gap. Treating the colonisers leaves the mechanism untouched. The practical corollary is unglamorous and is the part patients most often skip: the single most effective intervention is keeping the hands dry and out of irritants. Gloves outperform prescriptions here. ### Acute paronychia: drainage, and how much to disturb Once pus has formed, antibiotics alone will not clear it, the collection has to be released [1]. The traditional approach lifts the nail fold off the nail plate to decompress the abscess, removing part of the nail where pus has tracked beneath it. A nail-preserving alternative is the Swiss roll technique, in which the nail fold is elevated and rolled back over a suture rather than incised or excised, held for a few days and then unrolled [4]. The attraction is that it drains a collection that has spread across the fold without sacrificing nail plate or nail fold, which matters where the alternative would be a wide incision. The general principle across both is that the incision should decompress the fold rather than enter the pulp of the finger, since the pulp is a separate compartment and opening it converts a straightforward paronychia into a more troublesome wound. ### Eponychial marsupialisation For chronic paronychia that has not settled, the operation is one described in 1976 and essentially unchanged since. Keyser and Eaton's procedure removes a crescent of the thickened proximal nail fold, taking the inflamed tissue while stopping short of the germinal matrix, and leaves the defect open to heal by contraction, which draws the fold back down onto the nail plate and restores the seal the disease destroyed [5]. The anatomy is what makes the margin critical. Beneath the cuticle sits a two-to-three-millimetre cul-de-sac of germinal matrix that produces the nail plate, and the subcutaneous layer over it governs the nail's surface. Disturb that layer, by infection, pressure or trauma, and nail production is deranged in proportion: brief episodes give transverse ridges, long-standing disease gives the longitudinal grooving and thickening that characterises chronic paronychia [5]. So sparing the germinal matrix is what prevents a permanent nail deformity, and leaving the wound open is what produces the contraction that reseals the fold, closing it would defeat the purpose. ### The refinement that removed the recurrences The most useful piece of outcome data is a small series with a clear internal comparison. As reported, fingers with nail irregularities treated by marsupialisation alone went on to recur in a minority of cases, whereas a subsequent group of fingers with nail irregularities treated by marsupialisation plus removal of the nail plate did not; fingers without nail irregularities healed with marsupialisation alone [6]. The series is small and sequential rather than randomised, so this is a signal rather than a proof — and the full text was not available to us, so the figures above are as summarised in the secondary literature rather than read from the paper. But it gives a concrete intraoperative rule: an irregular or ridged nail is evidence that the disease has already involved the matrix beneath, and in that finger the nail plate should come off as well. A normal-looking nail can be left. That is an unusually actionable finding for a condition this common, and it is the reason the state of the nail plate, not just the fold, is worth examining before deciding on the operation. --- ### Drainage of an Acute Paronychia URL: https://www.cqupperlimb.com/education/hand/paronychia-drainage/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. An acute paronychia is an infection in the skin beside or under a fingernail. It usually causes redness, warmth, swelling and marked… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. An acute paronychia is an infection in the skin beside or under a fingernail. It usually causes redness, warmth, swelling and marked tenderness. Early infections may settle with antibiotics alone. More advanced infections need incision and drainage, which means making a small opening to let the pus out. Antibiotics are often not needed afterwards for straightforward cases in people who are not at risk. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We assess your history, examine your finger and arrange imaging where needed. If the infection has already collected pus, or it has kept getting worse while you were taking antibiotic tablets, we will usually recommend drainage. We aim to relieve the pain quickly and stop the infection spreading deeper into the finger, where it can harm the tendon or bone. We will talk through the plan with you before anything happens. ## Before the operation Most of the preparation is simple. You will need to stop eating and drinking for seven hours before surgery. We ask for seven rather than six so we can bring you forward if the theatre list runs early. Your surgeon will tell you which of your regular medicines to skip on the day, and it helps to bring a written list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing. Imaging such as an X-ray, ultrasound or MRI scan may be used to plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, but most people need neither. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist, the doctor who puts you to sleep and keeps you safe during the operation. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. After that, you are taken into the operating theatre, where the operation is performed. When it is finished, you will wake up in the recovery area. Nurses will stay with you there while the anaesthetic wears off. Once you are stable, you will either move to a ward or go home the same day, depending on the procedure and how you are recovering. ## What the operation involves The aim of the operation is simple: to make a small opening beside or under your nail so the pus can drain out and the pressure goes away. Your surgeon makes a small cut in the skin next to the nail, at the spot where the infection has collected. The pus is released, and the space is washed out. Most people feel relief from the throbbing pain soon after this. There is more than one way to open the space, and there is no single agreed technique. Your surgeon will choose the approach that suits your finger. If the infection has spread around to the skin fold on the other side of the nail, a technique may be used that treats both nail folds at once. If the pus has collected under the nail plate itself, a small opening may be made through the nail to let it drain. If the infection is more severe, or it has grown thickened, lumpy tissue at the nail edge, your surgeon may remove that tissue as well, so the area can settle and heal cleanly. The cut is usually left open or lightly closed so any remaining infection can escape, and a dressing is placed over the finger. You will go home with that dressing in place. For straightforward infections in people who are not at risk, antibiotics are often not needed after the drainage. If your infection is more complex, your surgeon may prescribe a course of antibiotic tablets afterwards to help clear it fully. ## After the operation You will wake up in the recovery area, where nurses stay with you while the anaesthetic wears off. Your finger will have a dressing on it, and you may have some numbness if a nerve block was used. Pain relief will be arranged so you stay comfortable. You can move around as soon as you feel steady, and you will use your hand gently within the limits of the dressing. Someone should stay with you for the first 24 hours after you get home. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery The throbbing pain that brought you in usually settles quickly once the pus has been drained. The finger will still be tender and swollen for a while, and the skin beside the nail may look red as it heals. Keeping your hand raised on a pillow when you rest helps the swelling go down. The pain relief we arrange for you will keep you comfortable while this settles. You will go home with the dressing on, and we leave it in place for about 10 days. Please do not take it off yourself; we change or remove it when we see you. Until then, use your hand gently within the limits of the dressing. Keep it clean and dry. You can do most light daily tasks at home, but avoid soaking the finger and avoid anything that bumps or squeezes the healing nail fold. Once the dressing comes off, the aim is to get the finger moving and working normally again. Your rehabilitation after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she will guide your exercises and make any splint you need. She may show you gentle stretching and strengthening so the finger does not stiffen while it heals. As the swelling settles and movement returns, you can gradually do more with the hand. Once you can grip and pinch without pain, most everyday activities feel normal again. Recovery varies from person to person. Your timeline may differ, and your surgeon and therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The main concern with this infection is that it keeps going or comes back. If the swelling, redness and tenderness beside your nail do not settle, or they get worse after treatment, the infection can dig deeper. In time it can wear its way down into the small joint of the finger. You might notice pain that feels deeper than before, a finger that will not bend without sharp pain, or a joint that looks swollen and feels hot. If you notice any of these, call the clinic rather than waiting for your next visit. Poor healing and slow seeking of care make this more likely. If the wound is not settling the way you expected, or you have put off getting treatment, mention it at your next review so we can look at it properly. Keeping the finger clean matters while it heals. Good hand hygiene helps the skin recover and lowers the chance of the infection flaring up again. If you are unsure how to care for the finger once the dressing comes off, ask us at your review and we will show you. Some nail infections are caused by the cold sore virus rather than bacteria, and these can sometimes hold a pocket of pus as well. If that is what you have, drainage is still the treatment. You may worry the virus will return later or cause lasting trouble in the finger. In cases like this, people followed over the long term have had no return of the virus and no lasting problems from the drainage itself. If you notice new blisters or small tender spots near the nail after you have healed, bring it up at your review. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if you get a fever, if the redness or discharge from the finger gets worse, or if the pain suddenly becomes severe. Go to emergency if you have calf swelling, shortness of breath, loss of feeling in the finger, or you cannot move it. These signs need checking straight away. If something about the finger worries you and it is outside clinic hours, go to your nearest emergency department rather than waiting. --- ### Phalangeal Fracture Fixation URL: https://www.cqupperlimb.com/education/hand/phalangeal-fracture-fixation/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Broken finger bones are a common hand injury, and some breaks settle well without an operation. Others are shifted out of place, twisted, angled, or… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Broken finger bones are a common hand injury, and some breaks settle well without an operation. Others are shifted out of place, twisted, angled, or unstable, and these usually need surgery so the bone can heal straight. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging if it is needed to work out what has been broken. Because this is an injury, the right treatment depends on the break itself. Some injuries heal without surgery, and others need an operation soon after they happen, so being seen promptly matters. When the bone ends are badly out of place or will not stay lined up on their own, surgery aims to hold the pieces steady while they heal. This lets you start moving your finger early, which can help you regain more finger movement. The goal is a finger that moves, grips, and looks close to the way it did before the injury. ## Before the operation Once your operation is booked, we will give you clear instructions to follow. You will need to stop eating and drinking seven hours before your operation. We ask for seven hours rather than a shorter time so your surgery can be brought forward if the theatre list runs early. Your surgeon will tell you which of your regular medicines to stop and when, so bring a written list of everything you take. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing on the day. If you have other medical conditions, you may need blood tests or a review with the anaesthetist before surgery. Most people need neither. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist before your operation. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. Afterwards, you wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves There are two ways your surgeon can do this operation, and the choice depends on your fracture. With a closed approach, the bone is lined up without opening the skin. The repair is then held with fine wires or a screw passed in through small puncture wounds. With an open approach, your surgeon makes a single cut over the broken bone so the pieces can be seen and fitted back together. This is used when the break goes into a joint, breaks into several pieces, or will not line up on its own. The aim is the same either way: to put the bone back in its normal position and hold it there while it heals. Your surgeon may use one of several ways to hold the bone, chosen to suit the shape and position of the break. Fine wires can be passed across the bone. A small screw can be placed down the inside of the bone, which is called an intramedullary screw, for some shaft and neck fractures. Small screws can be placed across a long oblique or spiral break, where the bone has snapped at an angle or twisted apart. Or a small plate with screws can be used to hold the pieces steady. If wires are left sticking out through the skin, they are usually removed in the clinic after a few weeks, once the bone is stable. Screws and plates that sit under the skin are usually left in place unless they cause a problem. The wound is closed with stitches. You will go home with a dressing on your hand, and your surgeon will tell you when it comes off. ## After the operation You will wake up in the recovery area, where nurses watch you as the anaesthetic wears off. Your hand will be in a dressing and a splint made by the hand therapist. If you had a nerve block, your fingers may feel numb or heavy for about 24 hours. This is expected. Once it wears off, call the clinic if you have numbness or cannot move your fingers. Pain relief will be arranged before you go home. Someone should stay with you for the first 24 hours. You may go home the same day or stay one night in hospital after this operation. Both are common, and your team will talk with you about which suits you. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Your finger will be sore and swollen for the first days and weeks. This is normal. Keeping your hand raised on a pillow, even while you sleep, helps the swelling settle. The pain relief you go home with eases the discomfort, and it usually improves steadily as the days pass. Your hand will be in a splint made by your hand therapist, Ruby Doolan at Extend Rehabilitation, who will also direct your hand therapy. You should not drive while the splint is on, because it stops you gripping the steering wheel safely. Once the splint is off and your surgeon clears you, see our page on driving after upper-limb surgery. Early on, you can manage light daily tasks around the home within what your splint and comfort allow. Hand therapy starts soon after surgery. Your therapist will show you gentle exercises to keep your fingers moving as the bone heals. Moving early matters, because fingers that stay still while a fracture heals can become stiff, and scar tissue can glue the moving parts of the finger together. Doing your exercises little and often is more useful than one long session. As the swelling settles and movement returns, you will notice your grip getting stronger. Once you can grip without pain, heavier tasks and sport become possible again, and your therapist will guide the steps up to that point. Recovery varies between people, so your timeline may differ from someone else's. Your surgeon and your hand therapist will guide you at each review. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The commonest problem after a broken finger is stiffness. The finger may not bend or straighten as far as it used to, and it can feel tight or slow to warm up in the morning. Doing your hand therapy exercises little and often is the best way to limit this, so tell your therapist if the finger feels stiffer rather than looser week by week. Infection can happen around the wound or where a wire comes out through the skin. Watch for redness that spreads out from the wound, fluid or pus leaking from it, or fever. Call the clinic the same day if you notice any of these. Pain that keeps getting worse despite your pain medicines also needs a same-day call. Sometimes the metalwork shifts or fails before the bone has healed. You might feel a clunk, notice the finger looking angled or shortened, or feel pain returning where it had settled. Bring this up at your next review, or call the clinic if it comes on suddenly. A screw or plate that sits close to a tendon can rub or catch. You may notice clicking, catching, or a grating feeling as the finger moves, or the tendon may not glide smoothly. Mention this at your review so it can be checked. If a wire works loose, the finger can feel sore at the wire site and the bone may drift out of place. Tell the clinic if a wire looks bent, moves, or the finger changes shape. Rarely, problems with healing mean the bone does not join. The finger stays painful and tender at the break site long after you expected it to settle. Raise this at your review. If you cannot reach the clinic out of hours or on a weekend, go to your nearest emergency department. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems give warning signs you can spot at home. Call the clinic the same day if you have a fever, redness spreading around the wound, or fluid or pus leaking from it. Call us too if pain keeps getting worse despite your pain medicines. Go to the emergency department if your calf becomes swollen or painful, if you become short of breath, or if your fingers turn pale, cold, white, blue or dark. These can be signs of a blood clot or a problem with blood flow to the finger. Once the nerve block has worn off, after about 24 hours, call the clinic if your fingers stay numb or you cannot move them. Numbness in the first 24 hours is expected and is not a worry. If you cannot reach us out of hours or on a weekend, go to your nearest emergency department. --- ### PIP Joint Fracture-Dislocation URL: https://www.cqupperlimb.com/education/hand/pip-fracture-dislocation/ Region: hand · condition A PIP joint is the middle knuckle of your finger. A fracture-dislocation here means the knuckle has broken and the joint surfaces have slipped out of line. It usually happens when a ball or a fall forces the finger backwards or twists it while the finger is bent. You may feel… ## What you're feeling A PIP joint is the middle knuckle of your finger. A fracture-dislocation here means the knuckle has broken and the joint surfaces have slipped out of line. It usually happens when a ball or a fall forces the finger backwards or twists it while the finger is bent. You may feel or hear a pop at the moment of injury. Straight away, the middle knuckle will be painful and swollen. The swelling is often mild to moderate at first. The finger may look crooked or twisted, and it may sit out of line with its neighbours. You will probably not want to bend or straighten it. Everyday things get hard fast: turning a key, doing up buttons, holding a cup, typing. It is easy to assume this is just a jammed finger that will get better on its own, because most jammed fingers do. This injury is different. The broken piece of bone and the slipped joint need to be lined up early. If the joint stays out of line, the finger can stiffen into a fixed bent position, and getting the finger straight and moving again later becomes much harder. That is why this injury needs a proper check rather than waiting it out. In the first days and weeks, the knuckle will hurt when you try to move it, and it may ache at night. The swelling and pain should gradually settle as healing starts. Your surgeon will also check the joints further along the finger, because the same fall can injure the end knuckle too. Some warning signs need urgent care. Go to the emergency department the same day if your finger or hand turns pale, cold, white or blue, or if you suddenly lose feeling or movement in it after the injury. Go the same day if the skin over the injury is broken, if bone is showing, or if the finger looks clearly deformed. If your finger or hand becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. ## What's actually happening Your middle knuckle is where three things meet: the end of the finger bone nearest your palm, the base of the next bone along, and a soft cushion of tissue that stops the joint bending backwards. In this injury, the joint surfaces have slipped out of place and a piece of that second bone has broken off. Some of the soft tissue holding the joint together has torn as well. Think of the joint like a hinge held steady by a strap underneath and two straps at the sides. When the finger is forced backwards, the strap underneath tears away from the bone, and the side straps can tear too. The hinge then slides out of its groove. When a chunk of bone breaks off with the strap, the hinge has nothing solid to rest on, so it will not stay lined up on its own. The amount of broken bone matters a lot. If the break involves a small part of the joint surface, the joint can still be stable once it is lined up. If more of the surface is involved, the joint becomes unstable and will not hold its position without help. The size of the fragment, how far the joint has slipped, and which soft tissues are torn all shape what happens next. Healing works differently for each tissue. Broken bone knits back together with new bone over weeks. Torn soft tissue scars down to the bone it tore away from, but only if it is held in the right position while that happens. If the joint is left out of line, the healing tissue sets in the wrong place, and the joint surfaces grind instead of gliding. Over time that wearing can leave the knuckle painful and stiff for good. This is why getting the joint lined up early matters. Once the pieces are held where they belong, both bone and soft tissue have their chance to heal in a working position. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some of these injuries heal without an operation, and others need surgery soon after the injury, so prompt assessment matters. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a history, examine your finger, and arrange imaging where it is needed. The scan shows how much of the joint surface is involved and whether the joint stays in place when it moves. That decides which path suits you. If the break involves a small part of the joint surface and the joint is stable once lined up, we can often treat it without surgery. A splint holds the finger still while it heals. For some stable injuries, the splint sits on the back of the finger and stops the middle joint straightening fully while still letting it bend. Buddy taping, where the injured finger is taped to its neighbour, can also work for stable injuries and lets the finger keep moving early. We monitor healing with repeat imaging, and a hand therapist guides your return to movement at the right stage. If more of the joint surface is broken, or the joint will not stay in place on its own, we recommend surgery from the outset. The aim is to hold the broken pieces and the joint in a working position so you can start moving early. There are several ways to do this, from wires through the skin to plates and screws, and the choice depends on your injury pattern and your needs. This is a shared decision, and we will talk through what each option means for you. Whichever path you take, the first weeks look similar. Pain settles steadily as healing starts, and we will help you keep it comfortable. You protect the finger while the bone and soft tissue knit together. Hand therapy with Ruby Doolan at Extend Rehabilitation starts at the right stage, and Ruby makes any splint you need along the way. ## What to expect Healing starts as soon as the joint is lined up and held there. Broken bone knits together over weeks, and torn soft tissue needs those same weeks held still before it scars down. Pain and swelling settle steadily during this time, though the knuckle will stay tender for a while and may ache after you use your hand. The middle joint is naturally a stiff one after this kind of injury, and regaining bend takes months rather than days. Hand therapy with Ruby Doolan at Extend Rehabilitation starts at the right stage and guides your return to movement. Most people can manage light daily tasks early, such as writing, eating and typing, while heavier gripping and lifting come back later. When you can return to work depends on what your job involves, and sport waits until the joint is strong and moving well. Outcomes vary with the injury and with how quickly it is treated. If treatment is delayed and the joint has stiffened into a fixed bent position, the outlook for full movement is worse, and releasing the tight tissues may be needed. Surgery aims to let you move early, and holding the joint firmly in place makes that possible. Some people are left with stiffness, a finger that does not fully straighten, or ongoing pain. A small number need further surgery, and arthritis can develop in the joint over time. Watch the healing finger as you go. If your finger or hand becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. If symptoms are not settling, are getting worse over weeks, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone Seek urgent care if your finger looks clearly deformed, if the skin over the injury is broken, or if bone is showing. Go to the emergency department the same day if your finger or hand turns pale, cold, white or blue, or if you suddenly lose feeling or movement in it after the injury. The same applies if your finger or hand becomes hot, red, swollen and painful, especially with a fever. For everything else, see your GP first. Ask for a specialist review if the pain is not settling, or if the swelling, movement or use of your finger are not improving week on week as healing progresses. This injury is easy to dismiss as a jammed finger, but waiting it out can let the joint stiffen into a fixed bent position. The sooner the joint is lined up, the better the outlook for movement. --- ### PIP Joint Arthritis URL: https://www.cqupperlimb.com/education/hand/pipj-arthritis/ Region: hand · condition Osteoarthritis and inflammatory arthritis of the PIP joint — non-operative and surgical options. ## What you're feeling The joint at the middle of your finger (the one you bend when you make a fist) becomes painful, stiff and sometimes swollen. The pain is usually aching, felt at the front and the back of the joint. It often worsens when you move the finger, especially when you straighten it against resistance. Sometimes the ache travels up towards your knuckle. Pressing on the joint can be tender. Everyday tasks that pinch or grip become hard. Pinching with your thumb loads the index finger joint sideways, so buttons, keys and picking up small objects can hurt. The finger may drift or sit crooked, and it may not bend or straighten fully. Swelling and stiffness can last a long time, particularly if the joint was injured in the past, such as after a sprain or a dislocation. Symptoms do not always follow a steady path. Many people find their symptoms are fewer in the late stages of arthritis than they were early on. Pain, stiffness or a crooked finger that will not settle after three months or more of simple treatment is the point at which surgery is usually considered. If your finger, hand or arm becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. If your finger turns pale, cold, white or blue, or you suddenly lose feeling or movement after an injury, go to the emergency department the same day. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## What's actually happening Your finger has three bones in it, and the painful spot is the middle joint, called the PIP joint. It is a simple hinge. It bends and straightens in one direction only, like a door on well-oiled hinges. When healthy, the bone ends fit together snugly, which keeps the joint steady when your finger is straight. Covering each bone end is a smooth, slippery layer called cartilage. Think of it as the tread on a tyre, or the shock absorber between two bones. In arthritis, that layer wears away. The bone ends then grind on each other instead of gliding. The body responds by growing extra bone around the edges of the joint, and the joint lining thickens. That grinding and thickening is what produces the ache, the swelling and the grinding feeling you may notice. The joint is also wrapped in strong straps called ligaments, which hold the two bones in line, a bit like guy ropes on a tent. Arthritis and old injuries stretch and scar these straps. When they loosen, the finger can drift or sit crooked, and the joint can feel unstable. Stiffness follows, because the same wrapping of ligament and capsule tightens up when a painful joint is not moving. An old injury matters here. This joint is prone to lasting trouble after a sprain or dislocation. Injuries around it leave a poor result in about 30% of cases, with ongoing instability, pain, stiffness or a finger that will not fully straighten. Damage like this can also bring on arthritis earlier than wear alone would. There is one named pattern worth knowing. If the strap that straightens the middle joint weakens, the finger bends at the middle joint while the end joint bends backwards the other way. Doctors call this a boutonniere deformity. Early on, you can still straighten the finger yourself and function is barely affected. Later, the tightness sets in and the finger will not straighten even when someone else tries to move it for you. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your first visit we take a history, examine your finger and arrange X-rays if they are needed. For a long-standing problem like this, we usually try non-operative care first and consider surgery when that has not given enough improvement. The first steps are things you can do yourself. Changing how you use your hand, so you pinch and grip differently, takes load off the sore joint. Hand therapy aims to keep the joint moving and keep your grip working. A splint or a cast can hold the finger straighter; for some people, serial casting, where the cast is changed in stages, can correct a finger that has stiffened in a bent position. Give these measures at least 3 months before judging them. Pain tablets and anti-inflammatory medicine, taken as your GP advises, can settle the ache enough for you to keep using the hand. We do not use injections for this joint. If simple treatment has not helped after 3 months, and the X-ray shows arthritis together with ongoing pain, surgery becomes an option. The two main operations are replacing the joint with an implant, which keeps some movement, or fusing the joint, which removes pain by stopping it moving altogether. Which suits you depends on the joint itself: whether it is stable, which finger it is, and what you need your hand to do. We will talk through that choice with you. Before any operation, we check that the tendons around the joint are intact and that the joint still has some stability, because replacement needs both. A very crooked finger, one deviated more than 30 degrees to one side, is hard to correct with a replacement and is likely to fail. ## What to expect Arthritis of this joint does not usually go away on its own. The ache and stiffness tend to persist, and simple treatment eases them rather than cures them. Many people find their symptoms quieten down over the years, but the joint rarely returns to how it was before. Without treatment, the outlook depends on what is driving the problem. After an old injury such as a sprain or dislocation, a poor result is common: ongoing pain, stiffness, instability or a finger that will not fully straighten. A stiff, bent finger can sometimes be corrected with splinting or serial casting, where the cast is changed in stages. Keeping the joint moving matters, because a painful joint that is not used stiffens further. With treatment, most people get enough relief to keep using their hand. Non-operative care, given a fair trial of at least 3 months, settles symptoms for many people. Where surgery is needed, both options have a realistic pattern of results. Replacing the joint relieves pain and keeps some movement, but the movement can lessen over time, and further operations are common after joint replacement in this joint. Fusing the joint removes the pain reliably, at the cost of all movement in that finger. If a replacement fails, the usual salvage is fusing the joint. Recovery is gradual rather than quick. Regaining comfortable motion and grip after an injury or surgery to this joint is genuinely difficult, and progress is measured in months. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation; she directs your therapy and makes any splint you need. Some people find that better straightening of the finger does not translate into the easier function they hoped for, which is worth knowing before treatment starts. ## When to see someone See your GP or ask for a specialist review if your finger is painful, stiff or crooked and has not settled after 3 months or more of simple treatment such as hand therapy, splinting or medicine. Ask sooner if the symptoms are getting worse over weeks, wake you at night, or stop you working or using your hand. Seek review promptly after a sprain or dislocation of this joint, because swelling, stiffness and loss of function can last a long time, and a fracture-dislocation can develop a fixed deformity quickly. Go to the emergency department the same day if your finger, hand or arm becomes hot, red, swollen and painful, especially with a fever. Go the same day if your finger turns pale, cold, white or blue, or you suddenly lose feeling or movement after an injury. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Arthritis of the middle finger joint is worth the extra reading because the choice between fusing it and replacing it is decided by something most people would not think to ask about, whether the joint is stable, and because which finger it is matters as much as what the X-ray shows. ### Stability, not severity, chooses the operation Two operations are available. Fusion sets the joint permanently in a chosen position, reliably removing pain at the cost of all movement. Replacement preserves movement. The comparison across 1,868 patients defines when each is appropriate. Silicone implants remain a valuable option for stable joints, while surface-replacing implants might be better for unstable or deviated joints, although they carry a higher risk of reoperation [1]. The important variable there is stability. A silicone implant is a flexible spacer rather than a hinge; it works by sitting between the bone ends and allowing them to move around it, which requires the surrounding ligaments to provide the stability. Where those ligaments have failed and the joint deviates sideways, a spacer has nothing to work against, hence the move to a surface-replacing design, and hence the higher reoperation rate that comes with a more constrained implant. ### Which finger it is changes the recommendation This is the part rarely explained. The index finger takes a large sideways force in pinch, pressing against the thumb, and that force is exactly what a replaced joint tolerates least. The ring and little fingers are used mainly for grip, where the loads run along the finger rather than across it. The practical consequence is that replacement is generally better suited to the ulnar fingers, and fusion is often preferred at the index, where a stable post to pinch against is worth more than movement. Two identical-looking joints on an X-ray can therefore attract different recommendations based only on their position in the hand. ### Fusion is reliable, and the technique matters less than expected Where fusion is chosen, the technique debate is modest. Across 1,923 patients, all described techniques can achieve the goal of fusing an osteoarthritic joint, with a trend in more recent literature towards compression techniques [2]. Comparing techniques directly across 286 patients, they had similar fusion time, nonunion and complication rates, with screw arthrodesis showing a lower nonunion rate than wire fusion, though the data carry significant limitations [3]. ### Where the joint has been destroyed by injury rather than wear A fracture through the base of the middle bone destroys the joint surface directly. Where more than half the surface is involved, one option is to rebuild it with a graft taken from the hamate bone in the wrist, whose contour resembles the lost joint surface. Hemi-hamate autograft can be considered reliable for acute and chronic fracture-dislocations with joint involvement greater than 50%, though longer-term follow-up is required, particularly to establish the rate of later arthritis [4]. A separate review of 235 patients found it affords symptomatic relief and functional restoration [5]. That outstanding question about later arthritis is the honest caveat: the graft restores the shape of the joint, and whether a reconstructed surface wears at the same rate as a native one is not yet answered. --- ### PIP Joint Fusion URL: https://www.cqupperlimb.com/education/hand/pipj-fusion/ Region: hand · operation PIP joint fusion stabilizes a severely damaged middle finger joint, relieving pain when other treatments fail. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging if it is needed to work out what is wrong. This operation is a fusion of the middle joint of your finger. The two bones forming that joint are joined together so they heal as one, and the joint no longer moves. We usually suggest it when the joint is painful, stiff or deformed, and when simpler care such as activity change, physiotherapy or hand therapy, and splinting has not given you enough improvement. For some injuries or structural problems, surgery may be recommended straight away. The aim is to restore hand function by taking away the pain and holding the joint steady. ## Before the operation In the weeks before surgery we confirm the plan with fresh images of your finger, such as an X-ray, and sometimes an MRI or ultrasound scan. These show the surgeon what the joint looks like and help plan the fusion angle. Most people need nothing more than that. If you have other medical conditions, you may also need blood tests or a review with the anaesthetist, but this is not routine. In the days before your operation we will tell you which of your usual medicines to stop and when. Do not eat or drink for seven hours before surgery; we ask for a little extra time so your slot can be brought forward if the theatre list runs early. Arrange a lift home, as you will not be able to drive yourself. Bring a written list of your current medicines and wear loose, comfortable clothing. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist there. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. You wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves Your surgeon makes a single cut over the middle joint of your finger. Through this cut, the joint is opened up and the worn, damaged surfaces of the two bones are prepared so they can grow together. The bone ends are shaped to fit against each other, and the finger is set at a bent position that lets your hand work well for gripping and pinching. The bones are then held together while they heal. Your surgeon uses small metal implants, such as wires or screws, to keep the two bones still and in the right position. This holding is what allows the joint to fuse into one solid bone. Once the bones are lined up and fixed, the wound is closed with stitches and covered with a dressing. The aim of all this is simple: the painful, moving joint is taken away and replaced with a steady, pain-free connection between the two bones. Because the joint no longer moves, the finger will be stiffer than before, but it should no longer catch or hurt with use. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You wake up in the recovery ward, where nurses keep an eye on you while the anaesthetic wears off. Your hand will be dressed and may be supported with a splint, and we will give you pain relief to keep you comfortable. You can get up and move around as soon as you feel steady. Please arrange for someone to stay with you for the first 24 hours. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Your finger will be sore and swollen for the first days and weeks. This is normal and settles gradually. Keeping your hand raised on a pillow, even while you sleep, helps bring the swelling down. The pain relief we give you keeps you comfortable while this happens. You will wear a splint on your finger to protect it while the bones heal. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she directs your exercises and makes any splint you need. Your therapy will focus on keeping the rest of your hand and fingers moving, so your grip and pinch stay strong while the fused joint settles. You can do most light daily activities at home straight away, using your other hand to help. Avoid heavy lifting, gripping hard, or anything that puts strain on the healing finger until we clear you. Once the dressing comes off and the wound has healed, you can use your hand more freely for everyday tasks. Driving is not safe while the splint stops you gripping the wheel properly. Once the splint comes off and your surgeon clears you, see our page on Driving after upper-limb surgery. Recovery varies from person to person. Your timeline may differ, and your surgeon and therapist will guide you at each review. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The main risk with a fusion is that the two bones fail to join. If that happens, the finger may stay painful, and you might feel a click or movement where there should be none. Tell us at your next review if the pain does not settle as expected. The metal implants holding the bones can also cause trouble. A wire or screw can work loose, break, or press on the skin. You might notice a sharp edge under the skin, or the finger looking out of line. Bring this up at your review so we can check it. Infection is uncommon but needs fast attention. Watch for a deep, throbbing pain that does not ease with simple painkillers, redness spreading out from the wound, or fluid leaking from it. You may feel hot and generally unwell. If you see any of these signs, call the clinic straight away. If it is after hours or the redness is spreading quickly, go to the emergency department. Infection can also reach a finger joint from a cut or puncture wound to the finger, from a nearby skin infection, or through the bloodstream from elsewhere in the body. Signs of infection in a small hand joint often start within days of the injury. See your GP promptly if a finger becomes hot, swollen and painful after a knock or wound, so it can be treated early. Stiffness and ongoing pain can happen even when the fusion heals well. If your finger stays very stiff or painful after the expected recovery period, we will assess it and discuss what can be done. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us straight away if you have a fever, if the skin around your wound becomes more red or starts leaking fluid, or if you have sudden severe pain that simple painkillers do not settle. Go to the emergency department if you have calf swelling or pain, or shortness of breath, as these can signal a blood clot. Also go to emergency if your fingers go numb, lose colour, or you cannot move them at all. If it is after hours and you are worried, go to emergency rather than waiting for the clinic to open. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the PIP Joint Arthritis page. --- ### PIP Joint Replacement URL: https://www.cqupperlimb.com/education/hand/pipj-replacement/ Region: hand · operation PIP joint replacement addresses painful arthritis in the middle finger joint when non-surgical options fail. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging if it is needed. That tells us what is wrong with the joint. This operation replaces the middle joint of a finger with an artificial implant. It is usually offered to people with wear-and-tear arthritis or arthritis after an injury, most often in older, less active patients. The aim is to keep the joint moving and to avoid fusing it, which means joining the bones together permanently. We usually try non-operative care first for long-standing arthritis. That can mean changing how you use your hand, hand therapy, or splinting. If those have not given enough improvement, we then discuss surgery with you. The main goals are pain relief and a joint you can use. ## Before the operation To plan your operation we take X-rays of your finger, and sometimes an MRI or ultrasound scan as well. These pictures show the worn joint and help us choose the right implant. In the weeks before surgery, prepare a few practical things. Stop eating and drinking for seven hours before your operation. We ask for seven hours rather than six so your time can be brought forward if the theatre list runs early. Your surgeon will tell you which of your regular medicines to stop and when. Bring a written list of everything you take. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing with sleeves that slide easily over your hand. If you have other medical conditions, you may need blood tests or a review with the anaesthetist (the doctor who gives the anaesthetic). Most people do not need either. ## On the day You arrive at the hospital's surgical admissions unit. Staff check you in and prepare you for theatre. You then meet the anaesthetist. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. Next you are taken into the operating theatre, where the operation is performed. When it is finished, you wake up in the recovery area. Nurses watch over you there while the anaesthetic wears off. Once you are stable, you either move to a ward or go home the same day. Which of these happens depends on the procedure and on how your recovery is going. ## What the operation involves Dr Hirpara performs this operation through a single cut on the palm side of your finger, over the sore joint itself. Opening the joint from this side keeps the tendon that straightens your finger undisturbed, which helps you start moving soon after surgery. Once the joint is open, your surgeon takes out the worn and damaged joint surfaces. These are replaced with an artificial implant that forms a new, smooth surface between the two finger bones. The implant is designed to let the joint bend and straighten while easing the pain that the rough, worn surfaces were causing. The wound is then closed with stitches, and a dressing is placed over the top. You will go home with that dressing in place, and we will review the wound with you when it comes off after about 10 days. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You wake up in the recovery area, then move to the ward. Nurses check on you regularly and give you pain relief as needed. Your finger will be in a dressing, and we leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. You can get up and move around as soon as you feel able, and the nurses will help you. Please have someone stay with you for the first 24 hours after you get home. ## Recovery For the first few days your finger will be sore and swollen. This settles gradually. Keeping your hand raised on a pillow, even while you sit or sleep, helps bring the swelling down. Simple pain relief as directed by your team will ease the discomfort. Your dressing stays on for about 10 days, and we will check the wound when we see you. After that, your recovery is guided by hand therapy with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she directs your exercises and makes any splint your finger needs. You will do gentle bending and straightening movements at home, little and often. The aim is to protect the healing tendon while the joint slowly regains its motion, so follow the plan she gives you rather than pushing through pain. Day to day, you will use your other hand for most tasks at first. You can get dressed, prepare simple meals and move around the house as soon as you feel able. You will not drive while your finger is in a splint if it stops you gripping the wheel safely. Once the splint comes off and your surgeon clears you, driving can resume; see our page on driving after upper-limb surgery. As the swelling settles and movement returns, you will notice the joint bending further and doing more for you. Milestones are anchored on events like these, not on dates. Everyone heals at their own pace, so your timeline may differ. Your surgeon and your hand therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the implant itself causes trouble. It can loosen, or a small crack can appear in the bone around it. You might notice new pain in the joint, a feeling that the finger is less steady than before, or a clicking or grinding sensation when you move it. The lining of the joint can also become irritated and swollen. If the joint starts to drift out of line again, or the finger will not bend or straighten as far as it used to, bring it up at your next review. These changes are worth checking even when they are painless. The implant can break. With a silicone implant (a soft, flexible spacer), a broken implant often causes pain that returns after a period of improvement. If your finger becomes painful again, or movement stays restricted with or without pain, tell us. Sometimes the finger develops a sideways lean that was not there before. Any of these changes means the implant should be assessed. The joint can become unstable. The finger may feel wobbly from side to side, or it may slip partly out of place. A joint that sits visibly out of line needs prompt attention, so call the clinic rather than waiting for your next appointment. Stiffness can develop. The finger may not bend or straighten fully, and the joint can feel tight. Persistent stiffness with pain should be reviewed. Infection is uncommon but serious. Watch for a deep, throbbing pain that does not ease with simple painkillers, redness that spreads out from the wound, warmth, or discharge. If you notice these signs, contact the clinic straight away, or go to the emergency department if it is after hours. Fractures around the implant can happen during or after surgery. Sudden pain, swelling or a change in the shape of the finger afterwards should be reported. If a problem does develop, further surgery is sometimes needed. This can mean fixing or replacing the implant, or in some cases joining the bones together permanently instead. If that becomes necessary, we will talk you through it. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up in the ways we described above, but a few need urgent attention. Call us straight away if you have a fever, if the redness around your wound is spreading, or if there is new discharge from it. Call us if you have sudden severe pain, or if your finger becomes numb or you cannot move it. Go to the emergency department if you have calf swelling or pain, or shortness of breath, as these can signal a blood clot. If it is after hours and you are worried, go to emergency rather than waiting until morning. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the PIP Joint Arthritis page. --- ### Pregnancy and Hand Conditions URL: https://www.cqupperlimb.com/education/hand/pregnancy-and-hand-conditions/ Region: hand · condition Carpal tunnel in pregnancy and de Quervains "mummy thumb" — why they happen, what is safe, and when they settle. Aches, pins-and-needles and a sore thumb are remarkably common in pregnancy and in the first months of looking after a new baby. They can be miserable at a time when your hands are busier than they have ever been, but the reassuring news is that almost all of these problems are temporary, driven by the changes of pregnancy and early motherhood, and the great majority settle on their own with simple measures and time. Surgery is rarely needed. This page explains the two conditions we see most often, and the simple things that help. It is a companion to our pages on carpal tunnel and nerve compression and de Quervain's tenosynovitis, and on numbness and tingling in the hand and arm; here we focus on what is different when these problems come along with pregnancy and a new baby. ## Why the hands get sore in pregnancy Pregnancy changes the body in ways that fall hard on small structures in the wrist. You carry more fluid in your tissues, and hormonal shifts soften and swell the linings around tendons and nerves. The wrist is a crowded place (nerves and tendons run through tight tunnels there), so even a little extra swelling can press on something that was perfectly comfortable before. Add the brand-new, repetitive job of lifting and feeding a baby, and it is easy to see why hands and wrists complain. The key thing to hold on to is that the cause is usually passing: as the fluid and hormone changes of pregnancy resolve after birth, and as your body recovers, the pressure comes off and symptoms tend to fade. ## Carpal tunnel syndrome in pregnancy The carpal tunnel is a narrow channel at the front of the wrist that carries the median nerve to the hand. In pregnancy, fluid retention swells the tissues inside that tunnel and squeezes the nerve. The result is numbness and tingling in the thumb, index and middle fingers (and half the ring finger), often described as pins-and-needles, and classically worst at night, sometimes waking you to shake the hand out. Some women notice it most in the last few months of pregnancy. The encouraging part is how it behaves after delivery: for most women the symptoms ease within weeks of the birth, once the extra fluid clears. Because of that, treatment in pregnancy is almost always simple and aimed at getting you comfortable while nature takes its course: - Night wrist splints are the mainstay. A splint that holds the wrist straight keeps the tunnel as open as possible while you sleep and is often the single most helpful thing. - Activity adjustments: easing off positions and tasks that bend the wrist for long periods, and taking breaks. - Hand therapy for advice on splinting, posture and gentle techniques. - A steroid injection into the carpal tunnel is occasionally used if symptoms are severe and not settling, to buy comfort until after delivery. Surgery is rarely needed during pregnancy, precisely because the problem so often resolves once the baby arrives. ## De Quervain's tenosynovitis ("mummy thumb") De Quervain's tenosynovitis is a painful swelling of the tendons on the thumb side of the wrist, where they pass through a tight tunnel near the wrist bone. The pain sits over the thumb-side of the wrist and is brought on by gripping, lifting and turning the wrist, and it often radiates a little into the thumb and forearm. It earns its nickname "mummy thumb" because it is so strongly linked to the repeated lifting and scooping of a baby, loading the wrists dozens of times a day, often in awkward positions, when you pick up, carry and feed an infant. Hormonal changes around pregnancy and breastfeeding play a part too. Unlike carpal tunnel, which often peaks before birth, de Quervain's commonly appears or worsens after delivery, during the months of caring for a newborn. It usually settles, and the treatment is again largely simple: - A thumb (spica) splint that supports the thumb and wrist while leaving the thumb tip free: this rests the irritated tendons and is the cornerstone of treatment. - Changing how you lift the baby: scooping from underneath with the wrist kept straight and the forearms doing the work, rather than gripping with thumb and wrist outstretched. A hand therapist can show you simple technique changes that make a real difference. - Where pain is stubborn, a steroid injection into the affected tendon tunnel works well and is often curative. Many cases ease as the demands of the early months pass, and in breastfeeding mothers the condition frequently settles once breastfeeding has finished. ## Other aches that can come and go A few other hand and wrist niggles can show up around this time, all common and usually temporary: - General wrist and hand aching and swelling, from the same fluid retention, which tends to be worse later in the day and eases after birth. - Trigger finger: a finger or thumb that catches, clicks or locks as it bends, from swelling around a tendon. It can appear in pregnancy or the postpartum months and often settles, with a splint, hand therapy or, if needed, a steroid injection. ## What's safe in pregnancy and breastfeeding A common worry is whether anything can safely be done while pregnant or nursing. The good news is that the first-line treatments are also the safest ones: - Splints, hand therapy and activity changes carry no risk to you or your baby and are where we almost always start. They are often all that is needed. - Steroid injections and surgery are held in reserve for the minority of cases that don't settle, and are discussed with you individually, weighing the timing against your pregnancy or breastfeeding so that any decision is made with full information and is right for your situation. Because so many of these conditions resolve on their own after birth, the usual plan is to keep you comfortable with the gentle measures and let time do the rest. ## When to see someone Please get in touch with us, or see your GP, midwife or our team, if: - The numbness or tingling becomes severe or constant, rather than coming and going at night. - You notice weakness in the hand, a weak grip, or wasting (thinning) of the muscle at the base of the thumb: these can be signs that a nerve needs more attention. - Symptoms are not settling in the months after your baby is born, when you would expect them to be improving. - The pain or weakness is affecting your ability to care for your baby (feeding, lifting or carrying) and simple measures aren't keeping up. Reaching out early means we can fit a proper splint, arrange hand therapy and, if it's ever needed, talk through the small number of other options, so that a common and usually short-lived problem doesn't get in the way of enjoying your new baby. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Hand conditions in pregnancy are worth the extra reading because the association is real and now quantified in very large numbers, and because one modifiable factor stands out as raising the risk of both of the common problems. ### Pregnancy is a genuine risk factor, not a coincidence of timing Carpal tunnel syndrome and de Quervain's tenosynovitis both cluster around pregnancy and the months after it, and it is easy to attribute that to the demands of caring for a newborn. A study of 715,337 patients establishes it more firmly: pregnancy is a significant risk factor for hand conditions, associated with increased odds of de Quervain tenosynovitis [1]. That scale matters because it separates an association from an impression. The fluid retention and hormonal changes of pregnancy plausibly raise pressure inside the carpal tunnel and swell tendon sheaths, and lifting a growing infant loads the thumb repeatedly. The data confirm the pattern without needing to settle the mechanism. ### Gestational diabetes raises the risk of both The same dataset identifies gestational diabetes as a significant risk factor for both carpal tunnel syndrome and de Quervain tenosynovitis [1]. This is the most useful item here, because it links a hand problem to something already being monitored in pregnancy. It also fits what is known outside pregnancy: diabetes is an established risk factor for both conditions, and the connective tissue changes that drive that appear to operate over a shorter timescale than expected. ### Which pregnancies carry the higher risk of de Quervain's For postpartum de Quervain's specifically, the gestational risk factors identified were first pregnancy and a long pregnancy of more than 40 weeks. Notably, the child's birthweight and the number of babies were not shown to increase risk [2]. The two negative findings are as informative as the positive ones. A heavier baby does not predict it, and twins do not predict it, which argues against a simple "more lifting causes it" explanation and points back towards the hormonal environment. First pregnancy may reflect unfamiliarity with handling technique, or simply that the condition, once experienced, changes how someone lifts subsequently. ### What the evidence does not yet provide Treatment guidance is where the literature thins out considerably. A review of carpal tunnel syndrome in pregnancy found reported prevalence varying substantially with the diagnostic criteria and study design used, and, importantly, a paucity of high-quality evidence addressing optimal treatment strategies during and after pregnancy, with the authors calling for well-designed trials [3]. So the risk is well established and the treatment pathway is not. In practice this supports a conservative approach through pregnancy and the early postpartum period, because many cases settle as the physiological changes reverse, but it should be understood as reasoning from natural history rather than from trial evidence. Two practical consequences follow. Symptoms persisting well beyond the postpartum months are less likely to resolve on their own and deserve reassessment rather than continued waiting. And because these conditions are common, real and time-limited in most people, they are worth mentioning at routine antenatal or postnatal review rather than tolerated silently as an inevitable part of new parenthood. --- ### Infected Flexor Sheath (Pyogenic Flexor Tenosynovitis) URL: https://www.cqupperlimb.com/education/hand/pyogenic-flexor-tenosynovitis/ Region: hand · condition An infected flexor sheath is an infection in the tunnel that a finger's bending tendon slides through. The whole finger often swells evenly, along its full length, rather than in one sore spot. The finger may sit slightly bent and be hard to straighten. Straightening it, or… ## What you're feeling An infected flexor sheath is an infection in the tunnel that a finger's bending tendon slides through. The whole finger often swells evenly, along its full length, rather than in one sore spot. The finger may sit slightly bent and be hard to straighten. Straightening it, or someone gently straightening it for you, usually hurts the most, especially near the base of the finger where the swelling can show. The pain sits along the line of the tendon, from the base of the finger down towards the palm, rather than over one joint. It tends to be there all the time and worsens when the finger is pushed straight. Bending the finger a little often eases it, which is why the finger curls up. The swelling and pain can make everyday tasks difficult: gripping a kettle, turning a key, doing up buttons, holding a pen or holding a handrail. This infection can move quickly, and it is one that should not wait. If your finger or hand becomes hot, red, swollen and painful, especially with a fever, go to an emergency department the same day. You do not need a GP referral first. The same applies if your finger turns pale, cold, white or blue, or if you suddenly lose feeling or movement in it. ## What's actually happening Along the underside of each finger runs a bending tendon, a strong cord that pulls the fingertip towards the palm. That tendon slides inside a closed tunnel called the flexor sheath. The tunnel is lined with a slippery layer that keeps the tendon fed, lubricated and gliding freely, a bit like a cable running through a greased sleeve. When bacteria get inside that sleeve, usually through a cut, a puncture or a bite, the closed space fills with pus. Because the sleeve is sealed, the pus sits under pressure against the very surface the tendon needs to glide on. The pressure squeezes the tendon's blood supply and starts scarring between the tendon and its lining. That is why the whole finger swells evenly, why it curls up, and why straightening it hurts so much: every part of the tunnel is inflamed at once. The infection can travel. The thumb's tunnel connects to a fluid space in the palm called the radial bursa, and the little finger's connects to one called the ulnar bursa. In many people these spaces run right up towards the wrist, so infection in one finger can spread towards the palm or even across to the thumb or little finger, forming what is called a horseshoe abscess. The stakes come down to timing. The tendon depends on gliding, and pus trapped against it does lasting damage the longer it sits. Treated early, most fingers recover well. Left too long, the tendon itself can die, the finger can scar stiff, and in severe cases the finger can be lost. Even with prompt antibiotics and surgery, some stiffness in the finger afterwards is common, because the healing tissue tends to grip rather than glide. Your surgeon will check how far the infection has spread before deciding how urgently to drain it. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, treats an infected flexor sheath as an emergency and starts treatment straight away. This infection does not wait, and neither should you. The aim is to clear the infection before it damages the tendon that lets your finger bend. The first step is antibiotics given through a drip in your arm. Antibiotics work with the drainage, not instead of it. Because the sheath is a sealed tunnel, antibiotics alone often cannot clear the infection on their own. Draining the pus takes the pressure off the tendon and lets the antibiotics reach the whole area. Most cases need surgery to drain the sheath. We make small incisions, small cuts in the skin, so we can open the tunnel and wash the pus out. Washing the sheath out promptly protects the gliding surface your tendon needs. The exact timing and type of surgery depend on how far the infection has spread and how early you arrive. After surgery, your finger may need a splint to rest it. Your hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she guides your exercises and makes any splint you need. Her focus is getting the tendon gliding again, because scarring between the tendon and its lining is what limits movement later. Some infections come from unusual germs, such as mycobacteria or fungi, which need specific antibiotic or antifungal treatment over a longer course. If the infection has badly damaged the tendon, rebuilding it is a separate operation that can be done once the infection has fully settled. The outlook depends heavily on timing. Coming in early is the one thing that most protects your finger, so if your finger is hot, red, swollen and painful, especially with a fever, go to an emergency department the same day. ## What to expect The outlook for an infected flexor sheath depends mostly on how quickly it is treated. Coming in early gives your finger the best chance of bending normally again. Waiting lets the pus sit under pressure against the tendon, and that pressure does damage that cannot be undone later. With prompt treatment, most fingers settle and start to move again over the following weeks and months. Even so, some stiffness afterwards is common, even in otherwise healthy people who had antibiotics and surgery quickly. The healing tissue tends to grip rather than glide, so the finger may not bend or straighten as freely as it did before. Hand therapy works on this, but it takes time and steady effort. If the infection is severe or left too long, the outlook is harder. The tunnel around the tendon can be destroyed, and scarring can leave the finger permanently stiff. In some cases the swelling becomes so severe that it squeezes the blood supply to the finger itself, a problem called compartment syndrome. In the most severe infections, the finger can die and need amputation, even when treatment was timely and thorough. A few less common things can also happen. Sometimes the infection does not fully clear and needs a second washout. Rarely, an unusual germ can appear in the finger weeks after treatment and need further care. The one thing you can control is timing. If your finger or hand becomes hot, red, swollen and painful, especially with a fever, go to an emergency department the same day. You do not need a GP referral first. The same applies if your finger turns pale, cold, white or blue, or if you suddenly lose feeling or movement in it. ## When to see someone This infection is an emergency, and it moves fast. Go to an emergency department the same day if your finger or hand becomes hot, red, swollen and painful, especially with a fever. The same applies if your finger turns pale, cold, white or blue, or if you suddenly lose feeling or movement in it. You do not need a GP referral first. If you cannot reach the clinic, for example out of hours or on a weekend, go to your nearest emergency department. The warning signs follow the shape of the infection: the whole finger swells evenly, it sits bent, it hurts along the line of the tendon, and straightening it is very painful. You do not need all of these signs before getting checked. A finger that shows only some of them can still have this infection. See your GP or ask for a specialist review if symptoms are not settling, are getting worse over weeks, or stop you using the hand. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. An infected flexor sheath is worth the extra reading because it is the one hand infection that is a genuine emergency, and because two of the things that most determine how it ends were decided before you reached hospital — one of them years before. ### The diagnosis rests on four signs from the 1930s that have never been properly tested Allen Kanavel described four signs of an infected flexor sheath: a finger swollen along its whole length rather than in one spot, held slightly bent, tender all the way along the tendon sheath rather than over one joint, and, the most useful of the four, severe pain when someone gently straightens the finger [1]. Nearly a century later, those four signs are still how the diagnosis is made, and their sensitivity, specificity and interobserver reliability have never been properly established [1]. That is a remarkable gap for a diagnosis whose delay costs fingers. The practical consequence is the part worth carrying: not all four signs appear in every case, particularly in children, and the absence of one or more does not exclude the diagnosis [1]. A finger that fails only one of Kanavel's tests is not a finger that has been cleared. ### How it is drained changes how well the finger moves afterwards Once the diagnosis is made the sheath has to be decompressed, and there are two broad ways to do it: open the sheath surgically, or pass a fine catheter into it and irrigate through a much smaller wound. A systematic review covering 763 patients found that catheter irrigation produced better range of motion than open washout, and that using antibiotics as part of treatment, rather than relying on drainage alone, also improved movement [2]. Note that this is the opposite of the position on a felon, where a properly drained pulp abscess needs no antibiotic at all. The difference is the anatomy: a felon is a closed pocket you can empty completely, while a sheath is a long tube lined with the very surface the tendon must glide against. You cannot debride it clean without damaging what you are trying to save, so the antibiotic does work the surgery cannot. ### The risk of losing the finger is mostly a property of the patient This is the least comfortable finding and the most useful one. In the pooled series, amputation rates were driven overwhelmingly by background health rather than by surgical technique: 39% in patients with diabetes, 64% with renal failure, and 71% with peripheral vascular disease, all statistically significant [2]. Those numbers describe a different disease from the one a healthy person with a splinter injury has. They are why an infected sheath in someone with diabetes or poor circulation is treated with more urgency and a lower threshold for repeat washout, and why the honest answer to "will I keep the finger" depends more on the answer to "what else is going on with your health" than on anything that happens in theatre. ### Why the delay matters more than almost anything else The sheath is a closed space with a poor blood supply and a tendon inside it that depends on gliding. Pus under pressure inside that space does two things at once: it strangles the tendon's blood supply, and it seeds the adhesions that later limit movement. Both are time-dependent, which is why early treatment consistently improves outcomes [2] and why the standard advice for this specific infection is an emergency department rather than a GP appointment [3]. Stiffness afterwards is common even when everything is done correctly and promptly. How much stiffness is set largely by how long the sheath was under pressure, which is the one variable a patient can influence, by coming in early. --- ### Pyrocarbon interposition arthroplasty URL: https://www.cqupperlimb.com/education/hand/pyrocarbon-interposition-arthroplasty/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging if it is needed to confirm the diagnosis. This operation replaces the worn surface of a small joint with a smooth, shaped piece of carbon. It is usually offered for long-standing arthritis that has not settled with activity change, hand therapy, or splinting. We usually try non-operative care first and consider surgery when that has not given enough improvement. For some structural problems, surgery may be recommended straight away. The operation aims to relieve pain while keeping the joint moving. It also aims to keep the natural height of the thumb and preserve pinch and grip strength. For the thumb joint at the base, 91% of implants are still working well at medium-term follow-up. We will talk through this option with you and decide together whether it suits your hand and your goals. ## Before the operation In the seven hours before your operation, do not eat or drink anything. We ask for seven hours rather than six so your surgery can be brought forward if the theatre list runs early. Your surgeon will tell you which of your usual medicines to stop and when, and it helps to bring a written list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing. X-rays are usually all we need to plan the operation, though an MRI or ultrasound scan is sometimes used as well. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, the doctor who gives the anaesthetic. Most patients need neither. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist, the doctor who looks after your anaesthetic. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. Afterwards you wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Once you are stable, you either go to a ward or go home, depending on the procedure and how your recovery is going. ## What the operation involves Your surgeon makes a single cut over the area of your hand being operated on. Through this opening, they remove the worn, damaged surfaces of the joint. In place of the worn surfaces, they fit a smooth, shaped piece of carbon that sits between the bones. This spacer takes over the job of the worn joint surface, so the bones glide smoothly instead of grinding on each other. For the thumb joint at the base of your hand, your surgeon keeps the natural height of the thumb by placing the spacer between the bones. The joint is then repaired and supported so it heals in a good position. Your thumb may be held still in a straight position while it heals. The cut is closed with stitches. A dressing goes over the wound, and our team will tell you how to care for it in the first days. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You wake up in the recovery area, then move to the ward. Nurses will keep you comfortable and give you pain medicine if you need it. Your hand will be in a dressing and a splint, which protect the operation while it heals. You can get out of bed and move around as soon as you feel steady. Please arrange for someone to stay with you for the first 24 hours at home. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Expect some pain and swelling in your hand during the first days and weeks. This is a normal part of healing and settles gradually. Keeping your hand raised when you are resting helps, and the pain medicine we give you will ease the discomfort. Most people find the worst of the pain passes early, and comfort improves steadily from there. Your hand will be in a dressing and a splint, which protect the joint while it heals. We leave the dressing on for about 10 days and change or remove it when we see you. Rehabilitation after hand surgery is hand therapy, not physiotherapy. Your hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she will guide your exercises and make any splint you need as your hand recovers. Early on, the exercises are gentle and focus on keeping swelling down. As movement returns, they build up to restore bending, straightening and grip. You will be able to manage light daily tasks around the home within the limits of your splint. You will not be able to grip, pinch or lift with the operated hand while it is held still. Once the splint is removed and your surgeon clears you, you can start using the hand more normally, and driving can follow. See our page on Driving after upper-limb surgery for the details. Recovery varies between individuals. Your timeline may differ, and your surgeon and therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the implant changes position or settles into the bone. You might notice new pain in the joint, a feeling that the finger or thumb is not sitting straight, or a change in how it moves. If you notice any of these, bring them up at your next review. The implant can also loosen. This usually feels like pain that returns after a good stretch of improvement, often worse when you grip or pinch. Tell your surgeon if this happens. Stiffness can develop in the joint. The finger or thumb may not bend or straighten as far as it did, and the tendon on the back of the joint can become stuck down by scar tissue. Mention this at your review so your therapist can adjust your exercises. The joint can become unstable or the original deformity can come back. You may see the finger drifting out of line again. Raise this at your next appointment. Infection is uncommon but needs quick attention. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it. Pain that keeps getting worse despite your pain medicines also means you should call the clinic the same day. Nearby structures can be irritated or injured during this type of surgery. A nerve near the thumb can become sensitive, giving tingling or altered feeling in the skin. The artery on the thumb side of the wrist, or a tendon at the front of the wrist, can be affected. If you notice numbness or cannot move your fingers once the nerve block has worn off, at about 24 hours, call the clinic. Numbness and weakness in the first 24 hours after a nerve block are expected. A bone in the hand can occasionally break during or after surgery. This causes sudden pain and swelling. Call the clinic if this happens. If an implant fails and cannot be saved, other operations can help. The implant can be removed and the joint treated another way, which reliably eases pain. In rare cases the joint can be fused, meaning it is permanently stiffened, or the finger may need to be removed. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up early, and quick action makes them easier to sort out. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it. Call the clinic the same day too if pain keeps getting worse despite your pain medicines. Call the clinic if you notice numbness or cannot move your fingers once the nerve block has worn off, at about 24 hours. Numbness and weakness in the first 24 hours after a nerve block are expected. Go to the emergency department if you have calf swelling or pain, or shortness of breath or chest pain. These can be signs of a blood clot. Go to the emergency department if your fingers, hand or thumb turn pale, cold, white, blue or dark. This can be a circulation problem. If you cannot reach the clinic, out of hours or on a weekend, go to your nearest emergency department. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Basal Thumb Arthritis page. --- ### Raynaud's Phenomenon URL: https://www.cqupperlimb.com/education/hand/raynauds-phenomenon/ Region: hand · condition Fingers that go white, blue then red in the cold — primary vs secondary Raynaud's, keeping warm, and when it needs assessment. ## What you're feeling Your fingers change colour and feel strange when you get cold or stressed. A typical attack runs through three stages: the fingers first go white and feel cold and dead, then turn blue as the blood drains away, and finally flush red and may throb or tingle as the blood comes flooding back. Along the way you might notice numbness, pins and needles, or an aching pain. The same thing can sometimes affect the toes, the nose, the ears, or the lips. Attacks come and go. They are often triggered by something small (taking food out of the freezer, a cold morning, holding a chilled drink, or a sudden wave of stress) and they usually settle on their own once you warm up, over a few minutes to half an hour. Between attacks the fingers typically look and feel completely normal. ## What's actually happening The small blood vessels that supply your fingers are designed to narrow in the cold, to keep your core warm. In Raynaud's, those vessels over-react and clamp down far harder than they need to. This is called vasospasm. For a short while, very little blood reaches the skin of the fingers: that's the white, cold, numb stage. As the spasm eases, the blood returns and the fingers turn blue, then red and warm again. It helps to know there are two kinds. Primary Raynaud's is by far the most common and is essentially the body being over-sensitive to cold on its own, with no underlying disease behind it. It often starts in younger women, affects both hands fairly evenly, and is harmless even though it can be a nuisance. Secondary Raynaud's is less common but more important, because here the vasospasm is linked to another condition, usually one that affects the connective tissues, such as scleroderma or lupus. The clues that point toward the secondary type are: attacks starting later in life, attacks that hit one hand or only a few fingers rather than both hands evenly, attacks that are very severe, sores or ulcers at the fingertips, or other symptoms like joint pains or a rash. Those features are worth a proper medical check. ## What we can do about it For most people, the mainstay is simple and effective: keep warm and avoid the triggers. - Stay ahead of the cold. Wear gloves (mittens keep the fingers together and warmer), use hand-warmers, and dress in layers. Keeping your whole body and core warm matters as much as the hands themselves; your fingers stay open when your core is warm. - Side-step sudden cold. Wear gloves to reach into the fridge or freezer, run the car heater early, and hold cold drink cans or bottles in an insulated holder. - Quit smoking. Smoking narrows blood vessels and makes Raynaud's worse, and stopping is one of the most useful things you can do. - Go easy on caffeine and on anything that revs you up, since both can set off attacks. Managing stress with whatever works for you also helps, because stress alone can trigger the vasospasm. If attacks are frequent, painful, or severe, there are medicines that relax the blood vessels and reduce how often attacks come. The most common are a group called calcium-channel blockers (such as nifedipine), and there are other options if those don't suit. When the cause is secondary Raynaud's, treating the underlying condition is an important part of the plan, so getting the right diagnosis matters. ## What to expect For the great majority (those with primary Raynaud's) this is a manageable nuisance rather than a danger. With sensible warmth and trigger-avoidance, many people keep attacks to a minimum and carry on normally; the fingers recover fully after each episode and no lasting harm is done. It tends to be a long-term tendency rather than something that disappears, but it is very controllable, and medicines are there for the times when simple measures aren't enough. Secondary Raynaud's needs closer attention, because the underlying condition drives how things go and, in some cases, the reduced blood flow can damage the fingertip skin. That's exactly why sorting out which type you have is worthwhile, so the right level of care is matched to your situation. ## When to see someone See a doctor for assessment if: - Your attacks started later in life, are severe, or affect one hand or only a few fingers rather than both hands evenly: these can be signs of the secondary type and usually warrant blood tests and a look at the small vessels at the base of your nails. - You develop sores, ulcers, cracks or skin breakdown at the fingertips, or an area of finger that stays white, blue, painful or numb and won't warm back up: this needs prompt attention. - You have other symptoms alongside the colour changes: joint pain or swelling, a rash, dry eyes or mouth, difficulty swallowing, or tight or thickened skin on the fingers. - Attacks are frequent or painful enough to interfere with your daily life despite keeping warm and avoiding triggers; medication can help. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Raynaud's phenomenon is worth the extra reading because only one class of drug has good evidence behind it, and because the treatment attracting most current interest works by an unexpected mechanism. ### One drug class has the evidence Raynaud's is episodic spasm of the small arteries in the fingers, so treatment aims to keep those vessels open. Many vasodilators have been tried. A meta-analysis of 17 trials concluded that calcium channel blockers demonstrated a statistically significant benefit in reducing the frequency and severity of symptoms, and that there was no evidence supporting oral vasodilatory agents other than calcium channel blockers [1]. That second clause is the useful one. It is a negative finding across a whole category of alternatives, and it explains why treatment tends to start and often stay with one drug family rather than working through a list. ### Botulinum toxin, and why it is not doing what you would guess The intervention generating most interest in refractory cases is botulinum toxin injected around the arteries at the base of the fingers. Its use for Raynaud phenomenon refractory to medical treatment has shown favourable results, serving as a non-invasive alternative to surgery with demonstrated efficacy in small-scale studies [2]. The mechanism is worth understanding because it is counter-intuitive. Botulinum toxin is known for paralysing muscle, and the obvious guess would be that it relaxes the muscle in the artery wall directly. The current understanding is different: it interferes with the sympathetic nerve signalling that drives the vessels to constrict, and appears to act on pain pathways as well, which is why reported benefit sometimes includes pain relief out of proportion to any change in blood flow. Note the honest framing in the evidence itself: "small-scale studies". This is a promising option for people who have exhausted medical treatment, not an established one. ### The distinction that determines everything else The single most consequential question is whether the phenomenon is primary, occurring on its own, or secondary to an underlying condition, most often an autoimmune connective tissue disease such as scleroderma or lupus. The difference is not academic. Primary Raynaud's is a nuisance with a good outlook and no tissue damage. Secondary Raynaud's can progress to ulceration and tissue loss at the fingertips, and the underlying disease needs identifying and treating in its own right. The features that raise concern are onset after about 30 years of age, asymmetry between hands, ulcers or pitting scars at the fingertips, and abnormal capillaries at the nail fold. Those warrant investigation rather than reassurance, and it is why a first presentation of Raynaud's is usually worked up rather than simply managed with gloves. ### Where surgery sits For severe secondary disease with threatened tissue, periarterial sympathectomy, stripping the sympathetic nerve fibres from the surface of the digital arteries, is the surgical option, and it targets the same signalling pathway as botulinum toxin by a permanent route. It is reserved for critical ischaemia and non-healing ulcers rather than for cold, uncomfortable fingers, which is consistent with the treatment ladder above: the further along it you go, the more the goal shifts from comfort to saving tissue. --- ### Remplir Nerve Wrap URL: https://www.cqupperlimb.com/education/hand/remplir-nerve-wrap/ Region: hand · device Remplir is a soft wrap made from collagen, a natural protein found in your body. It is used in surgery to help a damaged peripheral nerve heal. Peripheral nerves are the nerves that run from your spinal cord out to your arms, hands and legs. When one of these nerves is injured… ## What is it Remplir is a soft wrap made from collagen, a natural protein found in your body. It is used in surgery to help a damaged peripheral nerve heal. Peripheral nerves are the nerves that run from your spinal cord out to your arms, hands and legs. When one of these nerves is injured, it needs protection while it repairs itself. Remplir works like a protective sleeve around the injured nerve. Your surgeon places it over the repaired nerve during the operation. The wrap shields the nerve and creates a good environment for new nerve fibres to grow through. It then does its job and disappears. Remplir dissolves within 3 to 6 months, so nothing artificial is left behind in your body once healing is under way. ## What it's made of Remplir is a biological material, not a plastic or metal implant. It is made from collagen, a natural protein that already exists in your body. The collagen is processed from animal tissue and made sterile before it reaches the operating theatre. Because it comes from biological material, your body treats it as something familiar rather than foreign. The wrap does not stay in you forever. It dissolves within 3 to 6 months, so once the nerve has started to heal, nothing artificial remains at the repair site. ## How your surgeon uses it Remplir is placed during the operation, after your surgeon has repaired the injured nerve. The wrap is laid around the repair site like a soft sleeve. It sits between the nerve and the surrounding tissue, so scar tissue cannot squeeze in and crowd the healing nerve. The collagen material is soft and flexible, so it moulds to the shape of the nerve and stays in place without any hardware. Once the wrap is positioned, it gets to work. It protects the nerve while new nerve fibres grow through the repair. It also creates a moist, calm space around the nerve, which is the kind of setting nerves need to regenerate. Over time, your body absorbs the wrap and replaces it with your own tissue. Nothing artificial is left behind. Your surgeon may use Remplir in different types of nerve surgery, wherever a repaired peripheral nerve needs protection during healing. It is not a stand-alone treatment. It is one part of a larger operation that repairs the nerve itself. ## What to expect The wrap itself does not change your recovery. It dissolves on its own within 3 to 6 months, so there is nothing to remove and no extra procedure to attend. Your body absorbs it and replaces it with your own tissue as the nerve heals. Research comparing nerve wraps with surgery done without them found no differences in how nerves regrew, how they reconnected to muscle, or how well patients recovered [1]. In plain terms, the wrap is there to protect the nerve while it heals, not to speed up or change the healing path. Because of this, your recovery follows the same course as the main operation that repaired your nerve. Your surgeon will guide you through what to expect from that operation, including follow-up visits and any exercises. One thing worth knowing: because the wrap is made from collagen, your body treats it as part of you rather than something foreign. Studies of collagen nerve conduits found they took on an encapsulation-like appearance as the body remodelled them [2]. This is a normal part of healing, not a complication. ## What the evidence says Research on nerve wraps is still building. Studies comparing surgery with a wrap to surgery without one found no differences in how nerves regrew, how they reconnected to muscle, or how well patients recovered [1]. In plain terms, the wrap protects the nerve while it heals. It does not speed up healing or change the outcome. Early results for collagen nerve tubes compare favourably with other published results for nerve repair [3]. A study of the same kind of collagen device, used to repair injured nerves in the arm, reported recovery of movement [4]. Because the wrap is made from collagen rather than nerve taken from your own body, it avoids the problems that can come from a second wound where nerve graft material is harvested [5]. The honest picture is this: the evidence is early, and longer-term studies are needed. What is known so far is that the wrap does its protective job and dissolves as planned. No claims are made here about guaranteed results. Your surgeon will talk with you about what the evidence means for your specific injury and operation. --- ### Sagittal Band Rupture (Boxer's Knuckle) URL: https://www.cqupperlimb.com/education/hand/sagittal-band-rupture/ Region: hand · condition A knuckle injury where the tendon slips off the top of the joint — the "boxer's knuckle" — and how early splinting or surgery treats it. ## What you're feeling The knuckle at the base of one of your fingers (most often the middle finger) feels sore, a little swollen, and something isn't moving the way it should. The classic sign is a feeling that the tendon on the back of the knuckle snaps or jumps sideways when you bend and straighten the finger. You may notice the finger drifts slightly toward the little-finger side, and that it is hard to get the finger to straighten on its own from a bent position, though once someone gently straightens it for you, it can hold there. Many people first feel this after throwing a punch (against a bag, a wall, or in a fight), which is why the injury is nicknamed "boxer's knuckle." But it can also happen with a much smaller movement, like forcefully flicking a finger straight, or it can creep up gradually in people with inflammatory arthritis. There may be a painful clicking or catching every time you use the hand. ## What's actually happening On the back of each knuckle, the straightening (extensor) tendon runs down the centre of the finger like a cable in a groove. Thin slings of tissue called the sagittal bands sit on either side and hold that tendon centred over the top of the knuckle. The sling on the thumb side is the important one. When that sling tears or stretches (from a punch, a sudden forceful movement, or long-standing joint inflammation) the tendon is no longer held in place and slips off the top of the knuckle into the valley between the bones, toward the little-finger side. Because the tendon is now sitting to the side rather than on top, it can't pull the finger straight efficiently from a fully bent position, and it snaps back and forth as the finger moves. That slipping, snapping, and weakness of straightening is the whole problem in a nutshell. ## What we can do about it In our clinic, Dr Kieran Hirpara manages this condition by first confirming the diagnosis through a thorough assessment and imaging if needed. For a recent injury we usually start with splinting, and consider surgery when the tendon keeps slipping or the injury is older. The good news is that if it's caught early, this often heals without surgery. The key is to stop the tendon slipping while the sling repairs itself. Splinting (non-surgical). The most common treatment is a small, custom splint that holds the injured knuckle from bending too far while leaving the other fingers, and the finger joints further out, free to move normally. One neat version, sometimes called a relative-motion or "yoke" splint, simply holds the injured finger a touch higher than its neighbours, which keeps the tendon centred while you keep using the hand. The splint is usually worn for around six to eight weeks. Started within the first few weeks of the injury, this works well for most people. Surgery. If the injury is old by the time it's seen, if the splint doesn't settle it, or if the tendon is fully dislocating, surgery can put things right. The surgeon either repairs the torn sling directly or rebuilds it using a nearby strip of tendon to re-create the sling and re-centre the tendon over the knuckle. After surgery the finger is protected in a splint for a period while it heals. ## What to expect For early injuries treated in a splint, the outlook is good: the snapping settles, the finger straightens normally again, and most people return to full use of the hand. It does ask for patience: the splint is worn for several weeks, and pushing the hand too hard too soon can let the tendon slip again before the sling has healed. For injuries that need surgery (usually the older or more severe ones), repair or reconstruction is generally reliable at stopping the dislocation and restoring smooth movement, followed by a period of splinting and hand therapy to rebuild motion and strength. Boxers, martial artists and other athletes can usually return to their sport, but the hand needs time to heal properly first to avoid the problem coming straight back. ## When to see someone - A knuckle that snaps, clicks or catches when you bend and straighten the finger, especially after a punch or forceful movement: get it looked at early, because early splinting is what makes the difference. - Difficulty straightening a finger on its own from a bent position, or the finger drifting toward the little-finger side. - Ongoing pain and swelling over a knuckle that isn't settling, or a feeling that the tendon is "out of place." - A knuckle injury in a boxer or martial artist: these injuries are easy to play through and easy to miss, and they do better when treated sooner rather than later. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Sagittal band injury is worth the extra reading because it is the extensor problem most often missed, the tendon has not torn, it has simply moved, and because getting the splint on early is what determines whether an operation is needed at all. ### Nothing is torn through; something has slipped The extensor tendon runs down the back of the finger over the knuckle, held centrally by a thin hood of tissue on either side, the sagittal bands. When the radial band gives way, the tendon slides into the valley between the knuckles. The consequences follow directly from that mechanics. The finger can be held straight once someone else straightens it, because a tendon lying in the valley can still hold an extended position, but it cannot be actively straightened from a bent start, because the displaced tendon has lost its line of pull. That distinction, between passive and active extension, is what separates this injury from a tendon rupture, and it is why a hand held open on the desk can look entirely normal. The classic causes are a flicking or forced-flexion injury to a straight finger, a direct blow over the knuckle, the boxer's presentation, and, without any injury at all, rheumatoid arthritis, where the hood attenuates over time and the tendons drift towards the little finger. ### Splinting works if it is started early The treatment evidence is qualitative rather than numerical, and it points clearly. Acute sagittal band injuries can be successfully treated by splinting the injured digit in neutral or hyperextension, while patients with chronic injuries, or those failing non-operative management, may benefit from surgical exploration [1]. The splinting position is the specific part. A relative-motion or yoke splint holds the injured finger slightly more extended than its neighbours, which relieves tension on the healing band while allowing the hand to be used, an unusually tolerable form of immobilisation, and one reason compliance is generally good. What makes the timing critical is that this is a soft-tissue injury that heals by scar. Splinted early, the band can heal at a length that holds the tendon centrally. Left for months, it heals elongated, the tendon continues to subluxate, and reconstruction rather than healing becomes the remaining option. ### Why classification is being revised rather than settled Contemporary work has focused on refining how these injuries are graded, with a modification to the most prevalent classification system proposed to guide treatment and standardise description [2]. That reflects the state of the field: the treatments are reasonably agreed, but which injury belongs in which category, and therefore who needs surgery, is still being worked out. Practically, this means the strength of a recommendation here rests more on the examination findings than on a grade. Whether the tendon actively subluxates when the finger is bent, and how long it has been doing so, carries the decision. ### It sits within a family of injuries that are readily confused Sagittal band injury is one of three closed extensor mechanism injuries defined by where the failure occurs, mallet at the fingertip, boutonnière at the middle joint, and sagittal band at the knuckle [3]. Each requires a different splinting position, and a swollen finger early after injury can present ambiguously. Because the treatment window for the sagittal band closes as the tissue heals long, distinguishing them promptly is worth more here than in the other two. --- ### Swan-Neck Deformity of the Finger URL: https://www.cqupperlimb.com/education/hand/swan-neck-deformity/ Region: hand · condition A finger that hyperextends at the middle joint and bends at the tip — why it happens and how splints or surgery can correct it. ## What you're feeling You may have noticed that one or more of your fingers has taken on an odd shape. The middle joint of the finger (the big knuckle in the middle, not the one at the base) bends backwards so the finger looks slightly arched or "swan-like," while the small joint nearest the fingernail droops forwards. Side on, the finger makes a shallow zig-zag. Early on this may be more of a nuisance than a pain: the finger can feel like it gets "stuck" or snaps as you try to bend it, and it can be hard to make a smooth fist or grip small objects. As it becomes more fixed, the finger may no longer straighten or curl the way it used to, and everyday tasks (doing up buttons, picking up coins, gripping a pen) become fiddly and tiring. Some people first notice it simply because the finger catches when they reach into a pocket or a glove. ## What's actually happening Your finger is balanced by a clever system of tendons and small ligaments that run along the top, bottom and sides of each joint. The middle joint (the PIP joint) is normally stopped from bending backwards by a tough little ligament on its palm side called the volar plate, and by tendon bands that sit along the sides of the finger. In a swan-neck deformity that balance is lost. If the volar plate becomes loose, or the side-tendons (the lateral bands) slip up onto the top of the joint, the middle joint is pulled back into hyperextension, and because the tendons are all connected, the tip of the finger is dragged into a droop. The two go together. There are several reasons the balance can fail. Sometimes it starts at the fingertip: an untreated mallet finger (a dropped fingertip after a tendon injury) shifts the pull of the tendons and slowly tips the middle joint backwards. Often it is driven by inflammatory arthritis, especially rheumatoid arthritis, which stretches and weakens the ligaments. It can also follow loose-jointedness, old injuries, or conditions that increase muscle tightness. Whatever the trigger, the end result is the same recognisable shape. ## What we can do about it Dr Kieran Hirpara leads our upper-limb service at Mater Private Hospital Rockhampton, where we guide patients from initial referral through to a clear management plan. Your journey begins with a thorough clinic assessment to confirm the diagnosis and understand how your finger is moving. We typically start with non-operative care for long-standing issues and consider surgery only when that approach has not provided enough relief. The right treatment depends on how flexible the finger still is and what is driving it, so the first step is always a proper hand assessment and treating any underlying arthritis. If the finger is still supple and the joint can be straightened and bent freely, we often start without surgery. A small, custom figure-of-eight splint (sometimes a neat silver-ring style splint) sits across the middle joint and quietly blocks the backward bending while still letting the finger work. Many people manage very well this way, and hand therapy helps keep the joints moving. If splinting isn't enough, or the finger is becoming stuck, surgery can re-balance it. There are several well-established options, chosen to fit your finger: re-tethering the middle joint with a slip of one of your own tendons so it can no longer snap backwards (a tenodesis); tightening the loose ligament on the palm side; or moving the slipped side-tendons back where they belong. If the joint surface itself is worn out and stiff (common in long-standing arthritis) we may instead fuse the joint into a good working position or, in selected cases, replace it. ## What to expect Caught early, while the finger is still flexible, the outlook is good; a splint or a re-balancing operation can restore a much more useful, smoother finger. The more rigid and arthritic the joint becomes, the more limited the options, which is exactly why it's worth being seen before the finger sets in one position. If you have surgery, expect a period in a splint and a course of hand therapy afterwards to retrain the finger and protect the repair; this rehab is a real part of the result, not an optional extra. Where an underlying arthritis is the cause, keeping that well controlled with your rheumatology team protects the other fingers from going the same way. ## When to see someone - A fingertip that droops and won't fully straighten after a knock or jamming injury (a mallet finger); treating this early can head off a swan-neck later. - A finger that is starting to arch backwards at the middle joint, or that catches, snaps or locks when you bend it. - Increasing stiffness, or a finger that no longer makes a smooth fist. - Known rheumatoid or inflammatory arthritis with changing finger shapes: worth reviewing before the deformity becomes fixed. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Swan neck deformity is worth the extra reading because it is not one condition, the same finger shape arises from several different failures, at both ends of the finger, and the correct treatment depends entirely on which one started it. ### One shape, several causes A swan neck finger hyperextends at the middle joint and drops at the fingertip. That posture is the end state of an imbalance in a linked system, and the initiating fault can sit at either end. From the fingertip. An untreated mallet injury leaves the extensor mechanism detached distally [1]. The extensor force it no longer delivers to the fingertip is transmitted instead to the middle joint, which is progressively pulled into hyperextension. A swan neck can therefore be the late consequence of an injury weeks or months earlier that appeared to involve only the fingertip. From the middle joint. If the volar plate, the thick ligament preventing the middle joint from hyperextending, is stretched or torn, the joint drifts backwards. The lateral bands then ride above the joint's axis and reinforce the extension, while the deep flexor tendon is left with slack that flexes the fingertip. From generalised laxity or inflammatory disease. In hypermobility, the volar plate is constitutionally lax rather than injured. In rheumatoid arthritis, synovitis attenuates the restraints over time, and the deformity is usually part of a wider pattern across several fingers [3]. ### Why the distinction decides the treatment Treatment aims to stop the middle joint hyperextending, and the level at which it is corrected must match the level of the fault. Where the deformity is driven from the fingertip, correcting the middle joint alone does not address the imbalance producing it. Where the volar plate has failed, a tenodesis using a slip of the superficialis tendon can be used to restrain hyperextension [2]. Where the cause is inflammatory, the underlying disease determines whether any reconstruction will hold, soft-tissue procedures in an actively inflamed hand tend to stretch out over time. A silver-ring or figure-of-eight splint, which blocks the last few degrees of hyperextension while allowing the finger to bend, is often used first. It is more effective than it appears, because preventing that small range interrupts the mechanism driving the deformity. ### Flexible versus fixed is the other decisive question The second question is whether the finger can still be straightened passively. A flexible deformity — one that can be corrected by hand, may respond to splinting or soft-tissue rebalancing. A fixed deformity, where the joint no longer moves through its range, has established joint contracture and soft-tissue procedures alone will not correct it [4]. The practical implication is the same as for boutonnière deformity, and it is the reason both are worth showing to someone early: these are progressive, self-reinforcing deformities. The window in which a splint can hold a flexible finger straight is considerably wider than the window in which surgery can restore a fixed one. ### A note on the related deformity Boutonnière is in some ways the mirror image, middle joint bent, fingertip hyperextended, and arises from failure of the central slip rather than of the volar plate. The two are covered separately, and confusing them matters because the splinting positions are opposite. --- ### Hand Tendon and Nerve Injuries URL: https://www.cqupperlimb.com/education/hand/tendon-and-nerve-repair/ Region: hand · condition Hand tendon and nerve injuries – understanding symptoms, diagnosis, and treatment options. ## What you're feeling When a tendon or nerve in your hand is cut, the effects depend on which one is injured and where. A cut tendon usually means you cannot bend or straighten one or more fingers the way you normally would. A cut nerve causes numbness or pins and needles in the area it supplies, and you may notice a tingling or electric feeling when you tap over the injury. That tapping sensation can be a sign the nerve is starting to recover. The pain is usually felt right at the wound, and it tends to flare when you try to use the hand: gripping, pinching, carrying shopping, turning a key or doing up buttons. Many people find the hand aches more at night or on waking. Resting the hand and keeping it still often settles the pain, while movement and loading make it worse. If a tendon was only partly cut, the finger can work at first but later catches, clicks or gives way. Daily tasks that need feeling in your fingertips become hard: picking up small objects like coins, doing up buttons or zips, holding a pen, handling cutlery or feeling whether water is hot. You may drop things without noticing, because the hand cannot tell you how hard you are gripping. If the injury involves a broken bone as well as the tendon or nerve, the weakness and numbness are often more severe. Some warning signs need urgent care. Go to the emergency department the same day if your finger, hand or arm becomes hot, red, swollen and painful, especially with a fever, or if your fingers or hand turn pale, cold, white or blue, or if you suddenly lose feeling or movement after an injury. See your GP or ask for a specialist review if symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using the hand. ## What's actually happening Your hand is built around 27 small bones, arranged in five finger rays. Each ray is a chain of bones that bends and straightens together. The muscles that move your fingers sit partly in the forearm and partly inside the hand itself, and they pull on the fingers through cords called tendons. Think of a tendon as a rope running inside a smooth tunnel. On the palm side of each finger there are two such ropes: one bends the middle joint, and one reaches all the way to the fingertip and bends the end joint. On the back of the hand, other tendons straighten the fingers. When you cut your hand, one of these ropes can be sliced through, or partly through. A fully cut tendon means the muscle pulling on it has lost its connection to the finger, so that finger will not bend or straighten on its own. A partly cut tendon can still work at first, which is why the finger may seem fine before it starts catching or giving way. The tendons slide inside those smooth tunnels, so a repair needs to heal strong enough to glide as well as hold. Nerves are the wiring. They carry feeling from your fingertips back to your brain and carry commands out to the muscles. A cut nerve breaks that circuit, which is why you get numbness, tingling or an electric feeling in the area it supplies. Unlike a tendon, a nerve cannot simply be sewn back and work straight away. The nerve has to regrow down its outer sheath at roughly a millimetre a day, so feeling returns slowly over months, and often as an uncomfortable oversensitivity before it becomes useful. If the injury also involves a broken bone, the damage affects more than one structure at once, and the weakness and numbness tend to be worse. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some hand tendon and nerve injuries heal without an operation, and others need surgery soon after the injury, so prompt assessment matters. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a careful history and examine your hand, and arrange imaging or nerve tests where they are needed. Those tests show how badly the nerve or tendon is injured and help us decide on treatment. Not every injury needs an operation. If a nerve is bruised rather than cut, we may simply watch it while it recovers on its own. If there is no sign of the muscles working again after 6 weeks of observation, or if weakness keeps getting worse, we would recommend looking at the nerve directly. While a nerve or tendon heals, something that holds the hand still, such as a splint or cast, protects the repair. After surgery your rehabilitation is hand therapy, not physiotherapy: Ruby Doolan at Extend Rehabilitation guides your exercises and makes any splint you need. When surgery is needed, the aim is to restore the job the cut structure was doing: a tendon is sewn back together so the finger can bend or straighten again, and a cut nerve is joined so feeling can regrow. If the two nerve ends cannot be brought together without pulling, we may bridge the gap with a graft or a small tube, or in some cases reroute a working nerve to a more useful job. If a nerve injury has left a muscle permanently weak, a tendon can be moved from a job it can spare to take over that muscle's work. Sometimes we repair the nerve and move the tendon in the same operation. For a painful lump where a nerve has healed badly, surgery aims mainly to relieve the pain and secondarily to restore feeling. ## What to expect Recovery depends on which structure was injured and how badly. A bruised nerve that is still in one piece usually recovers better than a nerve that was cut and repaired. A repaired tendon generally heals with the finger moving again, but the repair is at its weakest a few weeks in, when the finger starts to feel better, so the hand needs protecting while it heals. Nerve recovery is slow no matter how well the repair is done. Feeling returns at roughly a millimetre a day, so a nerve cut at the wrist can take many months, and feeling often comes back as an uncomfortable oversensitivity before it becomes useful. Some things make that recovery more likely: getting the nerve repaired sooner rather than later, a shorter gap between the nerve ends, and being young. Delay in repair of less than 6 months and a gap of less than 5 cm are both linked with better recovery. Even so, not every repaired nerve returns to normal. Only 24% of repaired digital nerves regain feeling close to or equivalent to the level before the injury, so some change in sensation can be permanent. Tendon repairs have their own risks to weigh. About 6% of flexor tendon repairs need a further operation, most often because scar tissue glues the tendon down and stops it gliding, or because the repair pulls apart. A repair that pulls apart happens in about 4% of cases. When a nerve injury has left a muscle permanently weak, a tendon transfer can restore useful movement, and this is a well-established option when nerve repair alone does not bring function back. What tends to happen if an injury is left alone depends on the structure. A fully cut tendon will not heal on its own, so that finger stays unable to bend or straighten. A cut nerve will not regrow across a gap either, and the numbness persists. Delayed treatment generally leads to poorer results than repair close to the time of injury, though good results are still possible even after a long delay. If symptoms are not settling or are getting worse over weeks, see your GP or ask for a specialist review. ## When to see someone A hand injury that breaks the skin needs checking promptly, because a cut tendon or nerve will not heal on its own. Go to an emergency department the same day if your finger, hand or arm becomes hot, red, swollen and painful, especially with a fever, if your fingers or hand turn pale, cold, white or blue, if you suddenly lose feeling or movement after an injury, or if the skin is broken over a fracture or joint, bone is showing, or the finger looks obviously out of shape. Ask for a specialist review if a finger that seemed fine at first starts catching, clicking or giving way, which can happen when a tendon was only partly cut. See your GP if pain is severe and you cannot keep the hand still enough for an examination, as a scan can settle whether the tendon is intact. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Tendon and nerve repair in the hand is worth the extra reading because the operation is only half the treatment, what happens in the following weeks determines the result as much as the repair itself, and the evidence there has become quite specific. ### Moving early beats protecting After a flexor tendon repair, two things compete. Move the finger and the repair may rupture; keep it still and the tendon scars to its sheath, so it heals intact but cannot glide, a stiff finger with a healed tendon inside it. Across 569 patients, the early active motion group obtained greater total active motion than the early passive motion group. The qualification matters as much as the finding: a higher risk of rupture was noted in the active flexion-and-extension subgroup where the repair used only a 2-strand core suture [1]. That is the trade stated precisely. Early active movement produces better final motion, but it demands a repair strong enough to withstand it. This is why the number of strands crossing the repair is discussed at all, it is not technical detail for its own sake, but what determines whether the safer, better rehabilitation can be used. ### The relative motion approach, and where its evidence actually applies Relative motion orthoses hold the injured finger in slightly different alignment from its neighbours, unloading the repair while allowing the hand to be used. It is a considerable advance in tolerability over immobilising a hand for six weeks. The evidence base is uneven, and worth knowing accurately. There is now good evidence that the relative motion approach is safe in zones V-VI extensor tendon repairs, but limited evidence for zones IV and VII extensor and for flexor tendon repairs [2]. So an approach well supported for extensor repairs on the back of the hand is not, on current evidence, equally established for flexor repairs in the finger. Where it is used there, it is reasonable extrapolation rather than demonstrated practice. ### For nerves, the technique matters less than the gap Digital nerve repair has attracted a range of techniques, direct suture, autograft taken from elsewhere, processed allograft, and synthetic conduits. Across 625 repairs, all available techniques have reasonable outcomes, and where there is a gap, excluding direct repair, autograft and allograft performed comparably [3]. The decisive variable is therefore whether the nerve ends can be brought together without tension. If they can, direct repair is done. If they cannot, the gap must be bridged, and the current evidence does not compel taking a nerve from elsewhere in the patient to do it, which spares a donor site and the numb patch that comes with it. ### Why recovery is measured in months Both tissues heal on a biological timetable that no technique shortens. A repaired tendon is at its weakest around three weeks, when the initial fibrin has been resorbed and new collagen has not yet matured, which is precisely when the finger feels better and people are most tempted to use it. Nerves regenerate by growing axons down the remaining sheath at roughly a millimetre a day. From a cut at the base of a finger, reaching the fingertip therefore takes several months, and sensation returns gradually and imperfectly, often as an unpleasant hypersensitivity before it becomes useful feeling. That sequence is expected recovery, not a complication. --- ### Thumb UCL injury URL: https://www.cqupperlimb.com/education/hand/thumb-ucl-injury/ Region: hand · condition A thumb UCL injury affects the ligament on the inside edge of your thumb, at the joint where the thumb meets your hand. The injury usually happens when your thumb is bent sharply sideways, often during a fall onto an outstretched hand. In skiing, it can happen if you fall while… ## What you're feeling A thumb UCL injury affects the ligament on the inside edge of your thumb, at the joint where the thumb meets your hand. The injury usually happens when your thumb is bent sharply sideways, often during a fall onto an outstretched hand. In skiing, it can happen if you fall while still gripping the ski pole, and snowboarders can injure a thumb during falls and turns. The pain sits over the inside edge of your thumb, at the joint closest to your palm. It usually starts with a sudden injury, along with swelling and tenderness in that spot. Pinching, gripping and anything that pushes your thumb sideways will hurt. Everyday tasks that load the thumb this way become hard: turning a key, opening a jar, holding a heavy pan by the rim. Your thumb may also feel unsteady, as if it gives way when you press it against something. Some people notice a small firm lump on the inside edge of the thumb joint. Your thumb may also sit or twist slightly out of line compared with the other thumb. If the injury happened some time ago, the pain may be less obvious, but the thumb can still feel weak or loose when you pinch or grip. Watch for these signs and act on them the same day: a finger, hand or arm that becomes hot, red, swollen and painful, especially with a fever; broken skin over the injured joint, bone showing, or an obvious deformity; a thumb or hand that turns pale, cold, white or blue; or sudden loss of feeling or movement after the injury. These need emergency department care straight away, and no GP referral is needed. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## What's actually happening Down the inside edge of your thumb, where it joins your hand, there is a strong strap of ligament called the ulnar collateral ligament. Think of it as a guy rope holding a tent pole steady: it stops the thumb joint from bending sideways when you pinch or grip. Every time you press your thumb against a finger, this strap takes the load. That is why a tear here shows up as weakness and pain in exactly those tasks. When your thumb is forced sideways, this strap can stretch, partially tear, or tear right through. Doctors grade it by how much it has torn: a stretch or partial tear, and a complete tear where the ligament comes away from the bone. Sometimes the ligament tears off the bone along with a small chip of bone. A partial tear can usually heal in a splint. A complete tear often cannot, because the torn end can flip back and get caught under a sheet of tissue that lies over the joint. Once that happens, the ligament ends up resting away from the bone it needs to reattach to, so it cannot knit back together on its own. If the tear is not treated, the joint stays loose. Your thumb keeps giving way under sideways load, and over years that constant movement can wear the joint out and lead to arthritis. That is why this injury is taken seriously even when it feels like a simple sprain. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some thumb ligament tears heal without an operation, and others need surgery soon, so prompt assessment matters. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a history, examine your thumb, and arrange imaging where it is needed. That may include x-rays, an ultrasound scan or an MRI, which uses a strong magnet to take detailed pictures of the ligament. These scans show whether the ligament is torn all the way through and whether the torn end has flipped out of place. If the tear is partial, or the ligament has come off the bone with a small chip that has not moved, we usually hold the thumb still in a cast for up to 4 weeks. After that you wear a removable splint for 3 more weeks and start gentle movement exercises. Your hand therapist, Ruby Doolan at Extend Rehabilitation, directs these exercises and makes any splint you need. A complete tear where the torn end has not flipped out of place is usually given a trial of immobilisation first, holding the joint still for 4 to 6 weeks to let the ligament knit back. Surgery is considered when the tear is complete and unstable, when the torn ligament end has flipped out of place, or when a bone fragment has moved out of line. In these situations the ligament cannot heal back onto the bone on its own, so an operation reattaches it. If the injury happened some time ago and the ligament can no longer be repaired directly, we can rebuild it using a strip of tendon from your own arm or from donated tissue. The operation has its own page, and we will talk through what it involves before you decide anything. ## What to expect With treatment, most thumb ligament tears settle well. A partial tear held still in a splint or cast usually heals, and your thumb regains its strength for pinching and gripping. If you need an operation, the results are generally good: most people keep the movement, pinch and grip strength of their thumb, and problems after surgery are uncommon. People who had this surgery have gone back to playing sport at their previous level, and professional players have played similar numbers of games and had similar career lengths afterwards. Recovery takes patience. Your thumb will be held still at first, because early stiffness is the main thing to avoid later on. Once movement is allowed, gentle, gradual exercises matter: slowly loading and stretching the healing ligament improves movement and function. Patient-reported outcomes improve significantly at three and 12 months after surgery compared with before it. If your injury happened some time ago, repair still works, though a late repair tends to cost you slightly more thumb movement than an early one would have. Without treatment, the outlook is different. Three in four complete tears fail to heal on their own, even when rested. The joint stays loose, your thumb keeps giving way under load, and pinch stays weak and painful. Over years, that constant looseness wears the joint out: 88% of people who had a chronic tear repaired later already had some arthritis in the thumb joint. Older age at the time of injury is linked with more severe arthritis in that joint. Some things are worth knowing as you plan ahead. If your thumb becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day; no GP referral is needed. If symptoms are not settling or are getting worse over weeks, see your GP or ask for a specialist review. ## When to see someone Get your thumb checked soon after any injury where it is forced sideways, even if it seems like a simple sprain. The sooner a complete tear is assessed, the more options you have, because a tear left too long may need a bigger operation or may leave lasting stiffness and weakness. Ask for a specialist review if your thumb still gives way when you pinch or grip, if pinch stays weak or painful after a few weeks, or if you can feel a small firm lump on the inside edge of the joint. If the injury happened some time ago and your thumb is loose or wearing out, it is still worth being assessed. And if your thumb becomes hot, red, swollen and painful, especially with a fever, go to an emergency department the same day. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Thumb ulnar collateral ligament injury is worth the extra reading because the whole decision turns on a single anatomical question, whether the torn ligament has flipped out of reach, and because there is now a clear answer about which scan to use to settle it. ### The Stener lesion, and why it changes everything The ulnar collateral ligament stabilises the thumb against the sideways force of every pinch and grip. When it tears from its attachment, it usually stays where it can heal. Sometimes it does not. A sheet of tendon called the adductor aponeurosis lies superficial to the ligament, and if the torn end retracts back over the top of that sheet, the aponeurosis interposes between ligament and bone. That is a Stener lesion, and it is the reason this injury is treated differently from most sprains: the ligament is no longer in contact with the bone it needs to heal to, so no amount of splinting will reattach it. Everything about management follows from whether that has happened. ### Ultrasound is enough to answer it Because the decision is binary and consequential, the imaging question is unusually well defined — and it has been answered. Across 422 patients, both ultrasound and MRI demonstrate high diagnostic accuracy in detecting Stener lesions, and ultrasound is an appropriate first-line imaging modality [1]. That is a useful piece of practical information. Ultrasound is quicker, cheaper and more accessible than MRI, and where an experienced operator is available it does not need to be followed by an MRI to confirm what it has already shown. It is also dynamic, the thumb can be stressed during the scan. ### Where there is no Stener lesion, laxity drives the decision The British Society for Surgery of the Hand guideline sets out the pathway plainly. Patients with acute injuries should be assessed with history, clinical examination and radiographs. Those without significant joint laxity can be treated non-surgically, while those with significant laxity may be treated with either non-surgical immobilisation or surgical repair, after a shared decision [2]. Two things are worth drawing out. The first is that radiographs come before advanced imaging, partly to exclude an avulsion fracture, which changes the treatment again. The second is that even significant laxity does not mandate surgery: the guideline explicitly frames it as a shared decision between immobilisation and repair, which is a more honest position than presenting operation as the only route. ### Why the consequences of getting it wrong are specific An incompetent ulnar collateral ligament does not produce pain at rest or difficulty with most activities. It produces a thumb that gives way under sideways load, turning a key, opening a jar, holding a heavy pan by the rim, because pinch depends on a stable post to press against. Left untreated, chronic instability leads to arthritis of that joint over years. This is the reason an injury that feels like a simple sprain warrants a definite assessment: the cost of missing it is not felt in the weeks afterwards, when the thumb settles and seems fine, but much later. --- ### Thumb UCL Repair URL: https://www.cqupperlimb.com/education/hand/thumb-ucl-repair/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. The ligament involved is on the inner side of your thumb, at the joint where the thumb meets the hand. This operation repairs that ligament so the… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. The ligament involved is on the inner side of your thumb, at the joint where the thumb meets the hand. This operation repairs that ligament so the joint is stable again. We usually start with non-operative care. For a partial tear, a cast or splint can hold the thumb still while it heals, and this often leaves a stable, painless thumb. But when the ligament is torn right through, it often will not heal on its own. About 75% of complete tears fail to heal with splinting alone. The torn end of the ligament can also slip out of place, which stops it from rejoining the bone. If a tear like this is left untreated, it can cause long-term pain and trouble using your thumb. Surgery may be recommended straight away for a complete tear, or after splinting has not given enough improvement. The aim is a thumb that is stable, painless, and strong enough for gripping and pinching. Patient-reported pain and function improve at three and 12 months after repair compared with before surgery. ## Before the operation Your surgeon will plan the operation using scans of your thumb. This usually starts with an X-ray, which can show any small fracture where the ligament tore away. An MRI or ultrasound scan may also be used to show the ligament itself and confirm whether the torn end has slipped out of place. Before surgery, you will be given clear instructions. You should not eat for seven hours before your operation. This allows your surgery to be brought forward if the theatre list runs early. You may need to stop some medications, and your surgeon will tell you which ones and when. Bring a list of everything you take. Arrange someone to drive you home afterwards, and wear loose, comfortable clothing. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist there. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. Afterwards, you will wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you will either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves Your surgeon makes a small cut over the side of your thumb where the ligament tore away. Through this cut, they find the torn end of the ligament and prepare a small spot on the bone where it used to attach. The ligament is then stitched back down onto that spot using a small anchor set into the bone. This holds the ligament in place while it heals back onto the bone. If the ligament has been torn for a long time, the ends may be too worn to stitch together. In that case, your surgeon can rebuild the ligament using a nearby tendon from your own thumb, folded to form a new strap that joins the bone on either side of the joint. If the ligament tore away with a small piece of bone, that fragment is held back in place with a small plate and screws. Some repairs are strengthened with a ribbon-like tape stitched alongside the ligament. This tape acts like a temporary safety rope, sharing the load while the ligament heals. Because it takes some of the strain, your thumb may be able to start moving earlier than with a repair alone. Your surgeon may also place a small metal pin through the thumb joint to hold it still and protect the repair from side-to-side strain. The pin is removed later, once healing is under way. The cut is closed with stitches and covered with a dressing. You will go to the recovery area, and the nursing team will check on you as you come round. ## After the operation You will wake up in the recovery area, then move to the ward. Your hand will be in a splint or cast, with dressings over the wound. Nurses will keep you comfortable and give you pain medicine if you need it. You can get up and move around as soon as you feel able. Someone should stay with you for the first 24 hours at home. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Your thumb will be sore and swollen for the first days and weeks. This settles gradually. Keeping your hand raised when you are resting helps, as does the pain medicine your team gives you. You will go home in a splint or cast that protects the repair while it heals. Your day-to-day routine changes more than you might expect. You will need help with some tasks at first, especially anything that needs a firm grip, like opening jars or carrying heavy things. Most people find they can manage light daily tasks quite soon, and desk work within the ranges shown in the table on this page. Hand therapy is an important part of your recovery. Your hand therapist, Ruby Doolan at Extend Rehabilitation, will guide your exercises and make any splint you need as your thumb heals. The exercises start gently and build as the repair strengthens. As the swelling settles and movement returns, everyday tasks get easier. Once your surgeon is happy the repair has healed, you will gradually build back to heavier work, sport and the gym. The final result keeps improving for some time, as pain settles and strength returns. Recovery varies from person to person. Your timeline may differ from the typical ranges, and your surgeon and therapist will guide you at each stage. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The wound can become infected. You might notice redness spreading out from the cut, fluid or pus leaking from it, or a deep, throbbing pain that does not ease with simple painkillers. Call the clinic the same day if you notice any of these signs. Sometimes a small nerve near the thumb is irritated during surgery. This can cause numbness, tingling or a patch of odd feeling on the back of the thumb. Numbness and weakness in the first 24 hours after a nerve block are expected and settle as the block wears off. If numbness lasts beyond that, call the clinic. The joint can stay a little loose or stiff. Some people notice mild aching at the base of the thumb when they pinch or grip, or that the thumb does not bend quite as far as before. A few find their grip is not quite as strong. These changes are usually mild and often settle with time and hand therapy. Bring them up at your next review if they bother you. The repair itself can fail. This is uncommon, but a fall or a knock on the thumb in the early weeks can strain or tear the healing ligament again. You would feel sudden pain, swelling and a sense of the thumb giving way. Call the clinic if this happens. If a metal pin has been used to hold the joint still, the skin around it can become irritated or infected. Redness, tenderness or fluid around the pin site should be reported to the clinic the same day. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most people recover without problems, but some signs need quick attention. Go to the emergency department if you have swelling or pain in your calf, or shortness of breath or chest pain. These can be signs of a blood clot. Go to the emergency department if your thumb, hand or fingers turn pale, cold, white, blue or dark. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it. Call the clinic the same day if pain keeps getting worse despite your pain medicines. Numbness and weakness in the first 24 hours after a nerve block are expected and settle as it wears off. If numbness lasts beyond that, or you cannot move your thumb, hand or fingers once the block has worn off, call the clinic. If you cannot reach the clinic, out of hours or on a weekend, go to your nearest emergency department. --- ### Touch thumb arthroplasty URL: https://www.cqupperlimb.com/education/hand/touch-thumb-arthroplasty/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging if it is needed to confirm the diagnosis. Wear-and-tear arthritis at the base of the thumb is a common cause of pain and weakness. It can make pinching, gripping and turning a key hard to do. We usually try non-operative care first, such as changing how you use your hand, hand therapy and splinting. Surgery is considered when those measures have not given you enough improvement. This operation, a thumb joint replacement, replaces the worn joint at the base of your thumb with an artificial implant. It is typically offered to people with arthritis confined to that joint whose pain has not settled with non-operative care. We may have suggested it for you because it aims to relieve pain and restore movement, strength and stability so you can use your thumb with confidence. Most Touch implants are still in place at 2 years, with 96% implant survival reported. Whether this operation suits you is a decision we make together. ## Before the operation In the weeks before surgery we confirm the plan with imaging of your thumb, such as an X-ray, MRI or ultrasound. These pictures show the worn joint and help us plan the replacement. You will get clear instructions from our team about preparing. You will need to stop eating and drinking seven hours before your operation. We ask for seven rather than six so we can bring you forward if the theatre list runs early. Some medicines need to be paused, and we will tell you which ones and when. Bring a list of your current medications. Arrange for someone to drive you home afterwards. Wear loose, comfortable clothing. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day On the day of your operation you come to the hospital's surgical admissions unit. There you are checked in and prepared for theatre. You will meet the anaesthetist, the doctor who looks after your sleep and comfort during surgery. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. Afterwards you wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Once you are stable you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves Your surgeon makes a single cut over the base of your thumb to reach the worn joint. The damaged joint surfaces are removed and replaced with artificial parts: a small stem placed in the thumb bone and a cup fitted into the small bone next to it. The new parts are designed to move against each other like a healthy joint, so you can pinch and grip again. The aim is to keep your thumb at its natural length and line-up, which helps the thumb look and work as close to normal as possible. Because the joint is replaced rather than removed, the muscles and tendons that move your thumb do not have to work as hard to produce a pinch. When the replacement is in place, your surgeon closes the cut with stitches and applies a dressing. You will wake up with your thumb wrapped up, and the dressing stays on for about 10 days. Afterwards, a hand therapist guides your recovery. They show you how to move and use your thumb as it heals, and they guide when and how much to lift. Keeping heavy loads off the new joint helps it last. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You wake up in the recovery area, then move to the ward. Nurses check your pain and give you medicine to keep it comfortable. Your thumb will be wrapped in dressings and supported in a splint. Keep your hand raised on pillows when resting; this helps settle swelling. You can get up and walk around the ward, and you will use your other hand for most tasks. Please arrange for someone to stay with you for the first 24 hours at home. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your thumb will be sore and swollen. Keeping your hand raised on pillows helps the swelling settle. Simple pain medicine, taken as directed, keeps you comfortable while the worst passes. You will go home with your thumb in a splint, and the dressing stays on for about 10 days. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she shows you gentle exercises that keep your fingers moving while the new joint heals, and she makes any splint you need as your thumb recovers. She also guides when and how much to lift, because keeping heavy loads off the new joint helps it last. Day to day, you will use your other hand for most tasks at first. You cannot drive while the splint is on, because it stops you gripping the wheel safely. Once the splint is removed and your surgeon clears you, driving can begin; see our page on Driving after upper-limb surgery. As the swelling settles and movement returns, you will start using your thumb for light daily tasks, then build up to gripping and pinching without pain. Recovery varies from person to person. Your timeline may differ, and your surgeon and hand therapist will guide you at each step. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The new joint parts can sometimes loosen. This usually feels like a deep, aching pain at the base of your thumb that returns or worsens after a period of relief. If your thumb becomes painful again weeks or months after surgery, call the clinic so we can arrange imaging and see what is happening. The joint can also dislocate, meaning the new parts slip out of place. You would feel a sudden clunk, followed by pain and a thumb that will not move normally. Call the clinic straight away if this happens. A fracture of one of the small bones around the new joint can happen during or after surgery. This feels like sharp pain and swelling that is much worse than expected. Call the clinic so we can check it. Nerves near the thumb can be irritated or bruised. You might notice tingling, pins and needles, or numbness on the back of your thumb. Numbness and weakness in the first 24 hours after a nerve block are expected. Once the block has worn off, call the clinic if numbness stays or you cannot move your thumb or fingers. Infection is uncommon but serious. Call the clinic the same day if you have a fever, redness spreading out from the wound, or fluid or pus leaking from it. Go to the emergency department if your thumb turns pale, cold, white, blue or dark, as this can be a circulation problem. Some patients develop ongoing pain and sensitivity in the hand after surgery, sometimes with swelling and changes in skin colour or temperature. If pain keeps getting worse despite your pain medicines, call the clinic the same day. If the new joint does not work out, further surgery is sometimes needed. This can mean fixing or replacing the implant, or converting to a different operation that removes the worn joint and cushions the space with your own tissue. We will talk through the options with you if this ever arises. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up early, and we would rather hear about them soon. Call the clinic the same day if you have a fever, redness spreading out from the wound, or fluid or pus leaking from it, or if pain keeps getting worse despite your pain medicines. Call us if numbness stays or you cannot move your thumb or fingers once the nerve block has worn off, about 24 hours after surgery. Go to the emergency department if you have swelling or pain in your calf, shortness of breath or chest pain, as these can be signs of a blood clot. The same applies if your thumb turns pale, cold, white, blue or dark. If you cannot reach the clinic out of hours or on a weekend, go to your nearest emergency department. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Basal Thumb Arthritis page. --- ### Trapeziectomy URL: https://www.cqupperlimb.com/education/hand/trapeziectomy/ Region: hand · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging if it is needed to confirm the diagnosis. This operation is called a trapeziectomy. It means removing one small bone at the base of the thumb, the trapezium, which is where wear-and-tear arthritis has worn out the joint surface. We usually try non-operative care first, such as changing how you use your hand, hand therapy, and splinting. Surgery comes into the picture when those steps have not given you enough improvement. We may have suggested this operation because your thumb pain is limiting what you can do, or because the joint changes seen on your scans line up with your symptoms. Removing the worn-out bone takes away the painful surfaces that rub together. The aim is lasting relief from pain and a thumb you can use with more confidence in daily tasks. ## Before the operation Before your operation, we will give you clear instructions to follow. You will need to stop eating and drinking seven hours before your operation. We ask for seven hours rather than six so that we can bring you forward if the theatre list runs early. Your surgeon will tell you which of your regular medicines to stop and when. Bring a written list of everything you take. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing on the day. We will already have imaging such as X-rays, and sometimes an MRI or ultrasound, to plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day On the day of your operation, you come to the hospital's surgical admissions unit. There, staff check you in and prepare you for theatre. You will then meet the anaesthetist, the doctor who looks after your anaesthetic and pain relief during surgery. After that, you are taken into the operating theatre, where the operation is performed. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. When the operation is finished, you wake up in the recovery area. Nurses stay with you and keep an eye on you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and how your recovery is going. ## What the operation involves A trapeziectomy is done as an open operation through a single cut over the area being operated on, at the base of your thumb. Through that cut, your surgeon removes the trapezium, the small worn-out bone that sits between your thumb and your wrist. Taking the bone out removes the rough, painful surfaces that have been rubbing together. Once the bone is gone, the space it leaves fills in with your own scar tissue over time, and the thumb settles onto a cushioned pad instead of a worn-out joint. Your surgeon does not put in any artificial joint or implant. The wound is closed with stitches, and a dressing is placed over the top. The operation itself is straightforward, and it is done as day surgery, so you go home the same day. ## After the operation You may go home the same day or stay one night in hospital after this operation. Both are common, and your team will talk with you about which suits you. Your hand will be in a splint with dressings over the wound, and a sling can help you rest your arm comfortably in the first day or two. Nurses will show you how to manage the dressings and keep your hand raised to help with swelling. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Pain relief will be arranged before you leave, and the nurses will explain how to take it. Ask someone to stay with you for the first 24 hours after you get home. ## Recovery For the first few days your hand will be sore and swollen, and the wound area may throb. Keeping your hand raised on pillows, even when you are resting or asleep, helps the swelling settle. Take the pain relief as prescribed rather than waiting for the pain to build. Your thumb will rest in a splint while the wound heals. A hand therapist will show you gentle exercises to keep your fingers moving and stop stiffness setting in. You will be able to manage light daily tasks around the home using your other hand, but you will not grip, pinch or lift with the operated thumb while it is protected. You cannot drive while the splint is on, because it stops you holding the wheel safely. Once the splint is removed and your surgeon clears you, driving can resume; see our page on Driving after upper-limb surgery. As the weeks pass, the swelling settles and movement returns bit by bit. Hand therapy continues, and your therapist will gradually build up how much you use the thumb. Grip and pinch strength come back slowly, and many people notice their thumb feels less strong than before even once daily activities feel normal. The full benefit builds over time, and it is common for pain and strength to keep improving for up to a year. Your timeline may differ from someone else's. Your surgeon and your hand therapist will guide you at each step. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes a nerve near the thumb becomes irritated after surgery. This can feel like tingling, burning or numbness on the back of the hand or thumb. If this happens, it usually settles completely within a year. Mention it at your next review so we can keep an eye on it. The wires sometimes used to hold the bones in place can cause problems. The skin around the wire may become sore or irritated, or the wire can loosen or shift. A wire that moves usually needs to be taken out early, and this has not been found to harm the final result. Tell us at a review if the wire site becomes painful or the skin looks inflamed around it. Infection is uncommon but can happen in any wound. Watch for redness that spreads out from the wound, fluid or pus leaking from it, or fever. Call the clinic the same day if you notice any of these. Pain that keeps getting worse despite your pain medicines also needs a same-day call to the clinic. Very rarely, the blood supply to the thumb can be affected. Go to the emergency department if your thumb, fingers or hand turn pale, cold, white, blue or dark. If a tendon cushion is used to fill the space where the bone was, it can occasionally bulge under the skin. You might notice a soft lump or a tender, inflamed area near the thumb. This can usually be treated with a small operation to remove it, which relieves the pain. Some rarer problems are linked to more complex versions of this operation, such as artificial joint implants. These carry more risks than a simple trapeziectomy, which is one reason we favour the simpler option. If a first operation needs correcting later, the results tend to be less reliable than the first time around. We will talk through any of this with you before you decide. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up in the first few weeks, so it helps to know what to watch for. Go to the emergency department if you have swelling or pain in your calf, shortness of breath or chest pain, because these can be signs of a blood clot. Go to the emergency department if your thumb, fingers or hand turn pale, cold, white, blue or dark. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it. Call the clinic the same day if pain keeps getting worse despite your pain medicines. Numbness or weakness in the first 24 hours after a nerve block is expected. Once the block has worn off, call the clinic if you cannot feel or move your arm, hand or fingers. If you cannot reach the clinic, go to your nearest emergency department. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Basal Thumb Arthritis page. --- ### Trigger Finger URL: https://www.cqupperlimb.com/education/hand/trigger-finger/ Region: hand · condition Trigger finger causes painful catching or locking of a finger, often treated with splinting or steroid injection. ## What you're feeling Trigger finger affects the tendons that bend your finger or thumb. These tendons slide through a narrow tunnel in your palm called a pulley. When the tendon thickens, it catches as it moves through that tunnel. You feel pain and tenderness in the palm, at the base of the affected finger or thumb. Some people notice a small lump or knot in the palm there. That lump is the thickened part of the tendon or its tunnel, and it moves when the tendon moves. The catching usually starts as a mild annoyance and builds over weeks. Early on, your finger may click or catch when you bend and straighten it, and you may need to straighten it with your other hand. As it gets worse, the finger can lock in a bent position and stay that way. Many people find it is stiffest on waking, and the finger frees up as they move during the day. Gripping and pinching are what aggravate it, so tasks like holding a steering wheel, carrying shopping bags, using scissors or gripping a jar lid can become uncomfortable. Some people also feel aching on the back of the knuckle or middle joint of the same finger, even though the problem is in the palm. Trigger finger is common. It affects 2% to 3% of people, women more often than men, and it usually appears after age 45. If more than one finger triggers, it is worth mentioning this to your surgeon, as it can be linked with other conditions such as diabetes. Trigger finger also often travels with carpal tunnel syndrome, which causes pins and needles or numbness in the hand, and the two occur together in 40% to 60% of people with trigger finger. See your GP or ask for a specialist review if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand. ## What's actually happening The tendons that bend your finger are like ropes running through a set of guiding loops in your palm and finger. The first of these loops sits in the palm at the base of the finger. It is called the A1 pulley. When you grip or squeeze repeatedly, the tendon can become irritated where it slides through that loop. The irritated area thickens, so the rope no longer glides smoothly. Instead it bunches up and then jams through the narrowed loop, which is the catching or snapping you feel. The thickened spot on the tendon is often a small nodule, a knot of changed tissue a little wider than the rest of the rope. Each time you bend the finger, that knot has to squeeze under the pulley. It slips through with a click, then catches on the far side as you try to straighten. That is why the finger may lock bent and need your other hand to free it, and why the problem feels worst in the morning after a night of the finger resting in a bent position. Doctors describe how far this has progressed in four stages. The first is pain and tenderness in the palm at that first loop. The second adds catching of the finger. The third is locking that you can still straighten by pushing it with your other hand. The fourth is a finger stuck bent and no longer able to be straightened at all. Earlier stages often settle with simpler treatments, while a finger that is locked usually needs a small procedure to open the pulley so the tendon can glide again. Several things make this thickening more likely. Repeated firm gripping plays a part, which is why it is common in rowers and others who load their grip heavily. It is also linked with conditions such as diabetes, an underactive thyroid, gout and rheumatoid arthritis, where the tissue around the tendon becomes inflamed or changes in ways that narrow the tunnel. If several fingers trigger at once, that pattern is worth flagging, as it can point to one of these underlying conditions. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging only if it will change the plan. For a long-standing problem like this we usually try non-operative care first and consider surgery when that has not given enough improvement. The first step is settling your hand down. Changing how you grip and easing off tasks that load the palm, such as heavy carrying or firm squeezing, gives the irritated tendon a chance to settle. Hand therapy aims to restore smooth gliding of the tendon through the pulley and keep the finger's joints moving. A splint that holds the finger still can be part of this, and it works best when worn long enough: a single joint held still for 6 to 10 weeks is the duration the evidence supports, which is longer than most people expect. Give these measures a fair trial over several weeks before judging them. If simple measures have not settled things, an injection of cortisone into the tendon tunnel is the usual next step. Cortisone reduces the swelling and thickening that make the tendon catch. People with diabetes tend to respond less well to cortisone injections, which is worth knowing when choosing between options. Most people expect the injection to hurt more than it does, and say afterwards that it was easier than they had braced for. Surgery comes into the picture when the finger stays locked, or when injections and splinting have not given enough improvement. The operation releases the tight pulley at the base of the finger so the tendon can glide freely again. It is done through a small incision in the palm, and it is a straightforward, well-established procedure. We will talk through whether it suits you and decide together. Afterwards, your rehabilitation is hand therapy with Ruby Doolan at Extend Rehabilitation; she will guide your exercises and make any splint you need. ## What to expect Trigger finger rarely goes back to normal on its own once the finger is catching or locking. Early on, when there is only pain and tenderness in the palm, simpler treatments such as changing how you grip, hand therapy and a splint can settle things down. A splint needs to be worn long enough to work: for a single joint, 6 to 10 weeks is the duration the evidence supports. If those measures have not helped, a cortisone injection into the tendon tunnel settles the problem in a little over half of people, which is why a second injection or a move to surgery is a normal next step rather than a sign that something has gone wrong. When the finger has reached the locked stage, release of the tight pulley is the treatment that deals with the cause. The tendon can then glide through the tunnel again, and normal use of the finger or thumb is encouraged afterwards. Most people are glad they had it done. Still, it is honest to know the small print. About 1 in 20 fingers has a mild, short-lived problem afterwards, most often pain, stiffness or swelling around the wound. Stiffness that lasts happens in about 8.6% of people, and delayed wound healing in 1.2%. Serious problems such as nerve injury or deep infection are uncommon: nerve injury or lasting numbness occurs in 0.6%, and surgical site infection in 2.1%. About 1 in 200 fingers needs a second operation, and triggering comes back in 2.2%. A few things shape your outlook. If the middle joint of the finger has been aching for a long time before treatment, that joint pain may not fully settle even after the pulley is released. Having several fingers released at once tends to mean more postoperative pain and stiffness than releasing one finger. And people who have surgery within a month of a cortisone injection have a higher chance of a wound infection afterwards, which is worth factoring into timing. If your finger becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone See your GP or ask for a specialist review if your finger or thumb catches, locks bent, or needs your other hand to straighten it. The same applies if you have a tender lump in the palm that moves with the tendon, or if the catching is stopping you gripping, working or sleeping. If more than one finger triggers, mention this too, as it can point to an underlying condition such as diabetes. This matters even more in a child: a triggering finger or thumb in more than one digit, or triggering together with pins and needles or numbness, needs a specialist review rather than a watch-and-wait approach. Go to an emergency department the same day if your finger becomes hot, red, swollen and painful, especially with a fever, or if your fingers turn pale, cold, white or blue. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Trigger finger is worth the extra reading because the first-line treatment works a little over half the time, a figure rarely quoted, and because in children the same clinical picture means something different enough to change the investigation. ### The injection works, and the honest number is 57% Corticosteroid injection is the standard first intervention, and it is usually described simply as effective. The pooled figure from level I and II studies is more specific: corticosteroid injections are effective in 57% of patients with trigger finger. Despite the limitations of the included studies, it remains a recommended first-line treatment on the basis of its simplicity and symptom relief [1]. Fifty-seven percent is worth knowing before you have one. It reframes a second injection, or a decision to proceed to surgery, as the expected path for a substantial minority rather than as something having gone wrong. ### Splinting is a real alternative, and the duration is longer than most expect Where injection is unsuitable, in diabetes, for instance, where injections can disturb glycaemic control, orthotic management has a reasonable evidence base. The consistent finding across studies is that results were similar regardless of which joint was immobilised, with a recommendation that a single joint be immobilised for 6 to 10 weeks [2]. That duration is the part people underestimate. A splint worn for a fortnight is not a trial of splinting. ### Surgical release: the technique debate is settled, the approach question is not Release of the A1 pulley can be done open, through a small incision under direct vision, or percutaneously with a needle or blade. Pooling 548 patients, there was no significant difference between open and percutaneous techniques in the need for revision, complications, or post-operative pain, so both are appropriate [3]. The larger analysis of percutaneous release across 2,114 digits found it effective and safe, and added two useful details: ultrasound guidance may improve success, while success rates were not affected by the instrument used or by whether cortisone was given alongside [4]. A 2025 review of 685 patients found combining percutaneous release with corticosteroid injection was well tolerated with a low complication rate [5]. Taken together: the pulley needs dividing, and how that is achieved matters less than that it is achieved completely. The instrument does not determine the result. ### In a child, the same finding warrants a different response Paediatric trigger finger is not simply the adult condition arriving early. The presence of bilateral or multiple trigger digits, or concurrent carpal tunnel syndrome, should raise suspicion of an atypical underlying pathology such as mucopolysaccharidosis [6]. This is the single most clinically consequential item in this section. A child with more than one triggering digit, or with triggering plus nerve symptoms, warrants investigation for a systemic storage disorder rather than a straightforward release, because the hand finding may be the presenting sign of a diagnosis that has implications well beyond the hand. A single triggering thumb in an otherwise well child is a different and far more common situation. --- ### Trigger Finger Release URL: https://www.cqupperlimb.com/education/hand/trigger-finger-release/ Region: hand · operation Trigger finger release — understanding the condition, conservative treatments, and surgical options for a stuck or clicking finger. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging if it is needed. That tells us what is causing your finger or thumb to catch or lock. Trigger finger happens when a tendon in the finger or thumb catches as it glides through a tight tunnel in the palm. Non-operative care usually comes first. That can include a splint, hand therapy, or a steroid injection (a medicine placed near the tendon to settle inflammation). We consider surgery when these have not given enough improvement, or when the finger has become stuck in a bent position that can no longer be straightened. The operation itself is a release: a single cut is made over the area being operated on, and the tight part of the tunnel is opened so the tendon can glide freely. About 97% of people have complete resolution of their triggering after surgery. The aim is a finger or thumb that moves smoothly, without catching, locking or pain. ## Before the operation Most people need little preparation. You will be told not to eat or drink for seven hours before surgery. We ask for seven hours rather than six so your time can be brought forward if the theatre list runs early. Your surgeon will tell you which medicines to stop and when, and you should bring a written list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing on the day. Imaging such as an X-ray, MRI or ultrasound is sometimes arranged beforehand to help plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist (the doctor who gives the anaesthetic), but most people need neither. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist (the doctor who gives the anaesthetic). This operation can be done under local anaesthetic (an injection that numbs just the area of surgery, with you awake) or under general anaesthetic (fully asleep). Most people choose local: recovery is quicker and you can go home soon after. If you'd prefer to be asleep, that's also a reasonable choice; discuss it with your surgeon and anaesthetist. You are then taken into the operating theatre, where the operation is performed. Afterwards you wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. Most people having this operation go home the same day. Bring the driver you arranged in the previous section, and follow any instructions the nurses give you about your hand before you leave. ## What the operation involves The operation is called a trigger finger release. Your surgeon makes a single cut over the area being operated on, usually about 2 cm long. Through this cut, your surgeon reaches the tight part of the tunnel in your palm that the tendon glides through. The tight band of tissue is carefully opened, about 1 cm at a time, until the tendon can move freely. Your surgeon will then check that the finger or thumb bends and straightens smoothly without catching. For a trigger thumb, only one tight band needs releasing. For a finger, a second nearby band may also be opened. Your surgeon works carefully to protect the nearby nerves and to leave the deeper supporting bands of tissue in the finger untouched, because these keep the tendon working properly. Once the release is complete, the wound is closed with stitches. A compression dressing (a firm bandage) is placed over the hand. You will keep this dressing on for about 10 days, and the stitches are removed at 10 to 14 days. Normal use of your finger or thumb is encouraged straight away. If you have rheumatoid arthritis (a condition that causes joint inflammation), the plan may differ slightly. In that case, your surgeon may remove a small slip of tendon rather than release the band, because releasing it can allow the finger to drift sideways over time. Your surgeon will explain the exact plan for your hand before you consent. ## After the operation You will wake up in the recovery area, where nurses keep an eye on you while the anaesthetic wears off. This is a day case, so you will go home the same day. Your hand will have a compression dressing (a firm bandage) on it, and you can move your finger or thumb straight away. Some soreness is normal for the first day or two; simple pain relief from your pharmacist or GP is usually enough. Ask someone to stay with you for the first 24 hours. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Most people are back to driving within one to two weeks, once the wound is comfortable and they can grip and turn the wheel without protecting the hand. ## Recovery Most people are surprised by how quickly the hand settles. The area around the cut will be sore and a little swollen for the first few days. Simple pain relief from your pharmacist or GP is usually enough to keep you comfortable, and keeping your hand raised on a pillow when you sit or rest helps the swelling go down. Some tenderness around the scar can last longer than the rest, and this eases as the wound matures. You will move your finger or thumb straight away, and normal everyday use is encouraged from the start. There is no cast or brace to wear, just the dressing, which we leave on for about 10 days. When we see you, we will change or remove it and take out the stitches. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby will guide you through simple exercises that keep the finger bending and straightening smoothly, and she can make a splint if your hand needs one. You can do most things at home as soon as you feel able: eating, dressing, typing and light tasks around the house. Avoid heavy gripping, lifting and dirty or wet environments until the wound has healed. Once you can grip and turn the steering wheel without protecting the hand, driving is usually close by; see our page on driving after upper-limb surgery. Recovery varies from person to person, and your timeline may differ. Your surgeon and your therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The most common problems are minor ones around the wound, or a finger that feels stiff for a while. You might notice some ongoing soreness, swelling, or that the finger does not bend as freely as you expected in the early weeks. If this is not settling, bring it up at your next review. Infection is uncommon but worth knowing about. Watch the wound for redness that spreads out from the cut, increasing pain, warmth, or oozing. A deep infection can cause a deep, throbbing pain that does not ease with simple painkillers, and you may feel unwell. If you notice any of these signs, call the clinic straight away rather than waiting for your next appointment. A nerve near the surgery can occasionally be irritated. This feels like numbness, tingling or pins and needles in part of the finger or thumb. Some numbness at the wound edge is expected at first, but if it persists or spreads, mention it at your review. The triggering can come back in a small number of people. If the catching or locking returns after it had settled, let us know at your follow-up. Some people develop stiffness in the finger, where it does not straighten or bend fully even though the triggering has gone. Hand therapy exercises help prevent this, so keep up the movements Ruby has shown you. If the finger seems to be stiffening rather than loosening, tell your therapist or surgeon early. If your finger was triggering for a long time before surgery, the joint in the middle of the finger can stay achy even after the release. This tends to improve slowly rather than straight away. Finally, surgery for trigger finger is linked with a small chance of developing Dupuytren disease, a condition where firm cords form in the palm and pull the fingers bent. If you notice thickening or lumps in your palm later on, have it checked. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call the clinic straight away if you have a fever, or if redness, warmth or oozing around the wound is getting worse. Call us if pain suddenly becomes severe, or if numbness or tingling spreads and does not settle. Go to emergency if you have calf swelling or pain, or shortness of breath, as these can be signs of a blood clot. Go to emergency if you cannot move the finger or thumb at all, or if the hand becomes cold or pale. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Trigger Finger page. --- ### Surgery & Recovery URL: https://www.cqupperlimb.com/education/recovery/ Region: recovery · region-landing General guides that apply to most upper-limb operations — getting ready for surgery, looking after yourself in the early days at home, and getting back to driving, work and sport. ## Before your operation Preparing for Surgery General checklist for the days before upper-limb surgery — fasting, what to bring, medications. Open → The day of your surgery What to expect on the day of day-case upper-limb surgery, from arrival and meeting the team to waking up and going home. Open → Fasting Before Surgery: What You Can Eat and Drink, and Why Why you must stop eating before an anaesthetic, when you can still sip water, and what can happen if you do not fast. The clear fasting rules that keep your stomach empty and your lungs safe during surgery. Open → Your shoulder nerve block The nerve block we use for shoulder surgery — how it numbs your arm, why it controls pain so well, and what to expect as it wears off. Open → Blood Thinners Around Surgery How anticoagulants and antiplatelets work, and why the timing of stopping each before surgery differs — platelet turnover, half-lives and clot risk. Open → ## The first days and weeks Looking after your wound Dressings, showering, and signs of infection after upper-limb surgery. Open → Is my wound infected? How to tell normal healing from a wound infection after surgery — the warning signs and when to seek help. Open → Your wound check and stitch removal What happens at the post-op wound check, dissolvable vs removable stitches, what removal feels like, and when to seek help sooner. Open → Wearing and Sleeping in an Arm Sling How to sleep in an arm sling, get the sling position right, and look after it after shoulder, elbow or wrist surgery, including whether to keep the sling on overnight. Open → Cast and splint care at home Looking after a plaster or splint at home — keeping it dry, elevation, keeping joints moving, and the urgent signs of a too-tight cast. Open → Daily life after shoulder surgery Washing, dressing, sleeping and managing day-to-day with the operated arm in a sling after shoulder surgery. Open → Daily life after hand, wrist or elbow surgery Keeping a hand or wrist dressing dry, elevation to control swelling, and one-handed living after hand, wrist or elbow surgery. Open → Swelling and elevation after surgery Why a hand or arm swells after surgery, how elevation and gentle movement control it, and when swelling is a warning sign. Open → Managing pain after surgery What pain to expect, how to use pain relief well, and when to call. Open → Constipation and gut care after surgery Why constipation is common after surgery (especially with strong painkillers) and how to prevent and manage it. Open → Heat vs Ice When ice helps, when heat helps, and how to use either safely on the upper limb. Open → Preventing Blood Clots After Surgery Reducing the risk of deep vein thrombosis after upper-limb surgery — mobilisation, hydration, medication. Open → Scar Management Massage, silicone, sun protection and the 12-month timeline for surgical scars to soften and fade. Open → ## Getting back to normal Hand therapy basics What to expect from hand therapy, how often you'll go, and what good rehab looks like. Open → Driving After Shoulder and Arm Surgery: When Is It Safe and Legal? After most shoulder surgery, including rotator cuff repair, you usually cannot drive for about six weeks, and not while your arm is in a sling. When it is safe and legal to get back to the wheel after hand, wrist, elbow or shoulder surgery. Open → Returning to work When you can return to desk, light, and heavy work after upper-limb surgery. Open → Returning to sport Phased return to sport after upper-limb surgery, and when contact sport is safe again. Open → Flying and travel after surgery Clot risk, cast tightness at altitude, fitness to fly and the practicalities of travelling after upper-limb surgery. Open → ## Looking after yourself Eating well for healing Everyday food to support recovery after surgery — protein, energy, healing vitamins, and preventing constipation. Open → Sleep, Pain and Recovery How sleep and pain affect each other, why surgery and shoulder problems disturb sleep, and what helps you rest and recover. Open → Melatonin After Shoulder Surgery Why we prescribe melatonin after shoulder surgery, what the trial evidence shows, the dose we use, and what to expect from it. Open → Mind, Stress and Recovery How stress, low mood, anxiety and worry about pain affect recovery and surgical outcomes — and what helps. Open → Explore Surgery & Recovery in the evidence explorer → --- ### Fasting Before Surgery: What You Can Eat and Drink, and Why URL: https://www.cqupperlimb.com/education/recovery/anaesthesia-and-fasting/ Region: recovery · recovery Why you must stop eating before an anaesthetic, when you can still sip water, and what can happen if you do not fast. The clear fasting rules that keep your stomach empty and your lungs safe during surgery. On the day of surgery, two things matter most for your safety: the type of anaesthetic you have, and how strictly you follow the fasting instructions you were given. ## Why we ask you to fast A general anaesthetic relaxes the muscles that normally stop stomach contents from coming back up the throat. If your stomach is full, that material can spill into your lungs while you are unconscious, which is serious. Fasting empties the stomach, which makes this very unlikely. The standard rules are: - Nothing to eat or drink from the fasting time in your surgery details email. No food, no milk, no water, no tea or coffee, no lollies or chewing gum. The time is worked out from your admission time: usually seven hours before it, or midnight if you are admitted early in the morning. - If you take an injectable diabetes or weight-loss medicine (Ozempic, Wegovy, Mounjaro, Trulicity, Byetta), keep taking it, but your fast is 24 hours before your surgery time. These medicines slow the emptying of the stomach, and the usual fasting time is not enough. - If your procedure is under local anaesthetic only, your email will say that you do not need to fast. If you have your normal blood-pressure or epilepsy tablets in the morning, take them with a small sip of water unless your anaesthetist has told you otherwise. Diabetes tablets are not taken on the morning of surgery; aspirin and clopidogrel are continued, and anticoagulants such as warfarin stop 48 hours before; the blood thinners and preparing for surgery pages have the details. ## Types of anaesthesia we use Most upper-limb surgery is done under one of three approaches, sometimes combined: - General anaesthetic: you are fully asleep. The anaesthetist puts you to sleep through a small drip in the back of your hand and looks after you the whole time. - Regional block: local anaesthetic is injected around the nerves in your neck or armpit, numbing the whole arm for several hours. You may also be sedated so you sleep through the surgery, but you are not on a ventilator. - Local anaesthetic: small operations (like a trigger-finger release) can often be done with the area numbed and you fully awake, sometimes with light sedation. Your anaesthetist will discuss the options with you on the day. The choice depends on the operation, your general health, and what you prefer. ## What to expect on the day You'll arrive 1–2 hours before your scheduled theatre time. A nurse will check your fasting, place a drip, and go through a final consent form. The anaesthetist will see you in person before you go to theatre. After surgery you'll wake up in the recovery area. If you had a regional block, your arm will feel heavy and numb; this is normal and lasts 8–24 hours. Protect a numb arm: keep it in the sling, don't lean on it, and keep it warm. Sensation comes back gradually, often with some pins and needles. Nausea, drowsiness, and a sore throat (from the breathing tube) are common in the first few hours. Drink slowly, eat lightly, and rest. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Anaesthesia is worth the extra reading because the two things patients most want reassurance about, nerve damage from a block, and whether being "awake" is safer than being asleep, both have decent numbers attached, and neither answer is the one intuition supplies. ### The risk of lasting nerve trouble from a block Almost everyone having upper-limb surgery is offered a nerve block, and almost everyone asks whether the needle can damage the nerve. It is a fair question, and the honest answer needs a distinction: temporary altered sensation is not rare, and lasting injury is. A systematic review pooling 12,532 patients examined postoperative neurologic symptoms after regional anaesthesia for upper-extremity surgery, and its central point is methodological but important to you: the aggregate risk looks very different depending on how it is measured [1]. Prospectively assessed randomised trials, where someone actively asks every patient, report far higher rates than retrospective series, where only patients who complain loudly enough get counted [1]. The practical reading: if a study quotes you a very low figure, ask whether anyone went looking. Symptoms that resolve are common enough that they should be described to you as expected rather than as a complication; symptoms that persist are genuinely uncommon. ### Awake is not automatically safer There is a widespread belief, held by patients and not only patients, that avoiding a general anaesthetic must be safer, particularly in older people, and particularly regarding confusion afterwards. The most direct test of that comes from hip fracture surgery, where the question has been studied at scale because the patients are old and frail. Pooling 3,736 patients, regional anaesthesia did not significantly reduce postoperative delirium or mortality compared with general anaesthesia [2]. That is a genuinely surprising result and it deserves care in interpretation. It does not mean the choice is irrelevant, it means the choice should be made on the specifics of your heart, lungs, airway and the operation planned, rather than on a general belief that one category is safer. Modern general anaesthesia in a fit patient is very safe, and a block is not a free pass. ### Where blocks genuinely earn their place The strongest case for regional anaesthesia is not safety, it is pain. A systematic review of 1,872 patients undergoing surgical repair of proximal humerus fractures concluded that regional anaesthesia is a good option for postoperative analgesia [3], the first hours after a shoulder operation are the worst, and a block covers precisely that window. There is also more than one way to do it. For shoulder arthroscopy, a review of 1,382 patients found suprascapular nerve block was not more effective than interscalene block for pain control, but had a more favourable side-effect profile [4]. Interscalene blocks reliably produce a temporarily weak arm and can affect the nerve to the diaphragm, which matters if your breathing is already marginal. Where that is a concern, a different block is not a compromise, it is the better operation-specific choice. ### Why fasting is the way it is Fasting exists for one reason: an anaesthetised airway cannot protect itself, so stomach contents that come up can go down into the lungs. That event is rare and serious, and the fasting rule is the cheap insurance against it. The common error is treating "nil by mouth" as a competition. Prolonged fasting does not add safety, and arriving dehydrated makes you feel worse, makes cannulation harder and does nothing for your stomach. Clear fluids empty from the stomach quickly, which is why modern guidance permits them much closer to surgery than food. Follow the times you are given rather than the times you assume, and if surgery is delayed, ask, rather than sitting parched on the assumption that more fasting must be better. --- ### Blood Thinners Around Surgery URL: https://www.cqupperlimb.com/education/recovery/blood-thinners-around-surgery/ Region: recovery · recovery How anticoagulants and antiplatelets work, and why the timing of stopping each before surgery differs — platelet turnover, half-lives and clot risk. "Blood thinner" covers two families of medicine that work in completely different ways, and for upper-limb surgery our instruction depends on which family you take. Antiplatelet medicines such as aspirin and clopidogrel are continued. Anticoagulants such as warfarin, Xarelto, Eliquis and Pradaxa are stopped 48 hours before your operation. Knowing which one you take, and how it actually works, makes those two instructions far less mysterious. ## First, how does blood actually clot? A clot forms when platelets clump at an injury and a mesh of fibrin threads traps blood cells to seal it. OpenStax, Anatomy & Physiology, CC BY 3.0 To make sense of the different blood thinners it helps to know how your blood normally seals a leak, because each medicine interrupts a different step. When a blood vessel is cut or damaged, your body plugs it in two stages: - Platelets plug the gap: the fast first responders. Platelets are tiny cell fragments that circulate in the blood doing nothing until they are needed. The instant they meet a damaged vessel wall they turn sticky, pile onto the injury and clump together, forming a soft, temporary plug within seconds to minutes. Think of it as the body's emergency patch. - The clotting cascade sets the plug solid. That platelet plug is fragile on its own. To reinforce it, the blood runs a chain reaction called the clotting cascade, a series of proteins called clotting factors (most made by the liver, several of them needing vitamin K) that switch one another on in sequence, like a row of dominoes. The cascade finishes by turning a protein called fibrinogen into fibrin, a mesh of fine threads that weaves through the platelet plug and locks it into a firm, stable clot. So a finished clot is really platelets held together by a fibrin mesh. When it seals a wound that is exactly what you want; but the same process happening unwanted inside an artery or vein causes a heart attack, stroke or DVT. That is what blood thinners are prescribed to prevent. Here is the key to everything below: the two families of blood thinner each jam a different stage. Antiplatelet medicines blunt the first step (the platelets); anticoagulant medicines interrupt the second (the clotting- factor cascade). That single difference also explains why the timing before surgery is so different, because "undoing" a platelet is not the same as "undoing" a clotting factor. ## Antiplatelet medicines (aspirin, clopidogrel/Plavix, ticagrelor/Brilinta, prasugrel/Effient) These stop the tiny blood cells called platelets from sticking together to start a clot. - Aspirin and clopidogrel (and prasugrel) work irreversibly: once the drug reaches a platelet, that platelet is switched off for the rest of its life. Your body cannot turn it back on. The only way back to normal clotting is to make brand-new platelets, and platelets live only about 7–10 days, with roughly 10% replaced each day. A short break therefore achieves very little, and a long enough break to matter would leave a heart stent or a stroke risk unprotected for a week. That is why we do not ask you to stop them: the small bleeding risk is outweighed by the clot risk. - Ticagrelor is reversible; it lets go of the platelet rather than permanently disabling it, so it clears a little faster than the irreversible ones. - Aspirin and clopidogrel are continued. Do not stop them for your operation, and that includes the combination tablets (DuoCover, DuoPlidogrel, Piax Plus Aspirin). We ask whether you take them so that the team knows and can plan around it. If we do want you to stop a blood thinner, the instruction will be in your surgery details email; if your email carries no such instruction, keep taking everything as normal. ## Anticoagulants These work further down the clotting chain, on the clotting factors in the blood rather than on the platelets. Warfarin (Coumadin, Marevan). Warfarin stops your liver from making several vitamin-K-dependent clotting factors. It does not remove the factors already circulating; those have to be used up and cleared naturally, which takes about 5 days. Our instruction for warfarin is to stop it 48 hours before, so on the day it is still having some effect. That is expected; if we want a blood test (the INR) before your operation, we will arrange it and tell you. The newer tablets: DOACs (apixaban/Eliquis, rivaroxaban/Xarelto, dabigatran/Pradaxa, edoxaban). Each blocks a single specific clotting factor, and the body clears them quickly, with a half-life of around 12 hours. Because they wash out so fast, 48 hours is long enough for them to have largely cleared. Tell us if you have kidney problems, because the drug then takes longer to leave the body (especially dabigatran, which leaves mostly through the kidneys). They need no INR monitoring. Heparin / low-molecular-weight heparin (enoxaparin/Clexane) injections. Short-acting; used to prevent clots. Because they wear off in hours, if you are on injections you will be given a specific time for your last one. ## Why the timing is what it is — in one line Two rules, one for each family. Antiplatelet medicines (aspirin, clopidogrel and the combination tablets): keep taking them. A short break achieves little and a long one is dangerous, so we do not ask for either. Anticoagulants (warfarin, Xarelto, Eliquis, Pradaxa): last dose 48 hours before your operation. In practice: - Surgery on a Monday: last dose on the previous Friday night, or Saturday morning, depending on when you usually take it. - Surgery on a Friday: last dose on the previous Tuesday night, or Wednesday morning. Your surgery details email gives you the day and time worked out for you. ## What you must do - Bring an exact list of everything you take to your pre-operative assessment, including aspirin and supplements like fish oil, which also affect bleeding. - If you take aspirin or clopidogrel, keep taking them, and make sure we know. - If you take an anticoagulant, follow the last-dose day and time in your surgery details email, and the restart instructions you are given afterwards, exactly. - Never stop, start or change a blood thinner on your own, and don't assume your timing matches a friend's. - Tell every clinician involved that you take one. ## After your operation Blood thinners are restarted once the bleeding risk has settled, sometimes within a day, sometimes longer after higher-bleeding-risk surgery. You'll be told exactly when. The clot the medicine prevents doesn't disappear because you've had an operation, so restarting on time matters as much as stopping did. ## Call us if - You realise you took a dose you were told to skip, or skipped one you were told to take - You have unusual or heavy bruising or bleeding, blood in the urine or stool, black tarry stools, or bleeding that won't stop - You are unsure what to do with your blood thinner before your operation: always ask rather than guess --- ### Cast and splint care at home URL: https://www.cqupperlimb.com/education/recovery/cast-and-splint-care/ Region: recovery · recovery Looking after a plaster or splint at home — keeping it dry, elevation, keeping joints moving, and the urgent signs of a too-tight cast. A cast or splint holds your healing bone, tendon or joint perfectly still so it can mend in the right position. It will be with you for a few weeks, and how you look after it makes a real difference, both to your comfort and to how well things heal. Most of it is common sense, but a few points are worth getting right, and there is a short list of warning signs at the end that you should never ignore. ## Keep it clean and dry This is the single most important rule. A plaster cast that gets wet goes soft and crumbly and stops doing its job. A fibreglass (synthetic) cast holds its shape better, but the soft padding underneath still soaks up water, and damp padding sitting against your skin for hours causes itching, irritation and skin breakdown. - Cover it to shower or bathe. Use a proper waterproof cast cover or sleeve, or wrap it in a plastic bag sealed with tape at the top. Even when it's covered, keep the limb out of the direct stream of water and don't dunk it under; a determined splash finds its way in. - If covering is awkward, sponge-wash around it instead and keep the cast well clear of the water. - If it does get wet, dry the outside and the padding at the edges as best you can with a towel or a hairdryer on the cool setting (never hot; you can't feel a burn through a cast). If a plaster cast gets soaked through, soft, cracked or smelly, call us so it can be checked or replaced. A removable splint is easier: take it off as we've instructed, keep it dry, and let the skin underneath air and dry fully before you put it back on. Only remove it for the reasons and the length of time we've told you; it's there to protect a healing part. ## Never poke anything down inside The skin under a cast often gets itchy. It's very tempting to slide a knitting needle, pen, ruler or coat hanger down to scratch. Please don't. You can't feel how hard you're scraping, you can break the skin, and a small graze trapped in a warm, dark, padded space is exactly how an infection starts. You can also bunch up the padding and create a pressure point. If the itch is driving you mad, try tapping the outside of the cast, or blow cool air down it with a hairdryer on the cold setting. Don't put powder, lotion or anything else inside. If the itching is severe or there's a raw, sore spot, tell us rather than battling it yourself. ## Don't trim, cut or remove it yourself It can feel too tight, too long, or just in the way, but never trim, cut, bend or remove a cast or splint on your own. The shape and length are deliberate; cutting it can let the bone shift or leave a sharp edge that digs in. If it genuinely feels too tight or is rubbing badly, that's a reason to contact us, not to take scissors to it (see the warning signs below). ## Elevate to settle the swelling For the first few days, swelling is the main thing working against you, and gravity is the enemy. Keep the limb raised above the level of your heart as much as you can. - For an arm or hand, prop it on pillows when you're sitting or lying so the hand sits higher than your elbow, and your elbow higher than your shoulder. A sling helps during the day, but don't let the hand dangle. - Raising the limb lets fluid drain back rather than pooling in the fingers, which eases throbbing and stops the cast feeling tighter overnight. Some swelling and a snug feeling in the first 24–48 hours is normal and settles with elevation. Swelling that keeps getting worse, or that comes with the warning signs below, is not. Get in touch. ## Keep moving what you can A cast stops one part moving, but everything outside it should keep working gently; this prevents stiffness and keeps the blood flowing. - Wiggle your fingers and thumb regularly, several times an hour while you're awake, unless we've specifically told you a finger must stay still. - Move the joints that are left free: usually your shoulder and elbow if you have a forearm or wrist cast. Gentle shoulder circles and bending the elbow stop those joints seizing up while the wrist heals. - Don't force anything that's painful, and follow any specific exercises we've given you. ## Protect the cast and the skin - Don't bear weight on it or lean on it. It's there to rest the limb, not to take your weight. Leaning on a forearm cast puts pressure on the bone underneath and on your skin. - Keep an eye on the skin at the edges. A little redness where the cast meets the skin is common; raw, broken or persistently sore skin is not. - Keep the cast clean and avoid dirt, sand or small objects getting inside. ## When to seek help — don't wait Most casts settle down after the first day or two. But a cast that becomes too tight is a genuine emergency: it can squeeze the muscles and nerves inside, cutting off the blood supply (a condition called compartment syndrome), and that can cause permanent damage within hours. The warning signs below are your early alarm. Do not wait. Contact us the same day, or go to your nearest emergency department, if you notice any of the following: - Pain that is increasing, severe, or worse than you'd expect, especially pain that doesn't ease with your usual pain relief, or pain that feels deep and relentless. - The cast or splint feeling tighter rather than easier as the days pass. - Numbness, pins and needles, or burning in the fingers. - Fingers turning pale, white, blue, dusky or cold, or looking very swollen and not settling with elevation. - Not being able to move your fingers when you try. - A burning, rubbing or pressure spot under the cast: this can be a pressure sore forming. - A bad smell coming from the cast, or any discharge or fluid leaking out: a sign of a skin sore or infection underneath. - A fever or feeling generally unwell with any of the above. If you have several of these together, particularly severe pain plus numbness, coldness or colour change in the fingers, treat it as urgent and seek help straight away rather than waiting to see if it settles. It is always better to have a cast checked and find nothing wrong than to leave a tight cast on too long. For ordinary itching, mild swelling that settles with elevation, or a cast that's simply annoying, you can wait and raise it with us at your next clinic visit. When in doubt, ring the rooms; we would much rather hear from you. --- ### Constipation and gut care after surgery URL: https://www.cqupperlimb.com/education/recovery/constipation-and-gut-care-after-surgery/ Region: recovery · recovery Why constipation is common after surgery (especially with strong painkillers) and how to prevent and manage it. Constipation is one of the most common things people run into after an operation, and it catches a lot of patients by surprise. The good news is that it is predictable, which means it is also largely preventable. A little planning in the first few days, particularly around your painkillers, usually keeps everything moving comfortably. ## Why surgery slows your bowels down Several things gang up on your gut at once after an operation: - Strong (opioid) painkillers are the big one. Medicines like codeine, oxycodone, tramadol, tapentadol and morphine relieve pain well, but they also act directly on the bowel and slow it down markedly. This is the single most important cause. Unlike the drowsiness and nausea these tablets can cause (which usually wear off after a few days), the gut does not get used to opioids. The slowing-down lasts for as long as you keep taking them, so it needs to be managed deliberately rather than waited out. - You move around less. Walking and general activity help drive the natural muscular wave that moves things through your gut. Resting up after surgery quietens that down. - You eat and drink less. Reduced appetite, less fibre on board, and not drinking as much as usual all make stools harder and slower to pass. - The anaesthetic itself. A general anaesthetic temporarily makes the bowel sluggish, and it can take a day or two to wake back up properly. Put those together and a slow, blocked-up feeling for a few days is very common. It is uncomfortable, but in most cases it is not dangerous. ## The most important step: a laxative alongside your strong painkillers If you are sent home on opioids or codeine, the key message is this: start a laxative at the same time as the painkillers, from day one. Don't wait until you are already constipated and uncomfortable to begin. Because these painkillers reliably slow the gut, the sensible approach is to stay ahead of the problem rather than chase it. Your pharmacist can recommend a suitable over-the-counter laxative; a common choice is a gentle stimulant such as senna, sometimes combined with a stool softener (docusate). Take it regularly while you are on the strong painkillers, not just as a one-off. If we have prescribed or suggested a specific laxative for you, follow that. The other half of the message is just as important: step down off the strong painkillers as soon as your pain allows. As pain settles over the first days, move from opioids onto simpler options like paracetamol (and an anti-inflammatory if you have been told one is suitable for you). The less opioid you take, the less your bowels are slowed, and coming off them is one of the best things you can do for your gut, as well as for your overall recovery. There is more on this on our page about managing pain and opioids after surgery. ## Keep things moving — the everyday basics Alongside the laxative, a few simple habits make a real difference: - Drink plenty of fluids. Water through the day keeps stools soft and helps the laxatives work. This matters even more if you are on painkillers. - Eat fibre as your appetite returns. Fruit and vegetables, wholegrain bread and cereals, beans and pulses, and especially prunes or prune juice, all help. A warm drink in the morning can also nudge things along. - Keep moving as much as you are allowed. Even gentle, regular walking around the house helps wake the bowel up. Stick within any limits we have given you for your operation, but don't spend all day sitting still. - Answer the call promptly. When you feel the urge, don't hold on, and give yourself unhurried time. A footstool that raises your knees a little can make passing a stool easier. One small caution: bulk-forming fibre supplements (such as psyllium / Metamucil) are not the best choice in the early days after surgery, particularly if you are not drinking much, because they need a lot of fluid to work and can otherwise make things worse. Food fibre and the laxative approach above are more reliable at this stage. ## What is normal, and when to be patient It is normal not to open your bowels for a couple of days after an operation, especially if you have had an anaesthetic and some strong painkillers. A bloated, sluggish feeling that gradually eases as you get moving, drink more, cut back the opioids and let the laxatives work is to be expected and is nothing to worry about. Most people are back to their usual pattern within a week or so. ## When to seek help — don't wait Constipation is usually a nuisance rather than a danger, but occasionally the bowel can become genuinely blocked or fail to wake up after surgery (a condition called an ileus). The warning signs below are your cue to get reviewed rather than to keep waiting. Contact us, your GP, or your nearest emergency department if you notice: - No bowel movement for several days together with a swollen, bloated, painful tummy, particularly if it is getting worse. - Nausea or vomiting alongside not being able to open your bowels or pass wind: this can signal that the bowel is blocked or has stopped moving. - Severe or worsening abdominal (tummy) pain or cramping. - Any bleeding from the back passage, or blood in the stool. - A fever or feeling generally unwell along with any of the above. If you have several of these together, especially a distended, painful tummy with vomiting, treat it as urgent and seek help straight away. For ordinary slow bowels in the first few days, the fluids-fibre-movement-laxative plan above will almost always sort it out. When in doubt, ring the rooms. We would much rather hear from you. --- ### Daily life after hand, wrist or elbow surgery URL: https://www.cqupperlimb.com/education/recovery/daily-life-after-hand-wrist-elbow-surgery/ Region: recovery · recovery Keeping a hand or wrist dressing dry, elevation to control swelling, and one-handed living after hand, wrist or elbow surgery. After surgery on your hand, wrist or elbow, your arm will usually be in a bandage, splint or cast for the first week or two. It may feel awkward and a little clumsy at first, and ordinary jobs suddenly need some planning. This page walks you through the practical side of those first days and weeks: how to keep the dressing dry, how to settle the swelling, and how to manage the small frustrations of living one-handed for a while. Most of it comes down to two simple habits: keep it dry, and keep it up. ## Keeping the dressing or cast dry Your dressing, splint or plaster needs to stay completely dry until we take it down or change it. A wet dressing or a damp cast traps moisture against the wound, and that is exactly where infection starts. A soggy plaster also loses its shape and stops doing its job. For showering, the easiest approach is to cover the whole dressing with a waterproof bag or a purpose-made cast cover before you get in. A large plastic bag sealed at the top with a couple of rubber bands or tape will do the job; reusable waterproof cast and arm covers are inexpensive, slide on with one hand, and seal more reliably if you would rather not fuss with bags. Keep the covered arm out of the direct stream of water and pointed slightly downwards so any splashes run away from the opening rather than into it. If you would rather not risk a cover at all, simply wash with the arm held out of the water: sit on a chair beside the bath or hang the arm outside the shower screen and keep it clear of the spray. A handheld shower head makes this much easier. Whichever way you wash: - Never let the plaster or dressing get wet. If it does get damp, pat the edges dry and let us know, as a wet cast usually needs changing. - Pat dry around the edges of the dressing afterwards; don't tuck a towel underneath or poke anything inside. - Don't be tempted to remove or re-wrap the dressing yourself to "air it out" unless we've shown you how. ## Keeping your hand up — elevation If there is one thing that makes the biggest difference in the first few days, it is keeping the hand and forearm raised above the level of your heart. When the hand hangs down, blood and fluid pool in it, and that is what causes the throbbing, the tight swollen fingers and a lot of the early stiffness. Lifting the hand lets that fluid drain away. So for the first three to five days, keep it up as much as you possibly can: - When you're sitting or lying down, rest the hand on a pillow or two so it sits higher than your chest, not down in your lap. - When you're up and walking about, a sling keeps the hand supported and elevated. - Keep it up even when it feels comfortable. Elevation prevents swelling far better than it cures it once it has set in. At the same time, unless we've specifically told you otherwise, keep the fingers moving: gently make a fist and stretch them straight, a few times an hour. Moving the fingers pumps the swelling out and stops them stiffening. Give your shoulder and elbow a gentle move through the day too, so they don't get stiff from being held still in a sling. ## Managing one-handed For a while, your operated arm is mostly out of action, and you'll be doing most things with your other hand. A bit of forward planning makes this far less frustrating: - Dressing: choose loose, front-opening clothes: shirts and jackets rather than things you pull over your head. When you dress, put the operated arm in first, and take it out last when undressing. Slip-on shoes and elastic waistbands save a lot of fiddling. - In the kitchen: prepare simple meals, use pre-cut or easy-open foods, and let the bench or a damp cloth hold things steady instead of your hand. A non-slip mat under a bowl lets you stir or mix one-handed. - Washing and grooming: a long-handled sponge, a pump bottle of soap and a toothbrush propped against the basin all help. - Ask for help with two-handed jobs: opening jars, carrying shopping, cutting up food, lifting anything heavy. This is the time to let other people pitch in. - Most importantly, don't use the operated hand for gripping, lifting or leaning on until we've told you it's safe. Even if it feels okay, the repair underneath needs time to heal, and weight-bearing too early can undo it. Treat the hand as "along for the ride" rather than a working hand for now. ## Sleeping Swelling and throbbing are often worse at night, simply because the hand ends up flat or hanging off the bed. Prop the hand and forearm up on a pillow beside you so it stays raised overnight, tucked alongside you rather than under you. Many people find it most comfortable to sleep on their back, or on the un-operated side with the sore arm supported on pillows in front. If you were given a splint to sleep in, wear it as instructed. ## When to seek help Some discomfort, bruising and mild swelling are completely normal in the first days. But the dressing and cast are firm, and the limb inside is swelling, so there are a few warning signs that mean the dressing or cast may have become too tight and is squeezing the nerves and blood supply. These need urgent attention. Seek help straight away (go to your nearest emergency department or call us) if you notice: - numbness, or pins and needles in the fingers that doesn't settle when you elevate the hand - fingers turning pale, white, blue or cold - severe or steadily increasing pain that your tablets aren't touching, especially pain that feels worse than you'd expect - being unable to move your fingers, or pain when you try to straighten them - the cast or dressing feeling uncomfortably tight, as though it's gripping Any of those together suggest the dressing is too tight and the limb needs to be released without delay; don't wait to see if it settles. Also contact us during the day if you notice signs of a wound problem: - the dressing becomes wet, soaked, or smells unpleasant - spreading redness, heat or swelling around the wound - fluid or pus leaking through, or a wound that has come open - a fever or feeling generally unwell For ordinary swelling, bruising and aching, the answer is almost always the same simple recipe: keep the hand up, keep the fingers moving, and stay on top of your pain tablets. It settles steadily over the first week or two. --- ### Daily life after shoulder surgery URL: https://www.cqupperlimb.com/education/recovery/daily-life-after-shoulder-surgery/ Region: recovery · recovery Washing, dressing, sleeping and managing day-to-day with the operated arm in a sling after shoulder surgery. For the first few weeks after shoulder surgery your arm lives in a sling. Your hand still works (you can grip, write and use a phone), but the arm itself needs to stay supported and at rest. The repair we have done needs time to heal undisturbed, which means the arm must not actively lift, reach or take weight until you are cleared. The good news is that almost everything in daily life can still be managed one-handed, with a few tricks and a little planning. This page is the practical companion to our separate guide on wearing a sling (that guide covers how the sling goes on and how long you wear it); this one is about getting through the day. A bit of honesty up front: most people find the first couple of weeks the hardest, and many need a hand with washing, dressing and a few household tasks at the start. That is completely normal and temporary, and eases steadily as the weeks pass. Lining up some help in advance makes a real difference. ## Washing and showering Good news on washing: your dressings are waterproof, so you can shower and let the water splash over them: a normal shower is fine. The rule is splash, don't scrub or soak: don't rub at the dressing with a flannel or sponge, and avoid baths, swimming or holding the shoulder under water, which can lift the edges and let water track underneath to the wound. Let the water run over it, then pat (don't rub) the area dry afterwards. If a dressing peels at the edges or comes loose, leave it and let us know. Many people sit on a shower stool for the first weeks (it lowers the risk of slipping while you are off-balance and one-handed). You can usually take the sling off to wash, but the principle is to keep the arm still and supported, not to use it. Let it rest against your side or in your lap. If your surgeon has said it is allowed, you can lean your body gently forward and let the arm hang loosely from the shoulder, using gravity rather than your own muscles, so the arm stays completely relaxed. Never actively lift or reach with it to wash. The armpit on the operated side is the awkward one, because you cannot lift the arm to get into it. The trick is to lean your upper body away from that side and let the arm relax and drift gently outward under its own weight; this opens the armpit enough to clean and dry it with a flannel or wet wipe, and to apply deodorant. Let gravity do the work; do not hitch the shoulder up to make room. Hair and back are genuinely hard one-handed. A long-handled sponge helps for the back. For hair, leaning over the basin or asking someone to help for the first week or two is the easy answer; it is not worth a contortion that strains the shoulder. Dry shampoo can bridge a few days if you would rather wait. ## Getting dressed Choose your clothes for the week ahead with the sling in mind: - Loose and front-opening. Button-up or zip-front shirts, cardigans and large-armhole tank tops are far easier than anything snug. Avoid fiddly small buttons and hooks while you are working one-handed. - Avoid over-the-head garments. Tight T-shirts and jumpers that have to go on overhead force the shoulder into exactly the movements we are trying to avoid. - Dress the operated arm first, and undress it last. Feed the resting arm gently into the sleeve before your good arm, and slip the good arm out first when undressing. This keeps the operated shoulder from having to stretch to catch up. - Slip-on shoes. Laces are nearly impossible one-handed; slip-ons or Velcro save a lot of frustration. Elastic laces are a cheap fix for shoes you already own. ## Sleeping Sleep is often the hardest part of the early weeks, and one of the most common frustrations, but it settles steadily as the shoulder calms down. Lying flat lets the arm drift backwards and pulls on the shoulder, so most people sleep far better semi-upright: in a recliner, or propped up on several pillows or a back wedge in bed. A few things make a real difference: - Support the whole arm. Tuck a pillow under the elbow and forearm so it cannot drag down on the shoulder, and put a pillow at your side so you do not roll onto the operated shoulder in your sleep. - Settle the pain first. Many people take their pain relief about half an hour before bed so it is working by the time they lie down. - Mind the strap. A thin singlet or T-shirt under the sling stops it rubbing or chafing your neck overnight. Whether you keep the sling on while you sleep, and how long you will be wearing it, is covered in our separate guide on wearing a sling. ## Eating, cooking and around the house Almost all of this is workable with your good hand plus the gripping hand of the operated side; the key is to slide and steady rather than lift: - Slide heavy pots, plates and the kettle along the bench instead of carrying them. Fill the kettle to only the level you need so it is lighter. - A non-slip mat under a bowl or chopping board lets one hand do the work of two. Simple one-handed aids (a jar opener, a plate guard, rocker-blade cutlery) are inexpensive and genuinely helpful. - Prepare ahead. Batch-cooking and stocking some easy meals before surgery, and moving everyday items (mug, cereal, medications) to bench-height where you can reach them without stretching, removes a lot of daily hassle. - Get help with the heavy and awkward jobs: full laundry baskets, shopping, changing bedding, anything two-handed and lifted. There is nothing to prove by struggling with these; let the shoulder heal. ## Keep the rest of the arm moving A sling rests the shoulder, not the whole arm. Unless you have been told otherwise, gently and regularly move the parts that are allowed to move: - Hand and wrist: open and close your fingers, and circle the wrist, a few times an hour. This keeps them supple and helps pump away swelling. - Elbow: if your surgeon has said it is allowed, take the arm out of the sling a few times a day and gently straighten and bend the elbow (keeping the shoulder still) so the elbow does not stiffen. - Posture: it is easy to hunch protectively around a slinged arm. Sit tall, draw the shoulder blades gently back now and then, and roll the good shoulder, to ease the neck and upper-back tightness that the sling tends to cause. These are general principles; your own movement rules come first. Every operation has its own dos and don'ts, so if our written instructions or your physiotherapist say something different about your elbow or shoulder, follow that. ## When to seek help Most of recovery is uneventful, but contact us, your GP, or seek urgent care if you notice any of the following: - Pain that is increasing and not controlled by your prescribed painkillers, or that suddenly becomes much worse. - Wound problems: spreading redness, heat, swelling, or fluid or pus leaking from the wound, especially with a fever or feeling unwell. - Fingers that go numb, cold, pale or blue, or swell tightly: this can mean the sling or a dressing is too tight, or circulation is affected. Loosen the sling and seek advice promptly. - Calf pain, swelling or redness in a leg, or sudden breathlessness or chest pain: these can signal a blood clot and need urgent medical attention. Call 000 for sudden breathlessness or chest pain. When in doubt, it is always better to ask. We would far rather hear from you early than have you wait and worry. --- ### Driving After Shoulder and Arm Surgery: When Is It Safe and Legal? URL: https://www.cqupperlimb.com/education/recovery/driving-after-upper-limb-surgery/ Region: recovery · recovery After most shoulder surgery, including rotator cuff repair, you usually cannot drive for about six weeks, and not while your arm is in a sling. When it is safe and legal to get back to the wheel after hand, wrist, elbow or shoulder surgery. Driving after upper-limb surgery is both a medical and a legal question. The short answer: you can drive again when you can safely control the vehicle in all foreseeable situations, including an emergency stop with both hands on the wheel, and your surgeon and treating clinicians agree. ## The legal position Under the Austroads Assessing Fitness to Drive guidelines used across Australia, the driver is responsible for being fit to drive at all times. Insurers may refuse a claim if you were driving against medical advice. If you are still in a sling, splint, or cast, do not drive. If you cannot hold the steering wheel firmly with both hands or operate the gear-stick or indicators, do not drive. ## Typical timelines These are general guides; your surgeon will give you a specific date. Operation Earliest typical return Carpal tunnel release 1–2 weeks (when the wound is comfortable) Trigger finger release 1–2 weeks Wrist ganglion excision 2–3 weeks Elbow nerve release 2–3 weeks Distal biceps repair 6 weeks (when out of the brace) Rotator cuff repair 6 weeks (out of sling, with surgeon sign-off) Shoulder replacement 6 weeks Wrist fusion 6 weeks (once the splint is off) Finger joint fusion 4–6 weeks (once the splint is off) Latarjet / shoulder stabilisation 6 weeks ## Practical test Before you drive on the road, sit in a stationary car and try: - Both hands on the wheel for 5 minutes without your arm tiring - Turning the wheel fully both ways - Reaching across to the gear-stick and indicators - Pretending to perform an emergency stop If anything is awkward or painful, you are not ready. ## Insurance Tell your insurer if your doctor has told you not to drive and you choose to drive anyway; your cover may not apply. If you are unsure, ask your insurer in writing. ## Long drives Take more breaks than usual for the first month back. Stiffness and fatigue build up faster than you expect. --- ### Preventing Blood Clots After Surgery URL: https://www.cqupperlimb.com/education/recovery/dvt-prophylaxis-at-home/ Region: recovery · recovery Reducing the risk of deep vein thrombosis after upper-limb surgery — mobilisation, hydration, medication. Blood clots in the leg veins (deep vein thrombosis, or DVT) are most often discussed after hip and knee surgery. The risk after upper-limb surgery is much lower, but not zero: being in a sling and moving less than usual is enough to nudge it up. A few simple habits at home keep that risk where it should be. ## Why upper-limb surgery still carries some risk After shoulder or elbow surgery you are often less mobile for the first week or two. You may sleep upright in a chair, walk less, and avoid long outings. Sitting still slows the blood flow in your leg veins, and that is the main thing that makes a clot more likely. A few things raise the baseline risk further: a previous DVT or pulmonary embolism, a strong family history of clots, the combined oral contraceptive pill or hormone replacement therapy, recent long-haul travel, smoking, obesity, and some medical conditions including cancer and inflammatory bowel disease. If any of these apply to you, your surgeon may have specifically recommended blood-thinning tablets or injections; follow that advice exactly. ## What you can do every day Most patients do not need blood-thinning medication after upper-limb surgery. The protective habits below are usually enough: - Keep walking. Five short walks around the house are better than one long one. Aim for movement every hour you are awake, even if it's just to the kettle. - Move your ankles often. While sitting, point your toes up and down twenty times every hour. This pumps blood out of the calf veins. - Drink water. Two litres a day. Dehydration thickens the blood; pain medications and reduced appetite both push you towards drinking less than usual. - Don't sit cross-legged for long periods, and don't sit in a recliner with strong pressure under the knees. - Avoid long-haul flights for at least two weeks after major surgery if you can. If you must fly, walk the aisle every hour and wear compression stockings. Smoking dramatically raises clot risk; if you have stopped for the operation, this is a great window to keep going. ## Warning signs — call us or go to the emergency department - One calf becomes painful, swollen, warm, or red compared to the other side - Sudden shortness of breath, chest pain, or coughing up blood: go straight to the emergency department, this can be a clot in the lung (pulmonary embolism) - Dizziness or fainting with any of the above Don't wait for your follow-up appointment if any of these happen. Treated early, blood clots are very manageable; left late, they can become dangerous. --- ### Eating well for healing URL: https://www.cqupperlimb.com/education/recovery/eating-well-for-healing/ Region: recovery · recovery Everyday food to support recovery after surgery — protein, energy, healing vitamins, and preventing constipation. Good food won't make an operation heal overnight, but eating well genuinely helps your body do its repair work, and eating poorly can slow it down. After surgery your body is busy: knitting a wound together, laying down new tissue, and mending tendon or bone. All of that runs on the food you give it. The good news is that you don't need anything special, fancy or expensive. A normal, balanced diet, with a little attention to a few things, covers almost everything your healing needs. ## Protein — the main building block If you remember one thing, make it this: protein is the raw material your body repairs itself with. New skin, healing tendon, bone and the cells that fight infection are all built from it. In the weeks after surgery your need for protein actually goes up, just when many people are eating a bit less than usual. Try to include a protein food at every meal rather than saving it all for dinner: - lean meat, chicken, fish (tinned fish like tuna or salmon is easy) - eggs - milk, cheese and yoghurt - beans, lentils and chickpeas - tofu, nuts and nut butters You don't need to weigh or count anything. A simple rule of thumb is a palm-sized serving of a protein food at each main meal, plus protein-rich snacks like a yoghurt, a handful of nuts, cheese and crackers, or a glass of milk. ## Enough energy overall Healing burns energy, so your body needs enough fuel to do it. This is not the time for a crash diet or to try to lose weight. Cutting your intake right back leaves your body short of the energy it needs to mend, and recovery can stall. Aim to eat regular, balanced meals as you normally would. If your appetite has dropped (which is common after an operation, an anaesthetic, or while you're on strong painkillers), it often works better to eat small amounts more often rather than facing a big plate. Nourishing snacks between meals, and choosing foods you actually feel like eating, both help while your appetite finds its feet again. ## The vitamins and minerals that help you heal A varied diet with plenty of fruit, vegetables and wholegrains supplies the vitamins and minerals your repair work relies on. The ones that matter most after surgery are: - Vitamin C helps build collagen, the scaffolding your body uses to close and strengthen a wound. It's in citrus fruit, berries, kiwifruit, tomatoes, capsicum and leafy greens. - Zinc supports wound healing and your immune system. Good sources are meat, seafood, eggs, dairy, nuts, seeds and wholegrains. - Vitamin D and calcium matter especially after a fracture or bone surgery, because they're what bone is rebuilt from. Calcium comes from dairy, fortified plant milks, tinned fish with soft bones and leafy greens; vitamin D mostly comes from sunlight, with smaller amounts in oily fish and eggs. If you've had bone surgery, it's worth a look at our bone health page. - Iron helps carry oxygen around your body and rebuild your blood, which is useful if you lost blood during your operation. Red meat, eggs, beans, lentils and green vegetables all supply it, and having a vitamin-C food alongside helps you absorb the iron from plant sources. You'll notice these all come from ordinary, everyday foods. Eat a reasonable mix across the week and you'll cover them without thinking too hard about any single one. ## Keep things moving — fibre and fluids One very common, very unwelcome part of recovery is constipation. Strong pain medicines (especially anything with codeine or oxycodone in it) slow the bowel right down, and being less active than usual makes it worse. A little planning heads it off. - Drink plenty of fluids through the day: water is ideal. This alone makes a real difference. - Eat fibre: fruit, vegetables, wholegrain bread and cereals, oats, beans and lentils all help keep things moving. - Keep gently active within whatever limits we've given you; even short, regular walks help your bowel along. If you know you'll be on strong painkillers for more than a day or two, it's sensible to keep up the fluids and fibre from the start, and to ask your pharmacist about a gentle laxative rather than waiting until you're uncomfortable. ## Do you need supplements? For most people, the answer is no. If you're eating a reasonably balanced diet, you'll get what you need from food, and there's no good evidence that piling on extra vitamin pills makes a healthy person heal faster. The sensible exception is correcting a known shortfall. If a blood test has shown you're low in something (vitamin D or iron are the usual ones), then topping that up genuinely helps. That's different from taking a handful of supplements "just in case." If you're already taking supplements, or you're thinking about a specific one, it's worth a quick word with us or your GP, as some can interact with medicines or shouldn't be taken around surgery. (Our separate page on nutritional supplements for musculoskeletal health goes into this in more detail.) If you have diabetes, there's one thing worth real attention: keeping your blood sugars well controlled. High blood sugar interferes with healing and raises the risk of wound problems and infection, so the weeks around surgery are a good time to be on top of your levels and to follow your usual diabetes advice closely. ## Eating one-handed while your arm's out of action After upper-limb surgery, the practical problem often isn't what to eat but how to prepare and eat it with one arm in a sling. A bit of forward planning makes a big difference: - Stock easy, no-fuss protein: yoghurt, cheese, tinned fish, eggs, milk, nut butter, hummus, baked beans, pre-cooked chicken. - Prepare ahead while you can. Batch-cook and freeze meals before your operation, or cook extra in the days after so you've got portions ready to reheat one-handed. - Buy things ready to go: pre-cut vegetables and fruit, grated cheese, microwave rice, ready meals, and easy-open packaging. - Set yourself up to eat comfortably: a non-slip mat under the plate stops it sliding, and simple meals such as a sandwich or a one-pot dish are far easier than food that needs a knife and fork together. - Accept help. If family or friends offer to drop in a meal or do a shop in the first week or two, say yes; it's one of the easiest ways for them to help, and it takes the pressure off. ## Seek advice if Most people eat their way through recovery without any trouble. But have a word with us, your GP or a dietitian if: - your appetite is persistently poor, or you're losing weight without meaning to - you're having trouble swallowing, or food or drink makes you cough or choke - you have diabetes and your sugars are running high or are hard to control - you've been told you have a deficiency (such as low iron or vitamin D) and aren't sure how to put it right Eating well is one of the few parts of recovery that's genuinely in your own hands. You don't have to get it perfect, just aim for regular, balanced meals with protein at each one, plenty of fluids, and enough variety to cover the vitamins and minerals. Your body will do the rest. --- ### Flying and travel after surgery URL: https://www.cqupperlimb.com/education/recovery/flying-and-travel-after-surgery/ Region: recovery · recovery Clot risk, cast tightness at altitude, fitness to fly and the practicalities of travelling after upper-limb surgery. Most people travel again happily after upper-limb surgery, and a recent operation is rarely a reason to cancel a trip outright. But surgery does change a few things, and a long journey (especially a long-haul flight) deserves a little planning. The points below are the ones worth thinking through before you book or set off. If any of them apply to you, the safest move is simply to check with us first. ## Clots on long journeys Sitting still for hours on a long flight, train or car trip slightly raises the risk of a clot forming in the deep veins of the leg, what's called a deep vein thrombosis, or DVT. Recent surgery raises that risk too, so the two together are worth taking seriously, particularly on flights longer than about four hours. The good news is that the things that lower the risk are simple, and they're the same things that make any long journey more comfortable: - Move regularly. Get up and walk the aisle every hour or two if you can, and on a car journey, stop and stretch your legs. - Work your calves while seated. Pump your ankles up and down, and circle your feet, several times an hour. This is the calf muscle's job: to push blood back up the leg, and it matters most when you can't get up. - Stay well hydrated, and go easy on alcohol and caffeine, both of which dry you out. - Some people are advised to wear compression flight socks: ask us whether that applies to you. We have a separate page on preventing clots at home after surgery that goes into the warning signs of a DVT and what to do about them. It's worth a read before you travel, since the same advice applies on the move. ## Swelling, altitude and your cast The cabin of an aircraft is pressurised to roughly the equivalent of a mountain altitude, not sea level. At that lower pressure, tissues tend to swell a little, and a hand or arm that's already healing can swell more than usual. If you're in a cast, that swelling has nowhere to go, and the cast can start to feel tighter during the flight. This matters most with a brand-new cast. A fresh, full (unsplit) plaster applied in the days before you fly may need to be split along its length first, so it can open slightly and accommodate the swelling. Most airlines expect this for a recently applied cast, and it's a sensible precaution regardless. Don't assume your cast is ready to fly in: check with the team before you travel, and we'll split it or advise you if needed. Whether or not you're in a cast, keep the arm elevated during the journey, resting it up on the tray table or a folded jacket, or in a sling, so fluid drains back rather than pooling in the hand. And know the warning signs of a cast that's become too tight (increasing pain, numbness, pins and needles, or fingers that turn pale, cold or blue). These are covered on our cast-care page, and they need attention straight away, not at the end of the flight. ## How soon is it safe to fly? This is the question to ask us directly, because the honest answer is it depends, on the operation you've had, whether you had a general anaesthetic, how you're healing, and how long and how far you're travelling. As a general guide, the first days to weeks after an operation or a general anaesthetic are when caution matters most, and longer flights warrant longer waits than short hops. For bigger procedures, surgeons and airlines often suggest avoiding long-haul travel for a few weeks either side of surgery. But these are minimums and broad rules of thumb; your situation may be quite different in either direction. So if you're planning to fly soon after surgery, or you're booking a long-haul trip, please get clearance from us before you commit to dates. It's a quick conversation, and far easier to have before the tickets are booked than after. ## Airport security and your hardware If your operation involved metal (a plate, screws, wires or a small implant) you may wonder about airport scanners. In practice, the small hardware used in most hand and upper-limb surgery is rarely large enough to set off security scanners (large metal joint replacements are a different story). You don't usually need an "implant card" or a doctor's letter, and one isn't required to fly. That said, if you'd like the reassurance, you can ask us for a brief note or carry your implant details, and if a scanner does flag, simply tell the security officer you've had surgery. They deal with this routinely and will guide you through. ## The practical things A few odds and ends that make travel after surgery smoother: - Plan for luggage you can't lift. You won't be able to carry, lift or drag bags with the operated arm, so pack light, use bags with wheels, and arrange help: porters, travelling companions, or assistance booked through the airline. - Protect the arm in crowds. A sling not only supports the arm but signals to people around you to give it room in a busy terminal or cabin. - Tell your travel insurer. This is the one not to skip: declare your recent surgery, including any implants or planned procedures, to your travel insurance provider. An undeclared recent operation can leave you uncovered for anything related to it, which is exactly when you'd want the cover. A quick call or online declaration sorts it out. - Carry your medication (and any pain relief) in your hand luggage, with a copy of your prescription for longer trips. ## Check with us before you travel or fly None of this is meant to put you off a trip. Most people travel after surgery without any trouble at all. But a few situations are genuinely worth a quick word with us before you go: - you're planning to fly soon after your operation or a general anaesthetic - you have a long-haul flight or a long journey ahead - you're in a fresh or full cast, or you're not sure whether it needs splitting before you fly - you've had a clot before, or you have other reasons to be at higher risk A short conversation lets us tailor the advice to your operation and your trip: when it's safe to fly, whether your cast needs attention, and anything specific to your recovery. When in doubt, ring the rooms before you book. --- ### Hand therapy basics URL: https://www.cqupperlimb.com/education/recovery/hand-therapy-basics/ Region: recovery · recovery What to expect from hand therapy, how often you'll go, and what good rehab looks like. Hand therapy is physiotherapy and occupational therapy that focuses on the hand, wrist, and elbow. After most upper-limb surgeries you will see a hand therapist regularly; they are the people who turn a successful operation into a successful recovery. ## What hand therapists do A hand therapist will: - Remove and replace your dressings and check the wound - Make a custom splint where one is needed (this is often moulded directly to your hand from a sheet of warm thermoplastic) - Teach you exercises to keep stiffness down without overloading the repair - Track your progress against a recovery timeline - Tell your surgeon if something isn't healing the way it should ## How often will I go? Most upper-limb operations involve 6–12 sessions over 3–6 months. The first appointment is usually within the first week or two after surgery once the dressing is changed. Sessions are typically 30–45 minutes. ## What does a session look like? Sessions usually have three parts: checking the wound and any splint or sling, doing the exercises with the therapist watching technique, and upgrading your home exercise plan for the next week. You will also get specific guidance on what daily activities you can and can't do, using cutlery, writing, computer work, lifting. ## What good rehab looks like The right amount of effort is just enough that the area gets a little warm and a little tired, but doesn't swell up overnight or hurt for hours afterwards. If exercises hurt, that is information; tell your therapist; they will adjust the dose. Pain is not the goal. --- ### Heat vs Ice URL: https://www.cqupperlimb.com/education/recovery/heat-vs-ice/ Region: recovery · recovery When ice helps, when heat helps, and how to use either safely on the upper limb. After an injury or operation, "should I use heat or ice?" is one of the most common questions we get asked. The short answer is ice for swelling, heat for stiffness, but the timing matters more than the choice. ## Ice — for the first few days Ice is most useful in the first 48 to 72 hours after a fresh injury or after surgery. It works by narrowing the blood vessels under the skin, which slows the inflammatory response and reduces swelling and pain. How to use it well: - 15 to 20 minutes at a time, no longer - Always wrap the ice pack in a tea towel; never put ice directly on skin - In the first week after surgery, icing every hour or so is fine if it helps; after the first few days, three or four times a day is usually enough - Stop if the skin goes numb, white, or bright red A bag of frozen peas wrapped in a towel works as well as any purpose-bought ice pack. Cheap and reusable. ## Heat — once the swelling has settled Heat helps stiff, aching muscles and joints, but it makes acute swelling worse. Switch from ice to heat once the early swelling has settled: for many operations that happens during the first week or two, and your therapist will guide the change. While the limb is still swollen, stay with ice. The exception is surgery done to release a stiff joint (capsular release, arthrolysis): there, heat before stretching is encouraged from the start. How to use it well: - A wheat bag heated in the microwave, a hot water bottle, or a warm shower all work well - 20 minutes at a time - Don't sleep with a hot pack on; burns happen when the skin is pressed against a heat source for hours Heat is especially helpful before exercises or physiotherapy sessions: it loosens stiff tissue so you can stretch further with less discomfort. ## When neither helps If your pain is getting worse rather than better, or if the limb is red, hot, increasingly swollen, or starting to look different from the other side, that's not a heat-or-ice question: call your treating clinician. ## Quick rule of thumb Stage What it feels like Use First 2-3 days Throbbing, tight, swollen Ice Week 1-2 Settling but stiff Either, follow your therapist's lead Week 2 onwards Stiff but not swollen Heat before exercises, ice after if sore Anytime Sharp pain that wasn't there before Phone, not packs --- ### Is my wound infected? URL: https://www.cqupperlimb.com/education/recovery/is-my-wound-infected/ Region: recovery · recovery How to tell normal healing from a wound infection after surgery — the warning signs and when to seek help. After an operation it is completely natural to keep a close eye on your wound and wonder whether it's healing as it should. The good news is that the great majority of surgical wounds heal without any trouble at all. A few even look a little angry in the first day or two and then settle down perfectly. The aim of this page is simple: to help you tell ordinary, healthy healing apart from the handful of signs that mean you should pick up the phone. The single most useful thing to remember is the direction of travel. Normal healing gets a little better every day. An infection gets worse: the redness creeps outward, the pain climbs instead of easing, and you start to feel off in yourself. If things are steadily improving, that is reassuring. If they are clearly going the wrong way, that is your cue to act. ## What's normal in the first few days In the first few days a healing wound often looks and feels like this, and none of it is cause for alarm: - A thin line of mild redness right at the wound edges. A narrow pink or red rim hugging the incision is the body doing its repair work. It should stay close to the wound, not spread out across the surrounding skin. - Some bruising around the area, which may spread and change colour (purple, then green-yellow) as it fades over a week or two. - Mild swelling and a snug, slightly firm feeling around the incision. - A small amount of clear or blood-tinged ooze in the first day or so, especially onto the dressing. Early drainage that is thin and clear or only faintly pink is expected. - Tenderness that steadily improves. The wound will be sore to begin with, but the soreness should ease day by day as the days pass. If your wound is following this pattern (settling, drying up, becoming less sore) it is almost certainly healing exactly as it should. ## The warning signs of infection Get in touch if you notice any of the following, especially if more than one is present or they are getting worse: - Redness that is spreading or expanding away from the wound, rather than staying as a thin line at the edges. - Pain that is increasing after the first 2–3 days: pain that climbs or becomes throbbing once it should be settling, rather than easing. - The area feeling hot to the touch. - Increasing swelling around the wound. - Pus, or yellow or green discharge: thick, cloudy or coloured fluid (quite different from the early thin, clear ooze). - An unpleasant smell coming from the wound or dressing. - The wound edges opening up or pulling apart rather than knitting together. - Red streaks spreading up the limb away from the wound. - Feeling generally unwell, feverish, hot and cold, or shivery. None of these on its own means disaster, but together they are the body signalling that the wound needs attention rather than just time. ## What to do If you think your wound might be infected, don't sit on it for days hoping it settles. Contact the surgical team (ring the rooms) or your GP promptly so it can be looked at. A wound infection caught early is usually a straightforward problem: a course of antibiotics, started in good time, sorts most of them out without any drama. The thing that turns a minor infection into a bigger one is leaving it too long. We would always far rather hear from you and find that all is well than have you wait at home while a treatable problem builds. When you call, it helps to be able to describe what you're seeing: how the redness has changed, whether there's any discharge and what colour it is, whether the pain is better or worse than yesterday, and whether you feel unwell in yourself or have had a temperature. ## When it's urgent — seek same-day care Most wound concerns can be sorted with a prompt phone call in working hours. But some signs point to a deeper or spreading infection and need urgent, same-day review, via your surgical team, an after-hours service, or your nearest emergency department: - A fever, or feeling hot and cold, shivery or genuinely unwell. - Redness that is spreading quickly across the surrounding skin. - Red streaks running up the arm away from the wound. - Rapidly increasing pain or swelling, or the wound edges opening with significant discharge. These can be signs that an infection has gone beyond the skin, and they shouldn't wait. Trust your instinct; if something feels clearly wrong, it is always better to be checked and reassured than to leave it. For everyday questions about looking after your healing wound, dressings and showering, see our wound care page. And whenever you're unsure, ring the rooms; that's exactly what we're here for. --- ### Managing pain after surgery URL: https://www.cqupperlimb.com/education/recovery/managing-post-op-pain/ Region: recovery · recovery What pain to expect, how to use pain relief well, and when to call. Some pain after surgery is normal and expected. The aim of post-operative pain management is not to feel nothing; it is to feel comfortable enough to sleep, do your exercises, and start moving again. ## What pain to expect Pain is usually worst on the day of surgery and the day after, then improves steadily over the first 1–2 weeks. By 4–6 weeks most patients have only occasional discomfort with activity. Throbbing or aching at night is common in the first week; keeping the arm elevated on pillows often helps. If your operation was done under local anaesthetic, the area will be numb for around 6–12 hours afterwards; rarely, this can continue for 2–3 days. Start your regular painkillers before the numbness wears off, not after the pain arrives. After shoulder surgery under a nerve block the numbness likewise usually wears off within 6–12 hours, though rarely it can continue for 2–3 days. Sharp, electric-shock pains can occur as nerves recover. They are unpleasant but normal and usually settle within a few weeks. ## Your discharge painkillers You will be prescribed painkillers after your procedure. In most cases they are dispensed before you leave hospital; if you are discharged after the hospital pharmacy has closed, you will be given a prescription instead, sometimes sent to your phone by SMS with a printed token in your discharge pack. Any pharmacy can fill it, including the hospital pharmacy. The prescription has two layers, and they are used differently: Regular painkillers: take these on schedule, not just when pain peaks: - Paracetamol 1 g (two standard tablets) every 4–6 hours, no more than 4 g (eight tablets) in 24 hours - Ibuprofen 400 mg every 8 hours, with food, unless you have a contraindication such as stomach ulcers or kidney disease, or have been told to avoid anti-inflammatories (your surgeon will tell you if bone healing is a concern) Breakthrough painkillers: only if pain is not controlled by the regulars: A stronger painkiller is usually prescribed alongside: most commonly tramadol, tapentadol (Palexia) or oxycodone, and sometimes two of these. Exactly which you receive depends on your anaesthetist, so take them as directed on your prescription label. The patterns that hold across all of our anaesthetists' regimens: - Use breakthrough tablets only when the regular painkillers aren't enough; they are not a substitute for them. - If you have been given two strong painkillers, start with the milder one; switch to the other if it isn't enough or makes you feel sick. - At night, one breakthrough tablet before bed is often all that is needed. By the second week, most patients need them only at night, if at all. - Some patients benefit from a breakthrough dose before hand-therapy or physiotherapy sessions; your therapist will tell you at the first appointment if that applies to you. - Aim to wind the strong painkillers down through the second week. They cause constipation and drowsiness, and become less effective the longer you take them. The discharge prescription is deliberately limited. If you think it will not be enough for your recovery, see your GP early after discharge rather than waiting until you run out. ## Side effects worth knowing about - Constipation: tramadol, tapentadol and oxycodone all cause it. Eat fibre and drink plenty of water from day one; if that isn't enough, a Movicol sachet once or twice a day settles it. - Nausea: if a strong painkiller makes you sick, switch to the alternative if you have one. If you were given ondansetron at discharge, take one tablet for nausea or vomiting. - Drowsiness: do not drive or make important decisions while taking strong painkillers. ## Non-medication strategies These work surprisingly well alongside the tablets: - Ice: place an ice pack over the wound for 15–20 minutes every hour or as needed in the first week. Never put ice directly on the skin; always wrap it in a bag or towel (see Heat vs ice) - Elevation: keep the hand higher than the elbow, the elbow higher than the heart. Less swelling means less pain - Movement: your prescribed exercises hurt a little but reduce stiffness, which is what makes a joint ache - Distraction: watching something you enjoy genuinely lowers pain perception in the early days ## When to call us - Pain that is getting worse rather than better after the first few days - Pain not controlled by the medications you've been given - New severe pain that came on suddenly - Calf pain or swelling (rare, but a sign of a blood clot) - Chest pain or shortness of breath: go to the emergency department --- ### Melatonin After Shoulder Surgery URL: https://www.cqupperlimb.com/education/recovery/melatonin-after-shoulder-surgery/ Region: recovery · recovery Why we prescribe melatonin after shoulder surgery, what the trial evidence shows, the dose we use, and what to expect from it. If you have had shoulder surgery with us, or are about to, you may have been given a prescription for melatonin alongside your painkillers. This page explains why we prescribe it, what it does and does not do, and how to take it. ## Why you have been given melatonin Sleep is one of the hardest parts of the first few weeks after shoulder surgery. The shoulder aches more lying down, you cannot get into your usual position, and the sling makes settling awkward. Broken sleep then makes the pain feel worse the next day. Our page on sleep, pain and recovery covers the practical side of that: positioning, timing your painkillers, and sleep habits. We now routinely prescribe melatonin after shoulder surgery because a good-quality trial in keyhole rotator cuff repair found that it improved sleep in the early weeks, and that patients who took it went on to report better shoulder function and used fewer strong painkillers in the months that followed. Melatonin is gentle, it is not habit-forming, and it does not interact with pain medication the way conventional sleeping tablets do. For a temporary problem with a predictable end, that is a good trade-off. ## What melatonin is Melatonin is a hormone your own body makes at night, released by a small gland in the brain once it gets dark. It is the signal that tells the rest of the body it is night-time. The tablet is a synthetic copy of that hormone. It is not a sedative. A sleeping tablet forces sleep on you; melatonin nudges the body clock and makes falling asleep, and staying asleep, easier. That is why it is usually taken an hour or so before bed rather than at the moment you want to be asleep, and why it works best as part of a regular bedtime routine. ## What the evidence shows The shoulder trial. In 2024 the Rothman Orthopaedic Institute in Philadelphia published a randomised trial of 80 patients having keyhole rotator cuff repair. Half took 5 mg of melatonin an hour before bed every night for six weeks, starting the day of surgery; the other half followed standard sleep-hygiene advice. Those taking melatonin had measurably better sleep at six weeks, rated their sleep quality higher out to six months, scored higher on a standard shoulder-function questionnaire at four and six months, and were using fewer opioid painkillers at four months. No side effects were reported in either group. It is one trial, from one centre, and the patients knew which group they were in, so the result should be read as encouraging rather than definitive. It is, however, the best evidence available for exactly the situation you are in. Other operations. Melatonin has been tested after many kinds of surgery. Pooling ten trials and 725 patients, it produced a small improvement in sleep quality after surgery overall. After hip and knee replacement, several placebo-controlled trials found little or no benefit beyond the first few nights. So melatonin is not a universal fix, and we do not claim it is. The shoulder result is the most convincing, which is why we use it there. Sleep improves anyway. It helps to know the natural course. After rotator cuff repair, sleep is usually at its worst around the two-week mark, clearly better by six weeks to three months, and back to normal for most people by six months, and it stays that way years later. Melatonin is there to make those first weeks easier. It is not a long-term treatment and you will not need it once the shoulder has settled. ## How we prescribe it - Dose: 2 mg to 5 mg, depending on your circumstances; your script will say which. - When: about an hour before your usual bedtime, at roughly the same time each night. - How long: from the night of surgery, or your first night home, for around six weeks, which is the period the trial covered. Then simply stop; there is no need to taper off. - Why a script: in Australia melatonin is a prescription medicine for most adults. The only over-the-counter form, a 2 mg slow-release tablet from a pharmacist, is approved for people aged 55 and over with insomnia. Because the dose and the reason are different after surgery, we write a script so that you get the right form. Take it alongside, not instead of, the other things that help: sleeping propped up for the first couple of weeks, wearing your sling at night as instructed, taking your regular painkillers on schedule so they are working before you lie down, and ice in the evening. ## Side effects and cautions Melatonin is well tolerated by most people. The commonest complaints are feeling a little groggy in the morning, vivid dreams, headache or mild nausea. Morning grogginess usually settles by taking the tablet a bit earlier in the evening or dropping to the lower dose. It is not addictive and there is no withdrawal when you stop. You will not be driving in the early weeks after shoulder surgery in any case; once you are cleared to drive, be aware of morning drowsiness for the first few days back behind the wheel. Avoid alcohol on the nights you take it. Tell us if any of these apply, so we can adjust the plan: - you take warfarin or another blood thinner, as melatonin can affect clotting tests - you have epilepsy or an autoimmune condition - you are pregnant or breastfeeding - you already take a sleeping tablet or an antidepressant ## What to expect Do not expect to be knocked out on the first night. The benefit in the trial showed up over weeks, as sleep gradually consolidated, rather than as a dramatic change on night one. If pain is what is waking you, the fix is pain control and positioning first; melatonin will not override a shoulder that is not comfortable. If it does not seem to help you, or you would rather not take it, that is fine. It is an optional part of your recovery, not an essential one. Tell us at your review and we will take it off your list. ## The bottom line Poor sleep after shoulder surgery is common, temporary, and worth treating. One good trial found that six weeks of melatonin makes the early weeks easier and may pay off in function later; the drug is gentle and non-addictive. That is why it is on your prescription. ## When to call us - Pain that is getting worse rather than better, or that your medications are not controlling - Daytime drowsiness or confusion that is more than mild - A rash, swelling of the face or lips, or difficulty breathing after a dose: stop the tablets and go to the emergency department - The usual wound and general warning signs listed on the sleep, pain and recovery page --- ### Mind, Stress and Recovery URL: https://www.cqupperlimb.com/education/recovery/mind-and-stress/ Region: recovery · recovery How stress, low mood, anxiety and worry about pain affect recovery and surgical outcomes — and what helps. Pain and mood travel together. Anyone who has had a bad week and noticed their shoulder hurting more already knows this. It does not mean the pain is imagined, and it does not mean it is your fault. It means the nervous system that carries pain and the part of you that worries are the same system, and it is worth understanding how they interact before an operation rather than discovering it afterwards. ## What stress does to pain Think of your nervous system as an alarm. Its job is to tell you when something is wrong. In a calm, rested body the alarm is sensitive but accurate: a real injury sets it off, ordinary movement does not. When you have been in pain for months, sleeping badly, or under strain at home or at work, the alarm gets turned up. It starts going off for things that are not dangerous: a light touch, a small movement, the weight of a blanket. The pain is real, but it is now bigger than the injury causing it. Doctors call this central sensitisation. In plain terms, the wiring has become over-sensitive, and worry, poor sleep and fear all turn the dial further. This is why two people with the same operation, done the same way, can have very different first weeks. The repair is the same; the alarm settings are not. ## Why it matters for your operation If you are living with anxiety or low mood, your recovery is likely to follow a different path from the textbook one. You will probably report more pain in the early weeks, and your scores on the questionnaires we use may climb more slowly. You will still get most of the benefit of the operation; you may just feel it later, and feel less sure of it along the way. Two specific things deserve a mention: - Fear of moving the arm is the single thing most likely to hold a recovery back. It is completely understandable. The arm hurts, it has just been operated on, and moving it feels like it must be doing harm. But a repair that is not moved stiffens, and stiffness is much harder to undo than it is to prevent. The exercises you are given are the treatment, not an optional extra. - Worry that starts after surgery is worth telling us about. People who become newly anxious or low in the weeks after a shoulder operation are more likely to end up back in hospital, usually over pain they were not expecting. Expecting it, and having a plan for it, is most of the answer. None of this changes whether you should have the operation. It changes how we prepare you for it. ## The habit that helps most: moving, gently, every day The exercises from your surgeon or hand therapist are deliberately small and deliberately boring. They are meant to be done several times a day, within the limits you have been given, whether or not you feel like it. Some tips that make it easier: - Do them by the clock, not by how you feel. Tie them to something you already do: after each meal, or each time you make a cup of tea. - Expect some discomfort and know the difference. A stretch that eases as you settle into it is fine. Sharp pain that gets worse, or pain that stays raised for hours afterwards, is not, and means you should ease off and let us know. - Rehearse the movement in your head. Sitting quietly and imagining the wrist bending, in detail, several times a day, sounds odd, but it has been shown to improve movement, grip and function after a wrist fracture [10]. The brain practises the movement even when the joint cannot yet. Try it before each set of exercises. - Keep the rest of you moving. Walk every day. The arm is in a sling; you are not. ## Simple things that help - Protect your sleep. Poor sleep and pain feed each other, and after shoulder surgery in particular sleep is hard. The sleep, pain and recovery page has practical steps. - Use your pain relief as prescribed in the first days, rather than waiting until pain is severe and then chasing it. See managing pain after surgery. - Keep a routine. Get up at the usual time, get dressed, eat at normal times. Days without shape are days when pain fills the space. - Listen to music you like. This is not a platitude. In a randomised trial, patients who had music therapy during shoulder replacement surgery had a greater fall in pain and anxiety scores than those who did not [11]. Headphones in the waiting area and at home cost nothing. - Slow breathing. Four seconds in, six seconds out, for a couple of minutes, several times a day and whenever pain spikes. It is the quickest way to turn the alarm down a notch. - Stay connected. Being one-handed is isolating. Say yes to visits and lifts, and let people help with the things that need two hands. - Go easy on alcohol and caffeine, both of which make sleep worse and anxiety louder. - Judge progress over weeks, not days. Recovery is not a straight line. A bad day in week three is not a failed operation. ## If you already live with anxiety or depression Tell us. It is common, it is not a reason to avoid surgery, and knowing about it lets us plan around it. - Keep taking your medication. Do not stop antidepressants or anxiety medication before surgery unless the doctor who prescribed them tells you to. Stopping suddenly makes the days around an operation harder. - Line up your supports before the day. If you see a psychologist or counsellor, let them know your surgery date. If you do not, and you would like to, your GP can arrange it. - Treating the anxiety helps the arm. In patients with anxiety or depression having a rotator cuff repair, treating the mood problem in the weeks around surgery improved not only distress but also shoulder movement and function in the first three months [12]. Your mind and your shoulder are not separate projects. ## When to seek help Call the rooms if: - pain is far worse than you were told to expect, or is not improving at all by the time you were told it should - you find yourself unable to do your exercises because of fear rather than because of pain - you notice new anxiety or low mood after your operation that is not lifting See your GP if low mood or worry lasts more than a couple of weeks, if you are not sleeping at all, or if you have stopped doing the things you normally enjoy. If you have thoughts of harming yourself, do not wait for an appointment. Call Lifeline on 13 11 14, any time, or 000 in an emergency. ## In more depth Advanced reading: the deeper science (optional) This section is for the reader who wants the evidence rather than the summary. The research on mind and orthopaedic recovery has grown quickly, and the honest picture is more nuanced, and more hopeful, than "anxious people do worse". ### Mental health shapes where you start, not only where you finish In patients undergoing revision rotator cuff repair, pre-operative mental health status showed the strongest association of any factor with baseline pain, function and satisfaction scores, before anything had been operated on [1]. That matters for interpreting everything that follows: if you begin from a lower score, a smaller final score can still represent the same amount of improvement. ### Anxiety and depression change the path, less so the destination A prospective cohort study of hip replacement found that anxiety and depression symptoms were associated with inferior outcomes, with recovery trajectories that differed from those of patients without such symptoms, despite major clinical improvement in both groups [2]. After patellar stabilisation surgery, patients with major depressive disorder, or with depression that had never been diagnosed, reported worse scores before and after surgery, but still benefited significantly from the operation [3]. At two years after hip arthroscopy, a history of anxiety or depression was consistently associated with poorer patient-reported outcomes, whereas resilience showed a weaker and less consistent association [4]. The repeated pattern is a shifted curve rather than a flat one: the benefit is real, and it is measured from a lower starting point. ### It is not a rule Two upper-limb studies push back on any simple story. After thumb base arthroplasty, a history of depression did not appear to worsen patient-reported outcomes [5]. And in surgery for painful nerve endings (neuromas) in the arm, patients with lower pre-operative mental health scores reported similar or greater improvements in pain, and similar improvements in function, to everyone else [6]. Mood is a factor, not a verdict. ### The modifiable part is fear of movement The psychological factor with the clearest mechanical consequence is kinesiophobia, the fear that movement will cause harm. After arthroscopic stabilisation of a dislocating shoulder, kinesiophobia adversely affected functional recovery and return to sport [7]. A related trait, pain catastrophising (the habit of expecting the worst from pain), predicted dissatisfaction six months after spinal surgery [8]. And in the weeks after arthroscopic shoulder stabilisation, patients who developed new anxiety or depression had a significantly higher risk of readmission within 90 days [9]. These are the findings behind the advice on this page to move by the clock, to expect discomfort, and to tell us about new worry rather than sit on it. ### What actually helps, tested properly Three properly randomised comparisons are worth knowing about. Adding motor imagery (structured mental rehearsal of the movement) to standard treatment after a distal radius fracture improved function, wrist extension and grip strength compared with standard treatment alone [10]. Music therapy during shoulder replacement produced a significantly greater reduction in pain and anxiety scores than usual care [11]. And in patients with anxiety or depression undergoing rotator cuff repair, treatment with duloxetine, an antidepressant also used for pain, improved anxiety and distress and also range of motion and functional scores over the first three months, at the cost of nausea or vomiting in about one patient in six [12]. None of these is a cure and the last is a prescribing decision for your GP or psychiatrist, not something to start yourself. But together they show the same thing from three directions: the mind is not a bystander in recovery, and it can be worked with. ### A note on the questionnaires You may be asked to fill in a short mental health questionnaire before surgery. This is not a test you can fail. A study comparing screening tools before joint replacement found that a brief standard mental health score performed better than a resilience questionnaire at identifying patients at risk of a poorer result [13]. The point of asking is to plan support, not to decide who is operated on. --- ### Preparing for Surgery URL: https://www.cqupperlimb.com/education/recovery/preoperative-preparation/ Region: recovery · recovery General checklist for the days before upper-limb surgery — fasting, what to bring, medications. Most of what makes an operation go smoothly is decided before you arrive at the hospital. This page covers the weeks and days leading up to your surgery: what we send you, what we need from you, what you can do for yourself, and what to have in place at home. The day itself, from checking in to going home, is covered on the day of your surgery page. ## Your pre-operative appointment Before your operation you will see us in the rooms to go through the plan. It is the best time to ask questions, so write them down beforehand. Useful ones are: what exactly will be done, what the alternatives are, what recovery looks like week by week, when you can drive and work, and what could go wrong. Bring with you: - An exact list of everything you take, with doses: prescription medicines, over-the-counter tablets, inhalers, creams, vitamins, fish oil, turmeric and any other supplements. Write it down or bring the boxes. - Any recent scans, X-rays or blood test results you have been given. - Details of other doctors involved in your care, especially a cardiologist or a diabetes specialist. - Your health fund details, and a support person if you would like one. You will also be asked to sign a consent form. Consent is a conversation, not just a signature. If anything is unclear, say so; we would rather explain it twice than have you sign something you are unsure about. ## The email we send you Once your operation is booked, the rooms will email you your surgery details. This is the single most important document you will receive, so read it carefully and keep it. It tells you: - which hospital, which day, and your admission time, and where in the hospital to go when you arrive - your fasting time: the time after which you have nothing to eat or drink. If your procedure is under local anaesthetic only, the email will say that you do not need to fast - your anaesthetist's name and how to contact them if you have a question about your anaesthetic or about medicines you take; for private patients it also covers how to enquire about their fee - whether you are staying overnight, or going home the same day, in which case you will need someone to bring you and drive you home - any fees payable to the rooms, and how to pay them - medicine instructions that apply to you, if you have told us you take a blood thinner, diabetes tablets, insulin, or an injectable diabetes or weight-loss medicine The email also carries instructions for the hospital's online admission. The hospital will not contact you to ask for your details; you complete their admission form yourself, online, and the instructions we attach walk you through it, including the item numbers for your procedure that the form asks for. Please do this as soon as you receive the email, not the night before. The form asks about your general health, and it matters that you answer fully. In particular, tell them about: - sleep apnoea, or loud snoring with daytime tiredness (see sleep, pain and recovery) - a pacemaker, heart stents, or any heart or lung condition - allergies, including to medicines, dressings, tape and latex, and whether you carry an EpiPen - any problem you or a blood relative has had with an anaesthetic - loose teeth, crowns or dentures - any chance that you could be pregnant If a week has passed since your booking and you have not received your surgery details, or you cannot get the online admission to work, ring the rooms. ## Medicines: what to stop and what to keep taking Most medicines are taken as normal right up to the morning of surgery, with a small sip of water. A few need a decision, and the decision depends on your operation and on you, so never stop or change a medicine on your own. The instructions that apply to you are in your surgery details email; if they are not there and you think they should be, tell us. - Blood thinners. Aspirin and clopidogrel (Plavix, and the combination tablets such as DuoCover) are kept going; tell us you take them so the team knows. Anticoagulants such as warfarin, Xarelto, Eliquis and Pradaxa are stopped 48 hours before, and your email tells you the day and time of your last dose. Follow it to the letter; the timing is there for a reason on both sides, bleeding during surgery and clotting if you stop too early. The blood thinners around surgery page explains how these medicines work and why the timing matters. Ask before restarting, too. - Diabetes tablets are not taken on the morning of surgery. The newer tablets known as SGLT2 inhibitors (Forxiga, Jardiance, Steglatro) are stopped three days before, because they can cause a dangerous build-up of acid in the blood during fasting. - Insulin. Take your usual long-acting insulin the night before as normal. On the morning of surgery take half your usual morning dose, or adjust it to your reading. Never stop insulin completely, and bring your insulin and your glucose meter with you to hospital. - Injectable diabetes and weight-loss medicines such as Ozempic, Wegovy, Mounjaro, Trulicity and Byetta are kept going as normal; do not stop them. What changes is your fasting. These medicines slow the emptying of your stomach, so the usual fasting time is not long enough to make the anaesthetic safe, and we ask you to fast for 24 hours before your surgery time instead. Your email will give you the time. See GLP-1 medicines and orthopaedic surgery. - Anti-inflammatory tablets and some supplements. Ibuprofen, naproxen, fish oil, turmeric, ginkgo and high-dose vitamin E can all make you bleed a little more during surgery. We will tell you whether to stop them, and when. - Regular blood pressure, heart, thyroid, epilepsy and reflux tablets are taken as usual on the morning of surgery unless you are told otherwise. - Antidepressants and anxiety medicines should be continued. Stopping them suddenly makes the days around surgery harder, not easier. If you are unsure about anything on your list, ring the rooms, or contact your anaesthetist using the details in your email. That question is far easier to answer on the phone the week before than at the admissions desk on the morning. ## Getting your body ready A few weeks is enough to make a real difference to how you heal. - Stop smoking and vaping. Nicotine narrows the small blood vessels that skin, tendon and bone rely on to heal, and it raises the risk of wound problems and slow healing. The earlier you stop the better, but stopping even in the last few weeks helps. See smoking and musculoskeletal healing. - Get your blood sugar under control if you have diabetes. High sugar levels in the weeks around surgery raise the risk of wound infection. If your readings have drifted, see your GP now rather than after. - Eat well. Healing is built from protein, and a lot of people arrive at surgery eating less of it than they need. The eating well for healing page has practical targets. - Cut back on alcohol in the week before, and have none the night before. Alcohol interferes with the anaesthetic, with your pain relief, and with sleep. - Keep moving. Walk, and keep the joints that are not being operated on active. Being generally fit makes the anaesthetic safer and the first weeks easier. Look after the skin on the arm being operated on: - Do not shave the arm in the week before surgery. Razors leave tiny nicks that bacteria get into. If hair needs to go, it is clipped in theatre. - Tell us about any cut, scratch, rash, pimple or infection on that arm, even a small one. Operating through infected or broken skin is not safe, and this is one of the commonest reasons an operation has to be delayed. - Take off nail polish and artificial nails on the hand being operated on. They hide the nail bed, which the team uses to check your circulation. - Keep the skin clean and moisturised, and avoid new tattoos or piercings on that arm in the month before. ## Getting your home ready After upper-limb surgery you will be doing everything one-handed for a while, often with the arm in a sling, cast or splint. Setting the house up before you go in saves a lot of frustration afterwards. - Arrange someone to bring you to hospital, drive you home and stay with you the first night. This is not optional. You cannot drive yourself after an anaesthetic, and you should not be alone overnight. - Plan your driving. You cannot drive on the day of surgery, and you cannot drive while your arm is in a sling, cast or splint. After shoulder surgery that means at least six weeks, whichever arm it is. The driving after shoulder and arm surgery page has the timelines by operation. Sort out lifts, or a period without a car, before the day. - Sort out work. How long you need off depends on your job as much as your operation. Talk to your employer early; the returning to work page will help you plan the conversation. - Stock up and prepare. Cook and freeze a few meals. Move the things you use every day, in the kitchen and the bathroom, to waist height so you are not reaching up or bending down with one arm. Buy shampoo and soap in pump bottles, and a long-handled sponge if you are having shoulder surgery. - Clothes. Loose, front-opening tops and slip-on shoes. Practise getting a shirt on and off one-handed before you need to do it in a sling. - Sleeping. After shoulder surgery most people sleep propped up for the first weeks. A recliner, or a wedge of pillows, is worth arranging in advance. See wearing and sleeping in an arm sling. - Children, pets and lifting. Organise help for anything that needs two hands or a strong grip in the first couple of weeks: small children, big dogs, shopping, bins and the like. - Pain relief. Fill your scripts before the day so the tablets are in the house when you get home. The managing pain after surgery page explains how to use them well. The practical pages on daily life after hand, wrist or elbow surgery and daily life after shoulder surgery are worth reading before your operation rather than after it. ## Fasting Your surgery details email gives you a time to stop eating and drinking. Follow the time in your email; it has been worked out from your admission time and from the medicines you take. Fasting is a safety requirement for the anaesthetic, not a formality, and getting it wrong is the other common reason an operation is postponed on the day. The fasting before surgery page explains why an empty stomach matters so much under an anaesthetic. ## The week before: a checklist - Surgery details email received, read, and kept somewhere you can find it. - Hospital online admission completed, item numbers entered. - Medicine list is written, and you know which ones to stop and when. - If you take warfarin, Xarelto, Eliquis or Pradaxa: the last-dose date from the email is in the diary. - Someone is booked to bring you, drive you home and stay the first night. - Work knows your dates; lifts are arranged for the time you cannot drive. - Scripts filled, meals in the freezer, the house rearranged for one hand. - Skin on the arm is intact; no shaving; nail polish off. - Fasting time from the email written down where you will see it the night before. - If you have diabetes: insulin and glucose meter packed. If you carry an EpiPen: packed, to hand to the nursing staff. ## Call us before the day if - you have not received your surgery details email, or you cannot complete the online admission - you become unwell in the days before surgery: a cold, cough, fever, or a tummy upset - there is a cut, rash, spot or any sign of infection on the arm we are operating on - you are unsure whether to take or stop any medicine - you have accidentally eaten or drunk inside your fasting time - anything about your health has changed since we last saw you - you have simply changed your mind, or want to talk the decision through again None of these is a bother. We would much rather hear from you the day before than have to send you home unoperated on the morning. ## In more depth Advanced reading: the deeper science (optional) This section is for the reader who wants to know which parts of preparing for surgery actually make a measurable difference. Most of the research here comes from hip and knee replacement, where large numbers of patients make the question easier to study; the lessons transfer to upper-limb surgery, but the numbers should not be assumed to. ### The conversation matters more than the format The strongest finding is a simple one: what you expect from an operation can be changed by talking about it beforehand, and expectations shape how satisfied people are afterwards. Randomised trials of pre-operative classes before hip and knee replacement showed that a structured session changed patients' expectations of their recovery [1]. Separately, a formal education program before joint replacement was associated with a shorter hospital stay [2]. It matters what the conversation is about. A randomised trial of a short pre-operative video specifically about opioid painkillers found that patients who watched it used significantly less opioid medication in the first week after knee replacement [3]. That is a large effect from a small intervention, and it is why we spend time before your operation on how to use your pain relief, not only on the operation itself. For hand surgery specifically, a systematic review found some indication that pre-operative opioid education helps, while noting that the studies were few and of limited quality [4]. ### More technology is not more understanding Two studies temper the enthusiasm. In hip arthroscopy patients, counselling with a patient-specific 3D-printed model of the hip did not improve understanding or satisfaction compared with the standard scan images alone [5]. And a pre-operative class delivered on a surgical mission trip increased patients' knowledge about joint replacement only modestly [6]. The practical reading is that a plain, unhurried explanation with a chance to ask questions is the intervention; the props are optional. ### Be careful where you read Many people prepare by searching online, and the quality of what they find is uneven. A review of YouTube videos about orthopaedic injection treatments found the content inconsistent, with most of it produced by independent users rather than health organisations [7]. This wiki exists partly for that reason. If something you read elsewhere contradicts what you have been told in the rooms, bring it to your appointment and we will go through it. --- ### Returning to sport URL: https://www.cqupperlimb.com/education/recovery/returning-to-sport/ Region: recovery · recovery Phased return to sport after upper-limb surgery, and when contact sport is safe again. Sport is rarely the first thing back after surgery; it is usually the last. Most patients can return to sport gradually once the joint has healed, range of motion is back, strength has returned, and the surgeon has signed it off. ## Three phases of return Returning to sport is a graded process, not a switch. - Movement. Smooth, painless range of motion in everyday tasks. - Strength. The repaired side feels close to the other side for straightforward loads: you can carry a shopping bag, push a door open, throw a tennis ball gently. - Sport-specific. You do the actual movements of your sport at low intensity: practice serves before tournament play, light resistance before squat-press. ## Typical timelines These are general; your surgeon and physiotherapist will give specific dates based on your operation and your sport. Operation Non-contact sport Contact / collision sport Carpal tunnel / trigger finger 4–6 weeks 6–8 weeks Wrist ganglion excision 6 weeks 8–12 weeks Elbow nerve release 6–8 weeks 12 weeks Tennis elbow release 8–12 weeks 12–16 weeks Distal biceps repair 4 months 6 months Rotator cuff repair 4–6 months 6–9 months Shoulder replacement 4–6 months (swimming earlier: breaststroke ~8 weeks, freestyle ~12 weeks) Contact sport not advised long-term Latarjet 4 months (non-contact) 6 months (contact) Wrist / PIP fusion 3 months Often avoided long-term ## Contact sport — special considerations Contact sport (rugby, football, AFL, mixed martial arts, judo) carries a real risk of re-injury. After a rotator-cuff repair or a shoulder stabilisation, a single bad tackle can undo months of recovery. Talk to your surgeon honestly about what your sport actually involves. ## Bracing and taping Some patients return to sport in a hinged brace or taping for the first season after stabilisation surgery. This is a sensible safety net rather than a sign that something is wrong. ## When to stop and reassess - Sharp or sudden pain during play (not muscle ache) - A click, pop, or "give-way" feeling - Swelling that lasts more than 48 hours after activity - Loss of range of motion you previously had --- ### Returning to work URL: https://www.cqupperlimb.com/education/recovery/returning-to-work/ Region: recovery · recovery When you can return to desk, light, and heavy work after upper-limb surgery. When you can return to work depends much more on what your job demands than on the operation itself. A bricklayer and an accountant will recover the same shoulder repair, but the bricklayer waits months longer to return to their full duties. ## Three categories of work It helps to think about your job in three buckets: - Sedentary: desk work, phone, computer, light writing. Typical returns: a few days to two weeks after keyhole shoulder surgery without a repair; 1–3 weeks after most hand and wrist surgery (after carpal tunnel release the reported median is about three weeks); 2–4 weeks after shoulder repairs and replacements; and longest after fusions, where many people wait until the splint comes off at around six weeks, or later. Adjustments such as one-handed typing or voice dictation can bring this forward. Your operation's own rehabilitation page gives the specific timeline. - Light manual: driving short distances, handling under 5 kg, light cleaning, retail, cooking. Typically 2–6 weeks depending on the operation. - Heavy manual: lifting over 10 kg, repetitive overhead work, scaffolding, trades, nursing with patient handling. Often 3–6 months, sometimes longer. ## Medical certificates We typically issue an initial certificate covering the first 2–4 weeks of recovery, then update it at each review appointment. A return-to-work certificate from your treating doctor lists what you can and cannot do. Many workplaces accept "graded return" (half days, lighter duties, or rotated tasks) for a few weeks before you go back to full duties. Talk to your manager and HR before your operation if you can. ## WorkCover If your injury is work-related, your treatment may be covered by WorkCover or a similar scheme. The treating doctor will fill in workers' compensation paperwork at each visit. ## What slows return down - Pain that isn't being managed well - Persistent swelling and stiffness - Wound problems that delay rehab starting - Trying to do too much, too early, leading to a setback ## What helps - Doing your hand-therapy exercises consistently - A workplace willing to offer modified duties - Being honest with your therapist about what your job actually involves --- ### Scar Management URL: https://www.cqupperlimb.com/education/recovery/scar-management/ Region: recovery · recovery Massage, silicone, sun protection and the 12-month timeline for surgical scars to soften and fade. A scar is the body's record of an injury. Once the wound itself has closed, the scar continues to change for 6–12 months. A bit of attention in those first few months makes a real difference to how soft, flat, and pale it ends up. ## How a scar matures For the first 2–3 weeks the wound is still knitting together: leave it alone, keep it dry, and follow the wound-care advice. From around 3 weeks onwards the wound is closed and the scar enters a remodelling phase. It will be raised, pink, and firm. This is normal. Over the next 6–12 months the body gradually replaces the rushed, disorganised collagen of the early scar with stronger, more orderly fibres. The scar flattens, softens, and fades. Older scars on your body that you have stopped noticing went through this same process. ## When and how to massage Once the wound is fully closed and any scabs have come off (usually by the end of week 3), gentle massage helps the underlying tissue glide freely and breaks down restrictive bands. - Use a plain, unscented moisturiser: sorbolene, vitamin E cream, or whatever you already have. Branded "scar creams" are fine but no better than a basic moisturiser. - Press firmly enough to move the skin over the deeper tissue, not just slide across the surface. The scar should blanch (go pale) as you press. - Two minutes, twice a day, for about three months. - Massage in small circles or back-and-forth across the line of the scar. If massage is uncomfortable for the first week or two, that's normal; the scar is sensitive. Stop and try again the next day if it is genuinely painful. ## Silicone gels and sheets Silicone is the only over-the-counter product with good evidence behind it for softening scars and reducing the chance of an overgrown (hypertrophic) scar. It is most useful if your scar is starting to look raised, red, or itchy at 6–8 weeks. You can buy silicone gel (paint on, dries in seconds, twice a day) or silicone sheets (stick over the scar, wear all day or overnight) from any chemist. Use for 8–12 weeks. Stop if you develop a rash from the adhesive. ## Sun protection A fresh scar pigments more than normal skin. UV exposure in the first 12 months can leave a scar permanently darker than the surrounding skin. Cover it with clothing or apply a high-SPF sunscreen whenever it will be exposed: at the beach, on a long walk, or even driving with your arm near the window. ## What's normal, and what isn't Normal: pink, firm, slightly raised, occasionally itchy, more sensitive than surrounding skin. Improves slowly over months. Hypertrophic scar: raised, red, and thick, but stays within the boundaries of the original wound. Often itchy. Most settle with silicone and time. We can offer a steroid injection if it is bothering you. Keloid scar: grows beyond the original wound edges, like a bubble. Rare on the upper limb. More common in darker skin types and on the front of the chest, earlobes, or shoulders. If you have a history of keloid, mention it before surgery so we can plan accordingly. ## Call us if - The scar becomes red, hot, swollen, or starts weeping again (this is more likely to be a late infection than a scar problem) - It grows visibly thicker or wider after the first 6 weeks - It is severely itchy and not settling with silicone and moisturiser - It catches and tears with normal use (sometimes a tight scar across a joint needs releasing) --- ### Sleep, Pain and Recovery URL: https://www.cqupperlimb.com/education/recovery/sleep-and-pain/ Region: recovery · recovery How sleep and pain affect each other, why surgery and shoulder problems disturb sleep, and what helps you rest and recover. Poor sleep is one of the most common, and most underestimated, parts of recovering from upper-limb surgery. Pain, an arm you can't get comfortable, and a sling all work against a good night. The reassuring part is that it is temporary, it follows a fairly predictable pattern, and there is a lot you can do to help it. ## What to expect Sleep often gets a little worse before it gets better, and the timing depends on your operation. - After rotator cuff repair, sleep is frequently at its worst around the two-week mark, when the shoulder is most tender. Most patients are back past their pre-surgery sleep by about six weeks, and the disturbance has largely settled by three months. - After shoulder replacement, it helps to know that most patients slept badly before surgery too; disturbed sleep affects the large majority of people with an arthritic shoulder. Improvement is real but gradual: expect little change in the first six weeks, then steady gains. - After carpal tunnel release, sleep is usually one of the first things to improve. The classic night-time waking with a numb, painful hand often eases within the first week or two, and for many people it is the most noticeable benefit of the operation. - After hand and smaller procedures, throbbing for the first few nights is normal and usually settles quickly as the wound heals. Whatever your operation, the broad pattern is the same: hardest in the first week or two, clearly improving by six weeks. ## Why sleep is harder after surgery A few things stack up: - Lying down raises the pressure in a freshly operated limb, so aching and throbbing are often worse at night than during the day. - You can't get into your usual position. Sleeping on the operated side is uncomfortable or not allowed, and side-sleepers in particular take time to adapt. - The sling keeps the arm safe but makes rolling over and settling awkward. - Pain wakes you, and poor sleep makes pain feel worse the next day. It is easy to fall into a cycle; breaking it is what the steps below are for. ## What helps Position - After shoulder surgery, many patients sleep far better propped up: a recliner, or a wedge of pillows behind the back and head, for the first couple of weeks. Lying flat often makes shoulder ache worse. - Support the operated arm on a pillow so it isn't dragging or dangling. - Wear your sling at night exactly as instructed (see Wearing a sling). It protects the repair and stops you rolling onto it. Settle the pain before bed - Take your regular painkillers on schedule so they are working before you lie down, not after the pain wakes you (see Managing pain after surgery). - A single breakthrough tablet before bed is often all that is needed in the first week or two. - Ice and elevation in the evening reduce swelling and night ache (see Heat vs ice). Sleep habits - Keep a regular bedtime and wake time, even while you are at home and less active. - Cut caffeine after lunch and screens in the hour before bed. - A dark, cool, quiet room and a short wind-down routine genuinely help. ## Medications and sleep Most sleep disturbance is best treated by controlling pain rather than by sleeping tablets. We try to avoid regular sedatives, which lose their effect quickly and don't mix well with strong painkillers. After shoulder surgery we now routinely prescribe melatonin for around the first six weeks. A randomised trial in keyhole rotator cuff repair found it improved sleep in the early weeks, and it is gentle and not habit-forming. See Melatonin after shoulder surgery for why you have been given it, the dose we use, and what to expect. If you are struggling badly with sleep despite these measures, tell us rather than reaching for over-the-counter sleeping pills; we would rather review your pain control first. ## If you have sleep apnoea If you use a CPAP machine or have been diagnosed with obstructive sleep apnoea, let us and the anaesthetist know before your operation, and bring your machine to hospital. Patients with sleep apnoea have a slightly higher rate of short-term medical complications after shoulder replacement, though the long-term result of the joint itself is no different. Good management around the time of surgery is the key. ## When to call us - Pain that is getting worse rather than better after the first few days, or that your medications aren't controlling - New severe pain that came on suddenly - A wound that is increasingly red, hot, swollen or leaking - Fever or feeling generally unwell - Calf pain or swelling, chest pain or breathlessness: go to the emergency department --- ### Your shoulder nerve block URL: https://www.cqupperlimb.com/education/recovery/supraclavicular-nerve-block/ Region: recovery · recovery The nerve block we use for shoulder surgery — how it numbs your arm, why it controls pain so well, and what to expect as it wears off. Almost all shoulder operations are done with a nerve block as well as a light general anaesthetic. The block is the single most effective thing we have for keeping you comfortable after surgery, and it is worth understanding what is planned so that none of it comes as a surprise. ## What a nerve block is All of the nerves that supply your arm pass through a tight bundle just above your collarbone. Using an ultrasound machine to see exactly where they lie, the anaesthetist places a small amount of local anaesthetic around that bundle. This is called a supraclavicular block. It switches off pain signals from the whole arm for several hours, long enough to cover your operation and the first part of your recovery, when pain would otherwise be at its worst. You are not awake during the operation. You will usually have a light general anaesthetic on top of the block, so you sleep through the surgery. The block does the pain relief; the general anaesthetic keeps you comfortably asleep. ## Why we use it for your shoulder A good block does far more than a needle's worth of numbing: - It controls pain better than tablets or a general anaesthetic alone. In study after study, patients who have a brachial plexus block have lower pain scores in the first hours after shoulder surgery and need much less strong painkiller. One review that pooled 36 separate trials and more than 3,000 patients having keyhole shoulder surgery found that brachial plexus blocks like this one both lowered pain scores and reduced the amount of strong opioid painkiller people needed afterwards. - It lets us give a lighter general anaesthetic. Because the block is doing the heavy lifting on pain, you generally wake up clearer, with less grogginess and less nausea. - It reduces how much opioid (strong painkiller) you need. That means fewer side effects (less constipation, drowsiness and nausea) and a smoother early recovery. - It gets you comfortable, mobile and home sooner. ## What it feels like Within about 20–30 minutes of the injection, the arm becomes heavy, warm, numb and weak. You will not be able to lift it or feel much in it, and you may not be able to move your fingers. This is exactly what is meant to happen. The numbness usually lasts 8 to 18 hours, occasionally up to a day. It is completely temporary: full feeling and movement always come back. ## Why you wear a sling While the block is working, your arm is numb and has no power of its own. The sling is there to hold and protect it, so it cannot flop, dangle or get knocked, and so you do not lean or roll onto an arm you cannot feel. Keep it supported in the sling, keep it warm, and do not let it hang down. Think of it as looking after a limb that cannot yet look after itself. ## Things you might notice (these are normal) Because the nerves we numb sit close to a few others in the neck, you may notice some harmless temporary effects on that side: - a droopy or heavy eyelid, and sometimes a slightly bloodshot eye - a slightly hoarse voice or a stuffy-feeling nostril - a sense that you can't take a completely full deep breath (the block can briefly quieten the nerve to the muscle under your lung on that side) The supraclavicular approach we use is chosen partly because it tends to cause these effects less often than blocks placed higher up in the neck. They all wear off as the block does, and need no treatment. ## When the block wears off — start your tablets early This is the most important part to get right. The block is excellent for the first 8–18 hours, and then sensation comes flooding back, often overnight. As it does, the pain can arrive quite suddenly. This is called rebound pain, and it catches people out because they felt so comfortable beforehand. The trick is simple: don't wait for the pain. Take your regular prescribed pain tablets before the arm fully wakes up: we'll give you a rough idea of when that will be, and keep taking them regularly for the first couple of days, even while the arm is still numb. Patients who stay ahead of it have a far smoother first night. Patients who wait until the pain hits spend a miserable few hours catching up. ## Call us, or seek help, if - your breathing feels genuinely hard or is getting worse (a slight sense of not filling your lungs is expected; real struggle to breathe is not: get reviewed) - your arm is still completely numb and floppy beyond about 24–30 hours - your fingers turn white, cold or blue, or you get chest pain For ordinary rebound pain as the block fades, take your tablets and stay ahead of it: it settles over the next day or two. --- ### Swelling and elevation after surgery URL: https://www.cqupperlimb.com/education/recovery/swelling-and-elevation/ Region: recovery · recovery Why a hand or arm swells after surgery, how elevation and gentle movement control it, and when swelling is a warning sign. After any operation on your hand or arm, the limb will swell. This is normal, it happens to almost everyone, and it is not a sign that anything has gone wrong. But swelling is also the main thing that makes the early days uncomfortable and stiff, so a little understanding, and a few simple habits, go a long way towards a smoother recovery. ## Why your hand or arm swells Two things are happening, and both are expected. The first is healing itself. Surgery is a controlled injury, and your body responds the way it would to any injury, by sending extra blood flow and fluid to the area to begin repairs. This is the inflammatory response, and the puffiness, warmth and tightness that come with it are simply the visible side of healing getting under way. The second is gravity. Your hand and arm are at the bottom of a long limb, and fluid naturally drains downhill. When the arm hangs by your side or rests in your lap, fluid pools in the hand and fingers and has a hard time getting back out. That is why a hand that felt fine first thing in the morning can look like a balloon by the evening if it has been hanging down all day. ## What's normal, and how long it lasts Some swelling is part of every recovery. Typically it builds over the first few days, peaks somewhere around day two to five, and then slowly settles over the following weeks as the healing fluid is reabsorbed and the limb starts moving again. A few points worth knowing: - It is normal for the hand to look and feel worse at the end of the day than first thing in the morning (gravity at work), and it eases overnight when the arm has been level. - Lingering puffiness and stiffness can persist for months, long after the early dramatic swelling has gone. A slightly fat, stiff finger or a thick feeling across the back of the hand is common for a good while and is not a setback. It improves steadily with movement and hand therapy. - The single biggest influence on how fast it settles is how well you keep the limb elevated and gently moving in those first days. ## Elevation — the most important thing you can do If you remember one thing from this page, remember this: keep the limb raised above the level of your heart. Elevation is by far the most effective way to control swelling, and it costs nothing. The aim is to let gravity work for you instead of against you, so fluid drains back towards the body rather than pooling in the hand. - When sitting or lying down, prop the whole arm up on pillows so the hand sits higher than the elbow, and the elbow higher than the heart. Don't just rest the elbow and let the hand flop down; it's the hand and fingers you most want to lift. - Aim to keep it elevated as much as you can for the first few days, particularly the first two or three. After that, raising it for twenty minutes or so every few hours through the day keeps things moving. - A useful rule: once letting the hand hang down no longer makes it throb, you can ease off the constant elevation. - At night, set up your pillows before you settle so the arm stays supported and raised while you sleep; overnight is a long time for a hand to spend flat. ## Keep the fingers moving — the muscle pump Gentle movement is the partner to elevation. Every time you move your fingers, the muscles squeeze the veins and lymph channels and pump fluid back up the arm, a bit like squeezing a sponge. - Unless we've specifically asked you to keep a finger still, gently make a fist and then fully straighten your fingers, slowly and repeatedly, several times an hour while you're awake. - Do it with the hand elevated for the best effect, with pumping and gravity working together. - Keep the joints that are free moving too. If your wrist is bandaged, keep the shoulder and elbow moving with gentle circles and bends so they don't stiffen up while the hand heals. - Move within comfort. A gentle stretch is fine; sharp pain means ease off, and always follow any specific exercises your surgeon or hand therapist has given you. ## Cold packs and light compression A cold pack can take the edge off swelling and pain in the early days. Wrap it in a thin towel, never put ice straight onto skin, and don't rest it on an area that is numb or has reduced feeling. Keep dressings and casts dry. There's more detail (including when cold helps and when gentle heat is better later on) on our heat-versus-ice page. A snug compression sleeve or wrap can also help, but only use compression if we've specifically advised it. The wrong wrap, or one applied too tightly, can do more harm than good by squeezing a limb that is already swollen. ## A sling, and not letting the arm hang When you're up and walking, your arm naturally drops to your side and the hand fills with fluid again. A sling keeps it supported and raised across your body while you're on the move, so the gains you've made resting with it elevated aren't lost. Use the sling for support when you're up and about, but take the arm out to do your gentle finger and elbow movements, and don't leave it dangling for long stretches. ## When to seek help — don't wait Most swelling is simply part of healing and settles with elevation and movement. But swelling can occasionally signal a problem, and a few warning signs need prompt attention. Trust your instincts: it is always better to have something checked and find it's fine. A cast, splint or dressing that is too tight is the one that can't wait. As the limb swells underneath, the dressing can start to squeeze the nerves and blood supply. Contact us the same day, or go to your nearest emergency department, if you notice: - Pain that is increasing, severe, or worse than you'd expect: especially pain that doesn't settle with your usual pain relief. - A cast, splint or bandage that feels tighter rather than easier as time passes. - Numbness, pins and needles, or burning in the fingers. - Fingers turning pale, white, blue, dusky or cold, or that won't settle with elevation. These together (particularly severe pain plus numbness or colour change in the fingers) should be treated as urgent. Signs of infection also need same-day review: - Swelling that is hot, red, and spreading, rather than easing. - A fever, or feeling generally unwell. - Pus, discharge or a bad smell from the wound or dressing. Signs of a possible blood clot are an emergency: call an ambulance or go straight to emergency if you notice: - Sudden swelling, pain or tightness in one calf or leg. - Breathlessness, or chest pain, especially with the above. For ordinary swelling that eases when you raise the limb and improves day by day, keep it up, keep the fingers moving, and raise any questions at your next clinic visit. When in doubt, ring the rooms; we would much rather hear from you. --- ### The day of your surgery URL: https://www.cqupperlimb.com/education/recovery/the-day-of-surgery/ Region: recovery · recovery What to expect on the day of day-case upper-limb surgery, from arrival and meeting the team to waking up and going home. The day of an operation is a lot less mysterious once you know how it unfolds. Almost all upper-limb surgery is day-case surgery, which means you arrive, have your operation, recover for a while, and go home the same day. This page walks you through that day from start to finish so that nothing comes as a surprise. Getting ready for surgery (stopping or continuing medications, sorting out time off, the fasting rules themselves) is covered on the preoperative preparation and anaesthesia and fasting pages; this one is about the day itself. ## Arriving and checking in We will give you an arrival time, and it is usually a couple of hours before your operation is actually due to start. That gap is deliberate and not wasted time: it lets the nursing team, your surgeon and your anaesthetist each see you, get everything checked and prepared, and make sure the list runs smoothly. Please come at the time you are given, even if your operation is later in the day. When you arrive, go to the admission area named in your email, check in at the desk, confirm your details, and then be shown through to the day-surgery area. A nurse will settle you in, and you will change out of your own clothes into a hospital gown and pop on an identification wristband that stays on until you go home. Before you come in, double-check the fasting time in your surgery details email. Usually that means nothing to eat or drink from a time worked out from your admission time; if you use an injectable diabetes or weight-loss medicine such as Ozempic, that fast is 24 hours. Fasting keeps you safe under anaesthetic, and getting it right means your operation is far less likely to be delayed or postponed. The anaesthesia and fasting page explains the exact timings. ## Meeting your team Several people will come and see you before your operation. This is one of the safest parts of the whole day: everyone is checking the same things from slightly different angles so that nothing is missed. - The nursing team settles you in, runs through a checklist, takes a few routine observations, and answers the everyday questions. - Your surgeon will see you, confirm exactly what operation is planned and which side it is on, answer any last questions, and mark the arm with a pen so there is no doubt at all about the correct site. Seeing that mark go on is reassuring; it is a deliberate safety step, done with you, every time. - The anaesthetist will discuss how you will be kept comfortable and asleep or numb. Depending on your operation, that may be a general anaesthetic (you are fully asleep), a regional nerve block (the whole arm is numbed; see the shoulder nerve block page), a local anaesthetic for smaller procedures, or a combination. This is the moment to raise anything that is on your mind. You will also be asked to confirm your name, date of birth and operation several times by different people. It can feel repetitive; it is meant to. Checking and re-checking is how operating lists stay safe. ## The wait There may be a wait between checking in and going to theatre. Lists are planned carefully and the team works hard to keep them running to time, but operations occasionally run a little long or the order changes for good clinical reasons, and that can push things back. It is rarely a sign that anything is wrong. Bring something to pass the time: a book, a magazine, music or a podcast and headphones, and try to settle in rather than clock-watch. ## Going to theatre and waking up When it is your turn, you will walk or be wheeled round to the theatre area. Your anaesthetic is started, and the next thing you will be aware of is waking up in the recovery area with a nurse close by looking after you. Your operation is already done. You may feel drowsy, a little cold, or have a dry mouth. All of this is completely normal and short-lived. If you had a nerve block, the arm will feel heavy and numb, which is exactly as intended. The recovery nurses keep a close eye on you, check your comfort and your dressing, and give pain relief and anti-sickness medication as needed. Once you are properly awake and settled, you will be taken back through to the day- surgery area. ## Going home Because your surgery is day-case, you will head home once a few simple boxes are ticked: you are awake and steady, your pain is controlled with tablets, any sickness has settled, you have had something to eat and drink, and the team is happy with you. For most people this is a few hours after the operation. Before you leave, the nurses will go through your dressing, your pain-relief plan, any sling or splint, what you can and cannot do, and when to return for review. Do not worry about remembering it all; it will be written down for you to take home, and you will have a number to call if you are unsure about anything later. ## Arranging your trip home and the first night This is the one piece of organising you must sort out in advance: you cannot drive yourself home, and you should not be alone for the first night. - Arrange a responsible adult to drive you home and to stay with you overnight. An anaesthetic stays in your system for the rest of the day; your judgement, reactions and coordination are not back to normal even when you feel fine, so driving (and being on your own) is not safe. - For the same reason, do not plan to make important decisions, sign anything legally binding, drink alcohol, or operate machinery for the rest of the day. ## What to bring and what to wear A little preparation makes the day smoother: - Wear loose, comfortable, front-opening clothes: a button-up or zip top rather than something tight that has to go over your head, so it slips easily over a dressing, sling or bandaged arm afterwards. - Bring a list of your medications, with doses, and bring any inhalers or essential medicines you might need during the day. - Bring any walking aids you normally use. - If you carry an EpiPen, bring it and hand it to the nursing staff. If you use insulin, bring it and your glucose meter. - Leave jewellery, watches and valuables at home. Rings in particular need to come off the operated arm, and the less you bring, the less there is to look after. - Bring your appointment details and a small amount of money or a card if you need to collect a prescription on the way out. ## Before you come in — call us if Most of the time the day runs exactly as planned. But in the days leading up to your operation, get in touch with us rather than simply turning up unsure, if: - you become unwell: a cold, a cough, a fever, a tummy upset, or any sign of infection (including a skin infection, scratch or wound on the arm we are operating on) - you are unsure about your medications: whether to take or stop something, especially blood thinners, diabetes medicines or anything you take in the morning - you are unsure about the fasting instructions or accidentally eat or drink when you should not have - anything about your health has changed since you were last seen It is always better to ring ahead. We would much rather hear from you and sort it out in advance than have you arrive unwell or unprepared and risk the operation having to be postponed. When in doubt, call the rooms. --- ### Wearing and Sleeping in an Arm Sling URL: https://www.cqupperlimb.com/education/recovery/wearing-a-sling/ Region: recovery · recovery How to sleep in an arm sling, get the sling position right, and look after it after shoulder, elbow or wrist surgery, including whether to keep the sling on overnight. A sling protects your shoulder, elbow, or wrist after surgery by stopping the arm from moving while the repair heals. How long you wear it depends on the operation; your surgeon will tell you specifically. ## How to wear it The sling should support your forearm with your elbow bent at about 90 degrees. The strap goes around your neck and across the back. The hand should sit slightly higher than the elbow, never hanging below it. If your fingers look swollen or feel pins-and-needles, the sling is probably too tight or your arm is hanging too low; re-position and tell your physiotherapist. Most slings are designed to keep the arm close to the body. Some are abduction slings (with a small pillow or wedge) that hold the arm slightly away from the body; these are heavier but ease the load on a repaired rotator cuff. ## Sleeping in a sling For the first week or two, keep the sling on overnight unless your surgeon has told you otherwise; it stops you unconsciously rolling onto the repair or twisting the arm into a bad position while you are asleep. A fresh cotton T-shirt under the strap stops it rubbing your neck. Most people are far more comfortable propped semi-upright (in a recliner, or on a few pillows or a back wedge) than lying flat, and it is best to avoid lying on the operated side early on. Take your pain relief a little before bed so it has taken effect by the time you settle. ## When can it come off? You can usually take the sling off briefly to wash, dress, and do gentle exercises your physiotherapist has prescribed. Your hand and elbow should be moved out of the sling several times a day to stop them stiffening up, even when the shoulder is being protected. ## Hygiene The sling itself can be hand-washed in warm soapy water; let it air-dry. A fresh cotton T-shirt under the sling is more comfortable than skin-to-strap contact. Keep the wound dry until your surgeon says otherwise. ## When to call us - The hand becomes cold, blue, or numb that doesn't go away when the sling is loosened - Severe pain that pain relief doesn't touch - Fever or wound problems --- ### Looking after your wound URL: https://www.cqupperlimb.com/education/recovery/wound-care/ Region: recovery · recovery Dressings, showering, and signs of infection after upper-limb surgery. A clean, healing wound is the foundation of a good recovery. The first two weeks after surgery are when the wound is most vulnerable to infection and to opening up if pulled or stretched. If you have any concerns about your wound, get in touch with the rooms; it is often helpful to take a photo of the wound and email it for review. ## What to expect Swelling after upper-limb surgery often causes concern, but it is normal. After hand or arm surgery the whole arm may swell; after shoulder surgery the arm and hand swell too. Depending on the extent of the injury and the surgery, swelling can persist from several weeks to several months. If swelling is persistent, not improving, or causing stiffness, contact the rooms for advice. Wounds may ooze or bleed for a few days, particularly hand wounds and arthroscopic (keyhole) shoulder wounds. The ooze usually settles by around 3–5 days; persistent ooze beyond that is a reason to call. Parts of the arm or hand may be numb at first. Local anaesthetic placed in the wound usually wears off over 6–12 hours, though rarely it can continue for 2–3 days; numbness from a shoulder nerve block usually lasts 8 to 18 hours, occasionally up to a day. If your arm is still completely numb beyond about 24 to 30 hours, contact us. ## Dressings You will leave hospital with a dressing already in place. As a rule, leave it alone: a dressing does its job best undisturbed, and most stay on until your wound review. The exception is a dressing that has become dirty or soaked through with blood: that one should be replaced (replacement waterproof dressings are available at most pharmacies). If you are not sure whether a dressing needs changing, send us a photo before disturbing it. What you have depends on your operation: - Hand and elbow surgery: usually a wool-and-crepe bandage with a dressing underneath. The bandage can come off after 48–72 hours; the dressing underneath stays until about day 10. Keep hand and elbow dressings dry until your wound review. - Arthroscopic (keyhole) shoulder surgery: several small waterproof dressings, which stay in place for 10 days. - Shoulder replacement: a single long dressing that should last 10–14 days. If you find you have to change it (especially for persistent ooze after 2–3 days), contact the rooms to discuss. After 10–14 days it can be removed, but if it is comfortable it can stay on longer. ## Showering After shoulder surgery the dressings are waterproof, so you can shower from day 1: let water run over the dressing, but don't soak the area or scrub it. After hand and elbow surgery, keep the dressings dry until your wound review: slip the arm into a plastic bag and tape it shut while you shower, or use a shower-cover from the chemist. No baths, swimming, or spas until the wound has fully healed (typically 2–3 weeks), and avoid any activity where the wound will be soaked or dirty. ## Stitches Most wounds are closed with dissolvable stitches. Some run under the skin with a small "tail" at each end of the wound; the buried part does not need removing, and the exposed tails can simply be cut flush with the skin after about 10 days. Others use small plastic strips called Steri-Strips that fall off on their own over 1–2 weeks. Larger wounds may have stitches that need removing at your wound review. If you cannot get back to our dressing clinic, your GP will usually be happy to trim or remove stitches for you. ## Your follow-up The rooms will contact you two to three days after your operation with the details of your follow-up appointments. The usual pattern: - Wound review at 1–2 weeks with the practice nurse. If you live out of town it may be more convenient to see your GP for wound care instead; bring your discharge summary, which has the details of your operation. - Post-operative review with Dr Hirpara at 6–8 weeks: earlier if your wound needs closer supervision. - Finger and tendon operations (Dupuytren's, finger fractures, tendon repairs and similar) are usually referred to a hand therapist, who looks after the whole package: wound care, suture removal, scar management and rehabilitation. Hand therapy is only available in some Central Queensland locations; where there is no hand therapist nearby, a physiotherapist takes over the rehabilitation and the practice nurse (or your GP) covers the wound care. ## Signs of normal healing In the first few days you can expect: - Mild redness around the edges of the wound - A small amount of clear or pink fluid soaking into the dressing - Tightness, itching, or "tingling" as the nerves reconnect - Bruising around the wound, sometimes spreading down the arm Over the next weeks the scar will be raised, pink, and firm; it gradually flattens and pales over 6–12 months. ## Signs that something is wrong — call us - Spreading redness past the wound edges - The wound feels hot to touch - Fluid that is yellow, green, or smells unpleasant - Increasing rather than decreasing pain after the first few days - A fever (temperature over 38°C) - The wound opens up These can all be early signs of infection. Don't wait for your scheduled appointment; call us straight away. ## Scar care after the wound has healed Once the stitches are out and the wound is dry and closed (usually two to four weeks after surgery), scar massage can begin: - 5–10 minutes, twice a day. For the first 2–4 weeks massage along the line of the incision; after that, in all directions. - Press firmly enough to blanch the scar from pink to pale, but never so hard that it hurts. Do not massage a scar that is open or looks infected. - Massage doubles as desensitisation: it is normal for a new scar to feel hypersensitive, and frequent touch settles it. - A plain unscented moisturiser (sorbolene, vitamin E cream, aloe vera) softens the scar and makes massage easier. - If the scar is raised, a strip of Fixomull or Hypafix tape worn over the incision line for up to 2 weeks (replaced daily; you can massage over the tape) helps flatten it. Most pharmacies stock it. - Sun protection matters: a fresh scar burns easily and sun damage can permanently darken it. Cover it with SPF 30+ sunscreen or zinc, clothing, or shade for the first year. Keep massaging daily until the scar is pale, soft and flat. --- ### Your wound check and stitch removal URL: https://www.cqupperlimb.com/education/recovery/wound-check-and-stitch-removal/ Region: recovery · recovery What happens at the post-op wound check, dissolvable vs removable stitches, what removal feels like, and when to seek help sooner. After your operation you'll be booked in for a wound check: a short appointment to make sure the wound has healed properly and, if you have the kind of stitches that need removing, to take them out. It's a quick, routine visit, and for most people it's the point at which the early restrictions start to lift. This page explains what to expect, so none of it comes as a surprise. (For day-to-day care of the wound itself in the meantime, see our separate wound care page; this page is about the check-up and the stitches.) ## When it happens and who does it The wound check is usually around 10 to 14 days after surgery, though the exact timing depends on the operation and where the wound is; we'll give you a date before you go home. It might be done in our rooms, or we may arrange for your GP or a practice nurse to do it closer to home. Either way it's the same simple check, and whoever sees you will know what to look for. Until that appointment, the most important thing is to leave the dressing intact — and, for hand and elbow wounds, dry. (Shoulder dressings are waterproof: showering water over them from day 1 is fine; see wound care.) Don't be tempted to peek underneath or change it yourself unless we've specifically asked you to. A clean, undisturbed dressing keeps the wound protected while the skin knits together. If the dressing comes loose, gets soaked, or you're worried about what's underneath, ring us rather than redoing it blind. ## The different kinds of stitches Not everyone's wound is closed the same way, and how it's closed decides whether anything needs removing. - Dissolvable (absorbable) stitches disappear on their own over a few weeks; your body slowly breaks them down, so there's nothing to take out. Often they're hidden under the skin and you'll never see them. Sometimes a stitch works its way to the surface as it dissolves and you notice a small bristle or a tiny pimple-like spot along the line; this is called "spitting," and it's usually nothing to worry about. It settles as the stitch finishes dissolving. Don't pull at it; if it's catching or sore, mention it at your check. - Non-dissolvable stitches are the kind that need removing, and that's the main job of the wound check, usually around 10 to 14 days, once the skin has sealed. - Sometimes the skin is held with Steri-strips (thin sticky paper strips) as well as stitches. These don't need removing; they peel or fall off by themselves over a week or two. - After a shoulder or elbow replacement, and after cubital tunnel and radial tunnel surgery, the wound is usually closed with a mesh-and-glue dressing instead. A fine self-adhesive mesh is laid over the wound to hold the skin edges together, and a liquid skin adhesive is painted over the top and left to set. There is nothing to take out: the whole thing lifts and peels away by itself after about one to two weeks. Whichever you have, let it come away naturally rather than picking at it. If you're not sure which kind you have, that's completely fine; we'll know, and we'll tell you at the appointment. ## What removal feels like If you do have stitches to come out, the good news is that taking them out is much easier than you might expect. Each stitch is snipped and gently slid free. You'll feel a light tug or a small pinch as each one comes away: a slightly odd sensation, but not usually painful, and it's over in a minute or two. A tiny spot of bleeding here and there is normal. Most people are surprised by how quick and uneventful it is. ## What we're checking for The wound check isn't only about the stitches. Whoever sees you is also making sure the wound has healed and sealed properly and that there are no signs of infection; they'll look for things like spreading redness, swelling, warmth, or any discharge, and ask whether it's been comfortable. If everything looks as it should, that's your green light to start easing back towards normal. ## After the check Once the wound has been confirmed healed and any stitches are out: - Getting it wet: you can usually start letting the wound get wet and washing normally in the shower at this point; we'll confirm exactly when, as it occasionally varies. Pat it dry gently rather than rubbing, and avoid soaking it in a bath, pool or spa for a little longer. - Scar care: once the wound is fully closed, you can begin gentle scar massage to keep the scar soft and supple; see our scar management page for how and when to start. - Activity: the check is often when some of the early restrictions lift. Follow the specific advice we give you for your operation about lifting, driving and returning to work or sport; those milestones are set by the surgery you had, not just by the state of the wound. ## When to seek help sooner You don't have to wait for the appointment if something looks wrong. Contact us, your GP, or seek medical care before your scheduled check if the wound: - becomes increasingly red, hot, swollen or painful, especially if the redness is spreading - starts leaking fluid, pus or blood, or develops a bad smell - opens up or gapes along the line before it has healed - is accompanied by a fever or feeling generally unwell A wound that's healing well settles and quietens down over the first week or two. Anything that's heading the other way is worth a phone call; we would always rather check it early than have you wait. --- ### Rehabilitation URL: https://www.cqupperlimb.com/education/rehabilitation/ Region: rehabilitation · region-landing Step-by-step rehabilitation protocols and exercise guides for upper-limb procedures. Your surgeon or hand therapist will confirm which protocol applies to you and may adjust the timings to your operation. ## Shoulder protocols AC Joint Stabilisation Rehabilitation after AC joint stabilisation or reconstruction, with the protective phase and staged return to sport. Open → Anterior Bankart Repair Rehabilitation protocol after arthroscopic anterior Bankart (labral) repair for anterior shoulder instability — apprehension-position precautions and staged return to sport. Open → Biceps Tenodesis Rehabilitation after isolated biceps tenodesis, protecting the tenodesis fixation through staged return of biceps loading. Open → Calcific Tendinitis Recovery after arthroscopic excision of a calcific deposit, from early movement to full activity. Open → Capsular Release Rehabilitation after arthroscopic capsular release for frozen shoulder — early in-hospital program and the outpatient phases that keep the range won at surgery. Open → Clavicle Fixation (ORIF) Rehabilitation after plate fixation of a clavicle fracture, gated on radiographic healing at review. Open → Comprehensive Arthroscopic Management (CAM) Open → Distal Clavicle Excision Rehabilitation after isolated arthroscopic distal clavicle excision; combined cases follow the rotator cuff repair protocol. Open → Latarjet Procedure Rehabilitation protocol after the Latarjet coracoid bone-block transfer for anterior shoulder instability — union-gated loading and subscapularis/graft precautions. Open → Pectoralis Major Repair Rehabilitation protocol after pectoralis major repair, with the protected safe zone and staged return to chest loading. Open → Posterior Stabilisation Rehabilitation protocol after posterior shoulder stabilisation, with posterior-specific precautions and return-to-sport criteria. Open → Shoulder Replacement for Fracture Rehabilitation after hemiarthroplasty or reverse shoulder replacement for a proximal humerus fracture — slower than elective replacement while the tuberosities heal. Open → Proximal Humerus Fixation (ORIF) Rehabilitation after locking-plate fixation of a proximal humerus fracture, gated on radiographic healing at review. Open → Reverse Shoulder Arthroplasty Phase-by-phase rehabilitation protocol after reverse shoulder replacement, including dislocation precautions and the early exercise program. Open → Rotator Cuff Repair Staged rehabilitation protocol after rotator cuff repair at Mater Private Hospital Rockhampton, with the early exercise program. Open → Shoulder Arthroscopy Recovery after simple or diagnostic shoulder arthroscopy with no repair — an early-mobilisation fast pathway. Open → Subacromial Decompression Rehabilitation after isolated arthroscopic subacromial decompression — early movement, staged strengthening and return to activity. Open → Suprascapular Nerve Decompression Rehabilitation after isolated arthroscopic suprascapular nerve decompression, with honest framing of nerve recovery. Open → Total Shoulder Arthroplasty Phase-by-phase rehabilitation protocol after total shoulder replacement, with criteria to progress and the early exercise program. Open → ## Elbow protocols Cubital Tunnel Release Recovery after surgical decompression of the ulnar nerve at the elbow, covering both in-situ (simple) release and anterior transposition. Open → Radial Tunnel Release Post-operative exercises and precautions after radial tunnel release, including radial nerve glides. Open → Lateral Epicondylitis (Tennis Elbow) A loading-based rehabilitation program for tennis elbow — settling pain then progressively strengthening the tendon — covering both non-operative care and recovery after ECRB tendon debridement. Open → Medial Epicondylitis (Golfer's Elbow) Loading-based rehabilitation for golfer's elbow (flexor-pronator tendinosis), with ulnar-nerve screening, eccentric reverse-Tyler-twist loading, and a separate post-operative pathway for the minority who need surgery. Open → Distal Biceps Tendon Repair A protected early-motion recovery plan after surgical repair of a ruptured distal biceps tendon, allowing comfortable movement from day one while guarding the repair from resisted lifting until strength is rebuilt in stages. Open → Distal Triceps Tendon Repair A protected recovery plan after repair of the distal triceps tendon at the elbow, resting the arm in a simple sling at 90 degrees and freeing movement, then active straightening, then strength in careful stages. Open → Olecranon Fracture (ORIF) Recovery after surgical fixation of an olecranon (point-of-elbow) fracture, protecting the triceps repair while restoring movement, with a simple sling and a staged return of active extension. Open → Radial Head Replacement A protected recovery plan after replacement of the radial head at the elbow with a metal implant, built around early protected elbow and forearm movement to prevent stiffness, with the forearm positioned to protect any repaired ligaments and the elbow rested in a simple sling for comfort. Open → Elbow Instability Rehabilitation after surgery for elbow instability, covering both lateral (terrible triad / LCL) injuries and throwing (medial UCL) injuries, built around protected early movement rather than immobilisation. Open → Stiff Elbow Release (Arthrolysis) An early, aggressive movement recovery plan after an operation to free up a stiff elbow — the surgeon regains the bend and straightening on the table, and the whole job of rehabilitation is to keep that range, starting from day one with no sling and no protection phase. Open → Total Elbow Replacement (Arthroplasty) Recovery after a total elbow replacement: gentle assisted motion in a simple sling early, a functional movement arc as the goal, and a permanent lifelong lifting limit to protect the implant. Open → ## Hand & wrist protocols Carpal Tunnel Release Post-operative exercises and precautions after carpal tunnel release, including tendon and nerve glides. Open → de Quervain's Release An early-motion recovery plan after surgical release of the first dorsal compartment for de Quervain's tenosynovitis, with brief comfort support, gentle thumb and wrist movement from the start to prevent stiffness, scar care, and a graded return to grip and pinch strength by around four to six weeks. Open → DIP Joint Fusion A protected recovery plan after fusion (arthrodesis) of the small fingertip joint nearest the nail, keeping the fingertip splinted while every other joint stays moving and swelling is controlled, then progressively rebuilding pinch and grip once the bone has joined. Open → Distal Radius Fracture (ORIF) Staged rehabilitation after plate fixation of a distal radius fracture, from the first days to return to full activity. Open → DRUJ Hemiresection Arthroplasty A recovery plan after hemiresection-interposition arthroplasty of the distal radioulnar joint, where the worn part of the ulnar head is partially removed to restore pain-free forearm rotation; after a brief period of protection, early forearm rotation (turning the palm up and down) is the priority, with heavier loading added gradually. Open → Dupuytren's Release Rehabilitation after Dupuytren's fasciectomy — the extension splint regime and exercise program, with hand-therapist follow-up. Open → Extensor Tendon Repair A recovery plan after repair of an extensor tendon on the back of the finger or hand (zones IV to VII), using a relative-motion (yoke) splint that lets you use the hand straight away while protecting the repair, then weaning the splint and building strength in careful stages. Open → Finger Surgery Post-operative exercises and precautions after finger surgery, including joint blocking and tendon glides. Open → Flexor Sheath Ganglion Excision A quick, motion-led recovery plan after excision of a flexor tendon sheath ganglion (volar retinacular cyst) at the base of a finger, protecting a small palm wound while you start gentle finger movement within days, then add scar care and grip as the wound settles. Open → Flexor Tendon Repair An early-active-motion recovery plan after repair of a flexor tendon in the finger, using the Manchester short splint to move the healing tendon gently and safely from the first week while protecting the repair for six weeks. Open → Mallet Finger A splint-led recovery plan for mallet finger, holding the fingertip joint completely straight without interruption for about six to eight weeks so the extensor tendon can heal, while the other finger joints keep moving. Open → MCP Joint Replacement A hand-therapy-led recovery plan after silicone (Swanson) knuckle-joint replacement, built around a dynamic extension splint that holds the knuckles straight and slightly radial while you bend them early — re-shaping the joints in a corrected position and reversing ulnar drift. Open → Partial Wrist Fusion A protected recovery plan after a partial wrist fusion (capitolunate fusion, usually with removal of the scaphoid) for a worn-out wrist, immobilised until the bones knit at about six to eight weeks, then progressively restoring a useful but deliberately reduced arc of wrist movement and grip strength. Open → PIP Joint Fusion A protected recovery plan after fusion (arthrodesis) of the middle finger joint, holding the fused joint still in a splint while keeping every other joint moving from day one, then restoring grip and pinch once the bone has united. Open → PIP Joint Replacement A protected recovery plan after silicone replacement of the worn middle joint of a finger (the PIP joint), where the speed of starting movement depends on whether the surgeon went in from the front (palm side) or the back of the finger. Open → Scaphoid Fixation A protected recovery plan after surgical fixation of a scaphoid fracture with a buried headless compression screw, easing the wrist back into movement early under the screw's protection while the slow-healing bone unites, then building grip and strength, with loading and contact sport held back until union is confirmed. Open → Thumb Base Joint Replacement (Touch) A staged recovery plan after a dual-mobility total joint replacement of the arthritic thumb base (the Touch implant), protecting the new joint in a thumb splint at first, then restoring opposition and movement, then building pinch and grip strength. Open → Trigger Finger Release Post-operative exercises and precautions after trigger finger release, including tendon glides and joint blocking exercises. Open → Wrist Arthroscopy A recovery plan after keyhole (arthroscopic) wrist surgery, where the pace depends on what was done inside: a clean-up (debridement, synovectomy, ganglion or central TFCC tidy-up) allows early movement and a quick return, while a TFCC repair protects forearm rotation in a splint or cast for about four to six weeks before motion and strength are rebuilt. Open → Wrist Fusion A recovery plan after total wrist fusion (arthrodesis), where the worn-out wrist is joined solid with a dorsal plate so it no longer moves by design, while the fingers, thumb and forearm rotation are kept moving from the start and grip is built up once the bone has united. Open → Wrist Ganglion Excision An early-motion recovery plan after excision of a dorsal or volar wrist ganglion, using minimal immobilisation then prompt movement of the wrist in every direction to prevent the stiffness that is the most common problem after this operation. Open → ## Exercise guides Tendon glides Finger tendon-glide exercise handout — hook and tabletop glide sequences, recreated from an Extend Rehabilitation sheet. Open → Carpal tunnel exercises Exercise handout for after endoscopic carpal tunnel release — wrist tenodesis, fist/hook glides and thumb opposition, recreated from an Extend Rehabilitation sheet. Open → Dupuytren's exercises Exercise handout following Dupuytren's release — extension, DIP/PIP flexion and wrist tenodesis exercises, recreated from an Extend Rehabilitation sheet. Open → Trigger finger exercises Exercise handout after trigger digit release — tenodesis, composite extension, blocked flexion and thumb opposition, recreated from an Extend Rehabilitation sheet. Open → Volar plate exercises Finger exercise handout — tip bends, hook bends and full fist, recreated from an Extend Rehabilitation sheet. Open → ## Inpatient programmes Inpatient exercises — shoulder replacement Early in-hospital exercises after a shoulder replacement (total, reverse, or for fracture) — gentle hand, elbow and shoulder movement, with sleep-in-sling precautions for the first six weeks. Open → Inpatient exercises — rotator cuff & stabilisation Early in-hospital exercises after rotator cuff repair or shoulder stabilisation — gentle hand, elbow and shoulder movement, with six-week sling precautions. Open → Inpatient exercises — capsular release & subacromial decompression Early in-hospital exercises after capsular release or subacromial decompression — gentle movement with a comfort-only sling to keep the shoulder moving freely. Open → Explore Rehabilitation in the evidence explorer → --- ### AC Joint Stabilisation URL: https://www.cqupperlimb.com/education/rehabilitation/ac-joint-stabilisation/ Region: rehabilitation · rehabilitation Rehabilitation after AC joint stabilisation or reconstruction, with the protective phase and staged return to sport. This protocol covers the rehabilitation after acromioclavicular (AC) joint stabilisation with Dr Kieran Hirpara at Mater Private Hospital Rockhampton, restoring the alignment of the joint between the collarbone and the shoulder blade after a dislocation using a suspensory device, sometimes reinforced with a tendon graft. Bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. Your rehabilitation is progressed individually by your physiotherapist through the phases below, depending on how your shoulder progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect AC joint stabilisation is different from most keyhole shoulder surgery: there is a repair that must be protected while it heals, and the thing that loads it most is simply the weight of your own arm. Gravity constantly pulls the arm (and with it the shoulder blade) downwards, away from the collarbone, which is exactly the direction the stabilisation has to resist. Early rehabilitation is therefore deliberately protective: the sling carries the weight of the arm, movement is kept within safe limits, and strengthening waits until the repair has matured. The sling is protective. Wear it for 6 weeks, and for the first three weeks keep it on while sleeping too, because even lying down the weight of the arm pulls on the repair. After three weeks it can come off in bed. When the sling is off for washing or exercises, keep the arm supported: rest the forearm on a pillow or table rather than letting the arm hang or carry anything. At night, most people are most comfortable on their back or on the non-operated side; if you lie on your back, a small pillow under the elbow and forearm stops the shoulder sagging backwards. Avoid lying on the operated shoulder while the repair heals. You must not drive for six weeks after any shoulder operation, and not while you are wearing a sling. Your exercise program uses three kinds of movement, and your team will mark which apply to you: - Active range of motion: movement is allowed without aid or help. - Active-assisted range of motion: using the other arm or an object to assist with moving the arm. - Passive range of motion: completely relaxed, using the other arm or force to do 100% of the work. The journey at a glance: - Phase I: Protecting the repair, weeks 0–6 - Phase II: Restoring your movement, weeks 6–12 - Phase III: Strengthening, weeks 12–18 - Phase IV: Return to sport and heavy work, week 18 onwards The week ranges are typical rather than fixed; published protocols for this operation vary, and your physiotherapist will progress you on how the repair and your movement are going, not on the calendar. Most people are using the arm for normal daily activities by around three months. Return to contact and collision sport typically takes around four to six months, and for some sports and occupations the build-up runs longer. ## Phase I — Protecting the repair (Weeks 0–6) Kieran Hirpara 4.0 #### Pendulum exercise Out of the sling, bend forward at the waist and let the operated arm hang gently away from the body. Let the arm swing in small, relaxed circles — the movement comes from your body, not the shoulder muscles. Stay within comfort, then support the arm back into the sling. Several times a day Kieran Hirpara 4.0 #### Scapular setting Sitting or standing tall with the arm supported, gently draw your shoulder blades back together and down, away from your ears. Hold for a few seconds, then relax. This keeps the posture muscles working without loading the repair. As guided by your physiotherapist Kieran Hirpara 4.0 #### Hand and grip exercises With the arm supported in the sling, make a full fist, then open the fingers out straight. A soft ball or rolled-up sock can be squeezed for grip work. Keep the hand, wrist and elbow moving from day one. As guided by your physiotherapist Kieran Hirpara 4.0 #### Ball squeeze With the arm supported in the sling, hold a soft ball or rolled-up sock and squeeze it firmly, then release. This keeps the grip and forearm working while the shoulder is protected. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wrist movement With the arm out of the sling and the forearm supported, bend your wrist forwards, backwards and side to side. Keeping the wrist moving from day one stops it stiffening while the repair is protected. As guided by your physiotherapist Kieran Hirpara 4.0 #### Elbow bends With the upper arm supported by your side, bend the elbow as far as it comfortably goes, then straighten it fully. Only the elbow moves — keep the shoulder relaxed and supported so the repair is not loaded. As guided by your physiotherapist Kieran Hirpara 4.0 #### Forearm rotation With the elbow tucked at your side and bent to a right angle, turn the palm up towards the ceiling, then down towards the floor. The forearm rotates while the shoulder stays still and supported. As guided by your physiotherapist Kieran Hirpara 4.0 #### Assisted external rotation with a stick Lie on your back with the operated elbow tucked by your side and bent to a right angle. Hold a stick in both hands and let the good arm gently turn the operated forearm outwards, only as far as comfort allows in this phase. Return slowly and keep the movement small and supported. As guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric external rotation Stand with your elbow tucked at your side and bent to a right angle, the back of your hand against a wall or doorframe. Gently press outwards into it without letting the arm move, hold a few seconds, then relax. The shoulder works but does not move, so the repair is not loaded. Sub-maximal and pain-free; as guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric internal rotation Stand with your elbow tucked at your side and bent to a right angle, the palm against a wall or doorframe. Gently press inwards into it without letting the arm move, hold a few seconds, then relax. A no-movement way to keep the rotator cuff active early on. Sub-maximal and pain-free; as guided by your physiotherapist The first six weeks are about letting the repair heal while keeping the rest of the arm moving. The sling carries the weight of the arm whenever you are up and about. Your hand, wrist and elbow should keep moving from day one: use the hand for light tasks such as writing and eating while the arm is in the sling. The shoulder itself starts with gentle pendulum exercises and assisted movements within strict limits: nothing above shoulder height, no reaching across your body, and no reaching behind your back. Ice and regular pain relief make the exercises manageable. Take your painkillers before your exercises and physiotherapy sessions. You can shower once your wound care advice allows; to wash under the operated arm, bend forward at the waist and let the arm fall gently away from the body, the same position as the pendulum exercise. During this phase, do not lift anything heavier than about half a kilogram with the operated arm, do not carry bags on that side, do not lean on the arm or use it to push yourself up from a bed or chair, and do not let the arm hang unsupported: each of these pulls the shoulder blade down away from the collarbone and loads the repair. For your physiotherapist: Goals - Protect the surgical stabilisation and allow soft-tissue healing - Control pain and swelling; protect wound healing - Prevent shoulder stiffness within the protected ranges - Maintain hand, wrist, elbow and neck range of motion Management - Sling for 6 weeks whenever up and about; arm supported when the sling is off - Pendulum exercises several times daily - Passive and active-assisted elevation in the plane of the scapula, limited to 90 degrees - Passive and active-assisted external rotation as comfort allows (initially to around 30 degrees) - Hand, wrist, elbow and forearm active range of motion; ball squeeze - Scapular setting (retraction and depression) and postural correction - Sub-maximal, pain-free isometric internal and external rotation in neutral as tolerated - Soft-tissue and scapulothoracic mobilisation as indicated; scar massage once the wound has healed - Ice 15–20 minutes, several times daily, as needed; analgesia before exercises and sessions Precautions - Do not let the weight of the arm pull on the fixation: no hanging arm, no carrying, no downward traction - No elevation above 90 degrees in any plane - No active shoulder range of motion beyond the prescribed assisted program - No cross-body (horizontal) adduction and no internal rotation behind the back - No lifting heavier than about half a kilogram; no supporting body weight through the arm - No driving for six weeks (this applies to any shoulder operation), and not while in the sling Criteria to progress - Around 90 degrees of passive flexion in the plane of the scapula - Around 30 degrees of passive external rotation in the plane of the scapula - Tolerating the range-of-motion and isometric program, with pain and swelling settling ## Phase II — Restoring your movement (Weeks 6–12) Kieran Hirpara 4.0 #### Countertop slide Sit at a table or bench with your hands resting on the surface. Slide the hands forward, letting your trunk lean in so the shoulder bends upward with support, then return. Move smoothly within comfort, without hitching the shoulder towards the ear. As guided by your physiotherapist Kieran Hirpara 4.0 #### Elastic-band row Anchor an elastic exercise band in front of you at about waist height. Pull the band towards you, drawing the shoulder blade back and down as the elbow travels past your side, then return with control. Keep the resistance light in this phase. As guided by your physiotherapist Kieran Hirpara 4.0 #### Side-lying external rotation Lie on your non-operated side with the top elbow bent to a right angle and tucked against your body. Keeping the elbow at your side, rotate the forearm up towards the ceiling, then lower with control. No weight in this phase — weight is added later, as guided. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wall finger-walk Stand facing a wall and rest the fingers of the operated hand on it. Walk the fingers slowly up the wall, letting them take some of the arm's weight as the shoulder lifts, then walk back down. Keep the shoulder blade relaxed — no hitching towards your ear. As guided by your physiotherapist Kieran Hirpara 4.0 #### Biceps curl With the upper arm by your side, bend the elbow to curl a light weight up towards your shoulder, then lower it slowly. Keep loads light in this phase — this rebuilds the arm without straining the repair. As guided by your physiotherapist Kieran Hirpara 4.0 #### Serratus punch Lie on your back with the operated arm pointing up towards the ceiling. Without bending the elbow, reach the fist a little further upwards so the shoulder blade lifts off the bed, then lower with control. This wakes up the muscle that holds the shoulder blade onto the ribs. As guided by your physiotherapist Kieran Hirpara 4.0 #### Prone T Lie face down with the arms hanging towards the floor. Squeeze the shoulder blades together and raise the operated arm out to the side into a 'T', then lower slowly. Keep it light — this trains the shoulder-blade muscles without loading the joint heavily. As guided by your physiotherapist Kieran Hirpara 4.0 #### Standing scaption Stand with the arm by your side, thumb pointing up. Raise the arm out at a forward angle, midway between straight ahead and out to the side, no higher than is comfortable, then lower slowly. Keep the shoulder blade settled and avoid shrugging. As guided by your physiotherapist Kieran Hirpara 4.0 #### Rhythmic stabilisation With your arm supported in front of you at about shoulder height, have your physiotherapist (or your good hand) apply small, gentle pushes from different directions while you hold the arm still and steady — do not let it move. This trains the shoulder's stabilising muscles to react. Keep all the efforts gentle. As guided by your physiotherapist From about six weeks you wean out of the sling and the limits on movement are progressively lifted. Assisted movements become active ones, and range builds steadily; as a guide, published protocols progress range in roughly 15-degree steps each week, aiming for full movement by about week 12. Light elastic-band exercises for the rotator cuff and shoulder blade muscles begin during this phase. The repair still needs respect: keep lifting to about a kilogram, and avoid forceful pushing and pulling, push-ups, and lifting across the body or overhead. Reaching behind your back is usually the last movement to be freed up. For your physiotherapist: Goals - Wean from the sling - Progressively restore active range of motion in all planes (full, or near-full, by around week 12) - Begin gentle strengthening; minimise muscle atrophy - Re-establish scapulohumeral rhythm and neuromuscular control Management - Progress active-assisted to active elevation; wall slides and countertop slides into flexion - Elevation in the scapular plane with attention to scapular mechanics: no hitching - Behind-the-back internal rotation introduced gradually (to the beltline initially) - Horizontal adduction as active reach only: no passive stretch yet - Theraband internal and external rotation, biceps curl, row and serratus punch - Dynamic scapular and cuff work: side-lying external rotation, prone row, prone extension, prone 'T's and 'Y's, standing scaption - Proprioception and rhythmic-stabilisation drills - Manual therapy and joint mobilisation as indicated Precautions - No lifting heavier than about a kilogram with the operated arm - No forceful pushing or pulling; no push-ups - No lifting of weighted objects overhead or across the body - Avoid end-range stretching into cross-body adduction; behind-the-back movement progresses gradually Criteria to progress - At least around 140 degrees of passive flexion and 60 degrees of passive external rotation in the scapular plane - Active flexion against gravity to at least around 100 degrees with good mechanics - Tolerating the active range-of-motion and early strengthening program ## Phase III — Strengthening (Weeks 12–18) Kieran Hirpara 4.0 #### Cross-body stretch Bring the operated arm across your chest and use the other hand, placed above the elbow, to draw it gently further across until you feel a stretch at the back of the shoulder. Hold, then release. This stretch was off-limits earlier and is now used to win the final degrees of range. As guided by your physiotherapist Kieran Hirpara 4.0 #### Sleeper stretch Lie on the operated side with the shoulder and elbow each bent to a right angle. Use the other hand to ease the forearm gently down towards the bed until a stretch is felt at the back of the shoulder. Hold, then relax — a stretch, not pain. As guided by your physiotherapist Kieran Hirpara 4.0 #### Behind-the-back stretch with a towel Hold a towel behind your back, the good hand over the shoulder and the operated hand at the small of the back. Gently draw the towel upwards with the good hand to ease the operated hand up the back until a stretch is felt, then release. Behind-the-back movement is one of the last to return, so progress it gently. As guided by your physiotherapist Kieran Hirpara 4.0 #### Hands behind head Clasp both hands behind your head and gently ease the elbows outwards and back until a stretch is felt at the front of the shoulder. Hold, then relax. This wins back the last of the outward-rotation range with the arm raised. As guided by your physiotherapist Kieran Hirpara 4.0 #### External rotation at 90 degrees Raise the arm out to shoulder height with the elbow bent to a right angle, holding an elastic band. Rotate the forearm upwards against the band so the back of the hand travels up, then return slowly. A higher-level rotator cuff exercise once movement and control are good. As guided by your physiotherapist Kieran Hirpara 4.0 #### Prone W Lie face down with the arms hanging. Squeeze the shoulder blades together and draw the elbows back and down so the arms make a 'W', then lower slowly. Builds the lower shoulder-blade muscles that steady the joint. As guided by your physiotherapist Kieran Hirpara 4.0 #### Diagonal band pattern (D1) Hold an elastic band and draw it on a diagonal, from across the front of your body up and out to the opposite side, then return slowly. These diagonal patterns train the shoulder the way it works in everyday reaching. As guided by your physiotherapist Kieran Hirpara 4.0 #### Diagonal band pattern (D2) Hold an elastic band low and across your body, then draw it up and out overhead to the side on a diagonal, finishing with the thumb up, and return slowly. A second diagonal pattern that builds control through a wider range. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wall push-up Stand facing a wall with your hands on it at shoulder height. Bend the elbows to bring your chest towards the wall, then push back; at the top, push a little further so your upper back rounds away from the wall. Start at the wall before progressing — keep the shoulder blades controlled. As guided by your physiotherapist Kieran Hirpara 4.0 #### External rotation at 90/90 (band) With the arm out to the side at shoulder height and the elbow bent to a right angle, rotate the forearm back and up against a light band or weight, then lower slowly. Builds rotator-cuff strength in the raised (throwing) position. 2 to 3 sets of 10 to 15, low resistance Kieran Hirpara 4.0 #### Internal rotation at 90/90 (band) From the same position with the arm out to the side at shoulder height, rotate the forearm forwards and down towards your feet against a light band or weight, then return with control. 2 to 3 sets of 10 to 15, low resistance Kieran Hirpara 4.0 #### Prone Y (lower shoulder blade) Lie face down with your operated arm reaching overhead and out at about 45° to form a Y, thumb pointing up. Lift the arm a small way off the surface by drawing the shoulder blade down and back, then lower slowly. Keep it light — this targets the lower shoulder-blade muscles. As guided by your physiotherapist — light, high repetitions Kieran Hirpara 4.0 #### Prone row Lie face down with the operated arm hanging down towards the floor. Draw your elbow up towards the ceiling, squeezing the shoulder blade in towards your spine, then lower slowly. Start with no weight and keep the movement controlled. As guided by your physiotherapist With the repair matured and movement largely restored, attention turns to rebuilding strength. The stretches that were off-limits earlier (across the body and up behind the back) are now used to win the final degrees of range. Resistance work progresses from elastic bands to light weights, and push-ups begin against a wall before progressing. Gym-based weight training is typically reintroduced from about week 16, with limited range and light loads at first. Heavy overhead lifting and forceful pushing and pulling are still avoided in this phase. For your physiotherapist: Goals - Full active and passive range of motion in all planes - Progressive strength, endurance and neuromuscular control of the cuff and scapular stabilisers - Prepare for a graduated return to sport-specific loading Management - Multi-directional end-range stretching: cross-body stretch, behind-the-back internal rotation, hands-behind-head, sleeper stretch, external rotation at 90 degrees of abduction - Progressive resistance (roughly 0.5–2.5 kg) added to the dynamic program: side-lying external rotation, prone row, prone extension, prone 'T's and 'Y's, standing scaption - Theraband progressions: 'T's, 'W's, diagonals, internal and external rotation at 90 degrees - Closed-chain work: wall push-ups from around week 12, progressing per tolerance - Machine-based weight training from around week 16: limited range, light load (rows, pull-downs, biceps and triceps; pressing reintroduced cautiously) - Rhythmic stabilisation, proprioception and scapulohumeral-rhythm drills Precautions - Avoid heavy lifting, particularly overhead, and forceful pushing and pulling - Strengthening stays pain-free and stops short of provocative end-range loading - Maintain scapular control through range: regress the load if hitching or compensation appears Criteria to progress - Active and passive shoulder motion within functional limits in all directions - Tolerating the progressive strengthening program without flare-up ## Phase IV — Return to sport and heavy work (Week 18 onwards) The final phase is a graduated return to strenuous work, overhead loading and sport. Plyometric and sport-specific drills are layered onto the strengthening program, and interval programs guide the return to throwing, swimming, golf and racquet sports. Return to contact and collision sport typically takes around four to six months from surgery, depending on regaining full movement, strength and confidence in the arm; published programs for collision athletes sometimes run longer, up to around nine months. Strength athletes typically rebuild towards their usual training over a similar timeframe. Your physiotherapist and surgeon will guide the final clearance, and some collision athletes choose to wear a shoulder brace for the first season back. For your physiotherapist: Goals - Maintain full range of motion - Progress strength, power and endurance to the demands of the patient's work and sport - Graduated, criteria-based return to contact and overhead sport Management - Continue and progress the Phase III strengthening program - Closed-chain progressions: push-up progression to unstable surfaces, ball-on-wall work - Plyometrics for throwing and overhead athletes: rebounder throws, weighted-ball work, wall dribbles, deceleration drills - Interval sport programs for throwing, golf, tennis and swimming - Function- and occupation-specific kinetic-chain strength and endurance Precautions - Return to contact and collision sport only with full range, restored strength and surgical clearance - Progression remains symptom-guided: if pain or a sense of instability appears, step back a stage ## After your protocol The phases above are drawn from published rehabilitation protocols for AC joint stabilisation and reconstruction: Massachusetts General Brigham Sports Medicine, the Massachusetts General Hospital sports medicine AC joint reconstruction program, the ACJ stabilisation guidelines of UK shoulder units, and a systematic review of publicly available AC joint reconstruction protocols. The week ranges are typical rather than fixed, and published programs vary; your ongoing rehabilitation is guided individually by your physiotherapist, working with the practice, based on how your repair and movement recover. This page works alongside the practice's general recovery advice; see managing post-operative pain and wound care. For the operation itself and the injury it treats, see AC joint stabilisation. The evidence behind this protocol (the reconstruction, the loss-of-reduction literature, and the rehabilitation studies) is summarised in the evidence section, available as a PDF from the top of this page. --- ### Anterior Bankart Repair URL: https://www.cqupperlimb.com/education/rehabilitation/anterior-bankart/ Region: rehabilitation · rehabilitation Rehabilitation protocol after arthroscopic anterior Bankart (labral) repair for anterior shoulder instability — apprehension-position precautions and staged return to sport. This protocol guides your recovery after an arthroscopic anterior Bankart repair with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It pairs a plain-English explanation of each stage with a structured programme you can share with your physiotherapist; bring this page or its PDF to your first appointment so your rehabilitation stays coordinated. Your physiotherapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect A Bankart repair fixes the torn rim of cartilage (the labrum) and the stretched capsule back onto the front of the socket, after the shoulder has dislocated or come partly out of joint towards the front. That repair is soft tissue, and like a healing tendon it needs time to knit firmly back onto the bone: roughly twelve weeks before it is reliably strong. This whole programme is built around protecting that healing. The single most important rule is to protect the front of the shoulder early by limiting how far the arm rotates outwards. Turning the arm outwards (especially with the arm raised out to the side) pulls directly on the repair at the front. So outward rotation is kept small at first and opened up only in careful steps, reaching full by around twelve weeks. Recovery is staged rather than rushed. Movement comes back first, then strength, then the demands of sport and heavier work. Soft-tissue labral repairs heal more slowly than the bony Latarjet operation, so the timeline here is deliberately patient: most people return to contact or overhead sport at four to six months, once they have met the targets, not on a fixed date. ## The procedure Your Bankart repair is done arthroscopically (keyhole). Through small incisions, the torn labrum and capsule at the front of the shoulder are re-attached to the rim of the socket with small anchors and stitches, restoring the bumper and the tension that keep the ball centred in the socket. The job of rehabilitation is to protect that re-attachment while it heals, then gradually rebuild full movement, strength and confidence in the shoulder. ## Wearing your sling You will wear a simple shoulder sling, not a special brace. Dr Hirpara uses a simple sling held in neutral rotation (forearm resting across the stomach); no abduction pillow, wedge or "gunslinger" brace is needed. Your protection comes from the sling and from keeping the arm out of the at-risk position, not from the shape of the brace. - Wear the sling for 6 weeks for daytime support, especially when you are out of the house or around other people. - You do not sleep in the sling. It is daytime support only; sleep out of it, with your arm comfortable and supported on a pillow. While you are asleep, keep your arm in front of you and tucked in towards your body: do not let it fall out to the side and turn outwards (the position described below). - Take it off for showering and for your exercises (once you have been shown how). Whenever the sling is off, keep your arm relaxed, in front of you, and by your side. - Use ice if the shoulder is swollen or sore, especially after exercise. Watch your posture while you are using the sling: keep your ears, shoulders and hips in line and avoid slumping. ## Key precautions — do NOT - Do NOT put your arm into the "hand-up" or throwing position (arm raised out to the side and rotated outwards, as if waving or about to throw). This is the position the shoulder dislocates in, and it pulls directly on the front repair. A simple guide some people use is "always keep your elbows where you can see them": keep the arms in front of you. - Do NOT actively rotate the arm outwards past the limits below in the early weeks. Outward rotation is opened up in stages: only a small amount (around 20°, well short of the straight-ahead position) in the first weeks, building to full by about 12 weeks. - Do NOT actively move the shoulder under its own power until about 6 weeks: let your good arm or a stick do the work before then. - Do NOT reach behind your back, do up a bra, or put your hand in a back pocket early. - Do NOT lift, push, pull, or bear weight through the operated arm for 6 weeks. - Do NOT do push-ups, bench press, wide-grip or chest-fly weights, military (overhead) press, or pull-downs behind the neck until late in the programme; these all load or stretch the front of the shoulder. - Do NOT force or stretch into the position that feels like the shoulder might slip; pain or a feeling of apprehension is a signal to stop. - Do NOT drive while the sling is required (6 weeks). ## Phase I: Protection (weeks 0–6) Kieran Hirpara 4.0 #### Open and close hand Make a tight fist with your hand, then open it fully. This keeps your hand moving and helps prevent stiffness and swelling. 10 times per hour Kieran Hirpara 4.0 #### Wrist bends Gently bend your wrist forwards, then back, as far as is comfortable. 10–15 times per hour Kieran Hirpara 4.0 #### Elbow bends With your palm facing up, gently bend your elbow as far as you can, then straighten your arm again. Keep your upper arm tucked at your side. Do NOT let the arm rotate outwards as you do this. 10–15 times, 2–3 times a day Kieran Hirpara 4.0 #### Ball squeeze Gently squeeze a soft ball or a rolled-up sock in your hand, then release. This keeps the hand and forearm active while the shoulder rests. 10–15 times, a few times a day Kieran Hirpara 4.0 #### Pendulum swings Lean forwards and let your operated arm hang down, completely relaxed. Make small circles — clockwise, then the other way — by rocking your body, NOT by using your shoulder muscles. Keep the circle small (under about 20 cm) and keep the arm hanging straight down — do not let it swing out to the side and turn outwards. Your operated arm stays relaxed throughout. 10 in each direction, 2–3 times a day Kieran Hirpara 4.0 #### Shoulder-blade setting Gently squeeze your shoulder blades downwards and together, hold, then relax. This is a light muscle-activation drill — your arm does not move and your shoulder stays relaxed. Hold 5 seconds, 5 times, 2–3 times a day Kieran Hirpara 4.0 #### Assisted external rotation to neutral From about week 2, only if your physiotherapist directs it. With your elbow tucked at your side and bent to 90° and your hand resting across your stomach, use your good hand to gently guide the forearm outwards — but only a SMALL amount (about a quarter turn, roughly 20°) and never past the straight-ahead (neutral) position in these early weeks. Stay strictly within the limit your physiotherapist sets and never force it. This is the motion that stresses the repair, so it is deliberately kept small. As guided by your physiotherapist, within the set limit The first six weeks are about one thing: protecting the repair at the front of the shoulder while it starts to heal onto the bone. You stay in the simple sling for daytime support, sleep out of it (with the arm kept in front, never out-and-rotated), manage swelling with ice, and do gentle drills that keep your hand, wrist and elbow moving without loading or stretching the repair. There is no active shoulder movement under your own power yet; your good arm or a stick does the work for you, and you stay completely relaxed. - Sling: simple sling in neutral rotation for daytime support; sleep OUT of the sling but keep the arm in front and tucked in; off for exercises and hygiene. - Movement allowed: assisted and passive movement only (nothing under your own shoulder power). From about week 2, gentle assisted forward lift towards about 90° (halfway up), and assisted outward rotation only a small amount (around 20°, not reaching the straight-ahead position). Keep the arm in front of the body throughout; never out to the side and rotated outwards. - Exercises: pendulum swings; gentle hand, wrist and elbow movement; ball squeezes; shoulder-blade setting; from about week 3, gentle pain-free muscle-setting holds (pressing the arm very lightly into a wall or your other hand and holding, without rotating the arm, no turning in or out yet) as your physiotherapist directs; and, from about week 2 if your physiotherapist directs it, small-range assisted outward rotation strictly within the set limit. Ready for the next phase when: your pain is settling and controlled with simple pain relief (about 3/10 or less); you have completed the six weeks of sling protection; your wound has healed with no signs of a problem; you can tolerate the gentle assisted movements within their limits without any feeling that the shoulder might slip; and there is no sign the repair has been over-stressed. ## Phase II: Restoring movement and rotation (weeks 6–12) Kieran Hirpara 4.0 #### Isometric external rotation From about week 6–8, once your physiotherapist agrees. Stand with your elbow tucked at your side and bent to 90°, the back of your hand near a wall or door frame. Press the back of your hand gently outwards into the surface WITHOUT letting the arm move — a gentle effort, about a quarter of your strength, with no pain. Hold, then relax. Build this up slowly, because outward rotation is the direction the repair is most sensitive to. Hold ~5 seconds, gentle (~25% effort), as guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric internal rotation From about week 6–8, once your physiotherapist agrees. Stand with your elbow tucked at your side, palm against a wall. Press the palm gently inwards WITHOUT letting the arm move — about a quarter effort, with no pain. Hold, then relax. Hold ~5 seconds, gentle (~25% effort), as guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric arm-out-to-the-side From about week 6–8, once your physiotherapist agrees. Stand side-on with the outside of your upper arm near a wall, elbow at your side. Press the arm gently outwards into the wall WITHOUT letting it move — about a quarter effort, no pain. Hold, then relax. Hold ~5 seconds, gentle (~25% effort), as guided by your physiotherapist Kieran Hirpara 4.0 #### Assisted forward lift in lying Lying on your back, hold a stick in both hands and use your good arm to lift the operated arm forwards and up — the operated shoulder stays relaxed. Move smoothly, never force, and lower with control. Build the height gradually within the range your physiotherapist sets. 10 times, 2–3 times a day Kieran Hirpara 4.0 #### Seated table slide Sit at a table with your operated hand on a towel. Slide the hand forwards along the surface so the arm reaches forwards and up, letting the table take the weight, then slide back. Keep the arm in front of you — do not slide it out to the side and let it turn outwards. 10 times, 2–3 times a day Kieran Hirpara 4.0 #### Cross-body stretch From about week 6–8 if your physiotherapist directs it. Use your good hand to draw the operated arm gently across your chest until you feel a comfortable stretch at the back of the shoulder. Keep it gentle — do not force. This stretches the back of the shoulder and does not stress the front repair. Hold 10–20 seconds, a few times, as guided by your physiotherapist The sling is now off and the focus is restoring movement, not power. You progress from assisted movement to moving the arm under your own power, and, importantly, outward rotation is gradually opened up: from around 30–45° early in this phase towards full by about twelve weeks. This is done in steps, never forced, because the front repair is still maturing. Light muscle-activation (isometric) drills are added as movement improves. - Sling: off. - Movement allowed: assisted movement building to movement under your own power. Forward lift progresses towards full overhead. Outward rotation is advanced in stages: roughly 30–45° early in this phase, then opened up towards full by about week 12. Reaching behind the back is reintroduced gently and late in this phase. - Exercises: assisted forward lift in lying; seated table slide; gentle isometric (press-and-hold) external rotation, internal rotation and arm-out-to-the-side drills; cross-body stretch for the back of the shoulder. Ready for the next phase when: you can lift the arm forwards under your own power to nearly full height with good control (no shrugging or hitching of the shoulder blade); your outward rotation has progressed to full or nearly full and is comfortable; gentle isometrics are tolerated without a pain flare-up afterwards; and you have no feeling that the shoulder might slip during everyday movements. ## Phase III: Strengthening (weeks 12–16) Kieran Hirpara 4.0 #### Sidelying outward rotation From about week 12. Lie on your good side, operated elbow tucked at your waist and bent to 90°. Rotate the operated forearm upwards towards the ceiling, then lower with control. Start with no weight, staying within the range your physiotherapist sets. This rebuilds the outward-rotation strength last, as it is the direction the repair is most protective of. As guided by your physiotherapist Kieran Hirpara 4.0 #### Sidelying outward rotation with a light weight The sidelying outward rotation as before, now with a light weight, building the load gradually. Keep the elbow tucked in at your waist. Stop if the shoulder is painful. As guided by your physiotherapist Kieran Hirpara 4.0 #### Sidelying inward rotation with a light weight From about week 12. Lie on your operated side, elbow tucked at your waist and bent to 90°, holding a light weight. Lift the forearm upwards towards your stomach, then lower with control. As guided by your physiotherapist Kieran Hirpara 4.0 #### External rotation with a band From about week 12, once full rotation is comfortable. Keep your elbow tucked at your side and bent to 90°. Rotate the forearm outwards against a light band, then return with control. Use a light band and many repetitions, not heavy resistance. As guided by your physiotherapist Kieran Hirpara 4.0 #### Internal rotation with a stick From about week 12. Hold a stick behind your back and use your good hand to draw the operated hand gently up your back, then lower with control. Keep it comfortable and within your physiotherapist's limits. As guided by your physiotherapist Kieran Hirpara 4.0 #### Sleeper stretch From about week 12, if your physiotherapist directs it. Lie on your operated side with the arm forwards and elbow bent. Use your top hand to gently press the forearm down towards the bed until you feel a comfortable stretch at the back of the shoulder. Gentle only — do not force. Hold 10–20 seconds, a few times, as guided by your physiotherapist Kieran Hirpara 4.0 #### Rhythmic stabilisation With your arm supported in front of you at about shoulder height, have your physiotherapist (or your good hand) apply small, gentle pushes from different directions while you hold the arm still and steady — do not let it move. This trains the shoulder's stabilising muscles to react. Keep all the efforts gentle. As guided by your physiotherapist By twelve weeks the repair is strong enough to begin proper strengthening, and the focus shifts from regaining movement to rebuilding strength, endurance and control. Resistance work with light bands and light weights starts now: high repetitions, low loads. The rotator-cuff muscles that hold the shoulder in are strengthened in all directions, with outward rotation built up carefully as the direction the repair is most sensitive to. Always keep movements controlled and pain-free. - Sling: none; full movement expected. - Exercises: sidelying outward rotation (progressing to a light weight); sidelying inward rotation with a light weight; external rotation with a light band, elbow at the side; internal rotation with a stick; sleeper stretch for the back of the shoulder. Your physiotherapist may also add rhythmic stabilisation (gentle hold-steady drills where they push lightly on your arm and you resist) to retrain the shoulder's control. This is hands-on work with no diagram. Ready for the next phase when: you have full, pain-free movement under your own power with even shoulder-blade control; no pain or swelling after strengthening sessions; rotation strength is building steadily towards the other side; and you have no apprehension or instability with everyday loaded tasks. ## Phase IV: Return to sport and work (4–6 months) Kieran Hirpara 4.0 #### Resistance-band row With a band anchored in front of you, pull the handles towards you, drawing your elbows back and squeezing your shoulder blades together, then return with control. Keep your elbows close to your sides and in front of you — do not let them drift backwards behind the line of your body. Light band, high repetitions. As guided by your physiotherapist Kieran Hirpara 4.0 #### Shoulder-blade pull with a weight Draw your shoulder blades back and down against a light weight or band, hold briefly, then release with control. This builds the muscles that steady the shoulder blade and support the repaired shoulder. As guided by your physiotherapist Kieran Hirpara 4.0 #### Diagonal band pattern (reaching down and across) From about week 12, once you have full comfortable movement. With a light band, move the arm in a smooth diagonal line — from up and out, down and across towards the opposite hip, then back. This trains the shoulder in the natural diagonal patterns used in daily tasks and sport. Keep it controlled and pain-free. As guided by your physiotherapist Kieran Hirpara 4.0 #### Diagonal band pattern (reaching up and across) From late in this phase, once outward rotation is full and comfortable. With a light band, move the arm in a smooth diagonal line — from down and across the body, up and out overhead, then back. Because this pattern takes the arm into the raised, rotated-out position, introduce it only when your physiotherapist agrees you are ready. Keep it controlled and pain-free. As guided by your physiotherapist This phase is the bridge from a strong, controlled shoulder back to the demands of sport and heavier work. You keep the range you have won and build the strength, power and endurance to use it confidently. Returns are staged, not sudden; for overhead and contact sport, an interval programme that builds up volume and intensity step by step is the safest route back. - Sling: none. - Exercises: progressive cuff and shoulder-blade strengthening (resistance-band rows, shoulder-blade pulls); diagonal band patterns that train the shoulder through natural reaching lines, with the overhead-and-rotated pattern added only when outward rotation is full and comfortable; then sport- and work-specific conditioning and controlled higher-speed drills as appropriate. Ready to return when: your strength is at least 85% of the other side and the balance between your outward- and inward-rotation strength is good; you have full, pain-free movement with no feeling of instability under load; and you pass the task-specific tests for your sport or job. Return to contact or overhead sport is usually around 4–6 months, based on meeting these criteria and on Dr Hirpara's and your physiotherapist's clearance, not the calendar alone. ## Returning to sport and work The return to sport and work is criteria-based: pain-free, with full range, balanced strength, and no feeling that the shoulder might slip, and signed off by both Dr Hirpara and your physiotherapist, not decided by the calendar alone. - Light, sedentary work: within a few weeks, with the arm protected. - Strengthening: light resistance from about 12 weeks. - Throwing and overhead sport: not before 4 months, and only after a graded build-up. - Contact and collision sport: usually 4–6 months, criteria-based. A soft-tissue Bankart repair heals more slowly than the bony Latarjet operation, so the return is typically a little later; patience here protects the repair and lowers the chance of the shoulder coming out again. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain and wound care. --- ### Biceps Tenodesis URL: https://www.cqupperlimb.com/education/rehabilitation/biceps-tenodesis/ Region: rehabilitation · rehabilitation Rehabilitation after isolated biceps tenodesis, protecting the tenodesis fixation through staged return of biceps loading. This protocol covers the rehabilitation after biceps tenodesis with Dr Kieran Hirpara at Mater Private Hospital Rockhampton, whether the operation was done arthroscopically (keyhole) or through a small open incision near the front of the armpit (open subpectoral technique). Bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. Your rehabilitation is progressed individually by your physiotherapist through the phases below, depending on how your shoulder and arm progress. This protocol is for an isolated biceps tenodesis. If your operation also included a rotator cuff repair, follow the rotator cuff repair protocol instead; the repaired tendon sets a slower pace. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect In a biceps tenodesis, the long head of the biceps tendon is detached from its original anchor point inside the shoulder and fixed to the upper arm bone (humerus) instead, using an anchor or screw. That new attachment needs time to heal securely to the bone, and the early weeks of rehabilitation are organised around protecting it. The biceps muscle does two jobs: it bends the elbow and it turns the palm upwards (supination). That is why (unusually for a shoulder operation) the early restrictions are mostly about the elbow: for the first weeks the elbow is moved passively (the other hand, or your physiotherapist, does the bending) so the healing tendon is not asked to pull. Lifting and carrying with the operated arm are off the menu early for the same reason. A few shoulder positions that put tension on the tendon are also limited at first: rotating the arm outwards past about 40 degrees, and taking the arm behind the line of the body. You will wear a sling for about three to four weeks, including while sleeping, weaning out of it from around week three as comfort allows. Do not drive for at least six weeks after any shoulder operation, even once the sling is gone; your surgeon will clear you to drive, typically at the six-week review. The journey at a glance: - Phase I — Protecting the tenodesis (roughly the first four weeks) - Phase II — Active movement (week 4–6) - Phase III — Strengthening (week 6–12, with resisted biceps work from week 10) - Phase IV — Return to full activity (week 12 onwards) The week ranges are typical rather than fixed, and your physiotherapist will progress you on how your arm is healing and moving, not on the calendar. Physiotherapy usually starts within the first week or two after surgery, and your first appointment is detailed in your discharge pack unless you have chosen to arrange your own. ## Phase I — Protecting the tenodesis (Week 0–4) Kieran Hirpara 4.0 #### Passive elbow bending Let the operated arm rest completely relaxed and use your other hand to bend the elbow up, then let it straighten back out. Your other hand does all the work — the biceps must stay switched off so the healing tendon is not asked to pull. Do the same for turning the palm up and down. Every day Kieran Hirpara 4.0 #### Pendulum exercise Out of the sling, bend forward at the waist and let the operated arm hang gently away from the body. Let the arm swing in small, relaxed circles — the movement comes from your body, not the shoulder or arm muscles. Stay within comfort, then return the arm to the sling. As guided by your physiotherapist Kieran Hirpara 4.0 #### Hand and grip exercises With the arm supported, make a full fist, then open the fingers out straight. A soft ball or rolled-up sock can be squeezed for grip work. The hand, wrist and fingers stay active from the start. As guided by your physiotherapist Kieran Hirpara 4.0 #### Scapular setting With the arm supported, gently draw your shoulder blades back together and down, away from your ears. Hold for a few seconds, then relax. This keeps posture and shoulder-blade control working without loading the tenodesis. As guided by your physiotherapist Kieran Hirpara 4.0 #### Assisted overhead lift (lying) Lie on your back and use your good arm to help lift the operated arm up in front of you towards about shoulder height, then lower it back down with the good arm still helping. Your other arm does the work so the biceps stays relaxed. Stay within comfort — this keeps the shoulder moving while the tenodesis heals. As guided by your physiotherapist Kieran Hirpara 4.0 #### Assisted movement out to the side Cradle the operated forearm with your other arm and gently lift both out to the side, letting the good arm do the work, then lower with control. Keep it comfortable and within early limits — this maintains gentle shoulder range without asking the biceps to work. As guided by your physiotherapist Kieran Hirpara 4.0 #### Assisted outward rotation with a stick Lie on your back with the elbow tucked by your side and bent to a right angle. Hold a stick in both hands and use your good arm to turn the operated hand outwards. Only go to about 40 degrees in these early weeks — this is a limited, protected stretch, not a full one, to keep tension off the healing tendon. As guided by your physiotherapist, to about 40 degrees Kieran Hirpara 4.0 #### Assisted inward rotation with a stick Using the same stick, let your good arm guide the operated hand gently inwards across the front of the body, to about 45 degrees, then return. Keep the operated arm relaxed and stay within the early limit — this maintains inward rotation without loading the tenodesis. As guided by your physiotherapist, to about 45 degrees The first weeks are about letting the tendon heal onto the bone while keeping everything around it moving. Your hand, wrist and fingers stay active from the start. Your elbow is moved every day, but passively: let your other hand do the bending and the palm-up/palm-down turning, so the biceps itself stays relaxed. The shoulder is moved gently within the limits below, with pendulum exercises and assisted movements. Use ice for pain relief, take your painkillers before your exercises and physiotherapy sessions, and keep the sling on, including in bed. Do not lift or carry anything with the operated arm, and do not drive while the sling is required. Light tasks with the forearm supported, such as writing or typing, are generally fine as comfort allows. For your physiotherapist: Goals - Protect the tenodesis fixation while it heals to bone - Settle pain, swelling and the inflammatory response - Full passive elbow and forearm range of motion; comfortable passive shoulder range within the limits below - Maintain scapular function and posture Management - Sling for about 3–4 weeks including at night, weaning from around week 3 - Passive range of motion of the elbow: flexion/extension and forearm supination/pronation - Active range of motion of the wrist and hand; ball squeezes - Shoulder passive and gentle active-assisted range of motion within limits: pendulums, flexion and scaption to about 90 degrees initially, progressing as comfort allows; external rotation to 40 degrees; internal rotation to about 45 degrees - Scapular setting and retraction (arm supported), progressing to scapular isometrics; cervical range of motion and posture work - Cryotherapy for pain and swelling; analgesia before exercises and sessions - A towel roll or small pillow under the elbow when lying on the back, to avoid shoulder extension Precautions - No active elbow flexion and no resisted forearm supination; the biceps stays unloaded - No active shoulder range of motion; no external rotation beyond 40 degrees; no shoulder extension or horizontal abduction past neutral - No lifting or carrying with the operated arm - No friction massage over the proximal biceps / tenodesis site - No driving for six weeks (this applies to any shoulder operation) Criteria to progress - Wound healed and pain well controlled - Full passive elbow flexion/extension and forearm rotation - Comfortable passive shoulder range of motion within the prescribed limits ## Phase II — Active movement (Week 4–6) Kieran Hirpara 4.0 #### Active elbow bending and straightening Bend and straighten the elbow under its own power, with nothing in the hand, and turn the palm up and down. The biceps is now moving but not yet working against load — keep lifting to a minimum (nothing heavier than a cup of tea with that arm) until your physiotherapist progresses you. As guided by your physiotherapist Kieran Hirpara 4.0 #### Table slide Sit at a table with your hand resting on a towel or cloth. Slide the hand forwards along the surface, leaning in so the arm travels up in front of you, then slide back. The table supports the weight, helping the shoulder move actively as your range returns. As guided by your physiotherapist Kieran Hirpara 4.0 #### Active lift in the scapular plane Stand and raise the operated arm up and slightly forwards — about halfway between straight in front and out to the side — with the thumb pointing up, as if holding a full can. Lift under your own power within comfort, then lower slowly. This restores active shoulder lift without any added weight. As guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric external rotation Stand with your elbow tucked at your side and bent to a right angle, the back of your hand against a wall or doorframe. Gently press outwards into it without letting the arm move, hold a few seconds, then relax. This starts building the rotator cuff with no movement and no load on the biceps. Hold a few seconds, several times; as guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric internal rotation Stand with your elbow tucked at your side and bent to a right angle, your palm against a wall or doorframe. Gently press inwards into it without letting the arm move, hold a few seconds, then relax. A submaximal hold — firm but easy, never straining. Hold a few seconds, several times; as guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric abduction Stand side-on to a wall with your elbow at your side. Press the outside of your upper arm gently into the wall as if lifting it out to the side, without letting it move, hold a few seconds, then relax. This builds the shoulder muscles statically before active loading begins. Hold a few seconds, several times; as guided by your physiotherapist Kieran Hirpara 4.0 #### Cross-body stretch Bring the operated arm across your chest and use your other arm to draw it gently further across until you feel a comfortable stretch at the back of the shoulder. Hold, then relax. This eases tightness at the back of the shoulder as your active range returns. As guided by your physiotherapist Kieran Hirpara 4.0 #### Sleeper stretch Lie on the operated side with that arm out in front and the elbow bent to a right angle. Use your other hand to gently press the forearm down towards the bed until you feel a stretch at the back of the shoulder. Keep it gentle — relax into the stretch rather than forcing it. As guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric squeeze-in (adduction) Stand with your elbow tucked at your side and a rolled towel between your upper arm and your body. Gently squeeze your arm inwards against the towel WITHOUT moving — a gentle effort, about a quarter of your strength, with no pain. Hold, then relax. Hold ~5 seconds, gentle (~25% effort), as guided by your physiotherapist With the sling gone, the arm starts moving under its own power. The shoulder progresses from assisted movements to active movement in all directions, and the elbow now bends and turns actively, but still without load. The biceps is moving, not yet working: keep lifting to a minimum (nothing heavier than a cup of tea with that arm) and leave pushing, pulling and carrying to the other side. Light desk-based work is typically comfortable in this phase. Driving resumes from six weeks, once your surgeon has cleared you and you can control the car comfortably and safely. For your physiotherapist: Goals - Gradual restoration of full active shoulder and elbow range of motion - Normal scapular mechanics with movement - Begin submaximal shoulder isometrics - Light waist-level functional use of the arm Management - Shoulder active-assisted progressing to active range of motion in all planes (for example lawn-chair progression, wall and rail slides, supine flexion to standing scaption) - Active elbow flexion/extension and forearm supination/pronation, unresisted - Submaximal shoulder isometrics: internal rotation, external rotation, abduction, adduction - Continue scapular stabilisation and posture work - Scar massage as the wound matures; no cross-friction over the tenodesis site - Posterior capsule stretching (cross-body, sleeper stretch) as indicated - Walking or stationary bike for fitness; no weight bearing through the affected arm Precautions - No resisted biceps work; no loading of the elbow flexors or supinators - No lifting with the operated arm; no running yet - Avoid overstressing the healing tendon with aggressive stretching or manual therapy Criteria to progress - Full, pain-free active range of motion of the shoulder, elbow and forearm - Proper scapular mechanics with movement and light function - Pain well controlled ## Phase III — Strengthening (Week 6–12) Kieran Hirpara 4.0 #### Elastic-band row Anchor an elastic exercise band in front of you at about waist height. Pull the band towards you, drawing the shoulder blade back and down as the elbow travels past your side, then return with control. Part of the shoulder-blade program — keep the load low and the repetitions high. As guided by your physiotherapist Kieran Hirpara 4.0 #### Band external rotation Anchor an elastic band at waist height. With your elbow tucked at your side and bent to a right angle, pull the band outwards, rotating the forearm away from your body, then return slowly. Start light with high repetitions — this strengthens the rotator cuff. As guided by your physiotherapist — low load, high repetitions Kieran Hirpara 4.0 #### Resisted internal rotation Lie on the operated side with a light weight in the hand and the elbow bent at your side. Lift the weight by rotating the forearm up towards your body, then lower slowly. This strengthens the inward rotators of the cuff — keep the load light to begin with. As guided by your physiotherapist — low load, high repetitions Kieran Hirpara 4.0 #### Prone T raise Lie face down with your arms hanging over the edge. Raise the operated arm out to the side to shoulder height, squeezing the shoulder blade, so the arms form a T, then lower slowly. Part of the shoulder-blade program — control matters more than weight. As guided by your physiotherapist Kieran Hirpara 4.0 #### Prone W raise Lie face down and draw the elbows back and down towards your waist, bending them so the arms form a W, squeezing the shoulder blades together, then lower slowly. This trains the lower shoulder-blade muscles that support good posture. As guided by your physiotherapist Kieran Hirpara 4.0 #### Low row With the arm at your side, press down and back against a band or surface, drawing the shoulder blade down and in, then release. This is part of the scapular program, building control low around the shoulder blade. As guided by your physiotherapist Kieran Hirpara 4.0 #### Serratus punch Lie on your back and reach the operated arm straight up towards the ceiling. Punch upwards a little further so the shoulder blade lifts off the floor, then lower it back. This trains the serratus muscle that holds the shoulder blade against the ribs. As guided by your physiotherapist Kieran Hirpara 4.0 #### Diagonal band pattern (D1) Using an elastic band, draw the arm on a diagonal from across the front of your body up and out away from you, then return with control. These diagonal patterns rebuild coordinated, functional shoulder strength. As guided by your physiotherapist Kieran Hirpara 4.0 #### Diagonal band pattern (D2) Using an elastic band, sweep the arm on a diagonal from low across your body up and outwards overhead, then control it back down. A second diagonal pattern that builds strength through fuller, sport-like ranges. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wall push-up plus Stand with both hands on a wall at shoulder height. Keeping the elbows straight, push the chest away from the wall so the shoulder blades round forward, then relax back. This is the start of the push-up plus progression — wall, then counter, then knees, then floor, as guided. As guided by your physiotherapist Kieran Hirpara 4.0 #### Biceps curl Not before week 10. With a light weight in the hand and the elbow at your side, bend the elbow to lift the weight, then lower slowly. Resisted palm-up rotation is added the same way. Start light and progress slowly — this is deliberately the last exercise to load the healing tendon. From week 10 — low load, high repetitions Kieran Hirpara 4.0 #### Resisted forearm rotation Not before week 10. Rest the forearm on a table with the hand off the edge, holding a light weight. Slowly turn the palm up, then turn it down, keeping the movement controlled. Turning the palm up works the biceps directly, so this waits with the curls — start light and build gradually. From week 10 — low load, high repetitions Kieran Hirpara 4.0 #### External rotation at 90/90 (band) With the arm out to the side at shoulder height and the elbow bent to a right angle, rotate the forearm back and up against a light band or weight, then lower slowly. Builds rotator-cuff strength in the raised (throwing) position. 2 to 3 sets of 10 to 15, low resistance Kieran Hirpara 4.0 #### Internal rotation at 90/90 (band) From the same position with the arm out to the side at shoulder height, rotate the forearm forwards and down towards your feet against a light band or weight, then return with control. 2 to 3 sets of 10 to 15, low resistance Kieran Hirpara 4.0 #### Hand-behind-back reach Standing, place the back of your operated hand against your lower back and gently slide it up your spine as far as is comfortable using your own muscles, then lower. Move only within a comfortable range and never force it. As guided by your physiotherapist Kieran Hirpara 4.0 #### Prone Y (lower shoulder blade) Lie face down with your operated arm reaching overhead and out at about 45° to form a Y, thumb pointing up. Lift the arm a small way off the surface by drawing the shoulder blade down and back, then lower slowly. Keep it light — this targets the lower shoulder-blade muscles. As guided by your physiotherapist — light, high repetitions Kieran Hirpara 4.0 #### Prone row Lie face down with the operated arm hanging down towards the floor. Draw your elbow up towards the ceiling, squeezing the shoulder blade in towards your spine, then lower slowly. Start with no weight and keep the movement controlled. As guided by your physiotherapist Strengthening starts gently and works from the shoulder blade outwards: rotator cuff and scapular muscles first, with elastic bands and light weights at low load and high repetitions. Resisted biceps work (curls and resisted palm-up rotation) waits until week 10, then starts light and progresses slowly. Published protocols introduce it anywhere between week 6 and week 10; this protocol follows the more protective end of that range to give the tenodesis fixation the longest run before it is loaded. Normal daily activities should be largely back to usual through this phase, and from around week 8 you can typically return to running, cycling and golf, as guided by your physiotherapist. For your physiotherapist: Goals - Normalise strength, endurance and neuromuscular control - Restore function from waist level through chest level towards overhead Management - Maintain full shoulder and elbow range of motion throughout - Isotonic rotator cuff strengthening: internal and external rotation with light resistance, from neutral progressing towards 90 degrees of abduction - Scapular program: prone series progressing through the phase; resisted serratus punch, low row, push-up plus progression (wall, counter, knees, floor) - Resisted biceps curls, supination and pronation from week 10; short lever first, low load, high repetitions, progressed cautiously - Rhythmic stabilisation and diagonal (D1/D2) patterns; closed-chain stabilisation work - Return to running, cycling and golf from around week 8, with proper mechanics Precautions - Avoid long-lever resisted elbow flexion and supination early in the phase - No heavy lifting or carrying until strength has recovered - No swimming or throwing in this phase - Strengthening waits until range of motion is close to full, and stays pain-free Criteria to progress - Full, pain-free active range of motion with normal scapulohumeral rhythm - 5/5 rotator cuff strength at 90 degrees of abduction in the scapular plane, and 5/5 scapulothoracic strength - Strengthening tolerated without flare-up of symptoms ## Phase IV — Return to full activity (Week 12 onwards) The final phase is a graduated return to heavier work, overhead activity and sport. Most people are cleared for the gym, manual work and recreational sport between three and four months, building loads progressively; overhead and contact athletes (throwing, swimming, racquet sports) are staged back over a longer run, often four to five months or more. The biceps keeps gaining strength and confidence for months after that, so progress in this phase is judged on what the arm can do, not the date. For your physiotherapist: Goals - Full strength and power without compensatory movement patterns - Stability and control with higher-velocity and sport-specific movements - Return to normal sport and work activities Management - Multi-joint and compound strengthening, progressing load steadily - Plyometric training starting below shoulder height with both arms, progressing to single-arm and overhead - Interval return-to-sport programs for throwing, swimming or racquet sports as relevant - Address core and hip strength and control so the shoulder is not compensating Precautions - Progress exercises that stress the anterior shoulder (for example bench press, upright row) slowly - Return to sport follows clearance, with roughly 90% strength compared with the other arm and pain-free control of high-velocity, sport-specific movements ## After your protocol The phases above are adapted from published rehabilitation protocols for isolated biceps tenodesis: Massachusetts General Brigham Sports Medicine, the University of Virginia Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center and UW Health (University of Wisconsin). The week ranges are typical rather than fixed, and your ongoing rehabilitation is guided individually by your physiotherapist, working with the practice, based on how your arm recovers. This page works alongside the practice's general recovery advice; see managing post-operative pain and wound care. For the operation itself, see biceps tenodesis. The evidence behind this protocol (fixation and healing, the tenodesis-versus-tenotomy decision, complication and failure rates, and how the rehab pace is chosen) is summarised in the evidence section, available as a PDF from the top of this page. --- ### Calcific Tendinitis URL: https://www.cqupperlimb.com/education/rehabilitation/calcific-tendinitis/ Region: rehabilitation · rehabilitation Recovery after arthroscopic excision of a calcific deposit, from early movement to full activity. This protocol covers the rehabilitation after arthroscopic excision of a calcific deposit with Dr Kieran Hirpara at Mater Private Hospital Rockhampton: keyhole surgery to remove the calcium deposit from the rotator cuff tendon, sometimes combined with a subacromial decompression to make more room for the tendon. Bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. Your rehabilitation is progressed individually by your physiotherapist through the phases below, depending on how your shoulder progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. If the split in the tendon was stitched closed (removing the deposit often leaves a split in the tendon, and it is commonly closed with a few stitches), your recovery is a little slower than after removal alone, but quicker than after a standard rotator cuff repair: the sling stays on for three to four weeks, movement starts with assisted exercises and becomes fully active from about four weeks, strengthening starts at about ten to twelve weeks, and return to the gym, sport and heavy work is usually at four to six months. Dr Hirpara will tell you after the operation if this applies to you. ## What to expect Both pathways start moving the shoulder early. Even when the tendon split has been stitched, it is a light repair that does not need months of protection; the aim of treatment is to remove the source of pain, and the aim of rehabilitation is to settle the post-treatment flare, keep the shoulder moving so it does not stiffen, and then rebuild strength. - After arthroscopic excision a sling is provided for comfort only. It is worn briefly, typically days and rarely beyond two weeks, and should be left off as much as possible. You do not need to sleep in it. Recovery to full, unrestricted activity typically takes around three months. - If the tendon split was stitched the sling is worn for three to four weeks. Assisted movement comes first, then full active movement from about four weeks, and strengthening from about ten to twelve weeks. Recovery to full activity typically takes around four to six months. Do not drive for at least six weeks after any shoulder operation, even once the sling is gone; your surgeon will clear you to drive, typically at the six-week review. With either treatment, the shoulder can take time to settle completely. Discomfort often improves in stages rather than all at once, and after surgery it can take several months (occasionally up to nine) for the pre-treatment symptoms to fade fully. Steady improvement, not instant comfort, is the expected pattern. This is keyhole day surgery through several small incisions. The calcific deposit is located within the rotator cuff tendon and removed, and a subacromial decompression is often performed at the same time to give the tendon more room. The dressings are waterproof — you can shower over them from day 1 — and stay on until your wounds are checked at your first post-operative appointment about a week to ten days after surgery. ## Phase I — Early movement (weeks 0–2) Kieran Hirpara 4.0 #### Open and close hand Keep your hand and fingers moving by opening and closing them, or by squeezing a soft ball. Start this straight away to keep the hand and arm working while the shoulder settles. 10 times, three times a day Kieran Hirpara 4.0 #### Wrist movement Keep your wrist moving by bending it forwards, backwards and side to side. Do this with the arm out of the sling. 10 times, three times a day Kieran Hirpara 4.0 #### Elbow bends With the upper arm resting by your side, bend the elbow as far as it comfortably goes, then straighten it fully. Only the elbow moves — keep the shoulder relaxed. 10 times, three times a day Kieran Hirpara 4.0 #### Assisted overhead stretch (lying) Lie on your back and use your good arm to help lift the operated arm up above shoulder height as a gentle stretch, then lower it back down with the good arm still helping. It will be uncomfortable at first — that is expected — and it is the key exercise for stopping the shoulder stiffening. 10 repetitions, three times a day You will wake from surgery with your arm in a sling, but the sling is for comfort only: try to do without it as much as you can, and most people are out of it within days. You can use the arm without restriction below shoulder height from the start. Lifting the arm above shoulder height is allowed and safe, although it will be uncomfortable at first; several times a day, use your good arm to help lift the operated arm above shoulder height as a gentle stretch, so the shoulder does not stiffen. Avoid carrying anything heavier than about two kilograms with the operated arm in these first weeks, as this will be painful. Start your exercises as soon as possible, aiming for ten repetitions of each, three times a day. Take pain relief before your exercises, and use ice for comfort. Do not drive: driving resumes only after your surgeon clears you, typically at the six-week review. For your physiotherapist: Goals - Settle post-operative pain and swelling - Early restoration of range of motion: the priority is preventing stiffness, to which calcific tendinitis patients are prone - Normal use of the arm below shoulder height Management - Sling for comfort only; wean as quickly as comfort allows, typically within days - Unrestricted active use of the arm below shoulder height from day one - Active elevation above shoulder height as tolerated - Passive and active-assisted elevation above shoulder height several times daily (using the other arm) to prevent stiffness - Home exercise program ten repetitions each, three times daily - Analgesia before exercises; cryotherapy for pain relief as needed Precautions - No carrying or lifting beyond approximately two kilograms with the operated arm - No driving for six weeks (this applies to any shoulder operation) Criteria to progress - Wound review satisfactory at the first post-operative appointment - Out of the sling and using the arm comfortably below shoulder height ## Phase II — Regaining your range (weeks 2–8) Kieran Hirpara 4.0 #### Supported abduction Cradle the operated forearm with your other arm and lift both out to the side, letting the good arm do most of the work, then lower with control. Progress the range as comfort allows — stretching to firm discomfort is acceptable; forced, severely painful stretching is not. As guided by your physiotherapist Kieran Hirpara 4.0 #### Assisted external rotation with a stick Lie on your back with the elbow tucked by your side and bent to a right angle. Hold a stick in both hands and use your good arm to turn the operated hand outwards, rotating the shoulder. Restoring this outward rotation is one of the goals of this phase, so keep working it gently a little further each week. 10 times, three times a day Kieran Hirpara 4.0 #### Over-door pulley Sit under an over-door pulley with a handle in each hand. Pull down with your good arm to raise the operated arm overhead as far as it comfortably goes, then lower slowly. Work into a gentle stretch, not sharp pain. 10 times, three to four times a day Kieran Hirpara 4.0 #### Scapular setting Sitting or standing tall, gently draw your shoulder blades back together and down, away from your ears. Hold for a few seconds, then relax. Continue this alongside your stretches to keep the shoulder blade moving well as your range returns. As guided by your physiotherapist You will be reviewed in the rooms at about two to three weeks, where your wound and your passive range of motion are checked. The work of this phase is range: progress your forward elevation stretches and add movements out to the side, with physiotherapy guiding the progression. The typical aims are to lift the arm actively to horizontal by six weeks, with the assisted (passive) range (forward, out to the side and in rotation) back to normal by six weeks. Driving resumes from six weeks, once your surgeon has cleared you and you can perform an emergency stop safely. For your physiotherapist: Goals - Active forward flexion and abduction to horizontal by six weeks - Passive flexion, abduction and external rotation to normal by six weeks - Independence with daily activities Management - Progress passive and active-assisted forward flexion; introduce and progress abduction - Progress to active range of motion in all planes as comfort allows - Continue scapular setting and postural work - Continue analgesia before sessions, and heat or ice around stretching as preferred Precautions - Keep lifting light while range is restored; progression remains symptom-guided - Stretching to firm discomfort is acceptable; forced, severely painful stretching is not Criteria to progress - Passive range of motion at or near normal - Active elevation to horizontal or better, with pain settling ## Phase III — Strengthening and return to full activity (weeks 8–16) Kieran Hirpara 4.0 #### Isometric external rotation Stand with your elbow tucked at your side and bent to a right angle, the back of your hand against a wall or doorframe. Gently press outwards into it without letting the arm move, hold a few seconds, then relax. This builds the rotator cuff with no movement — the starting point for strengthening from about eight weeks (ten to twelve weeks if the tendon split was stitched). Hold a few seconds, several times; as guided by your physiotherapist Kieran Hirpara 4.0 #### Band external rotation Stand with your elbow tucked into your side and bent to a right angle, holding an elastic band anchored at waist height. Keeping the elbow at your side, rotate the forearm outwards against the band, then return slowly. Progresses on from the isometric work as your strength builds. 2 to 3 sets of 10 to 15, low resistance Kieran Hirpara 4.0 #### Low row Hold a band anchored in front of you at waist height. Keeping the arm fairly straight, pull it back and down towards your hip, squeezing the shoulder blade down and back, then return slowly. Builds the shoulder-blade muscles that support the cuff. 2 to 3 sets of 10 to 15 Kieran Hirpara 4.0 #### Side-lying external rotation with weight Lie on your non-operated side with the top elbow bent to a right angle and tucked against your body. Holding a light weight, rotate the forearm up towards the ceiling, then lower slowly. Part of the rotator cuff strengthening from about eight weeks (ten to twelve if the tendon split was stitched) — keep mobility work going alongside it. Low load, higher repetitions You will usually be reviewed again at about eight weeks. With your range restored, rehabilitation turns to strengthening the rotator cuff, typically under your physiotherapist's supervision, and to using the arm freely above shoulder height. The aim is full active forward elevation and abduction by about twelve weeks. Recovery from removal of the deposit alone typically takes about three months, after which there are no restrictions; if the rotator cuff needed a repair, recovery is longer (typically around five months) and follows the rotator cuff repair protocol instead. Do not be concerned if some ache persists beyond this point: after this operation it can take up to nine months for the pre-operative symptoms to settle completely, with the trend steadily in the right direction. For your physiotherapist: Goals - Full active forward flexion and abduction by approximately twelve weeks - Graduated restoration of rotator cuff and scapular strength and endurance - Return to full, unrestricted activity by approximately three months Management - Progressive rotator cuff strengthening from eight weeks (from ten to twelve weeks if the tendon split was stitched): isometrics progressing to elastic-band and light-weight work, low load and higher repetitions - Progress active use of the arm above shoulder height - Advance gym-, work- and sport-specific loading as tolerated through weeks twelve to sixteen Precautions - Strengthening should not come at the cost of range; continue mobility work throughout - Build heavy and overhead loading gradually; a flare of pain means easing back a step Criteria to progress - Full active range of motion with strength returning and symptoms continuing to settle - Discharge from routine follow-up when progressing well, typically from around eight to sixteen weeks ## After your protocol The phases above are adapted from published patient guidance and rehabilitation protocols for this procedure: The London Shoulder Partnership's calcific deposit excision rehabilitation protocol, patient guidance from ShoulderDoc (UK) on surgery for calcific tendinitis, and Dr Kevin Ko's patient guide to arthroscopic excision. The week ranges are typical rather than fixed, and your ongoing rehabilitation is guided individually by your physiotherapist, working with the practice, based on how your shoulder recovers. This page works alongside the practice's general recovery advice: see managing post-operative pain and wound care. For the condition itself and how these treatments work, see calcific tendinitis. The evidence behind this protocol (natural history, barbotage, and the surgical-excision literature) is summarised in the evidence section, available as a PDF from the top of this page. --- ### Capsular Release URL: https://www.cqupperlimb.com/education/rehabilitation/capsular-release/ Region: rehabilitation · rehabilitation Rehabilitation after arthroscopic capsular release for frozen shoulder — early in-hospital program and the outpatient phases that keep the range won at surgery. This protocol covers the rehabilitation after an arthroscopic capsular release with Dr Kieran Hirpara at Mater Private Hospital Rockhampton, both what happens in hospital and over the weeks and months afterwards. Bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. Your rehabilitation is progressed individually by your physiotherapist through the phases below, depending on how your shoulder is moving. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect Capsular release is an operation for a stiff shoulder (frozen shoulder), and that changes everything about how you rehabilitate. Most shoulder operations repair something, such as a tendon or a torn ligament, and the early job is to protect that repair, so you wear a sling and keep movement within limits. This operation is the opposite. Nothing has been stitched back together that needs protecting. The surgeon has released the tight, scarred lining of the joint and moved the shoulder through a full range while you were asleep, so the result of the operation is the movement. From the moment you wake up, the job of rehabilitation is to keep that movement before the shoulder tries to stiffen up again. That means there is no protected period and no holding back. You start moving the shoulder straight away, both moving it yourself and using your other arm to push it, and you keep pushing the range, in every direction, several times a day. Your exercises use three kinds of movement, and your team will mark which apply to you: - Passive movement means the shoulder stays completely relaxed while your other arm, a stick or a pulley does all the work. - Active-assisted movement means you move the arm yourself with some help from the other arm or an object. - Active movement means you move the arm under its own power, without help. ## Why there is no sling After a capsular release there is no sling to protect a repair, and keeping the shoulder still works against you. Left to rest, the released shoulder simply tightens up again. Re-stiffening is the main reason this operation can disappoint, and it is largely preventable by moving early and often. So unlike a repair, you do not sleep in a sling, you do not keep the arm still, and there is no movement that is off-limits. You are encouraged to use the arm freely and to push your range in every direction, including rotating the arm outwards, right from day one. A simple sling is offered only for short-term comfort and to stop the arm being knocked when you are out and about; leave it off as much as you can and do not let it tempt you into keeping the shoulder still. ## Key points - Keep moving. Use the arm for normal everyday tasks such as washing, dressing and eating, from the start. Movement keeps the range you gained at surgery. - Push the range, in every direction. Stretch to the point of firm discomfort, not severe pain, and take the shoulder to its limit in every plane, including rotating the arm outwards. There is no "do not go past here" precaution after this operation. - Stretch little and often. A short home stretching program done several times a day beats one long session. Re-stiffening happens between sessions, so frequency matters. - Control the pain so you can move. Take your pain relief before your exercises and before your physiotherapy appointments. Good pain control is what makes the stretching possible. Many people find heat before stretching and ice afterwards helpful. - Go to physiotherapy often. Aim for at least twice a week for the first six weeks. Bring this page to your first visit. - No driving for six weeks. This applies after any shoulder operation, even though you will be out of the sling almost immediately; your surgeon will clear you to drive, typically at the six-week review. A steroid is often injected into the joint at the time of the operation to calm the inflammation and reduce the tendency to re-stiffen. ## In hospital — your first exercises Kieran Hirpara 4.0 #### Wrist movement Keep your hand moving by bending your wrist forwards, backwards and side to side. 10 times, 3 times per day Kieran Hirpara 4.0 #### Open and close hand Keep your hand and fingers moving by opening and closing them, or by squeezing a soft ball. 10 times, 3 times per day Kieran Hirpara 4.0 #### Elbow bends Bend and straighten your elbow. 10 times, 3 times per day Kieran Hirpara 4.0 #### Pendulums This is a relaxed, passive exercise. Lean forward and let your arm hang and relax down. Use your body to swing the arm gently in small circles, clockwise and anti-clockwise, and to and fro. Let the weight of the arm do the work, with the shoulder muscles relaxed. About 30 seconds each way, 3 times per day Kieran Hirpara 4.0 #### Assisted forward flexion (lying) If you prefer, lie on your back and hold a stick (or a rolled towel) in both hands. Use your good arm to push the operated arm up over your head, as far as it will comfortably go, then lower it slowly. Push into a firm stretch each time. 10 times, 3 times per day Kieran Hirpara 4.0 #### Assisted abduction (cradle) Cradle the operated arm in your other arm, supporting it under the elbow, and gently rock it out to the side and back, like rocking a baby. Take it to a firm stretch out to the side each time. 10 times, 3 times per day Kieran Hirpara 4.0 #### Assisted external rotation with a stick Lie on your back with your elbow tucked by your side and bent to 90 degrees. Hold a stick in both hands and use your good arm to push the hand of the operated arm outwards, rotating the shoulder. Take it all the way to a firm stretch: there is no limit on how far out you go after this operation, so push the range. 10 times, 3 times per day Kieran Hirpara 4.0 #### Lower trapezius setting Squeeze your shoulder blades downwards and together, hold, then relax. Hold 5 seconds, 5 times; repeat 3 times daily Kieran Hirpara 4.0 #### Upper trapezius stretch Use your good arm to bring your ear gently towards your shoulder, away from the operated side, until you feel a stretch up the side of the neck. Hold 10 seconds, 3 times; repeat 3 times per day Kieran Hirpara 4.0 #### Levator scapulae stretch Use your good arm to bring your nose down towards your armpit on the opposite side, until you feel a stretch at the base of the neck. Hold 10 seconds, 3 times; repeat 3 times per day A physiotherapist will see you in hospital and start you on the exercises below before you go home. These keep the hand, elbow and shoulder moving and begin pushing the shoulder's range straight away. Take your pain relief beforehand so you can move freely. Do them as marked by your team, and carry on with them at home. ## Your outpatient rehabilitation After a capsular release, rehabilitation runs in the opposite direction to operations that repair a tendon: there is nothing to protect, so the whole effort goes into keeping the movement. The shoulder is most likely to stiffen up again in the first weeks, so physiotherapy starts straight away, stays frequent, and continues for some months until your range is stable. The phases below follow the pattern of published rehabilitation protocols for this operation. The week ranges are typical rather than fixed: your physiotherapist will progress you on how your shoulder is moving, not on the calendar. The journey at a glance: - Phase I — Early rehabilitation: roughly the first two weeks - Phase II — Keeping and restoring your range: week 2 to 6 - Phase III — Strengthening: week 6 to 12 - Phase IV — Return to full activity: week 12 onwards By about three weeks, movement below shoulder height usually becomes more comfortable and most of your range is back, although the arm is often still uncomfortable overhead. By about three months most people find their symptoms have largely settled, and improvement typically continues for six to nine months, sometimes up to a year. ## Phase I — Early rehabilitation (Week 0–2) Kieran Hirpara 4.0 #### Over-door pulley Sit under an over-door pulley with a handle in each hand. Pull down with your good arm to raise the operated arm overhead as far as it will go, then lower slowly. Push into a firm stretch each time, not severe pain. 10 times, 3 to 4 times daily Kieran Hirpara 4.0 #### Behind-the-back stretch with a towel Hold a towel behind your back with the operated hand below, and use your upper hand to draw the lower hand up your back as far as it will go. Take it to a firm stretch, then release: the stretch should ease soon afterwards. 10 times, 3 to 4 times daily Kieran Hirpara 4.0 #### Cross-body stretch Use your good hand to draw the operated arm across your chest until you feel a firm stretch at the back of the shoulder, then release. 10 times, 3 to 4 times daily Kieran Hirpara 4.0 #### Assisted forward elevation (sitting) Sitting and leaning forward slightly, support the operated forearm with your good hand and use it to lift the operated arm forwards and up in front of you, as far as is comfortable, then lower it slowly. Let the good arm do the work so the operated shoulder stays relaxed. As guided by your physiotherapist The goal of these first two weeks is simple: do not lose the range you gained at surgery. You carry on the hospital exercises at home, several times a day, and add stretches that push the shoulder to its limit in every direction. Good pain control is what makes this possible, so keep taking your pain relief before your exercises and physiotherapy sessions, and use heat before stretching and ice afterwards if it helps. Use the arm for normal light daily activities such as washing, dressing and eating. Push every stretch to the point of firm discomfort, not severe pain, and remember there is no plane you need to hold back from. Ready for the next phase when… you are doing your home program confidently and independently several times a day, your pain is controlled enough to stretch into the range, and you are holding on to the movement your shoulder had at surgery. ## Phase II — Keeping and restoring your range (Week 2–6) Kieran Hirpara 4.0 #### Wand external rotation (full range) Continue the stick-assisted external rotation from hospital, now pushing further as the range frees up. With the elbow by your side, rotate the forearm outwards as far as it will go. Keep taking it to its full limit: pushing this range is the whole point of the operation. 10 times, 3 to 4 times daily Kieran Hirpara 4.0 #### Sleeper stretch Lie on the operated side with the arm out in front and the elbow bent. Use your good hand to press the forearm down gently towards the bed, until you feel a stretch deep in the shoulder, then ease off. Hold 20 to 30 seconds, 3 times; 3 to 4 times daily This phase carries on the frequent physiotherapy and the home stretching program, done several times a day, so the movement won at surgery is not lost and the range keeps building. Your exercises progress from assisted movements towards moving the arm actively in all directions, and your physiotherapist may add hands-on joint mobilisation to help. Keep pushing range in every plane, including external rotation, to its full limit. Use the arm normally for light daily activities. Ready for the next phase when… the range gained at surgery is being held or is still improving, movement below shoulder height is comfortable, and your pain has settled enough to begin gentle resistance work. ## Phase III — Strengthening (Week 6–12) Kieran Hirpara 4.0 #### Band external rotation Stand with your elbow tucked into your side and bent to 90 degrees, holding an elastic band anchored at waist height. Keeping the elbow at your side, rotate the forearm outwards against the band, then return slowly. 2 to 3 sets of 10 to 15, 5 days per week Kieran Hirpara 4.0 #### Band internal rotation With your elbow tucked into your side, hold a band anchored to one side and rotate the forearm inwards across your body against the band, then return slowly. 2 to 3 sets of 10 to 15, 5 days per week Kieran Hirpara 4.0 #### Low row Hold a band anchored in front of you at waist height. Keeping your arm fairly straight, pull it back and down towards your hip, squeezing the shoulder blade down and back, then return slowly. 2 to 3 sets of 10 to 15, 5 days per week Kieran Hirpara 4.0 #### Side-lying external rotation (light weight) Lie on your good side with the operated elbow bent to 90 degrees and tucked against your side, holding a light weight (about 0.5 to 1.5 kg). Rotate the forearm upwards, then lower slowly: the slow lowering is the important part. Keep the work below shoulder height. 2 to 3 sets of 10 to 15, low load With your range stable, attention turns to rebuilding the shoulder's strength. Daily stretching continues throughout this phase, because strengthening must never come at the cost of the range you have worked for. Resistance work starts gently, using elastic bands and light weights for the rotator cuff and shoulder-blade muscles, with low loads and higher repetitions. Normal daily activities should be largely back to usual, and lighter recreational activities typically resume during this phase, as guided by your physiotherapist. Ready for the next phase when… you have full, or near-full, pain-free movement in all directions, and you can manage the strengthening exercises without a flare-up of pain or any loss of range. ## Phase IV — Return to full activity (Week 12 onwards) The final phase is a graduated return to heavier work, overhead tasks and sport. Formal rehabilitation usually runs three to four months in total, and the shoulder keeps improving well beyond that: most people continue to gain comfort and confidence for six to nine months, sometimes up to a year. It is worth keeping up a short stretching routine until your range looks after itself without formal exercises. Progression stays guided by how you feel, so if stiffness or pain starts to return, the answer is to ease back and restore the range, not to rest the shoulder. ## Returning to activity Most people are back to normal daily activities and to many kinds of work by four to six weeks, because recovery here is driven by keeping your range rather than waiting for tissue to heal. Heavier, more physical work and overhead sport come back gradually over the following weeks to months, as your strength returns. If at any point the shoulder starts to stiffen again, treat it as a signal to push your stretches harder and see your physiotherapist, not to rest. ## Your exercises These are the exercises from your handout. Start them as guided by Dr Hirpara and your physiotherapist. After a capsular release there is no repair to protect, so keeping the shoulder still works against you — the released shoulder simply tightens up again between sessions. That is why the list is long and why little and often beats one long session: the early wrist, hand and elbow movements plus pendulums keep the whole arm loose, the assisted stretches (lying flexion, cradle abduction, stick external rotation) hold the range the operation gained, and the band and scapular work is added later to build control. Frequency matters more than force. Stop anything that causes sharp pain rather than a stretch. ## After your protocol The outpatient phases above are adapted from published rehabilitation protocols for arthroscopic capsular release, with recovery milestones drawn from the same sources. The week ranges are typical rather than fixed, and your ongoing rehabilitation is guided individually by your physiotherapist, working with the practice, based on how your shoulder movement recovers. This page works alongside the practice's general recovery advice: see managing post-operative pain and wound care. For the operation itself and the condition it treats, see capsular release and frozen shoulder. --- ### Carpal tunnel exercises URL: https://www.cqupperlimb.com/education/rehabilitation/carpal-tunnel-exercises/ Region: rehabilitation · rehabilitation Exercise handout for after endoscopic carpal tunnel release — wrist tenodesis, fist/hook glides and thumb opposition, recreated from an Extend Rehabilitation sheet. Prepared in association with Extend Rehabilitation ## Anatomy After surgery, the healing edges of the ligament beneath the skin are usually tender for at least four to six weeks after the procedure. Temporary tenderness on each side of the palm where the ligament is attached to the bones is common after surgery and is called “pillar pain”. This generally resolves gradually. ## General - Keep hand elevated above heart level as much as possible especially during the first week. - Avoid tight fist/grip. - Avoid repetitive gripping tasks. - Avoid heavy lifting. - Avoid vibratory machines/tasks e.g. lawn mowing - Limit driving for the first week ## Dressings Apply these dressings to control swelling and support the carpal arch, as shown by your therapist. - Kinesiotaping - Coban - Tubigrip ## How much should I use my hand? We recommend that you use your hand for light to moderate tasks, but follow the precautions outlined under general on this page. ## Will my ligament heal over again? The original ligament will not reattach, however scar tissue will form and create a "pseudo-ligament" that performs the same function as the original ligament. ## Exercises #### Exercise 1 Resting on elbow with fingers relaxed, bend wrist forward and then backwards. As prescribed by your hand therapist — ____ reps, ____ times per day #### Exercise 2 Supporting wrist back, make a loose fist – then “hook” – and then straighten and spread your fingers. As prescribed by your hand therapist — ____ reps, ____ times per day #### Exercise 3 Move thumb toward base of little finger and then straighten. As prescribed by your hand therapist — ____ reps, ____ times per day You will need to perform the following exercises ___ times per day. CARDS ## Scar/sensitivity management - Massaging (in small circles) as shown by your therapist will assist in reducing the discomfort and sensitivity - Tapping the sensitive region is also recommended. It is best to do this for short periods frequently e.g. 2-3 minutes each hour. - You may also be supplied with a silicone pad and/or glove to assist with the scar and sensitivity. - 5 x 'Hello World' nerve glides --- ### Carpal Tunnel Release URL: https://www.cqupperlimb.com/education/rehabilitation/carpal-tunnel-release/ Region: rehabilitation · rehabilitation Post-operative exercises and precautions after carpal tunnel release, including tendon and nerve glides. This protocol guides your recovery after carpal tunnel release with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It explains what to expect as your wound heals, the precautions for the first weeks, and the exercise program that keeps your nerve and tendons gliding freely while everything settles. Bring this page or its PDF to your physiotherapist or hand therapist so your rehabilitation stays coordinated. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect Care of your wound is explained in the practice's wound care guidance. At the wrist the nerve and tendons run close together, right where the surgery heals, so the exercises on this page matter: keeping the nerve and tendons gliding stops them from sticking to the healing tissue as your wound settles. The healing edges of the released ligament stay tender for at least four to six weeks. Tenderness on each side of the palm (where the ligament attaches to the bones) is also common; this is called "pillar pain" and it settles gradually. The ligament itself is not meant to re-join: scar tissue forms a "pseudo-ligament" that does the same job, which is why the release frees the nerve without leaving the wrist unstable. Studies that have followed patients after carpal tunnel release show how predictably this tenderness fades: roughly four in ten people still notice pillar-type discomfort one month after surgery, about one in four at three months, and by twelve months it has settled in nearly all hands (Povlsen & Tegnell, 1996). So if the sides of your palm are still tender a few weeks after surgery, that is a normal part of healing, not a sign that something has gone wrong. Hand strength follows a well-described recovery curve. In a frequently cited study, grip strength was about a quarter of its pre-operative level three weeks after surgery and about three-quarters by six weeks, was back to the pre-operative level by three months, and went on to exceed it by six months; pinch strength recovers sooner, reaching close to its pre-operative level by six weeks (Gellman et al., 1989). A temporary drop in grip in the early weeks is therefore expected; it reflects the healing ligament and palm rather than a problem with the operation, and it recovers as the pillar tenderness settles. Moving early is deliberate, and the evidence supports it. Current clinical guidance is that the wrist should not be routinely held in a splint after carpal tunnel release (AAOS, 2024), and published hand-centre protocols start active movement of the fingers, thumb and wrist straight away to keep the tendons and median nerve gliding while the wound heals. A Cochrane review of rehabilitation after carpal tunnel release found that recovery is usually straightforward and that no single add-on treatment has strong evidence behind it, which is why this program is kept simple, and why your hand therapist tailors it to how your own hand is recovering (Peters et al., 2016). For the first week, keep the hand elevated above heart level as much as possible; less swelling means less pain and a freer nerve. Your therapist may also apply compressive dressings or taping (Coban, Tubigrip or kinesiotape) to control swelling and support the arch of the palm. Once your wound is healed, apply heat to your hand for 20 minutes before performing these exercises. After completing the exercises, ice may be applied to prevent inflammation. Sometimes the hand or wound becomes sensitive. This is normal, and it can be prevented or eased with daily desensitisation: gently tapping and rubbing over the wound (or dressing) and the palm, starting immediately after your surgery. This "sensory feedback" retrains the nerve to read touch and texture normally. Short, frequent sessions work best (for example 2–3 minutes each hour), and your therapist may supply a silicone pad or glove to help settle the scar and the sensitivity. Once the wound is fully healed, commence scar massage: firm circles over the incision. The wound care page has more information on scar management. ## Getting back to work and activity Most people return to work within a few weeks of carpal tunnel release, and the timing depends mainly on what your job asks of your hand. A systematic review of 56 studies found that people in desk-based or non-manual roles went back to work a median of three weeks after surgery (reported range one to six weeks), while those in manual roles took a median of about five and a half weeks (reported range roughly three to fourteen weeks); many returned sooner on modified or lighter duties before resuming full duties (Newington et al., 2018). Treat these figures as a guide rather than a deadline: the right timing for you depends on your wound, your comfort and the precautions below. As a practical guide, you are usually ready to return to a particular task when: - your wound has healed and tolerates the pressure or contact the task involves; - you can use the hand comfortably for what the task actually requires, within the precautions below; and - any heavier gripping, lifting or vibration exposure in your role waits until the precautions are lifted. If your work is heavy, repetitive or involves vibrating tools, raise it at your post-operative review so that a return date and any modified duties in the meantime can be planned with your employer. ## Precautions and limitations Light functional use of your hand is encouraged for daily living tasks such as self-care, feeding, dressing, writing and typing. Beyond that, the limits for the early weeks are: - No lifting, gripping, weight-bearing or use of vibration machinery (for example power tools or the lawn mower) for up to 6 weeks post-operatively. - Driving is limited for the first 1–2 weeks, or until you can achieve a full fist. For your physiotherapist: Management - Wound care as per the practice's wound care guidance - Elevation above heart level as much as possible in the first week; compressive dressings/taping (Coban, Tubigrip, kinesiotape) for swelling control and carpal-arch support as indicated - Tendon gliding and median nerve gliding program as per the exercise cards below, to prevent adhesion of the nerve and tendons during wound healing - Once the wound is healed: heat to the hand for 20 minutes before exercises; ice after exercises to prevent inflammation - Daily desensitisation from immediately post-surgery: gentle tapping / rubbing over the wound (dressing) and palm, to allow the nerve to normalise touch and texture - Scar massage (firm circles over the incision) once the wound is fully healed Precautions - Light functional use of the hand is encouraged for activities of daily living (self-care, feeding, dressing, writing, typing) - No lifting, gripping, weight-bearing or use of vibration machinery (e.g. power tools, lawn mower) for up to 6 weeks post-operatively - Driving limited for the first 1–2 weeks, or until a full fist is achieved Evidence notes - Immobilisation: moderate evidence is against routine post-operative splinting after carpal tunnel release (AAOS CPG, 2024); early active motion as per the exercise cards is the intended default - Rehabilitation adjuncts: the Cochrane review found limited, low-certainty evidence for individual post-CTR rehabilitation treatments (Peters et al., 2016); tailor the program to the patient rather than protocolise adjuncts - Strength recovery: expect grip ≈28% of pre-operative level at 3 weeks and ≈73% at 6 weeks, returning to pre-operative level by 3 months and exceeding it by 6 months; pinch recovers faster (≈96% by 6 weeks) (Gellman et al., 1989) - Return to work: median 21 days for non-manual work (range 7–41) versus 39 days for manual work (range 18–101); modified duties earlier (Newington et al., 2018) - Pillar pain: reported in ≈41% at 1 month, ≈25% at 3 months and ≈6% at 12 months after open release (Povlsen & Tegnell, 1996) These are the exercises from your handout, performed as described on each card. This exercise program was written in association with Sarah Farrell, BOccThy AHT (occupational therapist and accredited hand therapist), with additional post-operative guidance from Ruby Doolan, Accredited Hand Therapist, Extend Rehabilitation. ## Your exercises Kieran Hirpara 4.0 #### Wrist flexion / extension stretch Rest your elbow on a table (or your wrist over the edge of a table or armchair) and gently rock your wrist back and forth. Once more comfortable, grasp your palm with the other hand and push the wrist backwards (fingers loose, pointing to the ceiling) — hold 15 seconds; then the other way (fingers loose, pointing to the floor) — hold 15 seconds. Repeat 5 times in each direction. 10 reps (5 each direction, holding 15 seconds), 4–5 times daily Kieran Hirpara 4.0 #### Tendon glides — Series A With your hand in front of you and your wrist straight, fully straighten all of your fingers (1). Bend the tips of your fingers into the “hook” position with your knuckles pointing up (2). Make a tight fist with your thumb over your fingers (3). 5–10 repetitions, 2–3 times a day Kieran Hirpara 4.0 #### Tendon glides — Series B With your hand in front of you and your wrist straight, fully straighten all of your fingers (1). Make a “tabletop” with your fingers by bending at your bottom knuckle and keeping the fingers straight — ensure your wrist does not drop forward (2). Bend your fingers at the middle joint, touching your fingers to your palm (3). 5–10 repetitions, 2–3 times a day Kieran Hirpara 4.0 #### Median nerve glides Move your hand through the six positions shown, holding each position for 3–7 seconds. Do not put too much pressure on your thumb in position 6. Then add the nerve stretch: straighten your arm in front of you with your palm facing up, and bend your wrist back so that your fingers point down. Use your other hand to gently ease your fingers back until you feel a mild stretch along the palm side of your forearm. Hold for 15 seconds, and repeat 5 times. Keep it gentle: ease off if the tingling increases. 10–15 repetitions a day, holding each position 3–7 seconds Kieran Hirpara 4.0 #### Thumb opposition Move your thumb across your palm toward the base of your little finger, then straighten it back out. 5–10 reps, 2–3 times a day, daily Start the exercises below only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. The wrist stretch and the two tendon-glide series keep the tendons and the released nerve moving freely so they do not stick down in the healing scar; these start early, within comfort. The median nerve glides are added to keep the nerve sliding rather than tethering, and thumb opposition rebuilds the pinch that is often weak beforehand. Tenderness directly over the scar in the palm is expected for some weeks. Stop anything that causes sharp or electric pain into the fingers. ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain, wound care and hand therapy basics. For the operation itself, see carpal tunnel release. --- ### Clavicle Fixation (ORIF) URL: https://www.cqupperlimb.com/education/rehabilitation/clavicle-fixation/ Region: rehabilitation · rehabilitation Rehabilitation after plate fixation of a clavicle fracture, gated on radiographic healing at review. This protocol guides your recovery after plate fixation of a fractured clavicle (collarbone), open reduction and internal fixation (ORIF), with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. Each phase below opens with a plain-English explanation of what is happening and what matters most, followed by the structured protocol written for your physiotherapist; bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. Your physiotherapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect The operation holds the broken ends of the collarbone in position with a plate and screws so that the bone can heal. The plate is strong, but it is a splint, not a substitute for healed bone: the bone itself typically takes around six to twelve weeks to unite, and it keeps strengthening (remodelling) for months after that. Rehabilitation is staged around that biology: the early weeks protect the fixation while the fracture starts to knit, movement is recovered next, and loading and sport come last, once the bone can take them. Because this is a fracture, each major step up (moving the arm above shoulder height, strengthening, heavier lifting, and return to sport) depends not just on the calendar but on how the fracture looks on x-ray, as confirmed at your review with Dr Hirpara. The week ranges below are typical rather than fixed. Bone healing is slower in smokers and in people with diabetes, and smoking in particular can delay or even prevent a fracture from uniting. If you smoke, the weeks after a fracture are a particularly worthwhile time to stop. The collarbone sits directly under the skin, so it is common to feel (and see) the plate once the swelling settles. It may be tender under a seatbelt or a backpack strap in the early months; this usually settles as the area desensitises. If the plate remains bothersome after the fracture has fully healed, removing it is an option that can be discussed at a later review; it is a separate, unhurried decision, made well after the bone has united. The journey at a glance: - Phase I — Protection: weeks 0–3 - Phase II — Early motion: weeks 3–6 - Phase III — Strengthening: weeks 6–12 - Phase IV — Return to full activity and sport: week 12 onwards ## Wearing your sling The sling supports the weight of the arm, eases discomfort and protects the healing bone in the early weeks. The rules are simple: - Wear it especially when out of the house, to protect the arm and to stop people bumping into it. You don't need to sleep in it. - For the first three weeks, wear it most of the time. From then on it is weaned as comfort allows, and most people have discarded it by six weeks. - Take it off for showers, for your exercises, and for quiet tasks done sitting down with the arm supported: eating, writing, reading. - Resting at home, the sling can come off if you are sensible about it: arm supported on a pillow while sitting, and the hand kept below shoulder height. - No driving for six weeks (this applies to any shoulder operation), and not while you are wearing a sling. After that, driving resumes once you can control the car comfortably and safely, as confirmed at your review with Dr Hirpara. ## Your first days after surgery If a nerve block was used during surgery, the arm may feel numb and heavy for some hours afterwards; keep it protected in the sling until normal feeling returns. A few practical tips for the early days: - Take your painkillers before you do your exercises, and before your physiotherapy appointments. - Use ice over the area for pain and swelling, about 15–20 minutes at a time, wrapped in a damp cloth, never directly on the skin or the wound. - When wearing the sling, relax your shoulder and let the sling take the weight of your arm. - Watch your posture: keep your ears, shoulders and hips in line and avoid letting the shoulders slump forward; good posture protects the fracture position and helps prevent stiffness. - Keep your fingers, wrist, elbow and neck moving from the start. - If you have any problems, contact the rooms or let your physiotherapist know. ## Phase I — Protection (Week 0–3) Kieran Hirpara 4.0 #### Pendulum exercises Lean forward, supporting yourself on a table with your other hand, and let the operated arm hang relaxed. Make small circles — clockwise, then anticlockwise — by gently rocking your body. The arm stays relaxed throughout; the movement comes from your body, not the shoulder. As guided by your physiotherapist Kieran Hirpara 4.0 #### Table slides Sit at a table with your forearm resting on it. Lean gently forward so your hand slides along the table, letting the table take the weight of the arm, then sit back up. Stay within comfort and keep the arm below shoulder height. As guided by your physiotherapist Kieran Hirpara 4.0 #### Assisted shoulder flexion (lying) Lie on your back. With your other hand supporting the operated arm at the wrist, gently lift it forwards to a maximum of 90 degrees — pointing at the ceiling, no higher — then lower it. The operated arm stays relaxed; your other arm does the work. Do not go beyond 90 degrees until cleared at your six-week review. As guided by your physiotherapist Kieran Hirpara 4.0 #### Ball squeezes With the arm supported, squeeze a soft ball or make a tight fist, then open the hand fully. Keep your fingers, wrist and hand moving from the start. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wrist movement With the arm out of the sling and supported, keep your wrist moving by bending it forwards, backwards and side to side. Keeping the wrist working from the start prevents stiffness while the shoulder is protected. As guided by your physiotherapist Kieran Hirpara 4.0 #### Elbow bends With the upper arm resting by your side and supported, bend the elbow as far as it comfortably goes, then straighten it fully. Only the elbow moves — keep the shoulder relaxed. This keeps the elbow free while the collarbone is protected. As guided by your physiotherapist Kieran Hirpara 4.0 #### Forearm rotation With the elbow tucked at your side and bent to a right angle, turn the palm up, then turn it down. Keep the upper arm still so only the forearm rotates. From the second week your physiotherapist may add gentle resistance to this. As guided by your physiotherapist Kieran Hirpara 4.0 #### Assisted external rotation with a stick Lie on your back with the operated elbow tucked by your side and bent to a right angle. Hold a stick in both hands and use your good arm to gently turn the operated hand outwards, rotating the shoulder, then return. Keep the elbow in at your side — this is an assisted movement, not a forced one. As guided by your physiotherapist Kieran Hirpara 4.0 #### Scapular setting Sitting or standing tall, gently draw your shoulder blades back together and down, away from your ears. Hold for a few seconds, then relax. This keeps the shoulder-blade muscles active without moving the healing collarbone. As guided by your physiotherapist Kieran Hirpara 4.0 #### Walking with the arm in the sling Keep up gentle cardiovascular activity by walking, with the operated arm resting in the sling. This maintains your general fitness while the fracture is protected. As guided by your physiotherapist The first weeks are about protecting the fixation while the fracture starts to knit. You will be in the sling, managing swelling with ice, and doing gentle exercises that keep the rest of the arm moving: the hand, wrist, elbow and neck, along with pendulums and gentle assisted shoulder movement below shoulder height. The rules that matter most: do not lift the elbow above shoulder height, no lifting or carrying with the operated arm, no pushing up through the arm, and no driving for six weeks (this applies to any shoulder operation) or while you are wearing the sling. For your physiotherapist: Goals - Protect the fixation and healing bone and soft tissue - Settle pain and swelling - Restore passive shoulder range below 90° of elevation - Maintain full elbow, wrist, hand and cervical range of motion Management - Cryotherapy and modalities as needed; analgesia before exercises and sessions - Check sling fit; educate on sling use (protective wear, especially out of the house; not required overnight per practice convention) and posture - Pendulums and table slides - PROM: external and internal rotation in the plane of the scapula to comfort; flexion / scaption / abduction to a maximum of 90° - AAROM: external rotation with a stick in neutral; supine assisted flexion to 90° - AROM: elbow, wrist, hand and cervical spine; grip work (ball squeezes) - From week 2: resisted wrist flexion/extension and forearm rotation; gentle scapular setting and retraction - Cardio: walking with the arm in the sling; stationary or recumbent bike with the arm in the sling Precautions - No active shoulder elevation - No shoulder flexion or abduction beyond 90°, including passively - No lifting or carrying with the operated arm; no weight-bearing through the arm - No driving for six weeks (this applies to any shoulder operation), and not while wearing the sling Criteria to progress - Comfortable passive flexion/scaption to 90° and external rotation to about 30° - Pain settled below 4/10 at rest - Full elbow, wrist and hand active range - Wound healed, with no signs of complication ## Phase II — Early motion (Week 3–6) Kieran Hirpara 4.0 #### Side-lying external rotation Lie on your non-operated side with the operated arm on top, elbow bent to 90 degrees and tucked against your body. Keeping the elbow in, rotate the forearm up away from your tummy as far as is comfortable, then lower with control. No weights in this phase — the arm moves under its own power. As guided by your physiotherapist Kieran Hirpara 4.0 #### Low row with elastic band Anchor an elastic band in front of you at waist height. Standing tall, pull the band towards you, drawing the shoulder blade gently down and back, then release with control. Keep the resistance light. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wall slides (finger walk) Stand facing a wall and rest your fingers on it. Walk your fingers up the wall to raise the arm, letting the wall take some of the weight, then walk back down. Keep the arm below shoulder height in this phase — the wall does the assisting, so it stays gentle. As guided by your physiotherapist Kieran Hirpara 4.0 #### Over-door pulley Sit under an over-door pulley with a handle in each hand. Pull down with your good arm to raise the operated arm as far as is comfortable, then lower slowly. Keep within a gentle range and below shoulder height for now — the good arm does the work. As guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric external rotation Stand with your elbow tucked at your side and bent to a right angle, the back of your hand against a wall or doorframe. Gently press outwards into it without letting the arm move, hold a few seconds, then relax. This wakes up the rotator cuff with no movement of the shoulder. As guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric internal rotation Stand with your elbow tucked at your side and bent to a right angle, the palm of your hand against a wall or doorframe. Gently press inwards into it without letting the arm move, hold a few seconds, then relax. A gentle way to begin activating the cuff. As guided by your physiotherapist Kieran Hirpara 4.0 #### Biceps curl With the upper arm by your side, bend the elbow to raise a light weight towards your shoulder, then lower it with control. Keep the load light — this is gentle arm conditioning, not heavy lifting. As guided by your physiotherapist The fracture is starting to knit, but it is not yet healed: this phase recovers movement, not strength. The sling is weaned as comfort allows, passive and assisted range progresses towards full, and you begin moving the arm under its own power below shoulder height, along with gentle muscle-activation (isometric) exercises. Keep anything you lift or carry to no more than the weight of a cup of coffee, and avoid any forceful stretching. This phase ends with an x-ray and review with Dr Hirpara at around six weeks; that review, not the calendar alone, opens the gate to strengthening and to movement above shoulder height. For your physiotherapist: Goals - Wean from the sling (discarded by about week 6) - Progress passive range towards full in all planes - Establish active range below 90° with good mechanics - Begin gentle isometric and periscapular work Management - PROM: progress towards full range in all planes, to tolerance; no forceful stretching - AAROM: supine flexion with a dowel progressing towards upright (lawn-chair progression), wall and rail slides, pulleys - AROM: below 90° elevation, pain-free; supine flexion progressing to standing; seated and side-lying external rotation - Isometric rotator cuff work in neutral; light periscapular strengthening (scapular retraction, low row, mid row); light biceps and triceps work - Monitor for compensation patterns (shoulder hitching, scapular substitution) - Cardio: walking; stationary bike Precautions - No lifting or carrying heavier than about a cup of coffee - No active elevation beyond 90° until fracture healing is confirmed at the six-week review - No forceful stretching of the shoulder or positions that provoke pain - No weight-bearing through the arm - No driving for six weeks (this applies to any shoulder operation), and not while wearing the sling Criteria to progress - Full, or near-full, passive range of motion - Active elevation to 90° with minimal compensation and pain below 4/10 - Satisfactory fracture healing on x-ray, as confirmed at the review with Dr Hirpara ## Phase III — Strengthening (Week 6–12) Kieran Hirpara 4.0 #### Cross-body stretch Use your other hand to draw the operated arm across your chest until you feel a stretch at the back of the shoulder. Hold briefly, then release. Stretch to firm discomfort only — never into sharp pain. As guided by your physiotherapist Kieran Hirpara 4.0 #### Sleeper stretch Lie on your operated side with the shoulder and elbow both bent to 90 degrees. With your other hand, gently press the forearm down towards the bed until you feel a stretch at the back of the shoulder, then release. Keep it gentle — no sharp pain. As guided by your physiotherapist Kieran Hirpara 4.0 #### Band external rotation Stand with your elbow tucked into your side and bent to a right angle, holding an elastic band anchored at waist height. Keeping the elbow at your side, rotate the forearm outwards against the band, then return slowly. This progresses the rotator cuff on from the earlier isometric work. As guided by your physiotherapist Kieran Hirpara 4.0 #### Low row Hold a band anchored in front of you at waist height. Keeping the arm fairly straight, pull it back and down towards your hip, squeezing the shoulder blade down and back, then return slowly. This builds the shoulder-blade muscles that support the cuff. As guided by your physiotherapist Kieran Hirpara 4.0 #### Scaption raises (full can) With thumbs pointing up, raise the arm out to about 45 degrees in front of you — between straight ahead and straight out to the side — then lower with control. Once your range above shoulder height is cleared, raise into a comfortable overhead range. Keep the load light. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wall push-ups Stand facing a wall with your hands flat on it at shoulder height. Bend the elbows to lean towards the wall, then push back, adding a gentle push through the hands at the end to spread the shoulder blades. Introduce this only late in this phase, as guided by your physiotherapist. As guided by your physiotherapist Kieran Hirpara 4.0 #### Side-lying external rotation with weight Lie on your non-operated side with the top elbow bent to a right angle and tucked against your body. Holding a light weight, rotate the forearm up towards the ceiling, then lower slowly. Keep the load light and the repetitions higher. As guided by your physiotherapist Kieran Hirpara 4.0 #### Side-lying internal rotation with weight Lie on your operated side with the elbow bent to a right angle and tucked in. Holding a light weight, raise it up towards your tummy by rotating the shoulder inwards, then lower slowly. Keep the load light and the repetitions higher. As guided by your physiotherapist Once your review confirms the fracture is healing well, movement above shoulder height begins and full active range is built up over the following weeks. Strengthening starts gently: muscle-activation work first, then elastic bands, then light weights for the rotator cuff and shoulder blade muscles. Lifting stays light (no more than about 2 kg) until twelve weeks, heavy or overhead lifting waits, and there is no contact sport in this phase. Swimming and cycling typically return during this phase, as guided by your physiotherapist. For your physiotherapist: Goals - Full active range of motion in all planes, with normal mechanics - Initiate and progress rotator cuff and periscapular strengthening - Return to normal daily activities Management - Progress AROM above 90° in all planes, minimising compensatory patterns - Stretching as needed: latissimus, pectoral, posterior capsule and sleeper stretches - Strengthening: isometric cuff work progressing to resisted external/internal rotation with bands, initially below shoulder height; scapular retraction and rows; scaption raises, serratus work and wall push-ups late in the phase - Light free weights progressing as tolerated: low load, higher repetitions - Cardio: stationary bike and walking; swimming and running from around 8–10 weeks if cleared at review Precautions - No lifting heavier than about 2 kg until 12 weeks - Avoid heavy lifting overhead or away from the body until 12 weeks - No contact sport; no plyometric or impact loading until late in the phase (around 10–12 weeks) - Strengthening stays within the comfortable range and should not provoke pain that lingers Criteria to progress - Active range of motion at least 90% of the other side - Good rotator cuff and periscapular activation, with pain no more than 3/10 on resisted work - Fracture union progressing on x-ray, as confirmed at review with Dr Hirpara ## Phase IV — Return to full activity and sport (Week 12 onwards) Kieran Hirpara 4.0 #### Diagonal pattern with a band (D1) Hold an elastic band and draw it diagonally across your body — from down and across at one hip up and out to the opposite side, then reverse with control. These functional diagonal patterns rebuild the coordinated, whole-arm movement used in work and sport. Add only once the fracture has united. As guided by your physiotherapist Kieran Hirpara 4.0 #### Diagonal pattern with a band (D2) Hold an elastic band and draw it on a diagonal from across the body down low up to overhead and out, then reverse with control. This builds the overhead, sport-specific patterns of the shoulder. Add only once the fracture has united and overhead work is cleared. As guided by your physiotherapist The final phase is a graduated return to heavier lifting, manual work and sport. Strength work progresses through heavier resistance, overhead positions and (for athletes) plyometric, throwing and sport-specific drills. Contact and collision sport (football, rugby, horse riding) needs a united fracture on x-ray, as confirmed at your review with Dr Hirpara, typically from around three to four months at the earliest, and some protocols stage collision sport as late as six months. Returning before the bone has united risks re-fracture, so this is one gate worth respecting. For your physiotherapist: Goals - Full, pain-free range of motion maintained - Strength at least 90% of the uninvolved side - Graduated return to manual work, recreation and sport Management - Progressive resistance training, including eccentric loading, overhead positions and functional patterns as tolerated - Rhythmic stabilisation and proprioceptive work; plyometric and interval throwing or racquet programs for overhead athletes - Work-specific conditioning for manual workers; sport-specific drills before unrestricted play - Return-to-sport decision-making individualised (contact versus non-contact, upper-limb demand) and coordinated with the surgeon Criteria to progress - Full, pain-free active range of motion - Strength at least 90% of the uninvolved side on dynamometry, with no pain on strength testing - Completion of a graded return-to-sport program without pain or apprehension - Radiographic union confirmed at review with Dr Hirpara before contact or collision sport ## After your protocol The phases above are adapted from published rehabilitation protocols for clavicle fracture fixation: Massachusetts General Brigham Sports Medicine, Mammoth Orthopedic Institute, the University of Colorado (Dr Jonathan Bravman) and Midwest Orthopaedics at Rush (Dr Brian Cole), together with NHS physiotherapy guidance from West Suffolk and United Lincolnshire, and return-to-sport evidence from a systematic review of clavicle fractures in athletes. The week ranges are typical rather than fixed, and your progression is guided by your physiotherapist and gated on fracture healing at your reviews with Dr Hirpara. This page works alongside the practice's general recovery advice; see managing post-operative pain and wound care. For the operation itself, see clavicle fixation. The evidence behind this protocol (the operative-versus-non-operative trial data, union and return-to-sport rates, and the published surgeon protocols) is summarised in the evidence section, available as a PDF from the top of this page. --- ### Comprehensive Arthroscopic Management (CAM) URL: https://www.cqupperlimb.com/education/rehabilitation/comprehensive-arthroscopic-management/ Region: rehabilitation · rehabilitation This protocol covers the rehabilitation after a Comprehensive Arthroscopic Management (CAM) procedure with Dr Kieran Hirpara at Mater Private Hospital Rockhampton, both what happens in hospital and over the weeks and months afterwards. Bring this page or its PDF to your first… This protocol covers the rehabilitation after a Comprehensive Arthroscopic Management (CAM) procedure with Dr Kieran Hirpara at Mater Private Hospital Rockhampton, both what happens in hospital and over the weeks and months afterwards. Bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. Your rehabilitation is progressed individually by your physiotherapist through the phases below, depending on how your shoulder is moving and what was done at the time of your operation. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect The CAM procedure is a keyhole (arthroscopic) operation for a worn, arthritic shoulder. Rather than replacing the joint, it aims to clean it up and free it off so it moves and hurts less: the surgeon smooths the rough cartilage, removes loose fragments and bone spurs, releases the tight joint lining so the shoulder can rotate again, and frees the nerve that runs just below the joint (the axillary nerve). The goal is to buy you good years of a more comfortable, more mobile shoulder and to put off, or avoid, a joint replacement. That mix of work shapes how you recover. Because the surgeon has released a tight, stiff shoulder and worked hard to restore your rotation, the most important job afterwards is to keep that movement: a shoulder like this will try to stiffen up again if it is left still. But because the surgeon has also worked on the worn joint surfaces themselves, the early movement is done in a measured, graded way: you move early and often, but you ease into the stretches rather than forcing them, so the joint settles rather than flares up. Recovery is therefore led by movement, like a frozen-shoulder release, but it is gentler and more gradual. Your exercises use three kinds of movement, and your team will mark which apply to you: - Passive movement means the shoulder stays completely relaxed while your other arm, a stick or a pulley does the work. - Active-assisted movement means you move the arm yourself with some help from the other arm or an object. - Active movement means you move the arm under its own power, without help. ## About your sling You will usually be given a sling for comfort in the first week or two. It is there to rest the arm and protect it from being knocked while the joint settles; it does not hold a repair together. The key message is the opposite of a tendon or ligament repair: the sling is for comfort only, and the shoulder must not be left to stiffen. Come out of the sling for your exercises from day one, use the arm for light everyday tasks as comfort allows, and leave the sling off as much as you can once the early soreness eases. If the surgeon reattached your biceps tendon as part of the operation (a biceps tenodesis), your team will ask you to avoid lifting and forceful bending of the elbow for about six weeks while that heals, and they will tell you if this applies to you. ## Key points - Keep it moving. Use the arm for light everyday tasks such as washing, dressing and eating from the start. Gentle, regular movement is what stops the shoulder stiffening up again. - Work the rotation. Turning the arm outwards (external rotation) is one of the main movements this operation restores, so keep coming back to it. Regaining and keeping it is a key goal. - Ease into stretches, do not force them. Stretch to the point of a gentle pull, not sharp pain. The joint surfaces have been worked on, so forcing hard, painful stretches can inflame the shoulder and set you back. Little and often beats long, forceful sessions. - Control the pain so you can move. Take your pain relief before your exercises and before your physiotherapy appointments. Many people find heat before stretching and ice afterwards helpful. - Go to physiotherapy regularly. Aim for regular sessions through the first six weeks. Bring this page to your first visit. ## In hospital — your first exercises Kieran Hirpara 4.0 #### Wrist movement Keep your hand moving by bending your wrist forwards, backwards and side to side. 10 times, 3 times per day Kieran Hirpara 4.0 #### Open and close hand Keep your hand and fingers moving by opening and closing them, or by squeezing a soft ball. 10 times, 3 times per day Kieran Hirpara 4.0 #### Elbow bends Bend and straighten your elbow. If your biceps tendon was reattached during the operation, your team will tell you to take this gently and avoid lifting with the arm for the first few weeks. 10 times, 3 times per day Kieran Hirpara 4.0 #### Pendulums This is a relaxed, passive exercise. Lean forward and let your arm hang and relax down. Use your body to swing the arm gently in small circles, clockwise and anti-clockwise, and to and fro. Let the weight of the arm do the work, with the shoulder muscles relaxed. About 30 seconds each way, 3 times per day Kieran Hirpara 4.0 #### Assisted forward flexion (lying) If you prefer, lie on your back and hold a stick (or a rolled towel) in both hands. Use your good arm to guide the operated arm up over your head, as far as it comfortably goes, then lower it slowly. 10 times, 3 times per day Kieran Hirpara 4.0 #### Assisted abduction (cradle) Cradle the operated arm in your other arm, supporting it under the elbow, and gently rock it out to the side and back, like rocking a baby. Take it to a comfortable stretch out to the side each time. 10 times, 3 times per day Kieran Hirpara 4.0 #### Assisted external rotation with a stick Lie on your back with your elbow tucked by your side and bent to 90 degrees. Hold a stick in both hands and use your good arm to turn the hand of the operated arm outwards, rotating the shoulder. Rotating outwards is an important movement to regain after this operation, so keep working it gently and a little further as the weeks go on. 10 times, 3 times per day Kieran Hirpara 4.0 #### Lower trapezius setting Squeeze your shoulder blades downwards and together, hold, then relax. Hold 5 seconds, 5 times; repeat 3 times daily A physiotherapist will see you in hospital and start you on the exercises below before you go home. These keep the hand, elbow and shoulder moving and begin restoring the shoulder's range straight away. Take your pain relief beforehand so you can move comfortably. Do them as marked by your team, and carry on with them at home. ## Your outpatient rehabilitation After a CAM procedure, rehabilitation is led by movement: the shoulder was stiff and has been freed off, so the early effort goes into keeping and rebuilding that range before it tightens again, but in a graded way that respects the joint surfaces that were worked on. Physiotherapy starts early, stays regular, and continues for some months. The phases below follow the pattern of the published rehabilitation protocol for this operation. The week ranges are typical rather than fixed: your physiotherapist will progress you on how your shoulder is moving, not on the calendar. Clinic review is usually arranged at about 2 weeks, 6 weeks, and 3 to 4 months. The journey at a glance: - Phase I — Early motion: roughly the first two weeks - Phase II — Restoring your range: week 2 to 6 - Phase III — Strengthening: week 6 to 12 - Phase IV — Return to full activity: week 12 onwards (around three months) Most people notice meaningful pain relief and easier movement within the first one to three months, and improvement typically continues to build over six to twelve months. ## Phase I — Early motion (Week 0–2) The goal of these first two weeks is to get the shoulder moving and keep the range that was freed at surgery, without stirring the joint up. You carry on the hospital exercises at home several times a day: passive and active-assisted movements, pendulums, and gentle stretches in all directions, including turning the arm outwards. Use the sling for comfort only, and take it off for your exercises and light daily tasks. Good pain control is what makes the movement possible, so keep taking your pain relief before your exercises, and use heat before and ice after if it helps. Ease into each stretch to a gentle pull, not sharp pain. Ready for the next phase when… you are doing your home program confidently several times a day, your pain is settling, and the shoulder is moving freely into its early range. ## Phase II — Restoring your range (Week 2–6) Kieran Hirpara 4.0 #### Over-door pulley Sit under an over-door pulley with a handle in each hand. Pull down with your good arm to raise the operated arm overhead as far as it comfortably goes, then lower slowly. Work into a gentle stretch, not sharp pain. 10 times, 3 to 4 times daily Kieran Hirpara 4.0 #### Cross-body stretch Use your good hand to draw the operated arm across your chest until you feel a gentle stretch at the back of the shoulder, then release. 10 times, 3 to 4 times daily Kieran Hirpara 4.0 #### Wand external rotation Continue the stick-assisted external rotation from hospital, working a little further as the range frees up. With the elbow by your side, turn the forearm outwards as far as it comfortably goes, then return. 10 times, 3 to 4 times daily Kieran Hirpara 4.0 #### Assisted forward elevation (sitting) Sitting and leaning forward slightly, support the operated forearm with your good hand and use it to lift the operated arm forwards and up in front of you, as far as is comfortable, then lower it slowly. Let the good arm do the work so the operated shoulder stays relaxed. As guided by your physiotherapist This phase keeps up the regular physiotherapy and the home program, working the range further as the shoulder allows. Your exercises progress from assisted movements towards moving the arm actively in all directions, your physiotherapist may add hands-on joint mobilisation, and you keep returning to external rotation. Stretching stays graded, firmer than week one, but still easing in rather than forcing. Most people are out of the sling and using the arm normally for light daily activities through this phase. Ready for the next phase when… your range is steadily improving, movement below shoulder height is comfortable, and your pain has settled enough to begin gentle resistance work. ## Phase III — Strengthening (Week 6–12) Kieran Hirpara 4.0 #### Band external rotation Stand with your elbow tucked into your side and bent to 90 degrees, holding an elastic band anchored at waist height. Keeping the elbow at your side, rotate the forearm outwards against the band, then return slowly. 2 to 3 sets of 10 to 15, 5 days per week Kieran Hirpara 4.0 #### Band internal rotation With your elbow tucked into your side, hold a band anchored to one side and rotate the forearm inwards across your body against the band, then return slowly. 2 to 3 sets of 10 to 15, 5 days per week Kieran Hirpara 4.0 #### Low row Hold a band anchored in front of you at waist height. Keeping your arm fairly straight, pull it back and down towards your hip, squeezing the shoulder blade down and back, then return slowly. 2 to 3 sets of 10 to 15, 5 days per week Kieran Hirpara 4.0 #### Side-lying external rotation (light weight) Lie on your good side with the operated elbow bent to 90 degrees and tucked against your side, holding a light weight (about 0.5 to 1.5 kg). Rotate the forearm upwards, then lower slowly: the slow lowering is the important part. Keep the work below shoulder height. 2 to 3 sets of 10 to 15, low load With your range improving, attention turns to rebuilding strength. Gentle stretching continues so you do not lose the movement you have worked for. Resistance work starts lightly at around six weeks, using elastic bands and light weights for the rotator cuff and shoulder-blade muscles, with low loads and higher repetitions. Normal daily activities should be largely back to usual, and lighter recreational activities typically resume during this phase, as guided by your physiotherapist. Ready for the next phase when… you have full, or near-full, comfortable movement in all directions, and you can manage the strengthening exercises without a flare-up of pain. ## Phase IV — Return to full activity (Week 12 onwards) The final phase, from around three months, is a graduated return to heavier work, overhead tasks and sport, with more advanced strengthening. The shoulder keeps improving well beyond this point: most people continue to gain comfort and confidence over six to twelve months. Progression stays guided by how you feel: if stiffness or an ache starts to build, ease back, restore the range and settle the joint rather than pushing through. ## Returning to activity Most people are back to desk work and light daily activities within the first few weeks, once they are comfortable and out of the sling. Heavier, more physical work and overhead sport come back gradually over the following weeks to months, usually from around three months, as your strength returns. Driving after any shoulder operation follows the practice's standard policy rather than a fixed point in this protocol: see driving after upper-limb surgery and confirm with your surgeon at review. ## Your exercises These are the exercises from your handout. Start them as guided by Dr Hirpara and your physiotherapist. The early exercises — wrist movement, opening and closing the hand, elbow bends and pendulums — keep the rest of the arm moving while the shoulder settles. The assisted stretches (lying flexion, cradle abduction, stick external rotation) restore range without loading the joint, and the band, low row and side-lying work is added later once movement is comfortable. Progress the range first and the strength second. Stop anything that causes sharp pain rather than a stretch. ## After your protocol The outpatient phases above are adapted from the published rehabilitation protocol for the CAM procedure, with recovery milestones drawn from the same sources. The week ranges are typical rather than fixed, and your ongoing rehabilitation is guided individually by your physiotherapist, working with the practice, based on how your shoulder recovers and exactly what was done at your operation. This page works alongside the practice's general recovery advice: see managing post-operative pain and wound care. For the operation itself and the condition it treats, see comprehensive arthroscopic management and shoulder arthritis. --- ### Cubital Tunnel Release URL: https://www.cqupperlimb.com/education/rehabilitation/cubital-tunnel-release/ Region: rehabilitation · rehabilitation Recovery after surgical decompression of the ulnar nerve at the elbow, covering both in-situ (simple) release and anterior transposition. This protocol guides your recovery after surgical release of the ulnar nerve at the elbow (cubital tunnel release) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It explains what to expect, the precautions for the early weeks, and the exercises that keep the nerve gliding freely while everything settles. Bring this page or its PDF to your physiotherapist or hand therapist so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. Two different operations, two slightly different recoveries. The ulnar nerve can be freed in two main ways, and which one you had changes your early precautions: - In-situ (simple) decompression: the nerve is freed where it lies, without moving it. This is the standard operation Dr Hirpara performs, and recovery is quick: gentle full movement of the elbow begins early. No rigid brace is used. - Anterior (submuscular) transposition (the nerve lifted and re-routed to a more protected position in front of the elbow): done only in the less common situation where the nerve subluxes or dislocates over the bony bump (medial epicondyle) when the elbow bends. This needs a more careful early phase, avoiding end-range elbow bending and straightening for the first few weeks while the nerve and soft tissues settle in their new position. A simple sling may be worn for comfort only. Follow the guidance below for the operation you had: in-situ in most cases, transposition where your nerve was unstable. ## What to expect For wound, swelling and scar management, see the practice's wound care guidance. The aim of the surgery is to take the pressure off the ulnar nerve (the nerve that supplies feeling to your little and ring fingers and powers many of the small muscles of the hand). Once the pressure is relieved, the nerve begins to recover, but nerves heal slowly. How quickly your symptoms improve depends a lot on how long the nerve was compressed and how irritated it had become before surgery. Tingling and pins-and-needles often ease first, sometimes within days or weeks. Numbness and hand strength take longer (frequently months) and the final result can continue to improve for up to a year or more after the operation. Where the nerve was very irritated for a long time before surgery, some numbness or weakness may not fully recover; the operation is then aimed at stopping things getting worse and giving the nerve its best chance. Comparing the two operations, large reviews of the published trials have found that simple in-situ decompression and anterior transposition give similar overall results, with simple decompression tending to have fewer wound and soft-tissue complications [1][2]. The choice between them is made by your surgeon based on your nerve and your elbow. ## Precautions and limitations Light functional use of your hand for everyday tasks such as self-care, feeding, dressing, writing and typing is encouraged from the start, within comfort. The early limits depend on which operation you had: - After in-situ (simple) decompression (the usual operation): gentle full elbow, forearm, wrist and hand movement is encouraged early to keep the nerve gliding. No brace is used. Keep lifting, gripping and weight-bearing through the arm light for about the first six weeks, then build up gradually. - After anterior transposition (only if your nerve was unstable): the elbow is protected for the first few weeks; avoid forcing it fully bent or fully straight, and avoid holding it bent for long periods, while the nerve settles in its new position. A simple sling may be worn for comfort only. Nerve glides start a little later than after a simple release (usually around two to three weeks). As with an in-situ release, keep lifting and resistance light for about the first six weeks, then build up gradually. As a general guide, lifting and resistance strengthening are kept light until around six weeks, then built up gradually [3][4]. Leaning on the elbow (resting your elbow on a hard surface) puts pressure right over the nerve and should be avoided while it recovers. Once your wound is healed, scar massage helps keep the skin and tissues supple over the nerve. The wound care page has more information on scar management. These are the exercises from your handout, performed as described on each card. Start them as guided by Dr Hirpara and your therapist: the start date for the nerve glides, and any elbow range limit, depends on which operation you had. ## Your exercises Kieran Hirpara 4.0 #### Ulnar nerve glides These gentle movements keep the ulnar nerve sliding freely so it does not become stuck to the healing tissue. Move smoothly through each position only as far as is comfortable — a light pull or tingle is normal, but stop short of any sharp or strong pins-and-needles. Never force the stretch. Begin only when your surgeon or therapist tells you to (this is usually later if you have had a transposition — see the precautions below). 5 slow repetitions, 2–3 times daily Kieran Hirpara 4.0 #### Elbow bends (flexion) With your upper arm supported, gently bend your elbow to bring your hand towards your shoulder, then lower it again. Move within a comfortable range. If you have had a transposition, your surgeon may ask you to avoid bending the elbow all the way up for the first few weeks — follow the limit you have been given. 10 repetitions, 3–4 times daily, within your allowed range Kieran Hirpara 4.0 #### Elbow straightening (extension) From a bent position, gently straighten your elbow as far as is comfortable, then return. If you have had a transposition, avoid forcing the elbow fully straight in the early weeks if you have been asked to — settle for the comfortable range your surgeon has set. 10 repetitions, 3–4 times daily, within your allowed range Kieran Hirpara 4.0 #### Forearm rotation With your elbow tucked by your side and bent to a right angle, slowly turn your palm up towards the ceiling, then down towards the floor. Keep your elbow against your body throughout. 10 times each way, 3–4 times daily Kieran Hirpara 4.0 #### Wrist and finger movement Gently bend your wrist up and down, and open and close your fingers fully, making a loose fist and then spreading the fingers. This keeps the whole limb moving and helps reduce swelling and stiffness while the elbow settles. 10 of each, several times daily Start the exercises below only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. The ulnar nerve glides are the important ones — they keep the nerve sliding freely rather than scarring down, and they start early. Elbow bending, straightening and forearm rotation stop the elbow stiffening, and the wrist and finger movements keep everything else working. Avoid resting for long periods with the elbow fully bent, which is what irritates the nerve in the first place. Stop anything that causes sharp or electric pain down the forearm into the little and ring fingers. ## Getting back to work and activity Most people return to desk-based or light work within one to two weeks, while heavier, repetitive or manual roles usually take about four to eight weeks. You are ready for a particular task when your wound tolerates the contact and pressure it involves, and you can do it comfortably within the precautions above. If your work is heavy, involves leaning on the elbow, or uses vibrating tools, raise it at your post-operative review so a plan (including any modified duties) can be made. Driving usually resumes around two to three weeks, once you are out of any sling and can control the vehicle and react in an emergency without pain. Return to sport and overhead activity is generally around six to twelve weeks. Nerve recovery runs on a slower timeline of its own. Tingling often settles first, within days to weeks, while numbness and strength continue to improve over many months and can keep getting better for up to about a year. Where the nerve was very compressed for a long time, some numbness or weakness may not fully recover, and the operation then aims to stop things progressing. ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain, wound care and hand therapy basics. The phased plan above is consistent with published evidence on decompression of the ulnar nerve at the elbow, and your ongoing recovery is guided individually by your physiotherapist or hand therapist according to how your nerve and elbow progress. --- ### de Quervain's Release URL: https://www.cqupperlimb.com/education/rehabilitation/de-quervains-release/ Region: rehabilitation · rehabilitation An early-motion recovery plan after surgical release of the first dorsal compartment for de Quervain's tenosynovitis, with brief comfort support, gentle thumb and wrist movement from the start to prevent stiffness, scar care, and a graded return to grip and pinch strength by… This protocol guides your recovery after a de Quervain's release, a small operation that opens the tight tunnel over the thumb-side tendons of your wrist, with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist; bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your hand therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect De Quervain's tenosynovitis is irritation of the two tendons that run to your thumb (the abductor pollicis longus and extensor pollicis brevis) where they pass through a snug tunnel (the first dorsal compartment) on the thumb side of the wrist. The release is a small operation that opens that tunnel so the tendons have room to glide freely, settling the pain and catching. Because nothing is stitched back together or tightened (the tunnel is simply opened and is meant to stay open), this is an early-motion recovery, not a long protected one. There is no construct that needs months of healing. The whole aim of the rehabilitation is to keep the tendons moving through the healing surgical bed so they do not stick down, while the small wound and the skin nerves over it settle. So the plan is simple: a soft dressing (sometimes a light thumb splint just for comfort) for the first few days to about a week or two, gentle thumb and wrist movement started early, scar care once the wound is healed, and a gradual build-up of grip and pinch strength. Most people are back to comfortable normal activity by around four to six weeks. Two things are watched after this particular operation. The first is a small skin nerve, the radial sensory nerve, whose branches run right across the front of the surgical site; it can be left tingly or tender for a while, and the early nerve-settling work is aimed at it. The second is the position of the tendons: opening the tunnel too far towards the palm side can occasionally let a tendon slip forwards (subluxate) when you move the thumb. Both are uncommon, and your hand therapist will keep an eye out for them. ## Precautions and limitations - Keep the thumb and wrist moving from the start: gentle movement is the treatment here, not rest. Stiffness from doing too little is the main thing we are trying to avoid. - Use any comfort splint only as directed and only for the first days to a week or two: it is for comfort, not protection, and should come off for your exercises. - Keep the wound clean and dry until it is healed; do not start scar massage until the dressings are off and the skin is closed. - Avoid heavy gripping, forceful pinching, lifting and twisting (wringing a cloth, opening tight jars, heavy tools) until around three to four weeks, then build back up gradually. - Tell your therapist or the rooms if you notice tingling, numbness or a sharp shooting feeling over the back of the thumb and wrist, or a tendon that snaps or slips when you move the thumb. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### Thumb movement (bend, straighten and reach) Gently move your thumb through its full range: bend the tip down towards your palm, straighten it out, then move the whole thumb across to touch the base of your little finger and back out wide. Keep it slow and comfortable. Early thumb movement keeps the released tendons gliding so they do not stick down in the healing scar. 10 of each, 3–4 times a day, within comfort Kieran Hirpara 4.0 #### Wrist movement (up, down and side to side) With your forearm resting on a table, gently bend the wrist up and down, then tilt it side to side (towards the thumb, then towards the little finger). Move only as far as is comfortable. This keeps the wrist supple while the wound settles. 10 each direction, 3–4 times a day Kieran Hirpara 4.0 #### Tendon glides (thumb and finger gliding) Open your hand wide, then slide the thumb across to touch each fingertip in turn, then make a loose fist and open again. The aim is smooth gliding, not force. Keeping the tendons moving through the released tunnel is the single most important thing in the early weeks to avoid stiffness and adhesions. 5–10 slow cycles, 3–4 times a day Kieran Hirpara 4.0 #### Scar massage Once the wound is fully healed and the dressings are off (commonly from around two weeks), rub a little plain moisturiser into the scar with small firm circles for a minute or two. This softens the scar and helps the skin and the tender nerve branches underneath settle. Stop if the area is still open or weepy. 1–2 minutes, 2–3 times a day, once healed Kieran Hirpara 4.0 #### Grip and pinch strengthening A LATER exercise — usually from around three to four weeks, once the wound has healed and movement is comfortable. Squeeze a soft ball or therapy putty for grip, and pinch a small piece of putty between your thumb and fingertips for pinch. Build the effort up gradually. This rebuilds the strength that always dips after surgery. 10–15 squeezes/pinches, 2–3 times a day (from ~3–4 weeks) Kieran Hirpara 4.0 #### Radial nerve glide (if the wrist-back feels tingly or tender) Only if your hand therapist starts it — for tingling, tenderness or sensitivity over the back of the thumb and wrist. With the arm out in front, gently ease the wrist and thumb down into a light stretch until you feel a mild pull, hold a moment, then release. It should never be painful or make the tingling worse. This calms the small skin nerve that runs right over the operation site. 5–10 slow glides, 1–2 times a day, only as guided These are the exercises from your handout. Start them as guided by Dr Hirpara and your hand therapist. The early exercises (thumb movement, wrist movement and tendon glides) keep everything moving and gliding so the released tendons do not stick down; these begin within the first days, within comfort. Scar massage starts once the wound is healed. Grip and pinch strengthening is a later addition, usually from around three to four weeks. The nerve glide is only added if the skin over the wrist feels tingly or tender. Stop anything that causes sharp or shooting pain over the thumb side of the wrist. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after de Quervain's (first dorsal compartment) release. This section is to be provided to your hand therapist, and each phase opens with a plain-English explanation of what is happening. This is a decompression, not a repair: the first dorsal compartment is divided and is meant to stay divided, so there is no construct to protect. The programme is therefore an early-motion, glide-based pathway: keep the APL/EPB tendons gliding through the surgical bed to prevent adhesion, control oedema, manage the scar and the radial sensory nerve, and restore grip and pinch. Prior to treatment, check the patient's operation report and liaise with the treating surgeon regarding the release (longitudinal/dorsal incision, whether a separate EPB sub-sheath/septum was found and released), the dorsal positioning of the release to protect against volar tendon subluxation, and any radial sensory nerve handling. Dr Hirpara performs an open release through a dorsal/longitudinal approach, protecting the radial sensory nerve branches and keeping the release dorsal to avoid volar subluxation; immobilisation is for comfort only (soft dressing ± short thumb spica for a few days to ~1–2 weeks), and early thumb and wrist motion is the default. ### Phase I — early motion, oedema and wound care (week 0 to ~2) The first week or two protect the wound and settle swelling while motion starts immediately. There is no protected arc to respect: the goal is to get the released tendons gliding straight away. Any splint is for comfort only and comes off for exercises. For your hand therapist: Education and precautions - This is a decompression: no construct to protect; early active motion is the intended default - Comfort support only: soft dressing ± short thumb spica for the first few days to ~1–2 weeks; off for exercises and washing - Keep the wound clean and dry until healed; defer scar work until skin is closed - Avoid forceful grip, pinch, lifting and wrist twisting in this window - Screen the radial sensory nerve distribution (dorsoradial thumb/wrist) for paraesthesiae, hypersensitivity or Tinel's; screen for APL/EPB subluxation on resisted/active thumb extension–abduction Management - Wound: surgical dressings as directed; monitor for infection - Oedema: elevation, gentle retrograde massage, ice as needed - Exercises: active thumb ROM (flexion/extension, palmar + radial abduction, opposition), active wrist ROM, APL/EPB tendon glides, full active finger ROM; light functional hand use within comfort Criteria to progress - Wound healed/settling; swelling controlled; comfortable active thumb and wrist motion ### Phase II — restoring motion and scar management (weeks ~2 to 4) Once the wound is healed, the comfort splint is discarded and the focus shifts to full, comfortable motion plus active scar and nerve desensitisation. Light strengthening begins towards the end of this window. For your hand therapist: Assessments - Thumb and wrist active/passive ROM; scar quality; radial sensory nerve symptoms; subluxation screen Education and precautions - Discontinue any comfort splint; encourage normal light hand use - Continue to avoid heavy/forceful grip and pinch until ~3–4 weeks Management - Scar: massage and silicone/moisturiser once healed; desensitisation if hypersensitive - Nerve: radial sensory nerve glides/desensitisation if irritable; settle before loading - Exercises: progress to full thumb and wrist ROM; continue tendon glides; begin light grip/pinch (putty, soft ball) from ~3–4 weeks Criteria to progress - Full, pain-free thumb and wrist ROM; healed, mobile scar; settling nerve symptoms ### Phase III — strengthening and return to activity (weeks ~4 to 6 and beyond) With motion restored and the wound mature, grip and pinch are built up and the patient is returned to full activity. Most reach comfortable normal use by around four to six weeks; heavier manual demands take a little longer and are criterion-based. For your hand therapist: Assessments - Grip and pinch strength versus the other side; pain with loading; functional/work-specific testing as appropriate Education and precautions - Graded return to gripping, pinching, lifting and twisting; full activity as comfort and strength allow - Persisting dorsoradial pain/tingling or a snapping tendon → refer back to the treating surgeon (consider neuroma, incomplete release, or volar subluxation) Management - Exercises: progressive grip and pinch strengthening; task- and work-specific loading; continue any residual scar/nerve work - Consider discharge once strength is near-symmetrical and function is restored - Consider referral back to the treating doctor if recovery plateaus or there is a poor outcome Criteria for discharge / return to full activity - Near-symmetrical grip and pinch; pain-free functional and work-specific use ## Getting back to work and activity Light everyday hand use (eating, writing, dressing, light tasks) is encouraged from the start, within comfort. Because the operation is on the wrist and the hand needs to move freely and grip safely, driving resumes once the wound is comfortable, any comfort splint is off, and you can grip and turn the wheel confidently, for most people within the first week or two, as confirmed at your review. Forceful gripping, pinching, lifting and twisting wait until around three to four weeks and are then built up gradually. Desk and light work often resume within days to a week or two; heavier manual work that depends on strong, repeated thumb and wrist loading is usually back by around four to six weeks, judged by your regained strength and comfort rather than the calendar alone, by Dr Hirpara and your hand therapist. ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain, wound care and scar management. The phased plan above reflects published rehabilitation guidance after de Quervain's release, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your hand progresses. --- ### DIP Joint Fusion URL: https://www.cqupperlimb.com/education/rehabilitation/dipj-fusion/ Region: rehabilitation · rehabilitation A protected recovery plan after fusion (arthrodesis) of the small fingertip joint nearest the nail, keeping the fingertip splinted while every other joint stays moving and swelling is controlled, then progressively rebuilding pinch and grip once the bone has joined. This protocol guides your recovery after a DIP joint fusion (arthrodesis), which permanently joins the small joint at the very tip of your finger, nearest the nail, with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist: bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect A DIP joint fusion is done when the small joint nearest the nail is worn out and painful, usually from arthritis (the bony lumps called Heberden's nodes), or to remove a troublesome mucous cyst together with the bone spur underneath it. Rather than trying to keep a painful, damaged joint moving, the operation fuses it solid in a slightly bent, functional position (up to about 35°). By design, that joint never moves again, and in exchange the pain goes and the fingertip becomes stable and strong to pinch with. The fixation is usually a small buried headless screw that stays in for good (no need to remove it), or sometimes a K-wire that is taken out at around six weeks. If a mucous cyst was removed, you will also have skin or nail-fold care to do as the area heals. The whole of your rehabilitation is built around one simple idea: protect the fusion until the bone has joined, but keep everything else moving. The bone typically feels united by about six to eight weeks, with the X-ray catching up by around ten weeks. Until then: - The fused fingertip is splinted and protected so the healing bone is not disturbed. - Every other joint keeps moving: the middle joint of the finger, the knuckle, the thumb, the wrist, and all your other fingers, so the hand does not stiffen. - Swelling is controlled and the scar is managed so the finger stays comfortable and supple. - Once the bone has joined, pinch and grip are rebuilt gradually rather than all at once. ## Precautions and limitations - Wear your fingertip splint as directed. Early on it is worn continually; later it is worn only for activity. It holds the fused joint still but leaves the middle joint of the finger (the PIP) free to move. - Do NOT power-grip, pinch hard or lift heavily with the operated finger until the fusion has joined and you are cleared; keep to about 1 kg (≈2 lb) in the first six weeks. - Keep every other joint moving from the start: the middle and knuckle joints of the finger, the thumb, the wrist, and all your other fingers. - Keep the dressing dry and the hand elevated in the first 10–14 days to settle swelling, and follow any nail-fold or cyst-site care if a mucous cyst was removed. - If you have a K-wire, protect it and keep the area clean until it is removed at about six weeks; a buried screw needs no removal. - Do NOT drive until you are out of the bulky splint and can safely grip and control the wheel, usually around six weeks, at your surgeon's discretion. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### PIP and MCP movement (the joints either side of the fusion) With your DIP splint on (it holds only the fingertip joint still), bend and straighten the MIDDLE joint of the finger and the big knuckle joint at its base, making a gentle fist and opening fully. The fused tip is not meant to move, but the joints either side of it must stay loose so the finger does not stiffen up. Move smoothly and within comfort. 10 times, 3–4 times a day Kieran Hirpara 4.0 #### Move all your other fingers, thumb and wrist Keep everything that was NOT operated on moving freely from day one: make a full fist and open right out, touch your thumb to each fingertip, and bend your wrist gently up and down. Only the fused fingertip is restricted — the rest of the hand should work as normally as comfort allows so it does not get stiff or weak. 10 of each, several times a day Kieran Hirpara 4.0 #### Tendon glides (hook, fist, straight) Move your fingers through three shapes — a hook (bend the tip and middle joints, knuckles straight), a full fist, then a flat straight hand — pausing briefly in each. This keeps the tendons gliding smoothly through the healing area so they do not stick down. Keep the splinted fingertip comfortable throughout; the glide is for the rest of the finger. 5–10 of each shape, 3 times a day Kieran Hirpara 4.0 #### Swelling control (elevation and compression) Keep your hand raised above the level of your heart as much as you can in the first couple of weeks — propped on a pillow or cushion. Once the wound allows, a light compression sleeve or self-adherent (Coban) wrap on the finger helps settle swelling. Less swelling means an easier, freer-moving hand. Elevate often through the day; compression as fitted by your hand therapist Kieran Hirpara 4.0 #### Scar massage Once the wound is fully healed and your hand therapist gives the go-ahead, rub a little plain moisturiser into the scar with small, firm circles for a minute or two. If a mucous cyst was removed, your therapist will also guide care of the nail fold and surrounding skin. This keeps the scar soft and less sensitive. 1–2 minutes, 2–3 times a day, once the wound is healed Kieran Hirpara 4.0 #### Grip and pinch strengthening (after union) A LATER exercise — only once the fusion has joined on X-ray and your hand therapist starts it (commonly from around 6–8 weeks). Begin gently squeezing therapy putty and doing light pinches between thumb and fingertip, then build up the effort slowly over the following weeks. Do not power-grip or pinch hard before you are cleared — loading the fingertip too early can disturb the healing bone. As guided by your hand therapist, building gradually (from ~6–8 weeks) These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist, staying within whatever limits you have been given. The early exercises keep the rest of the hand moving freely without disturbing the fused fingertip: movement of the joints either side of the fusion, all your other fingers, thumb and wrist, tendon glides, and swelling control. Grip and pinch strengthening belongs to a later phase and should not be started until the fusion has joined on X-ray and you are specifically cleared. Stop anything that causes sharp pain at the fingertip. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after DIP joint (distal interphalangeal) arthrodesis. This section is to be provided to your hand therapist, and each phase opens with a plain-English explanation of what is happening. The principle is protect the arthrodesis site until bony union while preserving full motion at every other joint: the DIP is immobilised in a P2–P3 splint that leaves the PIP free, oedema and scar are managed, and pinch/grip are reloaded progressively only after union. Prior to treatment, check the patient's operation report and past medical history, and liaise with the treating surgeon regarding the fixation (headless compression screw, buried, no removal, vs K-wire, removed ~6 weeks), the fusion position (slight flexion, up to ~35°), and whether a mucous cyst with skin/nail-fold excision was performed. Clinical union is typically expected around 6–8 weeks with radiographic union around 10 weeks; the rehab timeline below is low-level expert consensus and is subject to surgeon discretion and X-ray confirmation of union before splint weaning and loading. ### Phase 1 — protect and settle (weeks 0 to 2) The first fortnight protects the freshly fixed fusion and settles swelling and the wound, while keeping every uninvolved joint moving so nothing stiffens. For your hand therapist: Education and precautions - Bulky surgical dressing/splint with elevation for the first 10–14 days; keep the dressing dry - Protect the arthrodesis site; no loading of the operated fingertip - If a K-wire is present, protect the pin site; review nail-fold/cyst-excision wound where applicable Management - Wound: surgical dressings as directed; monitor for infection - Oedema: elevation, gentle hand pumping, ice as appropriate - Exercises: AROM of all uninvolved joints: PIP and MCP of the operated finger, thumb, wrist, and all other digits; commence tendon glides as comfort allows Criteria to progress - Wound settling; swelling controlled; ready to transition into a custom removable DIP-blocking splint at around two weeks ### Phase 2 — DIP-blocking splint with activity (weeks 2 to 6) From about two weeks the bulky dressing is replaced by a custom removable DIP-blocking splint (a Stax/mallet-type orthosis spanning P2–P3) that immobilises only the fingertip joint and leaves the PIP free. It is worn continually through this phase. Full active motion is encouraged everywhere else, swelling and scar are managed, and the fingertip stays unloaded. For your hand therapist: Education and precautions - Custom removable DIP-blocking splint (P2–P3, PIP free) worn continually through this phase - No power grasp or pinch; functional load limit ~2 lb (≈1 kg) Management - Exercises: active PIP, MCP, thumb and wrist motion plus all-other-digit motion; tendon glides (hook, full fist, straight) - Oedema: continue elevation and add compression (Coban/light sleeve) as tolerated - Scar: commence scar massage once the wound is fully healed; nail-fold care where a mucous cyst was excised Criteria to progress - Maintained PIP/MCP motion; controlled swelling; healed wound; clinical union emerging at around six weeks (proceed to weaning only with X-ray confirmation of union) ### Phase 3 — wean the splint and begin gentle strengthening (weeks 6 to 8) Once the fusion is united on X-ray (clinically ~6–8 weeks), the splint is weaned (worn for activity/protection only) and a K-wire, if used, is removed at about six weeks. Gentle strengthening of pinch and grip begins. For your hand therapist: Education and precautions - Wean the DIP splint once union is confirmed: continued protective/activity-only wear as needed; K-wire removed ~6 weeks - Progress loading gradually; functional limit ~5 lb (≈2 kg) from around 8 weeks Management - Exercises: begin gentle grip and pinch strengthening: therapy putty, light pinch and grip work; continue full motion at all other joints; continue scar management - Reassess any residual swelling or PIP/MCP stiffness and address as needed Criteria to progress - Radiographic union confirmed; comfortable fingertip; tolerating gentle loading without pain at the fusion site ### Phase 4 — progressive strengthening and discharge (weeks 8 to 12) With the fusion solid, strengthening is progressed towards normal hand function, and restrictions are lifted by around twelve weeks. For your hand therapist: Education and precautions - Progressive grip and pinch strengthening; functional limit ~10 lb (≈4.5 kg) at around 10 weeks - No restriction from around 12 weeks, subject to surgeon review Management - Exercises: graded resistive grip and pinch (putty → grippers → task-specific loading); restore full functional hand use - Consider discharge once a stable, pain-free fingertip with near-normal hand function and strength is achieved - Refer back to the treating surgeon if there is pain over the fusion, concern about union, or a poor functional outcome Criteria for discharge - United, pain-free fusion; full motion at all non-fused joints; functional pinch and grip restored ## Getting back to work and activity Light everyday use of your other fingers and the rest of the hand is encouraged from the start, within comfort; only the fused fingertip is held back. Driving usually resumes at around six weeks, once you are out of the bulky splint and can grip and control the wheel safely; this is at Dr Hirpara's discretion at your review, so plan for help with transport in the early weeks. Gentle pinch and light grip typically begin around six weeks and build up from about eight weeks, once the bone has joined. Full, heavy or sporting use of the hand is generally reached by around twelve weeks. These timelines are expert-consensus guidelines rather than fixed deadlines: your surgeon's discretion and your X-ray (confirming the bone has joined) come first. ## After your protocol This protocol works alongside the practice's general recovery advice; see also managing post-operative pain, wound care and scar management. The phased plan above reflects published rehabilitation guidance after DIP joint arthrodesis, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your finger heals. --- ### Distal Biceps Tendon Repair URL: https://www.cqupperlimb.com/education/rehabilitation/distal-biceps-repair/ Region: rehabilitation · rehabilitation A protected early-motion recovery plan after surgical repair of a ruptured distal biceps tendon, allowing comfortable movement from day one while guarding the repair from resisted lifting until strength is rebuilt in stages. This protocol guides your recovery after surgical repair of a ruptured distal biceps tendon with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your physiotherapist or hand therapist. Bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect The distal biceps tendon is the cord that anchors your biceps muscle to the radius bone just below the front of the elbow. When it ruptures it is reattached to its bony footprint on the radius. Dr Hirpara repairs it using a cortical button, a small, strong fixation that holds the tendon firmly against the bone while it heals back on. Because this is a strong repair, the recovery is built around comfortable early movement rather than rigid immobilisation. You will wear a simple sling for about 6 weeks (not a hinged elbow brace) and you are encouraged to move the elbow through its full comfortable range from day one, including straightening it out. Early movement keeps the elbow from going stiff, which is one of the main problems after this operation. The strength of the repair is deliberately spent on allowing this early movement. It is not a licence to lift early. The tendon still has to knit biologically back onto the bone, and that healing is what protects you from re-rupture. For that reason, loading the arm (lifting, gripping hard and resisted strengthening) is held back until about 4 months, then introduced lightly and built up gradually. The sling is mainly for comfort and as a reminder not to use the arm heavily; it comes off for your exercises and for washing. For wound, swelling and scar management, see the practice's wound care guidance. ## Precautions and limitations Do - Move your elbow, forearm, wrist and hand through their full comfortable range from day one: bending, straightening and rotating the forearm. - Take the sling off for your exercises and for hygiene; wear it for comfort and protection the rest of the time for about 6 weeks. - Use the arm for very light everyday tasks (eating, light self-care) within comfort. Do not - Do not lift, carry, grip hard or do any resisted strengthening with the operated arm until you are cleared at about 4 months. This is the single most important precaution. - Do not force a sudden, sharp straightening of the elbow against a load, and avoid forced or jerky movements. - Do not stretch your shoulder back into hyperextension early, as this pulls on the healing wound at the front of the elbow. ## Your exercises Kieran Hirpara 4.0 #### Elbow bend and straighten (to comfort) With your palm facing up, gently bend your elbow up towards your shoulder as far as is comfortable, then slowly straighten it back down as far as is comfortable. There is no limit on how far you move — let comfort be your guide and move smoothly. Keep your upper arm resting at your side. 10 times, 3–4 times a day Kieran Hirpara 4.0 #### Assisted elbow bend Let the operated arm relax completely, then use your other hand to gently bend the elbow up towards your shoulder. You are not pulling with the operated arm — the other hand does the work. This keeps the elbow supple in the early weeks. 10 times, 3–4 times a day Kieran Hirpara 4.0 #### Elbow straightening (to comfort) Slowly straighten your elbow down to a comfortable position and then bend it back up. Full straightening is allowed as comfort permits — there is no need to block or hold back the straightening direction. Move gently and avoid any sudden or forced movements. 10 times, 3–4 times a day Kieran Hirpara 4.0 #### Forearm rotation (palm up / palm down) Tuck your elbow into your side and bend it to about a right angle. Gently turn your palm up towards the ceiling, hold for a moment, then turn it down towards the floor. Keep the elbow tucked in so the movement comes from the forearm, not the shoulder. 10 times each direction, 3–4 times a day Kieran Hirpara 4.0 #### Hand, wrist and grip movement Keep your hand and fingers moving from the start. Open your hand wide, then make a gentle fist and release. Move your wrist up and down too. This keeps the hand supple and prevents stiffness and swelling while the elbow heals. 10–15 times, several times a day Kieran Hirpara 4.0 #### Resisted biceps curl (from about 4 months) Begin ONLY once Dr Hirpara or your therapist has cleared you to start loading (from about 4 months). With your palm facing up, hold a light weight and slowly curl it up towards your shoulder, then lower under control. Start very light and add resistance gradually over the following weeks. 10–15 times, building up gradually once cleared Kieran Hirpara 4.0 #### Resisted forearm rotation (from about 4 months) Begin ONLY once you have been cleared to start loading (from about 4 months). With your elbow tucked in, turn your palm up against the light resistance of a band or a light weight held at one end, then return under control. This rebuilds the twisting (supination) strength the biceps provides. Start light and progress gradually. 10–15 times, building up gradually once cleared These are the exercises from your handout for keeping your elbow, forearm and hand moving in the early weeks. Take the sling off to do them. Move only as far as is comfortable, and start them as guided by Dr Hirpara and your therapist. The two strengthening exercises are introduced later: only once you have been cleared to begin loading at around 4 months. ## Your clinical protocol The rest of this page is the clinical protocol for rehabilitation after a cortical-button distal biceps tendon repair. This section is to be provided to your physiotherapist or hand therapist, and each phase below opens with a plain-English explanation of what is happening. The guiding principle is early comfortable motion with delayed loading: the cortical-button construct is strong enough to permit unrestricted movement from day one, so there is no hinged brace and no extension block. The construct's strength is used to prevent stiffness, not to justify early loading; resisted strengthening and lifting are deliberately deferred to protect tendon-to-bone healing and minimise re-rupture. ### Phase I — Protected comfort motion (Week 0 → 6) A simple sling is worn for comfort and as a reminder against heavy use; it is removed for exercises and hygiene. The aim is to maintain comfortable, near-full range of motion while protecting the repair from any load. For your physiotherapist: - Immobilisation: Simple sling for 6 weeks, off for exercises and hygiene. No hinged brace; no extension block. - Range of motion: All motion as comfort allows from day 1: active and passive elbow flexion, extension and forearm rotation. No arc restriction and no extension block. - Goals: Maintain comfortable full range of motion; protect the repair from load; keep the hand, wrist and shoulder mobile. - Exercises: Active elbow flexion/extension to comfort; assisted (passive) elbow flexion; forearm pronation/supination active range with the elbow tucked at the side; hand, wrist and grip movement; scapular and shoulder range of motion. No resisted biceps or supination loading. - Precautions: No lifting, gripping or resisted strengthening; avoid sudden forced eccentric extension against load; avoid shoulder hyperextension. - Criteria to progress: Wound healed, comfortable near-full range of motion, out of the sling at 6 weeks. ### Phase II — Full motion, unloaded (Week 6 → ~4 months) The sling is discontinued. The arm is used freely for light everyday tasks, but without resisted loading or lifting: the tendon is still maturing onto bone, and this is the window where caution against load matters most even though motion is safe. For your physiotherapist: - Goals: Full symmetric pain-free range of motion; normal light functional use of the hand and arm. - Range of motion / use: Full motion as comfort allows; everyday light use without resisted loading or lifting. - Exercises: Continue range-of-motion work; hand, wrist and grip; scapular and shoulder conditioning. No resisted biceps or supination loading yet. - Criteria to progress: Full painless range of motion; wound and repair settled → begin graded loading at about 4 months. ### Phase III — Strengthening and graded loading (~4 → 6 months) Loading begins. Light resisted strengthening for elbow flexion and forearm supination is introduced and progressed gradually towards functional, then job- or sport-specific demands. For your physiotherapist: - Goals: Rebuild flexion and supination strength; return to work and sport. - Exercises: Start light resisted strengthening and lifting at about 4 months; progress gradually (isotonic curls and resisted supination → functional patterns → job- and sport-specific loading). - Criteria to progress: Pain-free resisted flexion and supination; strength approaching the other side. ## Getting back to work and activity In the first 6 weeks, expect to use the arm only for light, comfortable everyday tasks with the sling on for protection. Light desk-based or one-handed duties are often possible early; heavier or two-handed manual work waits until loading has begun and built up. The key milestones are: - No lifting and no resisted loading in the early months: this is deliberate, to let the tendon heal onto the bone. - Light lifting and strengthening from about 4 months, started gently and progressed week by week. - Return to non-contact sport from about 4 months; unrestricted (contact) sport at about 6 months, once the criteria are met: full painless range of motion, strength at least 90–100% of the other side, and tolerance of the specific demands of your job or sport. You must not drive while you are wearing the sling. Driving resumes once you are out of the sling and can comfortably and safely control the vehicle, as confirmed at your review. Always follow Dr Hirpara's specific advice, as timings can vary with the demands of your work and sport. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain and wound care. The phased plan above is consistent with published evidence on rehabilitation after distal biceps tendon repair, and your ongoing recovery is guided individually by your physiotherapist or hand therapist according to how your elbow progresses. --- ### Distal Clavicle Excision URL: https://www.cqupperlimb.com/education/rehabilitation/distal-clavicle-excision/ Region: rehabilitation · rehabilitation Rehabilitation after isolated arthroscopic distal clavicle excision; combined cases follow the rotator cuff repair protocol. This protocol guides your recovery after arthroscopic distal clavicle excision (also called AC joint excision, or the Mumford procedure) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. Each phase below opens with a plain-English explanation of what matters most, followed by the structured protocol written for your physiotherapist; bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. Your physiotherapist will progress you through the phases based on how your shoulder is recovering, not on the calendar. This protocol is for an isolated distal clavicle excision. If your operation also included a rotator cuff repair, follow the rotator cuff repair protocol instead, as the repaired tendon sets a slower pace. (Distal clavicle excision is also commonly combined with a subacromial decompression; the protocol below applies equally in that case.) If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect Distal clavicle excision removes a few millimetres of bone from the end of the collarbone, so the worn surfaces of the AC joint (the small joint on top of your shoulder) no longer grind against each other. Nothing is repaired that needs protecting while it heals, so rehabilitation moves quickly: the sling is for comfort only and most people are out of it within the first week or two, movement starts straight away, and the published protocols for this operation all push towards early motion rather than rest. Two things are specific to this operation and shape the protocol: - Reaching across your body is the slow mover. Cross-body (horizontal adduction) movements compress the area where the bone was removed, so they are often the last movements to feel comfortable. Early on they are deliberately avoided, then reintroduced gradually. - Heavy pressing comes last. Exercises that load the AC joint hard (bench press, dips and push-ups) are the final things to return, typically over three to four months. Most other activities come back well before that. The journey at a glance: - Phase I — Early recovery and movement — week 0–2 - Phase II — Restoring your range — week 2–6 - Phase III — Strengthening and return to activity — week 6–12 - Phase IV — Return to full activity — week 12 onwards Most people are using the arm for light everyday tasks within the first couple of weeks, back to most normal activities by four to six weeks, and back to sport and heavier work somewhere between eight and twelve weeks. Athletes in repetitive overhead sports (throwing, swimming, tennis) typically take a little longer, in the range of two to four months. ## Phase I — Early recovery and movement (Week 0–2) Kieran Hirpara 4.0 #### Pendulum exercise Bend forward at the waist and let the operated arm hang gently away from the body. Let the arm swing in small, relaxed circles — the movement comes from your body, not the shoulder muscles. Start from day one and stay within comfort. Home program 3–5 times daily Kieran Hirpara 4.0 #### Pulley-assisted elevation Sit beneath an over-door pulley holding a handle in each hand. Pull down with the good arm to raise the operated arm upwards, letting it stay relaxed, then lower it back with control. Work within comfort and progress the height as tolerated. Home program 3–5 times daily Kieran Hirpara 4.0 #### Wand-assisted external rotation Lie on your back holding a stick or cane in both hands with the elbows bent to right angles and tucked at your sides. Use the good arm to push the operated forearm gently outward, away from the body, then return. The operated arm stays relaxed and lets the stick do the work. Home program 3–5 times daily Kieran Hirpara 4.0 #### Behind-the-back internal rotation Hold a stick or cane behind your back, with the operated hand low and the good hand above. Use the good arm to draw the operated hand gently up the back, then lower. Move within comfort — this direction returns gradually. Home program 3–5 times daily Kieran Hirpara 4.0 #### Grip strengthening Make a full fist, then open the fingers out straight. A soft ball or rolled-up sock can be squeezed for grip work. Keep the elbow, wrist and hand moving from day one. As guided by your physiotherapist Kieran Hirpara 4.0 #### Elbow bends With the upper arm resting by your side, bend the elbow as far as it comfortably goes, then straighten it fully. Only the elbow moves — keep the shoulder relaxed. Keep the elbow, forearm, wrist and hand moving from day one. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wrist movement Keep your wrist moving by bending it forwards, backwards and side to side, with the arm out of the sling. Keeping the whole arm working from day one helps the shoulder settle. As guided by your physiotherapist Kieran Hirpara 4.0 #### Forearm rotation With the elbow tucked at your side and bent to a right angle, turn the palm up towards the ceiling and then down towards the floor. Keep the forearm moving from day one while the shoulder rests. As guided by your physiotherapist Kieran Hirpara 4.0 #### Assisted forward elevation (lying) Lie on your back and use your good arm to help lift the operated arm up overhead as a gentle stretch, then lower it back down with the good arm still helping. Lying down lets gravity assist and the shoulder muscles stay relaxed. Work within comfort. Home program 3–5 times daily Kieran Hirpara 4.0 #### Isometric external rotation Stand with your elbow tucked at your side and bent to a right angle, the back of your hand against a wall or doorframe. Gently press outwards into it without letting the arm move, hold a few seconds, then relax. This is a gentle isometric only — there should be no movement and no strain. Stay within comfort. As guided by your physiotherapist Kieran Hirpara 4.0 #### Scapular setting Sitting or standing tall, gently draw your shoulder blades back together and down, away from your ears. Hold for a few seconds, then relax. Good shoulder-blade rhythm from the start makes the rest of the program work better. As guided by your physiotherapist The first two weeks are about settling pain and swelling while getting the shoulder moving. Use ice regularly: three to four times a day is typical in the first week or two. The sling is for comfort only: wear it as much or as little as it helps, take the arm out often, and stop using it as soon as you are comfortable without it. Many people find it most useful when out of the house, to stop people bumping the arm. Do not drive for at least six weeks after any shoulder operation, even once the sling is gone; your surgeon will clear you to drive, typically at the six-week review. Start moving straight away: your elbow, wrist and hand should be moving from day one, along with gentle pendulum exercises and assisted shoulder movements (using your other arm, a stick or a pulley to help the operated arm upwards and outwards). Take your painkillers before your exercises and before physiotherapy appointments. The one movement to leave alone for now is reaching across your body towards the opposite shoulder. For your physiotherapist: Goals - Settle pain and swelling - Early range of motion: approximately 140° of forward flexion and 40° of external rotation at the side by the end of the phase - Independence with the home exercise program Management - Sling for comfort only: wean and discontinue within the first 1–2 weeks, as comfort allows - Cryotherapy 3–4 times daily, especially after exercise - Immediate active range of motion of the neck, elbow, forearm, wrist and hand - Pendulum exercises from day one - Passive and active-assisted shoulder range of motion as tolerated: forward elevation, external rotation and behind-the-back internal rotation, using pulleys, a wand or cane, and supine gravity-assisted positions - Scapular setting and periscapular range of motion; attention to scapulohumeral rhythm from the start - Grip strengthening; gentle shoulder isometrics as pain allows - Analgesia before exercises and physiotherapy sessions - Home program performed 3–5 times daily Precautions - Avoid cross-body (horizontal) adduction - No resisted shoulder exercise beyond gentle isometrics - No lifting beyond light everyday items; no weight-bearing through the arm (pushing up from a chair or bed) - No driving for six weeks (this applies to any shoulder operation) Criteria to progress - Sling discarded and pain settling - Comfortable assisted elevation to approximately 140° and external rotation to approximately 40° ## Phase II — Restoring your range (Week 2–6) Kieran Hirpara 4.0 #### Cross-body stretch Bring the operated arm across your chest and use the other hand, placed above the elbow, to draw it gently further across. Reintroduce this gradually, guided by symptoms — some pinching awareness at the end of the movement is common after this operation and settles with time. As guided by your physiotherapist Kieran Hirpara 4.0 #### Sleeper stretch Lie on your operated side with that arm out in front and the elbow bent to a right angle. Use your good hand to gently press the forearm down towards the bed, until you feel a stretch at the back of the shoulder, then ease off. This gentle posterior stretch helps restore reaching behind the back. Stretch to firm discomfort, not sharp pain. As guided by your physiotherapist Kieran Hirpara 4.0 #### Band external rotation Stand with your elbow tucked into your side and bent to a right angle, holding an elastic band anchored to one side. Keeping the elbow at your side, rotate the forearm outwards against the band, then return slowly. Begin once your movement is close to full — work high repetitions with light resistance. High repetitions, low load; as guided by your physiotherapist Kieran Hirpara 4.0 #### Low row Hold a band anchored in front of you at about waist height. Keeping the arm fairly straight, pull it back and down towards your hip, squeezing the shoulder blade down and back, then return slowly. This builds the shoulder-blade muscles that steady the shoulder as your strength returns. High repetitions, low load; as guided by your physiotherapist Kieran Hirpara 4.0 #### External rotation at 90/90 (lying) Lie on your back with the arm out to the side at shoulder height and the elbow bent to a right angle, supported on a pillow. Slowly rotate the forearm back towards the head as far as is comfortable, then return with control. This restores rotation in the raised position. 10 times, as guided by your physiotherapist Kieran Hirpara 4.0 #### Hand-behind-back reach Standing, place the back of your operated hand against your lower back and gently slide it up your spine as far as is comfortable using your own muscles, then lower. Move only within a comfortable range and never force it. As guided by your physiotherapist With the sling gone, this phase works the shoulder towards full movement in all directions: assisted movements first, then under the arm's own power. Once your movement is close to full, gentle strengthening of the rotator cuff and shoulder blade muscles begins with elastic bands and light weights. Use the arm normally for daily activities, but keep lifting modest (no more than about 5 kg) and hold off on anything that presses or loads the arm hard. Reaching across your body is reintroduced gradually during this phase as comfort allows; some pinching awareness at the end of that movement is common and settles with time. Many people find heat before stretching and ice afterwards helpful, and lighter lower-body exercise such as walking, an exercise bike or jogging typically resumes from about week four. For your physiotherapist: Goals - Full, or near-full, active range of motion in all planes by the end of the phase - Normalised scapulohumeral kinematics - Commence rotator cuff and periscapular strengthening once active range is near full Management - Progress passive and active-assisted range of motion to active range in all planes: flexion and scapular-plane elevation towards full, external rotation at the side and at 90° of abduction as tolerated, internal rotation behind the back with gentle posterior capsular stretching - Reintroduce cross-body adduction range gradually, guided by symptoms - Manual therapy and glenohumeral mobilisation as indicated - Progress from isometrics to elastic-band rotator cuff and scapular stabiliser strengthening once active range of motion is near full: high repetitions, low load - Heat before and ice after sessions as preferred; analgesia before exercises - Graduated return to normal daily activities; light lower-body conditioning (walking, stationary bike, jogging) from approximately week 4 Precautions - Keep lifting light: approximately 5 kg or less on the operated side - Avoid loaded end-range horizontal adduction and positions of impingement - No pressing exercises: bench press, dips, push-ups - Defer combined abduction–rotation (90/90) stretching if the shoulder is irritable Criteria to progress - Full or near-full active range of motion without significant discomfort - Band strengthening tolerated without flare-up of pain ## Phase III — Strengthening and return to activity (Week 6–12) Kieran Hirpara 4.0 #### Side-lying external rotation with weight Lie on your non-operated side with the top elbow bent to a right angle and tucked against your body. Holding a light weight, rotate the forearm up towards the ceiling, then lower slowly. This progresses your rotator cuff strengthening from bands to dumbbells. 2–3 sets of 8–15 repetitions, low load Kieran Hirpara 4.0 #### Side-lying internal rotation with weight Lie on your operated side with that elbow bent to a right angle and tucked against your body. Holding a light weight, lift the forearm up towards your body, then lower slowly. This balances the rotator cuff strengthening with the outward-rotation work. 2–3 sets of 8–15 repetitions, low load Kieran Hirpara 4.0 #### Full-can scaption Stand holding a light weight in each hand, arms slightly out in front of you at about a 30-degree angle with the thumbs pointing up. Raise the arms to shoulder height, then lower slowly. This strengthens the deltoid and rotator cuff together through a comfortable mid-range. 2–3 sets of 8–15 repetitions, low load Kieran Hirpara 4.0 #### Prone W Lie face down with your arms by your sides. Draw your elbows back and down towards your hips, making a W shape, while squeezing your shoulder blades together, then lower slowly. This strengthens the lower shoulder-blade muscles that support good shoulder mechanics. 2–3 sets of 8–15 repetitions Kieran Hirpara 4.0 #### Standing row Hold a band or light weight in front of you and pull it back towards your body, drawing the elbow behind you and squeezing the shoulder blade in, then return slowly. This builds the mid-back and shoulder-blade strength that supports your shoulder as you return to activity. 2–3 sets of 8–15 repetitions Kieran Hirpara 4.0 #### External rotation with the arm raised With your arm out to the side at shoulder height and your elbow bent to 90°, rotate your forearm upwards and back, then return with control. Keep the movement smooth and within a comfortable range. This trains outward rotation in the raised position. As guided by your physiotherapist — light and controlled With full movement back, attention turns to rebuilding strength and getting you back to what you do. Resistance work progresses from bands to dumbbells for the rotator cuff, deltoid and shoulder blade muscles, and exercise becomes more functional: gym work, swimming, a graduated throwing program for throwers, and a staged return to work duties and sport. Most people return to sport and heavier work during this phase, between roughly eight and twelve weeks, guided by comfort and strength rather than the calendar. The pressing exercises that load the AC joint most (bench press, dips and push-ups) are the last to be reintroduced, starting light and shallow. For your physiotherapist: Goals - Restore strength, endurance and neuromuscular control of the shoulder girdle - Graduated return to work duties, recreational activity and sport-specific training Management - Progressive resistance for the rotator cuff, deltoid and scapular stabilisers: bands to light dumbbells, typically 2–3 sets of 8–15 repetitions - Add eccentric work, closed-chain exercise and, late in the phase, plyometric drills where relevant to the patient's sport - Functional and sport-specific training: swimming, interval throwing program for throwers, sport drills under controlled conditions - Graduated return to full work duties and sport, criteria-based Precautions - Reintroduce AC-loading presses (bench press, dips, push-ups) last: begin light, with reduced range, and avoid the elbows dropping below or behind the line of the body - Progression remains symptom-guided: an irritable AC joint settles with a short step back in load, not by pushing through Criteria to progress - Full, pain-free functional range of motion - No pain or tenderness over the operated area with loading - Strength approaching the other side on testing ## Phase IV — Return to full activity (Week 12 onwards) Kieran Hirpara 4.0 #### Push-up plus This is part of the staged return to pressing, so it comes last. Begin against a wall or from the knees with a shallow range, keeping the elbows from travelling behind the line of your body. At the top of each push-up, press a little further to round the upper back, then lower with control. Progress depth and load only as the AC joint stays comfortable — a return of aching over the area means easing back. As guided by your physiotherapist The final phase is the return to unrestricted activity. Day-to-day life and most sport are usually back well before this point; what remains is the heaviest end of loading. Pressing strength in the gym is rebuilt progressively, and returning to previous bench press performance can take up to about four months. Athletes in repetitive overhead sports are progressed back over roughly two to four months from surgery. Full return to sport and heavy work is confirmed at your follow-up review, based on full movement, comfortable loading and a satisfactory examination. For your physiotherapist: Goals - Unrestricted return to work, gym and sport - Maintain shoulder girdle strength and mechanics in the long term Management - Advance gym- and sport-specific conditioning as tolerated, including progressive heavy pressing with attention to technique that limits AC joint strain (controlled depth, elbows not travelling behind the body line) - Complete interval throwing and overhead-sport progressions where relevant Precautions - Progression remains symptom-guided: recurrent aching over the AC area with a particular lift is a signal to adjust load or technique before progressing ## After your protocol The phases above are adapted from published rehabilitation protocols for distal clavicle excision (Saint Louis University Department of Orthopaedic Surgery, University of Utah Sports Medicine, Sports Surgery New York, Palm Beach Orthopaedic Institute, OrthoVirginia and Specialty Physicians of Illinois), with the week ranges expressed as typical rather than fixed. Your rehabilitation is guided individually by your physiotherapist, working with the practice, based on how your shoulder recovers. This page works alongside the practice's general recovery advice; see managing post-operative pain and wound care. For the operation itself, see distal clavicle excision. The clinical evidence behind this operation and its rehabilitation (including the open-versus-arthroscopic comparison, how much bone is removed and why, and the published protocols this page draws on) is summarised with full references in the evidence section, available as a PDF from the top of this page. --- ### Distal Radius Fracture (ORIF) URL: https://www.cqupperlimb.com/education/rehabilitation/distal-radius-orif/ Region: rehabilitation · rehabilitation Staged rehabilitation after plate fixation of a distal radius fracture, from the first days to return to full activity. This protocol guides your recovery after surgical fixation of a distal radius (wrist) fracture (open reduction and internal fixation, ORIF) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your physiotherapist or hand therapist: bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect For wound, swelling and scar management, see the practice's wound care guidance. Following your surgery, you may be referred to a hand therapist for fabrication of a thermoplastic splint. In this situation, the splint will be worn temporarily for comfort and protection, and you will still be required to remove the splint for your home exercise program. If you are referred for a splint, you will receive more information regarding wear and care. The exercises below are essential for regaining range of motion of your fingers, wrist and forearm. Heat and ice are good modalities often used for regaining movement, restoring function and improving comfort. Once the wound is healed, you may apply heat prior to exercises; an ice pack may be used afterwards to prevent or settle inflammation. Scar management (particularly massage) is very important after distal radius surgery, so that the tendons running beneath the incision keep gliding freely and do not become stuck down (adherent) to the healing scar. A volar locking plate is designed to hold the fracture firmly enough for movement to begin early, and this protocol is built around that. Research comparing early wrist movement with several weeks of immobilisation after volar plate fixation shows that starting motion early can improve short-term movement, grip and comfort without compromising the position of the fracture [1][2]. At the same time, trials comparing wrist motion started at about two weeks with motion started at about six weeks found the two groups were similar by three to six months [3], so while there is an early benefit, there is no need to rush, and the steady progression set out below is well supported. Bone healing follows its own timeline regardless of how the wrist feels, which is why the later precautions (no weight-bearing, heavy lifting or contact sport until 12 weeks after the fracture) are kept even once movement is comfortable. ## Precautions and limitations Light functional use of your hand is encouraged for daily living tasks such as self-care, feeding, dressing, writing and typing. It is important to protect the wrist from lifting, gripping and impact in the early weeks, and to avoid weight-bearing through the arm, heavy lifting and contact sport until 12 weeks after your fracture. Gentle strengthening is introduced gradually from about week 4, starting with light finger work and isometric wrist exercises, and is built up carefully so that it does not undo this early protection. These are the exercises from your handout, for regaining movement of your fingers, wrist and forearm. If you have a splint, remove it for your exercises. Start them as guided by Dr Hirpara and your therapist. ## Your exercises Kieran Hirpara 4.0 #### Wrist flexion / extension Rest your elbow on a table and gently rock your wrist back and forth (or rest it over the edge of a table or armchair, as pictured). Once more comfortable, use your other hand on the palm to push the wrist backwards (fingers pointing to the ceiling), then the other way (fingers pointing to the floor), keeping the fingers loose. Hold each stretch for 15 seconds. 10 times each direction, 4 times daily Kieran Hirpara 4.0 #### Forearm rotation (pronation / supination) With your elbow by your side and your forearm in a neutral position (thumb up), gently rotate your palm up towards the ceiling (supination), hold for 3–5 seconds, then return to neutral. Repeat palm down towards the floor (pronation). Don't let your elbow come away from your body. You may assist the movement with your other hand, held at wrist level. 10 times each direction, 4 times daily Kieran Hirpara 4.0 #### Ulnar / radial deviation Place your hand and forearm on a flat surface. Keeping your forearm still, gently move your wrist and hand from side to side (as pictured). 10 times, 4 times daily Kieran Hirpara 4.0 #### Six pack hand exercises With your hand in front of you and your wrist straight, work through the six positions shown: straight fingers; “tabletop” (bend at the bottom knuckles, fingers straight); “hook” (bend the fingertips, knuckles up); tight fist with the thumb over the fingers; fingers spread then back together; and thumb to each fingertip, from index to little finger. 5–10 of each, 2–3 times a day; progress as tolerated Start the exercises below only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. Because the fracture is held by a plate, the wrist can start moving early rather than waiting for the bone to unite. Wrist bending, forearm rotation and side-to-side movement keep the joint from stiffening, and the six-pack hand exercises keep the fingers, thumb and knuckles moving — stiff fingers are a far more common problem after this operation than a problem with the bone. Do them little and often. Stop anything that causes sharp pain at the fracture site. ## Your clinical protocol The rest of this page is the accelerated clinical protocol for a distal radius fracture treated with open reduction and internal fixation with a volar plate. This section is to be provided to your physiotherapist or hand therapist, and each phase below opens with a plain-English explanation of what is happening. ## Days 1–4 after your operation In the first few days the focus is on protecting the fixation, settling swelling, and keeping your fingers, wrist, forearm, elbow and shoulder moving. Your surgical bandage stays in place until day 3, when it is reduced and the wound is redressed. Keep the hand elevated when resting, use it for light everyday tasks (under 1–2 kg) within comfortable limits, and avoid weight-bearing through the arm, tight gripping or lifting. A splint is not routinely needed, but one can be arranged if you are returning to work or the wrist is more painful. For your physiotherapist: Prior to treatment, check the patient's x-ray, operation report and past medical history (PMHx), and liaise with the treating surgeon regarding the stability of the fixation of the fracture and the likely prognosis. Education and precautions - Avoid weight-bearing through the arm, tight gripping or lifting - Encourage use of the affected hand for light (less than 1–2 kg) activities of daily living (ADL) tasks within pain limits and normal movement patterns Management - Splint: nil required, but may be utilised if the patient is returning to work or in the presence of increased pain; consider a thermoplastic splint or off-the-shelf support - Wound: surgical dressings/bandage to be left intact until day 3; debulk bandage and redress wound from day 3 post-operation; education regarding wound management - Oedema: provide education regarding elevation; provide compression therapy and retrograde massage as required - Exercises: provide active six pack exercises to maintain finger range of motion (ROM); provide active wrist, forearm and finger range of motion exercises; encourage regular active elbow and shoulder ROM ## Week 2–4 after your operation Your sutures come out at day 10–14, and scar massage begins once the wound has healed enough. The exercise program continues (the six pack exercises stop once your fingers regain full movement) and gentle muscle-activation (isometric) wrist strengthening starts. During this phase the wrist should still move only under its own muscle power: no one, including you, should push or stretch it passively yet, as the fracture is still uniting. Keep avoiding weight-bearing, tight gripping and lifting; light everyday tasks under 1–2 kg are encouraged. You must not drive while your wrist is in a splint; driving resumes once you are out of the splint, as confirmed at your review. For your physiotherapist: Assessments - Self-reported assessments: Patient-Rated Wrist Evaluation (PRWE), Disabilities of the Arm, Shoulder and Hand (DASH) - Oedema circumferential measurements - Visual analogue pain scale (VAS) or numerical rating scale - Active range of motion (AROM) goniometry measurements: hand, wrist - Subjective review, including the patient's compliance with the regime, functional use of the hand in ADL tasks, and problems/concerns Education and precautions - Avoid weight-bearing through the arm, tight gripping or lifting - No passive wrist movement - Encourage use of the affected hand for light (less than 1–2 kg) ADL tasks within pain limits and normal movement patterns - No driving while in a splint; driving resumes once out of the splint, confirmed at review Management - Wound/scar: removal of sutures at day 10–14; commence scar management as appropriate, dependent on healing progress - Oedema: consider use of compression bandaging, retrograde massage, manual oedema mobilisation (MEM), contrast bathing and/or elevation if required - Exercises: cease active six pack exercises once full finger range achieved; consider passive finger and thumb exercises, including place/hold, if active ROM not full in the hand; continue active wrist ROM exercises; encourage regular active elbow and shoulder ROM; commence wrist isometric strengthening Troubleshooting - Monitor for signs of wound infection, sensory changes in the hand, or early signs of complex regional pain syndrome (CRPS) - Identify aberrant movement patterns and intervene as required ## Week 4–6 after your operation Strengthening starts gently in this phase: low-resistance finger strengthening from week 4, while the isometric wrist work continues and is gradually upgraded. If your x-ray is satisfactory and the fixation is stable, gentle passive wrist stretches (where the wrist is moved with help from your other hand or your therapist) can begin at 4–6 weeks. Restoring movement still takes priority over building strength. Keep avoiding weight-bearing through the arm and heavy lifting, while continuing to use the hand for light everyday tasks. For your physiotherapist: Assessments - Oedema circumferential measurements - Visual analogue pain scale or numerical rating scale - AROM goniometry measurements and quality of movement patterns - Subjective review, including the patient's compliance with the regime, functional use of the hand in ADL tasks, and problems/concerns - Grip strength using dynamometer (3 each limb) Education and precautions - Avoid weight-bearing through the arm, or heavy lifting - Encourage use of the affected hand for light (less than 1–2 kg) ADL tasks within pain limits and normal movement patterns Management - Scar: continue scar management as required - Oedema: continue compression therapy, retrograde massage, MEM and elevation as required; discontinue contrast bathing - Exercises: continue passive finger and thumb exercises if ROM not full; continue active wrist ROM exercises; commence finger strengthening exercises against low resistance at 4 weeks; commence gentle passive wrist exercises at 4–6 weeks if the ORIF is stable and the x-ray satisfactory; encourage regular active elbow and shoulder ROM; continue/upgrade isometric wrist strengthening exercises Troubleshooting - Review for signs of CRPS and shoulder pain - Consider the volume of exercises in the home programme and prioritise ROM over strength - If wrist ROM is significantly limited, consider commencing gentle passive range of motion (PROM) wrist exercises within 4/10 VAS, with the surgeon's approval ## Week 6–8 after your operation This phase begins a graded return to full activity over the next 3 weeks. Wrist strengthening steps up to light weights (0.5–1.0 kg) or low-resistance theraband, and the resistance for finger strengthening increases. Three hard limits remain: no weight-bearing, heavy lifting or contact sport until 12 weeks after the fracture. Your therapist will consider discharging you once you have full movement and a suitable return of function. For your physiotherapist: Assessments - Oedema circumferential measurements as required - Visual analogue pain scale or numerical rating scale - AROM goniometry measurements - Grip strength - Subjective review Education and precautions - Graded return to full activity over the next 3 weeks - Avoid weight-bearing, heavy lifting and contact sport until 12 weeks post fracture Management - Scar: continue scar management as required - Oedema: continue oedema management as required - Exercises: continue passive finger and thumb exercises if ROM not full; continue active and passive wrist ROM exercises if required; increase resistance in finger strengthening exercises; commence wrist strengthening exercises with use of 0.5–1.0 kg weights or low-resistance theraband; upgrade weights and resistance used in the wrist strengthening programme as tolerated Troubleshooting - Consider/commence night serial progressive splinting, boxing glove or dynamic splinting if slow improvement of ROM - Monitor any signs of wrist instability and treat as appropriate - Consider discharge when full ROM and suitable return of function - Consider referral back to the treating doctor if the condition plateaus and/or there is a poor outcome This protocol was written in association with Sarah Farrell, BOccThy AHT, and Kristy Gerlach, BOccThy AHT. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain, wound care and hand therapy basics. For the operation itself and the injury it treats, see distal radius fixation (ORIF) and distal radius fracture. The phased plan above is consistent with published evidence on rehabilitation after volar locking plate fixation, and your ongoing recovery is guided individually by your physiotherapist or hand therapist according to how your wrist progresses. --- ### Distal Triceps Tendon Repair URL: https://www.cqupperlimb.com/education/rehabilitation/distal-triceps-repair/ Region: rehabilitation · rehabilitation A protected recovery plan after repair of the distal triceps tendon at the elbow, resting the arm in a simple sling at 90 degrees and freeing movement, then active straightening, then strength in careful stages. This protocol guides your recovery after surgical repair of the distal triceps tendon (the tendon that anchors the triceps muscle, which straightens your elbow, to the point of the elbow), with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your physiotherapist or hand therapist; bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect A distal triceps repair re-attaches the torn tendon back onto the bone at the point of the elbow (the olecranon). At the end of the operation, Dr Hirpara checks that the repair is safe and intact with the elbow bent to a right angle (90°). Because of that, your elbow is rested in a simple sling at about 90°, a comfortable, standard position. There is no hinged brace, and the elbow is not held out near straight. The sling comes off for your exercises and for washing. The tendon is loaded (put under strain) in two ways, and the early plan is built around protecting against both: - Bending the elbow stretches the repair. So for about the first six weeks, bending is capped at 90° (a right angle). Straightening, on the other hand, relaxes the tendon, so straightening out fully is free and encouraged within comfort. - Actively straightening the elbow works the triceps, which pulls on the repair. So for about the first six weeks you do not actively straighten the elbow under its own power; movement in that direction is done gently and with help, not by the triceps itself. Movement is then opened up in careful stages: fuller bending from about six weeks, active straightening from about six weeks, and resisted (loaded) strengthening from about twelve weeks. The repair keeps maturing for several months, which is why heavier loading and return to sport are built back gradually rather than all at once. ## Precautions and limitations - Do NOT bend your elbow past a right angle (90°) for about the first six weeks, as bending stretches and strains the repair. Straightening out fully is fine and encouraged. - Do NOT actively straighten the elbow under its own muscle power for about the first six weeks; let it be straightened gently with help, not by working the triceps. - Do NOT do any resisted straightening or push/press through the arm until about twelve weeks: no triceps kickbacks, no bench or overhead press, and no pushing up from a chair or bed with the operated arm. - Wear your sling at 90° as directed (not a brace, not held straight), and do NOT drive while you are in it or while your arm cannot safely control the wheel. - Keep your hand, wrist and shoulder moving from the start, and use the hand for light everyday tasks within comfort, as long as it does not involve pushing, lifting or forced bending of the elbow. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### Protected elbow movement (0–90° arc) Out of the sling, gently move the elbow within its safe range: you may straighten it fully (extension is free, to comfort), but do NOT bend it past a right angle (90°) — about as far as holding a phone to your ear. Move slowly and stay within that arc. Bending past 90° pulls on the healing tendon, so it is held back for about the first six weeks. 10 times, 2–3 times a day, within the 0–90° arc Kieran Hirpara 4.0 #### Assisted (passive) elbow bend Use your other hand to gently bend the operated elbow up towards your shoulder, keeping the triceps completely relaxed — you are not pulling with the operated arm. Stop at your set limit (about 90° early on). This keeps the elbow supple without working the triceps. 10 times, 2–3 times a day, to your set limit only Kieran Hirpara 4.0 #### Forearm rotation (palm up / palm down) With your elbow tucked at your side and bent comfortably, gently turn your palm up towards the ceiling, then down towards the floor. Keep it slow and easy. This keeps the forearm supple and does not load the triceps repair, so it can begin early. 10 times each direction, 2–3 times a day Kieran Hirpara 4.0 #### Triceps muscle-set (gentle, no movement) A LATER exercise — only once your physiotherapist starts it (commonly from around 8 weeks). With the elbow supported, gently tighten the muscle on the BACK of your upper arm (the triceps) as if to straighten the elbow, but WITHOUT letting it actually move — a light press, hold, then relax. Do not do this in the first six weeks. Hold ~5 seconds, 5–10 times, as guided (later phase) Kieran Hirpara 4.0 #### Active elbow straightening (no resistance) A LATER exercise — begins from around 6 weeks, once cleared. Gently straighten the elbow under its own power with NO weight in the hand, then use your other hand to help lower it back down (so the triceps does not have to control the downward phase yet). Stay pain-free. There is NO active straightening in the first six weeks. 10 times, as guided (from ~6 weeks, no resistance) Kieran Hirpara 4.0 #### Triceps muscle-set against light hold (isometric extension) A LATER exercise — from around 8 weeks, as guided. Press the forearm gently against your other hand or a fixed surface as if to straighten the elbow, building the effort up only to a light, comfortable level, holding without the elbow moving. This wakes the triceps up before resisted work is allowed. Hold ~5 seconds, 5–10 times, as guided (later phase) Kieran Hirpara 4.0 #### Resisted elbow straightening with a band (late strengthening) A LATE exercise — only once resisted work is cleared, commonly from around 12 weeks. Straighten the elbow against a light resistance band, then control it slowly back. Build the resistance up gradually over several weeks. This directly loads the repaired tendon, so it is the last thing to start — never rush it, and stop if it is painful. As guided by your physiotherapist (from ~12 weeks only) These are the exercises from your handout. Start them only as guided by Dr Hirpara and your physiotherapist, staying within whatever range and limits you have been given. The early exercises keep the elbow and forearm moving without working or stretching the repair: gentle movement within the protected 0–90° arc, assisted bending, and forearm rotation. The triceps muscle-sets, active straightening and band work belong to later phases and should not be started until you are specifically cleared. Stop anything that causes sharp pain at the back of the elbow. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after distal triceps tendon repair. This section is to be provided to your physiotherapist or hand therapist, and each phase opens with a plain-English explanation of what is happening. The repair is loaded by elbow flexion (which stretches it) and by active or resisted extension (which contracts the triceps onto it), so the protocol protects both while restoring motion, then active extension, then resisted strength. Prior to treatment, check the patient's operation report and past medical history, and liaise with the treating surgeon regarding the fixation (transosseous tunnels vs suture-anchor footprint), tissue quality, and the protected arc. Dr Hirpara's repair is checked intra-operatively to be safe at 90° of flexion and is rested in a simple sling at 90° (no hinged brace, not held in extension); the protected arc is 0–90° with extension free to comfort and flexion capped at 90°. ### Phase I — protected motion in a 90° sling (weeks 0 to 6) The first six weeks protect the repair while keeping the elbow from stiffening. The arm rests in a simple sling at 90°, off for exercises and hygiene. The elbow moves only within the protected 0–90° arc, straightening out fully to comfort but not bending past a right angle, and never under active triceps power. For your physiotherapist: Education and precautions - Immobilise in a simple sling at 90° (no hinged brace, NOT held near extension); off for exercises and washing - Protected arc 0–90° only: extension free to full/comfort; flexion not past 90° - No active or resisted elbow extension (active triceps contraction loads the repair) - No weight-bearing or pushing through the operated arm; light unloaded hand use within comfort - Keep shoulder PROM gentle early (protects the long head crossing the shoulder) Management - Wound: surgical dressings as directed; monitor for infection - Oedema: elevation, gentle hand pump, ice as needed - Exercises: AAROM/PROM elbow within 0–90° (extension to comfort, flexion capped at 90°); active wrist, hand and grip ROM; gentle shoulder ROM; gentle forearm rotation; no active extension Criteria to progress - Wound healed; comfortable, controlled 0–90° arc at around six weeks ### Phase II — advancing flexion and starting active extension (weeks 6 to 12) From about six weeks the flexion cap is released and bending is progressed past 90° towards full. Active straightening (extension) is introduced without resistance, and the triceps is gently re-activated with isometrics. Resisted extension and weight-bearing are still withheld. For your physiotherapist: Assessments - Active and passive range of motion (flexion now progressing past 90°, extension); pain and swelling; wound/scar review Education and precautions - Progress flexion past 90° toward full gradually from around six weeks - No resisted extension and no weight-bearing through the arm until 12 weeks Management - Exercises: weeks 6–8 begin active concentric extension with NO resistance, pain-free range (assist the lowering/eccentric phase with the other arm); week 8 light submaximal triceps isometrics; continue full-arc mobility and forearm rotation; commence scar management once healed Criteria to progress - Full painless ROM; full active extension with good control; pain ≤3/10 ### Phase III — strengthening and return (weeks 12 to 16 and beyond) Once movement is restored and resisted work is cleared (around twelve weeks), strengthening begins and is built up gradually: resisted triceps work (concentric then eccentric), then light closed-chain weight-bearing, then limited-range pressing. Return to sport is criterion-based, at the earliest around five to six months. For your physiotherapist: Assessments - Triceps strength versus the other side; pain/swelling response to loading; functional and sport-/work-specific testing as appropriate Education and precautions - Begin resisted triceps strengthening (concentric → eccentric) from around 12 weeks; build load gradually - Closed-chain weight-bearing from around 12 weeks (start light, small range); light pressing (push-ups, limited range) from around 14 weeks Management - Exercises: progressive resisted elbow extension (band → light weights); graded closed-chain loading; limited-range pressing; continue any residual mobility work - Consider discharge once strength is near-symmetrical and a suitable return of function is achieved - Consider referral back to the treating doctor if recovery plateaus or there is a poor outcome Criteria for return to sport - 5/5 triceps strength; pain-free high-velocity and sport-specific control ## Getting back to work and activity Light everyday hand use (eating, writing and light self-care) is encouraged from the start, within comfort, as long as it does not involve pushing, lifting or bending the elbow past its limit. Because you must not drive while the arm is in the sling or unable to safely control the wheel, plan for help with transport in the early weeks; driving resumes once you are out of the sling and can control the car, as confirmed at your review. Resisted loading and weight-bearing through the arm (pushing, pressing, lifting and pulling) waits until about twelve weeks, and are then built up gradually. Return to sport is at the earliest around five to six months, and is based on regaining full pain-free movement and adequate, symmetrical triceps strength, judged by Dr Hirpara and your physiotherapist, not by the calendar alone. Heavier manual work follows the same criterion-based progression. ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain, wound care and returning to sport. The phased plan above reflects published rehabilitation guidance after distal triceps tendon repair, and your ongoing recovery is guided individually by Dr Hirpara and your physiotherapist according to how your elbow progresses. --- ### DRUJ Hemiresection Arthroplasty URL: https://www.cqupperlimb.com/education/rehabilitation/druj-hemiresection/ Region: rehabilitation · rehabilitation A recovery plan after hemiresection-interposition arthroplasty of the distal radioulnar joint, where the worn part of the ulnar head is partially removed to restore pain-free forearm rotation; after a brief period of protection, early forearm rotation (turning the palm up and… This protocol guides your recovery after hemiresection-interposition arthroplasty of the distal radioulnar joint (DRUJ), an operation that reshapes the worn end of the forearm to restore comfortable, pain-free rotation of the forearm, with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist; bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect The distal radioulnar joint (DRUJ) is the small joint near your wrist on the little-finger side where the two forearm bones (the radius and the ulna) meet. It is the joint that lets you turn your forearm over, palm up (supination) and palm down (pronation). When this joint wears out and becomes arthritic, turning the forearm becomes painful. In a hemiresection arthroplasty, only the worn, arthritic part of the head of the ulna is shaved away (a partial removal: "hemi" means half), and a small cushion of your own soft tissue is tucked into the gap to keep the surfaces from rubbing. This operation preserves the key stabilising structures, including the TFCC (the cartilage and ligament hammock that supports the wrist on that side), the ulnar styloid, and the soft-tissue attachments, so the end of the ulna stays supported. This is what makes it different from a complete removal of the ulnar head (a Darrach procedure). Because the joint surfaces are reshaped rather than repaired or reconstructed, there is no tendon or ligament that has to heal under protection for months. The goal of this operation is pain-free forearm rotation, and the most important part of your rehabilitation is getting that rotation moving early. After a brief period of protection in a splint to let the soft tissues settle, restoring the turn of the forearm (palm up and palm down) becomes the headline of your recovery. Strength and heavier loading are added gradually afterwards. ## Precautions and limitations - For about the first two to three weeks, wear your splint as directed; it gently limits forearm rotation while the interposition tissue settles. Keep your fingers, and (when allowed) your wrist, moving throughout. - Once cleared out of the splint, make forearm rotation your priority, keeping it pain-free and unloaded. Early rotation should be done with an empty hand, not against weight. - Do NOT load the forearm in rotation early: no twisting open jars, wringing cloths, using a screwdriver, or carrying heavy bags on that side until strengthening is cleared (commonly around six to eight weeks). - Be alert to pain or a sense of instability on the little-finger side of the wrist when you push or load through the forearm, as this is the area the operation works on. Mention it to your hand therapist; do not push through it. - Keep your fingers, thumb, elbow and shoulder moving freely from the start, and use the hand for light everyday tasks within comfort, as long as it does not involve forced or loaded twisting. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### Forearm rotation (palm up / palm down) This is the headline exercise — it is the movement the operation is designed to restore. With your elbow tucked in at your side and bent to a right angle (so your shoulder cannot cheat the movement), gently turn your palm up towards the ceiling, then slowly down towards the floor. Move only as far as is comfortable. Begin it when Dr Hirpara and your hand therapist clear you to come out of the splint for exercises — usually around two to three weeks — and make it your main focus from then on. 10 times each direction, 3-4 times a day, pain-free range Kieran Hirpara 4.0 #### Wrist movement (bend and straighten) Gently bend your wrist forwards (palm towards forearm) and backwards (back of hand towards forearm), keeping the movement slow and within comfort. This keeps the wrist from stiffening while the distal ulna settles. Keep it gentle early on and do not force the end of the range. 10 times each direction, 2-3 times a day Kieran Hirpara 4.0 #### Finger movement (full fist and stretch) Start this from day one. Make a full, firm fist, then open the hand and stretch your fingers out straight. Keeping the fingers moving early prevents stiffness and helps any swelling drain. Do it often through the day, even while your forearm is still in the splint. 10 times, every couple of hours while awake Kieran Hirpara 4.0 #### Scar massage Once the wound is fully healed and there are no scabs (usually from around three to four weeks), rub a small amount of plain moisturiser into the scar with firm little circles for a couple of minutes. This softens the scar and helps the skin and tendons over the distal ulna move freely. Stop if the wound is not yet fully closed. 2-3 minutes, twice a day, once the wound is healed Kieran Hirpara 4.0 #### Grip and rotation strengthening (later) A LATER exercise — only once Dr Hirpara and your hand therapist clear strengthening, commonly from around six to eight weeks. Squeeze a soft ball or putty to rebuild grip, and turn the forearm palm-up and palm-down against a light resistance (for example a light hand weight held like a hammer). Build the resistance up slowly over several weeks. Stop if turning the forearm under load is painful on the little-finger side of the wrist. As guided by your hand therapist (from ~6-8 weeks only) These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. Finger movement starts straight away. Forearm rotation (the exercise this whole operation is built around) and wrist movement begin once you are cleared out of the splint, usually around two to three weeks, and rotation then becomes your main focus. Scar massage starts once the wound is fully healed. Grip and rotation strengthening belongs to a later phase and should not be started until you are specifically cleared. Stop anything that causes sharp pain on the little-finger side of the wrist. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after hemiresection-interposition arthroplasty of the distal radioulnar joint. This section is to be provided to your hand therapist, and each phase opens with a plain-English explanation of what is happening. This is a joint-reshaping (arthroplasty) procedure, not a repair: there is no construct under tension to protect for months. The deliberate restraint is short: a brief splinted period to let the soft-tissue interposition and capsule settle, after which early restoration of forearm rotation is the explicit priority because rotation is the function the operation exists to restore. The principal load to respect throughout is rotational loading of the distal ulna, which is what provokes painful ulnar-stump instability and radioulnar convergence. Prior to treatment, check the patient's operation report and past medical history, and liaise with the treating surgeon regarding any concurrent procedures (TFCC repair, distal radius osteotomy, PIN neurectomy, extensor reconstruction), the stability of the distal ulnar stump assessed intra-operatively, and the prescribed splint and rotation ceiling. A concurrent TFCC repair or distal radius osteotomy lengthens the protected phase; an isolated hemiresection for degenerative or post-traumatic arthritis follows the shorter pathway below. Dr Hirpara preserves the TFCC, ulnar styloid and ulnar soft-tissue attachments, so the distal ulna remains supported, and the rehab can therefore prioritise early rotation. ### Phase I — protected settling in a splint (weeks 0 to 2-3) The first two to three weeks protect the soft-tissue interposition and capsule while keeping the rest of the limb mobile. The forearm rests in a splint (commonly an above-elbow / Muenster-type splint or cast that limits forearm rotation), removed only for hygiene and, towards the end of the phase, for the first gentle rotation. Fingers move from day one. For your hand therapist: Education and precautions - Immobilise in the prescribed splint (above-elbow / Muenster-type, or per surgeon) limiting forearm rotation; off only for hygiene and cleared exercises - No loaded forearm rotation; no weight-bearing or twisting through the operated forearm - Reassure that early grip weakness and swelling on the ulnar side are expected Management - Wound: surgical dressings as directed; monitor for infection - Oedema: elevation, gentle hand pump, ice as needed - Exercises: active finger, thumb and (if not blocked by the splint) shoulder ROM from day one; gentle elbow ROM as the splint allows; introduce gentle pain-free active forearm rotation in the last few days of this phase if the surgeon permits early removal Criteria to progress - Wound settling; splint period (≈2-3 weeks for isolated hemiresection) complete; cleared by surgeon for active rotation ### Phase II — early forearm rotation (the priority) (weeks 2-3 to 6) This is the defining phase. Out of the splint, active pronation and supination become the headline of rehabilitation: gentle, frequent, pain-free, and unloaded. Wrist motion is added. Rotation is the function the operation restores, so it is pursued actively here while loading is still withheld. For your hand therapist: Assessments - Active and passive forearm pronation/supination (target restoration toward the ~80° each direction reported in outcome series); wrist and finger ROM; pain on the ulnar wrist; swelling; wound/scar review Education and precautions - Forearm rotation is the priority: frequent, pain-free, unloaded active pronation/supination, elbow tucked at the side to isolate the forearm - No resisted or loaded rotation, no heavy gripping, no twisting tasks until ~6-8 weeks - Some splints further limit end-range rotation for a few weeks after cast removal; respect any prescribed ceiling Management - Exercises: active and active-assisted pronation/supination as the main focus; active wrist flexion/extension and radial/ulnar deviation; continue finger and grip ROM (no resisted grip yet); begin scar management once the wound is fully healed - Modalities for oedema and scar as needed Criteria to progress - Comfortable, controlled, near-full pain-free active forearm rotation; wound healed; pain ≤3/10; no provocative ulnar-side pain on gentle rotation ### Phase III — strengthening and return (weeks 6-8 and beyond) Once rotation is restored and pain-free, strengthening begins and is built up gradually: grip first, then loaded forearm rotation, watching specifically for painful ulnar-stump instability or radioulnar convergence under load. Return to heavier work and sport is criterion-based. For your hand therapist: Assessments - Grip strength versus the other side (outcome series report recovery toward ~85-90% of the contralateral side); forearm-rotation strength and any pain or instability on loaded rotation; functional and work-/sport-specific testing as appropriate Education and precautions - Introduce resisted grip first, then graded loaded forearm rotation (e.g. hammer turns with a light weight) from around six to eight weeks; build load slowly - Watch for painful ulnar-stump instability / radioulnar convergence under axial or rotational load: if provoked, reduce load and liaise with the surgeon Management - Exercises: progressive grip/putty work; graded resisted pronation/supination (light → moderate); task-specific loading; continue any residual ROM work - Consider discharge once rotation and grip are functional and near-symmetrical and a suitable return of function is achieved - Consider referral back to the treating doctor if recovery plateaus, or if there is persistent ulnar-side load pain suggesting stump instability or convergence Criteria for return to load/sport - Near-symmetrical grip and rotation strength; pain-free loaded rotation; no instability on functional testing ## Getting back to work and activity Light everyday hand use (eating, writing, light self-care) is encouraged from the start, within comfort, as long as it does not involve forced or loaded twisting of the forearm. Because your forearm is splinted early and you must be able to safely control the wheel (including turning it), plan for help with transport in the first few weeks; driving resumes once you are out of the splint and can comfortably and safely rotate the forearm to steer, as confirmed at your review. Loaded twisting tasks (opening stiff jars, wringing, using a screwdriver, carrying heavy bags on that side) wait until strengthening is cleared (commonly around six to eight weeks) and are then built up gradually. Return to heavier manual work and sport follows the same criterion-based progression and depends on regaining pain-free, near-symmetrical forearm rotation and grip, judged by Dr Hirpara and your hand therapist rather than the calendar alone. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain, wound care and scar management. If your DRUJ problem followed a wrist fracture, the distal radius fracture fixation protocol is a useful companion. The phased plan above reflects published rehabilitation guidance after distal radioulnar joint hemiresection arthroplasty, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your forearm progresses. --- ### Dupuytren's exercises URL: https://www.cqupperlimb.com/education/rehabilitation/dupuytrens-exercises/ Region: rehabilitation · rehabilitation Exercise handout following Dupuytren's release — extension, DIP/PIP flexion and wrist tenodesis exercises, recreated from an Extend Rehabilitation sheet. Prepared in association with Extend Rehabilitation Name: ____________________  Date: ____________ ## What is Dupuytren’s Disease Dupuytren’s Disease presents as abnormal lumps and ‘cords’ of tissue in the palm and fingers. These lumps and cords represent an abnormal growth of the palmar fascia (fibrous tissue that holds the skin of the palm in place). As the Dupuytren’s cords tighten over time, the joints of the fingers are pulled into flexion, causing the fingers to remain bent. It most commonly affects the ring and little fingers. The thumb may also be affected, though this is less common. The rate at which symptoms progress is highly variable among patients. In many patients the disease may be stable over a long time and require observation only. In others, it may progress more rapidly and require earlier surgical intervention. ## What causes it? Dupuytren’s Disease mostly affects people with ancestors from Northern Europe. It occurs more often in men than in women, and usually starts after the age of 40. In many cases the disease runs in families. ## Treatment There is no permanent cure for Dupuytren’s Disease. Surgery can relieve the bending of the fingers into the palm, but the condition may return with time. The goal of surgery for Dupuytren’s Disease is to excise the diseased fascia and restore finger extension (straightening). ## What happens after surgery? Usually you will be referred to a Hand Therapist 2-3 days after surgery. They will make you a plastic splint to maintain the finger in an extended position and will instruct you to perform some gentle exercise. ## When do I wear the splint? And when can I use my hand? Initially you may need to wear the splint day and night, removing only for exercise. Usually after a week or so you will only need to wear your splint at night. You can begin to use your hand for light activity during the day at this time. Usually the splint needs to be worn at night for 3 months, and in some cases for up to 6 months. Your therapist/surgeon will advise you specifically regarding splint wear and activity. ## Wound care It is important to keep the wound clean and dry until your sutures are removed. Once sutures are removed, you can wet the skin, however avoid submerging your hand in water for another week. ## Exercises #### Active Extension With your wrist straight, straighten and spread your fingers. You may assist with your other hand. Relax. As prescribed by your hand therapist — ____ reps, ____ times per day #### Active DIP Flexion Support below the crease of the end joint with your other hand. Bend the end joint firmly. As prescribed by your hand therapist — ____ reps, ____ times per day #### Active DIP/PIP Flexion Place a pen at the base of your fingers. Curl your fingers around the pen so that both IP joints bend. As prescribed by your hand therapist — ____ reps, ____ times per day #### Composite Flexion Gently make a loose fist. As prescribed by your hand therapist — ____ reps, ____ times per day #### Wrist Tenodesis Resting on elbow with fingers relaxed, bend wrist forward and then backwards. As prescribed by your hand therapist — ____ reps, ____ times per day Exercises to be completed __________ times a day CARDS For the full phase-by-phase recovery plan, see the Dupuytren's release rehabilitation protocol. --- ### Dupuytren's Release URL: https://www.cqupperlimb.com/education/rehabilitation/dupuytrens-fasciectomy/ Region: rehabilitation · rehabilitation Rehabilitation after Dupuytren's fasciectomy — the extension splint regime and exercise program, with hand-therapist follow-up. This protocol guides your recovery after surgical release of Dupuytren's contracture (fasciectomy) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. The two pillars of a good result are the splint, which holds the freed fingers straight while everything heals, and the exercise program, which keeps them moving. Bring this page or its PDF to your hand therapist so your rehabilitation stays coordinated. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect Surgery for Dupuytren's disease removes the diseased cords of tissue that were pulling your fingers into the palm, restoring the ability to straighten them. The condition itself is explained on the Dupuytren's disease page; there is no permanent cure, and the goal of surgery is to excise the diseased tissue and restore finger extension. You will usually be referred to a hand therapist 2–3 days after surgery. The therapist will make you a custom plastic splint that holds the operated fingers in an extended (straight) position, and will start you on the gentle exercise program below. The splint and the exercises work together: the splint defends the straightness the surgery won, and the exercises keep the fingers bending so they don't stiffen. Keep the wound clean and dry until your sutures are removed. Once the sutures are out you can get the skin wet, but avoid soaking or submerging the hand in water for another week. The practice's wound care page covers dressings, signs of infection and scar care in detail. Scar massage matters after Dupuytren's surgery, and your therapist will guide it once the wound has healed. ## Caring for your scar The scar in the palm is often firm, raised and tender for the first weeks after Dupuytren's surgery before it gradually softens and fades over the following months. Scar massage is a routine part of Australian hand-therapy care: in a national survey of accredited hand therapists, almost all used it after hand surgery (typically starting around suture removal, once the wound has fully healed) to soften the scar, improve how the skin glides over the tissues beneath, and settle scar sensitivity, usually combined with silicone gel or sheeting rather than used on its own [6]. The research evidence behind scar massage is still developing, but it supports its use for reducing scar-related discomfort and improving movement [6]. Your therapist will show you the technique and may add a silicone product, often worn at night alongside the splint. ## Recovery, work and the long term Swelling and stiffness are normal in the early weeks and settle as the hand is used; comfort, motion and grip generally keep improving over several months. Keeping the hand elevated and gently moving in those early weeks helps the swelling settle and guards against the small joints stiffening. The straightness gained at surgery is usually well maintained through this period. In a randomised trial of rehabilitation after Dupuytren's release, most operated fingers held or improved their extension over the first three months of hand therapy [2]. Time off work depends on what you do with your hands. In a study of more than 2,500 people treated for Dupuytren's disease, the median return to work after open fasciectomy was about two weeks, and around nine in ten people were back at work within the year; physically demanding jobs took longer [4]. Dr Hirpara will discuss timing for your particular work at review; heavier manual work usually waits until the wound is soundly healed and grip is comfortable. Because Dupuytren's is a lifelong condition, some tightness can return over the years, and reported recurrence rates vary widely between studies depending on how recurrence is defined. The long-term picture is generally reassuring: in a follow-up of 142 fasciectomies over roughly four years using the modern consensus definition, true recurrence of contracture occurred in around 3–4% of hands, although about a third kept some residual curvature, usually mild and well short of the contracture corrected at surgery [5]. The splint, scar care and exercise program are all aimed at protecting your result; if a finger does begin to tighten again at any point, let the rooms know. ## Your splint - First week or so: wear the splint day and night, removing it only for your exercises (and washing, once permitted). - After the first week: most people move to night-only splint wear, and can begin using the hand for light activity during the day. - Night splinting continues for about 3 months (and in some cases up to 6 months) to protect against the fingers drifting back toward the palm while the tissues mature. - Your hand therapist and Dr Hirpara will advise you specifically about your splint-wear schedule and activity. The timings above are the usual pattern, not a fixed rule. You must not drive while your hand is in the splint. Once you move to night-only wear, daytime driving can resume as comfort and a safe grip on the wheel allow. For your physiotherapist / hand therapist: Management - Referral 2–3 days post-operatively for fabrication of a thermoplastic extension splint - Splint regime: day and night for approximately the first week (off for exercises), then night-only with light functional day use; night splinting continued for approximately 3 months (up to 6 months where needed), per surgeon/therapist review - Home exercise program as per the cards below: active extension, blocked DIP flexion, DIP/PIP flexion over a pen, composite flexion, wrist tenodesis - Wound care per the practice's wound care guidance; scar management once healed - Repetitions and daily frequency set by the treating therapist Precautions - Keep the wound clean and dry until suture removal; no soaking/submersion for a further week after - Splint compliance is central to maintaining the extension gained at surgery - No driving while the hand is in the splint These are the exercises from your handout, started with your hand therapist and continued at home. ## Your exercises Kieran Hirpara 4.0 #### Active extension With your wrist straight, straighten and spread your fingers as far as you can. You may assist gently with your other hand. Relax and repeat. As prescribed by your hand therapist Kieran Hirpara 4.0 #### Active DIP flexion Support the finger just below the crease of the end (DIP) joint with your other hand. Bend the end joint firmly, then relax. As prescribed by your hand therapist Kieran Hirpara 4.0 #### Active DIP/PIP flexion Place a pen across the base of your fingers. Curl your fingers around the pen so that both finger joints (the middle and end joints) bend, then relax. As prescribed by your hand therapist Kieran Hirpara 4.0 #### Composite flexion Gently make a loose fist, then relax and let the fingers straighten. As prescribed by your hand therapist Kieran Hirpara 4.0 #### Wrist tenodesis Resting on your elbow with your fingers relaxed, bend your wrist forwards and then backwards, letting the fingers follow naturally. As prescribed by your hand therapist Start the exercises below only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. Straightening is the whole point of this operation, so active extension is the priority exercise — the fingers will pull back toward a bent position if you let them, and the range you keep is the range you use. The bending exercises (DIP, DIP/PIP and composite flexion) matter too, because a finger that only straightens is no more useful than one that only bends. Wrist tenodesis links the two. Wear your night splint as directed. Stop anything that causes sharp pain, and tell your therapist if a finger starts losing extension. ## After your protocol This protocol was written in association with Ruby Doolan, Accredited Hand Therapist, Extend Rehabilitation. It works alongside the practice's general recovery advice: see managing post-operative pain, wound care and hand therapy basics. For the operation itself, see Dupuytren's fasciectomy. The recovery expectations, return-to-work figures and scar-care guidance above are drawn from published trials, reviews and surveys of rehabilitation after Dupuytren's surgery, including randomised trials and a systematic review of splinting and hand therapy after fasciectomy [1–3]. The splint regime and exercise program are the practice's own, agreed between Dr Hirpara and your hand therapist, and your splint-wear schedule is individualised at your reviews. --- ### Elbow Instability URL: https://www.cqupperlimb.com/education/rehabilitation/elbow-instability/ Region: rehabilitation · rehabilitation Rehabilitation after surgery for elbow instability, covering both lateral (terrible triad / LCL) injuries and throwing (medial UCL) injuries, built around protected early movement rather than immobilisation. This protocol guides your recovery after surgery for elbow instability with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It covers two different kinds of instability, and your surgeon will tell you which applies to you: - (A) A lateral (outer-side) injury: such as a "terrible triad" injury, a fracture-dislocation, or a repair of the lateral collateral ligament (LCL). These injuries are stabilised so the elbow no longer slips or pivots out of place. - (B) A throwing (medial, inner-side) injury: a repair or reconstruction of the ulnar collateral ligament (UCL), usually in overhead athletes. The whole plan is built on one idea: protected early movement, not immobilisation. Long spells in a cast or splint are the main cause of a permanently stiff elbow, so the goal is to start moving safely and soon. Bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect The elbow is held in place by ligaments on the inner and outer sides of the joint. When these are injured (by a dislocation, a fracture-dislocation, or repeated throwing), the joint can become unstable. Surgery repairs or reconstructs the damaged structures so the joint sits properly again. Dr Hirpara's approach avoids a bulky external hinged brace. If the repair is stable through its full range at the time of surgery, you will simply wear a light sling for comfort and begin moving the elbow early, within safe positions. If the stability needs more protection, an internal joint stabiliser can be fitted at the time of surgery: a small internal hinge that holds the elbow correctly reduced from the inside while still letting you bend and straighten it early. Because the protection is internal, you still avoid an external arc-limiting brace. If used, this internal device is usually removed once the ligaments have healed, at around four to six months. For wound, swelling and scar management, see the practice's wound care guidance. The single most important habit in this recovery is to keep moving within your safe range while respecting the positions your surgeon asks you to avoid. The exercises below are your starting point. ## Precautions and limitations The positions to protect depend on which injury you have. Your surgeon and therapist will confirm yours. For a lateral (outer-side) injury (terrible triad / LCL): - Do keep your forearm turned palm-down (pronated) for movement; this seats the joint and protects the outer repair. - Do exercise with your arm in front of your body, or lying down with the arm reaching toward the ceiling if asked, so gravity helps hold the joint together. - Do not let the arm fall out to the side (avoid shoulder abduction) or take weight through it early; gravity then pulls the repair apart. - Do not combine fully straightening the elbow with a palm-up (supinated) forearm until your surgeon clears it (around 16 weeks); this is the position that can make the joint slip again. - Do not push or stretch the elbow into pain, and avoid weight-bearing and contact loading for the first few months. For a throwing (medial, inner-side) injury (UCL): - Do keep your forearm biased palm-up (supinated) or neutral, as directed. - Do not load the shoulder into outward (external) rotation early; this stresses the inner repair. This is usually avoided until about 6 weeks. ## Your exercises Kieran Hirpara 4.0 #### Active elbow bends Gently bend your elbow as far as is comfortable, then straighten it again to the point your surgeon and therapist allow. Keep your forearm turned the way you have been instructed — for a lateral (outer-side) injury this usually means palm-down (pronated). Move only your own muscles; do not force the joint. 10–15 times, several times a day Kieran Hirpara 4.0 #### Assisted elbow flexion When your therapist allows, use your other hand to gently help your elbow bend a little further than it moves on its own. Take it to a comfortable stretch only — never to pain — and ease off slowly. Hold 10–15 seconds, 5–10 times, as directed Kieran Hirpara 4.0 #### Elbow straightening (extension to comfort) Straighten your elbow as far as is comfortable within the range your surgeon has set. For a lateral injury, keep your palm turned down as you straighten. Do not push into full straightening combined with palm-up rotation until your surgeon clears it. 10–15 times, several times a day Kieran Hirpara 4.0 #### Forearm rotation (palm up / palm down) With your elbow tucked at your side and bent to about 90°, gently turn your palm up, then palm down, within the range you have been given. Your safe direction depends on your injury — a lateral injury favours palm-down (pronation); a medial throwing injury favours palm-up (supination). Follow the direction your surgeon and therapist set. 10 times each allowed direction, several times a day Kieran Hirpara 4.0 #### Elbow muscle holds — straightening (isometric) With your elbow held still, gently press as if to straighten it against your other hand or a fixed surface. The elbow should not actually move. This wakes the muscles up without loading the healing ligaments. Hold 5 seconds, 10 times, once or twice daily — only when cleared Kieran Hirpara 4.0 #### Elbow muscle holds — bending (isometric) With your elbow held still, gently press as if to bend it against your other hand. The elbow should not move. Keep the effort comfortable — this is muscle activation, not a workout. Hold 5 seconds, 10 times, once or twice daily — only when cleared Kieran Hirpara 4.0 #### Grip strengthening Squeeze a soft ball or therapy putty in your hand and hold briefly, then release. This keeps your hand and forearm strong while your elbow is protected. 10–15 squeezes, 2–3 times a day These are the exercises from your handout, for regaining safe movement and keeping your hand, forearm and shoulder working while the elbow is protected. Start them, and progress them, only as guided by Dr Hirpara and your therapist; the safe forearm position and range depend on your specific injury. ## Your clinical protocol The rest of this page is the clinical protocol for your physiotherapist or hand therapist. It is written in two tracks because the two injuries are protected differently. Each phase is criteria-gated: progress when the milestones are met, not simply by the calendar. Prior to treatment, check the patient's x-ray, operation report and past medical history, and liaise with the treating surgeon regarding the stability achieved at surgery, the safe arc and forearm rotation, and whether an internal joint stabiliser was implanted. Dr Hirpara does not use an external hinged brace: a through-range stable repair is managed in a simple sling with early motion to comfort; where stability needs protecting, an internal joint stabiliser holds the reduction internally while permitting extension to comfort. ### Track A — Terrible triad / fracture-dislocation / LCL (LUCL) repair Aim: A stable, concentrically reduced elbow that moves early; prevent posterolateral rotatory re-subluxation. Key precautions throughout the early phase: - Keep the forearm pronated for an isolated lateral injury (tightens the lateral structures and seats the radiocapitellar joint). If both columns were repaired, hold the forearm neutral; supination is permitted only with the elbow flexed to ~90°. - Avoid varus stress and shoulder abduction: gravity imposes a varus load on the lateral repair. Perform active range of motion with the arm in front of the body, or supine-overhead (gravity-reduced) if the repair is tenuous. - No full-extension-with-supination until ~16 weeks (reproduces the pivot-shift). - No weight-bearing / closed-chain loading for 8–16 weeks. Weeks 0–2: Early motion. Simple sling for comfort. Begin digit, wrist and shoulder active range of motion immediately. Begin elbow active and active-assisted range of motion to comfort from day 2–3, forearm pronated, arm supported in front of the body (or supine-overhead if the repair is tenuous, so gravity compresses the joint). Where an internal joint stabiliser is in place, progress to full comfortable extension early; the device protects the reduction; no external brace is used. Weeks 2–6: Restore the arc. Progress to full comfortable flexion and extension (extension to comfort throughout; an internal stabiliser, if present, permits this). Maintain the pronation bias; avoid varus loading. Criteria to progress: full passive arc regained, no re-subluxation on examination or x-ray, pain ≤3/10. Weeks 6–12: Strengthening. Once clinically and radiographically healed (~week 6), begin progressive strengthening; introduce a static-progressive splint if a contracture is developing. Continue to avoid varus load. An internal stabiliser, if used, is usually retained until ligament healing. Weeks 12–20+: Advanced / return. Progressive resistance; return to heavy labour. Contact and overhead sport at approximately 6–9 months (and after any internal-stabiliser removal). Continue to avoid varus-loaded strengthening. ### Track B — Throwing (medial) UCL repair / reconstruction This is a chronic-overload medial problem. Dr Hirpara's preference is no external hinged brace: a suture-tape internal-brace augmentation (repair) or the tendon graft (reconstruction) provides the protection, and rehabilitation is throwing-specific. The forearm is biased to supination/neutral; resisted shoulder external rotation is avoided until ~week 6, as it valgus-loads the graft. Internal-brace–augmented repair (accelerated, matching the no-external-brace approach): - Early protected motion to comfort, weeks 0–4 (full arc by ~week 6). - Thrower's Ten program from ~week 3; plyometrics from ~week 6. - Interval throwing program from ~week 11; return to sport at ~5–7 months. Reconstruction (graft) track, if used (slower): - Full arc by ~week 6; interval throwing at weeks 14–16; throwing from a mound not before 6 months; competitive return to sport typically 9–16 months. ## Getting back to work and activity How quickly you return depends on which injury you had and on the demands of your job or sport. - Lateral injury (terrible triad / LCL): light desk and self-care tasks resume early, within your safe positions. Strengthening generally begins around 6 weeks once the elbow has healed clinically and on x-ray. Contact and overhead sport are usually delayed to about 6–9 months, and after removal of an internal joint stabiliser if one was fitted. Avoid taking weight through the arm or loading it out to the side until your surgeon clears it. - Throwing injury (UCL): with an internal-brace-augmented repair, a structured interval throwing program typically begins around 11 weeks, with return to sport at about 5–7 months. After a reconstruction, return to competitive throwing is slower, commonly 9–16 months. Driving is resumed once you have comfortable, safe control of the arm out of the sling and your surgeon has confirmed it is appropriate at review. Your therapist will progress your strengthening and sport- or work-specific drills toward your individual goals. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain and wound care. Your ongoing recovery is guided individually by your physiotherapist or hand therapist according to how your elbow progresses and which injury you had. The clinician-facing evidence summary for this protocol is kept alongside this page. --- ### Extensor Tendon Repair URL: https://www.cqupperlimb.com/education/rehabilitation/extensor-tendon-repair/ Region: rehabilitation · rehabilitation A recovery plan after repair of an extensor tendon on the back of the finger or hand (zones IV to VII), using a relative-motion (yoke) splint that lets you use the hand straight away while protecting the repair, then weaning the splint and building strength in careful stages. This protocol guides your recovery after surgical repair of an extensor tendon (one of the tendons on the back of the finger or hand that straightens the finger) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It covers repairs across the back of the finger, hand and wrist (the zones surgeons call IV to VII). It does not cover a mallet finger (a repair right at the fingertip) or a central-slip / boutonnière repair over the middle knuckle; those follow different plans. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist. Bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect An extensor tendon repair stitches a divided tendon back together on the back of the finger or hand. The old way to protect that repair was to splint the hand still for several weeks, but that often left the fingers stiff and slow to recover. Instead, your recovery uses a clever, modern approach called relative-motion rehabilitation (the Merritt method). The key is a small splint called a yoke, worn across the back of the hand. It holds the big knuckle of the repaired finger about 15 to 20 degrees more straightened than the knuckles of the fingers on either side. That small difference quietly takes the load off the healing tendon, so you can start using the hand straight away, gently and within comfort, instead of waiting weeks with it splinted still. Moving early in this protected way keeps the tendon gliding so it does not stick down, while the offset stops it being over-strained. For most repairs (the common zones on the back of the finger and hand) the yoke on its own is all you need. For some repairs (those closer to the wrist, weaker repairs, or where extra protection is sensible) a wrist splint is added for the first few weeks as well. Your hand therapist will tell you if you also have a wrist splint. The plan then opens up in careful stages: the yoke is worn full-time for about six weeks and weaned from around week five; coupled wrist-and-finger movement is added in the middle weeks; strengthening begins from about eight weeks; and full activity returns around ten to twelve weeks, once the repair is solid. ## Precautions and limitations - Wear your yoke splint full-time for about the first six weeks, including for exercises and everyday tasks, and only remove or wean it as your hand therapist directs. Your hand therapist will tell you if you also have a wrist splint. - Do light everyday use of the hand in the splint from the start, within comfort. Do NOT do any lifting, forced gripping or resisted work for the first several weeks. - Do NOT start grip or pinch strengthening until you are cleared, usually around eight weeks. - Do NOT make a hard full fist or force the finger early; move only in the gentle, controlled ranges you are shown. - Keep the smaller finger joints moving so they do not stiffen; gentle passive straightening helps with this. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### Wearing your relative-motion (yoke) splint Your repaired finger is held in a small splint called a yoke (or relative-motion splint). It keeps the big knuckle (the MCP, where the finger meets the hand) of the repaired finger about 15 to 20 degrees more straightened than the fingers either side. This small difference takes the strain off the healing tendon, which is what lets you use the hand straight away. Wear it full-time for about six weeks — including for your exercises and for everyday tasks — and only take it off as your hand therapist directs. Your hand therapist will tell you if you also have a wrist splint. Worn full-time for about 6 weeks, weaned from around week 5 as guided #### Knuckle-bend, fingers-straight (intrinsic-plus) Keeping the splint on, bend at the big knuckles (where the fingers meet the hand) while keeping the rest of each finger straight — like making a flat 'tabletop' or 'shelf' shape. Then return to straight. Move smoothly within comfort. This glides the repaired tendon a safe, controlled amount so it does not stick down, without putting it under strain. 10 times, every couple of hours through the day #### Knuckles-straight, finger-curl (intrinsic-minus / hook) Keeping the splint on, keep your big knuckles straight and curl only the smaller joints of the fingers down into a hook (claw) shape, then straighten them again. This moves the repaired tendon through its other range, again in a safe and controlled way. Stay within comfort and do not force it. 10 times, every couple of hours through the day #### Coupled wrist-and-finger motion (tenodesis) A LATER exercise — added by your hand therapist from around three to six weeks. Gently tip the wrist back and let the fingers relax open, then let the wrist drop forward as the fingers gently close. The wrist and fingers move together as a pair. This naturally and safely glides the extensor tendons and is started once the repair is stronger. 10 times, 2 to 3 times a day (from ~3 to 6 weeks, as guided) Kieran Hirpara 4.0 #### Passive finger straightening Gently use your other hand to support and straighten the smaller joints of the repaired finger, helping it reach full straight without forcing. This keeps the finger from stiffening into a bent position while the tendon heals. Keep it gentle and pain-free, and only as your hand therapist guides. Hold a few seconds, 5 to 10 times daily, as guided Kieran Hirpara 4.0 #### Grip/pinch strengthening (from wk 8) A LATER exercise — only from around eight weeks, once your hand therapist clears strengthening. Squeeze a soft ball or putty in the whole hand, and pinch it between your thumb and fingers, building the effort up gradually over several weeks. This rebuilds grip and pinch strength once the repair is solid. Do not start resisted gripping before you are cleared. 10 to 15 squeezes, 2 to 3 times a day (from ~8 weeks only) These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. The early exercises are done with the yoke splint on: gentle knuckle bends and finger curls that glide the repaired tendon a safe, controlled amount without straining it. The coupled wrist-and-finger movement and the grip/pinch strengthening belong to later phases and should not be started until you are specifically cleared. Stop anything that causes sharp pain over the back of the finger or hand. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after extensor tendon repair (zones IV to VII) using relative-motion extension (RME). This section is to be provided to your hand therapist, and each phase opens with a plain-English explanation of what is happening. The repair is protected by a yoke splint that holds the repaired digit's MCP 15 to 20 degrees more extended than the adjacent digits, offloading active extensor excursion via the quadriga effect and the juncturae tendineae, so immediate active motion is safe. Prior to treatment, check the patient's operation report and past medical history, and liaise with the treating surgeon regarding the zone(s) repaired, tendon(s) involved, repair strength, and whether a supplementary wrist orthosis is indicated. Dr Hirpara's default for zones V to VI is yoke-alone (relative-motion extension splint, repaired MCP held 15–20° more extended than neighbours). A wrist orthosis (~20–25° extension, first ~3 weeks) is added for zone VII, weaker repairs, or non-compliant patients. This protocol is for dorsal extensor repairs zones IV–VII only, NOT mallet (zones I–II) or central-slip/boutonnière (zone III). ### Phase I — yoke (± wrist splint), immediate active use (weeks 0 to 3) The first three weeks protect the repair with the yoke while the patient uses the hand actively straight away. The relative 15–20° extension offset offloads the repair, so controlled active gliding is encouraged from the outset. Light functional use in the splint is permitted; no lifting or resisted grip. For your hand therapist: Education and precautions - Fit the yoke / relative-motion extension splint: repaired digit's MCP held 15–20° more extended than the adjacent digits; worn full-time - Add a wrist orthosis (~20–25° extension) for the first ~3 weeks ONLY for zone VII / weaker repairs / non-compliant patients (yoke-alone is the default for zones V–VI) - Light use of the hand in the splint is encouraged; NO lifting, forced gripping or resisted work - Avoid forced composite fisting; keep ranges controlled Management - Wound: surgical dressings as directed; monitor for infection - Oedema: elevation, gentle digital pump, ice as needed - Exercises (in the splint, every ~2 h): active intrinsic-plus (MCP flexion with IPs extended) and intrinsic-minus / hook (MCP extension with IP flexion); passive IP extension daily to prevent IP stiffness - Commence scar management once the wound is healed Criteria to progress - Wound settling; no extensor lag developing; comfortable controlled active motion in the splint at ~3 weeks ### Phase II — wrist splint off, yoke continues, coupled motion (weeks 3 to 6) From about three weeks any supplementary wrist splint is discontinued (the yoke continues full-time). Coupled wrist-and-finger (tenodesis) motion and composite active flexion/extension are added, increasing tendon excursion in a controlled, repair-safe way. For your hand therapist: Assessments - Active and passive ROM (MCP and IP), extensor lag, pain and swelling; wound/scar review Education and precautions - Discontinue the supplementary wrist splint (if one was used); continue the yoke full-time - Progress motion gradually; still NO resisted grip or strengthening Management - Exercises: add coupled wrist-and-finger motion (tenodesis) and composite active flexion/extension; continue intrinsic-plus / intrinsic-minus gliding and passive IP extension; light functional use in the yoke - Continue scar massage once healed Criteria to progress - Composite active ROM progressing (full composite motion usually by ~6 to 8 weeks); no extensor lag; pain settling ### Phase III — wean the yoke, strengthen, return (weeks 6 to 12) From around week five to six the yoke is weaned. Progressive grip and pinch strengthening begins from about eight weeks once the repair is solid, building gradually toward full activity at ten to twelve weeks. For your hand therapist: Assessments - Full active and passive ROM, extensor lag, grip/pinch strength versus the other side; functional and work-specific testing as appropriate Education and precautions - Wean the yoke from ~week 5, off by around week 6 as motion and control allow - Introduce progressive grip/pinch strengthening from 8 weeks (not before) - Build resistance gradually toward full activity at 10 to 12 weeks Management - Exercises: graded grip and pinch strengthening (ball/putty squeeze, pinch) from week 8; progressive resistance; continue any residual mobility and IP-extension work - Consider discharge once motion and strength are near-symmetrical and functional return is achieved - Consider referral back to the treating doctor if an extensor lag persists, motion plateaus, or there is a poor outcome Criteria for return to full activity - Full painless ROM with no significant extensor lag; near-symmetrical grip/pinch; ~10 to 12 weeks ## Getting back to work and activity Light everyday use of the hand in the yoke splint (eating, writing, dressing, light self-care) is encouraged from the start, within comfort, as long as it does not involve lifting, forced gripping or resisted work. Strengthening begins from about eight weeks, and full, unrestricted activity returns around ten to twelve weeks once the repair is solid and your motion and strength are restored, judged by Dr Hirpara and your hand therapist, not by the calendar alone. Driving: light use of the hand in the yoke is fine, so driving is not banned outright, but you must be able to grip the wheel and control the car safely, including in an emergency. For most people that means resuming as the yoke is weaned (around six weeks); it can be earlier if you can control the car comfortably, and your surgeon confirms when it is safe for you. ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain, wound care and scar management. The phased plan above reflects published rehabilitation guidance after extensor tendon repair using relative-motion extension, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your hand progresses. --- ### Finger Surgery URL: https://www.cqupperlimb.com/education/rehabilitation/finger-surgery/ Region: rehabilitation · rehabilitation Post-operative exercises and precautions after finger surgery, including joint blocking and tendon glides. This protocol guides your recovery after finger surgery with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It explains what to expect in the weeks after your operation and sets out the exercise program that helps you regain movement and function in your finger and hand. Bring this page or its PDF to your first physiotherapy or hand therapy visit so your rehabilitation stays coordinated; your therapist may adjust the plan depending on your operation and how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect Care of your wound is explained on the practice's wound care handout. The exercises below are central to regaining movement and restoring function in your finger and hand. Once your wound is healed, apply heat to your hand for 20 minutes before performing these exercises. After completing the exercises, apply ice to settle any swelling or inflammation. Once the wound is fully healed, commence scar massage: firm circles over the incision. Please refer to the wound care handout for more information on scar management. Please monitor swelling, and call the rooms or speak to a hand therapist if you have concerns. Three principles underpin recovery from most finger operations, and the exercises below put each into practice. The first is controlling swelling: persistent hand swelling stiffens the soft tissues and limits how well the tendons and joints can move, so elevation, gentle movement and (where needed) retrograde massage and compression are priorities in the early weeks [1]. The second is early, gentle movement: fingers stiffen quickly, so moving them within the limits set for your particular operation (starting as soon as your wound and surgery allow) keeps the small joints supple and helps the tendons glide rather than stick down to the healing tissues around them. The third is tendon gliding. The different finger positions in your handout (straight, hook, tabletop and full fist) are not arbitrary: each position moves the deep and superficial finger tendons by a different amount relative to one another and to the tendon sheath, which is what keeps them sliding freely [2]. The DIP and PIP blocking exercises target this same gliding joint by joint. Little and often is the rule: steady, frequent, gentle practice through the day does more for your recovery than occasional hard effort. ## Precautions and limitations Light functional use of your hand is encouraged for daily living tasks such as self-care, feeding, dressing, writing and typing (unless advised otherwise). You will usually be asked to avoid lifting, gripping, weight bearing and impact for up to 6 weeks after surgery, depending on the injury and the surgery performed. You will be given more guidance on your precautions and limitations at your post-operative review. For your physiotherapist: Management - Wound and scar care as per the practice's wound care handout; commence scar massage (firm circles over the incision) once the wound is fully healed - Once the wound is healed, heat to the hand for 20 minutes before the exercise program; ice after exercises to settle swelling and inflammation - Monitor swelling; escalate to the rooms or a hand therapist if concerns arise - Oedema control is a priority where swelling is excessive or slow to settle: elevation and active movement first line, with retrograde massage, compression and manual oedema mobilisation as adjuncts in conjunction with standard therapy [1] - Home exercise program as per the cards below: wrist flexion/extension; distal interphalangeal (DIP) and proximal interphalangeal (PIP) joint blocking; tendon glides (Series A and Series B) - The tendon glide and joint-blocking sequences are designed to maximise differential excursion of the flexor tendons relative to one another and to the sheath: vary the positions (straight, hook, tabletop, fist) rather than repeating a single position [2] Precautions - Light functional use of the hand is encouraged for daily living tasks (self-care, feeding, dressing, writing, typing) unless advised otherwise - No lifting, gripping, weight bearing or impact for up to 6 weeks post surgery (depending on injury / surgery performed) - Specific precautions and limitations are confirmed at the post-operative review - This is a general post-operative finger program; where the specific operation carries its own protected range, motion limits or splinting (for example after a tendon repair), the operation-specific instructions take precedence These are the exercises from your handout, continued at home as guided by your physiotherapist or hand therapist. ## Your exercises Kieran Hirpara 4.0 #### Wrist flexion / extension Rest your elbow on a table and gently rock your wrist back and forth (or rest it over the edge of a table or armchair, as pictured). Once more comfortable, grasp the palm with your other hand and push your wrist backwards so your fingers point towards the ceiling, then the other way so they point to the floor. Keep your fingers loose — they will bend or straighten on their own. Hold each stretch for 15 seconds; repeat 5 times in each direction. 10 reps, 4–5 times daily Kieran Hirpara 4.0 #### DIP joint blocking Begin with the palm up, supporting your involved hand with your other hand just below the end joint — the distal interphalangeal (DIP) joint. Bend and straighten the end joint, holding each position for 3–5 seconds. Support the middle joint only enough so it does not bend. It is okay if the other fingers move during this exercise. 10 reps, 4 times a day, daily Kieran Hirpara 4.0 #### PIP joint blocking Begin with the palm up, supporting your involved hand with your other hand just below the second joint — the proximal interphalangeal (PIP) joint. Bend and straighten your finger at the middle joint, holding each position for 3–5 seconds. It is okay if the other fingers move as well. 10 reps, 4 times a day, daily Kieran Hirpara 4.0 #### Tendon glides — Series A With your hand in front of you and your wrist straight, fully straighten all of your fingers (1). Bend the tips of your fingers into the "hook" position with your knuckles pointing up (2). Make a tight fist with your thumb over your fingers (3). 5–10 reps, 2–3 times a day, daily Kieran Hirpara 4.0 #### Tendon glides — Series B With your hand in front of you and your wrist straight, fully straighten all of your fingers (1). Make a "tabletop" with your fingers by bending at your bottom knuckle and keeping the fingers straight — ensure your wrist does not drop forward (2). Bend your fingers at the middle joint, touching your fingers to your palm (3). 5–10 reps, 2–3 times a day, daily Start the exercises below only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. The blocking exercises are the specific ones: by holding the joint below still, you force the movement to happen at the joint you are trying to free rather than the one that already moves easily. The tendon-glide series keeps the flexor tendons running smoothly through the sheath, and the wrist stretch stops the wrist stiffening while the finger is the focus. Little and often works better than occasional long sessions. Stop anything that causes sharp pain. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain, wound care and hand therapy basics. For operations this program is commonly used after, see trigger finger release and Dupuytren's fasciectomy. This exercise program was written in association with Sarah Farrell, BOccThy, Accredited Hand Therapist. --- ### Flexor Sheath Ganglion Excision URL: https://www.cqupperlimb.com/education/rehabilitation/flexor-ganglion-excision/ Region: rehabilitation · rehabilitation A quick, motion-led recovery plan after excision of a flexor tendon sheath ganglion (volar retinacular cyst) at the base of a finger, protecting a small palm wound while you start gentle finger movement within days, then add scar care and grip as the wound settles. This protocol guides your recovery after a small operation to remove a flexor sheath ganglion, a firm cyst at the base of a finger on the palm side of the hand, with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist; bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your hand therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect A flexor sheath ganglion (also called a volar retinacular cyst) is a small, firm, often tender lump, usually only a few millimetres across, that grows from the sheath the flexor tendons run through, right at the base of a finger on the palm side (commonly over the firm band called the A1 pulley, at the crease where the finger meets the palm). It is fixed to the sheath and does not move when you bend the finger. It is a completely benign (non-cancerous) lump, and one of the more common ganglions in the hand and wrist. The operation is a small day-case excision. Through a short zig-zag cut in the palm, Dr Hirpara removes the cyst together with a small cuff of the tendon sheath it grew from. The two small nerves and blood vessels that run along each side of the finger are carefully protected. The sheath itself is not repaired: leaving it open is deliberate and does not weaken the finger. The skin is closed with sutures. Because nothing inside the finger has to be protected while it heals, this is a quick recovery: weeks, not months. The plan is simple: protect the small palm wound, control swelling, and start gentle finger movement within a few days so the finger does not stiffen and the tendons do not stick down to the healing scar. Once the wound is healed, scar massage and desensitisation settle the area, and grip is built back up. A bit of tingling or tenderness around the wound is common early on as the small skin nerves recover, and it usually settles over the following weeks. ## Precautions and limitations - Keep the dressing clean and dry until the wound is healed and the sutures are out (usually around day 10–14). There is no plaster and usually no splint, just a soft dressing. - Do start gentle finger movement within the first few days (bending, straightening and tendon glides) to prevent stiffness and tendon sticking. - Do keep the hand elevated and use it for light everyday tasks within comfort. - Do NOT do heavy gripping, lifting or forceful pinching until the wound has settled (around two to three weeks). - Do NOT massage the scar or soak the hand until the wound is fully healed. - Do NOT drive while the dressing stops you gripping the wheel safely, usually for about the first week. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### Finger movement (gentle fist and straighten) Within the first few days, gently make a soft fist and then straighten your fingers out fully, moving slowly and only as far as is comfortable. Early movement keeps the finger from stiffening and stops the tendons sticking to the healing wound. Do not force it — let the dressing and a little discomfort be your guide. 10 times, 3–4 times a day, within comfort Kieran Hirpara 4.0 #### Tendon glides (hook, fist, straight) Move your fingers through three shapes: a hook (bend the tips and middle joints but keep the knuckles straight, like a claw), a full fist, then a flat straight hand. These positions slide the flexor tendons through the surgical area so they keep gliding freely rather than sticking. Keep each one gentle and pain-free. 5 of each position, 3–4 times a day Kieran Hirpara 4.0 #### Swelling control Keep your hand raised up above the level of your heart as much as you can in the first week, and gently open and close the fingers to pump the swelling away. Less swelling means an easier, more comfortable finger and a freer recovery. A little swelling around the palm is normal early on. Elevate often through the day; gentle finger pumps every hour or so while awake Kieran Hirpara 4.0 #### Scar massage and desensitisation Once the wound is fully healed and the sutures are out (usually after about two weeks), rub a little moisturiser into the scar with firm small circles for a few minutes, and stroke the area with different textures (a soft cloth, then a towel). This softens the scar and settles the tenderness and tingling that are common at first as the small skin nerves recover. Do NOT massage an open or unhealed wound. A few minutes, 2–3 times a day, once fully healed Kieran Hirpara 4.0 #### Grip strengthening A LATER exercise — begin from around two to three weeks, once the wound has settled and your hand therapist is happy. Gently squeeze a soft ball or therapy putty, hold for a few seconds, then relax, building the effort up gradually. This rebuilds grip ready for full use. Stop if it is sharply painful over the wound. 10–15 squeezes, 2–3 times a day (from ~2–3 weeks) These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist, staying within whatever limits you have been given. The early exercises (gentle fist-and-straighten, tendon glides and swelling control) keep the finger moving and the tendons gliding from within the first few days, which is the single most important thing for a smooth recovery. Scar massage and desensitisation begin once the wound is fully healed, and grip strengthening belongs to a slightly later phase (from around two to three weeks). Stop anything that causes sharp pain over the wound. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after excision of a flexor sheath ganglion (volar retinacular cyst). This section is to be provided to your hand therapist, and each phase opens with a plain-English explanation of what is happening. This is an excision, not a repair: the tendon sheath is left open and there is no construct to protect. The programme is an early-motion pathway built around wound protection, oedema control, tendon gliding to prevent adhesion, and scar/desensitisation work, not protected immobilisation. Prior to treatment, check the operation report and past medical history, and liaise with the treating surgeon regarding the digit involved, the extent of sheath excision and the integrity of the digital neurovascular bundles. Dr Hirpara's excision is via a Bruner (zig-zag) palmar incision over the A1/proximal sheath, removing the cyst with a cuff of sheath; the sheath is not repaired and there is no immobilisation beyond a soft dressing. Transient digital-nerve paraesthesia is common and self-limiting. ### Phase I — wound protection and early motion (week 0 to ~1) The first week protects the small palm wound and gets the finger moving early so it does not stiffen or develop tendon adhesions. The hand is managed in a bulky soft dressing with no splint, kept elevated, with gentle active finger motion started within a few days. For your hand therapist: Education and precautions - Soft bulky dressing only, no splint; keep clean and dry until sutures out (~day 10–14) - Protect the wound from heavy load; light unloaded hand use within comfort - Counsel that transient digital-nerve paraesthesia / hypersensitivity around the wound is common and self-limiting Management - Wound: surgical dressing as directed; monitor for infection - Oedema: elevation above heart level, gentle finger pumping, ice as needed - Exercises: gentle active finger AROM (gentle composite fist and full extension) and tendon glides (hook / fist / straight) started within a few days; active motion of the uninvolved digits, thumb and wrist; light functional use Criteria to progress - Wound settling, no infection; comfortable early active arc; ready for full active/gentle passive motion as the wound permits ### Phase II — full motion, oedema and scar work (week ~1 to 3) From around one week, motion is progressed to full active and gentle passive range (full fist and full extension) and, once the wound is fully healed and sutures are out, scar massage and desensitisation begin. Oedema control continues. For your hand therapist: Assessments - Active and passive finger ROM (aim full fist and full extension); wound/scar status; swelling; digital-nerve sensitivity Education and precautions - Progress to full active and gentle passive finger motion as comfort allows - Begin scar massage and desensitisation only once the wound is fully healed - Avoid heavy gripping and forceful pinching until the wound has settled Management - Exercises: full composite fist and full extension; continued tendon glides; gentle passive stretch into any residual tightness - Scar: scar massage + textured desensitisation once healed; oedema management as needed Criteria to progress - Full, pain-free active motion; wound healed; settling scar; ready to load ### Phase III — strengthening and return (week ~3 to 6) Once the wound is healed and motion is full (around three weeks), grip and pinch strengthening begins and is built up gradually towards full unrestricted use. Most patients return to full activity by around four to six weeks, with a routine follow-up at about two months. For your hand therapist: Assessments - Grip and pinch versus the other side; residual scar tenderness or sensitivity; functional / task-specific demands Education and precautions - Begin grip and pinch strengthening from around 2–3 weeks once the wound has settled; build load gradually - Progress to full unrestricted use as comfort and strength allow Management - Exercises: putty / soft-ball grip squeezes, pinch strengthening, progressive functional loading; continue any residual scar work and desensitisation - Discharge once motion is full and grip is comfortable and near-symmetrical; routine surgical follow-up at ~2 months - Refer back to the treating doctor if recovery plateaus, the scar stays markedly hypersensitive, or there is concern about recurrence Criteria for full return - Full pain-free motion; comfortable grip and pinch; settled scar; able to meet work and activity demands ## Getting back to work and activity Light everyday hand use (eating, writing, light self-care) is encouraged from the start, within comfort, as long as it does not involve heavy gripping or forced pinching through the wound. Most people manage daily tasks within a few days. Driving usually resumes from about one week, once you can grip and control the wheel comfortably and are no longer limited by the dressing, confirmed with Dr Hirpara at your review. Gripping and strengthening start from around two to three weeks, once the wound has settled, and are built up gradually. Full, unrestricted activity is usually reached by around four to six weeks. Office work can often resume within a few days to a week; heavier manual work follows the same staged progression as your grip returns. A routine follow-up is usually arranged at about two months. ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain, wound care and scar management. Because this ganglion sits at the base of the finger over the A1 pulley, the recovery has much in common with other small palm-side finger-base procedures such as trigger finger release. The phased plan above reflects published guidance after ganglion excision, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your finger progresses. --- ### Flexor Tendon Repair URL: https://www.cqupperlimb.com/education/rehabilitation/flexor-tendon-repair/ Region: rehabilitation · rehabilitation An early-active-motion recovery plan after repair of a flexor tendon in the finger, using the Manchester short splint to move the healing tendon gently and safely from the first week while protecting the repair for six weeks. This protocol guides your recovery after surgical repair of a flexor tendon in the finger (the cord that runs down the palm side of the finger and bends it into the palm) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist: bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your hand therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect A flexor tendon repair stitches the cut ends of the tendon back together so the finger can bend again. The repair is strong enough to move gently straight away, but it is at its weakest in the first few weeks while the tendon knits, so the whole plan is built around moving it just enough to keep it gliding, without ever loading it hard enough to snap the stitches. To do this, your hand is rested in a special lightweight splint called the Manchester short splint. Unlike older, bulkier splints, it is short, ending at the wrist crease, so your wrist is left free. It lets your wrist move fully forwards and back to about 45 degrees, while a small block holds your big knuckles from straightening past about 30 degrees and leaves your finger joints free to move. You wear it full-time for six weeks, taking it off only as instructed for exercises and washing. The clever part is how the wrist is used. When you bend your wrist forwards, your finger straightens out almost by itself (this is called the tenodesis effect), and it lets you open the finger fully without your own muscles forcing it. When you bend your wrist back, it becomes easier and safer to gently curl the finger. Moving this way keeps the tendon sliding and, crucially, stops the finger from curling up into a stiff, bent position, the most common problem after this kind of repair. The early exercises (from about day 4–5) are gentle and specific: bending the finger passively first, then a light active 'hook' curl starting at the fingertip, then straightening the finger with the wrist bent. There is no hard gripping and no forced movement for six weeks. The splint comes off at six weeks, light strengthening starts, and most people return to full unrestricted use of the hand by ten to twelve weeks. ## Precautions and limitations - Wear the Manchester short splint full-time for six weeks: take it off only for your exercises and washing, as instructed. - Do NOT make a hard, tight fist and do NOT grip, lift, pull or carry anything with the operated hand for the first six weeks: heavy loading can rupture the repair. - Do NOT force the finger straight or force it bent; keep every movement gentle, within the range you have been shown. - You may use the hand for very light, safe tasks excluding the injured finger, as long as nothing pulls or strains it. - A snap or sudden 'give' with loss of finger bending may mean the tendon has ruptured: contact the rooms straight away if this happens. - Do NOT drive while you are in the splint; driving resumes after the splint is removed (about six weeks), once your grip and control are adequate and you have been cleared. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises #### Passive fist stretch (IP flexion) Use your other hand to gently curl the operated finger all the way into a fist, bending the finger joints fully — keep the finger completely relaxed so your other hand is doing all the work. This is done FIRST in every session to keep the finger joints supple and ready to move. It does not pull on the repair because your own muscle stays switched off. Move slowly and stop short of pain. 10 times, at the start of each session, several sessions a day #### Active hook fist from the DIP With your wrist bent back (extended) in or out of the splint, curl your fingertip down first to make a 'hook' — bending the end and middle joints while keeping the big knuckle straight. Hold gently, then release. Starting the curl at the fingertip glides the healing tendon the way it needs to. Use only gentle effort — never force it and never make a hard, tight fist. 10 times, several sessions a day as guided Kieran Hirpara 4.0 #### Tendon glides (hook to straight to full fist) Move gently through the tendon-gliding sequence: fingers straight, then a hook fist (fingertip curl), then a soft full fist, then back to straight. This keeps both flexor tendons sliding smoothly past each other and the surrounding tissue so they do not stick down. Keep every position light and easy — these are gliding movements, not strengthening, so there should be no straining. 5 of each position, several sessions a day as guided #### Finger straightening with the wrist bent (synergy) Let your wrist drop forwards (flexed) and then actively straighten your finger out. Bending the wrist this way naturally helps the finger straighten, so the finger extends easily without forcing. This is the key move that stops the finger curling up into a permanent bend — do it faithfully. Straighten only as far as it goes comfortably with the wrist helping; do not lever it straight. 10 times, several sessions a day as guided #### Place-and-hold Use your other hand to gently place the operated finger into a light fist, then let go and hold that position with just a whisper of your own muscle — barely enough to keep the finger there. This wakes the repaired tendon up safely because the hard work of bending is done by your other hand, and your own muscle only has to hold, not pull. Keep the effort tiny; relax fully between repeats. Hold a few seconds, 5–10 times, only as guided by your hand therapist Kieran Hirpara 4.0 #### Blocking (later, if adhesions) A LATER exercise — only if your tendon is sticking down and your hand therapist starts it. Steady your finger by holding the bone just below the joint you want to move, then actively bend that one joint on its own (for example, hold the middle of the finger still and curl just the fingertip). This concentrates the glide at a single joint to free a tendon that has become tethered. Do not start blocking on your own — it is more demanding and is added only when your therapist judges it safe. As guided by your hand therapist (later phase, only if needed) These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. Every session follows the same safe order: gently bend the finger passively first, then do your active 'hook' curl and tendon glides, then straighten the finger with the wrist bent to keep it from stiffening into a curl. Keep all of it light: this is gliding, not strengthening. Place-and-hold and blocking belong to later phases and should only be started when your hand therapist introduces them. Stop anything that causes sharp pain over the repair, and never make a hard fist before you are cleared. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after flexor tendon repair using the Manchester short splint and an early-active-motion (EAM) regimen. This section is to be provided to your hand therapist, and each phase opens with a plain-English explanation of what is happening. The repair is at its weakest in the early weeks and is loaded by active and resisted finger flexion (a hard fist); the protocol therefore protects against forceful flexion while deliberately driving tendon excursion and active IP extension to prevent the flexion contracture that is the principal nuisance complication. Prior to treatment, check the patient's operation report and past medical history, and liaise with the treating surgeon regarding the zone of injury, the core-suture configuration and strength of repair, any pulley venting, and concurrent digital nerve repair. Dr Hirpara's flexor repairs are managed in a Manchester short dorsal splint (ends at the wrist crease) permitting full wrist flexion and extension to 45°, with the MCP joints blocked at 30° of flexion and the IP joints free, worn full-time for six weeks. Night extension gutters are added only if an IP flexion deformity develops. ### Phase I — early active motion in the Manchester short splint (weeks 0 to 6) The first six weeks protect the knitting repair while keeping the tendon gliding and the finger from stiffening into a flexion contracture. The hand is splinted full-time in the Manchester short splint (full wrist flexion, extension to 45°, MCP block at 30°, IPs free). Active motion starts around day 4–5. Every session runs in a set order: passive IP flexion first, then active hook fist initiating at the DIP with the wrist extended, then active IP extension with the wrist flexed (synergistic, anti-contracture). No forced end-range and no resisted flexion. For your hand therapist: Education and precautions - Splint full-time in the Manchester short splint: full wrist flexion, extension to 45°, MCP blocked at 30°, IPs free; off only for exercises and hygiene - Begin EAM at day 4–5 - No forced end-range flexion and no resisted flexion; no gripping, lifting or pulling - Light "safe" use of the hand excluding the injured finger - Night extension gutter only if an IP flexion deformity begins to develop Management - Wound: surgical dressings as directed; monitor for infection - Oedema: elevation, gentle digital oedema control, manage adhesion risk - Exercise sequence each session: (1) full passive IP flexion first; (2) active hook fist initiating at the DIP with the wrist extended to 45°; (3) active finger extension with the wrist flexed (synergistic / tenodesis, anti-contracture); add place-and-hold to a light fist as guided - Hand-therapy review weekly through this phase Criteria to progress - Wound healed; repair intact at six weeks; tendon gliding maintained; no significant IP flexion contracture ### Phase II — out of the splint, soft-tissue and scar work (week 6) At six weeks the splint comes off. The focus shifts to recovering full passive and active range, releasing any early tightness, and managing the scar. Strengthening has not started yet; a night extension splint is used only if a residual flexion deformity remains. For your hand therapist: Assessments - Active and passive ROM at MCP/PIP/DIP; presence of any IP flexion contracture; tendon-gliding quality (assess for adhesion); scar and wound review Education and precautions - Splint discontinued at six weeks (night extension splint only for a residual IP flexion deformity) - Progress light functional use; still no resisted gripping or loading Management - Soft-tissue stretching to restore full composite flexion and extension; commence scar management once healed - Continue tendon glides; introduce blocking if adhesions are limiting differential glide - Progress light functional use of the hand Criteria to progress - Wound and scar settled; near-full passive ROM; gliding maintained; ready for graded strengthening ### Phase III — strengthening and return (weeks 6 to 12) With the repair more mature, graded stretching and progressive strengthening begin and are built up steadily towards unrestricted use. Return to full, unrestricted activity is expected at around ten to twelve weeks, criterion-based. For your hand therapist: Assessments - Composite ROM and any residual contracture; grip and pinch versus the other side; response of the repair to graded loading Education and precautions - Begin graded stretching and progressive strengthening from around six weeks; build load gradually - Avoid sudden maximal grip or resisted loading until strength is rebuilt Management - Progressive grip and pinch strengthening (putty → graded resistance); continue stretching for any residual tightness; continue scar work as needed - Advance towards full / unrestricted activity at 10–12 weeks - Consider discharge once ROM and strength are functional and a suitable return of activity is achieved; refer back to the treating surgeon if recovery plateaus or a flexion contracture persists Criteria for return to full activity - Functional composite ROM; adequate, near-symmetrical grip and pinch strength; pain-free unrestricted use, typically by 10–12 weeks ## Getting back to work and activity Light, safe use of the hand (excluding the injured finger) is encouraged from the start within the splint, as long as nothing pulls, grips or strains the repair. Plan for help in the early weeks, because there is no gripping, lifting or carrying with the operated hand for the first six weeks. The splint comes off at about six weeks, and light strengthening begins from then. Because you must not drive while you are in the dorsal splint, arrange transport for the first six weeks. Driving resumes after the splint is removed (about six weeks), once your grip and finger control are adequate and you have been cleared at your review. Return to full, unrestricted activity, including firm gripping and heavier tasks, is expected around ten to twelve weeks, built up gradually and judged by Dr Hirpara and your hand therapist on how the finger is moving and how strong it is, not by the calendar alone. ## After your protocol This protocol works alongside the practice's general recovery advice; see also managing post-operative pain, wound care and scar management. The phased plan above reflects published early-active-motion rehabilitation guidance after flexor tendon repair, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your finger progresses. --- ### Inpatient exercises — capsular release & subacromial decompression URL: https://www.cqupperlimb.com/education/rehabilitation/inpatient-capsular-release-and-decompression/ Region: rehabilitation · rehabilitation Early in-hospital exercises after capsular release or subacromial decompression — gentle movement with a comfort-only sling to keep the shoulder moving freely. These are the gentle exercises to begin in hospital after a capsular release or a subacromial decompression. For these operations the priority is to keep the shoulder moving freely. ## Your exercises Kieran Hirpara 4.0 #### Wrist movement Keep your hand moving by bending your wrist forwards, backwards and side to side. 10 times, 3 times per day Kieran Hirpara 4.0 #### Open and close hand Keep your hand and fingers moving by opening and closing them, or by squeezing a stress ball. 10 times, 3 times per day Kieran Hirpara 4.0 #### Elbow bends Bend and straighten your elbow. 10 times, 3 times per day Kieran Hirpara 4.0 #### Pendulums This is a passive exercise. Lean forward and let your arm relax down. Use your body to move the arm gently either clockwise or anti-clockwise, along with forwards, backwards and side to side. About 30 seconds each way, 3 times per day Kieran Hirpara 4.0 #### Assisted abduction Sitting on a chair and leaning forward, cradle the operated arm and help it out to the side (like rocking a baby). 10 times, 3 times per day Kieran Hirpara 4.0 #### Assisted external rotation with a stick Lie on your back with your elbow tucked by your side and bent to a right angle. Hold a stick in both hands and use your good arm to turn the operated hand outwards, rotating the shoulder. After this operation there is no limit on how far out you go, so gently push the range a little further as it frees up. 10 times, 3 times per day Kieran Hirpara 4.0 #### Assisted forward flexion (lying) If you prefer, lie on your back and hold a stick or a rolled towel in both hands. Use your good arm to push the operated arm up over your head, as far as it will comfortably go, then lower it slowly. Push into a firm stretch each time. 10 times, 3 times per day Kieran Hirpara 4.0 #### Over-door pulley Sit under an over-door pulley with a handle in each hand. Pull down with your good arm to raise the operated arm overhead as far as it will go, then lower slowly. Take it to a firm stretch each time, not severe pain. 10 times, 3 times per day Kieran Hirpara 4.0 #### Lower trapezius setting Squeeze your shoulder blades downwards and together. Hold 5 seconds, 5 times, 3 times per day Kieran Hirpara 4.0 #### Upper trapezius stretch Use your non-operated arm to bring your ear towards your shoulder, away from the operated side. Hold 10 seconds, 3 times, 3 times per day Kieran Hirpara 4.0 #### Levator scapulae stretch Use your non-operated arm to bring your nose towards your armpit area, away from the operated side. Hold 10 seconds, 3 times, 3 times per day Kieran Hirpara 4.0 #### Assisted forward elevation (sitting) Sitting and leaning forward slightly, support the operated forearm with your good hand and use it to lift the operated arm forwards and up in front of you, as far as is comfortable, then lower it slowly. Let the good arm do the work so the operated shoulder stays relaxed. As guided by your physiotherapist Begin these gentle exercises in hospital and continue them at home. They should be comfortable; ease back if pain increases. ## Wearing your sling - The sling is only to be worn for comfort, and should be left off as much as possible. You don't need to sleep in the sling. - Move and use your arm as much as possible. - It is advisable to wear the sling when out of the house, to prevent people knocking into your arm. - Aim for physiotherapy sessions at least twice a week for the first six weeks. - Use ice for pain relief if needed. - When wearing your sling, relax your shoulder and let the sling take the weight of your arm. - Take your painkillers before you do your exercises, and before your physiotherapy appointments. - Unless you have arranged your own physiotherapy, an appointment has been made for you and is detailed in your discharge pack. - If you have any problems, contact the rooms or let your physiotherapist know. ## When you go home Once you are home, your recovery continues with the full rehabilitation protocol for your operation: capsular release; subacromial decompression. These early in-hospital exercises are adapted from published patient guidance and rehabilitation protocols for these procedures, and the timing is typical rather than fixed; your physiotherapist guides your recovery individually based on how your shoulder responds. The evidence behind this early phase (why the priority after a capsular release is immediate movement rather than protecting the shoulder) is summarised in the evidence section, available as a PDF from the top of this page. --- ### Inpatient exercises — rotator cuff & stabilisation URL: https://www.cqupperlimb.com/education/rehabilitation/inpatient-rotator-cuff-and-stabilisation/ Region: rehabilitation · rehabilitation Early in-hospital exercises after rotator cuff repair or shoulder stabilisation — gentle hand, elbow and shoulder movement, with six-week sling precautions. These are the gentle exercises to begin in hospital after a rotator cuff repair or a shoulder stabilisation. They keep the hand, elbow and shoulder moving while the repair heals. ## Your exercises Kieran Hirpara 4.0 #### Wrist movement Keep your hand moving by bending your wrist forwards, backwards and side to side. 10 times, 3 times per day Kieran Hirpara 4.0 #### Open and close hand Keep your hand and fingers moving by opening and closing them, or by squeezing a stress ball. 10 times, 3 times per day Kieran Hirpara 4.0 #### Elbow bends Bend and straighten your elbow. 10 times, 3 times per day Kieran Hirpara 4.0 #### Pendulums This is a passive exercise. Lean forward and let your arm relax down. Use your body to move the arm gently either clockwise or anti-clockwise, along with forwards, backwards and side to side. About 30 seconds each way, 3 times per day Kieran Hirpara 4.0 #### Assisted forward flexion Sitting on a chair and leaning forward, cradle your operated arm with the other arm and gently move it upwards in front of you. Lower it back down with the help of your non-operated arm. You could also lie on your back in bed and help the arm upwards if you prefer. 10 times, 3 times per day Kieran Hirpara 4.0 #### Assisted abduction Sitting on a chair and leaning forward, cradle the arm again and help it out to the side (like rocking a baby). 10 times, 3 times per day Kieran Hirpara 4.0 #### External rotation Sitting on a chair, only move your arm from where it sits in the sling to pointing straight in front of you. Don't go further outwards. 10 times, 3 times per day Kieran Hirpara 4.0 #### Lower trapezius setting Squeeze your shoulder blades downwards and together. Hold 5 seconds, 5 times, 3 times per day Kieran Hirpara 4.0 #### Upper trapezius stretch Use your non-operated arm to bring your ear towards your shoulder, away from the operated side. Hold 10 seconds, 3 times, 3 times per day Kieran Hirpara 4.0 #### Levator scapulae stretch Use your non-operated arm to bring your nose towards your armpit area, away from the operated side. Hold 10 seconds, 3 times, 3 times per day Begin these gentle exercises in hospital and continue them at home. They should be comfortable; ease back if pain increases. ## Wearing your sling - You are allowed to take your arm out of the sling for your exercises and for showering. - You need to wear your sling for 6 weeks, especially when out of the house. - You don't need to sleep in the sling. - Use ice for pain relief if needed. - When wearing your sling, relax your shoulder and let the sling take the weight of your arm. - Take your painkillers before you do your exercises, and before your physiotherapy appointments. - Unless you have arranged your own physiotherapy, an appointment has been made for you and is detailed in your discharge pack. - If you have any problems, contact the rooms or let your physiotherapist know. ## When you go home Once you are home, your recovery continues with the full rehabilitation protocol for your operation: rotator cuff repair; anterior stabilisation & Latarjet; posterior stabilisation. ## After your protocol These early exercises are the in-hospital starting point shared by rotator cuff repair and shoulder stabilisation: they keep the hand, elbow and shoulder gently moving while the repair is protected. The doses are typical rather than fixed, and your ongoing rehabilitation is guided individually by your physiotherapist, working with the practice, based on how your shoulder recovers. This page works alongside the practice's general recovery advice; see managing post-operative pain and wound care. The full, operation-specific course continues in your own protocol (linked above). The evidence behind this early phase (the early-versus-delayed motion research after cuff repair and the immobilisation evidence after stabilisation) is summarised in the evidence section, available as a PDF from the top of this page. --- ### Inpatient exercises — shoulder replacement URL: https://www.cqupperlimb.com/education/rehabilitation/inpatient-shoulder-replacement/ Region: rehabilitation · rehabilitation Early in-hospital exercises after a shoulder replacement (total, reverse, or for fracture) — gentle hand, elbow and shoulder movement, with sleep-in-sling precautions for the first six weeks. These are the gentle exercises to begin in hospital after your shoulder replacement (total, reverse, or replacement for a fracture). They keep the hand, elbow and shoulder moving while the repair settles. ## Your exercises Kieran Hirpara 4.0 #### Wrist movement Keep your hand moving by bending your wrist forwards, backwards and side to side. 10 times, 3 times per day Kieran Hirpara 4.0 #### Open and close hand Keep your hand and fingers moving by opening and closing them, or by squeezing a stress ball. 10 times, 3 times per day Kieran Hirpara 4.0 #### Elbow bends Bend and straighten your elbow. 10 times, 3 times per day Kieran Hirpara 4.0 #### Pendulums This is a passive exercise. Lean forward and let your arm relax down. Use your body to move the arm gently either clockwise or anti-clockwise, along with forwards, backwards and side to side. About 30 seconds each way, 3 times per day Kieran Hirpara 4.0 #### Assisted forward flexion Sitting on a chair and leaning forward, cradle your operated arm with the other arm and gently move it upwards in front of you. Lower it back down with the help of your non-operated arm. You could also lie on your back in bed and help the arm upwards if you prefer. 10 times, 3 times per day Kieran Hirpara 4.0 #### Assisted abduction Sitting on a chair and leaning forward, cradle the arm again and help it out to the side (like rocking a baby). 10 times, 3 times per day Kieran Hirpara 4.0 #### External rotation Sitting on a chair, only move your arm from where it sits in the sling to pointing straight in front of you. Don't go further outwards. 10 times, 3 times per day Kieran Hirpara 4.0 #### Lower trapezius setting Squeeze your shoulder blades downwards and together. Hold 5 seconds, 5 times, 3 times per day Kieran Hirpara 4.0 #### Upper trapezius stretch Use your non-operated arm to bring your ear towards your shoulder, away from the operated side. Hold 10 seconds, 3 times, 3 times per day Kieran Hirpara 4.0 #### Levator scapulae stretch Use your non-operated arm to bring your nose towards your armpit area, away from the operated side. Hold 10 seconds, 3 times, 3 times per day Kieran Hirpara 4.0 #### Rhythmic stabilisation With your arm supported in front of you at about shoulder height, have your physiotherapist (or your good hand) apply small, gentle pushes from different directions while you hold the arm still and steady — do not let it move. This trains the shoulder's stabilising muscles to react. Keep all the efforts gentle. As guided by your physiotherapist Begin these gentle exercises in hospital and continue them at home. They should be comfortable; ease back if pain increases. If you had a reverse replacement, you can start moving the shoulder early; begin with assisted and gravity-assisted movements (easiest lying on your back, letting gravity help), then add gentle active movement as your comfort allows, staying within what feels comfortable. Just keep clear of the positions to avoid listed under "Wearing your sling." If you had a total (anatomic) replacement or a replacement for a fracture, keep your early movements assisted and gentle as shown; let your other arm do the work, and don't push the operated arm outwards past where the exercises ask, so the healing repair at the front of the shoulder is protected. ## Wearing your sling How long you wear the sling depends on which replacement you had; please follow the rule for your operation. If you had a reverse replacement: - The sling is mainly for comfort and support, and you'll wear it for about 2 weeks rather than full-time for 6 weeks. - You can take your arm out of the sling for your exercises and for showering. - You can start gentle shoulder movements straight away (see your exercises); there's no need to keep the arm completely still. - There are a few positions to avoid in the early weeks while everything settles: don't reach your arm behind your body or behind your back, don't combine reaching backwards with turning the arm inwards, don't lift anything, and don't push up through your hands (for example, pushing yourself up out of a chair). Your physiotherapist will go through these with you. If you had a total (anatomic) replacement, or a replacement for a fracture: - You need to sleep in the sling. - You are allowed to take your arm out of the sling for your exercises and for showering. - You need to wear your sling for 6 weeks, especially when out of the house. - A repair at the front of your shoulder needs time to heal, so your early movements are gentler and more guarded; keep to the assisted exercises shown and don't force the arm outwards past where the exercises ask. For everyone: - Use ice for pain relief if needed. - When wearing your sling, relax your shoulder and let the sling take the weight of your arm. - Take your painkillers before you do your exercises, and before your physiotherapy appointments. - Unless you have arranged your own physiotherapy, an appointment has been made for you and is detailed in your discharge pack. - If you have any problems, contact the rooms or let your physiotherapist know. ## When you go home Once you are home, your recovery continues with the full rehabilitation protocol for your operation: reverse shoulder replacement; total shoulder replacement; shoulder replacement for fracture. The evidence behind this early in-hospital phase (why the sling and gentle movements matter, why a reverse replacement can move early and freely with the main caution being to keep the arm from reaching behind the body, and why a total replacement is more guarded with external rotation limited to protect the repair at the front of the shoulder) is summarised in the evidence section, available as a PDF from the top of this page. --- ### Latarjet Procedure URL: https://www.cqupperlimb.com/education/rehabilitation/latarjet/ Region: rehabilitation · rehabilitation Rehabilitation protocol after the Latarjet coracoid bone-block transfer for anterior shoulder instability — union-gated loading and subscapularis/graft precautions. This protocol guides your recovery after a Latarjet procedure with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It pairs a plain-English explanation of each stage with a structured programme you can share with your physiotherapist; bring this page or its PDF to your first appointment so your rehabilitation stays coordinated. Your physiotherapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect A Latarjet is a bone-block operation for a shoulder that keeps dislocating at the front. Because it uses solid bone fixed with screws (rather than only stitched-up soft tissue), the repair is sturdy early, and your recovery is generally faster than for a soft-tissue stabilisation (a Bankart repair). On average, people return to sport at around 20 weeks, compared with roughly 32 weeks after a Bankart. But "faster" does not mean "anything goes". The pace of your recovery is set by one thing above all: the transferred bone healing onto your shoulder socket. This bony join (called union) usually takes about 6 to 8 weeks. Until your surgeon confirms it has united, loading the shoulder is held back, no matter how good the arm feels. The Latarjet also has two extra structures to protect that a Bankart does not, which is why some of the early restrictions below are specific to this operation. ## The procedure In a Latarjet, a small piece of bone called the coracoid (a bony bump at the front of your shoulder blade) is moved across and fixed with screws to the front rim of your shoulder socket, where bone has been lost. This adds bone where it was missing and creates a "sling" effect at the front of the shoulder that helps stop it dislocating. To move that bone into place, the surgeon has to pass it through the subscapularis (a muscle at the front of the shoulder), which is split, or partly detached and then repaired. Two things therefore need protecting while they heal: - the bone block and its screws, which must knit onto your socket (union, about 6–8 weeks); and - the subscapularis muscle at the front, which is repaired around the transferred bone. Some people are left with a small permanent loss of outward-rotation range (turning the hand outward) of roughly 7–8 degrees. This is expected and is not a complication; for most people it makes no difference to daily life. ## Wearing your sling You will wear a simple shoulder sling, not an abduction-pillow or wedge sling. Dr Hirpara uses a simple sling for stabilisation surgery, because the bone fixation is sturdy and protection comes mainly from keeping the arm in a safe position, not from the sling's shape. - Wear the sling for about 3 weeks for daytime support and comfort (it is weaned off from about week 3). The bony Latarjet needs a shorter time in a sling than a soft-tissue repair. - You do not sleep in the sling. Sleep with it off; keep your arm in a safe position while you are asleep: do not let it fall out to the side and turned outwards (the position the operation is protecting against). Lying with the arm supported on a pillow across your body or by your side is comfortable and safe. - Take it off for showering and for your exercises (once you have been shown how). Whenever the sling is off, keep your arm relaxed and by your side. - Use ice if the shoulder is swollen or sore, especially after exercise. Watch your posture while you are using the sling: keep your ears, shoulders and hips in line and avoid slumping. ## Key precautions — do NOT These protect the bone block, its screws, and the front muscle while they heal. - Do NOT force the arm into outward rotation (turning the hand outward) early. In the first 2 weeks, outward rotation is kept to about 25 degrees in a supported position, and only opened up gradually after that, always within the range your surgeon sets. - Do NOT push the arm backwards behind your body (shoulder extension), and avoid the combined position of the arm turned outward and stretched backwards. This pulls on the tendon attached to the transferred bone. - Do NOT do resisted inward-rotation strengthening early (pressing the hand hard inwards across the body against resistance). This works the healing front muscle (subscapularis) and is held back until your surgeon agrees. - Do NOT bear weight through the arm or hand, push up from a chair with the arm, or lift, push or pull anything heavy until your surgeon confirms the bone has united (about 6–8 weeks). The bony join, not the calendar, decides when heavier loading can begin. - Do NOT do heavy chest or overhead gym work early: no pec flys, wide-grip bench press, military (overhead) press, behind-the-neck lat pulldowns or triceps dips until late in your recovery. - Avoid any sudden jerk, grab or fall onto the arm. ## Phase I — Immediate protection (weeks 0–2) Kieran Hirpara 4.0 #### Open and close hand Make a tight fist with your hand, then open it fully. This keeps your hand moving and helps prevent stiffness and swelling. 10 times per hour Kieran Hirpara 4.0 #### Active wrist bends Gently bend your wrist forwards, then back, as far as is comfortable. 10–15 times per hour Kieran Hirpara 4.0 #### Active elbow bends With your palm facing up, gently bend your elbow as far as you can, then straighten your arm again. Keep your upper arm tucked at your side. Do NOT let the arm swing backwards behind your body. 10–15 times, 2–3 times a day Kieran Hirpara 4.0 #### Pendulum swings Lean forwards and let your operated arm hang down, completely relaxed. Make small circles — clockwise, then the other way — by rocking your body, NOT by using your shoulder muscles. Keep the circle small (under about 20 cm). Your operated arm stays relaxed throughout — you are not lifting it. Do NOT let the arm drift backwards behind your body. 10 in each direction, 2–3 times a day Kieran Hirpara 4.0 #### Shoulder-blade setting Gently squeeze your shoulder blades downwards and together, hold, then relax. This is a light muscle-activation drill — your arm does not move. Hold 5 seconds, 5 times, 2–3 times a day Kieran Hirpara 4.0 #### Ball squeeze Hold a soft ball or rolled-up sock in your hand and squeeze gently, then relax. This keeps the hand and forearm active while the shoulder rests. 10 times, 2–3 times a day The first two weeks are about protecting the freshly transferred bone block and the repaired front muscle while the swelling settles. You wear the simple sling in the day, sleep out of it (keeping the arm in a safe position), and do gentle drills that keep your hand, wrist and elbow moving without stressing the shoulder. The shoulder itself is moved only gently and passively; you do not lift the arm under its own power yet. - Sling: simple sling for daytime support and comfort; sleep OUT of the sling with the arm in a safe position; off for exercises and hygiene. - Movement allowed: gentle assisted and passive movement only; no lifting the arm under your own shoulder power. Forward elevation and reaching out to the side to comfort; outward rotation kept to about 25 degrees in a supported position; do not push the arm backwards behind the body. - Exercises: shoulder-blade setting; ball squeeze; gentle hand, wrist and elbow movement; pendulum swings (arm relaxed, not drifting backwards). Ready for the next phase when: your pain is settling and controlled with simple pain relief; your wound has healed with no signs of a problem; you are comfortable out of the sling; and your gentle movement stays within the safe range your surgeon has set. ## Phase II — Restoring movement (weeks 3–9) Kieran Hirpara 4.0 #### Full-can lift to shoulder height From about week 6, once you are moving the arm under your own power. Raise your arm forwards and slightly out to the side with your THUMB POINTING UP — the "full can" position — only up to about shoulder height (90°) at first, then lower with control. Use no weight or a very light weight (about 1–1.5 kg) and many repetitions. As guided by your physiotherapist Kieran Hirpara 4.0 #### External rotation at the side (band) From about week 6, within the outward-rotation range your surgeon has set. Tuck your elbow at your side with a rolled towel between your elbow and your body, and your elbow bent to 90°. Rotate the forearm gently outwards against a light band, then return with control. Stay inside your safe range and never force it. Use a light band and many repetitions, not heavy resistance. As guided by your physiotherapist Kieran Hirpara 4.0 #### Internal rotation with a stick From about week 6, gently and only as guided. Keep your elbow tucked at your side and use a stick in your good hand to rotate the operated forearm gently inwards across your stomach, then return. This is gentle movement only — do NOT push hard or add resistance early, as the front of your shoulder (the subscapularis muscle) is still healing. As guided by your physiotherapist Kieran Hirpara 4.0 #### Low row (shoulder-blade setting) From about week 6. With your hand on a fixed surface beside you, press down and back to draw the shoulder blade down and in, holding briefly. This steadies the shoulder blade. As guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric external rotation From about week 6, if your physiotherapist agrees and only within your safe range. Stand with your elbow tucked at your side and bent to 90°, the back of your hand near a wall or door frame. Press the back of your hand gently outwards into the surface WITHOUT letting the arm move — a gentle effort, about a quarter of your strength, with no pain. Hold, then relax. Hold ~5 seconds, gentle (~25% effort), as guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric internal rotation Held back until later (usually after the graft has united and your surgeon agrees), because pressing inwards works the healing front muscle (subscapularis). When cleared, stand with your elbow tucked at your side, palm against a wall, and press the palm gently inwards WITHOUT letting the arm move — about a quarter effort, no pain. Hold, then relax. Hold ~5 seconds, gentle (~25% effort), as guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric abduction From about week 6, if your physiotherapist agrees. Stand side-on with the outside of your upper arm near a wall, elbow at your side. Press the arm gently outwards into the wall WITHOUT letting it move — about a quarter effort, no pain. Hold, then relax. Hold ~5 seconds, gentle (~25% effort), as guided by your physiotherapist Now the focus is movement, not strength. The sling is weaned off from about week 3. You progress from assisted movement to moving the arm under your own power, and outward rotation is gradually opened up; early on to about 45 degrees in a supported position, then further to tolerance from about week 6, always within your surgeon's limits. Light press-and-hold (isometric) drills are added, keeping inward-rotation effort gentle to protect the front muscle. Loading still waits; the bone block is only just uniting through this phase. - Sling: weaned off from week 3. - Movement allowed: assisted movement building to movement under your own power by about week 6 (towards roughly 90–110° of elevation). Outward rotation opened up gradually; early about 45 degrees in support, later to tolerance, within the range your surgeon sets. Inward rotation gently to about 45 degrees. - Exercises: full-can lift to shoulder height; gentle outward-rotation band work over a towel roll; gentle inward rotation with a stick (no force); low row; gentle press-and-hold isometrics for outward rotation and abduction from about week 6 (inward-rotation isometrics held back until later). Your physiotherapist may also add gentle rhythmic stabilisation (hold-steady drills where they push lightly on your arm and you resist) to retrain control; this is hands-on work with no diagram. Ready for the next phase when: your surgeon has confirmed (usually on review around 6–8 weeks) that the bone block has united; you can move the arm under your own power with good control; your assisted and passive movement is full or nearly full and comfortable; and gentle isometrics cause no pain flare afterwards. Strengthening does not begin until union is confirmed: this is gated by the bone healing, confirmed by your surgeon, not by the calendar. ## Phase III — Strengthening (weeks 10–15) Kieran Hirpara 4.0 #### Full-can lift with a light weight From about week 10, once your surgeon has confirmed the bone block has united. The full-can lift as before, now building height and adding a light weight gradually. Keep the THUMB UP. Stop if the shoulder is painful or swells afterwards. As guided by your physiotherapist Kieran Hirpara 4.0 #### Light biceps curls From about week 10, once union is confirmed. With your upper arm tucked at your side, bend your elbow to curl a light weight, then lower with control. Build the weight gradually. The biceps tendon attaches close to the bone block, so start light and progress slowly. As guided by your physiotherapist Kieran Hirpara 4.0 #### Internal rotation up the back, with a stick (option 1) From about week 12, once your surgeon and physiotherapist are happy the front muscle (subscapularis) has healed. Hold a stick behind your back and use your good hand to draw the operated hand gently up your back, then lower with control. Keep it comfortable and within your physiotherapist's limits. As guided by your physiotherapist Kieran Hirpara 4.0 #### Internal rotation with a light weight, side-lying (option 2) An alternative to the stick version, with the same timing (from about week 12, once the front muscle has healed). Lie on your operated side with the elbow tucked at your waist and bent to 90°; rotate the forearm so the hand lifts a light weight towards your tummy, then lower with control. Your physiotherapist will pick whichever version suits you — both build the same inward-rotation strength. As guided by your physiotherapist Kieran Hirpara 4.0 #### Resistance-band row From about week 10, once union is confirmed. With a band anchored in front of you, pull the handles towards you, drawing your elbows back and squeezing your shoulder blades together, then return with control. Light band, high repetitions; stop if the shoulder becomes painful. As guided by your physiotherapist Kieran Hirpara 4.0 #### Push-up-plus (wall) From about week 10, once union is confirmed. Start against a wall (not the floor). Do a slow push-up; at the top, push a little further so your shoulder blades spread apart and your upper back rounds slightly. Keep your elbows from going further back than your shoulders. This works the front muscle (subscapularis) — keep it light and pain-free. As guided by your physiotherapist Kieran Hirpara 4.0 #### Forward punch (supine) From about week 10, once union is confirmed. Lie on your back, arm pointing up towards the ceiling, holding a light weight or none. Reach the hand a little further up towards the ceiling so the shoulder blade lifts off the bed, then lower with control. A gentle subscapularis drill — keep it light. As guided by your physiotherapist Kieran Hirpara 4.0 #### Rhythmic stabilisation With your arm supported in front of you at about shoulder height, have your physiotherapist (or your good hand) apply small, gentle pushes from different directions while you hold the arm still and steady — do not let it move. This trains the shoulder's stabilising muscles to react. Keep all the efforts gentle. As guided by your physiotherapist Once your surgeon has confirmed the bone has united, you can start to load the shoulder. Strengthening uses light bands and light weights to begin with: high repetitions and low loads, building gradually. The golden rule is one direction at a time: you only strengthen in a direction once you have comfortable, near-full movement in it. Inward-rotation and front-muscle (subscapularis) strengthening is still introduced carefully and later, as that muscle was repaired during your operation. - Sling: none; near-full, comfortable movement expected before loading a direction. - Exercises: full-can lift with a light, increasing weight; light biceps curls; resistance-band rows; wall push-up-plus and supine forward punch for the front muscle; internal rotation up the back with a stick (gentle, from about week 12 once the front muscle has healed). Build loads gradually and stop if the shoulder is painful or swells. Ready for the next phase when: you have full, pain-free movement under your own power with good shoulder-blade control; no pain or swelling after strengthening sessions; comfortable resisted lifting below shoulder height; and your outward-rotation strength is building towards the other side. ## Phase IV — Overhead and return to sport (weeks 16–20) Kieran Hirpara 4.0 #### Overhead full-can lift From about week 16, once your strength below shoulder height is good. Raise your arm forwards and slightly out to the side with your THUMB UP, now progressing above shoulder height, with a light, gradually increasing weight. Stop if the shoulder is painful or swells afterwards. As guided by your physiotherapist Kieran Hirpara 4.0 #### Progressive resistance-band row Continue the band row, now building the resistance and repetitions as a base for heavier work and sport-specific conditioning. Keep good shoulder-blade control. As guided by your physiotherapist This phase is the bridge back to a fully working shoulder and a graduated return to sport and heavier work. You keep the range you have won and build the strength, power and endurance to use it confidently, including overhead. Returns are staged, not sudden; for sport, an interval programme that builds volume and intensity step by step is the safest route back. - Sling: none. - Exercises: overhead full-can lifts with a light, increasing weight once strength below shoulder height is good; progressive band rows; sport- and work-specific conditioning and, late in the phase, controlled higher-speed (plyometric) drills as appropriate. Push-ups may be added with the elbows kept from travelling far back. Ready to return when: your outward-rotation strength is within about 8–10% of the other side and your overall rotation strength is building evenly; you have full, pain-free movement with no reactive swelling under heavier load; and you pass the task-specific tests for your sport or job. Return to sport is usually around 20 weeks, and contact or collision sport is often a little later (around 5–6 months), based on meeting these criteria and on Dr Hirpara's and your physiotherapist's clearance, not the calendar alone. ## Returning to sport and work Your return is criteria-based: pain-free, with adequate range, strength and endurance, and signed off by both Dr Hirpara and your physiotherapist, not decided by the calendar alone. Because the Latarjet uses solid bone, recovery is generally quicker than a soft-tissue repair, but everything heavier than gentle movement waits until the bone block has united (about 6–8 weeks, confirmed by your surgeon). - Light, chest-level activity returns from around 10–15 weeks. - Overhead and throwing activity from around 4 months. - Return to sport is around 20 weeks on average; full contact or collision sport is often around 5–6 months, and always once you meet the strength and movement criteria. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain and wound care. --- ### Lateral Epicondylitis (Tennis Elbow) URL: https://www.cqupperlimb.com/education/rehabilitation/lateral-epicondylitis/ Region: rehabilitation · rehabilitation A loading-based rehabilitation program for tennis elbow — settling pain then progressively strengthening the tendon — covering both non-operative care and recovery after ECRB tendon debridement. This page explains how tennis elbow is managed and how to rehabilitate it, whether you are treating it without surgery (which is the case for almost everyone) or recovering after an operation to clean up the tendon. It is overseen by Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your physiotherapist or hand therapist; bring this page or its PDF to your therapy visits so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. ## What to expect Tennis elbow (lateral epicondylitis) is a problem with the tendon on the outside of the elbow, specifically the common extensor tendon and in particular a small muscle called the ECRB. Despite the "-itis" in the name, it is not an inflammation that you can rest away. It is a wear-and-tear change in the tendon (a tendinosis), where the tendon fibres have become disorganised and have not healed properly. This matters because it completely changes the treatment. You do not get better by resting and protecting the elbow; in fact, prolonged rest tends to make the tendon weaker and slower to settle. You get better by gradually loading the tendon so that it remodels and rebuilds its tolerance for work and gripping. The pattern is: first settle the pain down, then progressively strengthen, starting with gentle held (isometric) exercises and building up to controlled, slow strengthening such as the Tyler twist. The good news is that tennis elbow usually settles on its own with the right loading program. Around 80–90% of people are better within a year, though it can occasionally take 12–18 months to fully resolve. Surgery is only considered after at least six months of good-quality, consistent rehabilitation has failed, and only a small minority (roughly 4–11%) ever reach that point. ## Precautions and limitations Do: - Keep using the arm: load the tendon, do not rest it. - Use pain as your guide: a mild ache during and after exercise is fine and expected; sharp or escalating pain means ease back. - Lift with the palm facing up (like carrying a bowl of soup) to take load off the sore tendon. - Use a counterforce brace over the forearm muscle during gripping and lifting tasks. Do not: - Do not immobilise the elbow in a cast or sling for tennis elbow that is being treated without surgery; that is the wrong treatment for a tendinosis. (After surgery is different: a sling is used for comfort in the first week, as set out in the post-operative pathway below.) - Do not do heavy provocative gripping with the elbow straight and the wrist bent (for example, lifting a heavy object palm-down). - Do not rush to a steroid injection. Cortisone can feel good for a few weeks, but the evidence shows it leads to worse results and more recurrences at 6–12 months than physiotherapy or simply waiting. It is not a first-line treatment. ## Your exercises Kieran Hirpara 4.0 #### Counterforce brace Wear the counterforce strap around your forearm, a couple of finger-widths below the elbow, over the bulk of the muscle (not on the bony point itself). It should be firm but not tight enough to make your hand tingle. Use it during gripping and lifting tasks to take load off the sore tendon; you do not need to wear it at rest or in bed. During aggravating activities; loosen if your hand tingles Kieran Hirpara 4.0 #### Isometric wrist extension Rest your forearm on a table with your palm facing down and your hand over the edge. Place your other hand on the back of your sore hand. Try to lift the back of your hand towards the ceiling while your other hand holds it still, so nothing actually moves — this is a held, push-against-resistance exercise. It should feel like firm effort but should not sharply hurt. Hold the push, then relax. Hold 30–45 seconds, 5 times, 1–2 times daily Kieran Hirpara 4.0 #### Wrist extensor stretch Hold your sore arm out in front of you with the elbow straight and the palm facing down. With your other hand, gently bend the wrist down so the fingers point towards the floor, until you feel a comfortable pull along the top of your forearm. Keep the elbow straight. Start with the elbow slightly bent if straightening it is too sharp, and progress to a fully straight elbow as it eases. Hold 30 seconds, 3 times, 2–3 times daily Kieran Hirpara 4.0 #### Wrist flexor stretch Hold your arm out in front of you with the elbow straight and the palm facing up. With your other hand, gently pull the fingers and wrist back and down until you feel a comfortable pull along the underside of your forearm. Keep the elbow straight. Hold 30 seconds, 3 times, 2–3 times daily Kieran Hirpara 4.0 #### Tyler twist (eccentric wrist extension) Hold a flexible rubber bar (FlexBar) vertically in your sore hand with the wrist bent back. Grip the top of the bar with your other hand and twist it. Now bring the bar in front of you, keeping the twist, and slowly let your sore wrist uncurl under control over 3–4 seconds — this slow, controlled lowering is the part that builds the tendon. The unwinding should feel like work, but not sharp pain. Mild ache during and a little afterwards is expected and is fine. 3 sets of 15, once daily (the core strengthening exercise) Kieran Hirpara 4.0 #### Forearm rotation Tuck your elbow into your side and bend it to a right angle. Slowly rotate your forearm so the palm faces up, then turn it so the palm faces down, keeping the elbow tucked in. As it gets easier, hold a light weight such as a hammer or a tin to add load. 10 each direction, 2–3 times daily; add light weight as able Kieran Hirpara 4.0 #### Grip strengthening Squeeze a soft ball or therapy putty in your hand, hold the squeeze briefly, then relax. Build up the firmness of the squeeze gradually as your tendon tolerates more. If gripping is still very sore, start later and lighter — grip work belongs in the strengthening phase, once the early irritation has settled. 10–15 squeezes, 2–3 times daily; progress firmness as tolerated These are the exercises from your handout. They follow the recovery in order: the counterforce brace and isometric holds help settle pain early, the stretches keep the forearm supple, and the Tyler twist, forearm rotation and grip work build the tendon back up. Start them as guided by Dr Hirpara and your therapist, and do not feel you must do all of them from day one; your therapist will tell you which to begin with and when to add the strengthening exercises. ## Your clinical protocol The rest of this page is the clinical rehabilitation protocol for lateral epicondylitis (tennis elbow). This section is to be provided to your physiotherapist or hand therapist, and each phase opens with a plain-English explanation of what is happening. The protocol has two arms: a non-operative pathway (first-line for essentially everyone) and a post-operative pathway for the small number who undergo ECRB debridement after failing six or more months of quality conservative care. ### Non-operative pathway The core principle is progressive tendon loading, guided by pain. The aim is to shorten the symptomatic course and restore load tolerance, not to rest the tendon. #### Phase I — Acute / pain control (0–2 weeks) The focus here is settling pain and restoring unloaded movement. There is no immobilisation; this is relative rest, not casting. For your physiotherapist: - Goals: settle pain; restore full unloaded active range of motion (AROM). - Management: activity modification, joint protection and ergonomic advice. Optional counterforce brace over the common extensor mass to offload the ECRB origin during grip; a wrist (cock-up) splint may be used if acutely painful with extension activities. Adjuncts to settle pain: ice, soft-tissue / instrument-assisted soft-tissue mobilisation (IASTM), gentle pain-free AROM, optional dry needling, nerve glides. - Criteria to progress: full unloaded AROM without pain; independent with the home program. #### Phase II — Sub-acute / early loading (2–4 weeks) Tendon loading begins gently, and the proximal chain (shoulder blade and rotator cuff) is addressed, because weakness higher up the arm drives overload at the elbow. For your physiotherapist: - Goals: begin tendon loading; address the proximal kinetic chain. - Exercises: isometric wrist extensor and flexor loading (light load; isometrics are well tolerated and analgesic in reactive tendinopathy); progressive stretching of the wrist flexors and extensors with the elbow at 90°; proximal work: serratus anterior, middle/lower trapezius, rotator cuff and scapular stabilisers. - Criteria to progress: full ROM maintained; tolerates the stretch at 90° elbow flexion; approximately 70% of contralateral grip/strength. #### Phase III — Strengthening / return (4–6+ weeks, often running to 12 weeks) This is where the tendon is rebuilt and load tolerance for work and sport is restored. Eccentric–concentric loading is the core therapeutic driver. For your physiotherapist: - Goals: restore load tolerance and sport/work capacity. - Exercises: eccentric–concentric loading of wrist extension and forearm pronation/supination; the Tyler twist (FlexBar) is the prototypical home eccentric tool. Progress stretching to the elbow-extended position; mobilisation-with-movement (Mulligan). Grip strengthening and task-/sport-specific loading; plyometrics for athletes. Gradually wean the counterforce brace as the patient becomes asymptomatic. Equipment modification for athletes (grip size, string tension, technique). - Criteria to progress (return to sport): approximately 90% of contralateral strength, pain-free function, and self-management competence. ### Post-operative pathway (ECRB debridement ± release) Surgery is reserved for the ~4–11% who fail ≥6 months of quality conservative care. Open Nirschl-type debridement and arthroscopic ECRB debridement give comparable results. The timeline below follows the Brigham & Women's Standard of Care for lateral epicondyle debridement. #### Phase 1 — Protect (Days 1–7) A sling is used for comfort only in the first week. For your physiotherapist: - Sling for comfort; ice 20 minutes, 2–3 times daily; an elbow pad over the incision. - Gentle pain-free hand, wrist and elbow AROM; active shoulder ROM; periscapular exercises. - Minimise ADLs that stress the extensor mechanism (lifting, combined full-elbow-extension with wrist flexion); lift palm-up to offload the extensors; optional wrist splint if acutely painful. #### Phase 2 — Early motion (Weeks 2–4) For your physiotherapist: - Discontinue the sling. Begin PROM and active-assisted motion within pain tolerance. - Gentle strengthening: active motion and sub-maximal isometrics. Commence scar management. #### Phase 3 — Strengthening (Weeks 5–7) For your physiotherapist: - Advance resistive strengthening (weights / Theraband), emphasising wrist-extensor endurance (light load, higher reps). Restore full active and passive ROM. - Introduce counterforce bracing to the common extensor tendon (with education to avoid nerve compression); gentle cross-fibre massage; begin functional preparation. #### Phase 4 — Functional / return (Weeks 8–12) For your physiotherapist: - Task-specific functional training; return to higher-level work and recreational activity. - Continue the counterforce brace as needed for pain-free ADLs and strengthening. ## Getting back to work and activity If you are treating tennis elbow without surgery, there is no fixed "off work" period; you can keep using the arm throughout, modifying the heaviest gripping and lifting tasks and using a counterforce brace to get through them. The realistic expectation is that the elbow settles over 6–12 months, with most people (80–90%) better within a year. It is a slow tendon problem, so progress is measured over weeks and months, not days. Sticking with the loading program is what gets you there; flare-ups along the way are normal and are not a setback as long as a mild ache settles by the next day. If you have had surgery, the sling is for comfort only in the first week and is discarded as the elbow settles. Strengthening builds through weeks 5–7, and most people make a functional return to work and recreation around weeks 8–12. Heavier and sport-specific demands are reintroduced gradually within that window, guided by how the tendon tolerates load. Return to sport (for both pathways) is guided by reaching roughly 90% of the strength of your other arm, with pain-free function and confidence to self-manage, rather than by the calendar alone. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain and, if you have had surgery, wound care and hand therapy basics. The phased plan above reflects current best evidence for tennis elbow (progressive tendon loading rather than rest), and your ongoing recovery is guided individually by your physiotherapist or hand therapist according to how your elbow progresses. --- ### Mallet Finger URL: https://www.cqupperlimb.com/education/rehabilitation/mallet-finger/ Region: rehabilitation · rehabilitation A splint-led recovery plan for mallet finger, holding the fingertip joint completely straight without interruption for about six to eight weeks so the extensor tendon can heal, while the other finger joints keep moving. This protocol guides your recovery from a mallet finger (a drooping fingertip caused by injury to the tendon that straightens the very last joint of the finger), under the care of Dr Kieran Hirpara at Mater Private Hospital Rockhampton. Most mallet fingers are treated without an operation, using a splint that holds the fingertip straight while it heals. It begins with your home program, followed by the structured clinical protocol written for your hand therapist. Bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about the finger, the skin under the splint, or your progress, get in touch with the rooms. It is often helpful to take a photo and email it for review. ## What to expect A mallet finger happens when the terminal extensor tendon (the fine tendon that straightens the very last joint of the finger, the DIP nearest the nail) is torn away from the bone. It usually follows a forced bend of a straight fingertip, such as a ball or a knock "jamming" the end of the finger. Sometimes the tendon pulls off a small flake of bone with it (a bony mallet); sometimes it tears on its own (a tendinous mallet). Either way the result is the same: the fingertip droops and you cannot straighten it yourself, even though the rest of the finger works normally. The good news is that this injury heals very reliably with splinting alone; no operation is needed for most people. The whole treatment rests on one simple principle: - The fingertip joint must be held completely straight, without interruption, while the tendon heals. A splint keeps the last joint straight (or very slightly back) so the torn ends can knit together. This is worn full-time (day and night) for about eight weeks for a tendinous mallet or about six weeks for a bony mallet. - The fingertip must never be allowed to bend during this period. If the tip droops even briefly (for example while changing the splint or washing), the healing breaks and the clock starts again from zero. Because of this, how carefully you keep the tip straight is the single biggest factor in how well the finger recovers. - The other joints of the finger stay free and keep moving. The middle joint (PIP) and the knuckle (MCP) are left out of the splint and should be moved freely from the start; moving them does not disturb the healing tip. After the full-time period, the splint is gradually weaned (first to night-time and risky-activity use only, then off) while you slowly begin to bend the tip again. It is normal to be left with a slight permanent droop of about five to ten degrees; this is expected, does not usually affect how the finger works, and most people are very satisfied with the result. ## Precautions and limitations - NEVER let the fingertip bend while it is in the splinting phase, not even for a second when washing or changing the splint. If it droops, the healing resets and the splinting period starts again. - Wear the splint full-time (day and night) for the whole period your therapist sets: about 8 weeks for a tendinous mallet, about 6 weeks for a bony mallet. - Only take the splint off to clean and dry the skin, and only if you can keep the tip dead straight the whole time (rest it flat on a table or hold it straight with your other hand). - Keep the middle joint and knuckle moving freely from the start; only the very last joint is held still. - Check the skin daily. Tell your hand therapist if the skin over the top of the joint goes pale, white or sore; the splint may be holding the tip too far back and need adjusting. - Do not start bending the fingertip until your hand therapist begins the weaning phase. For wound, swelling and skin management, see the practice's wound care guidance. ## Your exercises Davplast / Wikimedia Commons, CC BY-SA 4.0 #### Wearing your DIP extension splint (the fingertip must never bend) Wear your splint on the fingertip joint at ALL times — day and night — so the very last joint (the DIP, the one nearest the nail) is held completely straight. This is the single most important part of your treatment. The fingertip must NEVER be allowed to bend, even for a moment: if it droops at any time, the healing starts again from zero and the clock resets. Keep the splint on while washing, sleeping and working, and check that the tip always stays straight inside it. Worn continuously — tendinous mallet about 8 weeks, bony mallet about 6 weeks Kieran Hirpara 4.0 #### Changing the splint safely (keep the fingertip straight) The splint only comes off to clean and dry the skin — and only if you can keep the fingertip dead straight the whole time. Rest the finger flat along the edge of a table so the tip is supported and cannot drop, or use your other hand to hold it straight. Slide the old splint off, clean and dry, then slide the new one on — all without ever letting the tip bend. If you are not confident doing this, leave it to your hand therapist. Once a day for skin care, only with the fingertip kept fully straight Kieran Hirpara 4.0 #### Keep the middle and knuckle joints moving (PIP and MCP) While the fingertip is splinted straight, keep the OTHER joints of the finger moving so they do not stiffen. Bend and straighten the middle joint (the PIP) and the knuckle (the MCP) fully and freely — these joints are safe to move and moving them does not disturb the healing tendon at the tip. Make a part-fist and open out again, keeping the splinted tip straight throughout. 10 times at each joint, a few times a day, splint left on Kieran Hirpara 4.0 #### Skin and swelling care under the splint Each day, with the fingertip kept straight, check the skin — especially over the top of the joint and the nail. Some pinkness is normal, but if the skin looks pale, white or sore where the splint presses, the splint may be holding the tip too far back; tell your hand therapist so it can be adjusted. Keep the finger and splint clean and dry, and elevate the hand if it swells. Check daily; report any pale, sore or broken skin Kieran Hirpara 4.0 #### Graded fingertip bending (weaning phase) A LATER exercise — only once your hand therapist starts weaning (commonly from about 6 to 8 weeks) and there is no, or only acceptable, droop of the tip. Out of the splint, gently bend the fingertip joint a SMALL amount, then straighten it fully again, staying well within comfort. Do not force it. If the tip starts to droop again, go back to full-time splinting and tell your therapist. A few gentle bends, only as guided in the weaning phase These are the exercises from your handout. The most important "exercise" of all is simply wearing your splint correctly and keeping the fingertip straight at every moment; everything else is built around that. Early on, your job is to keep the splint on, keep the skin healthy, and keep the other finger joints moving freely. The gentle fingertip-bending and blocked-straightening exercises belong to the later weaning phase and should not be started until your hand therapist specifically begins them. Stop anything that makes the fingertip droop and go back to full-time splinting. ## Your clinical protocol The rest of this page is the staged clinical protocol for splint-led rehabilitation of a mallet finger. This section is to be provided to the hand therapist, and each phase opens with a plain-English explanation of what is happening. Healing depends on uninterrupted DIP extension: the terminal tendon (or the avulsed bony fragment) unites only if the DIP is never allowed to flex during the splinting period, while the PIP and MCP are kept free, because their motion does not disturb terminal-tendon healing. Patient compliance is the dominant outcome driver. Before treatment, confirm whether the mallet is tendinous or bony and review imaging. A DIP extension orthosis is used: Stack, thermoplastic, or volar/dorsal alumifoam; splint type makes no meaningful difference to outcome, so choose for fit, skin tolerance and compliance. Hold the DIP in full extension or slight hyperextension, but AVOID excessive hyperextension (dorsal-skin blanching/ulcer risk). For a bony mallet, prefer a straight/neutral DIP rather than hyperextension to avoid volar subluxation of the distal phalanx. The PIP is always left free. ### Phase I — uninterrupted full-time extension splinting (weeks 0 to 6/8) The fingertip joint is held continuously straight, day and night, so the tendon or bony fragment heals. The splint comes off only for skin care, and only with the DIP kept extended throughout; any single episode of DIP flexion restarts the healing clock. The PIP and MCP move freely. For your hand therapist: Education and precautions - Fit a DIP extension orthosis (Stack/thermoplastic/alumifoam), DIP in full extension or slight hyperextension; avoid excessive hyperextension (skin blanching/ulcer); bony mallet → straight/neutral, not hyperextended (subluxation risk) - Continuous wear: tendinous ~8 weeks, bony ~6 weeks; the DIP must never flex during this window - Teach a flat-surface splint change technique so the DIP is never allowed to drop; if the patient cannot maintain extension, the therapist performs changes - PIP and MCP left free and actively moved from day 1 Management - Skin: daily inspection over the dorsal DIP and nail fold; adjust the orthosis if blanching/pressure; keep clean and dry - Oedema: elevation; gentle proximal-joint motion - Exercises: full active PIP and MCP ROM; no DIP motion - Bony mallet: maintain radiographic surveillance during splinting (alignment/subluxation), as splinting is non-inferior to pinning for extensor lag but the fragment position must be monitored Criteria to progress - Full-time period completed (tendinous ~8 wk / bony ~6 wk) with no DIP extensor lag beyond an acceptable amount, and healthy skin ### Phase II — weaning and starting controlled DIP motion (weeks 6/8, then +2 to 6) Once the full-time period is complete and there is no, or only acceptable, extensor lag, the splint is weaned to night-time and risky-activity wear while gentle controlled DIP flexion begins. Night-splinting can be framed as optional (a Level-I study found it non-essential) and is used pragmatically. If a significant lag recurs, the patient returns to full-time extension splinting. For your hand therapist: Assessments - DIP active extension lag (degrees) and active flexion; skin; patient confidence with the tip out of the splint Education and precautions - Wean to night-time + high-risk-activity splinting for about 2 to 6 more weeks; night wear optional per current evidence - If extensor lag >20° recurs after splinting, resume full-time extension splinting for ~4 to 6 weeks Management - Exercises: begin gentle, graded active DIP flexion (small range first) and blocked active DIP extension (stabilise the PIP, extend the DIP); progress flexion range as the lag allows - Reduce daytime splint wear once the DIP holds extension actively with no, or acceptable (≤10–20°), lag - Continue full PIP/MCP motion; scar/skin care as needed - Chronic or delayed-presentation mallets still respond to extension splinting; a delayed start is not a contraindication Criteria to progress - DIP holds active extension with acceptable lag; controlled, pain-free DIP flexion regained; skin intact ### Phase III — strengthening and return (from about weeks 8 to 12) With the tendon healed and active motion regained, the finger is weaned fully out of the splint and graded strengthening and return to activity begin. A small permanent extensor lag (mean ~8°) is expected and compatible with an excellent functional result. For your hand therapist: Assessments - DIP active extension lag and flexion arc; grip; readiness for loading and sport Education and precautions - Splint-free daily use; protective splinting for contact sport during return - Counsel that a residual ~5–10° extensor lag is normal and does not affect satisfaction Management - Exercises: graded grip and pinch strengthening; full-finger ROM; task- and sport-specific progression - Return to sport/heavy work from ~8 to 12 weeks on a criterion basis (protective splint for contact sport) - Discharge once strength and function are adequate and the lag is stable; refer back if a marked lag persists or recurs ## Getting back to work and activity Light use of the splinted hand is fine from the start: the splint stays on, the fingertip stays straight, and you can use the hand for everyday tasks within that limit. You should not drive while the fingertip splint is on: driving waits until the splint has been removed and you can grip the wheel and control the car safely, as confirmed with Dr Hirpara at your review. Gripping and strengthening build up from about six to eight weeks, as the splint is weaned. Return to sport and heavier manual work is usually from about eight to twelve weeks, judged on regaining controlled movement rather than the calendar alone, and a protective splint is worn for contact sport during that return. Expect a slight permanent droop of the fingertip of about five to ten degrees; this is normal, does not affect how the hand works, and most people barely notice it. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain, wound care and scar management. The phased plan above reflects published guidance for mallet-finger splinting, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your fingertip progresses. ## A note if your mallet finger is fixed surgically Most mallet fingers never need an operation. Surgery is only considered for a bony mallet when the fracture involves a large part of the joint surface (more than about a third) or when the last joint is slipping out of place (volar subluxation). When fixation is done, it is commonly an extension-block (Ishiguro) K-wiring, sometimes with a temporary wire passed across the fingertip joint to hold it straight. That wire is usually kept in for about four to six weeks and removed at around five to six weeks, after which active fingertip movement begins and a night splint may be worn for about four more weeks. The evidence shows splinting is non-inferior to pinning for the final amount of droop, so an operation is reserved for the specific situations above rather than used routinely. --- ### MCP Joint Replacement URL: https://www.cqupperlimb.com/education/rehabilitation/mcpj-replacement/ Region: rehabilitation · rehabilitation A hand-therapy-led recovery plan after silicone (Swanson) knuckle-joint replacement, built around a dynamic extension splint that holds the knuckles straight and slightly radial while you bend them early — re-shaping the joints in a corrected position and reversing ulnar drift. This protocol guides your recovery after silicone (Swanson) replacement of the knuckle joints (the metacarpophalangeal or "MCP" joints) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist: bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your hand therapist may adjust the plan depending on how your recovery progresses. This is a hand-therapy-intensive, splint-driven recovery. The dynamic splint and your daily exercises are not optional extras: they are how the new joints are shaped into a corrected, straight position. Your result depends heavily on doing the splinting and movement faithfully. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect The knuckle joints can become worn, painful and badly deformed, most often in rheumatoid arthritis, where the fingers drift towards the little-finger side (ulnar drift) and the bases of the fingers slip down towards the palm (volar subluxation); they can also wear out from osteoarthritis. In this operation the worn knuckle joint is removed and replaced with a flexible silicone spacer (the classic Swanson implant). The aims are to relieve pain, correct the drift and the droopy knuckles (extensor lag), and restore a useful arc of bending. The implant is not a rigid hinge. It works as a flexible spacer while a new lining (a "capsule") forms around it over the first weeks, and the whole point of the rehabilitation is to make that capsule form with your fingers held straight and corrected, not drifted. That is why the splint and the early movement matter so much. The recovery is therefore built around a dynamic extension outrigger splint, usually fitted within the first few days: - At rest, the splint holds your knuckles straight and pulled gently towards the thumb side (radial deviation), directly opposing the old ulnar drift. - Within the splint you do early controlled active bending of the knuckles against soft elastic loops, which spring the fingers back out straight. Moving early (but only in this protected, corrected position) shapes the new capsule correctly and keeps the joints from stiffening. You wear the dynamic splint almost continuously for about six weeks, then wean to a resting / night splint, with graded strengthening added later. Light hand function returns over the first weeks; most people are back to most everyday activities by around three months, with the final result continuing to settle over several more months. ## Precautions and limitations - Wear your dynamic extension splint as directed: day and night for about the first six weeks. It holds the correction; taking it off too much lets the drift come back. - Do NOT let your fingers drift back towards the little-finger side. Every exercise guides them the other way, towards the thumb. - Do NOT do any strong gripping, pinching or heavy lifting early: hard grip pushes the fingers into ulnar drift and stresses the new joints before they are stable. Strengthening waits until your hand therapist clears it. - Keep your thumb, wrist and the tips of your fingers moving from the start, and use the hand for light everyday tasks within comfort. - Watch the wound for signs of infection (increasing redness, heat, swelling or discharge) and contact the rooms if you are concerned; infection around an implant is uncommon but important to catch early. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### Wearing your dynamic splint Your dynamic extension splint does the protecting for you: at rest it holds your knuckles straight and pulled gently towards the thumb side (radial), correcting the old drift. Wear it as directed — day and night for about the first six weeks — taking it off only for washing and for the exercises your hand therapist allows out of the splint. The loops on your fingers should sit comfortably; tell your therapist if anything rubs or pinches. Worn continuously for ~6 weeks, then nights/rest as guided Kieran Hirpara 4.0 #### Controlled knuckle bending in the splint While wearing the splint, gently bend your fingers down at the knuckles, pulling against the elastic loops, then relax and let the splint spring them back out straight. This early controlled movement is what shapes the healing capsule around the new joints in a good position. Move smoothly and stop short of pain — you are guiding the joint, not forcing it. 10 bends each hour you are awake, within the splint, as guided Kieran Hirpara 4.0 #### Active straightening (lifting the knuckles) Work on fully straightening your knuckles under your own power — lift the fingers up level. After surgery the knuckles can tend to droop (an extensor lag), so actively lifting them keeps the straightening tendons gliding and helps hold the correction. Your therapist will start this within the splint, then progress it out of the splint. 10 lifts, several times a day, as guided Kieran Hirpara 4.0 #### Finger walking towards the thumb (radial) Gently guide your fingers across towards your thumb (the radial direction) — the opposite way to the old drift. You can help with your other hand or walk the fingertips along a tabletop towards the thumb. This re-trains the fingers to line up straight and is the key correction this whole protocol is built around. Never let them drift back the other way. 10 times, several times a day, as guided Kieran Hirpara 4.0 #### Scar care Once your wounds are fully healed and your therapist says it is safe, massage the scars over the back of your hand with a little plain cream, using small firm circles for a few minutes. This keeps the scars soft and stops the skin sticking down over the tendons, so the knuckles move more freely. A few minutes, 2-3 times a day, once healed Kieran Hirpara 4.0 #### Grip strengthening (later) A LATER exercise — only once your hand therapist clears strengthening, usually from around twelve weeks. Gently squeeze a soft ball or therapy putty, then release. Build it up slowly. This is held back early because hard gripping pushes the fingers towards ulnar drift and stresses the new joints before the capsule is strong — so it is always the last thing to start. As guided by your hand therapist (from ~12 weeks only) These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. The early work is all done with the dynamic splint on: controlled bending against the loops, active straightening, and gently walking the fingers towards the thumb to hold the correction. Scar care begins once the wounds have healed, and grip strengthening belongs to a later phase and should not be started until you are specifically cleared. Stop anything that causes sharp pain in the knuckles. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after silicone (Swanson) MCP joint arthroplasty. This section is to be provided to your hand therapist, and each phase opens with a plain-English explanation of what is happening. The defining principle is that the new MCP capsule remodels around the implant in whatever position you hold it, so the splint and exercises hold the joints in extension with slight radial deviation while permitting early controlled active flexion, re-shaping the joints in a corrected position and reversing the ulnar drift. Prior to treatment, check the patient's operation report and past medical history, and liaise with the treating surgeon regarding the diagnosis (rheumatoid vs osteoarthritis), the soft-tissue reconstruction performed (radial collateral ligament reefing, ulnar intrinsic release, extensor centralisation / crossed-intrinsic transfer), and the achieved intra-operative correction and arc. The rheumatoid hand drifts and recurs more readily than the osteoarthritic hand and warrants particularly diligent radial-deviation splinting. The protocol below assumes the standard dynamic-extension-outrigger regime. ### Phase I — dynamic extension splint with early controlled motion (weeks 0 to ~6) The first six weeks are the decisive window: the capsule forms around the implant now, and the dynamic splint dictates the position it forms in. Fit a forearm-based dynamic MCP extension outrigger splint, typically within the first 3-5 days. At rest it holds the MCPs in full extension with the proximal phalanges pulled into slight radial deviation (correcting the old ulnar drift); the outrigger slings sit on the proximal phalanges and the elastic tension permits controlled active flexion, then returns the digits to extension. The patient performs early controlled active MCP flexion within the splint every waking hour. The wrist and IP joints are left free. For your hand therapist: Education and precautions - Fit and tension the dynamic extension outrigger splint: MCPs held in extension + slight radial deviation, slings on the proximal phalanges, radial pull to counter ulnar drift - Worn continuously (day and night) for ~6 weeks, off only for hygiene and supervised exercise - No strong grip, pinch or lateral (ulnar-directed) loading: these recreate the deforming forces - Protect any soft-tissue reconstruction (radial collateral / intrinsic balancing): avoid forced ulnar-deviating stress at all times - Keep the thumb, wrist and IP joints mobile; light unloaded hand use only Management - Wound: surgical dressings as directed; monitor for infection (implant present) - Oedema: elevation, gentle retrograde massage, light compression as tolerated - Exercises: controlled active MCP flexion within the splint against the loops, aiming to develop a useful flexion arc (target the surgeon's intra-operative arc, commonly up to ~70 degrees at the index-to-little MCPs) with full passive return to extension via the outrigger; active MCP extension (correct extensor lag); radial-deviation re-education (guide digits towards the thumb); free IP and wrist ROM Criteria to progress - Wound healed; settling oedema; emerging active flexion arc with maintained extension and corrected (radial) alignment at around six weeks ### Phase II — weaning the splint and consolidating correction (weeks ~6 to ~12) From about six weeks the capsule is maturing and the dynamic splint is weaned to a resting / night extension splint (often continued to ~12 weeks, and at night longer in rheumatoid hands prone to recurrence). Out-of-splint active motion is progressed, always biased towards extension and radial alignment. Light functional use expands; heavy grip and pinch remain withheld. For your hand therapist: Assessments - Active and passive MCP flexion/extension arc; extensor lag; ulnar-deviation (compare with intra-operative correction); pain and swelling; wound/scar review Education and precautions - Wean the dynamic splint; continue a night / resting extension splint to ~12 weeks (longer at night in rheumatoid patients) - Continue to avoid strong grip/pinch and any ulnar-deviating load - Vigilantly preserve the radial correction; recurrence of drift is the principal late failure Management - Exercises: progress active and gentle active-assisted MCP flexion/extension out of the splint; ongoing extensor-lag work and radial-deviation re-education; commence scar management once healed; light functional tasks within comfort, kept off the ulnar-deviating patterns Criteria to progress - Stable correction (minimal recurrent ulnar deviation, acceptable extensor lag) on a maturing capsule; comfortable functional arc; pain settling ### Phase III — strengthening and return (weeks ~12 and beyond) Once the capsule is robust and alignment is holding (around twelve weeks), graded strengthening is introduced, late and cautiously, because grip drives ulnar drift. Strength and the final functional result continue to improve over several more months. For your hand therapist: Assessments - Grip/pinch versus the other side and versus pre-operative; maintained arc, extension and alignment under load; functional and task-specific testing Education and precautions - Begin graded grip/strengthening from around 12 weeks only, building load gradually - Coach grip patterns that do not drive ulnar deviation; ongoing night splinting as indicated, especially in rheumatoid hands - Set realistic expectations: the aim is pain relief, a corrected position and a functional arc rather than a normal or powerful hand Management - Exercises: progressive putty/ball grip and pinch, isometric MCP control, functional strengthening; continue mobility and any residual extensor-lag/alignment work - Consider discharge once correction is stable, a useful arc is achieved and the patient manages daily function; provide a long-term night-splint and joint-protection plan - Refer back to the treating doctor if alignment deteriorates, the arc is lost, or implant problems are suspected Criteria for discharge - Stable corrected alignment, functional pain-free arc, adequate functional grip, sound joint-protection and night-splint routine ## Getting back to work and activity Light everyday hand use (eating, writing, light self-care) is encouraged from the start within comfort, as long as it avoids strong gripping, pinching and any sideways (ulnar) stress on the fingers. Plan for the dynamic splint to be on almost all the time for the first six weeks, which limits two-handed and heavy tasks; arrange help accordingly. Driving resumes once you can safely control the car and are out of the dynamic splint for driving (typically around six weeks), as confirmed at your review. Strengthening and heavier hand use wait until about twelve weeks and are then built up gradually under your hand therapist's guidance. Most people return to most everyday activities by around three months, with the final result (comfort, alignment and a useful arc) continuing to settle over several more months. Progression is judged by Dr Hirpara and your hand therapist on how your hand is correcting and functioning, not by the calendar alone. Heavier or repetitive manual work follows the same criterion-based progression, with joint-protection advice to keep the correction long-term. ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain, wound care and scar management. The phased plan above reflects the long-standing Swanson-style rehabilitation regime after silicone MCP arthroplasty, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your hand corrects and progresses. --- ### Medial Epicondylitis (Golfer's Elbow) URL: https://www.cqupperlimb.com/education/rehabilitation/medial-epicondylitis/ Region: rehabilitation · rehabilitation Loading-based rehabilitation for golfer's elbow (flexor-pronator tendinosis), with ulnar-nerve screening, eccentric reverse-Tyler-twist loading, and a separate post-operative pathway for the minority who need surgery. This page guides your recovery from medial epicondylitis (commonly called golfer's elbow) under the care of Dr Kieran Hirpara at Mater Private Hospital Rockhampton. Most people recover fully without surgery, and the cornerstone of treatment is a steady, loading-based exercise program rather than rest. It begins with your home exercise program, followed by the structured clinical protocol written for your physiotherapist or hand therapist; bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you develop pins-and-needles, numbness or weakness in your little and ring fingers, let the rooms or your therapist know; the ulnar nerve runs right behind the inner elbow and sometimes needs separate attention. ## What to expect Golfer's elbow is a wear-and-tear (degenerative) problem of the tendons on the inner side of the elbow: the flexor-pronator tendons, which bend the wrist and turn the palm down, where they attach to the bony bump called the medial epicondyle. Despite the old name "epicondylitis", it is not really an inflammation; the tendon has become weakened and disorganised from overload. That is why the modern treatment is not rest and anti-inflammatories, but a graded program that gently loads the tendon back to full strength. Recovery takes patience. Golfer's elbow is generally self-limiting, but it can take 6 to 18 months to fully settle. The good news is that the great majority of people get better with a good conservative program and never need an operation. Surgery is only considered after at least six months of quality therapy has failed. One feature that makes the inner elbow different from the outer (tennis) elbow is the ulnar nerve (the "funny bone" nerve), which runs in a groove immediately behind the medial epicondyle. Around half of people with golfer's elbow also have some irritation of this nerve, so your therapist will check it at each visit and may add specific nerve-gliding exercises. ## Precautions and limitations Do: - Keep using the arm for normal daily tasks within comfortable limits. - Modify, rather than completely stop, the activities that flare it up. - Wear a counterforce brace over the forearm muscle during aggravating activity if it helps. - Do your stretches and loading exercises regularly; consistency matters more than intensity. Do not: - Do not rest the elbow completely or put it in a cast; the tendon needs gentle load to heal. - Avoid the heavy valgus-loading activities early on: golf, throwing (especially the cocking and acceleration phases), swimming and racquet sports, until your strength is rebuilt. - Do not push any exercise into sharp pain, and do not push nerve glides into pins-and-needles or numbness. - If your ulnar nerve symptoms (tingling or numbness in the little and ring fingers) get worse, ease back and seek review before progressing your loading. ## Your exercises Kieran Hirpara 4.0 #### Counterforce brace Wear the brace around your forearm a few centimetres below the inner elbow, over the muscle bulk — not over the bony bump itself. It should feel firm but not tight enough to make your hand tingle or go numb. Use it during aggravating activities (gripping, lifting, sport) in the early weeks, and wean off it as your symptoms settle. During aggravating activity; wean as symptoms allow Kieran Hirpara 4.0 #### Wrist flexor stretch Straighten your affected arm out in front of you with the palm facing up. With your other hand, gently pull your fingers and wrist down towards the floor until you feel a comfortable stretch along the inner forearm. Early on, keep the elbow bent to about 90°; as you improve, do the stretch with the elbow straight. Hold without bouncing. Hold 20–30 seconds, 3–5 times, 2–3 times daily Kieran Hirpara 4.0 #### Pronator stretch With your elbow tucked by your side, turn your palm to face the floor. Use your other hand to gently turn the forearm a little further into the palm-down position until you feel a mild stretch on the inner forearm. Keep it gentle and pain-free. Hold 20–30 seconds, 3–5 times, 2–3 times daily Kieran Hirpara 4.0 #### Wrist isometric (flexor) loading Rest your forearm on a table with the palm facing up. Press the palm of your other hand against your fingers and try to curl your wrist up, but hold it still so the wrist does not actually move — a steady hold against resistance. This is an early-stage exercise to load the tendon gently and ease pain. Hold 30–45 seconds, 5 holds, 1–2 times daily Kieran Hirpara 4.0 #### Reverse Tyler twist (eccentric flexor loading) Hold a rubber exercise bar (FlexBar) in your affected hand with the wrist curled up (palm towards you), and twist the bar with your good hand. Bring the bar out in front of you, then slowly let your affected wrist uncurl in a controlled way over 3–4 seconds — your good hand does the twisting, your affected wrist does the slow controlled release (the 'eccentric' part). This is the key strengthening exercise for golfer's elbow and is introduced once early pain has settled (from about week 4). 3 sets of 15, once daily Kieran Hirpara 4.0 #### Forearm rotation With your elbow tucked by your side, slowly turn your palm up towards the ceiling, then down towards the floor, keeping the elbow still. This keeps the rotating muscles of the forearm moving and loads the pronators gently as you progress. 10 times each direction, 2–3 times daily Kieran Hirpara 4.0 #### Grip strengthening Squeeze a soft ball or therapy putty, hold briefly, then relax. Introduce this once your stretching and eccentric loading are comfortable — it builds the grip and forearm strength you need for daily tasks and sport. Stop short of sharp pain. 10–15 squeezes, 2–3 times daily Kieran Hirpara 4.0 #### Ulnar nerve glide The ulnar nerve runs in a groove just behind the bony bump on the inner elbow, and is often irritable in golfer's elbow. To keep it gliding freely: make an 'OK' ring with your thumb and index finger, then bring it up towards your face so the ring sits around your eye, with the elbow bent and the palm towards you. Move gently in and out of the position. Do NOT push into pins-and-needles or numbness — back off if your little and ring fingers tingle, and tell your therapist or the rooms if nerve symptoms are getting worse. 5–10 gentle glides, 2–3 times daily These are the exercises from your handout. Start them as guided by Dr Hirpara and your therapist. In the early weeks the emphasis is on settling pain, gentle movement and the isometric holds; the eccentric reverse Tyler twist and grip strengthening are added as you improve. The ulnar-nerve glide is included because the nerve is so often involved on the inner elbow; keep it gentle. ## Your clinical protocol The rest of this page is the clinical rehabilitation protocol. This section is to be provided to your physiotherapist or hand therapist. It is criteria-gated rather than purely time-based: progress between phases depends on meeting the goals listed, not simply on the calendar. The ulnar nerve is screened at every visit (Tinel's sign, subluxation), as roughly 50–60% of medial cases have concomitant ulnar nerve symptoms, which are the leading reason conservative care fails. There are two pathways below: the non-operative program (first-line, for the great majority) and the post-operative program (for the minority who proceed to surgery after failing conservative care). ### Non-operative pathway Phase I: Acute / pain control (0–2 weeks) Goals: settle pain; restore full unloaded range of motion. - Relative rest and activity modification: use pain as the limiter; avoid immobilisation. Modify golf, throwing, swimming, racquet sports, weightlifting and repetitive gripping. - Optional counterforce brace over the common flexor mass; a wrist splint may be used if acutely painful. - Pain-control adjuncts: ice, soft-tissue work / IASTM, gentle pain-free active range of motion (AROM), nerve glides. - Screen the ulnar nerve (Tinel, subluxation). - Criteria to progress: full unloaded AROM without pain; independent home program. Phase II: Sub-acute / early loading (2–4 weeks) Goals: begin flexor-pronator loading; address the proximal chain. - Isometric wrist-flexor and pronator loading (light). - Progressive stretching of the wrist flexors at 90° elbow flexion. - Proximal kinetic chain: scapular stabilisers (serratus anterior, mid/lower trapezius) and rotator cuff, critical in throwers where medial elbow overload is valgus-driven. - Criteria to progress: full ROM maintained; tolerates the 90° stretch; ~70% of contralateral strength. Phase III: Strengthening / return (4–6+ weeks) Goals: restore load tolerance and return to function and sport. - Eccentric-concentric loading of wrist flexion and forearm pronation: the medial analogue of the Tyler twist is the "reverse Tyler twist" (eccentric wrist flexion on a FlexBar). Combined eccentric-concentric loading is favoured; isometrics remain useful for early analgesia. - Mobilisation-with-movement; progress stretching towards the elbow-extended position. - Grip strengthening, then sport-specific loading; for throwers, an interval throwing program; plyometrics last. - Wean the counterforce brace as the elbow becomes asymptomatic; address equipment and technique. - Return-to-sport criteria: ~90% of contralateral strength, pain-free function, self-management. ### Post-operative pathway (flexor-pronator debridement ± repair ± ulnar nerve procedure) Surgery is reserved for the minority failing ≥6 months of conservative care. The open Nirschl-type operation debrides the pathological flexor-pronator origin and commonly repairs/reattaches it; the ulnar nerve is assessed and protected, with decompression or anterior transposition performed concurrently in a proportion of cases. Phase 1: Protect (0–2 weeks) - Posterior long-arm splint (elbow + wrist) for 10–14 days; sling for community use. - Elevation and oedema control; finger/tendon-glide AROM; active shoulder ROM; gentle cervical AROM. - Precautions: NO lifting, pushing, pulling or forceful gripping: protect the repair. Phase 2: ROM restoration (2–6 weeks) - At the ~2-week visit: suture removal; transition to a neutral wrist orthosis full-time (off for hygiene); Tubigrip at the elbow for swelling. - Begin AROM elbow flexion/extension (2–4 wk), then 4-way wrist AROM + forearm rotation and finger/thumb AROM (4–6 wk). - Ulnar nerve glides introduced at weeks 4–6 (the medial-specific addition). - Scapular stabilisation (gravity-resisted). No resistance strengthening until after 6 weeks. Phase 3: Strengthening (6–12 weeks) - Wean the orthosis as tolerated (night use may continue early on). - Progressive resistive strengthening of wrist and forearm. No resisted supination/pronation early; begin lifting in supination/neutral, with light pronated lifting from ~week 9. Phase 4: Return to activity / sport (12–16+ weeks) - Progress lifting in all forearm positions as tolerated; full return to activity by ~12–16 weeks; sport-specific / interval throwing program for athletes. Full recovery is commonly 3–6 months. Ulnar nerve precautions: if an anterior transposition was performed, limit end-range elbow flexion early and progress nerve excursion gradually. Persistent or worsening ulnar symptoms warrant surgeon review before advancing loading. ## Getting back to work and activity How quickly you return depends on which pathway you are on and the demands of your job and sport. Non-operative. You can usually keep working and stay active throughout, modifying the tasks that flare the elbow rather than stopping completely. Golf, throwing sports, swimming and racquet sports are eased back in during the strengthening phase, once your strength is roughly 90% of the other side and function is pain-free. Because golfer's elbow is self-limiting, full resolution may take 6 to 18 months even though day-to-day function improves much sooner. Post-operative. Light, restricted use begins early but heavier lifting and gripping are held back to protect the repair. Most people return to full activity by about 12 to 16 weeks, with full recovery commonly taking 3 to 6 months. Throwing athletes follow a graduated interval throwing program before returning to competition. Driving: avoid driving while you are in a splint or sling, or while the elbow is too sore to control the car safely. Resume once you are out of the splint and can move the arm comfortably, as confirmed at your review. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain, wound care and hand therapy basics. Golfer's elbow shares its loading-based approach with its outer-elbow counterpart, tennis elbow; ask your therapist if you would like the equivalent lateral epicondylitis guidance. Your ongoing recovery is guided individually by your physiotherapist or hand therapist according to how your elbow progresses. --- ### Olecranon Fracture (ORIF) URL: https://www.cqupperlimb.com/education/rehabilitation/olecranon-orif/ Region: rehabilitation · rehabilitation Recovery after surgical fixation of an olecranon (point-of-elbow) fracture, protecting the triceps repair while restoring movement, with a simple sling and a staged return of active extension. This protocol guides your recovery after surgical fixation of a fracture of the olecranon (the bony point of your elbow) with open reduction and internal fixation (ORIF), performed by Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your physiotherapist or hand therapist. Bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect The olecranon is the bony point of your elbow. The large triceps muscle at the back of your arm attaches to it, and it forms part of the hinge joint inside the elbow. When the olecranon breaks, the pull of the triceps tends to drag the broken piece apart, so the fracture is fixed surgically, either with a wire-and-pin "tension band" (for a clean, straight break) or with a plate and screws (for a more shattered or angled break). The fixation is built to hold the bone together firmly enough that you can start moving the elbow early. The whole aim of this rehabilitation is a balancing act. An elbow that is held still for too long becomes stiff very quickly, so we want to get it moving early. But the same triceps muscle that pulls the fracture apart is the muscle that straightens your elbow, so for the first six weeks we protect the repair by avoiding active straightening, while freely working on bending the elbow and rotating the forearm. Once the bone has had time to knit, straightening is reintroduced gradually: first using just the weight of your arm, and only much later against resistance. For wound, swelling and scar management, see the practice's wound care guidance. It is worth knowing from the outset that even after a well-fixed olecranon fracture, most people are left with a small permanent loss of the last 10–15 degrees of full straightening. This is normal, rarely noticeable in everyday life, and not a sign that anything has gone wrong. ## Precautions and limitations Do - Wear your simple sling for comfort and support, taking it off for your exercises. You do not need a rigid splint or brace. - Work on bending the elbow and rotating the forearm (palm up / palm down) from early on, within comfortable limits. - Keep your hand, wrist and shoulder moving freely, and squeeze a ball to keep your grip strong. Do not - Do not actively straighten your elbow under its own muscle power for the first 6 weeks; let it straighten with gravity only. Active straightening pulls on the triceps and can distract the fracture. - Do not do any resisted or weighted straightening until about 3 months, when your therapist clears it. - Do not lift, push or pull with the operated arm, and do not bear weight through it, in the early weeks. These are the exercises from your handout, for regaining movement of your elbow and forearm. Take your sling off for your exercises. Start them as guided by Dr Hirpara and your therapist. ## Your exercises Kieran Hirpara 4.0 #### Passive elbow flexion Rest your operated arm with the palm facing up. Use your other hand to gently bend the operated elbow as far as is comfortable, helping it move rather than using the operated arm's own muscles. Hold for a few seconds at the end of the comfortable range, then slowly let it straighten back. This builds your bend (flexion) without loading the repair. 10 times, 3–4 times a day Kieran Hirpara 4.0 #### Active elbow bends With your palm facing up and your upper arm tucked at your side, gently bend your elbow as far as you can, then let it straighten back under control. In the first six weeks, let the elbow straighten with gravity — do NOT push it straight using your own muscles. 10–15 times, 3–4 times a day Kieran Hirpara 4.0 #### Forearm rotation Keep your elbow tucked at your side and bent to about a right angle. Slowly turn your palm up towards the ceiling, hold for 3–5 seconds, then turn it down towards the floor. Keep the elbow still and against your body throughout. You may gently assist the movement with your other hand. 10 times each direction, 3–4 times a day Kieran Hirpara 4.0 #### Grip strengthening Squeeze a soft ball or a roll of putty in your hand, hold for a few seconds, then release. This keeps your hand and forearm strong while your elbow is protected. It does not load the elbow repair. 10–15 squeezes, 2–3 times a day Kieran Hirpara 4.0 #### Isometric elbow-bend hold With your elbow bent and your palm up, place your other hand under your forearm. Gently try to bend the elbow further while your other hand holds it still, so the muscle works but the arm does not move. Hold gently, then relax. This is a muscle-activation (isometric) drill — it works the bending muscles only and does NOT load the triceps or the repair. Hold 5 seconds, 5–10 times, 2–3 times a day Kieran Hirpara 4.0 #### Active elbow extension (against gravity) Only begin this once your surgeon or therapist clears it, usually from six weeks. With your upper arm supported, slowly straighten your elbow using your own muscle power, then bend it back under control. Work against gravity only — do NOT add any weight or resistance until your therapist advances you (usually around three months). 10 times, 2–3 times a day — from week 6 only Kieran Hirpara 4.0 #### Resisted band extension This is a late-stage exercise, started only from about three months when your therapist clears it. Anchor a light resistance band and straighten your elbow against its pull, then return slowly. Begin with the lightest band and progress to light weights (around 0.5–2 kg) only as guided. Resisted straightening directly loads the triceps and the repair, which is why it is delayed. 10–15 times, 3 times a week — from ~3 months only Start the exercises below only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. The exercises for the early weeks are deliberately limited. Passive and active bending is what the elbow needs early — it stiffens into a bent position far more readily than it loses its bend — while the triceps repair is protected. Do not lift, push or pull with the operated arm, and do not bear weight through it, in the early weeks; the pull of the triceps is exactly the force the fixation is protecting against. Keep your hand, wrist and shoulder moving freely between sessions. Stop anything that causes sharp pain at the point of the elbow. ## Your clinical protocol The rest of this page is the clinical protocol for an olecranon fracture treated with open reduction and internal fixation. This section is to be provided to your physiotherapist or hand therapist, and each phase below opens with a plain-English explanation of what is happening. The single most important rule that distinguishes this protocol from a generic elbow fracture is triceps protection: active extension is deferred to ~6 weeks and resisted extension to ~3 months, because the triceps inserts on the olecranon and loads the fixation. Prior to treatment, check the patient's x-ray, operation report and past medical history, and liaise with the treating surgeon regarding the fixation construct (tension-band wiring vs plate), its stability, and the likely prognosis. ### Weeks 0–1: immobilisation In the first week the focus is on resting the soft tissues, settling swelling, and keeping everything else moving. The elbow rests in a simple sling at about 90°, taken off for exercises. There is no rigid posterior splint or brace. For your physiotherapist: - Immobilisation: simple sling, elbow at ~90°, removed for exercises. No plaster splint or brace is used. - Goals: soft-tissue rest; oedema control (elevation, gentle compression, cold). - Exercises: active hand, wrist and shoulder range of motion; gentle active elbow and forearm range of motion may begin from day 2–3 if the construct is stable. - Precautions: non-weight-bearing upper limb; no lifting, pushing or pulling; no active elbow extension. - Criteria to progress: wound and swelling settling. ### Weeks 1–6: protected motion (extension restricted) This is the triceps-protection phase. Bending is advanced steadily while straightening is done passively or by gravity only, never under the elbow's own straightening power. The sling is weaned from about week 4. For your physiotherapist: - ROM ceiling: flexion advanced approximately 10° per week within a tension-free range; goal full passive extension, tension-free flexion to 120°, and full forearm rotation by 6 weeks. Passive extension only: NO active extension. - Exercises: active and active-assisted flexion plus pronation/supination; passive range of motion may begin ~week 4. Cuff, periscapular and forearm isometrics only, not elbow extension. - Orthosis: wean the sling at week 4 (worn out-of-house and at night thereafter for comfort). - Criteria to progress: full passive extension, flexion to ~120°, full rotation; pain ≤3/10. ### Weeks 6–12: active extension introduced Once the bone has had six weeks to knit, active straightening is reintroduced, against gravity only and with no added weight. Bending is advanced towards a full arc, and weight-bearing through the arm is progressed gently. For your physiotherapist: - Goals: complete the motion arc; introduce gentle active extension. - Exercises: active elbow extension against gravity only from week 6; advance flexion to full (goal full tension-free arc by ~week 9). Progress weight-bearing tabletop → wall → quadruped as tolerated. Progressive resistive exercise to flexion/rotation may begin, but still NO resisted extension: this is held to 3 months. - Criteria to progress: full active arc; no worsening extension lag; radiographic union. ### 3–6 months: resisted extension and return Resisted straightening (the step that directly loads the triceps and the repair) begins only now, once the fracture has united. For your physiotherapist: - Resisted elbow extension begins at ~3 months (bands progressing to light weights, ~0.5–2 kg / 1–5 lb, 3×/week). - Sport- and job-specific exercises from ~4.5 months. - Lifting and heavy labour return once full strength and union are achieved, usually by around 6 months. - Hardware removal is common after olecranon fixation (especially tension-band wires, the most frequently removed implant in the body) and is usually done after union, for relief of prominent or irritating hardware, not as a routine step. ## Getting back to work and activity Light, hands-on-lap use of the arm for self-care is fine from early on within the precautions above, but anything that loads the elbow waits its turn. Bending and forearm rotation usually feel comfortable by about six weeks; active straightening returns from six weeks and steadily improves over the following weeks. Heavier demands are staged: no resisted or weighted straightening until about three months, sport- and job-specific training from around four and a half months, and a return to lifting and heavy manual work usually by about six months, once your strength and the healing of the bone allow it. Desk-based and light duties can typically resume much sooner; discuss the timing with Dr Hirpara at your review, as it depends on your job and which arm was operated on. Driving resumes once you are out of the sling and can safely control the vehicle with both arms, as confirmed at your review. Remember to expect a small permanent loss of the last 10–15 degrees of straightening; this is normal and usually has no effect on everyday function. ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain and wound care. For the injury itself, see olecranon fracture. The phased plan above is consistent with published rehabilitation protocols after olecranon ORIF, and your ongoing recovery is guided individually by your physiotherapist or hand therapist according to how your elbow progresses. --- ### Partial Wrist Fusion URL: https://www.cqupperlimb.com/education/rehabilitation/partial-wrist-fusion/ Region: rehabilitation · rehabilitation A protected recovery plan after a partial wrist fusion (capitolunate fusion, usually with removal of the scaphoid) for a worn-out wrist, immobilised until the bones knit at about six to eight weeks, then progressively restoring a useful but deliberately reduced arc of wrist… This protocol guides your recovery after a partial wrist fusion (an operation that removes the worn-out scaphoid bone and fuses the small bones in the middle of the wrist, most often the capitate to the lunate in a capitolunate fusion) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist: bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your hand therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect A partial wrist fusion treats a wrist that has worn out (arthritis) along the path that follows an old scaphoid problem: either a scapholunate ligament injury (a "SLAC" wrist) or an old scaphoid fracture that never healed (a "SNAC" wrist). The damaged scaphoid is removed, and the bones of the mid-wrist are fused together so they no longer rub. Dr Hirpara most often fuses the capitate to the lunate (a capitolunate fusion), sometimes including the neighbouring bones; when the lunate, capitate, triquetrum and hamate are all fused this is called a four-corner fusion, and it follows the same recovery principles. The key idea behind this operation is that only part of the wrist is fused, not all of it. The joint between the lunate and the forearm bone (the radius) is deliberately left alone. That preserved joint is what allows the wrist to keep moving: - Fusing the worn surfaces takes the pain away: that is the main goal, and it is reliably achieved. - Keeping the radius–lunate joint means you keep useful movement. The trade-off is that the movement is reduced: most people end up with roughly half to two-thirds of their former bending range, and grip strength of about three-quarters of the other side. This is a normal, expected result (not a complication) and for a painful, worn wrist it is usually a very worthwhile exchange. The fused bones need time to knit solidly together, just like a fracture. For about the first six weeks the wrist is held still in a splint while this happens. During that time the fingers, thumb and forearm are kept moving freely, but the wrist itself is rested. Once the surgeon confirms on X-ray that the bones have united, wrist movement and then strengthening are opened up in careful stages. Setting your expectations early (a comfortable, useful wrist rather than a fully mobile one) is an important part of the recovery. ## Precautions and limitations - Keep your wrist still in its splint until your surgeon confirms the fusion has healed (usually about six weeks): the bones must knit before the wrist is moved. - Keep your fingers, thumb and forearm moving from day one, but do NOT move the wrist itself until cleared. - Do NOT grip hard, lift, push, pull or bear weight through the wrist until the fusion is confirmed solid: this protects the healing bone and any plate, screws or staples. - Expect a reduced final range of movement: this is the planned result of fusing part of the wrist, not a sign anything has gone wrong. - Keep the splint and dressing clean and dry, and do NOT drive while you are in the splint or cannot safely control the wheel. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### Finger and thumb movement From the day of surgery, keep your fingers and thumb moving while the wrist itself rests in the cast or splint. Fully straighten all your fingers, then make a complete fist, then touch your thumb to the tip of each finger in turn. This stops the hand stiffening and keeps the tendons gliding while the wrist bones knit together. Do not move the wrist itself. 10 times each, several times a day, every day from the start Kieran Hirpara 4.0 #### Forearm rotation (palm up / palm down) With your elbow tucked in at your side and bent to a right angle, gently turn your palm up to face the ceiling, then down to face the floor. Keep the movement coming from the forearm, not the wrist. This keeps the forearm supple and does not disturb the healing fusion, so it can begin straight away. 10 times each direction, 2–3 times a day Kieran Hirpara 4.0 #### Wrist movement (after union) A LATER exercise — only once the fusion has healed and your surgeon and hand therapist have cleared wrist movement (usually after about six to eight weeks). Gently bend the wrist up (back) and down (forwards), then tilt it towards the thumb and towards the little finger, moving only as far as is comfortable. Remember the fused part of the wrist will not move — you are restoring the movement that comes from the preserved joint, so the final range will be smaller than before, and that is expected. 10 times in each direction, 2–3 times a day, within comfort (after union) Kieran Hirpara 4.0 #### Scar care Once the wound is fully healed and dry, massage the scar with a little non-perfumed moisturiser, using small firm circles with the opposite thumb for a couple of minutes. This softens the scar and reduces sensitivity. Do not start until the wound has sealed and your therapist is happy. 2–3 minutes, twice a day, once the wound is healed Kieran Hirpara 4.0 #### Grip strengthening A LATER exercise — begun only once the fusion is solid and strengthening has been cleared (usually from around twelve weeks). Squeeze a soft ball or therapy putty in the palm, hold briefly, then release. Build the effort up gradually over several weeks. Heavy gripping, lifting and weight-bearing through the wrist are held back until your surgeon confirms the bones are fully united. 10–15 squeezes, 2–3 times a day, building gradually (later phase) These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. The early exercises keep the fingers, thumb and forearm moving without disturbing the healing fusion; the wrist itself stays still in its cast or splint. Wrist movement and grip strengthening belong to later phases and should not be started until your surgeon has confirmed the bones have united. Stop anything that causes sharp pain over the wrist. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after a partial wrist fusion (capitolunate ± scaphoid excision; the same principles apply to four-corner fusion). This section is to be provided to your hand therapist, and each phase opens with a plain-English explanation of what is happening. Unlike a tendon repair, the construct here is bony, and progression is gated by radiographic union of the fusion, not by a fixed calendar. Until the surgeon confirms union, the wrist is immobilised and only the fingers, thumb and forearm are mobilised; thereafter wrist range and then load are restored, with a realistic ceiling of roughly 50–65% of contralateral flexion–extension and ~70–80% grip. Prior to treatment, check the patient's operation report and confirm the fixation used (circular/dorsal plate, headless compression screws, staples or K-wires) and whether the scaphoid was excised. Do NOT initiate wrist motion until the treating surgeon confirms radiographic union (typically 6–8 weeks, sometimes longer with screw or staple fixation). Counsel the patient from the first visit that the goal is a pain-free, functional wrist with a deliberately reduced arc, not full mobility. ### Phase I — protected immobilisation until union (weeks 0 to ~6–8) The fusion is healing like a fracture, so the wrist is held still while the bones knit. The hand and forearm are kept fully mobile to prevent stiffness and tendon adhesion, but the wrist is not moved. For your hand therapist: Education and precautions - Wrist immobilised in a cast or splint until the surgeon confirms radiographic union (typically 6–8 weeks) - No active or passive wrist motion during this phase - No gripping, lifting, pushing, pulling or weight-bearing through the operated wrist - Set the expectation early: final motion will be reduced (the radiolunate joint is preserved; the midcarpal joint is fused) Management - Wound: surgical dressings as directed; bulky dressing/splint for ~10–14 days, then short-arm cast or thermoplastic splint; monitor for infection - Oedema: elevation above heart level, gentle hand pumping, ice as needed - Exercises: full active finger, thumb and MCP/IP ROM; forearm pronation/supination; gentle shoulder and elbow ROM; no wrist motion Criteria to progress - Radiographic union confirmed by the surgeon (do not progress on calendar alone); wound healed; swelling controlled ### Phase II — restoring wrist motion (from union, ~weeks 6–8 to 12) Once the surgeon confirms the fusion is solid, the wrist comes out of the cast and gentle wrist movement begins. Progress is gradual; the patient is reminded that the fused portion will not move and the achievable arc is smaller than before. For your hand therapist: Assessments - Wrist active and passive ROM (flexion/extension, radial/ulnar deviation), forearm rotation, grip baseline, pain and swelling, wound/scar review Education and precautions - Begin active and active-assisted wrist ROM within comfort; transition to a removable wrist splint for comfort/protection between sessions - Continue to avoid heavy gripping, loaded lifting and weight-bearing through the wrist until cleared for strengthening - Reinforce the reduced-motion expectation (target ~50–65% of the contralateral flexion–extension arc) Management - Exercises: active/active-assisted wrist flexion, extension, radial and ulnar deviation; commence scar massage and desensitisation once the wound is fully healed; continue full finger/thumb ROM and forearm rotation; oedema management as needed Criteria to progress - Comfortable, controlled wrist arc within the expected reduced range; pain settling; surgeon's clearance for strengthening ### Phase III — strengthening and return to function (from ~12 weeks) With the fusion solid and motion restored to its useful ceiling, strengthening and graded loading begin and are built up over weeks. Return to manual work and sport is criterion-based. For your hand therapist: Assessments - Grip and pinch strength versus the other side; pain/swelling response to loading; task- and job-specific functional testing Education and precautions - Begin progressive grip and wrist strengthening (putty, ball, then graded resistance) once cleared - Introduce loaded and weight-bearing tasks gradually; build up over several weeks rather than all at once - Expected end-point: grip recovering toward ~70–80% of the other side and a useful, pain-free, reduced arc Management - Exercises: progressive gripping and forearm/wrist strengthening; graded functional and work simulation; ongoing scar management and ROM maintenance - Watch for and refer back to the surgeon if there is persistent dorsal wrist pain on extension (possible dorsal impingement), suspected nonunion, or a recovery plateau - Consider discharge once strength and function are adequate for the patient's daily and occupational needs Criteria for return to load / work - Solid united fusion, pain-free within the restored arc, grip adequate for task; heavy manual demands deferred until ~4–6 months and graded up ## Getting back to work and activity Light everyday hand use (eating, writing, light self-care) is encouraged from the start, within comfort, as long as it does not load or twist the wrist. Because you must not drive while your wrist is in a cast or unable to safely control the wheel, plan for help with transport in the early weeks; driving resumes once you are out of the cast and can confidently control the car, as confirmed at your review. Gripping, lifting and weight-bearing through the wrist wait until the fusion is confirmed solid (usually after about six to eight weeks) and are then built up gradually. People with desk-based or light work often return at around three months; heavier manual work is usually closer to four to six months and is reintroduced in stages. Throughout, remember that the planned result is a comfortable, useful wrist with a reduced range of movement, judged by how the wrist feels and functions, with Dr Hirpara and your hand therapist guiding the pace, not the calendar alone. ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain, wound care and scar management. The phased plan above reflects published rehabilitation guidance after partial wrist fusion, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your wrist heals and progresses. --- ### Pectoralis Major Repair URL: https://www.cqupperlimb.com/education/rehabilitation/pec-major-repair/ Region: rehabilitation · rehabilitation Rehabilitation protocol after pectoralis major repair, with the protected safe zone and staged return to chest loading. This protocol guides your recovery after pectoralis major repair with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. Each phase below opens with a plain-English explanation of what is happening and what matters most, followed by the structured detail your physiotherapist needs; bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. Your physiotherapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. The incision sits close to the armpit crease, where sweat and moisture build up; keep it clean and dry, and report any redness, discharge or fever promptly. ## What to expect The pectoralis major is the powerful chest muscle that drives pressing and hugging movements: the bench press, push-ups, and bringing the arm across the body. A tear usually happens in a fit young man during the lowering phase of a heavy bench press, when the muscle is stretched and loaded at the same time. Repairing it re-attaches the torn tendon, and the whole programme is built around one simple idea: keep the repaired tendon off-stretch and off-load while it heals. The pectoralis major pulls the arm across the body and inward, and rotates it inward. The two movements that stretch and tension the repair most are taking the arm out to the side (abduction) and rotating it outward (external rotation), especially both together, which is the position that tears it in the first place. So early on, the arm is kept in front of the body, rotated gently inward, and those two movements are strictly limited and let back in a few degrees at a time. Because the repair can pull away from the bone if it is overloaded, heavy chest work (the bench press, flyes, dips, push-ups and contact sport) is deliberately delayed to four to six months. This is longer than it feels like it should take, but it is the single most important thing protecting your repair. The sling comes off at around 4 to 6 weeks, whichever way your tendon was repaired. Dr Hirpara will tell you how yours was done. Throughout this programme, you move forward when your shoulder is ready, not just when the calendar says so: each phase below lists what "ready" looks like. ## The procedure A pectoralis major repair re-attaches the torn chest-muscle tendon. Most often the tendon has pulled off where it inserts onto the upper arm bone (the humerus), and it is re-attached there with strong sutures through anchors or buttons; sometimes the tear is within the tendon itself and is stitched back together. The job of rehabilitation is to protect that re-attachment while it heals, then gradually rebuild full movement, strength and confident pressing power. ## Wearing your sling You will wear a simple sling: Dr Hirpara uses a simple sling, not a bulky abduction-pillow or gunslinger brace. The sling holds your arm in the protected position: in front of your body and rotated gently inward, where the repaired chest muscle is relaxed. - Wear the sling for 4 to 6 weeks. You don't need to sleep in it. - Take it off only for showers and for your exercises, once you have been shown how; whenever the sling is off, keep your arm in front of your body and by your side, not out to the side and not rotated outward. - Resting at home, it can come off if you are sensible about it: arm supported on a pillow, kept in front of you. - Use ice if the shoulder is swollen or sore, especially after exercise. While you are in the sling, watch your posture. Keep your ears, shoulders and hips in line and avoid letting your shoulders slump; good posture protects your back and helps prevent your shoulder stiffening. ## Key precautions — do NOT - Do NOT rotate the arm outward past the weekly limit your physiotherapist sets. Outward rotation starts at the straight-ahead (neutral, 0°) position and is let back in by only about 5° each week, because rotating outward stretches the repair. - Do NOT take the arm out to the side beyond the small amount allowed each week, and never combine taking the arm out to the side with rotating it outward: that is the position that tears the muscle. - Do NOT let the elbow travel backward behind the line of your chest (this stretches the repair); avoid this for a long time afterwards in the gym. - Do NOT do pendulum (arm-dangling) or stick-levered exercises in the first weeks; unusually for shoulder surgery, letting the arm dangle or levering it with a stick pulls on the repaired chest muscle. (Stick-assisted drills come in later, from about week 4.) - Do NOT push, press or load the chest (no bench press, flyes, dips, pec-deck, push-ups or contact sport) until cleared, not before 4 to 6 months. - Do NOT force or stretch any movement, and do not work the repaired chest muscle directly (resisted inward rotation or pressing) until your team starts it, from about week 9. ## Phase I — Protection (weeks 0–3) The first weeks are entirely about protecting the repaired tendon while it knits onto the bone. You stay in the simple sling during the day, with the arm in front of you and rotated gently inward; you don't need to sleep in it, but keep the arm in that safe position overnight. Your hand, wrist, fingers and elbow keep moving normally. From about week 2, your physiotherapist may begin to gently move the shoulder for you (passive movement) within strict limits, but nothing under your own power, nothing forced, and no pendulum or stick exercises. - Sling: simple sling, arm in front and rotated gently inward, worn during the day; sleep out of it with the arm kept in the same safe position. - Movement allowed: passive (assisted) movement only, started from about week 2 and kept within tight limits: outward rotation only to neutral (0°), forward lift only to about 45°, and arm-out-to-the-side only to about 30°. Your elbow, wrist and hand move freely. - Exercises: hand, wrist and elbow movement; gentle hand squeeze; shoulder-blade setting and low rows for the muscles around the shoulder blade (kept low, well below shoulder height). No chest-muscle loading at all. Ready for the next phase when: your pain is controlled; your wound has healed with no signs of a problem; your passive movement is comfortable within the limits above; and there is no sign the repair has been over-stressed. ## Phase II — Restoring movement and weaning the sling (weeks 4–6) Kieran Hirpara 4.0 #### Assisted forward lift in lying Lie on your back. Use your good hand under the elbow of the operated arm to help lift it forward, only to the height your physiotherapist has set, then lower slowly. The operated shoulder stays relaxed and your good arm does the work. Introduced from about week 4 — not in the first weeks. As guided by your physiotherapist Kieran Hirpara 4.0 #### Assisted outward rotation with a stick Hold a stick (or walking stick) in both hands with the elbow of the operated arm tucked at your side. Use your good arm to push the operated forearm gently outward, only to the weekly limit your physiotherapist has set, then return. Introduced from about week 4 — not in the first weeks. As guided by your physiotherapist Kieran Hirpara 4.0 #### Press-and-hold outward rotation Stand with your elbow tucked at your side and bent to 90 degrees, the back of your hand against a wall or door frame. Press the back of your hand gently outward into the wall — about a quarter of your effort — without the arm actually moving. Hold for about 5 seconds, then relax. 10 times, once or twice a day Kieran Hirpara 4.0 #### Press-and-hold arm-out-to-the-side Stand side-on with the outside of your upper arm against a wall, elbow at your side. Press gently outward into the wall — about a quarter of your effort — without the arm moving. Hold for about 5 seconds, then relax. 10 times, once or twice a day Kieran Hirpara 4.0 #### Press-and-hold arm-backward Stand with your back near a wall, arm at your side and elbow straight. Press the back of your arm gently backward into the wall — about a quarter of your effort — without the arm moving. Hold for about 5 seconds, then relax. This works the muscles behind the shoulder. We use this instead of an inward-pressing hold early, because inward pressing loads the repaired chest muscle. 10 times, once or twice a day The repair is healing and the sling is gradually weaned off somewhere between weeks 4 and 6. Your protected movement advances by only a few degrees each week, and gentle assisted (stick-assisted) drills can now begin. Light muscle-tensing (isometric) drills start for the muscles around the shoulder, but not for the chest muscle itself, and not for inward rotation, because both load the repair. - Sling: being weaned off (somewhere between weeks 4 and 6). - Movement allowed: passive and assisted movement, advancing by about 5° each week: outward rotation building up from neutral, forward lift towards about 65–85°, and arm-out-to-the-side towards about 50°. Still no movement under your own power, and no pushing past the weekly limits. - Exercises: assisted forward lift in lying; assisted outward rotation with a stick (only to the weekly limit); press-and-hold (isometric) drills for outward rotation, arm-out-to-the-side and arm-backward, not inward rotation; shoulder-blade setting. Ready for the next phase when: you are out of the sling; your protected movement is advancing on schedule; you have no pain at the front of the shoulder when rotating outward to the limit; and your isometric drills are comfortable. ## Phase III — Active movement (weeks 6–8) Kieran Hirpara 4.0 #### Supine punch (salute) Lie on your back with the operated arm pointing at the ceiling. Reach the hand up towards the ceiling so the shoulder blade lifts off the floor, then lower slowly. Keep the movement smooth and within a comfortable range. 10 times, once a day Kieran Hirpara 4.0 #### Outward rotation lying on your side Lie on your good side with the operated elbow tucked into your waist and bent to 90 degrees. Keeping the elbow tucked, rotate the forearm upward as far as is comfortable, then lower slowly. Start with no weight. 10–15 times, once a day Kieran Hirpara 4.0 #### Resistance-band rows Anchor a band in front of you at waist height. Stand tall and draw your elbows back towards your body, squeezing the shoulder blades, then return slowly. Keep your elbows close to your sides and do not let them travel behind the line of your body. 10–15 times, once a day Kieran Hirpara 4.0 #### Shoulder-blade pull-down (prone Y) Lie face down with your arms hanging down. Raise them out to the sides to shoulder level, squeezing the shoulder blades together, then lower slowly. Keep the movement small and controlled. 10 times, once a day Kieran Hirpara 4.0 #### Biceps curl With a light weight and your elbow tucked at your side, bend the elbow to lift the weight, then lower slowly. Keep the upper arm still and in front of your body. 10–15 times, once a day Kieran Hirpara 4.0 #### Cross-body stretch Use your good hand to gently draw the operated arm across your chest, below shoulder height, until a gentle stretch is felt at the back of the shoulder, then release. Do not force or stretch into pain. Hold 20–30 seconds, 2–3 times Kieran Hirpara 4.0 #### Sleeper stretch Lie on your operated side with the shoulder and elbow bent to 90 degrees. Use your good hand to gently press the forearm down towards the bed until a gentle stretch is felt at the back of the shoulder. Do not force it. Hold 20–30 seconds, 2–3 times From about six weeks the sling is gone and you start moving the arm under your own power, beginning in easy positions where gravity hinders least: lying down, or reaching towards the ceiling. Your protected ranges keep opening up by a few degrees a week towards full. The muscles around the shoulder are strengthened, and gentle stretches for the back of the shoulder begin, but the repaired chest muscle is still left alone. - Sling: discontinued. - Movement allowed: passive movement continuing towards full (about 5° more each week in each direction), and active movement under your own power beginning. Light weight-bearing through the arm is allowed. - Exercises: supine punch (salute); outward rotation lying on your side (no weight); resistance-band rows and shoulder-blade work; light biceps; cross-body and sleeper stretches for the back of the shoulder. Ready for the next phase when: your movement is full or nearly full in all directions; you can move the arm under your own power with good control (no shrugging or hitching); and there is no front-of-shoulder pain. ## Phase IV — Loading the chest muscle begins (weeks 9–14) Kieran Hirpara 4.0 #### PNF diagonal D1 with a band Holding a band, move the arm in a controlled diagonal — from across your tummy out and up towards the opposite side — then reverse smoothly. Your physiotherapist will set the start and end positions. Begin only once you have full, pain-free movement. As guided by your physiotherapist Kieran Hirpara 4.0 #### PNF diagonal D2 with a band Holding a band, move the arm in a controlled diagonal — from your opposite hip out and up overhead — then reverse smoothly. Your physiotherapist will set the range. Begin only once you have full, pain-free movement. As guided by your physiotherapist Kieran Hirpara 4.0 #### Band outward rotation With your elbow tucked at your side and bent to 90 degrees, hold a band and rotate the forearm outward against the resistance, then return slowly. Keep the elbow tucked at your side. 10–15 times, once a day Kieran Hirpara 4.0 #### Inward rotation with a stick Hold a stick or towel and gently guide the operated hand inward across your tummy or behind your back, to a comfortable range. Inward rotation loads the repaired chest muscle, so this is introduced only from about week 9 and built up gently. As guided by your physiotherapist This is the turning point: from about week 9, the repaired chest muscle itself starts to work, gently. It begins in a shortened (relaxed) position and progresses towards a lengthened one as it tolerates the load. Inward rotation, the chest muscle's own action deliberately held back until now, is also introduced here and built up slowly. Movement should be full, and the focus shifts to controlled, light loading. Heavier pressing still waits. - Movement: full or nearly full passive and active movement in all directions. - Exercises: gentle inward-rotation and chest-muscle tensing drills, shortened position first; inward rotation with a stick; band outward rotation; PNF diagonal patterns with a band (controlled diagonal movements your physiotherapist sets up). Ready for the next phase when: you have full, pain-free movement; and you can do the gentle chest-muscle drills without any pain afterwards. ## Phase V — Strengthening (weeks 14–20) Kieran Hirpara 4.0 #### Wall push-up to floor push-up Start with push-ups against a wall: lean in, then push away, letting the shoulder blades spread apart at the top. As you get stronger, progress to a kitchen bench, then your knees, then the floor. Keep your elbows from travelling back past the line of your body — never let the chest drop below the level of your elbows. As guided by your physiotherapist Kieran Hirpara 4.0 #### Overhead triceps With a light weight held overhead and the elbow bent, straighten the elbow to lift the weight, then lower slowly. Begin once overhead movement is full and comfortable. 10–15 times, once a day Kieran Hirpara 4.0 #### Rhythmic stabilisation With your arm supported in front of you at about shoulder height, have your physiotherapist (or your good hand) apply small, gentle pushes from different directions while you hold the arm still and steady — do not let it move. This trains the shoulder's stabilising muscles to react. Keep all the efforts gentle. As guided by your physiotherapist From about week 14, proper chest strengthening (light weights and resistance, or "isotonics") begins, building up gradually and symmetrically with the other side. Push-up work starts against a wall and progresses towards the floor only as strength allows. Two gym rules now matter for a long time, because they load the repaired tendon the way that tears it: never let your elbows travel back past the line of your body at the bottom of a press, flye or pec-deck; and avoid heavy weights with low repetitions: favour lighter loads and more repetitions, and warm up slowly. - Movement: full. - Exercises: wall push-ups progressing towards the floor; inward rotation against a band; overhead triceps; light, progressive chest and pressing work; a gentle doorway chest stretch. Ready for the next phase when: your strength is building evenly compared with the other side; and you have no pain with resisted chest work. ## Phase VI — Early return to sport (5–6 months) Kieran Hirpara 4.0 #### 90/90 outward and inward rotation With the arm out to the side at shoulder height and the elbow bent to 90 degrees, rotate the forearm up and down in a controlled range. This is a late-stage, sport-preparation drill — start only when cleared, as this position stretches the repaired chest muscle. As guided by your physiotherapist Kieran Hirpara 4.0 #### External rotation at 90/90 (band) With the arm out to the side at shoulder height and the elbow bent to a right angle, rotate the forearm back and up against a light band or weight, then lower slowly. Builds rotator-cuff strength in the raised (throwing) position. 2 to 3 sets of 10 to 15, low resistance Kieran Hirpara 4.0 #### Internal rotation at 90/90 (band) From the same position with the arm out to the side at shoulder height, rotate the forearm forwards and down towards your feet against a light band or weight, then return with control. 2 to 3 sets of 10 to 15, low resistance The arm is now strong and full-range, and training becomes specific to your sport, including faster, more explosive (plyometric) drills like chest passes and throwing positions. This is preparation for return to sport, not a green light for unrestricted heavy loading yet. - Movement: full. - Exercises: outward and inward rotation in the 90/90 (sport) position; plyometric chest and throwing drills as your physiotherapist directs. Ready for the next phase when: you pass the strength and task-specific tests for your sport; and both Dr Hirpara and your physiotherapist clear you. ## Phase VII — Unrestricted return (6 months onward) From around six months, with clearance, you return to full strenuous work and recreation. The bench press is resumed at about half your previous maximum and built up slowly, and contact sport is not before six months. The return is based on your strength being at least 85–90% of the other side and on Dr Hirpara's clearance, not the calendar alone. - Movement: full. - Exercises: full return to heavy pressing and lifting, built up gradually from light loads, and full sport-specific training. Ready when: your strength is at least 85–90% of the other side; you have full, pain-free movement and endurance with no reactive pain after heavy load; and both Dr Hirpara and your physiotherapist have signed off. ## Returning to sport and work The return to chest loading and sport is criteria-based: adequate range, strength and endurance, with no pain, signed off by both Dr Hirpara and your physiotherapist, not decided by the calendar alone. - Work: sedentary work as tolerated; manual or heavy work from at least 3 months. - Driving: approximately 6 to 8 weeks. - Light chest strengthening: from about week 14. - Bench press, heavy lifting, push-ups and contact sport: not before 4 to 6 months, and only once your strength has returned; the bench press resumes at about half your previous maximum and is built up slowly. For throwing and contact sports, complete a graded build-up programme before unrestricted play. ## Your early exercises Kieran Hirpara 4.0 #### Open and close hand Make a tight fist, then open the hand and spread the fingers fully. Keep your hand, fingers and wrist moving normally throughout the day. 10 times per hour Kieran Hirpara 4.0 #### Wrist movement With the forearm supported, bend the wrist forward as far as is comfortable, then back. Keep the movement gentle and regular through the day. 10–15 times per hour Kieran Hirpara 4.0 #### Active elbow bends With the upper arm resting by your side and in front of your body, bend the elbow as far as it will comfortably go, then straighten it fully. Only the elbow moves — the upper arm stays still. 10–15 times, 2–3 times a day Kieran Hirpara 4.0 #### Forearm rotation With the elbow bent to 90 degrees and tucked at your side, turn the forearm so the palm faces down, then up. Keep the elbow against your body so only the forearm rotates. 10 times, 2–3 times a day Kieran Hirpara 4.0 #### Hand squeeze With the arm supported and in front of your body, gently squeeze a soft ball or rolled-up sock, hold for a few seconds, then relax. This keeps the arm active without pulling on the repair. 10 times, 2–3 times a day Kieran Hirpara 4.0 #### Scapula setting Sitting or standing tall, gently draw your shoulder blades down and back together without moving the arms, hold for a few seconds, then relax. Keep your ears, shoulders and hips in line. 10 times, 2–3 times a day Kieran Hirpara 4.0 #### Low row (shoulder-blade setting) Sitting tall with the arm low and in front of you, gently draw the elbow down and back to set the shoulder blade, hold briefly, then relax. Keep the arm well below shoulder height — this works the muscles around the shoulder blade without loading the chest. 10 times, 2–3 times a day Kieran Hirpara 4.0 #### External rotation to neutral With the elbow bent to 90 degrees and tucked against your side, gently rotate the forearm from resting on your tummy until it points straight ahead (the neutral position — 0 degrees), then return. In the first weeks, stop at neutral; only go further outward by the small amount your physiotherapist sets each week. Do not take the arm out to the side. As guided by your physiotherapist Kieran Hirpara 4.0 #### Flexion on the table (table slide) Sit at a table with your forearm resting on it. Lean gently forward so your hand slides along the table, letting the table take the weight of the arm, then sit back up. Stay within the limit your physiotherapist has set — arm in front of your body, below shoulder height — and do not force or stretch. As guided by your physiotherapist These are the gentle exercises for the early (protection) phase, starting on the ward and continuing at home, done with your operated arm kept in front of your body and your shoulder muscles relaxed. Start them as guided by your physiotherapist, and stop anything that causes sharp shoulder pain. Remember the early rules: no pendulum or stick exercises yet, and never take the arm out to the side and rotate it outward at the same time. ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain and wound care. --- ### PIP Joint Fusion URL: https://www.cqupperlimb.com/education/rehabilitation/pipj-fusion/ Region: rehabilitation · rehabilitation A protected recovery plan after fusion (arthrodesis) of the middle finger joint, holding the fused joint still in a splint while keeping every other joint moving from day one, then restoring grip and pinch once the bone has united. This protocol guides your recovery after fusion (arthrodesis) of the PIP joint (the middle joint of a finger) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist: bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your hand therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect A PIP joint fusion takes a worn-out or unstable middle joint of the finger and joins it solid, so it no longer moves. The joint is set in a functional, slightly bent position rather than dead straight: the bend is gentle in the index and middle fingers (about 15–20°) and increases towards the little-finger side of the hand (about 25–40° in the ring and little fingers), following the natural cascade your fingers make when you curl them. The fused joint is held in place with a small implant (a tension-band wire, a headless screw, K-wires, or a small plate) which holds that angle steady until the bone joins across the fusion. This operation is often chosen for the index and middle fingers, where a stable joint for pinch matters more than movement at the middle joint. The PIP joint is meant to be stiff afterwards: that is the point of the operation. So unlike a tendon or ligament repair, recovery is not about regaining movement at that joint; it is about protecting the fusion until the bone joins, while keeping every other joint of the hand moving freely. The plan is built around four ideas: - Protect the fusion until the bone unites. Bony union usually takes about six weeks, and sometimes up to nine to twelve weeks. Until then the fused joint is supported in a splint. - Keep everything else moving from day one: the fingertip joint, the knuckle, the neighbouring fingers, the thumb and the wrist, so the tendons do not stick down and the rest of the hand does not stiffen. - Manage swelling and the scar in the early weeks. - Restore grip and pinch once the fusion has joined. Don't smoke: smoking is known to slow bone healing and delay a fusion uniting. ## Precautions and limitations - Do NOT load, grip or pinch hard through the operated finger until the fusion has united (usually about six weeks, sometimes longer): loading before the bone has joined risks the fusion not taking. - Keep the fused joint completely still in its splint as directed; do not try to "test" or bend it. - Keep every other joint moving from the first days: fingertip joint, knuckle, other fingers, thumb and wrist. - Keep the splint clean and dry, wear it as directed, and look after the wound and any pin sites. - Do NOT drive while you cannot safely control the wheel, usually until you are out of the splint at around four to six weeks. - Don't smoke: it delays the bone joining. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### DIP movement of the operated finger With your hand therapist's go-ahead, gently bend and straighten the very last (fingertip) joint of the operated finger. Steady the middle of the finger with your other hand so only the fingertip moves. The fused joint must stay completely still — only the tip bends. Keeping this joint moving stops the tendons sticking down while the fusion heals. 10 times, 3 times a day, fingertip joint only Kieran Hirpara 4.0 #### MCP knuckle movement of the operated finger Gently bend and straighten the big knuckle (where the finger meets the hand) of the operated finger. The fused middle joint stays still throughout — only the knuckle moves. This keeps the knuckle supple and stops the finger stiffening up while the fusion settles. 10 times, 3 times a day, knuckle joint only Kieran Hirpara 4.0 #### Move all your other fingers, thumb and wrist From the very first days, keep every joint that was NOT operated on moving freely — make a full fist and open right out with your other fingers, move your thumb in all directions, and bend, straighten and circle your wrist. This is the single most important thing you can do to keep your hand supple and prevent stiffness while the fused joint is protected. 10 times each, several times a day Kieran Hirpara 4.0 #### Tendon glides (hook, fist, straight) Move your hand slowly through three shapes to keep the tendons gliding: a hook (bend the tip and middle joints, knuckles straight), a full fist, then a flat straight hand. Do this with your unoperated fingers fully, and let the operated finger move only as far as the free (non-fused) joints allow. This keeps the tendons running smoothly and stops them sticking down near the surgery. 5 of each shape, 3 times a day Kieran Hirpara 4.0 #### Scar massage Once the wound is fully healed and your hand therapist has checked it, rub a little moisturiser into the scar using firm small circles for a couple of minutes. This softens the scar, settles the tenderness, and stops it tethering to the tissues underneath. Do not start this until the skin is fully closed. 2–3 minutes, 2–3 times a day (after the wound has healed) Kieran Hirpara 4.0 #### Pinch and grip strengthening (after union) A LATER exercise — only once the fusion has united and your hand therapist starts you on strengthening (usually after about six weeks). Squeeze a soft ball or putty for grip, and pinch a small object between your thumb and the operated finger to build the lateral pinch the fusion was done to make stable. Build the effort up gradually. Do NOT do any resisted gripping or pinching before you are cleared — it loads the fusion before the bone has joined. 10 times, 2–3 times a day, as guided (after union only) These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist, staying within whatever limits you have been given. The early exercises keep the fingertip joint, the knuckle, and all your other fingers, thumb and wrist moving, without moving or loading the fused joint itself, which stays still in its splint. Scar massage begins once the wound is healed. Pinch and grip strengthening belongs to a later phase and should not be started until the fusion has united and you are specifically cleared. Stop anything that causes sharp pain over the fused joint. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after PIP joint arthrodesis. This section is to be provided to your hand therapist, and each phase opens with a plain-English explanation of what is happening. The fusion must be protected from load until bony union (typically ~6 weeks, up to 9–12 weeks); the governing principle is "protect the fused joint, mobilise everything else": DIP, MCP, adjacent digits, thumb and wrist move from day one to prevent tendon adhesion and stiffness, with oedema and scar managed early and grip/pinch restored only after union. Prior to treatment, check the patient's operation report and past medical history, and liaise with the treating surgeon regarding the fixation used (tension-band wire, headless intramedullary screw, K-wires, or plate), the set fusion angle, and whether K-wires are buried or to be removed. Dr Hirpara fuses the PIP in a functional flexed position that increases ulnar-ward across the hand (index/middle ≈ 15–20°, ring/little ≈ 25–40°), most often for the index/middle finger where lateral pinch stability outweighs PIP motion. The fused joint is held in a splint until radiographic union; the evidence base is low-level (level-4 case series and expert consensus), so timings are individualised, not graded thresholds. ### Phase I — protect and settle (weeks 0 to 2) The first two weeks protect the fusion and settle swelling and the wound, while every other joint of the hand starts moving immediately. For your hand therapist: Immobilisation - Acute volar finger splint or cast spanning the MCP and PIP, but leaving the DIP free - Fused PIP held still; elevation for oedema Education and precautions - No grip, pinch or loading through the operated finger - Keep the splint clean and dry; protect the wound and any pin sites Management - Wound: surgical dressings as directed; monitor for infection and pin sites if K-wires used - Oedema: elevation, gentle pumping of the free joints, ice as needed - Exercises: from day one, active motion of all non-fused joints: adjacent fingers (full fist/extension), thumb, wrist; begin DIP active motion of the operated finger within days; tendon glides of the adjacent digits; no movement or loading of the fused PIP Criteria to progress - Wound settling; swelling controlled; ready for a definitive custom splint at around 2 weeks ### Phase II — custom thermoplastic splint and active motion of the free joints (weeks 2 to 6) From about two weeks a custom thermoplastic splint supports the fused joint while freeing the adjacent joints for active motion. The operated finger's DIP and MCP are exercised out of the splint; the fused PIP remains protected. No resisted grip, pinch or loading yet. For your hand therapist: Assessments - Adjacent-joint ROM, oedema, wound/scar review; confirm fixation stable on clinical grounds and per surgeon Immobilisation - Transition to a custom thermoplastic splint supporting the fused PIP while freeing adjacent joints; continuous protective splinting to ~6 weeks Education and precautions - No resisted grip, pinch or loading of the operated finger until union - Out of the splint for exercises only Management - Exercises: active DIP and MCP motion of the operated finger out of the splint (DIP started within days, MCP added here); tendon glides of adjacent digits; continued thumb/wrist/adjacent-finger motion; commence scar and oedema management once the wound is healed - No resisted grip/pinch/loading Criteria to progress - Radiographic union (typically around 6 weeks, up to 9–12); fused joint clinically and radiologically stable before any loading ### Phase III — wean the splint and progress light use (from ~6 weeks, once united) Once the fusion has united (usually around six weeks), the splint is weaned and progressively cut down, light functional use is introduced, and pinch, opposition and gripping are gradually rebuilt. K-wires, if used, are typically removed around six weeks. For your hand therapist: Assessments - Confirm radiographic union with the surgeon; grip/pinch strength versus the other hand; ROM of the free joints; scar Education and precautions - Wean and cut down the splint once union is confirmed; remove K-wire ~6 weeks if used - Progress loading gradually: light use first, then graded pinch/grip Management - Exercises: progress light functional use → pinch, opposition and gripping; commence grip/pinch strengthening (ball/putty, lateral pinch) and build gradually; continue scar work - Splint weaned after radiographic union Criteria to progress - United fusion tolerating light load pain-free; splint discontinued; ready for progressive strengthening ### Phase IV — progressive strengthening and return (from ~8–12 weeks) With the fusion united and light use restored, strengthening and loading are progressed, and return to sport, heavy or manual activity is built up. The final settled result is reached at around nine to twelve months. For your hand therapist: Assessments - Grip and pinch strength versus the other side; functional and work-/sport-specific testing as appropriate Education and precautions - Build resisted loading up gradually; the fused joint is permanently stiff by design; focus strength on grip and lateral pinch Management - Exercises: progressive strengthening and loading of grip and pinch; graded return to sport, heavy and manual tasks - Consider discharge once strength is functional and near-symmetrical; refer back to the treating doctor if recovery plateaus Criteria for return - Pain-free, stable fused joint under load; adequate grip/pinch strength for the task, judged clinically not by the calendar; final settled result at 9–12 months ## Getting back to work and activity Light everyday hand use with the rest of the hand is encouraged from the start, within comfort; the key restriction is no gripping, pinching or loading through the operated finger until the fusion has joined. Because you must not drive while you cannot safely control the wheel, plan for help with transport in the early weeks; driving usually resumes at around four to six weeks, once you are out of the splint and can safely control the car. After union (around six weeks) you can begin light use and gentle gripping. Lifting, gripping and pinch build up from about eight weeks, and full activity or sport from about twelve weeks. The fusion keeps settling for several months, so the final, fully settled result is at around nine to twelve months. These timings are expert-consensus single-clinic guides (typical and individualised, not graded thresholds) and your progress is judged by Dr Hirpara and your hand therapist according to how the fusion heals, not by the calendar alone. ## After your protocol This protocol works alongside the practice's general recovery advice; see also managing post-operative pain, wound care and scar management. The phased plan above reflects published guidance on rehabilitation after PIP joint arthrodesis, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your finger heals. --- ### PIP Joint Replacement URL: https://www.cqupperlimb.com/education/rehabilitation/pipj-replacement/ Region: rehabilitation · rehabilitation A protected recovery plan after silicone replacement of the worn middle joint of a finger (the PIP joint), where the speed of starting movement depends on whether the surgeon went in from the front (palm side) or the back of the finger. This protocol guides your recovery after replacement of the worn middle joint of a finger (the proximal interphalangeal (PIP) joint, the middle knuckle) with a flexible silicone spacer, performed by Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist. Bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect The middle joint of your finger had worn out from arthritis, which is painful and stiff. In this operation the worn joint surfaces are removed and a flexible silicone spacer (a Swanson-type implant) is placed between the two bones. The spacer is not a rigid mechanical hinge; it is a bendy spacer that holds the bones apart, lets the finger bend, and lets your own scar tissue form a new supportive sleeve around it. The main and most reliable benefit is pain relief. You should also expect a useful, modest arc of bending (usually around 40 to 60 degrees) rather than a full, normal range. Most people are very satisfied because the pain is gone and the finger is comfortable to use. The single most important thing about your recovery is which way the surgeon went in, because that decides how soon you can move: - From the front (the palm side, a volar approach): the straightening tendon on the back of the finger is left fully intact. Because nothing on the back has to heal, you can usually start moving the finger within a few days. - From the back (a dorsal approach): the straightening tendon (the central slip) has to be split or lifted to reach the joint, then repaired. That repair must be protected first, so the finger is splinted straight early on and bending is introduced more gradually, under your hand therapist's guidance. Your hand therapist will follow the plan for your surgical approach. Dr Hirpara will tell them which approach was used, and the timings below are tailored to it. Whichever approach you had, the new joint is a hinge: it likes bending and straightening in a straight line, but it does not like being pushed or twisted sideways. Protecting it from side-to-side stress is what keeps it stable for the long term. ## Precautions and limitations - Move the finger only in a straight line (bending and straightening) and avoid any sideways or twisting force on the operated finger. The new joint is a hinge and side stress can loosen or deform it. - Wear your splint as directed, and use buddy strapping for activity to keep the finger tracking straight. - If your surgery was from the back of the finger, do NOT push your own straightening beyond the limit you are given early on: the straightening tendon is healing. - Do NOT do firm gripping, hard pinching, or heavy or twisting tasks until your hand therapist clears strengthening (commonly from around six weeks). - Keep the other finger joints, your wrist and your shoulder moving from the start, and use the hand for light everyday tasks within comfort. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### Protected active bending (PIP joint) With your other fingers and the splint supporting the rest of the hand, gently bend and straighten the operated middle joint of the finger within the range your hand therapist has set. Keep it slow and straight — bend and straighten in a clean line, without letting the finger drift to one side. This keeps the new joint moving so it does not stiffen. 10 times, several times a day, within your set range Kieran Hirpara 4.0 #### Active straightening (extension) Gently straighten the operated finger out as fully and as straight as you can, then relax. If your surgery was from the back of the finger, this is the movement to protect early — your hand therapist will guide exactly how much to do and when, because the straightening tendon needs to heal first. Never force it. 10 times, several times a day, as guided Kieran Hirpara 4.0 #### Buddy strapping Tape the operated finger gently to the finger next to it (above and below the middle joint, not over it). The neighbouring finger acts as a splint that guides yours to bend and straighten in a straight line and stops it tipping sideways onto the new joint. Wear it for activity as advised. Worn during light activity, as guided by your hand therapist Kieran Hirpara 4.0 #### Tendon glides Move your hand through three shapes: fingers straight (flat hand), then bend only the end two joints into a hook, then curl into a gentle full fist, then straighten out again. This glides the tendons so they do not stick down as the finger heals. Stay within any bending limit you have been given. 5–10 times through the sequence, several times a day Kieran Hirpara 4.0 #### Scar massage Once the wound is fully healed, massage the scar with a little plain cream, using small firm circles for a few minutes. This keeps the scar soft and stops it tethering to the tendon and joint underneath. Do not start until your hand therapist confirms the wound has healed. A few minutes, 2–3 times a day, once the wound is healed Kieran Hirpara 4.0 #### Grip strengthening A LATER exercise — only once your hand therapist clears strengthening (commonly from around six weeks). Gently squeeze a soft ball or putty, building up slowly. Avoid hard pinching or any twisting that puts side-to-side force on the new joint until you are told it is safe. As guided by your hand therapist (later phase only) These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. The early work keeps the finger moving in a straight line without side stress: protected bending, gentle straightening, buddy strapping and tendon glides. If your surgery was from the back of the finger, the active straightening exercise is the one to protect early and build up slowly. Grip strengthening belongs to a later phase and should not be started until you are specifically cleared. Stop anything that causes sharp pain or makes the finger feel unstable. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after silicone PIP joint arthroplasty. This section is to be provided to your hand therapist, and each phase opens with a plain-English explanation of what is happening. The protocol is approach-dependent, and this is the central branch point: a volar (palmar) approach leaves the extensor mechanism intact and permits early active motion within days; a dorsal approach divides or splits the central slip, so extensor healing must be protected first with extension orthotics and graded flexion. Throughout, the silicone implant is a flexible spacer whose long-term stability depends on the peri-implant capsule, so coronal (lateral) stress is avoided and motion is kept in a pure sagittal arc. Prior to treatment, confirm with the treating surgeon the surgical approach (volar vs dorsal), the integrity/repair of the central slip and collateral ligaments, and any intra-operative arc. Dr Hirpara will specify the approach; select the volar (early-active-motion) or dorsal (extension-protected) pathway accordingly. The expected functional target is a pain-free arc of roughly 40–60°, not full range. ### Phase I — protect and initiate motion (weeks 0 to 3) The first weeks protect the soft tissues while preventing stiffness, with the pace set entirely by the approach. The implant is stable in flexion–extension but vulnerable to side load, so all motion is kept in a clean sagittal plane and the finger is supported by buddy strapping and a splint. For your hand therapist: Education and precautions - Identify the surgical approach and follow the matching pathway: - Volar approach: extensor mechanism intact → begin active PIP/DIP motion at 3–5 days. Fit a volar extension-block / template splint permitting a short flexion arc (commonly ~30° initially), increased progressively. - Dorsal approach (central slip split/repaired): protect extension. PIP splinted near full extension full-time; introduce active flexion in a limited short arc under supervision, respecting the central-slip repair. (A relative-motion / dynamic-extension scheme may be used per surgeon preference.) - Strict avoidance of coronal (lateral/radial–ulnar) stress on the operated joint: buddy strap to the adjacent digit to guide pure sagittal tracking. - No gripping, pinching or resisted/loaded use. Management - Wound: surgical dressings as directed; monitor for infection - Oedema: elevation, gentle retrograde massage, light compressive wrap - Exercises: protected active PIP/DIP flexion–extension within the set arc; tendon glides; active motion of uninvolved joints (DIP, MCP, wrist, thumb); commence buddy strapping for activity - Splint worn full-time between exercise sessions Criteria to progress - Wound healing satisfactorily; no extensor lag developing (dorsal pathway); comfortable, controlled motion within the current arc ### Phase II — advance motion (weeks 3 to 6) The flexion arc is opened up and, for dorsal-approach fingers, the extension protection is progressively relaxed as the central slip consolidates. The goal of this window is to bank the useful arc (≈40–60°) before scar maturation fixes the range. For your hand therapist: Assessments - Active and passive PIP arc; extensor lag (dorsal pathway); coronal stability; pain and oedema; wound/scar review Education and precautions - Progressively increase the permitted flexion arc toward the functional target (≈40–60°) - Volar: advance active flexion as tolerated; add gentle passive flexion if extension is full and stable - Dorsal: wean extension splinting per central-slip healing (commonly weaning daytime support across weeks 4–6); guard against extensor lag: do not chase flexion at the cost of active extension - Continue strict avoidance of lateral/torsional load; no resisted strengthening yet Management - Exercises: graded active and active-assisted PIP flexion–extension; blocking exercises to focus PIP motion; continue tendon glides and buddy strapping; commence scar massage once the wound is healed - Maintain full motion of adjacent joints Criteria to progress - Healed wound; stable joint in the coronal plane; functional pain-free arc established; minimal extensor lag (dorsal) ### Phase III — strengthen and return (weeks 6 to 12 and beyond) Once motion is established and the soft tissues are sound (around six weeks), light strengthening begins and is built up gradually. Strengthening is kept axial (grip and straight-line loading) while lateral/torsional stress on the implant is still respected long-term. For your hand therapist: Assessments - Grip and pinch versus the other side; final PIP arc; coronal stability; functional and task-specific testing Education and precautions - Begin light grip strengthening from around six weeks, building gradually - Introduce pinch loading cautiously and continue to avoid forceful lateral/twisting loads on the operated joint indefinitely (implant longevity) - Set realistic expectations: durable pain relief is the primary gain; the final arc is modest (≈40–60°) and largely set by ~3 months Management - Exercises: progressive grip/putty work; graded functional and work-specific loading; continue any residual mobility and scar work - Consider discharge once a stable, comfortable, functional finger with a useful pain-free arc is achieved - Refer back to the treating doctor if recovery plateaus, the joint becomes unstable/deviates, or implant failure is suspected Criteria for discharge / return - Comfortable, pain-free, coronally stable joint with a functional arc; adequate grip; able to meet daily and work demands ## Getting back to work and activity Light everyday hand use (eating, writing, light self-care) is encouraged from the start, within comfort, as long as it stays in a straight line and avoids side-to-side or twisting force on the operated finger. Driving is usually possible once you can grip the wheel comfortably and control the car safely, you are out of any restrictive splint, and you are no longer taking strong pain medication, typically a couple of weeks, and confirmed at your review. Firmer gripping and loaded tasks wait until about six weeks, and are then built up gradually. Heavier manual or twisting work is the last thing to return, and is based on regaining a comfortable, stable finger with adequate grip, judged by Dr Hirpara and your hand therapist, not by the calendar alone. Remember the lasting deal with this operation: reliable pain relief and a useful arc of around 40 to 60 degrees, with side-to-side stress on the joint avoided for the long term to protect the implant. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain, wound care and scar management. The phased plan above reflects published rehabilitation guidance after silicone PIP joint arthroplasty, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to which surgical approach was used and how your finger progresses. --- ### Posterior Stabilisation URL: https://www.cqupperlimb.com/education/rehabilitation/posterior-stabilisation/ Region: rehabilitation · rehabilitation Rehabilitation protocol after posterior shoulder stabilisation, with posterior-specific precautions and return-to-sport criteria. This protocol guides your recovery after posterior stabilisation of the shoulder with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. Each phase below opens with a plain-English explanation of what is happening and what matters most, followed by the structured programme you can share with your physiotherapist; bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. Your physiotherapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect Posterior stabilisation repairs the back (posterior) part of the shoulder, where the lip of cartilage (labrum) and the capsule have torn away from the socket. Because the repair sits at the back of the joint, the movement that loads it most is reaching forwards while turning the arm inwards, and three everyday movements are protected early on, because each one pushes the ball of the joint backwards against the fresh repair: - turning the arm inwards (internal rotation): reaching behind your back, or turning your hand in towards and across your stomach; - reaching across your body towards the opposite shoulder (cross-body adduction); - leaning or pushing through the operated arm. This is the mirror image of an anterior (front) stabilisation, where it is turning the arm outwards that has to be protected. For a posterior repair the safe direction is actually turning the arm outwards, and it is inward rotation that is restored last: gently, not at full range until about three months. The phases below set out exactly when each protected movement can return. There is always a temptation to push movement early, but the evidence shows that any extra range gained from rushing is temporary, and the repair is at its weakest in the first six weeks. A steady, staged programme gives the safest and most predictable return to full function. Posterior instability is uncommon, so this timeline is built on biomechanical reasoning and published fellowship protocols rather than large trials; Dr Hirpara will tailor the pace to you. You will wear a simple sling, not a special abduction or "gunslinger" brace. Protection comes from the positional precautions above (keeping the arm in front and avoiding inward rotation and reaching across), not from the shape of the sling. The journey at a glance: - Phase I — Protect, weeks 0–2 - Phase II — Early movement, weeks 2–4 - Phase III — Increase movement and begin strengthening, weeks 4–6 - Phase IV — Advance, weeks 6–8 - Phase V — Strengthen, weeks 8–12 - Phase VI — Full range and weight training, weeks 12–14 - Returning to sport: from week 12, with contact sport not before 5 months Returning to your activities: - Work: sedentary job: as tolerated; manual job: at least 3 months - Driving: once out of the sling and in control of the arm, usually around 6 weeks - Lifting: light lifting can begin in the early weeks within limits; avoid heavier lifting for about 3 months - Contact sport (football, rugby, martial arts, racket sports, rock climbing, horse riding): from 5 months at the earliest, and only once the return-to-sport criteria are met ## The procedure Your posterior stabilisation is usually done arthroscopically (keyhole), or occasionally through a small open incision. The torn labrum and capsule at the back of the shoulder are re-attached and tightened onto the rim of the socket (sometimes called a reverse Bankart repair or a posterior capsulorrhaphy). The job of rehabilitation is to keep the ball of the joint off that repair while it heals, by limiting forward, inward and across-the-body movements early, then rebuilding full movement, strength and function in stages. ## Wearing your sling Your sling supports the arm and is a reminder to keep it in the safe position while the repair heals. The rules are simple: - Wear a simple sling for about 6 weeks, especially when you are out of the house or around other people. Dr Hirpara does not use an abduction pillow, wedge or gunslinger brace; a simple sling plus the positional precautions below is what protects a posterior repair. - You do not sleep in the sling. Sleep out of it, keeping your arm out of the at-risk position: rest it slightly out in front of you, not turned inwards or tucked across your body. A pillow under the arm helps hold it there. - Take the sling off for showering and for your exercises (once you have been shown how). Whenever the sling is off, keep your arm relaxed and in front of your body; never let it drift behind your back or across your chest. - Use ice if the shoulder is swollen or sore, especially after exercise. Watch your posture while you are using the sling: keep your ears, shoulders and hips in line and avoid slumping. Good posture protects your back and helps stop the shoulder stiffening. Your physiotherapist will use three kinds of movement: passive range of motion (PROM) (your arm completely relaxed, with the other arm or the physiotherapist doing all the work); active-assisted range of motion (AAROM) (your good arm or an object helping the operated arm move); and active range of motion (AROM) (you moving the arm under its own power). Your treating team will tell you which applies at each stage. ## Key precautions — do NOT For the first six weeks especially, the following protect the repair at the back of the shoulder: - Do NOT turn the arm inwards past the straight-ahead (neutral) position: no reaching behind your back, and no turning the hand in across your stomach. Inward rotation is the single most important movement to avoid early, and it is the last to be restored. - Do NOT reach across your body towards the opposite shoulder (no cross-body movements). - Do NOT combine reaching forwards with turning the arm inwards; this is the exact position that loads the repair. - Do NOT lean on the operated arm, push up from a chair or bed with it, or bear weight through it. - Do NOT lift, push or pull anything heavy with the operated arm early. - Do NOT force or stretch into any of these directions; let range return gradually within your physiotherapist's limits. - Turning the arm outwards is the safe direction after a posterior repair, but still keep within the limits your physiotherapist sets. ## Your first days in hospital Kieran Hirpara 4.0 #### Wrist, hand and fingers Keep your hand moving by bending your wrist forwards, backwards and side to side, and by opening and closing your fingers or squeezing a soft ball. This keeps the hand and wrist supple and helps reduce swelling — it does not load the repair. 10 times, 3 times a day Kieran Hirpara 4.0 #### Elbow bends With your upper arm kept in front of your body, gently bend and straighten your elbow. Keep your shoulder relaxed and still. 10 times, 3 times a day Kieran Hirpara 4.0 #### Pendulum swings Lean forwards and let your operated arm hang down, completely relaxed. Use your body to swing the arm gently — small circles clockwise and anti-clockwise, and gently forwards/backwards and side to side. Your shoulder muscles do nothing; your body does the moving. Keep the swing small. About 30 seconds each way, 3 times a day A few rules for the ward and your first days at home: - Use ice for pain relief if needed. - When wearing your sling, relax your shoulder and let the sling take the weight of your arm, and keep the arm in front of your body. - Take your painkillers before you do your exercises and before your physiotherapy appointments. - You are allowed to take your arm out of the sling for your exercises and for showering. - Wear your sling for about 6 weeks, especially when out of the house. - Unless you have arranged your own physiotherapy, an appointment has been made for you and is in your discharge pack. - If you have any problems, contact the office or let your physiotherapist know. ## Phase I — Protect (weeks 0–2) Kieran Hirpara 4.0 #### Ball squeeze With your arm resting comfortably in front of you, squeeze a soft ball or rolled-up sock, hold briefly, then relax. This keeps your forearm and grip active without moving the shoulder. Hold 5 seconds, 10 times, 3 times a day Kieran Hirpara 4.0 #### Shoulder-blade setting Gently squeeze your shoulder blades downwards and together, hold, then relax. Your arm does not move — this is a light muscle-activation drill that steadies the shoulder blade. Hold 5 seconds, 5 times, 3 times a day Kieran Hirpara 4.0 #### Assisted forward lift Sit and lean forwards slightly, cradle your operated arm with your good arm, and gently help it up in front of you. Do NOT go past about halfway up (roughly 60°) in this first phase. Lower it back down with your good arm doing the work. Keep the arm in front of you the whole time and never force it. 10 times, 3 times a day, within your physiotherapist's limit Kieran Hirpara 4.0 #### Assisted outward rotation (to neutral only) Sitting, keep your elbow tucked in front of you and turn your forearm outwards only as far as pointing straight ahead. Turning outwards is SAFE after a posterior repair — but it is the inward direction you must avoid, so do NOT let the hand drift inwards across your body. Gently, 10 times, 3 times a day The first two weeks are about protecting the repair while staying gently mobile. You stay in the simple sling, keep the arm in front of your body, and do only gentle drills that keep your hand, wrist and elbow moving and start to "set" your shoulder blade, all without loading the back of the shoulder. Two rules matter most: keep the arm in front and never turn it inwards across your body, and nothing is forced or stretched. Assisted forward movement is kept to about halfway up, and turning outwards only as far as straight-ahead. - Sling: simple sling, daytime; sleep OUT of it but keep the arm in front, not turned inwards. Off for exercises and showering. - Movement allowed: assisted and passive movement only. Assisted forward lift to about 60° (roughly halfway up); turning outwards only to the straight-ahead (neutral) position; no inward rotation past neutral, no reaching behind the back, no across-the-body movement. - Exercises: pendulum swings; gentle hand, wrist and elbow movement; ball squeeze; shoulder-blade setting; assisted forward lift (to halfway); assisted outward rotation to neutral. Ready for the next phase when: your pain is settling and well controlled; you can comfortably keep the arm in the protected position (in front, not turned inwards); your assisted forward lift reaches about halfway comfortably; your wound has healed with no concerns; and you are confidently following the posterior precautions. ## Phase II — Early movement (weeks 2–4) Kieran Hirpara 4.0 #### Assisted arm-out-to-the-side Sitting and leaning forwards slightly, cradle your operated arm with your good arm and help it out to the side — like gently rocking a baby. Keep within the range your physiotherapist sets (about 90° / shoulder height) and keep the arm in front of the body, not behind. 10 times, 3 times a day Kieran Hirpara 4.0 #### Isometric outward rotation Stand with your elbow tucked in front of you and bent to 90°, the back of your hand near a wall or door frame. Press the back of your hand gently outwards into the surface WITHOUT letting the arm move — a gentle effort, about a quarter of your strength, with no pain. Hold, then relax. Hold ~5 seconds, gentle (~25% effort), 10 times, as guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric inward rotation (in neutral only) This is allowed only with the arm at your side, the hand pointing straight ahead (neutral) — NOT with the hand turned inwards across your body. Keep your elbow tucked in and press the palm gently inwards against a wall WITHOUT letting the arm move — about a quarter effort, no pain. Hold, then relax. Stop before your hand crosses towards your stomach. Hold ~5 seconds, gentle (~25% effort), 10 times, as guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric arm-out-to-the-side Stand side-on with the outside of your upper arm near a wall, elbow tucked in. Press the arm gently outwards into the wall WITHOUT letting it move — about a quarter effort, no pain. Hold, then relax. Hold ~5 seconds, gentle (~25% effort), 10 times, as guided by your physiotherapist Kieran Hirpara 4.0 #### Neck side-stretch Use your good arm to gently bring your ear towards your good shoulder, away from the operated side, until you feel a comfortable stretch in your neck. Hold 10 seconds, 3 times, 3 times a day Kieran Hirpara 4.0 #### Neck stretch towards the armpit Use your good arm to gently bring your nose down towards your armpit, away from the operated side, until you feel a comfortable stretch. Hold 10 seconds, 3 times, 3 times a day From week two, gentle movement increases, still strictly within the safe directions. Your physiotherapist guides supervised passive and assisted movement to set limits, and you add light press-and-hold (isometric) drills to start waking the muscles up while the arm stays still. The arm must stay in front of the body: still no reaching behind the back and no across-the-body movement, and inward rotation stays at neutral only. - Sling: continues; keep the arm in front; do not reach behind the back. - Movement allowed (physiotherapist-supervised): forward lift building towards about 60°, turning outwards to about 45°, out-to-the-side to about 90°; inward rotation kept at neutral (0°) at the side. No home pulleys. - Exercises: assisted arm-out-to-the-side; gentle isometric (press-and-hold) outward rotation, inward rotation (in neutral only) and out-to-the-side; shoulder-blade strengthening; neck stretches. Stop anything that provokes pain at the back of the shoulder. Ready for the next phase when: you reach the supervised movement limits above without symptoms at the back of the shoulder; your pain and any swelling are controlled; and your shoulder-blade control is good with gentle movement. ## Phase III — Increase movement and begin strengthening (weeks 4–6) Kieran Hirpara 4.0 #### Wall walks Face a wall or sit at a table with your operated hand resting on it. Slide the hand forwards and up along the surface so the arm reaches in front of you, letting the wall or table take the weight, then slide back. Keep the arm in front — do not let it drift across your body. This builds forward reach with the weight supported. 10 times, 3 times a day, within your physiotherapist's limit Kieran Hirpara 4.0 #### Light outward-rotation with a band From about week 4–6, if your physiotherapist agrees. With your elbow tucked in at your side and bent to 90°, hold a light band and turn your forearm outwards against it, then return with control. Outward rotation is the safe direction after a posterior repair. Use a light band and many repetitions, not heavy resistance. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wall walk out to the side Stand side-on to a wall with your fingertips resting on it. Walk your fingers up the wall out to the side, raising the arm as far as is comfortable, then walk them back down with control. The wall supports the arm as you regain movement out to the side. As guided by your physiotherapist Movement opens up further, and the first light strengthening begins in the safe (outward-rotation) direction. You start active-assisted reaching, such as wall walks, and gentle band work for the outward rotators. Inward rotation is allowed to creep in only a little, and only at your physiotherapist's direction; it remains the most protected movement. The sling continues by day to the six-week mark. - Sling: simple sling by day to about 6 weeks. If you take it off at night, still avoid turning the arm inwards. - Movement allowed: forward lift to about 90°, out-to-the-side as comfortable, turning outwards to about 45° at shoulder height (or full at the side); inward rotation limited to about 30° and only at your physiotherapist's direction. Begin active-assisted reaching (wall walks). No lifting, pushing or pulling heavier than about 2 lb, and nothing overhead. - Exercises: wall walks; continued shoulder-blade work and isometrics; begin light outward-rotation band work at the side. Ready for the next phase when: you have good active-assisted movement with smooth, even shoulder-blade control; your pain is well controlled; and you are progressing within the staged limits without provoking the back of the shoulder. ## Phase IV — Advance (weeks 6–8) Kieran Hirpara 4.0 #### Sidelying outward rotation Lie on your good side with the operated elbow tucked at your waist and bent to 90°. Rotate the forearm upwards (outwards) so the hand lifts towards the ceiling, then lower with control. This strengthens the outward-rotating cuff muscles — the safe direction at this stage. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wall push-up Stand with your hands flat on a wall at shoulder height and your arms straight. Bend your elbows to bring your chest towards the wall, then push back to the start, pushing the shoulder blades gently apart at the top. Build up gradually — this loads the back of the shoulder directly, so it is progressed slowly and only from this phase. As guided by your physiotherapist Kieran Hirpara 4.0 #### Diagonal band pattern (reaching out and up) A diagonal whole-arm strengthening pattern with a light band, starting low and across the front of your body and pulling out and up. Keep the movement smooth and within comfortable range; your physiotherapist will set the exact pattern and resistance. As guided by your physiotherapist Kieran Hirpara 4.0 #### Diagonal band pattern (reaching across and down) The opposite diagonal whole-arm pattern with a light band, from up-and-out to down-and-across. Keep it smooth and controlled, within the range your physiotherapist sets. As guided by your physiotherapist The sling comes off at six weeks. Movement under your own power is built up to full in every direction except inward rotation, which is still deliberately held back (capped at about 45° until twelve weeks). Strengthening steps up: light cuff and shoulder-blade work, the first carefully controlled push-ups against a wall, and diagonal whole-arm patterns with a light band. - Sling: discontinued at 6 weeks. - Movement allowed: active movement to full as tolerated EXCEPT inward rotation, which stays capped at about 45° until 12 weeks (at the side and at shoulder height). Light lifting up to about 5 lb. - Exercises: sidelying outward rotation; wall push-ups (built up gradually: they load the back of the shoulder directly); diagonal band patterns; continued cuff and shoulder-blade strengthening. Ready for the next phase when: you have full movement under your own power in every direction except inward rotation; your strength is building steadily; and there is no pain or swelling after the new strengthening drills. ## Phase V — Strengthen (weeks 8–12) Kieran Hirpara 4.0 #### Resistance-band row With a band anchored in front of you, pull the handles towards you, drawing your elbows back and squeezing your shoulder blades together, then return with control. Light band, high repetitions; stop if the shoulder becomes painful. As guided by your physiotherapist Kieran Hirpara 4.0 #### Prone T Lying face down (or bent forwards over a table), with your thumbs up, raise your arms out to the sides into a T shape, squeezing the shoulder blades together, then lower with control. Start with no weight and add a very light weight only as your physiotherapist directs. As guided by your physiotherapist Kieran Hirpara 4.0 #### Prone W Lying face down, draw your elbows back and down towards your waist, making a W shape and squeezing the shoulder blades together and down, then release with control. This strengthens the lower shoulder-blade muscles. As guided by your physiotherapist Kieran Hirpara 4.0 #### Shoulder-blade strengthening row Draw the shoulder blade back and down against a light weight or band, holding briefly, then release with control. This is part of a broader strengthening programme (your physiotherapist may call it the "Thrower's 10") that builds the cuff and shoulder-blade muscles together. As guided by your physiotherapist This phase builds strength, control and endurance towards your work and sport. Inward rotation is still capped at about 45° until twelve weeks, but every other plane is worked fully. The programme broadens into a fuller cuff and shoulder-blade strengthening routine (your physiotherapist may call it the "Thrower's 10") with dynamic control drills. - Sling: none. - Movement allowed: full in all planes except inward rotation, which stays capped at about 45° until week 12. - Exercises: resistance-band rows; prone T and prone W; shoulder-blade strengthening; dynamic-control and stabilisation drills. Your physiotherapist may add rhythmic stabilisation (gentle hold-steady drills where they push lightly on your arm and you resist) to retrain control; this is hands-on work with no diagram. Lifting builds gradually towards about 7–10 lb. Ready for the next phase when: your inward-rotation tolerance is improving; strengthening is pain-free with no reactive swelling; and your strength is building evenly compared with the other side. ## Phase VI — Full range and weight training (weeks 12–14) Kieran Hirpara 4.0 #### Internal rotation with a stick From week 12 — NOT before. Inward rotation is the last movement restored after a posterior repair, so behind-the-back reaching only begins now. Hold a stick behind your back and use your good hand to draw the operated hand gently up your back, then lower with control. Progress gradually and never force the end of the range. As guided by your physiotherapist Kieran Hirpara 4.0 #### Sidelying inward rotation From week 12. Lie on your operated side with the arm forwards and the elbow bent to 90°. Rotate the forearm so the hand turns downwards (inwards), then return with control. Begin with no weight and add a light weight only as directed — this strengthens the inward rotators, restored last after a posterior repair. As guided by your physiotherapist Kieran Hirpara 4.0 #### Cross-body stretch From week 12 — not before, as it loads the back of the shoulder and the repaired area. Use your good hand to draw the operated arm gently across your chest until you feel a comfortable stretch at the back of the shoulder. Progress gradually and do not force. As guided by your physiotherapist Kieran Hirpara 4.0 #### Sleeper stretch End-range inward-rotation stretching begins from week 12 — not before. Lie on your operated side with the arm out in front at shoulder height and the elbow bent to 90°. Use the other hand to press the forearm gently down towards the bed until you feel a comfortable stretch. Progress gradually and do not force. As guided by your physiotherapist Kieran Hirpara 4.0 #### Towel stretch (behind-back inward rotation) From week 12, to progress full behind-back reach. Hold a towel behind your back with the operated hand below, and use the upper hand to draw the lower hand gently up your back. Progress gradually and do not force end-range inward rotation. As guided by your physiotherapist Kieran Hirpara 4.0 #### Biceps curl From week 12, as general arm conditioning resumes. With your upper arm tucked at your side, curl a light weight up by bending the elbow, then lower with control. Keep the shoulder relaxed and still. As guided by your physiotherapist At twelve weeks, inward rotation is finally restored to full. This is when behind-the-back and across-the-body stretches begin, and gym work progresses from machines towards free weights. Push-ups build up from the wall towards the floor. The target at this stage is full, symmetric inward rotation, matching your other side, because inward rotation is the movement a posterior repair protects longest. - Sling: none. - Movement allowed: full range in all directions, including inward rotation, progressed gradually and never forced. - Exercises: internal rotation with a stick; sidelying inward rotation; cross-body stretch; sleeper stretch; towel stretch for behind-back reach; biceps curls and general conditioning. Continue and progress the cuff, shoulder-blade and diagonal strengthening from the previous phase. Ready to progress towards sport when: your inward rotation is becoming symmetric with the other side; you have full, pain-free movement in every direction; and your strength is building towards the other side without reactive swelling. ## Returning to sport and work Return is criteria-based, not decided by the calendar alone, and signed off by both Dr Hirpara and your physiotherapist. - Throwing and overhead athletes: a graded throwing or interval programme begins from about 14–16 weeks, building up volume and intensity step by step. - Contact and collision sport (rugby, football, martial arts, racket sports, rock climbing, horse riding): not before 5 months, and only once the criteria below are met. - Work: sedentary work as tolerated; manual or heavy work at least 3 months. You are ready to return to sport when: - you have full, pain-free range of motion in all directions, including inward rotation symmetric with the other side; - your outward and inward rotation strength is close to the other side (for your physiotherapist: a limb-symmetry index of about 90% or better for internal and external rotation strength on isokinetic or hand-held dynamometry; with a posterior repair, pay particular attention to symmetric internal-rotation strength, since that is the protected direction); - you have completed any sport-specific programme (such as an interval throwing programme) with no pain or apprehension; and - Dr Hirpara has cleared you at review. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain and wound care. For the condition itself, see shoulder instability. The phased timeline, posterior-specific protection limits, staged return of inward rotation and return-to-sport criteria were prepared with reference to published posterior stabilisation protocols from the University of Virginia Sports Medicine and University of New Mexico Sports Medicine (Posterior Labral Repair Rehabilitation Protocols), Massachusetts General Brigham Sports Medicine (Posterior Bankart Repair), and the clinical commentary "Rehabilitation Following Posterior Shoulder Stabilization" (International Journal of Sports Physical Therapy, 2021), adapted to this practice's approach by Dr Hirpara. The original exercise programme is based on the work of Leonard Funk and the Wrightington Shoulder Unit (shoulderdoc.co.uk). --- ### Shoulder Replacement for Fracture URL: https://www.cqupperlimb.com/education/rehabilitation/proximal-humerus-arthroplasty/ Region: rehabilitation · rehabilitation Rehabilitation after hemiarthroplasty or reverse shoulder replacement for a proximal humerus fracture — slower than elective replacement while the tuberosities heal. This protocol guides your recovery after a shoulder replacement performed for a broken shoulder (a proximal humerus fracture) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. Depending on the fracture, the replacement may be a reverse shoulder replacement or a hemiarthroplasty (replacing the ball of the joint only). The rehabilitation journey has the same shape for both, because what sets the pace is the healing of the bone fragments, not the type of implant. Each phase below opens with a plain-English explanation of what is happening and what matters most, followed by the structured protocol written for your physiotherapist: bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. Your physiotherapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## Why recovery is slower after a fracture When a shoulder is replaced electively for arthritis or a worn rotator cuff, the bone around the new joint is intact, and rehabilitation can move at the pace of soft-tissue healing. After a fracture it is different. The two bony knobs at the top of the arm bone (the greater and lesser tuberosities, where the rotator cuff muscles attach) have usually broken free, and during your operation they are stitched back into position around the new prosthesis. Those fragments must now heal onto the bone and the implant, just like any other fracture, and that typically takes a number of weeks to months. Published rehabilitation protocols for shoulder replacement performed for fracture are consistent on this point: how well the shoulder works afterwards depends heavily on whether the tuberosities heal in position, and early or forceful movement (even passive movement) can pull on the repair and put that healing at risk. The protocol therefore follows the same path as the elective reverse shoulder replacement protocol. After a fracture, the same journey runs more slowly because the bone fragments must heal first. Each step up in your rehabilitation is gated on two things together: enough time passing, and X-rays showing that the bone is healing, as confirmed at your review with Dr Hirpara. ## What to expect You will have a numb arm when you wake up, and the feeling usually returns within 6 to 12 hours. Rarely, some numbness or weakness can continue for 2 to 3 days. When you wake up from your operation, you will be in a sling, with a big pad over your shoulder. This pad will be removed before discharge. Underneath will be a waterproof dressing covering a surgical glue strip, which can be left alone for 2 weeks. Your stitches are dissolvable and do not need removing, but there may be some tails of stitch at each end of the wound that can be cut flush with the skin after 2 weeks. You will be booked to see our nurse for a wound check 1–2 weeks after your surgery. If you are unable to attend the dressing check, you can remove your dressing yourself after 2 weeks. Approximate timeframes for return to activities (slower than after an elective replacement, and always subject to how your bone is healing): - Driving: not for at least six weeks (this applies to any shoulder operation), and not while you are wearing the sling. Most people return somewhere between 6 and 12 weeks, once movement and control are back; discuss this at your review. - Swimming: breaststroke from about 4 months; freestyle later, as guided at your review. - Lifting: nothing heavier than a cup of coffee until about 12 weeks; light lifting builds gradually from 12 weeks; avoid lifting heavy items for 6 months. - Work: sedentary job: from about 6 weeks, as comfort allows; manual job: guided by Dr Hirpara. It is also worth setting expectations early: after a replacement for fracture, the shoulder typically does not regain the full range of an uninjured shoulder. Published results describe comfortable, pain-controlled use of the arm at waist and shoulder height (and often overhead) as the usual outcome, with movement and strength continuing to improve for 12–24 months after surgery. ## Wearing your sling Your sling (shoulder immobiliser) supports your shoulder while the bone fragments heal. The rules are simple: - Wear it for 6 weeks, including while sleeping. - Take it off only for showers, for your exercises once you have been shown how, and while resting at home with your arm supported on a pillow; whenever the sling is off, keep your arm by your side. - Do not drive for six weeks, and not while you are wearing a sling. - Use ice if the shoulder is swollen or sore, especially after exercise. Your physiotherapist will help you put the sling on at first, and will teach you to manage it independently before you go home. Fitting it correctly matters: a loose sling does not support you properly. - Always ensure that when fitting the sling, your elbow is positioned in the corner of the sling and well supported. - The end of a well-fitted sling should rest comfortably at the knuckle of your little finger. If your hand extends too far out of the sling, it will not provide you with adequate support. - Your sling has two Velcro straps: one attaches around your neck and one around your waist. - Once you have positioned your elbow and forearm correctly, use your non-operated arm to swing the upper strap around your neck to the front and attach it through the upper loop on the sling. - Use the same method to attach the lower strap around your waist, securing through the lower loop on the sling. During your time in the sling, be conscious of your posture at all times and avoid allowing your shoulders to adopt a slumped position. To achieve a good postural position, try to keep your ears, shoulders and hips in line. Good posture is important for your back and will help prevent stiffness in your shoulder joint. A rolled-up towel placed in the small of your back when sitting can serve as a friendly reminder. ## Your first days in hospital Before you go home, the hospital physiotherapists will start you on a simple program. It helps to understand three terms they will use. Active range of motion means movement you do yourself, without aid or help. Active-assisted range of motion means using your other arm (or an object, such as a cane) to help move the arm. Passive range of motion means the arm stays completely relaxed while your other arm (or someone else) does 100% of the work. After a replacement for fracture, the operated shoulder is moved only passively, and only within gentle limits, for the first six weeks; the joints you move actively are your elbow, wrist and hand. A few practical points for these first days: - You need to sleep in the sling. - Use ice for pain relief if needed. - When wearing your sling, relax your shoulder and let the sling take the weight of your arm. - Take your painkillers before you do your exercises, and before your physiotherapy appointments. - You are allowed to take your arm out of the sling for your exercises and showering. - You need to wear your sling for 6 weeks, especially when out of the house. - Keep your hand on the operated side gently busy: writing, eating and using a phone while the arm rests in the sling are all encouraged. - Unless you have chosen to arrange your own physiotherapy, an appointment has been made for you and is detailed in your discharge pack. - If you have any problems, contact the office or let your physiotherapist know. ## Phase I — Protection while the bone heals (Weeks 0–6) Kieran Hirpara 4.0 #### Pendulum exercises (fully relaxed) Lean forward, supported on a table with your other hand, and let the operated arm hang completely relaxed. Make small circles by gently rocking your body — the arm swings passively and the shoulder muscles do no work at all. If the arm is not staying relaxed, stop and ask your physiotherapist to check your technique. As guided by your physiotherapist Kieran Hirpara 4.0 #### Active elbow bends With the arm out of the sling and the upper arm resting by your side, bend the elbow as far as it will comfortably go, then straighten it fully. Only the elbow moves — keep the shoulder still and the arm by your side. As guided by your physiotherapist Kieran Hirpara 4.0 #### Open and close hand Make a tight fist, then open the hand and spread the fingers fully. Keep the hand gently busy through the day — writing, eating and using a phone while the arm rests in the sling are all encouraged. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wrist movement With the arm out of the sling and resting by your side, keep the wrist moving by bending it forwards, backwards and gently side to side. Like the elbow and hand work, this keeps the lower arm supple while the shoulder is protected. As guided by your physiotherapist Kieran Hirpara 4.0 #### Scapular setting and shrugs Sitting or standing tall, gently squeeze your shoulder blades down and together without arching your back, hold a few seconds, then relax. Add gentle shoulder shrugs — lift the shoulders toward the ears and let them settle. Keep your posture corrected through the day: ears, shoulders and hips in line. As guided by your physiotherapist The first six weeks are about one thing: letting the tuberosity fragments heal onto the bone and the prosthesis, undisturbed. You stay in the sling day and night, keep your elbow, wrist and hand moving, and let the shoulder itself be moved only passively (gently, by your physiotherapist or with the arm completely relaxed) within the limits below. The rules that matter most: do not move the shoulder actively, do not rotate the arm outwards past the limits, do not reach behind your back, do not lift anything, and do not push up through your hands. If you have a reverse replacement, these rules also protect the new joint against dislocation while the soft tissues heal. When lying on your back, keep a small pillow or rolled towel under your elbow so the shoulder does not stretch backwards. For your physiotherapist: Goals - Protect the tuberosity repair and prosthesis - Reduce swelling, minimise pain - Maintain active range of motion (ROM) in the elbow, wrist and hand - Gentle protective shoulder passive range of motion (PROM) within the safe zone - Maintain scapular and postural awareness - Patient education Sling - 6 weeks, including while sleeping - Removed only for washing and exercises; arm stays by the side when out of the sling Management - Swelling management: ice, compression - Range of motion / mobility: - PROM only, within the safe zone: elevation in the scapular plane ≤ 90 degrees; external rotation (ER) to neutral (0 degrees) for the first 4 weeks, then ≤ 30 degrees; no internal rotation (IR) behind the back - Pendulums, performed fully relaxed as a passive exercise - Active-assisted range of motion (AAROM): none for the shoulder - Active range of motion (AROM): elbow, wrist, hand and fingers; cervical spine - Scapular setting, shoulder shrugs and postural correction - Encourage light use of the hand while in the sling (writing, eating, phone) - Analgesia before exercises and physiotherapy sessions Precautions - No shoulder AROM or AAROM - No passive or active ER past the limits above (the greater tuberosity repair is loaded by external rotation) - No resisted internal rotation (the lesser tuberosity/subscapularis repair is loaded by internal rotation) - No reaching behind the back; no combined adduction, internal rotation and extension (reverse replacement dislocation position) - No lifting of objects; no supporting of body weight through the hands (for example pushing up from a chair or bed) - Place a small pillow or towel roll under the elbow while lying on the back, so the shoulder does not fall into extension - Do not force any movement into pain Criteria to progress - 6 weeks have passed AND X-rays show the tuberosities healing in position, as confirmed at your review with Dr Hirpara - Pain controlled with oral analgesia - No wound concerns and no signs of instability ## Phase II — Restoring movement (Weeks 6–12) Kieran Hirpara 4.0 #### Table slides Sit at a table with your forearm resting on it. Lean gently forward so your hand slides along the table, letting the table support the weight of the arm, then sit back up. Progress within comfort — do not push into pain. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wall climbs (finger walk) Stand facing a wall and walk your fingers slowly up it, letting the wall take the weight of the arm, then walk them back down with control. Go only as high as comfort allows, without shrugging the shoulder or arching your back. As guided by your physiotherapist Kieran Hirpara 4.0 #### Pulley-assisted flexion Sit beneath an over-door pulley. With the operated arm relaxed, pull down with your other hand so the rope gently raises the operated arm in front of you, then lower it slowly. The good arm does the work — do not force the range. As guided by your physiotherapist Kieran Hirpara 4.0 #### Stick-assisted external rotation Lie on your back holding a stick in both hands, elbows bent to 90 degrees and tucked at your sides. Push with the good arm so the operated forearm rotates outwards, staying within the limit agreed at your review, then return. The operated arm stays relaxed — never force the movement. As guided by your physiotherapist Kieran Hirpara 4.0 #### Assisted flexion (lying) Lie on your back and use your good arm — or a stick held in both hands — to help lift the operated arm up in front of you, as far as comfort allows, then lower it back down with the good arm still helping. The operated shoulder stays relaxed and the good arm does the work, helping range return without straining the healing repair. As guided by your physiotherapist Kieran Hirpara 4.0 #### Active scaption (full can) Once your physiotherapist has cleared active movement, raise the arm out at about a 45-degree angle between front and side, thumb pointing up as if holding a full can. Lift only as high as you have good control, then lower slowly. This begins active elevation once the tuberosities have started to heal — do not begin it earlier. As guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric forward press (deltoid) Stand facing a wall with the elbow bent and a folded towel between your fist and the wall. Press the fist gently forwards into the wall without letting the arm move, hold a few seconds, then relax. This wakes up the deltoid with no movement — start it only late in this phase, gently and pain-free. As guided by your physiotherapist Kieran Hirpara 4.0 #### Low row Sitting or standing tall, draw the elbow back and down towards your hip, squeezing the shoulder blade down and back, hold a moment, then release. This sets the shoulder-blade muscles that support the shoulder — keep it light and gentle in this phase. As guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric external rotation Stand with your elbow tucked at your side and bent to a right angle, the back of your hand against a wall or doorframe. Press gently outwards into it without letting the arm move, hold a few seconds, then relax. Introduce this only late in this phase, gently and pain-free, as the rotator cuff repair allows. As guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric internal rotation Stand with your elbow tucked at your side and bent to a right angle, the palm against a doorframe. Press gently inwards into it without letting the arm move, hold a few seconds, then relax. Begin this only once cleared at your review — the lesser tuberosity repair is loaded by internal rotation, so it is left until last. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wall walk out to the side Stand side-on to a wall with your fingertips resting on it. Walk your fingers up the wall out to the side, raising the arm as far as is comfortable, then walk them back down with control. The wall supports the arm as you regain movement out to the side. As guided by your physiotherapist At your six-week review, X-rays check that the bone fragments are healing in position. If they are, the sling comes off and the shoulder begins to move for itself, assisted at first using your other arm, a cane or a pulley, then actively. Passive range progresses towards full over these weeks, and the rotation limits ease. The first gentle muscle-activation work starts for the deltoid and the shoulder-blade (periscapular) muscles. What does not start yet is strengthening: the repair is still consolidating, so the lifting rule stays at nothing heavier than a cup of coffee, and there is still no pushing up through the hands. For your physiotherapist: Goals - Wean from the sling following the six-week review - Progress shoulder PROM towards full range as comfort allows - Initiate shoulder AAROM, progressing to AROM - Initiate gentle deltoid and periscapular activation - Restore use of the arm for light activities of daily living at waist and chest height - Patient education Sling - Discontinue after the six-week review; may be worn out of the house for protection in crowds during the first week or two of weaning Management - Continue Phase I interventions as needed - Range of motion / mobility: - PROM: progress towards full range in all planes by about weeks 8–10, respecting pain - AAROM: table slides, wall climbs, pulleys, cane-assisted flexion and external rotation, supine progressing to sitting - AROM: begin once AAROM is comfortable and movement quality is good, starting with supine flexion progressing to upright flexion and scaption - ER: progress beyond 30 degrees as comfort allows once healing is confirmed - Gentle functional hand-behind-back and extension introduced late in this phase, as cleared. Do not stretch into these positions. - Strengthening: - Pain-free sub-maximal isometrics only: deltoid in the scapular plane, periscapular setting, low row, scapular retraction - Gentle pain-free rotator cuff isometrics late in this phase; introduce resisted internal rotation only once cleared at review - Motor control: emphasise scapular control and avoid hitching or other compensatory patterns Precautions - No lifting of objects heavier than a cup of coffee - No supporting of body weight through the hands - No resistance or strengthening work beyond gentle isometrics - Avoid forcing range: stretch to firm discomfort only, never sharp pain Criteria to progress - Comfortable active movement below shoulder height with good scapular control and minimal compensation - Continued healing of the tuberosities on X-ray, as confirmed at your review with Dr Hirpara - Pain settled enough to begin resistance work ## Phase III — Strengthening (Weeks 12–24) Kieran Hirpara 4.0 #### Rows with elastic band Anchor an elastic band in front of you at waist height. Standing tall, pull the band towards you, drawing the shoulder blade down and back, then release with control. Start with light resistance — low load and higher repetitions, progressing as guided. As guided by your physiotherapist Kieran Hirpara 4.0 #### Serratus punch Lie on your back with the operated arm reaching straight up towards the ceiling. Without bending the elbow, push the hand a little higher so the shoulder blade lifts off the floor, then settle it back. This strengthens the muscle that anchors the shoulder blade to the ribs. Low load, higher repetitions Kieran Hirpara 4.0 #### Scapular retraction with weight Bending forward from the hips with a light weight in each hand, draw the elbows back and squeeze the shoulder blades together, then lower with control. This builds the shoulder-blade muscles against resistance — keep the load light and the movement smooth. Low load, higher repetitions Kieran Hirpara 4.0 #### External rotation with band Stand with your elbow tucked into your side and bent to a right angle, holding an elastic band anchored at waist height. Keeping the elbow at your side, rotate the forearm outwards against the band, then return slowly. Strengthen the rotator cuff progressively, as the healed tuberosities allow. Low load, higher repetitions Kieran Hirpara 4.0 #### Side-lying external rotation with weight Lie on your non-operated side with the operated elbow bent to a right angle and tucked against your body. Holding a light weight, rotate the forearm up towards the ceiling, then lower slowly. Part of the graduated rotator cuff strengthening — keep mobility work going alongside it. Low load, higher repetitions Kieran Hirpara 4.0 #### PNF diagonal with band (lift) Anchor an elastic band low and to the side of your operated arm. Draw the hand diagonally up and across the body, from near the opposite hip towards the shoulder, then return slowly. These diagonal patterns train the shoulder to work in the directions used in everyday life. As guided by your physiotherapist Kieran Hirpara 4.0 #### Weight bearing through the arm Place your hands on a wall or a sturdy bench and gently push your upper back away so the shoulder blades round forward, then return. This reintroduces taking weight through the arm — bring it in only once cleared during this phase, building up gradually. As guided by your physiotherapist Kieran Hirpara 4.0 #### External rotation with the arm raised With your arm out to the side at shoulder height and your elbow bent to 90°, rotate your forearm upwards and back, then return with control. Keep the movement smooth and within a comfortable range. This trains outward rotation in the raised position. As guided by your physiotherapist — light and controlled By about twelve weeks the tuberosities are usually well on the way to union, and your review with Dr Hirpara confirms whether the shoulder is ready to be loaded. Strengthening then begins, gently, starting with elastic bands and light weights, and concentrating on the deltoid and shoulder-blade muscles that drive the shoulder (after a reverse replacement, the deltoid does much of the work the rotator cuff used to do). The rotator cuff itself is strengthened as the healed tuberosities allow. Light lifting builds gradually through this phase, daily activities should feel close to normal at waist and shoulder height, and driving is usually back during this phase if it has not resumed already. For your physiotherapist: Goals - Maintain pain-free PROM and progress AROM in all planes - Graduated restoration of strength and endurance: deltoid, periscapular muscles, then rotator cuff - Improve dynamic stability, motor control and proprioception - Return to most daily activities, including light lifting Management - Continue range-of-motion and mobility work in all planes - Strengthening, progressing from isometrics to elastic bands and then light weights (low load, higher repetitions): - Periscapular: rows, serratus punches, scapular retraction with resistance - Deltoid: resisted flexion and scaption in functional positions, with controlled eccentric lowering - Rotator cuff: ER and IR with elastic resistance, side-lying ER, progressing as the healed tuberosities allow - Motor control: rhythmic stabilisation, proprioceptive neuromuscular facilitation (PNF) diagonal patterns, ball stabilisation work - Graduated lifting: from about 2 kg early in the phase towards about 5 kg by the end, as control allows - Gradual reintroduction of weight bearing through the arm (for example pushing up from a chair) during this phase, as cleared Precautions - No heavy lifting; keep loads under about 5 kg during this phase - Avoid forceful end-range stretching, and avoid loaded combined abduction and external rotation - Progression remains symptom-guided: if pain or swelling flares, step back a level Criteria to progress - Tuberosity union confirmed at review with Dr Hirpara - Pain-free activities of daily living, with strengthening tolerated without flare-up - Good movement quality through available range ## Phase IV — Return to full activity (6 months onwards) The final phase is a graduated return to heavier tasks, manual work and recreation, guided by your strength and control rather than the calendar. Heavier household and garden tasks come back progressively; manual work is guided by Dr Hirpara; swimming and golf typically resume around the four- to six-month mark. Very heavy lifting is best avoided long term after a shoulder replacement; published protocols suggest keeping regular lifting under about 10 kg. The shoulder keeps improving well beyond this phase: most people continue to gain movement, strength and confidence for 12–24 months after surgery, so it is worth keeping up your home exercise program well after formal physiotherapy finishes. For your physiotherapist: Goals - Optimise functional strength and endurance for the patient's daily demands - Graduated return to work, recreation and sport - Long-term joint-protection education and an independent home exercise program Management - Continue progressive resistance work at light weight and higher repetitions, emphasising rotator cuff and periscapular strengthening - Neuromuscular and proprioceptive training; functional and work-specific tasks as needed - Stage the return to swimming, golf and other recreation around the four- to six-month mark, as cleared at review - Customised home exercise program to continue once formal physiotherapy is completed Precautions - Avoid heavy lifting for 6 months from surgery; keep regular lifting under about 10 kg long term - Manual work and contact or load-bearing sport only as cleared by Dr Hirpara Criteria to complete the protocol - Clearance at review with Dr Hirpara, with tuberosity union confirmed - Pain-controlled, functional range of motion that meets the patient's daily demands - Independent with the long-term home exercise program ## After your protocol The phases above are adapted from published rehabilitation protocols for shoulder replacement performed for proximal humerus fracture (Texas Health Orthopedic Specialists, North Tees and Hartlepool NHS Foundation Trust for hemiarthroplasty for trauma and reverse shoulder arthroplasty, and the Robert Jones and Agnes Hunt Orthopaedic Hospital), with the emphasis on tuberosity healing drawn from the surgical literature. The week ranges are typical rather than fixed, and your rehabilitation is progressed individually by your physiotherapist, working with the practice, gated on your reviews with Dr Hirpara. This page works alongside the practice's general recovery advice; see managing post-operative pain and wound care. For the operation itself, see shoulder replacement for fracture; for the elective version of this journey, see the reverse shoulder replacement protocol. The evidence behind this protocol (why tuberosity healing sets the pace, the hemiarthroplasty-versus-reverse comparison, and the published rehabilitation guidelines) is summarised in the evidence section, available as a PDF from the top of this page. --- ### Proximal Humerus Fixation (ORIF) URL: https://www.cqupperlimb.com/education/rehabilitation/proximal-humerus-orif/ Region: rehabilitation · rehabilitation Rehabilitation after locking-plate fixation of a proximal humerus fracture, gated on radiographic healing at review. This protocol covers the rehabilitation after surgical fixation of a proximal humerus fracture (a break of the upper arm bone near the shoulder, repaired with a locking plate and screws, open reduction and internal fixation, ORIF) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. Bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. Your rehabilitation is progressed individually by your physiotherapist through the phases below, depending on how your fracture heals. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect Rehabilitation after a fracture fixation works differently from rehabilitation after most planned shoulder operations. The plate and screws hold the broken bone in position, but the bone itself still has to heal, and the speed of that healing varies considerably from person to person. For that reason, the timetable below is a typical guide rather than a fixed schedule: each step up in your program depends on both the number of weeks since surgery and on how the fracture is healing on your X-rays, as confirmed at your reviews with Dr Hirpara. Do not move yourself on to the next phase on the calendar alone; wait for your review. There is one more thing that makes this operation different. The bony knobs at the top of the humerus (the tuberosities) are where the rotator cuff tendons attach, and in many proximal humerus fractures these fragments are part of the break and are fixed back with the plate or with stitches. Working the rotator cuff muscles too hard, too early can pull on those fragments before they have healed. With a modern locking plate the fixation is strong from day one, so gentle early movement is encouraged: you may move the shoulder actively-assisted and gently actively within comfort from early on, raising the arm in a pain-free range. The cautious element is rotator-cuff loading: where the tuberosity fragments are not part of the fracture, or are solidly fixed, your surgeon may clear you to begin active rotation and cuff work sooner; where the tuberosities are involved and healing, active rotator-cuff work and forced outward rotation are held back a little longer. Dr Hirpara will tell you which applies to you. Your exercise program uses three kinds of movement, and your team will mark which apply to you: - Active range of motion: movement is allowed without aid or help. - Active-assisted range of motion: using the other arm or an object to assist with moving the arm. - Passive range of motion: completely relaxed, using the other arm or force to do 100% of the work. You will wake from surgery with your arm in a sling. Wear it full-time for the first three weeks or so, then wean out of it over the following weeks as comfort allows; published protocols average around three weeks of immobilisation, and the evidence supports earlier movement over longer time in the sling. You don't need to sleep in it. Take it off several times a day for your exercises and for washing and dressing, and when sitting quietly at home you may rest the arm out of the sling. Do not drive for at least six weeks after any shoulder operation; your surgeon will clear you to drive, typically at the six-week review. The journey at a glance: - Phase I — Protection and early movement: weeks 0–6 - Phase II — Regaining active movement: weeks 6–12 - Phase III — Strengthening: about months 3 to 4½ - Phase IV — Return to full activity: from about 4½–6 months ## Phase I — Protection and early movement (Weeks 0–6) Kieran Hirpara 4.0 #### Pendulum exercises Lean forward, supporting yourself on a table with your other hand, and let the operated arm hang relaxed. Make small circles — clockwise, then anticlockwise — by gently rocking your body. The arm swings passively; the movement comes from your body, not the shoulder muscles. Several times a day Kieran Hirpara 4.0 #### Active elbow bends With the arm out of the sling and the upper arm resting by your side, bend the elbow as far as it will comfortably go, then straighten it fully. Only the elbow moves — keep the shoulder still and the arm by your side. Several times a day Kieran Hirpara 4.0 #### Ball squeezes With the arm supported, squeeze a soft ball or make a tight fist, then open the hand fully. Keep the fingers, wrist and hand moving each time the arm is out of the sling. Several times a day Kieran Hirpara 4.0 #### Scapular setting Sitting or standing tall, gently draw your shoulder blades down and back together without moving the arms, hold for a few seconds, then relax. Keep your ears, shoulders and hips in line. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wrist movements With the arm out of the sling, keep the wrist moving by bending it forwards, backwards and gently side to side. This keeps the whole arm working while the shoulder is protected. Several times a day Kieran Hirpara 4.0 #### Assisted forward elevation (lying) Lie on your back and use your good arm to help raise the operated arm up in front of you, then lower it gently with the good arm still helping. Starting on your back lets gravity help and makes early lifting easier. Keep within a comfortable, pain-free range and stop where it begins to pull — do not force it. Several times a day, within a pain-free range Kieran Hirpara 4.0 #### Gentle forward-elevation isometric Stand facing a wall with the operated arm by your side and a soft fist against the wall in front of you. Gently press the hand forwards into the wall without letting the arm move, hold for a few seconds, then relax. This wakes up the shoulder-lifting muscles without straining the healing fracture. Only if your physiotherapist has started you on it. As guided by your physiotherapist The first six weeks are about protecting the fixed fracture while keeping the rest of the arm (and the shoulder joint itself) from stiffening. Because the locking plate holds the bone securely from the start, gentle early movement is encouraged rather than waiting six weeks. A physiotherapist will start you on gentle exercises before you go home: pendulum exercises (letting the arm hang and swing gently by rocking your body), and keeping the elbow, wrist and hand moving out of the sling several times a day. From early on, and within a comfortable, pain-free range, you can begin to move the arm with help from your other hand (active-assisted) and gently under its own power (active), raising it in front of you as comfort allows. The cautious part is rotator-cuff loading: avoid forcing the arm outwards (external rotation) and avoid resisted rotator-cuff work until your tuberosities have healed, as Dr Hirpara confirms. Use ice for pain relief, and take your painkillers before your exercises and physiotherapy appointments. For your physiotherapist: Goals - Protect the fixation and optimise bony healing - Settle pain and swelling - Establish early active-assisted progressing to active elevation within a pain-free range - Maintain full motion of the neck, elbow, wrist and hand Management - Sling full-time for ~3 weeks, then weaned as comfort allows (literature convention); removed several times daily for exercises and hygiene; not required in bed - Pendulum / Codman exercises several times daily - Early active-assisted and gentle active forward elevation within a comfortable, pain-free range from the outset for stable fixation; supine-start elevation progressing toward upright as control allows; advance the range as comfort permits - Passive range of motion as needed where active is not yet tolerated: forward elevation in the scapular plane to about 90°, internal rotation to the belly (not behind the back) - External rotation kept to a gentle early default of about 30–40° with the arm at the side; the surgeon may advance this where the tuberosities are uninvolved or solidly fixed - Cervical, elbow, wrist and hand active range of motion out of the sling; ball squeezes for grip - Scapular setting and scapular mobility work (elevation, depression, retraction, protraction) - Gentle deltoid and periscapular isometrics may be introduced as comfort allows - Cryotherapy and analgesia before sessions; scar mobilisation and desensitisation once the wound has healed Precautions - Avoid forced or resisted external rotation and heavy rotator-cuff loading until tuberosity healing is confirmed (surgeon-guided); active elevation in a pain-free range is permitted - No internal rotation behind the back; avoid abduction in the coronal plane - Keep early movement pain-free: gentle and within comfort, not forced - No lifting greater than about 0.5–1 kg with the operated arm - No weight-bearing through the operated arm (no pushing up from a chair or bed) - No driving for six weeks (this applies to any shoulder operation) - No forced or painful end-range movement Criteria to progress - Radiographic evidence of healing progressing, as confirmed at the review with Dr Hirpara at about 6 weeks - Pain well controlled - Full elbow, wrist and hand motion maintained - Comfortable active-assisted to active elevation within a pain-free range ## Phase II — Regaining active movement (Weeks 6–12) Kieran Hirpara 4.0 #### Side-lying external rotation Lie on your non-operated side with the operated arm on top, elbow bent to 90 degrees and tucked against your body. Keeping the elbow in, rotate the forearm up away from your tummy as far as is comfortable, then lower with control. No added weight — the arm moves under its own power. As guided by your physiotherapist Kieran Hirpara 4.0 #### Low row with elastic band Anchor an elastic band in front of you at waist height. Standing tall, pull the band towards you, drawing the shoulder blade gently down and back, then release with control. Keep the resistance light. As guided by your physiotherapist Kieran Hirpara 4.0 #### Biceps curls Holding a light weight with the palm up, bend the elbow to bring the weight towards your shoulder, then lower it slowly. Keep the upper arm still by your side, and keep the weight light — no more than about 1–2 kg in this phase. As guided by your physiotherapist Kieran Hirpara 4.0 #### Supported rows Lean forward with your good arm supported on a table, letting the operated arm hang with a light weight. Draw the shoulder blade back and row the weight up toward your hip, then lower with control. Keep the trunk steady — the movement comes from the shoulder blade and arm, not the back. As guided by your physiotherapist Kieran Hirpara 4.0 #### Table slides Sit at a table with your hand resting on a towel or cloth. Lean forward and slide the hand away from you along the table, letting the arm reach further out in front, then slide it back. The table takes the weight of the arm, so this is a gentle way to regain forward movement. As guided by your physiotherapist Kieran Hirpara 4.0 #### Over-door pulley Sit under an over-door pulley with a handle in each hand. Pull down with your good arm to raise the operated arm as far as it comfortably goes, then lower it slowly. Let the good arm do the work and stay within a comfortable range. As guided by your physiotherapist Kieran Hirpara 4.0 #### Assisted external rotation with a stick Lie on your back with the elbow tucked by your side and bent to a right angle. Hold a stick in both hands and use your good arm to turn the operated hand outwards. Once your healing is confirmed, gently work the outward rotation a little further — but stay within the range your surgeon and physiotherapist have set. As guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric external rotation Stand with your elbow tucked at your side and bent to a right angle, the back of your hand against a wall or doorframe. Gently press outwards into it without letting the arm move, hold a few seconds, then relax. This begins to wake up the rotator cuff with no movement — start it only once Dr Hirpara has confirmed your healing. As guided by your physiotherapist Kieran Hirpara 4.0 #### Triceps extensions Holding a light weight, bend and then straighten the elbow to work the muscle at the back of the upper arm. Keep the upper arm steady and the weight light — no more than about 1–2 kg in this phase. As guided by your physiotherapist Kieran Hirpara 4.0 #### Prone scapular row Lie face down with your arm hanging over the edge of a bed or bench. Draw the shoulder blade back and lift the arm out to the side a little way, squeezing the shoulder blades together, then lower with control. This strengthens the muscles that steady the shoulder blade. As guided by your physiotherapist At your review around six weeks, Dr Hirpara checks your X-rays. If healing is progressing as expected, any remaining sling use stops and you begin moving the arm yourself, first with assistance (using the other arm, a stick or a pulley), then actively. It usually works best to start active lifting of the arm while lying on your back, where gravity is less of an opponent, and progress to sitting and standing as control improves. Gentle muscle-setting (isometric) exercises for the rotator cuff begin in this phase once Dr Hirpara has confirmed healing; exercises against resistance come later. You may return to driving once you are out of the sling, have enough movement and control of the arm to drive safely, and are no longer taking strong painkillers; if in doubt, discuss it at your review. For your physiotherapist: Goals - Restore full passive range of motion - Progress from active-assisted to active range of motion in all planes - Re-establish normal scapulohumeral rhythm and minimise compensatory patterns - Return to normal light daily activities Management - Sling fully discarded by the 6-week review at the latest - Active-assisted range of motion: lawn-chair progression, table / wall slides, pulleys, stick exercises, progressing beyond the Phase I limits as comfort allows - Active range of motion from about 6–8 weeks: supine flexion progressing to upright elevation; side-lying external rotation and flexion; low rows / low punch - Submaximal rotator cuff and deltoid isometrics from about 6–8 weeks, with the arm at the side, once healing is confirmed - Light elbow isotonics (biceps curls, triceps extensions) and scapular strengthening (retraction, prone rows) - Glenohumeral and scapulothoracic mobilisation as indicated, progressing grades with healing - Postural correction; continue heat / ice and analgesia around sessions as preferred Precautions - No resisted (isotonic) rotator cuff strengthening until union is confirmed, typically not before 8–12 weeks - No forceful end-range overpressure or aggressive passive stretching - Lifting limited to about 1–2 kg with the operated arm - Watch for and correct shoulder hitching and trunk-lean compensation with elevation Criteria to progress - Full, or near-full, passive range of motion - Active elevation with good mechanics, at least below shoulder height - Isometrics well tolerated without a flare of pain - Union progressing on X-ray, as confirmed at your review with Dr Hirpara ## Phase III — Strengthening (about Months 3 to 4½) Kieran Hirpara 4.0 #### Cross-body stretch Use your other hand to draw the operated arm across your chest until you feel a stretch at the back of the shoulder. Hold briefly, then release. Stretch to firm discomfort only — never into sharp pain. As guided by your physiotherapist Kieran Hirpara 4.0 #### Behind-the-back stretch Hold a towel behind your back with the good arm above and the operated arm below. Use the upper hand to gently draw the lower hand up your back until you feel a comfortable stretch, hold, then release. Build the range gradually — never force the stretch or push into sharp pain. As guided by your physiotherapist Kieran Hirpara 4.0 #### Band external rotation Stand with your elbow tucked into your side and bent to a right angle, holding an elastic band anchored at waist height. Keeping the elbow at your side, rotate the forearm outwards against the band, then return slowly. This builds the rotator cuff with the arm at the side, the starting point for rotation strengthening. 2 to 3 sets of 8 to 12, low resistance Kieran Hirpara 4.0 #### Side-lying external rotation with weight Lie on your non-operated side with the top elbow bent to a right angle and tucked against your body. Holding a light weight, rotate the forearm up towards the ceiling, then lower slowly. Keep the load light and the repetitions higher as your rotator-cuff strength rebuilds. 2 to 3 sets of 8 to 12, low load Kieran Hirpara 4.0 #### Full-can raise (scaption) Holding a light weight with your thumb pointing up, raise the arm out to a forward-and-out diagonal — not straight to the side — to about shoulder height, then lower slowly. This works the front of the shoulder and the cuff together. Keep the weight light and stop if it provokes pain that lingers. 2 to 3 sets of 8 to 12, low load Kieran Hirpara 4.0 #### Prone row Lie face down with the operated arm hanging down towards the floor. Draw your elbow up towards the ceiling, squeezing the shoulder blade in towards your spine, then lower slowly. Start with no weight and keep the movement controlled. As guided by your physiotherapist Kieran Hirpara 4.0 #### Doorway chest stretch Stand in a doorway with your forearms resting on the frame and elbows at about shoulder height. Step one foot through and gently lean forwards until you feel a stretch across the front of your chest, then hold. Keep it gentle and never force it. Hold ~20–30 seconds, as guided by your physiotherapist Kieran Hirpara 4.0 #### Latissimus (side-of-back) stretch Reach the operated arm overhead — use your good hand to guide it if needed — and gently lean to the opposite side until you feel a stretch down the side of your back, then hold. Keep it comfortable and within your range. Hold ~20–30 seconds, as guided by your physiotherapist With the fracture united and your active movement returning, attention turns to rebuilding strength. Resistance work starts gently (elastic bands and light weights for the rotator cuff, deltoid and shoulder-blade muscles) and progresses gradually. Stretching continues alongside, working towards full movement in all directions, including reaching behind the back. Normal daily activities should be largely back to usual during this phase, and lighter recreational activities typically resume, as guided by your physiotherapist. For your physiotherapist: Goals - Full active range of motion in all planes with normal mechanics - Graduated restoration of rotator cuff, deltoid and scapular strength and endurance Management - Progress from isometrics to elastic-band and then light free-weight strengthening (about 0.5–2 kg) for the cuff, deltoid and scapular stabilisers: low load, higher repetitions (for example 2–3 sets of 8–12), resistance sessions about 3 times per week to avoid overload - Rotation strengthening initially with the arm at the side, below shoulder height - Emphasise anterior deltoid and the trapezius–serratus anterior force couple for a stable scapular base - Flexibility program for terminal range in all planes: posterior capsule (cross-body) stretch, behind-the-back internal rotation, anterior chest wall / pectoralis minor stretches, doorway stretch - Begin internal rotation behind the back and grade III–IV mobilisations as range allows - Upper-body ergometer with low resistance; general aerobic conditioning Precautions - Strengthening stays within the comfortable range and should not provoke pain that lingers - No lifting greater than about 4–5 kg with the operated arm during this phase - Avoid excessive weight-bearing through the arm (push-ups and similar come later) Criteria to progress - Full active range of motion with no compensatory strategies - Strengthening program tolerated without flare-up of pain or loss of range ## Phase IV — Return to full activity (from about 4½–6 months) The final phase is a graduated return to heavier lifting, manual work, overhead tasks and sport. Strength work advances to heavier resistance and compound movements, and, where it is relevant to your work or sport, to faster, more dynamic exercise. Most people are back to their usual activities by around six months, though strength and confidence typically keep improving for up to a year. The right finish line depends on what you need the arm to do, so the return to heavy manual work or contact and overhead sport is agreed with Dr Hirpara and your physiotherapist rather than set by the calendar. For your physiotherapist: Goals - Return to full work, recreational and sporting activity - Strength of the operated arm approaching that of the other side Management - Progressive resistance through bands, free weights and gym-based compound movements - Push-up progression (wall → bench → knees → full) and closed-chain stability work as tolerated - From about 4½ months: eccentric loading, plyometrics (weighted-ball work), proprioceptive and rhythmic-stabilisation drills where relevant - Resisted rotation at 90° of elevation, and interval sport-specific or vocation-specific programs as appropriate Precautions - Progression remains symptom-guided: if pain or loss of range recurs, ease back and restore comfortable movement first Criteria to discharge - Strength of the operated arm at least about 80% of the other side where measured - No pain with progressive strengthening - Independent with a maintenance home program ## After your protocol The phases above are adapted from published rehabilitation protocols for proximal humerus fracture fixation: Massachusetts General Brigham Sports Medicine, Twin Cities Orthopedics, the UConn Musculoskeletal Institute, NYU Langone Orthopedic Center and South Bend Orthopaedics, together with a systematic review of rehabilitation after proximal humerus fracture. Published protocols for this operation vary more than for most shoulder surgery, because the right pace depends on how the individual fracture was fixed and how it heals; your progression through the phases is therefore directed by Dr Hirpara at your reviews and adjusted by your physiotherapist between them. This page works alongside the practice's general recovery advice; see managing post-operative pain and wound care. For the operation itself, see proximal humerus fixation. If you would like to read the evidence behind this protocol (the research on early versus delayed movement after plate fixation, the surgery-versus-sling debate, and the complications the staged progression is designed to avoid), a fully referenced evidence summary is available as a PDF alongside this page. --- ### Radial Head Replacement URL: https://www.cqupperlimb.com/education/rehabilitation/radial-head-replacement/ Region: rehabilitation · rehabilitation A protected recovery plan after replacement of the radial head at the elbow with a metal implant, built around early protected elbow and forearm movement to prevent stiffness, with the forearm positioned to protect any repaired ligaments and the elbow rested in a simple sling… This protocol guides your recovery after radial head replacement at the elbow (where a shattered radial head is replaced with a small metal implant) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist; bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses and on exactly what was repaired during your operation. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect The radial head is the round top of one of the two forearm bones, where it meets the elbow. When it is broken into too many pieces to fix, it is replaced with a small metal implant that restores a stable, congruent elbow and a smooth forearm rotation axis. This is often done as part of repairing a more complex injury, a fracture-dislocation sometimes called a "terrible triad", where the radial head, a piece of the coronoid, and the ligaments on the side of the elbow are all injured together. Because the implant restores stability, the priority of your rehabilitation is early protected movement to prevent stiffness; elbows are very prone to going stiff after this kind of injury, and the best protection against that is to start moving early. Your elbow is rested in a simple sling for comfort between exercises (not a hinged brace), and the sling comes off for your exercises and for washing. Two things shape how soon and how far you move: - Any ligaments that were repaired need protecting. If the ligament on the outside of the elbow (the lateral collateral ligament) was repaired, the forearm is held and exercised turned palm-down (pronated) early on; if the ligament on the inside (the medial collateral ligament) was repaired, it is held palm-up (supinated); if both, in a neutral mid-position. Your therapist will tell you which applies to you. - The elbow must be protected from sideways (varus) stress and, early on, from full straightening if the elbow was unstable. This is why movement is opened up in stages rather than all at once. Movement is progressed steadily, with strengthening usually beginning from about six weeks and a return to full activity around three months. The implant and the healing keep settling for several months, which is why heavier loading is built back gradually. ## Precautions and limitations - Wear the simple sling for comfort as directed; it is not a hinged brace, and comes off for exercises and washing. - Keep the forearm in the position your therapist gives you during early exercises (palm-down if the outside ligament was repaired, palm-up if the inside one was, neutral if both), which protects the repair. - Do NOT put sideways (varus) stress through the elbow; avoid leaning on the elbow or letting the arm hang unsupported across your body early on. - Do NOT force full straightening early if you have been told the elbow was unstable; straighten only within your allowed range. - Do NOT lift, push, pull or bear weight through the operated arm until cleared (commonly around six weeks); keep early hand use light. - Keep your shoulder, wrist and fingers moving from the start, and do NOT drive while your arm is in the sling or cannot safely control the wheel. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### Elbow bends and straightening (active-assisted) Out of the sling, gently bend and straighten the operated elbow within the range you have been given, using your other hand to help guide it so the arm does not have to work hard. Early motion is the most important thing here — the metal implant has restored a stable elbow so it is safe to move, and moving early is what keeps the elbow from going stiff. Stay within any limit on full straightening if you have been given one. 10 times, 3–4 times a day, within your allowed range Kieran Hirpara 4.0 #### Forearm rotation (palm up / palm down) With your elbow tucked at your side and bent to a right angle, gently turn your palm up towards the ceiling, then down towards the floor. Keep the elbow still and let only the forearm rotate. Early on you may be asked to favour one direction (palm down, or palm up) to protect a repaired ligament — follow the direction your therapist gives you. This keeps the forearm supple, which is one of the first movements to stiffen after this injury. 10 times each allowed direction, 3–4 times a day Kieran Hirpara 4.0 #### Shoulder and hand movement Keep your shoulder, wrist and fingers moving freely from day one so they do not stiffen while the elbow recovers. Make a full fist and stretch the fingers out, circle the wrist, and move the shoulder gently. Use the hand for light everyday tasks within comfort. None of this loads the elbow repair. 10 times each, several times a day Kieran Hirpara 4.0 #### Scar care Once the wound is fully healed and the surgeon or therapist has cleared it, massage the scar with a little moisturiser using small circles for a few minutes. This keeps the scar supple and less sensitive. Do not start until the wound is completely closed. A few minutes, 2–3 times a day, once healed Kieran Hirpara 4.0 #### Strengthening from 6 weeks A LATER exercise — only once cleared, commonly from around six weeks. Begin gentle strengthening of the elbow, forearm and grip — for example squeezing a soft ball, then light resisted bending and straightening — and build the effort up gradually over the following weeks. Do not rush heavier loading; the elbow is still maturing for several months. As guided by your hand therapist (from ~6 weeks only) These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist, staying within whatever range and forearm position you have been given. The early exercises keep the elbow and forearm moving to prevent stiffness without straining any repair: active-assisted elbow bending and straightening, gentle forearm rotation in your allowed direction, and keeping the shoulder and hand free. Strengthening and scar care belong to later phases and should not be started until you are specifically cleared. Stop anything that causes sharp pain or a feeling that the elbow is giving way. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after radial head replacement (radial head arthroplasty), most commonly performed for an unreconstructable comminuted radial head fracture, often as part of a terrible-triad fracture-dislocation. This section is to be provided to the hand therapist, and each phase opens with a plain-English explanation of what is happening. The implant restores a stable, congruent radiocapitellar articulation, so the guiding principle is early protected motion to prevent the stiffness these elbows are prone to, with the arc and forearm rotation gated by the integrity of any collateral-ligament and coronoid repairs. Prior to treatment, check the patient's operation report and the examination-under-anaesthesia stability assessment, and liaise with the treating surgeon regarding: which collateral ligaments and/or coronoid were repaired, the stable arc demonstrated intra-operatively, and the protective forearm rotation. Dr Hirpara rests the elbow in a simple sling for comfort (no hinged brace) and favours an accelerated, early-motion approach where stability allows. Forearm-position rule: LCL repair → exercise/rest in pronation; MCL repair → supination; both → neutral mid-position; avoid varus stress and, where the elbow was unstable, terminal extension early. ### Phase I — early protected motion (weeks 0 to 2) The first two weeks start gentle protected motion as soon as wound stability allows (often within the first week) to get ahead of stiffness. The arm rests in a simple sling for comfort, off for exercises and hygiene. The elbow moves through its safe arc with the forearm held in the protective rotation for whichever ligament was repaired. For your hand therapist: Education and precautions - Immobilise in a simple sling for comfort (no hinged brace); off for exercises and washing - Begin active-assisted/active elbow flexion–extension within the intra-operatively demonstrated stable arc; avoid terminal extension if the elbow was unstable - Forearm rotation in the protective position: pronation if LCL repaired, supination if MCL repaired, neutral mid-range if both - No varus stress at any time; perform overhead exercises supine where unstable to neutralise varus and use gravity to coapt the joint - No weight-bearing or pushing through the operated arm Management - Wound: surgical dressings as directed; confirm wound stability before commencing motion - Oedema: elevation, gentle hand pump, ice as needed - Exercises: AAROM/active elbow flexion–extension within the stable arc; forearm pro/sup in the protected direction with the elbow at 90°; full active shoulder, wrist, hand and grip ROM Criteria to progress - Wound settling; comfortable controlled motion within the protected arc ### Phase II — progressing the arc and forearm rotation (weeks 2 to 6) From around two to six weeks the protected arc is gradually widened towards full extension and forearm rotation is opened up in both directions, with the aim of full pronation/supination by about eight weeks. Strengthening and loading are still withheld. For your hand therapist: Assessments - Active and passive elbow flexion–extension and forearm rotation; pain and swelling; wound/scar review; stability symptoms Education and precautions - Progress towards full extension as stability allows (release any early extension block gradually) - Progress forearm rotation in both directions towards full, still mindful of the repaired ligament early in this phase - Continue to avoid varus stress and any loading through the arm Management - Exercises: widen elbow flexion–extension arc to full; progress pro/sup towards full ROM (target full by ~8 weeks); commence scar management once the wound is healed; continue shoulder/wrist/hand ROM - An overhead (supine) motion programme remains useful where residual instability is a concern Criteria to progress - Approaching full painless ROM; no instability symptoms; pain ≤3/10 ### Phase III — strengthening and return (weeks 6 to 12 and beyond) Once movement is restored and the repairs are deemed secure (commonly around six weeks), strengthening begins and is built up gradually (grip first, then resisted elbow and forearm work), progressing through the following weeks. Return to heavier activity is criterion-based, typically around three months. For your hand therapist: Assessments - Elbow and forearm strength versus the other side; pain/swelling response to loading; functional and work-/sport-specific testing as appropriate Education and precautions - Begin gentle resisted strengthening (grip → resisted elbow flexion–extension and pro/sup) from around six weeks; build load gradually - Progress to functional and work-specific loading as tolerated; avoid sudden heavy or impact loading early Management - Exercises: progressive resisted elbow/forearm strengthening (band → light weights); grip strengthening; graded functional loading; continue any residual mobility work - Watch for and report persistent or worsening pain, mechanical symptoms or loss of motion (possible implant overstuffing/loosening or capitellar wear), and refer back to the treating doctor if recovery plateaus or there is a poor outcome - Consider discharge once motion is functional and strength is near-symmetrical Criteria for return to full activity - Functional pain-free ROM; near-symmetrical strength; confident, stable elbow under load ## Getting back to work and activity Light everyday hand use (eating, writing, light self-care) is encouraged from the start, within comfort, as long as it does not involve pushing, lifting or bearing weight through the elbow. Because you must not drive while the arm is in the sling or unable to safely control the wheel, plan for help with transport in the early weeks; driving resumes once you are out of the sling and can control the car, as confirmed at your review. Strengthening usually begins from about six weeks and is built up gradually. Return to heavier work, lifting and sport is typically around three months, and is based on regaining full pain-free movement and adequate, symmetrical strength with a stable elbow, judged by Dr Hirpara and your hand therapist rather than the calendar alone. Heavier manual work and contact sport follow the same criterion-based progression. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain, wound care and scar management. The phased plan above reflects published rehabilitation guidance after radial head arthroplasty and terrible-triad reconstruction, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your elbow progresses and exactly what was repaired. --- ### Radial Tunnel Release URL: https://www.cqupperlimb.com/education/rehabilitation/radial-tunnel-release/ Region: rehabilitation · rehabilitation Post-operative exercises and precautions after radial tunnel release, including radial nerve glides. This protocol guides your recovery after radial tunnel release with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It explains what to expect in the weeks after surgery and sets out the exercise program from your post-operative handout. Bring this page or its PDF to your first physiotherapy or hand therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect Care of your wound is explained in the practice's wound care advice. As your wound heals, the released nerve can stick to the surrounding tissue; the gliding exercises below are very important to keep it moving freely and stop it from becoming tethered. Sometimes the wound can become sensitive. This is normal, and can be prevented or minimised by commencing daily desensitisation: gently tapping and rubbing over the wound (or the dressing), starting immediately following your surgery. This type of "sensory feedback" allows the nerve to normalise touch and texture. Once the wound is fully healed, commence scar massage: firm circles over the incision. Refer to the wound care advice for more information on scar management. It is important to have realistic expectations of recovery. The radial nerve has to travel and stretch a measurable amount during ordinary arm movements, so keeping it moving early is what stops it adhering to the healing tissues [1]. Even so, the relief of pain after radial tunnel release is often gradual rather than immediate, and for some people it is only partial. This operation is, honestly, less predictable than some other nerve-release procedures: radial tunnel syndrome can be hard to diagnose with certainty and it often overlaps with tennis elbow, which is part of why results vary. Published long-term studies report good outcomes in around two-thirds of patients overall, with the best results in those who have radial tunnel symptoms alone [2][3]. Recovery tends to be slower and less complete when there is also tennis elbow (lateral epicondylitis), more than one nerve compression in the same arm, or a workers' compensation claim [2][4]. Your nerve-gliding program and graded desensitisation are the parts of rehabilitation most within your control, and steady daily practice gives the nerve its best chance to settle. ## Precautions and limitations Light functional use of your hand is encouraged for daily living tasks such as self-care, feeding, dressing, writing and typing. Beyond that, the limits are simple: no lifting, gripping, weight-bearing or use of vibration machinery (for example, power tools or a lawn mower) for up to 6 weeks after surgery, and driving is limited for the first 2–3 weeks. For your physiotherapist: Goals - Prevent the released nerve adhering to the healing wound (nerve gliding program) - Settle wound sensitivity through graded desensitisation - Maintain wrist, forearm and elbow range of motion - Support light functional use of the hand for activities of daily living Management - Daily desensitisation: gentle tapping / rubbing over the wound (dressing), commencing immediately post-operatively - Scar massage (firm circles over the incision) once the wound is fully healed - Home exercise program as per the cards below: wrist flexion / extension stretch; wrist supination / pronation stretch; elbow flexion / extension; radial nerve glides - Favour gentle sliding-type ("slider") nerve glides over aggressive end-range tensioning: sliding techniques achieve substantially greater nerve excursion at much lower nerve strain, which is better tolerated around a recently decompressed nerve [1][5] - Nerve mobilisation may be considered as an adjunct to the program; the evidence base for neural mobilisation in nerve-related conditions is supportive but of variable certainty, so progression should be symptom-guided [6] Precautions - Light functional use of the hand only (self-care, feeding, dressing, writing, typing) - No lifting, gripping, weight-bearing or use of vibration machinery (e.g. power tools, lawn mower) for up to 6 weeks post-op - Driving is limited for the first 2–3 weeks - Nerve glides and stretches should be gentle and essentially pain-free; avoid forcing into a range that reproduces the pre-operative nerve pain These are the exercises from your post-operative handout, started after surgery and continued at home as guided by your physiotherapist or hand therapist. The repetitions, hold times and frequency are listed on each card. ## Your exercises Kieran Hirpara 4.0 #### Wrist flexion / extension stretch Rest your elbow on a table and gently rock your wrist back and forth (or rest it over the edge of a table or armchair, as pictured). Once more comfortable, use your other hand on your palm to push the wrist backwards, then forwards, keeping your fingers loose. Hold each stretch for 15 seconds; repeat 5 times in each direction. 10 repetitions, 4–5 times daily Kieran Hirpara 4.0 #### Wrist supination / pronation stretch Bend your elbow at the side of your body, palm facing the ceiling. Turn your hand palm up and hold for 15 seconds, then palm down and hold for 15 seconds; repeat 5 times. As comfort increases, use your opposite hand — holding at your WRIST, not your hand — to gently push the rotation further into each position until you feel a stretch. 5 repetitions, 4 times a day, 5–7 days per week Kieran Hirpara 4.0 #### Elbow flexion / extension With your arm by your side, gently straighten your forearm and elbow as far as you can. Hold this end-range stretch for 3–5 seconds. Repeat in the opposite direction, bending your forearm up and attempting to touch your shoulder with your hand. 10 repetitions, 2 times a day, daily Kieran Hirpara 4.0 #### Radial nerve glides Stand with your arms loose at your sides. Drop your shoulder down and reach your fingers toward the floor. Internally rotate your arm (thumb toward your body) and flex your wrist, palm up. Gently tilt your head away from the side you are stretching, then raise your arm up and away from your body. Hold each position of the glide for 3 to 5 seconds. 5–8 repetitions, 2–4 times a day, 6–7 days per week This exercise program was written in association with Sarah Farrell, Bachelor of Occupational Therapy (BOccThy), Accredited Hand Therapist (AHT). ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain, wound care and hand therapy basics. For the operation itself and the condition it treats, see radial tunnel release and radial tunnel syndrome. --- ### Reverse Shoulder Arthroplasty URL: https://www.cqupperlimb.com/education/rehabilitation/reverse-shoulder-arthroplasty/ Region: rehabilitation · rehabilitation Phase-by-phase rehabilitation protocol after reverse shoulder replacement, including dislocation precautions and the early exercise program. This protocol guides your recovery after reverse shoulder arthroplasty (reverse shoulder replacement) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. Each phase below opens with a plain-English explanation of what is happening and what matters most, followed by the structured protocol written for your physiotherapist: bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. Your physiotherapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect You will have a numb arm when you wake up, and the feeling usually returns within 6 to 12 hours. Rarely, some numbness or weakness can continue for 2 to 3 days. When you wake up from your operation, you will be in a sling, with a big pad over your shoulder. This pad will be removed before discharge. Underneath will be a waterproof dressing covering a surgical glue strip, which can be left alone for 2 weeks. Your stitches are dissolvable and do not need removing, but there may be some tails of stitch at each end of the wound that can be cut flush with the skin after 2 weeks. You will be booked to see our nurse for a wound check 1–2 weeks after your surgery. If you are unable to attend the dressing check, you can remove your dressing yourself after 2 weeks. Approximate timeframes for return to activities: - Driving: 6 weeks - Swimming: breaststroke: 8 weeks; freestyle: 12 weeks - Golf: 4–6 months - Lifting: light lifting can begin at 6 weeks; avoid lifting heavy items for 6 months - Work: sedentary job: 6 weeks; manual job: guided by your surgeon ## Wearing your sling Your sling supports your shoulder for comfort while the early soreness settles. It is there to support the weight of the arm. It is not holding a repair in place. The rules are simple: - Wear it for about 2 weeks for comfort and support, then start weaning off it during the day. A brief spell in the sling at night is fine if it helps you settle, but it is optional. - Take it off for showers and for your exercises, once you have been shown how. - Resting at home, it can come off whenever you are comfortable: arm supported on a pillow while sitting. - Use ice if the shoulder is swollen or sore, especially after exercise. Your physiotherapist will help you put the sling on at first, and will teach you to manage it independently before you go home. Fitting it correctly matters, as a loose sling does not support you properly: - Always ensure that when fitting the sling, your elbow is positioned in the corner of the sling and well supported. - The end of a well-fitted sling should rest comfortably at the knuckle of your little finger. If your hand extends too far out of the sling, it will not provide you with adequate support. - Your sling has two Velcro straps: one attaches around your neck and one around your waist. - Once you have positioned your elbow and forearm correctly, use your non-operated arm to swing the upper strap around your neck to the front and attach it through the upper loop on the sling. - Use the same method to attach the lower strap around your waist, securing through the lower loop on the sling. During your time in the sling, be conscious of your posture at all times and avoid allowing your shoulders to adopt a slumped position. To achieve a good postural position, try to keep your ears, shoulders and hips in line; this is important for your back and will help prevent stiffness in your shoulder joint. A rolled-up towel placed in the small of your back when sitting can serve as a friendly reminder. ## Your first days in hospital Before you go home, the hospital physiotherapists will start you on a simple set of exercises, shown below. It helps to understand three terms they will use. Active range of motion means movement you do yourself, without aid or help. Active-assisted range of motion means using your other arm (or an object, such as a cane) to help move the arm. Passive range of motion means the arm stays completely relaxed while your other arm (or someone else) does the work. From the start you can begin moving the shoulder with assistance from your other arm and, within comfort, gently under your own power, often easiest lying on your back so gravity helps. Let comfort be your guide and progress as it allows. A few practical points for these first days: - Use the sling for comfort. A brief spell in it at night is fine if it helps you settle, but it is optional. - Use ice for pain relief if needed. - When wearing your sling, relax your shoulder and let the sling take the weight of your arm. - Take your painkillers before you do your exercises, and before your physiotherapy appointments. - You are allowed to take your arm out of the sling for your exercises and showering. - Wear the sling for comfort and support for about 2 weeks, then wean off it during the day. - Unless you have chosen to arrange your own physiotherapy, an appointment has been made for you and is detailed in your discharge pack. - If you have any problems, contact the office or let your physiotherapist know. These are the exercises the hospital physiotherapists will start you on, continued at home as guided by your physiotherapist. ## Your hospital exercises Kieran Hirpara 4.0 #### Open and close hand Keep your hand and fingers moving by opening and closing them, or by squeezing a soft ball. 10 times, 3 times per day Kieran Hirpara 4.0 #### Wrist movement Keep your wrist moving by bending it forwards, backwards and side to side. 10 times, 3 times per day Kieran Hirpara 4.0 #### Elbow Bend and straighten your elbow. 10 times, 3 times per day Kieran Hirpara 4.0 #### Pendulums This is a passive exercise. Lean forward and let your arm relax down. Use your body to move the arm gently either clockwise or anti-clockwise, along with forwards, backwards and side to side. About 30 seconds each way, 3 times per day Kieran Hirpara 4.0 #### Forward flexion Sitting on a chair and leaning forward, cradle your operated arm with the other arm and gently move your arm upwards in front of you. Lower it back down with the assistance of your non-operated arm. You could also try lying on your back in bed and helping the arm upwards if you would prefer. 10 times, 3 times per day Kieran Hirpara 4.0 #### Abduction Sitting on a chair and leaning forward, cradle the arm again and help it out to the side (e.g. like rocking a baby). 10 times, 3 times per day Kieran Hirpara 4.0 #### External rotation Sitting on a chair, only move your arm from where it would be in the sling to pointing straight in front of you. Don't go further outwards. Gently, 10 times, 3 times per day Kieran Hirpara 4.0 #### Lower trapezius setting Squeeze your shoulder blades downwards and together. Hold 5 seconds, 5 times; repeat 3 times daily Kieran Hirpara 4.0 #### Upper trapezius stretch Use your non-operated arm to bring your ear towards your shoulder, away from the operated side. Hold 10 seconds, 3 times; repeat 3 times per day Kieran Hirpara 4.0 #### Levator scapulae stretch Use your non-operated arm to bring your nose towards your nipple or armpit area. Hold 10 seconds, 3 times; repeat 3 times per day ## Phase I — Protection (Weeks 0–3) Kieran Hirpara 4.0 #### Seated table slide Sit at a table with your forearm resting on the surface. Let your hand slide forwards along the table as you lean gently in, letting the shoulder fold forwards without using the shoulder muscles, then slide back. Keep the movement relaxed and comfortable — the shoulder itself stays passive. As guided by your physiotherapist The first three weeks are about settling your new shoulder joint and easing it back into movement. You use the sling for comfort, manage swelling with ice and compression, and keep your elbow, wrist and hand moving. From the outset you also start gentle shoulder movement, assisted by your other arm and, within comfort, gently under your own power, often easiest lying on your back so gravity helps. Let comfort be your guide and do not force anything. The rules that matter most are about protecting the joint from slipping out of place: do not reach behind your back or rotate the arm inwards, do not lift anything, and do not push up through your hands. When lying on your back, keep a small pillow or rolled towel under your elbow so the shoulder does not stretch backwards. For your physiotherapist: Goals - Protect component stability (avoid the dislocation position) - Reduce swelling, minimise pain - Maintain upper extremity (UE) range of motion (ROM) in elbow, hand and wrist - Establish early shoulder active-assisted and active motion within comfort - Minimise muscle inhibition - Patient education Sling - Neutral rotation - For comfort and support; optional brief night use; wean off during the day from ~2 weeks Management - Swelling management: ice, compression - Range of motion / mobility: - PROM: external rotation (ER) in the scapular plane to tolerance; flexion/scaption ≤ 120 degrees; abduction (ABD) ≤ 90 degrees; seated glenohumeral (GH) flexion table slide; pendulums; seated horizontal table slides - Active-assisted range of motion (AAROM): from the start: active-assisted shoulder flexion (begin supine/gravity-assisted), within the PROM limits above - Active range of motion (AROM): from the start: gentle active shoulder motion as tolerated within comfort; plus elbow, hand, wrist Precautions - No shoulder PROM/AROM into internal rotation (IR) - No reaching behind back, especially into internal rotation - Avoid the combined extension + adduction + internal-rotation (dislocation) position - No lifting of objects - No supporting of body weight with hands - Place small pillow/towel roll under elbow while lying on back to avoid shoulder hyperextension Criteria to progress - Gradual increase in shoulder PROM, AAROM and AROM within comfort - 0 degrees shoulder PROM into IR - Pain < 4/10 - No complications with Phase I ## Phase II — Intermediate (Weeks 4–6) Kieran Hirpara 4.0 #### Cane external rotation stretch Lie on your back with your elbow by your side and bent to 90 degrees. Hold a cane or stick in both hands and use the non-operated arm to push the hand of the operated arm gently outwards, within comfort. Never force the movement. As guided by your physiotherapist Kieran Hirpara 4.0 #### Supine punch Lie on your back and hold the operated arm straight up towards the ceiling. Keeping the elbow straight, push the hand a little further towards the ceiling so the shoulder blade lifts off the bed, then lower back with control. As guided by your physiotherapist The shoulder now builds on the movement you began straight after surgery. Range of motion continues to increase, and the first activation and strengthening work for the shoulder-blade (periscapular) muscles and the deltoid begins around week 4. By this stage you should be out of the sling during the day; you may still use it briefly at night only if it adds comfort. The protective rules still apply: lift nothing heavier than a coffee cup, do not reach behind your back, do not push through your hands, and keep the pillow under your elbow when lying on your back. For your physiotherapist: Goals - Continue to protect component stability (avoid the dislocation position) - Reduce swelling, minimise pain - Gradually increase shoulder PROM - Progress shoulder AAROM/AROM - Initiate periscapular muscle activation and strengthening (~week 4) - Initiate deltoid activation and strengthening (~week 4; avoid shoulder extension when activating posterior deltoid) - Patient education Sling - Discontinue daytime use (weaned off from ~2 weeks) - Optional brief night use only if it adds comfort Management - Continue with Phase I interventions - Range of motion / mobility: - AAROM: active-assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane - AROM: supine flexion, salutes, supine punch - Strengthening: - Periscapular: scapular retraction, standing scapular setting, supported scapular setting, low row, inferior glide - Deltoid: isometrics in the scapular plane Precautions - No reaching behind back, especially into internal rotation - Avoid the combined extension + adduction + internal-rotation (dislocation) position through ~week 6 - No lifting of objects heavier than a coffee cup - No supporting of body weight with hands - Place small pillow/towel roll under elbow while lying on back to avoid shoulder hyperextension Criteria to progress - Gradual increase in shoulder PROM, AAROM, AROM - 0 degrees shoulder PROM into IR - Palpable muscle contraction felt in scapular musculature - Pain < 4/10 - No complications with Phase II ## Phase III — Intermediate, continued (Weeks 7–8) Kieran Hirpara 4.0 #### Wall climbs Stand facing a wall and walk the fingers of the operated arm up the wall as far as is comfortable, letting the wall assist the arm upwards. Walk the fingers back down with control — do not let the arm drop. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wall walk out to the side Stand side-on to a wall with your fingertips resting on it. Walk your fingers up the wall out to the side, raising the arm as far as is comfortable, then walk them back down with control. The wall supports the arm as you regain movement out to the side. As guided by your physiotherapist The sling is well behind you by now. Movement progresses in all directions, including the first gentle passive internal rotation (rotating the arm inwards), and the strengthening work for the deltoid and shoulder-blade muscles steps up, along with the first motor-control (coordination) exercises. The limits that remain: nothing heavier than a coffee cup, no reaching behind your back beyond your pant pocket, no body weight through your hands, and avoid stretching the arm backwards behind your body. For your physiotherapist: Goals - Minimise pain - Gradually progress shoulder PROM; initiate shoulder PROM IR in the scapular plane - Gradually progress shoulder AAROM - Gradually progress shoulder AROM - Progress deltoid strengthening - Progress periscapular strengthening - Initiate motor control exercise - Patient education Sling - Discontinue Management - Continue with Phase I & II interventions - Range of motion / mobility: - PROM: full in all planes; gradual PROM IR in scapular plane ≤ 50 degrees - AAROM: incline table slides, wall climbs, pulleys, seated shoulder elevation with cane with active lowering - AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 degrees - Strengthening: - Periscapular: row on a physioball, serratus punches - Deltoid: seated shoulder elevation with cane, seated shoulder elevation with cane with active lowering, ball roll on wall - Motor control: - IR/ER in scaption plane and flexion 90–125 degrees (rhythmic stabilisation) in supine - Stretching: - Sidelying horizontal adduction (ADD), triceps and lats Precautions - No reaching behind back beyond pant pocket - No lifting of objects heavier than a coffee cup - No supporting of body weight with hands - Avoid shoulder hyperextension Criteria to progress - ROM goals (PROM and AROM expectations are individualised and dependent upon ROM measurements attained in the operating room post-operatively): - Elevation ≤ 140 degrees - ER ≤ 30 degrees in neutral - IR ≤ 50 degrees in scapular plane, or back pocket - Minimal to no substitution patterns with shoulder AROM - Pain < 4/10 ## Phase IV — Transitional (Weeks 9–11) This phase is the bridge back to normal use of the arm. Passive movement should now be full in all planes, and the focus shifts to strengthening the deltoid and shoulder-blade muscles, building dynamic stability and coordination, and gradually restoring strength and endurance, with a return to full functional activities. The one firm limit: no lifting of heavy objects (over 5 kg). For your physiotherapist: Goals - Maintain pain-free ROM - Progress periscapular strengthening - Progress deltoid strengthening - Progress motor control exercise - Improve dynamic shoulder stability - Gradually restore shoulder strength and endurance - Return to full functional activities Management - Continue with Phase II–III interventions - Range of motion / mobility: - PROM: full ROM in all planes - Strengthening: - Periscapular: resistance band shoulder extension, resistance band seated rows, rowing, robbery, lawnmowers, tripod, pointer - Deltoid: gradually add resistance with deltoid exercise - Motor control: - IR/ER and flexion 90–125 degrees (rhythmic stabilisation) - Quadruped alternating isometrics and ball stabilisation on wall - Field goals - Proprioceptive neuromuscular facilitation (PNF): D1 diagonal lifts, D2 diagonal lifts Precautions - No lifting of heavy objects (> 5 kg) Criteria to progress - Performs all exercises demonstrating symmetric scapular mechanics - Pain < 2/10 ## Phase V — Advanced strengthening (Weeks 12–16) Kieran Hirpara 4.0 #### Push-up plus on knees From a push-up position on your knees with hands under the shoulders, keep the elbows straight and push the upper back towards the ceiling, letting the shoulder blades slide apart, then lower with control. As guided by your physiotherapist Kieran Hirpara 4.0 #### Biceps curl Holding a light weight with your palm facing up and your upper arm by your side, bend the elbow to bring the hand towards the shoulder, then lower with control. Keep the load light — heavy lifting (over 7 kg) is still off-limits in this phase. As guided by your physiotherapist The final phase conditions the shoulder for everyday life: keeping your movement pain-free while building the strength and endurance to use the arm confidently. If a rotator cuff repair was performed at the same time as your replacement, rotator cuff (RTC) strengthening starts now. The lifting limit rises, but heavy objects (over 7 kg) are still off-limits. This phase, and the protocol, finishes with clearance from your surgeon once all the milestones have been met. For your physiotherapist: Goals - Maintain pain-free ROM - Initiate rotator cuff (RTC) strengthening with a concomitant repair - Improve shoulder strength and endurance - Enhance functional use of upper extremity Management - Continue with Phase II–IV interventions - Strengthening: - Periscapular: push-up plus on knees, "W" exercise, resistance band Ws, prone shoulder extension Is, dynamic hug, resistance band dynamic hug, resistance band forward punch, forward punch, T and Y, "T" exercise - Deltoid: continue gradually increasing resisted flexion and scaption in functional positions - Elbow: bicep curl, resistance band bicep curls, and triceps - Rotator cuff: internal/external rotation isometrics, side-lying external rotation, standing external rotation with resistance band, standing internal rotation with resistance band, internal rotation, external rotation, sidelying ABD progressing to standing ABD - Motor control: - Resistance band PNF pattern, PNF D1 diagonal lifts with resistance, diagonal-up, diagonal-down, wall slides with resistance band Precautions - No lifting of heavy objects (> 7 kg) Criteria to progress - Clearance from the surgeon, and ALL milestone criteria have been met - Maintains pain-free PROM and AROM - Performs all exercises demonstrating symmetric scapular mechanics - QuickDASH and ASES patient-reported outcome measures ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain and wound care. For the operation itself, see reverse shoulder replacement. The clinical evidence behind this protocol (the published rehabilitation trials, the reasoning for the sling and movement rules, and the research references) is set out in the accompanying evidence summary (available as a downloadable PDF). --- ### Rotator Cuff Repair URL: https://www.cqupperlimb.com/education/rehabilitation/rotator-cuff-repair/ Region: rehabilitation · rehabilitation Staged rehabilitation protocol after rotator cuff repair at Mater Private Hospital Rockhampton, with the early exercise program. This protocol guides your recovery after a rotator cuff repair with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It pairs a plain-English explanation of each stage with a structured programme you can share with your physiotherapist; bring this page or its PDF to your first appointment so your rehabilitation stays coordinated. Your physiotherapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect A rotator cuff repair re-attaches torn tendon back onto the bone, and that biological re-attachment is what this whole programme protects. The repair is still soft at six weeks and keeps maturing for many months: in healing studies it has only around a quarter of its normal strength at six weeks, roughly half at twelve weeks, and it does not approach full strength until at least six months. That is why movement and load are added back in stages rather than all at once. It is tempting to push early, but the evidence is reassuring. For the common smaller and medium tears, any extra range you gain from early movement is temporary, and by one year there is no difference between starting early and starting a little later. Patience in the first weeks costs you nothing in the long run, and it protects the repair when it is at its weakest. There is also good evidence that starting aggressive therapy in the very first week does more harm than good, so the early weeks are deliberately gentle. The single most useful thing you can do for your shoulder is to protect the repair early. Most re-tears happen in the first three to six months, and patients who do not follow the early restrictions are far more likely to re-tear. Sticking to the protocol matters more than any exercise. Rotator cuff repairs are often combined with other procedures in the same operation: most commonly a subacromial decompression, distal clavicle excision, biceps tenodesis or suprascapular nerve release. When that happens, this protocol governs the whole recovery: the repaired tendon is the slowest-healing part, and its timeline sets the pace. Your timeline depends on the size of the tear that was repaired. It is the single biggest thing that sets the pace, because larger tears heal more slowly and are more likely to re-tear. Dr Hirpara will tell you which group your repair falls into, and the page splits the programme into two clearly labelled tracks below: - Small / medium tears: one or two tendons, good tissue quality. - Large / massive tears: bigger tears, two or more tendons, or poorer tissue quality. The steps are the same, but held longer and progressed more cautiously: protected motion is kept up longer, active movement comes back later, and strengthening is delayed. ## The procedure Your rotator cuff repair is done arthroscopically (keyhole), or occasionally through a small open incision. The torn tendon is re-attached to its bony footprint on the top of the upper arm bone, and the job of rehabilitation is to protect that re-attachment while it heals, then gradually rebuild full movement, strength and function. ## Wearing your sling You will wear a simple shoulder sling, not an abduction-pillow sling. There is no proven difference in outcomes between the two, and the simple sling is far easier to live with. Dr Hirpara uses a simple sling for every cuff repair, including large and massive tears. - Wear the sling for 6 weeks for daytime support, especially when you are out of the house or around other people. - You do not sleep in the sling. It is daytime support only; sleep out of it, with your arm comfortable and supported on a pillow. - Take it off for showering and for your exercises (once you have been shown how). Whenever the sling is off, keep your arm relaxed and by your side. - Use ice if the shoulder is swollen or sore, especially after exercise. - For pain relief, take regular paracetamol plus an anti-inflammatory (such as ibuprofen) unless you have been told otherwise, as set out in managing post-operative pain. A dose before your exercises helps. Watch your posture while you are using the sling: keep your ears, shoulders and hips in line and avoid slumping. Good posture protects your back and helps stop the shoulder stiffening. ## Key precautions — do NOT - Do NOT actively move the shoulder under its own power until about 6 weeks (the repair is only about 20% of normal strength at 4 weeks). - Do NOT lift, push, pull, or bear weight through the hand or arm for 6 weeks. - Do NOT rotate the arm outward past the straight-ahead (neutral) position early. - If the front cuff tendon (subscapularis) was repaired: keep active external rotation within about 30° for the first 12 weeks, and do not actively rotate the arm inward (against resistance) in that time; this protects the front repair. Your surgeon will tell you if this applies to you. - Do NOT do "empty-can" (thumb-down) raises. Ever. - Do NOT reach behind your back early, and avoid any sudden jerk or push. - Do NOT drive while the sling is required (6 weeks). ## Small / medium tears This is the track for tears of one or two tendons with good tissue. Where a phase gives a week number, this is your timing. ## Small-medium tears — Phase I: Protection (weeks 0–6) Kieran Hirpara 4.0 #### Circulation and deep breathing To reduce the risk of post-operative complications, aim to walk for at least 30 minutes a day (this does not have to be all at once), and take 4–6 deep breaths every hour. Throughout the day Kieran Hirpara 4.0 #### Open and close hand Make a tight fist with your hand, then open it fully. This keeps your hand moving and helps prevent stiffness and swelling. 10 times per hour Kieran Hirpara 4.0 #### Active wrist bends Gently bend your wrist forwards, then back, as far as is comfortable. 10–15 times per hour Kieran Hirpara 4.0 #### Active elbow bends With your palm facing up, gently bend your elbow as far as you can, then straighten your arm again. Keep your upper arm tucked at your side. 10–15 times, 2–3 times a day Kieran Hirpara 4.0 #### Pendulum swings Lean forwards and let your operated arm hang down, completely relaxed. Make small circles — clockwise, then the other way — by rocking your body, NOT by using your shoulder muscles. Also rock the arm gently forwards/backwards and side to side. Keep the circle small (under about 20 cm). Your operated arm stays relaxed throughout — you are not lifting it. 10 in each direction, 2–3 times a day Kieran Hirpara 4.0 #### Assisted forward lift in lying Lie on your back. Place your good hand under the elbow of your operated arm and use it to lift the operated arm towards the ceiling — your operated shoulder stays relaxed while your good hand does the work for you. Do NOT lift past shoulder height (about 90°) in this phase. Lower slowly back to the start. 10 times, 2–3 times a day Kieran Hirpara 4.0 #### Cradled arm-out-to-the-side Sitting and leaning forwards slightly, cradle your operated arm with your good arm and help it out to the side — like rocking a baby. Your operated shoulder stays relaxed; your good arm does the moving. 10 times, 2–3 times a day Kieran Hirpara 4.0 #### Assisted external rotation to neutral Sitting or standing, keep your elbow tucked at your side and start with your hand resting on your stomach. Gently turn your forearm outwards only as far as the straight-ahead (neutral) position — no further. Do NOT rotate past neutral. Slowly return. 10 times, 2–3 times a day Kieran Hirpara 4.0 #### Shoulder-blade setting Gently squeeze your shoulder blades downwards and together, hold, then relax. This is a light muscle-activation drill — your arm does not move. Hold 5 seconds, 5 times, 2–3 times a day Kieran Hirpara 4.0 #### Neck side-stretch Use your good arm to gently bring your ear towards your good shoulder, away from the operated side, until you feel a comfortable stretch in your neck. Hold 10 seconds, 3 times, 2–3 times a day Kieran Hirpara 4.0 #### Neck stretch towards the armpit Use your good arm to gently bring your nose down towards your armpit, away from the operated side, until you feel a comfortable stretch. Hold 10 seconds, 3 times, 2–3 times a day The first six weeks are about one thing: protecting the repair while the tendon starts to heal onto the bone. You stay in the simple sling for daytime support, sleep out of it, manage swelling with ice, and do gentle drills that keep your hand, wrist, elbow and neck moving without loading the repaired tendon. Your physiotherapist (or you, with help from your good arm) gently moves the shoulder for you; you stay completely relaxed. - Sling: simple sling for daytime support; sleep OUT of the sling; off for exercises and hygiene. - Movement allowed: assisted and passive movement only; nothing under your own shoulder power. Your good arm or a stick does the work. Build assisted forward elevation gradually towards about 90° (halfway up) early, and assisted outward rotation only as far as the straight-ahead (neutral) position. - Exercises: pendulum swings; assisted forward lift in lying; cradled arm-out-to-the-side; assisted external rotation to neutral; gentle hand, wrist and elbow movement; shoulder-blade and neck drills. Ready for the next phase when: your pain is settling and controlled with simple pain relief (about 3/10 or less); assisted forward elevation reaches about 90° comfortably; assisted outward rotation reaches the neutral position comfortably; your wound has healed with no signs of a problem; and there is no sign the repair has been over-stressed. ## Small-medium tears — Phase II: Restoring movement (weeks 6–12) Kieran Hirpara 4.0 #### Assisted forward lift in lying Lying on your back, hold a stick in both hands and use your good arm to lift the operated arm forwards and up — the operated shoulder stays relaxed. Build towards about 120° (roughly two-thirds of the way up) over this phase, staying within the range your physiotherapist sets. Move smoothly, never force, and lower with control. 10 times, 2–3 times a day Kieran Hirpara 4.0 #### Assisted external rotation with a stick Lying on your back, elbow tucked at your side and bent to 90°, hold a stick in both hands and use your good arm to push the operated hand gently outwards. Stay within the range your physiotherapist sets and never force it. 10 times, 2–3 times a day Kieran Hirpara 4.0 #### Seated table slide From about week 6, sit at a table with your operated hand on a towel. Slide the hand forwards along the surface so the arm reaches forwards and up, letting the table take the weight, then slide back. The same drill can be done out to the side as your physiotherapist directs. 10 times, 2–3 times a day Kieran Hirpara 4.0 #### Over-door pulley From about week 6, sit under an over-door pulley with a handle in each hand. Pull down with your good arm to raise the operated arm, keeping the operated arm relaxed, then lower it slowly. As guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric external rotation From about week 8, if your physiotherapist agrees. Stand with your elbow tucked at your side and bent to 90°, the back of your hand near a wall or door frame. Press the back of your hand gently outwards into the surface WITHOUT letting the arm move — a gentle effort, about a quarter of your strength, with no pain. Hold, then relax. Hold ~5 seconds, gentle (~25% effort), as guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric internal rotation From about week 8, if your physiotherapist agrees — but NOT before week 12 if the front cuff tendon (subscapularis) was repaired. Stand with your elbow tucked at your side, palm against a wall. Press the palm gently inwards WITHOUT letting the arm move — about a quarter effort, with no pain. Hold, then relax. Hold ~5 seconds, gentle (~25% effort), as guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric abduction From about week 8, if your physiotherapist agrees. Stand side-on with the outside of your upper arm near a wall, elbow at your side. Press the arm gently outwards into the wall WITHOUT letting it move — about a quarter effort, no pain. Hold, then relax. Hold ~5 seconds, gentle (~25% effort), as guided by your physiotherapist Kieran Hirpara 4.0 #### Cross-body stretch Late in this phase only (after week 9). Use your good hand to draw the operated arm gently across your chest until you feel a comfortable stretch at the back of the shoulder. Keep it gentle — do not force. Hold 10–20 seconds, a few times, as guided by your physiotherapist The repair is healing but still weak, at only about 20–30% of normal strength at six weeks. So this phase restores movement, not strength. The sling is now off. You progress from assisted movement to moving the arm under your own power, starting in easy positions (lying down, or sliding along a table where gravity is taken out) and building towards upright. Light muscle-activation (isometric) drills are added late in the phase. - Sling: weaned off (already mostly weaned by weeks 4–6). - Movement allowed: full assisted movement, building to movement under your own power from about week 6. Build assisted/active forward elevation towards about 120° and beyond. - Exercises: assisted forward lift in lying; assisted external rotation with a stick; seated table slide; over-door pulley; gentle isometric (press-and-hold) external rotation, internal rotation and abduction from about week 8; cross-body stretch late in the phase (after week 9). Ready for the next phase when: you can lift the arm forwards under your own power to at least 115–120° with good control (no shrugging or hitching of the shoulder blade); your assisted/passive movement is full or nearly full and pain-free; gentle isometrics are tolerated without a pain flare-up afterwards; and pain is no more than about 2/10 before resisted work begins. ## Small-medium tears — Phase III: Strengthening (weeks 12–16) Kieran Hirpara 4.0 #### External rotation at shoulder height (band) From about week 12, once overhead movement is comfortable. With your arm raised to shoulder height out to the side and the elbow bent to 90°, rotate the forearm upwards against a light band, then return with control. Use a light band and many repetitions, not heavy resistance. As guided by your physiotherapist Kieran Hirpara 4.0 #### Internal rotation with a stick From about week 12 (later if the front cuff tendon was repaired). Hold a stick behind your back and use your good hand to draw the operated hand gently up your back, then lower with control. Keep it comfortable and within your physiotherapist's limits. As guided by your physiotherapist Kieran Hirpara 4.0 #### Full-can lift From about week 12, once forward lifting is comfortable. Raise your arm forwards and slightly out to the side with your THUMB POINTING UP — the "full can" position — then lower with control. NEVER raise with the thumb pointing down ("empty can"). As guided by your physiotherapist Kieran Hirpara 4.0 #### Low row (shoulder-blade setting) From about week 12. With your hand on a fixed surface beside you, press down and back to draw the shoulder blade down and in, holding briefly. This steadies the shoulder blade (your physiotherapist may call it an "inferior glide"). As guided by your physiotherapist Kieran Hirpara 4.0 #### Resistance-band row From about week 12. With a band anchored in front of you, pull the handles towards you, drawing your elbows back and squeezing your shoulder blades together, then return with control. Light band, high repetitions; stop if the shoulder becomes painful. As guided by your physiotherapist Kieran Hirpara 4.0 #### Sleeper stretch From about week 12, if your physiotherapist directs it. Lie on your operated side with the arm forwards and elbow bent. Use your top hand to gently press the forearm down towards the bed until you feel a comfortable stretch at the back of the shoulder. Gentle only — do not force. Hold 10–20 seconds, a few times, as guided by your physiotherapist Kieran Hirpara 4.0 #### Rhythmic stabilisation With your arm supported in front of you at about shoulder height, have your physiotherapist (or your good hand) apply small, gentle pushes from different directions while you hold the arm still and steady — do not let it move. This trains the shoulder's stabilising muscles to react. Keep all the efforts gentle. As guided by your physiotherapist This is where the repair matures fastest, and the focus shifts from regaining movement to rebuilding strength, endurance and control. Resistance work with light bands and light weights starts from about week 12: high repetitions, low loads. The golden rule is one plane at a time: you only strengthen in a direction once you have near-full, comfortable movement in that direction. Always lift with the thumb up, never thumb-down. - Sling: none; full movement expected. - Exercises: band external rotation at shoulder height; internal rotation with a stick; full-can lift; low row (shoulder-blade setting); resistance-band rows; sleeper stretch. Your physiotherapist may also add rhythmic stabilisation (gentle hold-steady drills where they push lightly on your arm and you resist) to retrain control; this is hands-on work with no diagram. Ready for the next phase when: you have full, pain-free movement under your own power with even shoulder-blade control; no pain or swelling after strengthening sessions; comfortable resisted lifting in the shoulder-blade plane; and rotation strength building towards the other side (around 80% on gentle testing; full strength testing waits until much later). ## Small-medium tears — Phase IV: Return to sport and work (weeks 16–24) Kieran Hirpara 4.0 #### Full-can lift with a light weight The full-can lift as before, now with a light weight, building the load gradually. Keep the THUMB UP. Stop if the shoulder is painful or swells afterwards. As guided by your physiotherapist This phase is the bridge back to a fully working shoulder, then a graduated return to sport and heavier work. You keep the range you have won and build the strength, power and endurance to use it confidently: reaching, carrying, working overhead. Returns are staged, not sudden; for sport, an interval programme that builds up volume and intensity step by step is the safest route back. - Sling: none. - Exercises: full-can lift with a light, gradually increasing weight; sport- and work-specific conditioning, progressive loading, and controlled higher-speed (plyometric) drills late in the phase as appropriate. Ready to return when: your rotation strength is at least 85–90% of the other side; you have full, pain-free movement with no reactive swelling under heavier load; and you pass the task-specific tests for your sport or job. Return to sport or heavy work is usually around 4–6 months, based on meeting these criteria and on Dr Hirpara's and your physiotherapist's clearance, not the calendar alone. ## Large / massive tears This is the track for bigger tears (two or more tendons, or poorer tissue quality). The phases are the same, but each is held longer and progressed more cautiously to favour healing. Some surgeons deliberately delay formal therapy in this group; follow the specific instruction Dr Hirpara gives you. The sling is still a simple sling, with no abduction pillow, even for large or massive tears. ## Large-massive tears — Phase I: Protection (weeks 0–6) Kieran Hirpara 4.0 #### Pendulum swings Lean forwards and let your operated arm hang down, completely relaxed. Make small circles by rocking your body, NOT by using your shoulder muscles. Your operated arm stays relaxed throughout. 10 in each direction, 2–3 times a day Kieran Hirpara 4.0 #### Open and close hand Make a tight fist, then open your hand fully. Keeps the hand moving and reduces swelling. 10 times per hour Kieran Hirpara 4.0 #### Active wrist bends Gently bend your wrist forwards, then back, as far as is comfortable. 10–15 times per hour Kieran Hirpara 4.0 #### Active elbow bends With your palm up, gently bend your elbow, then straighten it, keeping your upper arm tucked at your side. 10–15 times, 2–3 times a day Kieran Hirpara 4.0 #### Shoulder-blade setting Gently squeeze your shoulder blades downwards and together, hold, then relax. Your arm does not move. Hold 5 seconds, 5 times, 2–3 times a day As for the small/medium track, but movement is kept strictly protected and progressed more slowly. Your physiotherapist or good arm moves the shoulder for you; you stay relaxed. In this group, formal therapy is sometimes delayed to favour healing. - Sling: simple sling for daytime support; sleep OUT of the sling; off for exercises and hygiene. - Movement allowed: protected passive movement only, to the limit Dr Hirpara sets; generally less range than the small/medium track. - Exercises: pendulum swings; gentle protected assisted movement as directed; hand, wrist and elbow movement; shoulder-blade setting. Ready for the next phase when: your pain is controlled; there is no sign the repair has been over-stressed; and Dr Hirpara clears you to progress (this group is individualised; do not advance on the calendar alone). ## Large-massive tears — Phase II: Restoring movement (weeks 6–12) The sling comes off around week 6, but active movement under your own power is reintroduced later and more individually than in the small/medium track, to protect the repair longer. Resisted cuff work is deliberately held back. - Sling: weaned around week 6. - Movement allowed: assisted movement progressing towards movement under your own power later than the small/medium track; the exact timing is set by your physiotherapist based on how you are healing. - Exercises: the same drills as the small/medium Phase II (assisted forward lift, assisted external rotation with a stick, table slide, over-door pulley), but progressed more slowly; resisted cuff work is deferred. Ready for the next phase when: your movement under your own power is steadily improving; assisted/passive movement is full; you have good shoulder-blade control; and your team is satisfied the repair is healing well enough to begin loading. ## Large-massive tears — Phase III: Strengthening (from about week 16) Kieran Hirpara 4.0 #### Rhythmic stabilisation With your arm supported in front of you at about shoulder height, have your physiotherapist (or your good hand) apply small, gentle pushes from different directions while you hold the arm still and steady — do not let it move. This trains the shoulder's stabilising muscles to react. Keep all the efforts gentle. As guided by your physiotherapist Strengthening is delayed to around week 16 rather than week 12, because the larger repair needs longer to mature. From there, the progression is the same as the small/medium strengthening phase: light bands and weights, high repetitions, low loads, one plane at a time, always thumb-up. - Sling: none; full movement expected. - Exercises: as for the small/medium strengthening phase (band external rotation, internal rotation with a stick, full-can lift, low row, band rows, sleeper stretch), started later and built up gradually. Rhythmic stabilisation (hands-on hold-steady drills) may be added as control improves. Ready for the next phase when: you have full, pain-free movement under your own power; no pain or swelling after strengthening; and your strength is building evenly compared with the other side. ## Large-massive tears — Phase IV: Return to sport and work (6 months onward) The return to sport and heavy work sits later for large and massive tears, usually six months or more, and often longer, with a slower return, and fewer people get back to their previous level. The build-up is the same staged, criteria-based approach as the small/medium track. - Sling: none. - Exercises: progressive loading and sport- or work-specific conditioning, built up gradually. Ready to return when: both Dr Hirpara and your physiotherapist clear you; your rotation strength is at least 85% of the other side; and you have full, pain-free movement and endurance with no reactive swelling under load. Expect six months or more (often longer) and base the decision on meeting these criteria, not the calendar. ## Returning to sport and work For every repair, the return is criteria-based (pain-free, with adequate range, strength and endurance) and signed off by both Dr Hirpara and your physiotherapist, not decided by the calendar alone. - Small / medium tears: sedentary work within a few weeks; heavier strengthening from 12–16 weeks; return to sport or heavy work from around 4–6 months. - Large / massive tears: 6 months or more, frequently longer, with a slower and more cautious build-up. For overhead and throwing sports, complete a graded interval programme before unrestricted play. Full (maximal) strength testing is deferred until 9–12 months after surgery. ## Your early exercises These are the gentle exercises for the early (protection) phase, starting on the ward and continuing at home, done with your operated arm out of the sling and your shoulder muscles relaxed. Start them as guided by your physiotherapist, and stop anything that causes sharp shoulder pain. They appear under each track's Phase I above. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain and wound care. For the operation itself, see rotator cuff repair. --- ### Scaphoid Fixation URL: https://www.cqupperlimb.com/education/rehabilitation/scaphoid-fixation/ Region: rehabilitation · rehabilitation A protected recovery plan after surgical fixation of a scaphoid fracture with a buried headless compression screw, easing the wrist back into movement early under the screw's protection while the slow-healing bone unites, then building grip and strength, with loading and… This protocol guides your recovery after surgical fixation of a scaphoid fracture (a break in the small boat-shaped bone deep in the wrist, held together with a buried headless compression screw) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist. Bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your hand therapist may adjust the plan depending on your fracture, your fixation and how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect The scaphoid is a small bone in the floor of the wrist that links the two rows of wrist bones. It has an unusual and fragile blood supply that runs into it backwards, from one end to the other, which is why a scaphoid fracture heals slowly and, if left alone, can sometimes fail to join (a nonunion). A scaphoid fixation holds the two pieces of bone firmly together with a single headless compression screw that is buried completely inside the bone; there is nothing to feel or remove. The screw squeezes the fracture together, which both helps it heal and lets the wrist start moving sooner than a fracture treated in a plaster cast alone. If the fracture was old or had not joined, a small piece of bone graft (often taken from the nearby forearm bone) may be added to encourage healing; this can make the early plan a little more cautious. The key idea of this recovery is that the screw does the holding while the bone slowly knits. Because the scaphoid heals slowly, the milestones in this plan are paced by how the bone is healing, not by the calendar alone. Your surgeon usually confirms that the fracture has joined ("union") with an X-ray, and often a CT scan, before clearing you for heavier loading and sport. How quickly you progress depends on the type and position of the fracture (a break near the slow-healing top, or "proximal pole", and a previous nonunion are more cautious) and on how stable the fixation is. Movement is opened up in careful stages: finger and thumb movement straight away; gentle wrist movement once your hand therapist allows it; then grip and strengthening only after the bone has united; and return to loaded or contact sport last of all. Because the repair keeps maturing for months, heavier loading and sport are built back gradually rather than all at once. ## Precautions and limitations - Wear your splint or cast as directed and keep it dry. Dr Hirpara and your hand therapist will tell you when to come out of it for exercises and when it can be left off. - Do NOT grip hard, lift, carry or push through the wrist until you are told the fracture has united; squeezing and loading strain the scaphoid and the screw while the bone is still healing. - Avoid forcing the wrist back into full backward bend (extension) and avoid the extremes of movement early; ease into the range, do not push the end of it. - Do NOT return to contact, collision or load-bearing sport (or to gym/weights, push-ups, racquet or stick sports) until your surgeon confirms the bone has joined and clears you; this is usually months, not weeks. - Keep your fingers, thumb, elbow and shoulder moving from the start so they do not stiffen, and use the hand for light everyday tasks within comfort, as long as it does not involve gripping, lifting or forcing the wrist. - If your fixation also used bone graft for a nonunion, expect a more cautious timeline; follow the specific plan your surgeon and hand therapist give you. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### Finger and thumb movement From the very first days, keep your fingers and thumb moving so they do not stiffen. Make a gentle full fist, then straighten the fingers right out, and touch your thumb to the tip of each finger in turn. Keep the wrist itself still inside its splint or cast while you do this. This is safe straight away — it keeps the hand supple without disturbing the healing scaphoid. 10 times each, several times a day, from day one Kieran Hirpara 4.0 #### Wrist movement (when allowed) Once your hand therapist clears it — often only a few weeks after surgery, depending on your fracture and fixation — begin gently moving the wrist: bend it up and down, then tilt it side to side, staying slow and within a comfortable, pain-free range. Do NOT force the end of the movement and do NOT push into full backward bend (extension) early. Your therapist will tell you when to start and how far to go. 10 times each direction, 2-3 times a day, only once cleared Kieran Hirpara 4.0 #### Forearm rotation (palm up / palm down) With your elbow tucked at your side and bent to a right angle, gently turn your palm up towards the ceiling, then down towards the floor. Keep it slow and easy. This keeps the forearm supple and does not load the scaphoid, so it can usually begin early — follow your hand therapist's guidance. 10 times each direction, 2-3 times a day Kieran Hirpara 4.0 #### Scar care Once the wound is fully healed and there are no scabs, massage the scar for a minute or two with a little unscented moisturiser, using small firm circles. This keeps the scar soft and less sensitive. If your screw was placed through a small keyhole cut, the scar is tiny but the same care still helps. 1-2 minutes, twice a day, once the wound is healed Kieran Hirpara 4.0 #### Grip strengthening (after union) A LATER exercise — only once your fracture has united and your hand therapist starts strengthening (commonly not before about 8 to 12 weeks, and confirmed on imaging). Squeeze a soft ball or therapy putty, hold briefly, then relax. Build up gradually. Grip is held back until the bone is solid because squeezing hard loads the scaphoid and the screw, and the scaphoid heals slowly. As guided by your hand therapist (after union is confirmed only) These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. The early exercises keep the fingers, thumb and forearm moving without disturbing the healing scaphoid, and gentle wrist movement is added only once your therapist allows it. Grip strengthening belongs to a later phase and should not be started until you are told the bone has united. Stop anything that causes sharp pain in the wrist, and let your therapist know. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after scaphoid fixation with a headless compression screw. This section is to be provided to the patient's hand therapist, and each phase opens with a plain-English explanation of what is happening. The scaphoid heals slowly because of its tenuous retrograde blood supply, so progression is union-gated and fixation- and fracture-dependent: rigid screw fixation of a stable acute waist fracture permits earlier protected wrist motion, whereas proximal-pole fractures, nonunions and bone-grafted cases warrant a more conservative course. Prior to treatment, check the operation report and past medical history, and liaise with the treating surgeon regarding the fracture pattern (waist vs proximal pole), whether the fracture was acute or a nonunion, whether bone graft was used, the stability of the fixation, and the planned imaging milestone for confirming union. The hand therapist follows the plan for the individual fracture and fixation. The timings below are typical guides for a stable, screw-fixed acute waist fracture; more cautious progression applies to proximal-pole, nonunion and bone-grafted fixations. ### Phase I - protected early motion (weeks 0 to 2) The first couple of weeks protect the wound and the fixation while keeping the hand mobile. The wrist rests in a splint or short cast; the fingers, thumb and forearm move freely from day one. Wound review is typically at around two weeks, when formal therapy begins. For your hand therapist: Education and precautions - Immobilise in a wrist splint or short cast as directed by the surgeon; keep dry; off only as cleared - Full, immediate active finger, thumb, elbow and shoulder ROM to prevent stiffness - No gripping, lifting, weight-bearing or pushing through the wrist - Avoid forced/end-range wrist extension Management - Wound: surgical dressings as directed; monitor for infection; wound review ~2 weeks - Oedema: elevation, gentle hand pump, ice as needed - Exercises: active finger/thumb composite flexion-extension; thumb opposition; gentle forearm pronation-supination; shoulder and elbow ROM Criteria to progress - Wound healed/healing; pain settling; surgeon clearance to begin wrist motion ### Phase II - protected wrist mobilisation (weeks 2 to 8, union-gated) From around two weeks (for a stable, screw-fixed acute waist fracture) gentle active wrist motion is introduced within a comfortable, pain-free range under the protection of the screw. Range is progressed gradually; end-range extension and any loading are still withheld. Proximal-pole, nonunion and bone-grafted fixations are kept in protective immobilisation longer and mobilised later, on surgeon guidance. For your hand therapist: Assessments - Active wrist ROM, pain, swelling; wound/scar review; liaise with surgeon on imaging and union status Education and precautions - Begin gentle active wrist flexion-extension and radial-ulnar deviation in a pain-free range; progress range gradually - Avoid end-range/forced wrist extension and avoid loading - No grip strengthening, no weight-bearing, no resisted work until union is confirmed - Continue full digital and forearm ROM; commence scar management once healed Management - Exercises: active and active-assisted wrist ROM within comfort; continue finger/thumb/forearm ROM; oedema and scar management - Splint between exercises early in this phase if advised; weaning of immobilisation is surgeon-directed Criteria to progress - Radiographic (often CT-confirmed) union confirmed by the surgeon; comfortable, controlled wrist ROM; minimal pain. All criteria required before any strengthening begins. ### Phase III - strengthening and return (after confirmed union) Once the surgeon confirms the fracture has united (commonly around 8 to 12 weeks for an acute waist fracture, and later for proximal-pole fractures and nonunions), strengthening begins and is built up gradually: grip and putty work first, then progressive resisted wrist and forearm strengthening, then loaded and sport-specific work. Return to contact, collision and load-bearing sport is criterion-based and union-gated, typically not before about three to four months and often later for higher-risk fractures. For your hand therapist: Assessments - Grip and pinch strength versus the other side; wrist ROM; pain/swelling response to loading; functional and sport-/work-specific testing as appropriate Education and precautions - Begin grip and putty strengthening only after surgeon-confirmed union; progress load gradually - Add progressive resisted wrist and forearm strengthening; then graded loaded and closed-chain work - Return to contact/collision/load-bearing sport is union-gated and criterion-based, typically not before ~3-4 months and later for proximal-pole/nonunion; a protective splint or cast may be used for early supervised return in athletes on surgeon direction Management - Exercises: graded grip/putty → resisted wrist and forearm strengthening (band → light weights) → loaded and sport-specific drills; continue any residual mobility work - Consider discharge once strength is near-symmetrical and a suitable return of function is achieved - Refer back to the treating surgeon if recovery plateaus, pain persists, or union is in doubt (consider delayed union/nonunion or AVN) Criteria for return to sport - Surgeon-confirmed union; full painless ROM; near-symmetrical grip strength; pain-free sport-specific loading and control ## Getting back to work and activity Light everyday hand use (eating, writing, dressing, light self-care) is encouraged from the start, within comfort, as long as it does not involve gripping, lifting or forcing the wrist. Office and other light, non-manual work is often possible early, sometimes within the first week or two on modified duties; heavier manual work that loads the wrist waits until the fracture has united and is then built up gradually. Because you must be able to control the car safely, do not drive while you are in a cast or splint that prevents safe control of the wheel, or while the wrist cannot safely steer and grip. Driving resumes once you are out of the restrictive cast and can confidently and safely control the car, as confirmed at your review. Plan for help with transport in the early weeks. Loading through the wrist (gripping hard, lifting, pushing, pressing and pulling) waits until your surgeon confirms the bone has united, and is then built up gradually. Return to contact, collision and load-bearing sport is union-gated, typically not before around three to four months and often later for proximal-pole fractures and nonunions. It is based on confirmed healing plus regaining full pain-free movement and adequate, symmetrical grip strength, judged by Dr Hirpara and your hand therapist, not by the calendar alone. ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain, wound care and scar management. The phased plan above reflects published rehabilitation guidance after scaphoid fixation, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to your fracture, your fixation and how your wrist heals. --- ### Shoulder Arthroscopy URL: https://www.cqupperlimb.com/education/rehabilitation/shoulder-arthroscopy/ Region: rehabilitation · rehabilitation Recovery after simple or diagnostic shoulder arthroscopy with no repair — an early-mobilisation fast pathway. This protocol covers the rehabilitation after a simple or diagnostic shoulder arthroscopy with Dr Kieran Hirpara at Mater Private Hospital Rockhampton: keyhole surgery where the joint was inspected, washed out or tidied up (debrided), with nothing repaired. Because no repair needs protecting, this is one of the quickest shoulder operations to recover from: the aim is early movement and a prompt return to normal life. Bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. This protocol applies when the arthroscopy involved no repair: debridement, washout or diagnostic assessment only. If something was repaired, decompressed or stabilised during your arthroscopy, follow the protocol for that procedure instead: for example, the rotator cuff repair protocol if your rotator cuff was repaired. If you are not sure what was done, check your operation note or ask the rooms before progressing. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect After an arthroscopy with no repair there is nothing inside the shoulder that needs protecting, so there are no strict movement restrictions; your shoulder is moved early and progressed on comfort, not on the calendar. A sling is provided for comfort only: most people use it for the first day or two and are out of it completely within the first week. Do not drive for at least six weeks after any shoulder operation, even though you will be out of the sling much sooner; your surgeon will clear you to drive, typically at the six-week review. The journey at a glance: - Phase I — Early movement and settling — roughly the first two weeks - Phase II — Restoring full movement and starting strength — week 2–6 - Phase III — Return to full activity — week 6 onwards Most people are back to desk-based work within a few days to a week. Driving resumes from six weeks, once your surgeon has cleared you. Heavier manual work and sport typically take longer, usually somewhere between six and twelve weeks depending on the demands on the shoulder. The shoulder often stays mildly achy for some weeks while the joint settles; this is normal and improves as movement and strength return. ## Phase I — Early movement and settling (Week 0–2) Kieran Hirpara 4.0 #### Pendulum exercises Lean forward, supporting yourself on a table with your other hand, and let the operated arm hang relaxed. Make small circles — clockwise, then anticlockwise — by gently rocking your body. The arm stays relaxed; the movement comes from your body, not the shoulder. As guided by your physiotherapist Kieran Hirpara 4.0 #### Pulley-assisted movement Sit beneath an over-door pulley. With the operated arm relaxed, pull down with your other hand so the rope gently raises the operated arm, then lower it slowly. Progress on comfort — easing back from sharp or lingering pain, not pushing through it. As guided by your physiotherapist Kieran Hirpara 4.0 #### Open and close hand Make a tight fist or squeeze a soft ball, then open the hand fully. Move your hand, wrist and elbow freely from the start, and use the arm for light everyday tasks as comfort allows. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wrist movement Keep your wrist moving by bending it forwards, backwards and side to side. Move the hand, wrist and elbow freely from the start so the whole arm stays working while the shoulder settles. As guided by your physiotherapist Kieran Hirpara 4.0 #### Elbow bends With your upper arm resting by your side, bend the elbow as far as it comfortably goes, then straighten it fully. Only the elbow moves — keep the shoulder relaxed. As guided by your physiotherapist Kieran Hirpara 4.0 #### Assisted movement with a stick Hold a stick (cane or wand) in both hands and let your good arm guide the operated arm out to the side and forwards, taking it as far as comfort allows, then lower with control. This active-assisted movement keeps the shoulder moving early while it settles. As guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric external rotation Stand with your elbow tucked at your side and bent to a right angle, the back of your hand against a wall or doorframe. Gently press outwards into it without letting the arm move, hold a few seconds, then relax. This gently switches on the rotator cuff without movement, as comfort allows. As guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric abduction Stand side-on to a wall with your elbow at your side and gently press the outside of your upper arm into the wall, as if lifting the arm out sideways, without letting it move. Hold a few seconds, then relax. This works the deltoid gently with no movement, as comfort allows. As guided by your physiotherapist Kieran Hirpara 4.0 #### Scapular setting Sitting or standing tall, gently draw your shoulder blades down and back together without moving the arms, hold for a few seconds, then relax. Keep your ears, shoulders and hips in line. As guided by your physiotherapist The first two weeks are about letting the shoulder settle while keeping it moving. Use the sling only while it is helping with comfort (typically the first day or two) and leave it off as much as possible; you do not need to sleep in it. Move your hand, wrist and elbow freely from the start, and use the arm for light everyday tasks such as eating, washing and dressing as comfort allows. Gentle shoulder movement starts straight away: pendulum exercises and assisted movements progressing to active movement as the shoulder allows. Ice and simple pain relief help keep the exercises comfortable. Your wound dressings are waterproof: you can shower from day 1 and let water run over them (don't soak or scrub the area). They come off about ten to twelve days after surgery. For your physiotherapist: Goals - Settle pain and swelling - Early range of motion progressing from assisted to active as tolerated - Independence with light activities of daily living - Wean from the sling within the first days Management - Sling for comfort only: encourage weaning over the first days and discontinuation within the first one to two weeks at the latest - Pendulum exercises; active-assisted range of motion (pulley, cane or wand) progressing to active range of motion in all planes as tolerated - Free movement of the hand, wrist and elbow; grip work as comfortable - Scapular setting and postural work - Gentle rotator cuff and deltoid isometrics as comfort allows - Cryotherapy and analgesia to support the exercise program Precautions - No driving for six weeks (this applies to any shoulder operation) - Movement is progressed on comfort: sharp or lingering pain means easing back, not pushing through - Dressings are waterproof (showering over them is fine); removed at around 10–12 days. Report excessive redness or discharge Criteria to progress - Out of the sling and comfortable with light daily activities - Pain settled enough to work on range of motion actively ## Phase II — Restoring full movement and starting strength (Week 2–6) Kieran Hirpara 4.0 #### Wall protraction Stand with your hands flat on a wall at chest height and your arms straight. Without bending the elbows, push the wall away so your upper back rounds and the shoulder blades slide apart, then return with control. As guided by your physiotherapist Kieran Hirpara 4.0 #### Cross-body stretch If the back of the shoulder remains tight, use your other hand to draw the operated arm across your chest until you feel a stretch at the back of the shoulder. Hold briefly, then release. Stretch to firm discomfort only — it should not provoke pain that lingers. As guided by your physiotherapist Kieran Hirpara 4.0 #### Sleeper stretch Lie on the operated side with the arm out in front and the elbow bent. Use your good hand to press the forearm gently down towards the bed until you feel a stretch deep in the shoulder, then ease off. This eases any residual tightness at the back of the shoulder. As guided by your physiotherapist Kieran Hirpara 4.0 #### Band external rotation (near neutral) Stand with your elbow tucked into your side and bent to a right angle, holding an elastic band anchored across your body at waist height. Keeping the elbow at your side, rotate the forearm outwards to about the midline against the band, then return slowly. This begins the rotator cuff strengthening as you move on from the isometric holds. Low resistance, as guided by your physiotherapist Kieran Hirpara 4.0 #### Shoulder-blade squeeze with band Holding a band anchored in front of you, draw your elbows back and squeeze your shoulder blades together and down, then return slowly. This strengthens the muscles that steady the shoulder blade as resistance is added through this phase. As guided by your physiotherapist Kieran Hirpara 4.0 #### Low row Hold a band anchored in front of you at waist height. Keeping the arm fairly straight, pull it back and down towards your hip, squeezing the shoulder blade down and back, then return slowly. This builds the shoulder-blade depressors that support the cuff. As guided by your physiotherapist Kieran Hirpara 4.0 #### Side-lying external rotation with weight Lie on your non-operated side with the top elbow bent to a right angle and tucked against your body. Holding a light weight, rotate the forearm up towards the ceiling, then lower slowly. This is light isotonic cuff work — low weight and higher repetitions — from around week four as comfort allows. Low load, higher repetitions, as guided by your physiotherapist Kieran Hirpara 4.0 #### External rotation at 90/90 (lying) Lie on your back with the arm out to the side at shoulder height and the elbow bent to a right angle, supported on a pillow. Slowly rotate the forearm back towards the head as far as is comfortable, then return with control. This restores rotation in the raised position. 10 times, as guided by your physiotherapist Kieran Hirpara 4.0 #### Hand-behind-back reach Standing, place the back of your operated hand against your lower back and gently slide it up your spine as far as is comfortable using your own muscles, then lower. Move only within a comfortable range and never force it. As guided by your physiotherapist With the shoulder settling, the focus turns to regaining full movement and beginning strengthening. Active movement is progressed in all directions towards full range, and resistance work starts gently, with isometric holds progressing to elastic-band exercises for the rotator cuff and shoulder blade muscles as comfort allows. Most people return to desk-based work in the first week or two if they have not already. Driving waits until your surgeon clears you at the six-week review. Lighter recreational activities resume during this phase as guided by your physiotherapist. For your physiotherapist: Goals - Full, or near-full, active range of motion in all planes - Begin graduated strengthening of the rotator cuff and scapular stabilisers - Return to normal daily activities and work (driving only after surgeon clearance at the six-week review) Management - Progress active range of motion in all planes towards full; typical interim targets are forward flexion beyond 140–160° and external rotation beyond 40–60° - Progress from isometrics to elastic-band rotator cuff work (internal and external rotation near neutral), advancing as tolerated - Scapular strengthening: shrugs, retraction, protraction and depression work progressing to resistance - From around week 4, light isotonic strengthening with low weights and higher repetitions as comfort allows - Manual therapy and stretching for any residual capsular tightness, including posterior capsule stretching where indicated Precautions - Strengthening stays within the comfortable range and should not provoke pain that lingers afterwards - Build loaded rotation in abduction (90/90 positions) gradually: introduce once neutral rotation work is comfortable - Avoid heavy lifting and forceful overhead work while strength returns Criteria to progress - Full or near-full active range of motion with minimal pain - Band and light-weight strengthening tolerated without flare-up ## Phase III — Return to full activity (Week 6 onwards) Kieran Hirpara 4.0 #### Push-up plus From a push-up position — against a wall, on your knees, or full as strength allows — complete the push-up, then push a little further so your upper back rounds and the shoulder blades spread apart, then return. This closed-chain work builds control and strength as you return to full activity. As guided by your physiotherapist The final phase is a graduated return to heavier lifting, manual work, gym training and sport. Conventional weight training can usually restart from about six weeks, beginning light and progressing steadily, and overhead or contact sport typically resumes somewhere between six and twelve weeks depending on the sport and how the shoulder is performing. The benchmark for finishing rehabilitation is a comfortable shoulder with full movement and confident strength; most people are back to everything they want to do by about three months, and any residual aching continues to settle beyond that. For your physiotherapist: Goals - Full, pain-free range of motion - Restoration of strength, endurance and confidence for work and sport - Graduated return to heavy manual work, gym training and sport Management - Progress to conventional resistance training from around week 6, advancing from machine to free weights as control allows - Eccentric and closed-chain work as tolerated - Sport-specific conditioning, including a staged throwing or overhead program where relevant - Limit heavy rotator cuff strengthening to around three sessions per week to avoid overload tendinopathy Precautions - Progression remains symptom-guided: pain that builds with load or lingers afterwards means stepping the load back - Return to contact or overhead sport waits for full, pain-free range and adequate strength Criteria to progress - Full, pain-free range of motion with strength comparable to the other side for the intended activity - Sport- or work-specific tasks performed without provocation ## After your protocol The phases above are adapted from published rehabilitation protocols for simple and diagnostic shoulder arthroscopy by Dr Jorge Chahla (Rush University Medical Center), Dr Benedict Nwachukwu (Hospital for Special Surgery), Dr Blake Obrock (orthopaedic sports medicine, Amarillo) and the Royal National Orthopaedic Hospital's patient guide to diagnostic shoulder arthroscopy. The week ranges are typical rather than fixed, and your rehabilitation is guided individually by your physiotherapist, working with the practice, based on how your shoulder recovers. This page works alongside the practice's general recovery advice: see managing post-operative pain and wound care. For the operation itself, see shoulder arthroscopy. The evidence behind this protocol (the early-motion rationale, the placebo-controlled surgical trials, and the published rehabilitation protocols it draws on) is summarised in the evidence section, available as a PDF from the top of this page. --- ### Stiff Elbow Release (Arthrolysis) URL: https://www.cqupperlimb.com/education/rehabilitation/stiff-elbow-arthrolysis/ Region: rehabilitation · rehabilitation An early, aggressive movement recovery plan after an operation to free up a stiff elbow — the surgeon regains the bend and straightening on the table, and the whole job of rehabilitation is to keep that range, starting from day one with no sling and no protection phase. This protocol guides your recovery after an operation to free up a stiff elbow (a release, or arthrolysis) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your physiotherapist or hand therapist; bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect A stiff elbow after a previous injury or operation happens because the lining (capsule) of the joint thickens and tightens, and sometimes extra bone forms, so the elbow can no longer bend and straighten through its full arc. During the release operation, done either with keyhole (arthroscopic) surgery or through an open incision, the surgeon removes that tight capsule (and any extra bone or trapped scar) so the elbow moves freely again on the operating table. The single most important thing to understand is that this recovery is the opposite of a repair operation. There is nothing that has been stitched or fixed that needs weeks of rest to heal. Instead, the surgeon establishes a near-full range of movement during the operation, and the whole job of your rehabilitation is to keep that movement, because the elbow's natural tendency after surgery is to stiffen up again. That is why there is no sling and no protection phase: you start moving the elbow on the first day, and you move it firmly and often. The enemy here is re-stiffening, not tissue failing. For wound, swelling and scar management, see the practice's wound care guidance. Swelling and pain are the main things that hold movement back in the early days, so controlling them with elevation, ice and your pain relief is an important part of keeping your range. Most of your improvement happens between about 6 weeks and 3 months, and the elbow usually reaches its best, settled range at around 4 months. To hold and even add to your range, a splinting program is used at night and rest times and is continued for at least 3 months. ## Precautions and limitations - Do start moving the elbow on day one, and keep moving it little and often throughout the day: this is the core of your recovery. - Do push gently into the end of each stretch; unlike a repair, there is no construct to protect, so reaching the range is the goal. - Do keep on top of swelling and pain with elevation, ice and your prescribed pain relief: they are what limit your movement, not the surgery itself. - Do take any anti-inflammatory medication (such as indomethacin) exactly as prescribed if Dr Hirpara has started it to discourage extra bone forming. - Do wear your night/rest splint as directed, for at least 3 months, to hold and build on the range you gain. - Do not rest the elbow or "take it easy" to let it settle: that is how the stiffness comes back. - Do not be alarmed by pins and needles or tingling into the little and ring fingers; the nerve on the inside of the elbow (the ulnar nerve) can become more sensitive as your bend improves, so let Dr Hirpara or your therapist know so it can be reviewed. ## Your exercises Kieran Hirpara 4.0 #### Active elbow bends (bending and straightening) Using your own muscles, bend the elbow up as far as it will go towards your shoulder, then straighten it out as far as you can. Push gently into each end of the movement and try to reach the same range the surgeon achieved during your operation. This is the single most important exercise — the elbow re-stiffens quickly, so it is done little and often through the day. 10–15 times each direction, every 1–2 hours while awake Kieran Hirpara 4.0 #### Assisted (passive) elbow bend With the operated arm completely relaxed, use your other hand to gently push the elbow further into a bend than it will go on its own, holding at the end where you feel a firm stretch. There is no repair to protect, so you are encouraged to push gently into the stretch — hold it, breathe, and let the elbow ease a little further. Stop short of sharp pain. Hold each stretch 20–30 seconds, 3–5 times, several times a day Kieran Hirpara 4.0 #### Active elbow straightening (extension) Work on getting the elbow as straight as you can — straightening (extension) is the movement most commonly lost, so it gets extra attention. Rest the back of your upper arm on a firm surface and let gravity, then gentle help from your other hand, ease the elbow towards fully straight. Hold at the end of the stretch. Hold 20–30 seconds, 5 times, several times a day Kieran Hirpara 4.0 #### Overhead triceps stretch (end-range straightening) Raise the operated arm overhead and gently use your other hand to push the elbow towards fully straight, stretching the back of the upper arm. This is a strong end-range stretch into straightening — hold it steady rather than bouncing. Hold 20–30 seconds, 3–5 times, a few times a day Kieran Hirpara 4.0 #### Wall walk into a bend (end-range flexion) Face a wall and walk your fingers up it, letting the elbow bend further as your hand climbs. Walk up until you feel a firm stretch deep in the elbow, hold, then walk a little higher. This helps recover the last part of the bend. Hold 20–30 seconds at the top, 5 times, a few times a day Kieran Hirpara 4.0 #### Forearm rotation (palm up / palm down) With your elbow tucked at your side and bent to about 90°, turn your palm up towards the ceiling, then down towards the floor, going as far as you can each way. A release operation often frees rotation as well as bending, so keep this moving fully alongside your bend and straighten work. You may use your other hand to gently push a little further at each end. 10–15 times each direction, several times a day Kieran Hirpara 4.0 #### Triceps muscle-set (gentle hold) An early activation exercise. With the arm supported, gently tighten the muscle on the BACK of your upper arm (the triceps) as though to straighten the elbow, helping to hold and reinforce the straightening you have gained. Keep it gentle and as guided by your physiotherapist. Hold ~5 seconds, 5–10 times, as guided Kieran Hirpara 4.0 #### Biceps curl (later strengthening) A LATER exercise — strengthening starts only once your movement is stable, usually from around 6 weeks. With your palm up, curl a light weight towards your shoulder, then lower it slowly under control. Build the weight up gradually as guided by your physiotherapist. As guided by your physiotherapist (from about week 6) These are the exercises from your handout for regaining and holding the movement of your elbow and forearm. Start them as guided by Dr Hirpara and your therapist; in this protocol they begin straight away. They are done firmly and often, because the range you keep is the range you use through these exercises every day. ## Your clinical protocol The rest of this page is the clinical protocol for rehabilitation after surgical release (arthrolysis) of a stiff elbow. This section is to be provided to your physiotherapist or hand therapist, and each phase below opens with a plain-English explanation of what is happening. The overriding principle is that the surgeon establishes a near-full arc on the table; rehabilitation's job is to not lose it. There is no fixation to protect and therefore no protection phase: pain and oedema control are the rate-limiters, not tissue healing. ### Day 0 to 2 after your operation In the first day or two the elbow is rested briefly, the arm is kept elevated, and swelling is controlled with ice and compression. The elbow is often supported in a fully straight (extension) position, because straightening is the movement most commonly lost and the one to bias towards. If extra bone formation is a concern (for example after removal of extra bone, or a high-energy original injury), Dr Hirpara may start an anti-inflammatory medication now to discourage it. For your physiotherapist: Prior to treatment, check the patient's imaging, operation report and past medical history (PMHx), and liaise with the treating surgeon regarding the intra-operative arc achieved, any ulnar nerve procedure, and whether heterotopic ossification (HO) prophylaxis has been started. Position and oedema - Brief immobilisation in full extension in a padded splint; arm elevated; cryotherapy/compression for oedema - Drains typically removed POD1 HO prophylaxis (if indicated) - Indomethacin (e.g. 25 mg TID, or 75–100 mg/day) for 3–6 weeks where indicated, especially after HO excision or high-energy trauma; ± single-dose perioperative radiotherapy in selected high-risk cases (surgeon's decision) ### Day 1 onward — immediate aggressive range of motion This is the core of the protocol. The splint comes off on the first day after surgery and firm, frequent movement begins: active-assisted and passive bending, straightening and forearm rotation, aiming to recover the full range the surgeon achieved on the table. There is no range ceiling: the goal is the full intra-operative arc. For your physiotherapist: ROM ceiling - None. Recover the full intra-operative arc. Splint off POD1. Exercises - Active-assisted and passive ROM in flexion, extension, pronation and supination; bias the stretch toward the tightest direction (usually extension) - Optional CPM: if used, start in-hospital POD1–2 at full available range (commonly cited 0–145° with a bolster behind the elbow) and continue at home to ~4 weeks, in addition to PT. CPM is an adjunct only and has not been shown superior to supervised PT; use is at the surgeon's discretion. - Cadence: daily supervised PT in the first post-operative week, then 2–3×/week for ~6 weeks Criteria to progress - Maintaining the on-table arc; oedema and pain controlled ### Weeks 2 to 6 — hold the arc and introduce splinting Movement continues firmly. To hold and build on the range, a splinting program is added at night and rest times: a low-load, prolonged stretch held at the end of range, alternating between bend and straighten. For your physiotherapist: Exercises and splinting - Continue aggressive active / active-assisted / passive ROM - Add static-progressive (or dynamic / serial-static / turnbuckle) splinting for low-load prolonged end-range stretch: a night/rest program alternating flexion and extension. Static-progressive (inelastic, patient-adjusted incremental torque) is the favoured modality for elbow flexion contractures. - Oedema and scar management Criteria to progress - Arc maintained or exceeded; ready for loading by ~week 6 ### Weeks 6 to 12 — strengthening and continued splinting Once movement is stable, usually around 6 weeks, strengthening begins with progressive resistive exercise as tolerated. The splinting program continues. For your physiotherapist: Exercises and splinting - Begin progressive resistive strengthening once motion is stable (typically ~6 weeks) - Continue splinting for at least ~3 months post-operatively for optimal final ROM ### Around 16 weeks — plateau Published series report patients reach their maximum arc of motion at a mean of about 16 weeks, with most recovery occurring between 6 weeks and 3 months. This expectation should be set pre-operatively. Final maintained gains in the bend/straighten and rotation arcs are typically held long term (around 15-month follow-up in large cohorts). For your physiotherapist: - Maximum arc reached at a mean of ~16 weeks; counsel that no pre-operative range threshold reliably predicts the recovery trajectory; apply the same ~16-week timeline to all patients ## Getting back to work and activity Because there is no fixation to protect, getting back to everyday activity is paced by your comfort, swelling and the range you are holding rather than by waiting for something to heal. Light use of the arm for daily tasks is encouraged from the start; in fact, using the elbow normally through the day is part of the treatment. Strengthening, and with it heavier and more demanding tasks, starts from about 6 weeks once your movement is stable, and is built up gradually as your strength and range allow. Most people reach their settled range and function by around 4 months, and the gains achieved are typically held long term. Return to driving, work duties and sport depends on regaining enough movement, strength and control for the specific task; discuss the timing for your situation with Dr Hirpara and your therapist, as it varies with your job and the extent of your surgery. The most important message is to keep up your movement and night/rest splinting program throughout, as that is what protects the range you have worked to regain. ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain and wound care. For the shoulder equivalent, where the lining of a stiff shoulder is released, see capsular release. The phased plan above is consistent with published evidence on rehabilitation after elbow contracture release, and your ongoing recovery is guided individually by your physiotherapist or hand therapist according to how your elbow progresses. --- ### Subacromial Decompression URL: https://www.cqupperlimb.com/education/rehabilitation/subacromial-decompression/ Region: rehabilitation · rehabilitation Rehabilitation after isolated arthroscopic subacromial decompression — early movement, staged strengthening and return to activity. This protocol covers the rehabilitation after an isolated arthroscopic subacromial decompression (acromioplasty, with or without removal of the inflamed bursa) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. Bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. Your rehabilitation is progressed individually by your physiotherapist through the phases below, depending on how your shoulder progresses. Important: subacromial decompression is often performed together with a rotator cuff repair. This protocol is for an isolated subacromial decompression. If your operation also included a rotator cuff repair, follow the rotator cuff repair protocol instead; the repaired tendon sets a slower pace. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect Subacromial decompression makes more room for the rotator cuff tendons by shaving the under-surface of the acromion (the bony roof of the shoulder) and removing the inflamed bursa. Nothing is repaired that needs protecting, so early rehabilitation is about movement, not rest: the shoulder is safe to move from the first day, and moving it early is what keeps it from stiffening while it settles. The sling you wake up with is for comfort only; it is not protecting anything. Leave it off as much as possible and wean out of it early: most people leave the sling off within the first few days, and published protocols expect it to be gone by two weeks at the latest. Do not drive for at least six weeks after any shoulder operation, even once the sling is gone; your surgeon will clear you to drive, typically at the six-week review. Your exercise program uses three kinds of movement, and your physiotherapist will guide which apply at each stage: - Active range of motion: movement is allowed without aid or help. - Active-assisted range of motion: using the other arm or an object to assist with moving the arm. - Passive range of motion: completely relaxed, using the other arm or force to do 100% of the work. The journey at a glance: - Phase I — Early movement — roughly the first two weeks - Phase II — Restoring your range and starting strength — week 2–6 - Phase III — Strengthening — week 6–12 - Phase IV — Return to full activity — week 12 onwards The shoulder is usually sore rather than fragile in the early weeks, and some people find it stays uncomfortable for up to six weeks. Published guidance suggests most people feel a clear improvement in pain by about three months, and symptoms can keep improving for up to a year. The week ranges below are typical rather than fixed; your physiotherapist will progress you on how your shoulder is moving, not on the calendar. ## Phase I — Early movement (Week 0–2) Kieran Hirpara 4.0 #### Pendulum exercise Bend forward at the waist and let the operated arm hang gently away from the body. Let the arm swing in small, relaxed circles — the movement comes from your body, not the shoulder muscles. Work within comfort; pain is the guide. As guided by your physiotherapist Kieran Hirpara 4.0 #### Pulley-assisted elevation Sit beneath an over-door pulley holding a handle in each hand. Pull down with the good arm to raise the operated arm upwards and slightly forward of the body, letting it stay relaxed, then lower with control. Do not force or overstretch — work within comfortable range. As guided by your physiotherapist Kieran Hirpara 4.0 #### Scapular setting Sitting tall, gently draw your shoulder blades back together and down, away from your ears. Hold for a few seconds, then relax. Pair this with attention to posture through the day. As guided by your physiotherapist Kieran Hirpara 4.0 #### Open and close hand Keep your hand and fingers moving by opening and closing them, or by squeezing a soft ball. Start this straight away to keep the hand and arm working while the shoulder settles. 10 times, three times a day Kieran Hirpara 4.0 #### Wrist movement Keep your wrist moving by bending it forwards, backwards and side to side. Do this from day one to keep the arm working while the shoulder settles. 10 times, three times a day Kieran Hirpara 4.0 #### Elbow bends With the upper arm resting by your side, bend the elbow as far as it comfortably goes, then straighten it fully. Only the elbow moves — keep the shoulder relaxed. Start this from day one. 10 times, three times a day Kieran Hirpara 4.0 #### Isometric flexion Stand facing a wall with your elbow bent and tucked at your side, the front of your fist resting against the wall. Gently press forwards into the wall without letting the arm move, hold a few seconds, then relax. This keeps the muscles working without movement while the shoulder settles. Hold a few seconds, several times; as guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric extension Stand with your elbow at your side and the back of your upper arm against a wall. Gently press the arm backwards into the wall without letting it move, hold a few seconds, then relax. A no-movement way to keep the muscles active early on. Hold a few seconds, several times; as guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric abduction Stand side-on with the outside of your upper arm near a wall, elbow tucked at your side. Press the arm gently outwards into the wall without letting it move, hold a few seconds, then relax. Hold a few seconds, several times; as guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric external rotation Stand with your elbow tucked at your side and bent to a right angle, the back of your hand against a wall or doorframe. Gently press outwards into it without letting the arm move, hold a few seconds, then relax. This builds the rotator cuff with no movement. Hold a few seconds, several times; as guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric internal rotation Stand with your elbow tucked at your side and bent to a right angle, the palm of your hand against a wall or doorframe. Gently press inwards into it without letting the arm move, hold a few seconds, then relax. A gentle way to begin activating the cuff. Hold a few seconds, several times; as guided by your physiotherapist A nerve block is often used during the operation, so the arm can feel numb for some hours afterwards; start your painkillers before it wears off. In the first two weeks the aims are simple: settle the pain and swelling, and get the shoulder moving within comfort. Use ice regularly for pain relief. Start moving your hand, wrist and elbow straight away, add pendulum exercises and assisted arm movements as comfort allows, and use the arm for normal light daily activities such as washing, dressing and eating. Take your painkillers before your exercises and before physiotherapy appointments. This is keyhole surgery, usually through two or three small puncture wounds covered with waterproof dressings; you can shower over them from day 1 (don't soak or scrub), and they stay on until your wound review at 10–14 days. People in desk-based jobs commonly return to work within the first two weeks; driving waits until your surgeon clears you, typically at the six-week review. For your physiotherapist: Goals - Settle pain and swelling - Re-establish non-painful range of motion (active-assisted progressing to active) - Prevent muscular atrophy and begin re-establishing dynamic stability - Independence with light activities of daily living Management - Cryotherapy regularly for pain and swelling; analgesia before exercises and sessions - Elbow, wrist, hand, neck and thoracic range-of-motion exercises from day 1 - Pendulums; pulley or wand active-assisted elevation in the scapular plane; external and internal rotation starting at 30–45° of abduction - Progress to active range of motion as comfort allows - Scapular setting in sitting; postural awareness - Submaximal isometrics (flexion, extension, abduction, external and internal rotation) and gentle rhythmic stabilisation - From week 2: heat before exercise if helpful; progress rotation work towards 90° of abduction; external and internal rotation with elastic tubing, arm at the side Precautions - Work within comfortable ranges: do not force or overstretch; pain is the guide - Sling for comfort only; wean within the first days and discard by two weeks - No driving for six weeks (this applies to any shoulder operation) - No heavy lifting, no lifting overhead, no jerking movements - Avoid pushing up from a chair or bed through the operated arm for the first six weeks: the acromion has been thinned and forceful loading should be avoided while it remodels Criteria to progress - Pain well controlled with simple analgesia - Swelling settling and wounds healed or healing without concern - Comfortable active-assisted movement, with active movement returning below shoulder height ## Phase II — Restoring your range and starting strength (Week 2–6) Kieran Hirpara 4.0 #### Side-lying external rotation Lie on your non-operated side with the top elbow bent to a right angle and tucked against your body. Keeping the elbow at your side, rotate the forearm up towards the ceiling, then lower with control. Begin without weight. Add light weight (0.5–1 kg) after a week of pain-free, well-controlled repetitions Kieran Hirpara 4.0 #### Prone horizontal abduction (prone 'T') Lie face down with the arm hanging towards the floor. Squeeze the shoulder blade in towards the spine and lift the arm out to the side to shoulder level, thumb leading, then lower slowly. Begin without weight; light weight can be added once repetitions are pain-free and well controlled. As guided by your physiotherapist Kieran Hirpara 4.0 #### Lower trapezius retraining Lie face down on a bed or table with the arm relaxed over the edge. Draw the shoulder blade down and in towards the spine, letting the arm lift as the blade moves — the effort comes from below the shoulder blade, not from hitching the shoulder. Lower slowly and repeat. As guided by your physiotherapist Kieran Hirpara 4.0 #### Behind-the-back stretch Hold a towel behind your back, with the operated hand low and the good hand above. Use the good arm to draw the operated hand gently up the back until a stretch is felt, hold briefly, then lower. A gentle stretch at the back of the shoulder is the aim — do not force it. As guided by your physiotherapist Kieran Hirpara 4.0 #### Sleeper stretch (posterior capsule) Lie on your operated side with the shoulder and elbow both bent to a right angle. With your other hand, gently press the forearm down towards the bed until you feel a stretch at the back of the shoulder, then ease off. This is the posterior capsular stretch your physiotherapist will use to free up rotation — keep it gentle, no sharp pain. Hold 20–30 seconds, a few times; as guided by your physiotherapist Kieran Hirpara 4.0 #### Assisted abduction with a stick Lie on your back and hold a stick in both hands. Use the good arm to guide the operated arm out to the side towards shoulder level, then lower with control. This helps restore abduction towards 90 degrees as your range returns. As guided by your physiotherapist Kieran Hirpara 4.0 #### Scaption (full-can elevation) Stand with the arm by your side, thumb pointing up. Raise the arm out at a forward angle — midway between straight ahead and out to the side — no higher than is comfortable, then lower slowly. Begin without weight; keep the shoulder blade settled and avoid shrugging. Begin unweighted; add light weight once repetitions are pain-free and well controlled Kieran Hirpara 4.0 #### Prone row Lie face down with the arms hanging towards the floor. Squeeze the shoulder blades together and draw the elbows back and down so the arms make a 'W', then lower slowly. Begin without weight; light weight can be added once repetitions are pain-free and well controlled. Begin unweighted; add light weight (around 0.5–1 kg) after a week of pain-free repetitions This phase is about getting the rest of your movement back and beginning to rebuild strength. Your exercises progress from assisted movements to moving the arm actively in all directions, with most published protocols expecting full or near-full range by about six to eight weeks. Strengthening starts gently: first without weight, then with elastic bands and very light weights for the rotator cuff and shoulder blade muscles. Many people find heat before exercise and ice afterwards helpful. Moderate work (light lifting below shoulder height) typically becomes possible during this phase, guided by your physiotherapist. For your physiotherapist: Goals - Full, or near-full, active range of motion in all planes by around week 6–8 - Regain and improve rotator cuff and scapular strength - Normalise scapulohumeral rhythm and neuromuscular control - Continue to settle pain Management - Progress range of motion in all planes, including behind-the-back internal rotation with gentle posterior capsular stretching - Glenohumeral joint mobilisation (inferior, posterior and anterior glides) as indicated - Isotonic program beginning unweighted (shoulder elevation, prone rowing, prone horizontal abduction, prone extension to neutral, sidelying external rotation, abduction to 90°), adding light weight (around 0.5–1 kg) after a week of pain-free, well-controlled repetitions - External and internal rotation with elastic tubing; progress towards rotation work in more elevated positions as comfort allows - Scapular neuromuscular control and lower trapezius work; trunk, core and lower-limb conditioning - Upper-limb endurance work; heat before and ice after sessions as preferred Precautions - Avoid loaded work in a painful impingement range; exercises may be hard, but should not reproduce the pre-operative pain - Do not target supraspinatus or mid-deltoid loading until it is pain-free, and avoid it if it provokes resting or night pain - Continue to avoid pushing up through the operated arm and heavy or overhead lifting until six weeks Criteria to progress - Full, non-painful range of motion with minimal tenderness - Rotator cuff strength around 4/5 on manual testing, with good scapular control ## Phase III — Strengthening (Week 6–12) Kieran Hirpara 4.0 #### Side-lying external rotation with weight Lie on your non-operated side with the top elbow bent to a right angle and tucked against your body. Holding a light weight, rotate the forearm up towards the ceiling, then lower slowly. Exercises should feel like work but stay essentially pain-free — ease off anything that provokes resting or night pain. 2–3 sets of 8–12 repetitions Kieran Hirpara 4.0 #### Band external rotation Stand with your elbow tucked into your side and bent to a right angle, holding an elastic band anchored at waist height. Keeping the elbow at your side, rotate the forearm outwards against the band, then return slowly. This progresses the rotator cuff on from the earlier isometric and unweighted work. 2–3 sets of 8–12 repetitions Kieran Hirpara 4.0 #### Band internal rotation With your elbow tucked into your side, hold a band anchored to one side and rotate the forearm inwards across your body against the band, then return slowly. Keep the resistance progressing as your strength builds. 2–3 sets of 8–12 repetitions Kieran Hirpara 4.0 #### Standing row Hold a band anchored in front of you at waist height. Keeping the arm fairly straight, pull it back and down towards your hip, squeezing the shoulder blade down and back, then return slowly. This builds the shoulder-blade muscles that support the cuff. 2–3 sets of 8–12 repetitions Kieran Hirpara 4.0 #### Wall push-up plus Stand facing a wall with your hands flat on it at shoulder height. Bend the elbows to lean towards the wall, then push back, adding a gentle push through the hands at the end to spread the shoulder blades. A closed-chain exercise to build control — introduce it as guided by your physiotherapist. As guided by your physiotherapist With your movement back, attention turns to strength, endurance and control. Resistance work progresses from bands to weights, and exercise becomes more dynamic, including, for people returning to sport, the start of controlled plyometric work and a graduated return to training. Swimming typically resumes from about six weeks (breaststroke first, freestyle when comfortable), and medium work (light lifting below shoulder height) is usually manageable from six weeks. An interval return-to-sport program commonly starts at weeks 10–12 when strength criteria are met. For your physiotherapist: Goals - Improve strength, power and endurance of the shoulder complex - Optimise neuromuscular control, proprioception and movement patterning (no shoulder hitching) - Prepare for a graduated return to sport and heavier work Management - Progress the isotonic program: isometrics → elastic bands → weights; rotator cuff, deltoid and scapular stabilisers at 2–3 sets of 8–12 repetitions - Introduce eccentrically resisted work, closed-chain exercises and rhythmic stabilisation; proprioceptive work including weight-bearing and four-point kneeling - Plyometric activities: two-handed drills (chest pass, side-to-side throws) progressing to one-handed drills (wall dribbles, throwing drills) towards the end of the phase - Begin an interval sports program at weeks 10–12 if criteria are met - Continue core and conditioning work; cryotherapy as needed Precautions - Exercises should be difficult but essentially pain-free; back off any work that provokes resting or night pain - Heavy lifting and sustained overhead loading wait until around three months Criteria to progress - Full, pain-free active range of motion (approximately equal to the other side) - Strength approaching the other side (published criteria range from 70% to enter dynamic training, towards 90% for return to sport) - No pain or tenderness with progressive loading ## Phase IV — Return to full activity (Week 12 onwards) The final phase is a graduated return to heavy work, overhead tasks and sport. Heavy or repetitive lifting and sustained work above shoulder height typically resume from about three months. Return to competitive sport (particularly overhead sport) is based on meeting criteria rather than the calendar: full pain-free movement, strength close to the other side and confidence with sport-specific drills. The shoulder commonly keeps improving well beyond this phase; published guidance describes improvement continuing for up to a year. For your physiotherapist: Goals - Graduated return to heavy work, overhead activity and sport - Maintain range of motion, strength and control in the long term Management - Continue the strengthening program, advancing gym- and sport-specific work as tolerated - Continue the interval sports program with a staged return to throwing and other overhead sport - Self-managed capsular stretches and maintenance exercises as needed Precautions - Progression remains symptom-guided; if pain recurs, reduce load, restore comfortable movement and rebuild Criteria to progress - Full, non-painful range of motion - Strength and functional testing satisfactory (around 90% of the other side in published return-to-sport criteria) - Satisfactory clinical review ## After your protocol The phases above are adapted from published rehabilitation protocols and patient guidance for arthroscopic subacromial decompression: OrthoIndy, Sports Surgery New York, Gundersen Health System Sports Medicine, Twin Cities Orthopedics, Oxford University Hospitals NHS Foundation Trust and Royal Berkshire NHS Foundation Trust. The week ranges are typical rather than fixed, and your ongoing rehabilitation is guided individually by your physiotherapist, working with the practice, based on how your shoulder recovers. This page works alongside the practice's general recovery advice; see managing post-operative pain and wound care. For the operation itself and the condition it treats, see subacromial decompression. The evidence behind this protocol (including how it fits the trial evidence on subacromial surgery) is summarised in the evidence section, available as a PDF from the top of this page. --- ### Suprascapular Nerve Decompression URL: https://www.cqupperlimb.com/education/rehabilitation/suprascapular-nerve-decompression/ Region: rehabilitation · rehabilitation Rehabilitation after isolated arthroscopic suprascapular nerve decompression, with honest framing of nerve recovery. This protocol covers the rehabilitation after an isolated arthroscopic suprascapular nerve decompression with Dr Kieran Hirpara at Mater Private Hospital Rockhampton: the release of the nerve at the suprascapular notch and/or the spinoglenoid notch, without any other repair. Bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. Your rehabilitation is progressed individually by your physiotherapist through the phases below, depending on how your shoulder recovers. Important: please read first. Suprascapular nerve decompression is often performed together with a rotator cuff repair. This protocol is for an isolated decompression only. If your operation also included a rotator cuff repair, follow the rotator cuff repair protocol instead: the repaired tendon sets a slower pace, and that protocol takes precedence over this one. If you are not sure which operation you had, ask the rooms before you start. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect When the nerve is released on its own, there is no tendon repair that needs protecting, so rehabilitation can move quickly. The sling is worn only for comfort and only briefly (usually for about the first week, and up to two weeks at most), and it is left off as much as possible once the shoulder settles. Gentle movement begins early, as comfort allows, and most people are back to their normal daily activities within a few weeks. Recovery of the nerve itself follows its own timeline, separate from the movement of the shoulder. The operation relieves the pressure on the nerve; the pain from that pressure often eases relatively quickly. Recovery of muscle strength and bulk in the muscles the nerve supplies (the supraspinatus and infraspinatus, which sit on the shoulder blade) is slower and works on a scale of months. How fully strength and muscle bulk return varies from person to person: in some people recovery is complete, in others it is partial, and a longstanding nerve problem may not recover fully. Your physiotherapy includes specific work to reactivate these muscles as the nerve recovers. Your physiotherapist and the practice will guide you on what to expect in your case. ## Phase I — Early movement (Week 0–2) Kieran Hirpara 4.0 #### Open and close hand Keep your hand and fingers moving by opening and closing them, or by squeezing a soft ball. Start this straight away to keep the hand working while the shoulder settles. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wrist movement Keep your wrist moving by bending it forwards, backwards and side to side. Do this with the arm out of the sling, alongside your hand and elbow movements. As guided by your physiotherapist Kieran Hirpara 4.0 #### Pendulum exercise Bend forward at the waist and let the operated arm hang gently away from the body. Let the arm swing in small, relaxed circles — the movement comes from your body, not the shoulder muscles. Stay within a comfortable, pain-free range. As guided by your physiotherapist Kieran Hirpara 4.0 #### Assisted elevation (lying) Lie on your back and use your good arm to help lift the operated arm upwards, then lower it back down with the good arm still helping. Move only within a comfortable, pain-free range — gentle, early movement is the aim, not range at any cost. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wand-assisted external rotation Lie on your back holding a stick or cane in both hands with the elbows bent to right angles and tucked at your sides. Use the good arm to push the operated forearm gently outward, away from the body, then return. Keep the movement comfortable and pain-free. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wand-assisted internal rotation Hold a stick behind your back with both hands. Use your good arm to gently guide the operated hand up your back, then ease it back down. This restores comfortable inward rotation early — keep within a pain-free range. As guided by your physiotherapist Kieran Hirpara 4.0 #### Elbow bends Bend and straighten the elbow through its full range. Keep the hand, wrist and elbow moving from the start so the rest of the arm stays supple while the shoulder settles. As guided by your physiotherapist Kieran Hirpara 4.0 #### Scapular setting Sitting or standing tall, gently draw your shoulder blades back together and down, away from your ears. Hold for a few seconds, then relax. Do this as comfort allows in the early days. As guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric deltoid setting Stand side-on to a wall with the operated elbow at your side. Gently press the outside of your arm into the wall as if to lift it out to the side, without letting the arm actually move. Hold a few seconds, then relax. This gently wakes the deltoid with no movement, as comfort allows. As guided by your physiotherapist The first aim is comfort and gentle, early movement. The sling is for comfort only and should be left off as much as possible once the shoulder settles; you do not need to sleep in it. Do not drive for at least six weeks after any shoulder operation, even once the sling is gone; your surgeon will clear you to drive, typically at the six-week review. Take your pain relief regularly in the early days so you can begin moving the arm. Keep your hand, wrist and elbow moving from the start, and begin gentle shoulder movement within a comfortable range as advised. For your physiotherapist: Goals - Comfort and wound protection - Early gentle range of motion within pain-free limits - Maintain hand, wrist and elbow movement Management - Sling for comfort only, typically through about postoperative day 7 (up to two weeks if needed for comfort), weaned as symptoms allow - Early gentle range of motion as comfort allows: pendulums, passive and active-assisted elevation, external and internal rotation, and elbow flexion/extension - Isometric deltoid setting and scapular setting as comfortable - Analgesia before exercise; cryotherapy for pain relief as needed Precautions - Keep early movement within a comfortable, pain-free range - No heavy lifting, forceful pushing or pulling - No driving for six weeks (this applies to any shoulder operation) Criteria to progress - Comfortable, settling pain - Wound healing satisfactorily - Early range of motion tolerated ## Phase II — Range and muscle reactivation (Week 2–6) Kieran Hirpara 4.0 #### Side-lying external rotation Lie on your non-operated side with the top elbow bent to a right angle and tucked against your body. Keeping the elbow at your side, rotate the forearm up towards the ceiling, then lower with control. Pain-free external rotation like this helps reactivate the muscles the nerve supplies. As guided by your physiotherapist Kieran Hirpara 4.0 #### Isometric external rotation Stand with your elbow tucked at your side and bent to a right angle, the back of your hand against a wall or doorframe. Gently press outwards into it without letting the arm move, hold a few seconds, then relax. This is the starting point for reactivating the muscles the nerve supplies, before adding a band. As guided by your physiotherapist Kieran Hirpara 4.0 #### Band external rotation Stand with your elbow tucked into your side and bent to a right angle, holding an elastic band anchored at waist height. Keeping the elbow at your side, rotate the forearm outwards against the band, then return slowly. Low resistance and higher repetitions — this is the key external-rotation work for reactivating the infraspinatus as the nerve recovers. Low load, higher repetitions; as guided by your physiotherapist Kieran Hirpara 4.0 #### Full-can scaption Stand and raise the operated arm out in front and slightly to the side, thumb pointing up as if holding a full can, to about shoulder height, then lower with control. This targets the supraspinatus — one of the muscles the nerve supplies — and is paced to its recovery, not forced. Low load, higher repetitions; as guided by your physiotherapist With the sling discarded, this phase restores full movement and begins light strengthening, including specific work to reactivate the supraspinatus and infraspinatus as the nerve recovers. Most people return to their normal daily activities during this phase. Progress is guided by comfort, not the calendar. For your physiotherapist: Goals - Full active range of motion in all planes - Begin light strengthening and rotator cuff (supraspinatus/infraspinatus) reactivation - Independence with activities of daily living Management - Progress to full active range of motion in all directions - Begin light strengthening from around week 2: isometrics progressing to elastic-band work for the rotator cuff, deltoid and scapular stabilisers, low load and higher repetitions - Particular attention to pain-free external rotation and to reactivating the supraspinatus and infraspinatus as the nerve recovers - Graduated return to normal daily activities, typically by around four weeks Precautions - Strengthening stays within a comfortable range and should not provoke pain that lingers - Avoid forceful pushing, pulling and heavy lifting while strength recovers - Expect strength to return gradually: reactivation work is paced to the nerve's recovery, not forced Criteria to progress - Full, or near-full, pain-free active range of motion - Light strengthening tolerated without flare-up ## Phase III — Strengthening and return to activity (Week 6–12 and beyond) Kieran Hirpara 4.0 #### Side-lying external rotation with weight From around week 12, the same side-lying rotation is done holding a light weight: elbow bent to a right angle and tucked at the side, rotate the forearm up towards the ceiling, then lower slowly. This isolates the muscles the nerve supplies as it recovers — progress is paced to the nerve, not forced. As guided by your physiotherapist Kieran Hirpara 4.0 #### Push-up plus From around six weeks, in a push-up position against a wall, a bench or the floor as you build up, push all the way up and then press a little further so your upper back rounds and the shoulder blades spread apart. This is a closed-chain exercise that builds shoulder-blade control to support the cuff. As guided by your physiotherapist Kieran Hirpara 4.0 #### Low row Hold a band anchored in front of you at waist height. Keeping the arm fairly straight, pull it back and down towards your hip, squeezing the shoulder blade down and back, then return slowly. Progressive resistance work that builds the shoulder-blade muscles supporting the cuff. As guided by your physiotherapist From around six weeks, strengthening progresses without specific restriction, building towards a return to overhead tasks, heavier work and sport. Isolated strengthening of the supraspinatus and infraspinatus is advanced as the nerve continues to recover, which typically continues over several months. For your physiotherapist: Goals - Full strengthening without restriction - Graduated return to overhead activity, heavier work and sport - Continued recovery of rotator cuff strength as the nerve recovers Management - From around week 6, progress to full strengthening, including closed-chain and progressive resistance work - From around week 12, advance isolated supraspinatus and infraspinatus strengthening - Stage the return to overhead work and sport; lighter overhead tasks usually return during this phase, with a graduated return to sport over the following weeks to months as strength allows and once pain-free - Continue a maintenance programme as the nerve and muscles keep recovering Precautions - Progression remains symptom-guided - Strength and muscle bulk in the affected muscles may keep recovering over several months, and recovery may be partial: pace expectations accordingly and avoid overstressing while strength is incomplete ## After your protocol The phases above are adapted from published technique papers and clinical studies on arthroscopic suprascapular nerve decompression. The week ranges are typical rather than fixed, and your ongoing rehabilitation is guided individually by your physiotherapist, working with the practice, based on how your shoulder and the nerve recover. This page works alongside the practice's general recovery advice; see managing post-operative pain and wound care. For the operation itself and the condition it treats, see suprascapular nerve decompression. The evidence behind this protocol (the pain-relief and strength-recovery literature on nerve decompression) is summarised in the evidence section, available as a PDF from the top of this page. --- ### Tendon glides URL: https://www.cqupperlimb.com/education/rehabilitation/tendon-glides/ Region: rehabilitation · rehabilitation Finger tendon-glide exercise handout — hook and tabletop glide sequences, recreated from an Extend Rehabilitation sheet. Prepared in association with Extend Rehabilitation --- ### Total Elbow Replacement (Arthroplasty) URL: https://www.cqupperlimb.com/education/rehabilitation/total-elbow-arthroplasty/ Region: rehabilitation · rehabilitation Recovery after a total elbow replacement: gentle assisted motion in a simple sling early, a functional movement arc as the goal, and a permanent lifelong lifting limit to protect the implant. This protocol guides your recovery after a total elbow replacement (total elbow arthroplasty) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your physiotherapist or hand therapist: bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect A total elbow replacement removes the worn or damaged joint surfaces at the elbow and replaces them with a metal-and-plastic implant. The two halves (one anchored in your upper arm bone, the humerus, and one in your forearm bone, the ulna) are usually joined by a small hinge, which is why it is called a semi-constrained or "linked" replacement. It is most often done for severe rheumatoid arthritis, for end-stage osteoarthritis, or for certain elbow fractures in older patients where the bone cannot be repaired. The aim of your recovery is to settle the elbow, protect the healing tissues, and restore a comfortable, pain-free functional arc of movement (enough bend and straighten to manage everyday tasks like eating, washing and dressing) rather than to make the elbow as strong as possible. For wound, swelling and scar management, see the practice's wound care guidance. The single most important thing to understand is this: the implant is designed for comfortable daily living, not for heavy work. Its long-term enemies are wear of the plastic bearing and gradual loosening of the implant in the bone, and both are driven by heavy loading. For that reason, a vigorous strengthening program is not appropriate after a total elbow replacement, and a lifting limit stays with you for life, not just while you heal. Keeping to that limit is the single biggest thing you can do to make your new elbow last. You will be in a simple sling for comfort after surgery, not a rigid splint or brace. Gentle assisted movement begins within the first week, and the plan builds slowly and carefully from there. ## Precautions and limitations Do: - Wear your simple sling for comfort, and use it as advised. - Begin the gentle assisted movements below within the first week, as guided by Dr Hirpara and your therapist. - Keep your hand, wrist and shoulder moving to prevent stiffness. - Keep to the lifelong lifting limit (below) once you have recovered. Do not: - Do not lift anything heavier than about a cup of tea (1 lb / 0.45 kg) with the operated arm in the first 6 weeks. - Do not force your elbow to bend, and do not snap or push it straight. - Do not push up out of a chair through the operated arm, carry, push or lean your weight through it, or let anyone pull or twist it. - If your triceps muscle was lifted during surgery, do not actively straighten the elbow against resistance until your surgeon clears you (usually 6–12 weeks). - Permanent, lifelong limits: do not repeatedly lift more than about 2 kg, and do not lift more than about 4.5–5 kg in a single effort. These limits are permanent, for life. No tennis, throwing, or impact sports, ever. ## Your exercises Kieran Hirpara 4.0 #### Assisted elbow bends (passive flexion) With your upper arm tucked in at your side, use your other hand to gently help bend the operated elbow up towards your shoulder, only as far as is comfortable. Do not force it. Lower it back down slowly. Your therapist will tell you how far to go. 5–10 times, several times a day, within comfort Kieran Hirpara 4.0 #### Gentle elbow bends and straightening With your palm facing up and your upper arm tucked at your side, gently bend your elbow as far as is comfortable, then let it straighten back down with the help of gravity. Keep the movement slow and unforced — let the arm do the work, do not push hard into the ends of the range. 5–10 times, several times a day Kieran Hirpara 4.0 #### Gravity-assisted elbow straightening (active extension) Rest your upper arm supported (for example on a cushion or the arm of a chair) and let your forearm lower so the elbow gently straightens with the help of gravity. Do not snap or force the elbow straight. If your surgeon has told you your triceps muscle was lifted during surgery, keep this gentle and avoid actively pushing the elbow straight until you are cleared. 5–10 times, several times a day, within comfort Kieran Hirpara 4.0 #### Forearm rotation (palm up / palm down) With your elbow bent and tucked at your side, gently turn your palm up towards the ceiling, hold for a moment, then turn it down towards the floor. Keep your upper arm still so the movement comes from the forearm. 10 times each direction, a few times a day Kieran Hirpara 4.0 #### Wrist movement Gently bend your wrist forwards, then back, as far as is comfortable. This keeps your wrist and hand moving and helps prevent stiffness and swelling while your elbow heals. 10–15 times, several times a day Kieran Hirpara 4.0 #### Triceps muscle tightening (isometric) This is a later exercise — only start it once your surgeon or therapist tells you your triceps is ready, usually around 6 weeks or later. With your elbow held still at a comfortable bend, gently tighten the muscle at the back of your upper arm as if you were going to straighten the elbow, but without actually moving it. Hold gently, then relax. Hold 5 seconds, 10 times, once cleared These are the exercises from your handout, for gently regaining movement of your elbow, forearm, wrist and hand. Start them as guided by Dr Hirpara and your therapist. Keep every movement gentle and unforced; early on, the goal is easy, assisted motion, not effort or stretch. ## Your clinical protocol The rest of this page is the clinical protocol for rehabilitation after a semi-constrained total elbow replacement (posterior approach, triceps-sparing assumed). This section is to be provided to your physiotherapist or hand therapist, and each phase below opens with a plain-English explanation of what is happening. Prior to treatment, check the patient's operation report and past medical history, and liaise with the treating surgeon regarding the surgical approach, specifically whether the triceps was spared, reflected or reattached (Bryan–Morrey), as this determines the early extension restrictions and resting position. ### Phase I — Immediate post-surgical, weeks 0–6 In the first six weeks the focus is on protecting the healing soft tissues and the triceps, settling the wound and swelling, and beginning gentle assisted motion so the elbow does not stiffen. Dr Hirpara uses a simple sling for comfort, not a posterior splint or brace. Gentle assisted (active-assisted) elbow bending and straightening begins between days 1 and 7, with the elbow held in at the side and the forearm neutral-to-pronated, using gravity to assist straightening. There is no lifting heavier than 1 lb (0.45 kg) with the operated arm, and no weight-bearing or pushing through it. For your physiotherapist: Immobilisation and precautions - Simple sling for comfort (KH practice: no posterior splint or brace). If the surgeon has used a brace or splint for soft-tissue concern, follow that direction; otherwise the simple sling is worn for about six weeks, coming off for exercises and hygiene. - Triceps-reflected / reattached cases (e.g. Bryan–Morrey): immobilise nearer extension, and avoid active and resisted elbow extension early to protect the repair (cf. distal-triceps-repair logic). - No forced flexion (stresses the triceps repair) and no sudden or forced extension. - No upper-limb weight-bearing, no pushing against resistance, no varus/valgus stress. - No lifting of objects > 1 lb (0.45 kg) with the operated arm. Exercises - Gentle active-assisted ROM (AAROM) elbow flexion/extension from day 1–7, elbow adducted to the side, forearm neutral-to-pronated; gravity-assisted extension stretch. - Active range of motion for the hand, wrist and shoulder to prevent stiffness. Criteria to progress to Phase II: wound healed, pain controlled, and gentle AAROM established. Do not progress to strengthening before 6 weeks. ### Phase II — Functional activity, from 6 weeks (not before) This phase begins gentle muscle activation and, later, very light strengthening, but never a vigorous program. Movement is built up towards a functional arc, and resistance is introduced cautiously and kept light. The lifting restriction continues throughout. For your physiotherapist: Timeline within Phase II - 6 weeks: begin submaximal, pain-free isometrics at mid-range, in all planes. If the triceps was reflected/reattached, confirm it is cleared before adding extension isometrics. - 8 weeks: progress to multi-angle submaximal isometrics, avoiding end-range. - 10–12 weeks: introduce light isotonic strengthening (no weights or resistance > 5 lb (2.3 kg)), single-plane first, then composite. Range-of-motion goal - Functional arc: 30–120/130° flexion, with 60° pronation and 60° supination. - If flexion is < 120° by 10–12 weeks, consider a dynamic or static-progressive splint. Precautions - Continue to avoid heavy loading, pushing and impact. - Strengthening philosophy (verbatim): "The need for a vigorous strengthening program is not appropriate following total elbow arthroplasty." Criteria to progress: a pain-free functional arc is achieved and maintained. ### Late Phase II and lifelong, from 12 weeks From around 12 weeks the elbow moves to a maintenance home program to keep the pain-free functional arc. There is no formal heavy strengthening, ever. The lifelong activity and lifting limits below now apply permanently. For your physiotherapist: - Home program to maintain the pain-free functional arc. - Reinforce the permanent activity restrictions with the patient. - Consider discharge once a stable, comfortable functional arc and suitable return of daily function are achieved. ## Getting back to work and activity Your new elbow is built for comfortable everyday living, and the limits below are permanent; they are what make the implant last. - Lifting (for life): do not repeatedly lift more than about 2 kg (a couple of full mugs), and do not lift more than about 4.5–5 kg in a single effort (around a full kettle), with the operated arm, ever. In the first 6 weeks the limit is much stricter: nothing heavier than about 1 lb (0.45 kg). - Sport and impact: no tennis, throwing, or impact loading at any point, for life. Gentle, low-load activities are encouraged once you are cleared, but the elbow should never be loaded heavily or jarred. - Driving: resume only once you are comfortable, out of the sling for driving, and can safely control the wheel. Confirm timing with Dr Hirpara at your review. - Work: light desk-based and self-care tasks resume early within comfort. Any role involving lifting, carrying, pushing or repetitive arm loading needs to be discussed individually with Dr Hirpara, as the lifelong limits apply at work too. Keeping faithfully to these limits is the single biggest thing you can do to protect your replacement and avoid loosening or wear over the years. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain and wound care. Your ongoing recovery is guided individually by your physiotherapist or hand therapist according to how your elbow progresses, and your lifelong activity limits should be kept in mind at every review. --- ### Total Shoulder Arthroplasty URL: https://www.cqupperlimb.com/education/rehabilitation/total-shoulder-arthroplasty/ Region: rehabilitation · rehabilitation Phase-by-phase rehabilitation protocol after total shoulder replacement, with criteria to progress and the early exercise program. This protocol guides your recovery after total shoulder arthroplasty (total shoulder replacement) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. Each phase below opens with a plain-English explanation of what is happening and what matters most, followed by the structured protocol written for your physiotherapist; bring this page or its PDF to your first physiotherapy visit so your rehabilitation stays coordinated. Your physiotherapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect You will have a numb arm when you wake up, and the feeling usually returns within 6 to 12 hours. Rarely, some numbness or weakness can continue for 2 to 3 days. When you wake up from your operation, you will be in a sling, with a big pad over your shoulder. This pad will be removed before discharge. Underneath is a waterproof dressing covering a surgical glue strip, which can be left alone for 2 weeks. Your stitches are dissolvable and do not need removing, but there may be some tails of stitch at each end of the wound that can be cut flush with the skin after 2 weeks. You will be booked to see our nurse for a wound check 1–2 weeks after your surgery. If you are unable to attend the dressing check, you can remove your dressing yourself after 2 weeks. The journey at a glance: - Protection: weeks 0–3 - Intermediate: weeks 4–6 - Intermediate, continued: weeks 7–8 - Transitional: weeks 9–11 - Advanced strengthening: weeks 12–16 Approximate timeframes for return to activities: - Driving: 6 weeks - Swimming: breaststroke 8 weeks; freestyle 12 weeks - Golf: 4–6 months - Lifting: light lifting can begin at 6 weeks; avoid lifting heavy items for 6 months - Work: sedentary job 6 weeks; manual job guided by your surgeon ## Wearing your sling Your sling (shoulder immobiliser) supports the shoulder while it heals. The rules are simple: - Wear it for 6 weeks, including while sleeping. - Take it off only for showers and for your exercises, once you have been shown how, and whenever the sling is off, keep your arm by your side. - Resting at home, it can come off if you are sensible about it: arm supported on a pillow while sitting. - Use ice if the shoulder is swollen or sore, especially after exercise. Fitting it correctly matters, and a loose sling does not support the shoulder properly: - Position your elbow right into the corner of the sling, well supported. - The end of the sling should rest at the knuckle of your little finger. If your hand extends further out, the sling is not supporting you properly. - The sling has two Velcro straps: one for your neck, one for your waist. - With your elbow and forearm positioned, use your non-operated arm to swing the upper strap around your neck and attach it through the upper loop. - Attach the lower strap around your waist through the lower loop the same way. While you are in the sling, watch your posture. Keep your ears, shoulders and hips in line and avoid letting your shoulders slump; good posture protects your back and helps prevent your shoulder stiffening. A rolled-up towel in the small of your back when sitting is a useful reminder. Before you go home, the ward physiotherapist will fit your sling, teach you to manage it independently, and start you on the gentle exercises below. Three terms come up often in shoulder rehabilitation, and it helps to know the difference: active range of motion (AROM) means moving the arm yourself, without aid or help; active-assisted range of motion (AAROM) means using the other arm or an object to help the arm move; and passive range of motion (PROM) means the arm stays completely relaxed while the other arm or an outside force does 100% of the work. Your physiotherapist will tell you which kind of movement each exercise uses. The early rehabilitation rules while you are in hospital and in the first weeks at home: - You need to sleep in the sling. - Use ice for pain relief if needed. - When wearing your sling, relax your shoulder and let the sling take the weight of your arm. - Take your painkillers before you do your exercises, and before your physiotherapy appointments. - You are allowed to take your arm out of the sling for your exercises and showering. - You need to wear your sling for 6 weeks, especially when out of the house. - Unless you have chosen to arrange your own physiotherapy, an appointment has been made for you and is detailed in your discharge pack. - If you have any problems, contact the office or let your physiotherapist know. These are your early exercises, started in hospital and continued at home as guided by your physiotherapist: ## Your first days in hospital Kieran Hirpara 4.0 #### Open and close hand Keep your hand and fingers moving by opening and closing them, or by squeezing a soft ball. 10 times, 3 times per day Kieran Hirpara 4.0 #### Wrist movement Keep your wrist moving by bending it forwards, backwards and side to side. 10 times, 3 times per day Kieran Hirpara 4.0 #### Elbow Bend and straighten your elbow. 10 times, 3 times per day Kieran Hirpara 4.0 #### Pendulums This is a passive exercise. Lean forward and let your arm relax down. Use your body to move the arm gently either clockwise or anti-clockwise, along with forwards, backwards and side to side. Approximately 30 seconds each way, 3 times per day Kieran Hirpara 4.0 #### Forward flexion (assisted) Sitting on a chair and leaning forward, cradle your operated arm with the other arm and gently move your arm upwards in front of you. Lower it back down with the assistance of your non-operated arm. You could also try lying on your back in bed and helping the arm upwards if you would prefer. 10 times, 3 times per day Kieran Hirpara 4.0 #### Abduction (assisted) Sitting on a chair and leaning forward, cradle the arm again and help it out to the side (like rocking a baby). 10 times, 3 times per day Kieran Hirpara 4.0 #### External rotation Sitting on a chair, only move your arm from where it would be in the sling to pointing straight in front of you. Don't go further outwards. Gently, 10 times, 3 times per day Kieran Hirpara 4.0 #### Lower trapezius setting Squeeze your shoulder blades downwards and together. Hold 5 seconds, 5 times; repeat 3 times daily Kieran Hirpara 4.0 #### Upper trapezius stretch Use your non-operated arm to bring your ear towards your shoulder, away from the operated side. Hold 10 seconds, 3 times; repeat 3 times per day Kieran Hirpara 4.0 #### Levator scapulae stretch Use your non-operated arm to bring your nose towards your nipple or armpit area. Hold 10 seconds, 3 times; repeat 3 times per day ## Phase I — Protection (Weeks 0–3) Kieran Hirpara 4.0 #### Seated table slide Sit at a table with your forearm resting on the surface. Let your hand slide forwards along the table as you lean gently in, letting the shoulder fold forwards without using the shoulder muscles, then slide back. Keep the movement relaxed and comfortable. As guided by your physiotherapist The first three weeks are about protecting your new shoulder while it settles. You will be in the sling (held in a neutral position and worn at night), using ice and compression for swelling, while your physiotherapist gently moves the shoulder for you within set limits and you keep your hand, wrist and elbow moving yourself. From week 2, gentle shoulder-blade exercises and ball squeezes begin. The rules that matter most: no active shoulder movement, no reaching behind your back, no lifting, and no pushing up through your hands. For your physiotherapist: Goals - Protect surgical repair - Reduce swelling, minimise pain - Maintain upper extremity (UE) range of motion in elbow, hand and wrist - Gradually increase shoulder passive range of motion (PROM) - Minimise muscle inhibition - Patient education Management - Sling: neutral rotation; use at night while sleeping - Swelling management: ice, compression - Range of motion / mobility: - PROM: external rotation (ER) ≤ 30 degrees in the scapular plane; internal rotation (IR) to belt line in the scapular plane - Flexion/scaption to tolerance; abduction (ABD) ≤ 90 degrees; pendulums; seated glenohumeral (GH) flexion table slide; seated horizontal table slide - Active-assisted range of motion (AAROM): active-assisted shoulder flexion - Active range of motion (AROM): elbow, hand, wrist - Strengthening (week 2): - Periscapular: scapular retraction, prone scapular retraction, standing scapular setting, supported scapular setting, inferior glide, low row - Ball squeeze Precautions - No shoulder AROM - No reaching behind back, especially into internal rotation - No excessive shoulder external rotation or abduction - No lifting of objects - No supporting of body weight with hands - Place small pillow/towel roll under elbow while lying on back to avoid shoulder hyperextension Criteria to progress - ≥ 50% shoulder PROM flexion and scaption compared with the contralateral side - ≤ 90 degrees of shoulder ABD PROM - ≤ 30 degrees of shoulder ER PROM in the scapular plane - ≥ 70 degrees of IR PROM in the scapular plane - Palpable muscle contraction felt in scapular musculature - Pain < 4/10 - No complications with Phase I ## Phase II — Intermediate (Weeks 4–6) Kieran Hirpara 4.0 #### Cane external rotation stretch Lie on your back with your elbow by your side and bent to 90 degrees. Hold a cane or stick in both hands and use the non-operated arm to push the hand of the operated arm gently outwards. Stay within the limit your physiotherapist sets for this phase, and never force the movement. As guided by your physiotherapist The shoulder is still being protected, but movement now builds steadily. The sling stays on at night, and during the day it is gradually weaned off over these two weeks. Your physiotherapist progresses the passive movement towards full range (still within set external rotation and abduction limits), adds assisted and then active movements, and starts gentle activation work for the rotator cuff and shoulder-blade muscles. Lift nothing heavier than a coffee cup, and keep avoiding extremes of rotation and reaching. For your physiotherapist: Goals - Continue to protect surgical repair - Reduce swelling, minimise pain - Gradually increase shoulder PROM - Minimise substitution patterns with AROM and AAROM - Improve periscapular muscle activation/strength - Initiate rotator cuff (RTC) activation (external rotators) - Patient education Management - Sling: use at night while sleeping; gradually start weaning the sling over the next two weeks during the day - Continue with Phase I interventions - Range of motion / mobility: - PROM: full, with the exception of ER ≤ 30 degrees in the scapular plane and ABD ≤ 90 degrees - AAROM: shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane - AROM: supine flexion, salutes, supine punch - Strengthening: - Rotator cuff: external rotation isometrics - Periscapular: row on physioball, serratus punches - Elbow: biceps curl, resistance band biceps curls and triceps - Motor control: - ER in scaption and flexion 90–125 (rhythmic stabilisation) - Stretching: - Side-lying horizontal adduction Precautions - No excessive shoulder external rotation or abduction - No lifting of objects heavier than a coffee cup - No supporting of body weight with hands - Place small pillow/towel roll under elbow while lying on back to avoid shoulder hyperextension Criteria to progress - ≥ 75% shoulder PROM flexion and scaption compared with the contralateral side - ≥ 75% shoulder PROM IR in the scapular plane compared with the contralateral side - 30 degrees of shoulder PROM ER in the scapular plane - 90 degrees of shoulder PROM ABD - Minimal substitution patterns with AAROM - AROM shoulder elevation to 100 degrees with minimal substitution patterns - Pain < 4/10 - No complications with Phase II ## Phase III — Intermediate, continued (Weeks 7–8) Kieran Hirpara 4.0 #### Over-door pulley Sit under an over-door pulley with a handle in each hand. Pull down with the non-operated arm to raise the operated arm, keeping the operated arm relaxed, then lower it slowly and smoothly. As guided by your physiotherapist Kieran Hirpara 4.0 #### Sleeper stretch Lie on your operated side with the arm out in front at shoulder height and the elbow bent to 90 degrees. Use the other hand to press the forearm gently down towards the bed until you feel a comfortable stretch at the back of the shoulder. Do not force the stretch. As guided by your physiotherapist Kieran Hirpara 4.0 #### Wall walk out to the side Stand side-on to a wall with your fingertips resting on it. Walk your fingers up the wall out to the side, raising the arm as far as is comfortable, then walk them back down with control. The wall supports the arm as you regain movement out to the side. As guided by your physiotherapist The sling is now finished with, and the aim is full movement in every direction, assisted where needed and increasingly under your own power. Strengthening steps up, with resistance-band work for the rotator cuff and shoulder-blade muscles, and you can return to full everyday activities. Two limits remain: nothing heavier than 5 kg, and nothing that overstresses the healing tissue at the front of the shoulder. For your physiotherapist: Goals - Do not overstress healing tissue (especially the anterior capsule) - Minimise pain - Maintain PROM - Improve AROM - Progress periscapular and RTC strength - Return to full functional activities - Patient education Management - Sling: discontinue - Continue with Phase I and II interventions - Range of motion / mobility: - Full range of motion in all planes - AAROM: incline table slides, ball roll on wall, wall climbs, pulleys - AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 degrees - Strengthening: - Rotator cuff: internal rotation isometrics, side-lying external rotation, standing external rotation with resistance band, standing internal rotation with resistance band, internal rotation, external rotation - Periscapular: resistance band shoulder extension, resistance band seated rows, rowing, lawn mowers, robbery - Motor control: - IR/ER and flexion 90–125 (rhythmic stabilisation) - Quadruped alternating isometrics and ball stabilisation on wall - Proprioceptive neuromuscular facilitation (PNF): D1 diagonal lifts, PNF D2 diagonal lifts - Stretching: - Internal rotation behind back with towel, side-lying horizontal adduction, sleeper stretch, triceps and lats Precautions - No lifting of heavy objects (> 5 kg) Criteria to progress - Minimal to no substitution patterns with shoulder AROM - Pain < 4/10 ## Phase IV — Transitional (Weeks 9–11) Kieran Hirpara 4.0 #### Push-up plus on knees From a push-up position on your knees with hands under the shoulders, keep the elbows straight and push the upper back towards the ceiling, letting the shoulder blades slide apart, then lower with control. As guided by your physiotherapist Movement should now be full and comfortable; this phase is about making it strong and steady. Resistance increases on the rotator cuff exercises, the shoulder-blade program broadens, and control work challenges the shoulder in diagonal, functional patterns. The 5 kg lifting limit still applies, and positions that strain the front of the joint (rotating the arm outwards while it is lifted above 80 degrees out to the side) are still avoided. For your physiotherapist: Goals - Do not overstress healing tissue (especially the anterior capsule) - Maintain pain-free PROM - Continue improving AROM - Improve dynamic shoulder stability - Gradually restore shoulder strength and endurance Management - Continue with Phase II–III interventions - Range of motion / mobility: - Full range of motion in all planes - Strengthening: - Rotator cuff: increase resistance of rotator cuff exercises - Periscapular: push-up plus on knees, "W" exercise, resistance band Ws, dynamic hug, resistance band dynamic hug, prone shoulder extension Is, resistance band forward punch, forward punch, tripod, pointer - Motor control: - Resistance band PNF pattern; PNF D1 diagonal lifts with resistance; diagonal-up, diagonal-down wall slides with resistance band Precautions - No lifting of heavy objects (> 5 kg) - Avoid exercises that put stress on the anterior shoulder capsule (i.e. shoulder ER above 80 degrees of ABD) Criteria to progress - Supine AROM flexion ≥ 140 degrees - Supine AROM ABD ≥ 120 degrees - Supine AROM ER in the scapular plane ≥ 60 degrees - Supine AROM IR in the scapular plane ≥ 70 degrees - AROM shoulder elevation to 120 degrees with minimal substitution patterns - Performs all exercises demonstrating symmetric scapular mechanics - Pain < 2/10 ## Phase V — Advanced strengthening (Weeks 12–16) Kieran Hirpara 4.0 #### Standing external rotation at 90 degrees (band) Standing, raise your arm to shoulder height out to the side with the elbow bent to 90 degrees. Rotate the forearm upwards against a light resistance band, then return with control. As guided by your physiotherapist Kieran Hirpara 4.0 #### Rhythmic stabilisation With your arm supported in front of you at about shoulder height, have your physiotherapist (or your good hand) apply small, gentle pushes from different directions while you hold the arm still and steady — do not let it move. This trains the shoulder's stabilising muscles to react. Keep all the efforts gentle. As guided by your physiotherapist The final phase conditions the shoulder for everything you want to use it for: building strength and endurance at higher positions, including rotation work with the arm raised to 90 degrees, and progressing stability work overhead. Moving beyond the protocol (including any return to sport) happens with your surgeon's clearance once all the milestones have been met, and for athletes the decision is individualised rather than calendar-driven. For your physiotherapist: Goals - Maintain pain-free range of motion - Improve shoulder strength and endurance - Enhance functional use of the upper extremity Management - Continue with Phase II–IV interventions - Strengthening: - Rotator cuff: external rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees - Periscapular: T and Y, "T" exercise, push-up plus with knees extended, wall push-up - Motor control: - Progress ball stabilisation on wall to overhead alternating isometrics / rhythmic stabilisation Criteria to progress - Clearance from the doctor, and ALL milestone criteria have been met - Maintains pain-free PROM and AROM - Performs all exercises demonstrating symmetric scapular mechanics - QuickDASH and ASES outcome scores Return to sport - For the recreational or competitive athlete, return-to-sport decision making should be individualised and based upon factors including the level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. Close discussion with the referring surgeon is encouraged prior to advancing to a return-to-sport rehabilitation program. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain and wound care. For the operation itself, see total shoulder replacement. The evidence behind this protocol, and why the early phase protects the subscapularis repair, is summarised in the evidence section, available as a PDF from the top of this page. --- ### Thumb Base Joint Replacement (Touch) URL: https://www.cqupperlimb.com/education/rehabilitation/touch-thumb-arthroplasty/ Region: rehabilitation · rehabilitation A staged recovery plan after a dual-mobility total joint replacement of the arthritic thumb base (the Touch implant), protecting the new joint in a thumb splint at first, then restoring opposition and movement, then building pinch and grip strength. This protocol guides your recovery after a thumb base joint replacement (a dual-mobility total joint replacement, the Touch implant) for arthritis of the thumb base, with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist; bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your hand therapist may adjust the plan depending on how your recovery progresses. All of your recovery is guided through formal hand therapy. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect The joint at the base of your thumb (the trapeziometacarpal, or CMC, joint) is where the thumb meets the wrist, and it is a very common site of arthritis. In this operation, the worn joint surfaces are removed and replaced with a small artificial joint: a dual-mobility implant, a tiny ball-and-socket with an extra moving surface that makes it stable and smooth. The trapezium bone is kept and the length of your thumb is preserved, so recovery is generally faster than a trapeziectomy (the older operation, which removes a bone and relies on scar tissue forming over many months). A well-seated implant is stable and able to share load straight away, which is why the thumb only needs to be protected for a short time rather than immobilised for weeks. The plan is to settle the soft tissues, then quickly get your thumb opposing (touching the fingers) and moving again, and then build strength. The recovery runs in three stages: - First, protect (about the first 2–3 weeks). A soft bulky dressing for the first week or so, then a thumb splint to rest the new joint while the wound and soft tissues settle. You keep your fingers, wrist and the rest of the hand moving. - Then, move (from about 2–3 to 6 weeks). Out of the day splint, you begin gentle active movement (opposition, lifting the thumb, opening the web space and circling) and use the hand for light everyday tasks. - Then, strengthen (from 6 weeks onwards). Once the implant has bonded to the bone, pinch and grip strengthening begins and is built up gradually. Strength keeps improving over the following 6 to 12 months. The one thing to respect early on is that the new joint can dislocate if it is forced into an extreme position before the tissues around it have healed. This is uncommon, and the early plan is simply built around not forcing the thumb while it settles. ## Precautions and limitations - Wear your thumb splint as directed (a day splint for the first 2–3 weeks, then a night splint through to 6 weeks) and keep the splint on for protection until your hand therapist advances you. - Do NOT force the thumb into extreme positions, and avoid sudden or awkward grabs in the early weeks; the new joint can dislocate if pushed too far before it settles. Move within comfort only. - Do NOT do any strong pinching, gripping, twisting (jar lids, keys, taps) or lifting until about 6 weeks; strengthening starts only when your hand therapist begins it. - Keep your fingers, wrist and the rest of the hand moving from the start, and keep your hand elevated early on to settle swelling. - Do NOT drive until about four to six weeks, once you are out of your splint and can grip the wheel comfortably and painlessly. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### Thumb opposition (Kapandji ladder) Slowly touch the tip of your thumb to the side of your index finger, then to the tip of each finger in turn, and then walk it down the little finger towards its base — climbing the 'ladder' a little further as you loosen up. Move only as far as is comfortable. This is the key movement to recover after a thumb base replacement, and it is started gently once you are out of your day splint (around two to three weeks). Work through the ladder 5–10 times, 2–3 times a day, within comfort Kieran Hirpara 4.0 #### Palmar abduction (lift thumb off palm) Rest your hand flat, palm up. Keeping your thumb straight, lift it up away from your palm towards the ceiling, as if opening your hand to hold a can — then lower it back down. This opens the web space and restores the thumb's reach. Keep it gentle and unforced; do not push into the end of the movement in the early weeks. 10 times, 2–3 times a day, within comfort Kieran Hirpara 4.0 #### Radial abduction (thumb out to the side) Rest your hand flat with the palm down. Slide your thumb out sideways, away from your index finger, keeping it in the same flat plane as your palm — like making an 'L' shape — then bring it back. This restores the sideways reach of the thumb. Move slowly and stop short of any strain. 10 times, 2–3 times a day, within comfort Kieran Hirpara 4.0 #### Web-space stretch Open the space between your thumb and index finger as wide as is comfortable, feeling a gentle stretch across the web. You can rest your hand on a table and let the thumb ease open, or cup it around a rounded object. Hold the open position briefly, then relax. This keeps the web space from tightening as you heal — keep it gentle, never forced. Hold ~5 seconds, 5–10 times, 2–3 times a day Kieran Hirpara 4.0 #### Thumb circumduction With your hand relaxed, draw slow, smooth circles with your thumb, taking it gently around its full range in both directions — as if stirring a small pot. Keep the circles easy and within comfort. This restores the combined, rolling movement of the new joint and is started gently once you are out of the day splint. 5–10 circles each direction, 2–3 times a day Kieran Hirpara 4.0 #### Putty / key pinch (from week 6) A LATER exercise — only from around six weeks, once your hand therapist starts strengthening. Pinch a piece of therapy putty between your thumb and the side of your index finger (a 'key' pinch), and press your thumb tip to your fingertips (a 'tip' pinch), building the effort up gradually over the following weeks and months. Do NOT do strong pinching or gripping before six weeks — the new joint needs that time to settle and bond to the bone. As guided by your hand therapist (from ~6 weeks), building gradually These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. The early exercises (opposition, lifting the thumb, the sideways movement, the web-space stretch and gentle circles) restore the thumb's movement without loading the new joint, and begin once you are out of your day splint. The putty and key pinch is a later strengthening exercise and should not be started until about six weeks, when your hand therapist begins it. Keep every movement gentle and unforced in the early weeks, and stop anything that causes sharp pain at the base of the thumb. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after a dual-mobility trapeziometacarpal (Touch) total joint replacement. This section is to be provided to your hand therapist, and each phase opens with a plain-English explanation of what is happening. Unlike a trapeziectomy, the implant is immediately stable and load-sharing, so immobilisation is minimal and active opposition is restored early; the implant-specific early risk is dislocation if forced into extreme range, so the first weeks protect against forced/end-range positions while restoring motion, then progress to loaded strengthening once osseointegrated. Prior to treatment, check the patient's operation report and past medical history, and liaise with the treating surgeon regarding implant seating/stability and any intra-operative concerns. Dr Hirpara's regimen is a soft bulky dressing for 7–10 days, then a thumb spica DAY splint for 2–3 weeks, followed by a NIGHT splint continuing to 6 weeks (wrist neutral, thumb in mid palmar abduction, IP free). The trapezium is retained and thumb length preserved. ### Phase I — protect (week 0 to ~2–3) The first few weeks settle the soft tissues and protect the new joint. The thumb rests in a soft bulky dressing, then a thumb spica day splint, while the fingers, wrist and rest of the hand keep moving. No resisted thumb work, and no forced or extreme thumb positions (early dislocation is the implant-specific risk). For your hand therapist: Education and precautions - Immobilise the thumb base: soft bulky dressing 7–10 days → thumb spica DAY splint for weeks ~2–3 (wrist neutral, thumb in mid palmar abduction, IP joint free) - Avoid forced/extreme thumb positions and sudden grasps: dislocation is the early implant-specific risk - No resisted thumb work (no pinch, grip, twisting or lifting) - Keep the implant unloaded; light unloaded hand use only Management - Wound: surgical dressings as directed; monitor for infection - Oedema: elevation, gentle hand pump, ice as needed - Exercises: active ROM of the IP joint of the thumb, the fingers, and the wrist; maintain full-hand mobility; no active CMC/opposition work yet, no loading Criteria to progress - Wound settling; comfortable; out of the day splint at around 2–3 weeks for active motion ### Phase II — active motion in a night splint (week ~2–3 to 6) From about two to three weeks the day splint comes off and gentle active thumb movement begins: opposition (a Kapandji progression), palmar and radial abduction, gentle circumduction and web-space mobilisation. A night splint continues to six weeks. Light everyday use is encouraged; heavy grip and pinch are still withheld. For your hand therapist: Assessments - Active thumb opposition (Kapandji score), palmar/radial abduction, web-space width; pain and swelling; wound/scar review Education and precautions - Out of the day splint; continue the NIGHT splint to 6 weeks - Active unresisted thumb motion only: no heavy grip or pinch before 6 weeks - Keep movement within comfort; avoid forcing end-range Management - Exercises: active unresisted opposition (Kapandji progression), palmar and radial abduction, gentle circumduction, web-space mobilisation; light everyday functional use of the hand; commence scar massage once the wound is healed Criteria to progress - Good active opposition restored; wound healed; pain-free unresisted motion at around 6 weeks ### Phase III — load and strengthen (week 6 onwards) From about six weeks the implant is osseointegrated and can be loaded. Pinch and grip strengthening begins (putty pinch, key and tip pinch, opposition strengthening) and is progressed gradually. Strength continues to mature over the following 6 to 12 months. For your hand therapist: Assessments - Key/tip pinch and grip strength versus the other side; opposition; pain/swelling response to loading; functional and work-specific testing as appropriate Education and precautions - Begin progressive pinch and grip strengthening from 6 weeks; build load gradually - Expect strength to mature over 6–12 months; counsel patience with heavier loading Management - Exercises: putty pinch, key/tip pinch, opposition strengthening, progressive resistance; grip strengthening; continue any residual mobility and scar work - Consider discharge once strength is functional and a suitable return of function is achieved - Consider referral back to the treating doctor if recovery plateaus or there is a poor outcome Criteria for discharge - Functional, near-symmetrical pinch and grip; pain-free everyday and work-specific use ## Getting back to work and activity Light everyday hand use (eating, writing, light self-care) is encouraged within comfort from early on, as long as it does not involve forcing the thumb or strong pinching and gripping. Because you must not drive until you are out of your splint and can grip the wheel comfortably, plan for help with transport in the early weeks. Driving usually resumes at around four to six weeks, once you can grip the wheel painlessly, as confirmed by Dr Hirpara. Office and light work is usually possible within two to four weeks; manual and heavier work waits until about six weeks and then builds up gradually, because strong pinch and grip loading only begins at six weeks. Strength keeps improving for 6 to 12 months, so heavier and more demanding tasks are returned to progressively rather than all at once, judged by how your thumb is responding, with Dr Hirpara and your hand therapist rather than the calendar alone. ## After your protocol This protocol works alongside the practice's general recovery advice; see managing post-operative pain, wound care and scar management. The phased plan above reflects published rehabilitation guidance after dual-mobility thumb base joint replacement, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your thumb progresses. --- ### Trigger finger exercises URL: https://www.cqupperlimb.com/education/rehabilitation/trigger-finger-exercises/ Region: rehabilitation · rehabilitation Exercise handout after trigger digit release — tenodesis, composite extension, blocked flexion and thumb opposition, recreated from an Extend Rehabilitation sheet. Prepared in association with Extend Rehabilitation Name: ____________________  Date: ____________ Trigger Finger/Thumb is a condition where your thumb or fingers can get stuck in a bent position and then straighten with a “snap”. This occurs because inflammation narrows the space so flexor tendons cannot pass through. Tendons are tough bands of tissue that connect muscles and bones. Together, the tendons and muscles in the hands and arms bend and straighten the fingers and thumbs. Trigger finger/thumb makes movement and gripping difficult for your fingers or thumb. ## What causes trigger finger/thumb? - People whose work or hobbies involve repetitive gripping are at higher risk of developing trigger finger. - Rheumatoid Arthritis - Diabetes - Two-thirds more common in women compared to men - Usually affects individuals between 40-60 years of age ## Symptoms - Soreness at the base of the finger or thumb. - Painful clicking or snapping when bending or straightening the finger. This catching sensation tends to get worse after resting the thumb or fingers and loosens up with movement. - In some cases, the finger or thumb locks in a bent or straight position as the condition gets worse and must be gently straightened with the other hand. ## How can hand therapy help? - The aim of treatment is to reduce inflammation to allow your flexor tendon to glide smoothly so the fingers can move without “triggering”. - This can be achieved by - Using a splint - the goal of splinting is to reduce movement of the irritated tendon. - Cortisone injection - this will help relieve the inflammation of the flexor tendon and pain. Splinting may also be used with the cortisone injection. - Surgically - the tendon sheath is surgically released to allow the flexor tendon to glide smoothly ## What you can do - Minimise swelling by applying: - Compression - Keep your hand elevated - Ice (first 48 hours) - Gentle pumps - Do not get your hand wet until you have your sutures removed and have discussed with your therapist. - Use of your hand for light activities: - You may begin using your hand for light tasks, e.g. dressing, eating etc. as soon as pain allows. Over time, slowly begin to use your hand more and for other tasks as tolerated. - You are able to drive as soon as pain allows and you are safe to control the vehicle. - It is very important not to overuse your hand following surgery, as this may delay your healing. If, after using your hand in daily activities, you notice a significant increase in your pain or swelling you should reduce your activities until your hand recovers. ## Exercises #### 1. Tenodesis action Resting on elbow with fingers relaxed, bend wrist forward and then backwards. #### 2. Active composite extension Resting your elbow on a table, straighten your fingers as far as possible push further with your other hand. Count to 5, and relax. #### 3. Passive composite extension Place your hand flat on a table (palm down). Apply pressure over the back of your hand and ‘massage’ towards your body. Count to 5, and relax. #### 4. Blocked DIP flexion With your other hand, grasp and support the finger just below the end joint crease. Bend at the end joint only. Count to 5, and relax. #### 5. Loose fist Supporting wrist back, make a loose fist – then “hook” – and then straighten and spread your fingers. #### 6. Thumb Opposition Start with the fingers straight and relaxed. Touch the tip of your thumb to the tip of the index finger. Hold for 5 seconds. Return to straightened position. Repeat with the middle, ring and little finger. 10 repetitions 3-4 times daily CARDS For the full phase-by-phase recovery plan, see the trigger finger release rehabilitation protocol. --- ### Trigger Finger Release URL: https://www.cqupperlimb.com/education/rehabilitation/trigger-finger-release/ Region: rehabilitation · rehabilitation Post-operative exercises and precautions after trigger finger release, including tendon glides and joint blocking exercises. This protocol guides your recovery after trigger finger release with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It explains what to expect, the precautions to follow, and the post-operative exercise program: bring this page or its PDF to your physiotherapist or hand therapist so your rehabilitation stays coordinated. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect Care of your wound is explained separately: see the wound care page linked at the end of this protocol. The exercises below are very important to prevent your tendons sticking as your wound heals. At times the joints in your fingers can become stiff following this procedure. Preventing this stiffness early is important, so you are encouraged to apply firm, prolonged stretches to your finger (using your other hand), especially for straightening. This form of passive stretching is safe and will not affect the surgery: the pulley has already been released, so there is nothing inside that a stretch can disturb. Once your wound is healed, apply heat to your hand for 20 minutes before performing these exercises. After completing the exercises, application of ice may be helpful to prevent inflammation. Sometimes the hand or wound can become sensitive. This is normal, and can be prevented or minimised by commencing daily desensitisation: gently tapping or rubbing over the wound (with the dressing in place), starting immediately following your surgery. This type of "sensory feedback" allows the skin to normalise touch and texture. In the first 48 hours, work to keep swelling down: keep the hand elevated, use ice, apply compression if your therapist has provided it, and gently "pump" the fingers (open and close) to move swelling along. Begin using the hand for light tasks (dressing, eating and similar) as soon as pain allows, and build up gradually. Don't overdo it: if your pain or swelling clearly increases after an activity, ease back until the hand settles, then build up again. Once the wound is fully healed, commence scar massage: firm circles over the incision. The wound care page has more information on scar management. ## What the evidence says about recovery Open release of the A1 pulley is a well-established operation with a strong track record in the published literature. The catching and locking is corrected by the surgery itself: once the pulley is divided the tendon glides freely again, and the triggering does not usually come back. In a series of nearly 1,600 open releases, fewer than 1% of patients needed a second operation for persistent or recurrent triggering, and there were no nerve injuries or deep infections [4]. A comparative study with over three years of follow-up likewise found no recurrences after open release [5]. Soreness in the palm settles substantially over the first one to two weeks. In one comparative study the median time to significant pain reduction after open release was about a week [5]. Some tenderness in the palm with firm gripping, mild swelling or finger stiffness can linger for several weeks after that. This is normal and reflects the scar maturing, which takes around three months [3]; the desensitisation, scar massage and exercise program in this protocol is designed to manage exactly this. In the large series above, about one in twenty digits had a documented problem after surgery, most commonly temporary stiffness or scar tenderness that settled with treatment; recovery of motion tends to be slower in people with diabetes, so the exercise program matters even more in that group [4]. Published hand-therapy protocols start active and passive finger motion and tendon-glide exercises within the first days after surgery, add scar management and desensitisation once the wound has healed, and reintroduce graded grip strengthening later [2][3], the same staged approach as the program on this page. Starting the exercises early is what keeps the tendon gliding and the joints supple while the wound heals. Return to work depends on what your job asks of the hand. In a comparative study, half of patients were back at work within about two weeks of open release [5]; people in lighter or desk-based roles often manage sooner, while heavier manual work waits until the lifting and gripping restriction below lifts. A randomised controlled trial compared three months of supervised therapy after open release with a self-directed home exercise program: overall function, motion and pain were similar between the groups at six months, grip strength recovered further with supervised therapy, and the patients who clearly benefited from formal therapy were those whose triggering had been present for more than twelve months before surgery and those doing housework or lighter work [1]. In practical terms, a well-performed home program (the exercises on this page) carries most patients through, with formal hand therapy adding value where the finger was stiff for a long time before surgery or progress is slow. ## Precautions and limitations Light functional use of your hand is encouraged for daily living tasks such as self-care, feeding, dressing, writing and typing. The limits that matter: - Avoid lifting, gripping and weight bearing for up to 4 weeks post-op. - Driving is limited for the first week; resume once pain allows, you can make a full fist, and you can safely control the vehicle. For your physiotherapist: Management - Home exercise program as per the cards below: wrist flexion/extension stretch; DIP (distal interphalangeal) and PIP (proximal interphalangeal) joint blocking; tendon glides (Series A and Series B) - Firm prolonged passive stretches to the finger, especially into extension, for early prevention of joint stiffness - Heat to the hand for 20 minutes before exercises once the wound is healed; ice after exercises to prevent inflammation - Daily desensitisation (gentle tapping / rubbing over the wound, dressing in situ) commencing immediately post-op - Swelling management in the first 48 hours: elevation, ice, compression as indicated, gentle finger pumps - Graded return to light functional use as pain allows, monitoring for post-activity pain/swelling flares - Scar massage (firm circles over the incision) once the wound is fully healed Precautions - Light functional use only for daily living tasks (self-care, feeding, dressing, writing, typing) - No lifting, gripping or weight bearing for up to 4 weeks post-op - Driving limited for the first week; resume when pain allows, a full fist is achieved and the patient can safely control a vehicle Expected milestones (criteria-based, guided by published protocols [1][2][3]) - Pain settled to comfortable levels with simple analgesia within 1–2 weeks [5] - Wound healed, with scar massage and ongoing desensitisation under way, by 2–3 weeks [2][3] - Full active finger flexion and extension (full fist and full composite extension) by about 3 weeks, restored and maintained through the blocking and tendon-glide program [2] - Graded grip and pinch strengthening (e.g. putty) introduced once the 4-week lifting/gripping precaution lifts, progressing to full functional use - Consider escalation to supervised hand therapy where triggering had been present for more than 12 months pre-operatively, where the patient's roles involve sustained light/fine hand use, or where range of motion or grip recovery is slow [1] These are the exercises from your handout, started after surgery and continued at home as guided by your physiotherapist or hand therapist. ## Your exercises Kieran Hirpara 4.0 #### Wrist flexion / extension stretch Rest your elbow on a table (or your forearm over the edge of a table or arm chair) and gently rock your wrist back and forth. Once more comfortable, grasp your palm with the other hand and push the wrist backwards (fingers loose, pointing to the ceiling) — hold 15 seconds; then the other way (fingers loose, pointing to the floor) — hold 15 seconds. Repeat 5 times each direction. 10 reps, 4–5 times daily Kieran Hirpara 4.0 #### DIP joint blocking The DIP (distal interphalangeal) joint is the end joint of your finger. Begin with the palm up, supporting your involved hand with your other hand just below the end joint. Bend and straighten the end joint, holding each position for 3–5 seconds. Support the middle joint only enough so it does not bend. It is okay if the other fingers move during this exercise. 10 reps, 4 times a day, daily Kieran Hirpara 4.0 #### PIP joint blocking The PIP (proximal interphalangeal) joint is the middle joint of your finger. Begin with the palm up, supporting your involved hand with your other hand just below the second joint. Bend and straighten your finger at the middle joint, holding each position for 3–5 seconds. It is okay if the other fingers move as well. 10 reps, 4 times a day, daily Kieran Hirpara 4.0 #### Tendon glides — Series A With your hand in front of you and your wrist straight, fully straighten all of your fingers — you may use your other hand to ensure the fingers achieve full extension (position 1). Bend the tips of your fingers into the "hook" position with your knuckles pointing up (position 2). Then make a tight fist with your thumb over your fingers (position 3). 5–10 reps, 2–3 times a day, daily Kieran Hirpara 4.0 #### Tendon glides — Series B With your hand in front of you and your wrist straight, fully straighten all of your fingers — you may use your other hand to ensure the fingers achieve full extension (position 1). Make a "tabletop" with your fingers by bending at your bottom knuckle and keeping the fingers straight — make sure your wrist does not drop forward (position 2). Then bend your fingers at the middle joint, touching your fingers to your palm (position 3). 5–10 reps, 2–3 times a day, daily Kieran Hirpara 4.0 #### Active composite extension Resting your elbow on a table, straighten your fingers as far as possible, then push a little further with your other hand. Count to 5, and relax. 10 reps, 3–4 times daily Kieran Hirpara 4.0 #### Passive composite extension Place your hand flat on a table, palm down. With your other hand, apply pressure over the back of the hand and 'massage' towards your body. Count to 5, and relax. 10 reps, 3–4 times daily Kieran Hirpara 4.0 #### Thumb opposition Start with the fingers straight and relaxed. Touch the tip of your thumb to the tip of your index finger. Hold for 5 seconds, then return to the start. 10 reps, 3–4 times daily Start the exercises below only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. The tendon-glide series and the blocking exercises keep the released tendon running freely through the sheath so it does not stick down in the healing scar — this is what stops the triggering coming back as stiffness instead. Active and passive composite extension keep the finger straightening fully, thumb opposition rebuilds pinch, and the wrist stretch stops the wrist stiffening while the finger is the focus. Tenderness directly over the scar in the palm is expected for some weeks. Stop anything that causes sharp pain. ## After your protocol This protocol was written in association with Sarah Farrell, BOccThy (Bachelor of Occupational Therapy), Accredited Hand Therapist, and incorporates updated post-surgical management guidance (April 2025) from Ruby Doolan, Accredited Hand Therapist, Extend Rehabilitation. It works alongside the practice's general recovery advice: see managing post-operative pain, wound care and hand therapy basics. For the operation itself, see trigger finger release. The recovery framing and milestones are additionally informed by published trigger finger release rehabilitation protocols, including those of the University of Virginia Hand Center and Twin Cities Orthopedics, and by published outcome studies of open trigger finger release, including a randomised controlled trial of post-operative rehabilitation (Saito et al., Journal of Clinical Medicine, 2023) and a large adverse-event series (Bruijnzeel et al., Journal of Hand Surgery, 2012). --- ### Volar plate exercises URL: https://www.cqupperlimb.com/education/rehabilitation/volar-plate-exercises/ Region: rehabilitation · rehabilitation Finger exercise handout — tip bends, hook bends and full fist, recreated from an Extend Rehabilitation sheet. Prepared in association with Extend Rehabilitation ## 1. Tip of finger bends ## 2. Hook bends ## 3. Full fist --- ### Wrist Arthroscopy URL: https://www.cqupperlimb.com/education/rehabilitation/wrist-arthroscopy/ Region: rehabilitation · rehabilitation A recovery plan after keyhole (arthroscopic) wrist surgery, where the pace depends on what was done inside: a clean-up (debridement, synovectomy, ganglion or central TFCC tidy-up) allows early movement and a quick return, while a TFCC repair protects forearm rotation in a… This protocol guides your recovery after keyhole (arthroscopic) surgery on the wrist with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. Wrist arthroscopy is done through a few tiny incisions (portals) on the back of the wrist, so the skin heals quickly, but the pace of your recovery depends on what was done inside the joint. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist. Bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated, and so your therapist follows the plan that matches your operation. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wounds after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect Wrist arthroscopy means the surgeon works inside your wrist through small keyhole portals using a tiny camera and fine instruments. Because the cuts are small, the skin and soft tissues heal fast, but the inside of the wrist sets the timetable, and there are two very different recovery paths: - A clean-up (debridement, synovectomy, dorsal ganglion removal, or a central TFCC tidy-up). Here, nothing is stitched back together that needs protecting; damaged or inflamed tissue is simply trimmed or removed. So immobilisation is brief (often just a soft dressing or short splint for comfort), wrist movement begins within days, and you return to most activities over a few weeks. The central part of the TFCC (the cushion on the little-finger side of the wrist) has no blood supply and cannot heal if stitched, so when it is torn there it is trimmed rather than repaired, and that trimming behaves like a clean-up. - A TFCC repair (a peripheral or foveal tear stitched back down). The outer rim of the TFCC does have a blood supply and can heal, so when it is torn there it is repaired, and that repair must be protected. The single biggest stress on a healing TFCC repair is turning the forearm (rotating the palm up and down). Because of that, the wrist and forearm are rested in a splint or a Muenster (above-elbow) cast for about four to six weeks; this lets the elbow bend but blocks the forearm rotation that would pull on the repair. Movement, then strength, are then rebuilt in careful stages, and full recovery takes around three months or more. Throughout both paths, the fingers are kept moving from the start (they were not operated on), swelling is controlled, and the small portal scars are looked after. Your hand therapist will follow the plan for what was actually done in your wrist; if you are unsure which path you are on, ask Dr Hirpara or check your operation note. ## Precautions and limitations - Keep your fingers moving from the start: make a fist and straighten out fully, several times a day. This is always allowed and prevents stiffness and swelling. - Follow the plan for what was done. After a clean-up, gentle wrist movement starts within days. After a TFCC repair, the wrist and forearm stay protected in a splint or cast and you do NOT turn the forearm (palm up / palm down) until your hand therapist clears it (about four to six weeks). - After a TFCC repair, do NOT force or load forearm rotation, and do NOT grip or lift heavily until cleared; rotation and load are exactly what stress the repair. - Keep the keyhole portals clean and dry until healed; do NOT soak or scrub them. Look after the small scars once they have healed. - Do NOT drive while your wrist is splinted, casted, or unable to safely control the wheel; arrange help with transport in the early weeks. - Use the hand for light everyday tasks within comfort, as long as it does not involve the movements or loading you have been told to avoid. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### Finger movement (early) From the first day or two, slowly make a full fist, then straighten your fingers all the way out. The fingers are not part of what was repaired, so keeping them moving is encouraged from the start — it controls swelling and stops the hand stiffening. Do this even while your wrist is resting in a splint or cast. 10 times, several times a day, from the start Kieran Hirpara 4.0 #### Wrist movement (per your plan) If you had a clean-up (debridement, synovectomy or ganglion removal), gentle wrist bending up and down — and side to side — usually begins within a few days, as soon as comfort allows. If you had a TFCC repair, the wrist is rested in a splint or cast first, and wrist movement begins later, only when your hand therapist starts it. Always stay within the range you have been given. 10 times each direction, 2–3 times a day, once started Kieran Hirpara 4.0 #### Forearm rotation — palm up / palm down (per your plan) With your elbow tucked at your side, gently turn your palm up towards the ceiling, then down towards the floor. After a clean-up this can usually begin early. After a TFCC repair this is the LAST motion to be freed — turning the forearm stresses the repair, so it is held back in a splint or cast for about four to six weeks and then re-introduced gradually. Only do this once your hand therapist has cleared it. 10 times each direction, 2–3 times a day, once cleared Kieran Hirpara 4.0 #### Scar and portal care Once the small portal wounds are fully healed and dry, massage each little scar with a fingertip using a plain moisturiser, in small circles. Keyhole portals are tiny but can feel tight or sensitive — gentle massage and tapping (desensitisation) keep the skin supple and settle any tenderness. A few minutes, 2–3 times a day, once wounds are healed Kieran Hirpara 4.0 #### Grip strengthening (later) A LATER exercise — only once your hand therapist starts it. Squeeze a soft ball or therapy putty, hold briefly, then relax. After a clean-up, light gripping often begins within a couple of weeks; after a TFCC repair, strengthening waits until about eight weeks, once movement has returned. Build the effort up gradually and stop if it is sharply painful. 10–15 squeezes, 2–3 times a day, when cleared These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. Finger movement and swelling control begin from the start for everyone. Wrist movement, forearm rotation and grip are gated by what was done: early after a clean-up, but held back after a TFCC repair (forearm rotation especially, which is the last thing to be freed). Scar and portal care begins once the small wounds have healed. Stop anything that causes sharp pain. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after wrist arthroscopy. This section is to be provided to the hand therapist, and each phase opens with a plain-English explanation of what is happening. The protocol forks on what was done. A diagnostic-or-therapeutic clean-up (debridement, synovectomy, dorsal ganglion excision, chondral or scapholunate debridement, central TFCC debridement) follows the early-motion path. A peripheral/foveal TFCC repair follows the protected-rotation path, because forearm rotation loads the repair. Always confirm with the operation note and the treating surgeon which path applies. Prior to treatment, check the patient's operation report and past medical history, and liaise with the treating surgeon regarding the procedure performed (pure debridement/synovectomy/ganglion/central-TFCC debridement vs peripheral/foveal TFCC repair), any associated DRUJ instability, and the prescribed immobilisation. The two pathways below differ chiefly in how long forearm rotation is protected. ### Path A — Clean-up (debridement / synovectomy / ganglion / central-TFCC debridement): early-motion The clean-up path removes or trims tissue without creating a construct that needs protecting, so the goal is to restore motion early and avoid stiffness. Immobilisation is brief and for comfort only. #### Phase I — early motion (weeks 0 to 2) The first couple of weeks settle swelling and pain while motion begins almost immediately. For your hand therapist: Education and precautions - Immobilisation is soft dressing or a short splint for comfort only, typically up to ~2 weeks; no rotation restriction for a pure central debridement/synovectomy/ganglion - Fingers, thumb and (where comfortable) wrist move from day one - Keep portals clean and dry until healed Management - Oedema: elevation, gentle finger pumping, ice as needed - Exercises: full active finger and thumb ROM from the start; active wrist flexion/extension and radial/ulnar deviation as comfort allows within the first days; gentle forearm pronation/supination as comfort allows - Wound: portal dressings as directed; monitor for infection Criteria to progress - Portals healed; swelling settling; comfortable early ROM #### Phase II — restoring motion and starting strength (weeks 2 to 6) Motion is normalised and light strengthening is added once range is comfortable. For your hand therapist: Assessments - Active and passive wrist ROM and forearm rotation; grip; pain and swelling; scar/portal review Management - Exercises: progress to full wrist and forearm ROM; begin light grip and putty strengthening from around 2 weeks; commence scar/portal desensitisation and massage once healed - Progress functional hand use as comfort allows Criteria to progress - Near-full painless ROM; settled swelling; grip building #### Phase III — strengthening and return (weeks 6 and beyond) Strength and task tolerance are built back; most patients return to normal activity over a few weeks. Note that a clean-up gives reliable symptom relief but that relief is not guaranteed for diffuse or recalcitrant ulnar-sided pain; manage expectations where pain is non-focal. For your hand therapist: Management - Exercises: graded grip and forearm/wrist strengthening; task- and work-specific loading - Return to light/most activity typically 2–6 weeks; heavier manual or sporting load as tolerated and criterion-based - Consider discharge once strength is near-symmetrical and function restored ### Path B — Peripheral / foveal TFCC repair: protected rotation The repair stitches the outer (vascularised) rim of the TFCC back down. Because forearm rotation stresses the repair, the forearm is protected in a splint or Muenster (above-elbow) cast (which allows elbow flexion/extension but blocks pronation/supination) for about four to six weeks. Motion, then strength, are then graded back. #### Phase I — protected immobilisation (weeks 0 to 6) The repair is protected from rotational load while the fingers stay mobile. Practice varies, but the most common pattern is forearm immobilisation in neutral-to-slight-supination for about six weeks; an above-elbow (Muenster) cast or splint is used when rotation must be firmly controlled. For your hand therapist: Education and precautions - Immobilise to protect forearm rotation: splint or Muenster/above-elbow cast (elbow free, forearm rotation blocked), forearm in neutral to slight supination, for ~4–6 weeks (commonly 6) - No active or passive forearm pronation/supination during this phase - Full finger and thumb ROM from day one; gentle shoulder ROM - Keep portals clean and dry; monitor for infection Management - Oedema: elevation, finger pumping, ice as needed - Exercises: finger/thumb AROM; isolated elbow flexion/extension if a Muenster permits; no wrist or forearm rotation loading - Wound/scar: portal care; begin scar work once healed Criteria to progress - ~4–6 weeks elapsed; repair protected; portals healed; fingers supple #### Phase II — graded motion (weeks 6 to 8) The cast/splint comes off and motion is rebuilt, introducing forearm rotation last and gradually, as it is the motion that stressed the repair. For your hand therapist: Assessments - Wrist and forearm ROM; pain and swelling; scar review Management - Exercises: begin active wrist flexion/extension and radial/ulnar deviation; gradually re-introduce forearm pronation/supination within comfort, building the rotation arc up over the following weeks rather than forcing it - Continue scar/portal desensitisation Criteria to progress - Comfortable, improving wrist and forearm ROM; pain settling #### Phase III — strengthening and return (weeks 8 to 12+ and beyond) Strengthening begins once roughly 70–100% of wrist and forearm motion is restored, then load and task tolerance are graded back. For your hand therapist: Assessments - Grip and forearm strength versus the other side; pain/swelling response to loading; functional and work-/sport-specific testing Management - Exercises: begin grip and forearm/wrist strengthening from around 8 weeks, once 70–100% of ROM is regained; progress to graded resisted and task-specific loading - Return to sport/heavier work is criterion-based, typically around three months (range ~3–4+ months depending on demand) - Consider discharge once strength is near-symmetrical and function restored; refer back to the treating doctor if recovery plateaus or DRUJ instability recurs ## Getting back to work and activity Light everyday hand use (eating, writing, light self-care) is encouraged from the start within comfort, as long as it stays within the limits you have been given. Driving resumes once you are out of any splint or cast and can safely control the wheel, as confirmed at your review; plan for help with transport in the early weeks. How quickly you return depends on what was done. After a clean-up (debridement, synovectomy, ganglion or central-TFCC tidy-up), most people are back to normal light activity within two to six weeks, with heavier load built back as comfort allows. After a TFCC repair, forearm rotation is protected for about four to six weeks, strengthening begins from around eight weeks, and return to sport or heavier manual work is usually around three months, judged by regaining movement and adequate, symmetrical strength, not by the calendar alone, and decided by Dr Hirpara and your hand therapist together. ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain, wound care and scar management. If your operation involved the distal radioulnar joint or you are unsure which pathway applies, the distal radioulnar joint (DRUJ) hemiresection protocol is a related sibling. The phased plan above reflects published rehabilitation guidance after wrist arthroscopy and TFCC surgery, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your wrist progresses. --- ### Wrist Fusion URL: https://www.cqupperlimb.com/education/rehabilitation/wrist-fusion/ Region: rehabilitation · rehabilitation A recovery plan after total wrist fusion (arthrodesis), where the worn-out wrist is joined solid with a dorsal plate so it no longer moves by design, while the fingers, thumb and forearm rotation are kept moving from the start and grip is built up once the bone has united. This protocol guides your recovery after a total wrist fusion (also called wrist arthrodesis, an operation that permanently joins the worn-out wrist solid so it no longer moves) with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist: bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect A total wrist fusion is done for a wrist that is worn out across all of its joints (end-stage, or "pancarpal", arthritis) and is painful with movement. Rather than trying to keep a worn joint moving, the operation takes the movement away on purpose: the forearm bone (the radius) is joined to the hand bones (the metacarpals) with a dorsal plate running along the back of the wrist, setting the wrist solid in a position of slight backward tilt (slight extension) that is best for gripping. Over the following weeks the bones knit together (unite) into one solid block. The key idea of this recovery is the opposite of most operations: the wrist is meant to stop moving: that is the cure, not a complication. So there is no goal of regaining wrist movement, and no exercises to bend or straighten the wrist. Instead, the whole rehabilitation protects two things that the fusion does not touch and that matter enormously for hand function: - Your fingers and thumb must stay fully mobile. Stiff fingers are the main thing that lets a wrist fusion down, so finger and thumb movement starts from day one. - Forearm rotation (turning your palm up and down) is preserved. The fusion does not involve this movement, and it takes over a lot of what the wrist used to do (turning keys, taps and doorhandles) so it is kept supple from the start. Because the dorsal plate holds the bones firmly (stable fixation), a splint is worn for about six weeks while the bone unites, and early finger and forearm movement is encouraged rather than held back. Once the surgeon confirms union, grip strengthening begins. Many people function very well after a wrist fusion, and because gripping is no longer painful, grip strength often improves compared with the painful wrist before surgery. ## Precautions and limitations - Do NOT try to move the wrist itself: it is fused solid by design. There are no wrist-bending exercises, now or ever. - Do keep your fingers, thumb and forearm rotation moving fully from day one: this is the single most important thing you can do for your hand. - Wear your splint or dressing as directed for comfort and protection until the bone has united; keep it clean and dry. - Do NOT load or grip hard, and avoid lifting more than a light cup, until the fusion has united and you are cleared (usually around six to eight weeks): heavy loading before union risks the plate or the fusion failing. - Do NOT drive while you are in a splint or cannot safely control the car; driving resumes once you are out of the splint and can manage the wheel, as confirmed at your review. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### Finger and thumb movement Keep your fingers and thumb moving fully from the very first days. Make a complete fist, then open the hand wide and stretch the fingers straight; then touch your thumb to the tip of each finger in turn. Your wrist does not move — that is normal and intended — but the fingers and thumb must stay loose and fully mobile, because stiffness here is the main thing that limits the hand after a wrist fusion. 10 times each, several times a day, from day one Kieran Hirpara 4.0 #### Forearm rotation (palm up / palm down) With your elbow tucked at your side and bent to a right angle, gently turn your palm up towards the ceiling, then down towards the floor. The fusion does not involve these turning movements, so they stay free — keeping them supple is important, as turning the forearm does a lot of the work the wrist used to do (turning a key, a doorknob, a tap). 10 times each direction, 2–3 times a day Kieran Hirpara 4.0 #### Swelling control For the first couple of weeks, rest your hand raised up on pillows above the level of your heart whenever you sit or lie down, and pump your fingers gently open and closed. This drains the swelling that always follows hand surgery; less swelling means the fingers move more freely and the wound settles faster. Elevate whenever resting; finger pumps 10 times, hourly while awake Kieran Hirpara 4.0 #### Scar care Once the wound has fully healed and there is no scab, massage the scar over the back of your wrist with a little moisturiser, using small firm circles. This keeps the scar soft and stops it sticking to the plate and tendons underneath. Your hand therapist will start this at the right time. A few minutes, 2–3 times a day, once healed Kieran Hirpara 4.0 #### Grip strengthening after union A LATER exercise — only once the fusion has united (usually around six to eight weeks) and you are cleared. Squeeze a soft ball or therapy putty in your palm and hold, then release. The fused wrist gives the hand a stable, pain-free base to grip from, so grip strength usually improves over the following months. Build it up gradually. 10–15 squeezes, 2–3 times a day, once cleared after union These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist. The early exercises all protect what the fusion leaves free (finger and thumb movement, forearm rotation, and swelling control) and none of them involve the wrist, which stays solid. Grip strengthening belongs to a later phase and should not be started until the fusion has united and you are specifically cleared. Stop anything that causes sharp pain over the back of the wrist. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after total wrist arthrodesis. This section is to be provided to your hand therapist, and each phase opens with a plain-English explanation of what is happening. There is no wrist-ROM goal: the radiocarpal (and usually third carpometacarpal) joints are fused with a dorsal plate. The protocol exists to preserve digital range, forearm rotation and oedema control while the fusion unites, then build grip on the stable construct. Prior to treatment, check the patient's operation report and past medical history, and liaise with the treating surgeon regarding the construct (dorsal arthrodesis plate; whether the third CMC joint is included or spared), the fused wrist position, any bone graft used, and the union status. Dr Hirpara fuses the wrist in slight extension with a dorsal plate; fixation is stable, so a light splint/dressing for comfort is used rather than prolonged rigid casting, and early digital and forearm motion is the priority. ### Phase I — protect the construct, mobilise the free joints (weeks 0 to 6) The first six weeks protect the healing fusion while keeping everything that is not fused fully mobile. A light splint or dressing is worn for comfort. There is no wrist motion (the construct is rigid by design) and the focus is entirely on the fingers, thumb, forearm and swelling. For your hand therapist: Education and precautions - Splint/dressing for comfort and protection until clinical and radiographic union; no rigid prolonged casting required given stable plate fixation - No wrist mobilisation: the radiocarpal/CMC construct is fused; there is no ROM target - No loaded grip or lifting beyond a light cup until union confirmed - Watch for digital stiffness: the principal threat to outcome after wrist fusion Management - Wound: surgical dressings as directed; sutures out and splint/X-ray review at around 10–14 days; monitor for infection - Oedema: elevation above heart level, gentle digital pumping, ice as needed - Exercises: full active finger and thumb AROM (composite fist → full extension, thumb opposition) from day one; active forearm pronation/supination; active shoulder and elbow ROM; no wrist motion, no resisted grip Criteria to progress - Wound healed; full or near-full digital ROM maintained; early radiographic signs of union at around six weeks ### Phase II — confirm union, begin grip loading (weeks 6 to 12) From about six weeks the fusion is usually uniting on X-ray, and once the surgeon confirms this the splint is discarded and grip strengthening begins. Forearm and finger work continues; the wrist remains fused and unloaded only until union is confirmed. For your hand therapist: Assessments - Confirm union status with the treating surgeon before loading; digital ROM; forearm rotation arc; grip baseline; wound/scar review Education and precautions - Begin grip and light loading only after the surgeon confirms union (commonly six to eight weeks) - Hardware over the dorsal wrist is subcutaneous; watch for prominence/irritation and report it - Continue to prioritise full digital ROM throughout Management - Exercises: progressive grip strengthening (soft ball → putty → graded grippers) once union confirmed; commence scar management once wound healed; continue forearm rotation and full digital ROM; introduce light functional hand use - Educate that forearm rotation now substitutes for lost wrist motion in daily tasks (keys, taps, turning) Criteria to progress - Confirmed union; pain-free light grip; full digital ROM; scar mobile ### Phase III — strengthening and return to load (weeks 12 and beyond) Once the fusion is solid, there are no movement restrictions to protect; the hand can be loaded as tolerated and built up. Grip and overall hand strength continue improving for several months, often to better than before surgery because gripping is now pain-free. For your hand therapist: Assessments - Grip strength versus the other side; functional and work-/task-specific testing; hardware tolerance Education and precautions - No movement restrictions once united; progress load as tolerated - Heavy/manual loading built up gradually; full strength gains continue up to around twelve months Management - Exercises: progressive resisted grip and forearm strengthening; graded return to functional and work tasks; continue any residual digital mobility work - Consider discharge once grip is functional and improving and daily tasks are managed; refer back to the treating doctor if digital stiffness, persistent hardware irritation, or a poor outcome develops Criteria for return to load - Solid union; functional, improving grip; pain-free task-specific loading ## Getting back to work and activity Light everyday hand use (eating, writing, light self-care) is encouraged from the start, within comfort, as long as you are not gripping hard or lifting more than a light cup before the fusion has united. Because you must not drive while in a splint or unable to safely control the car, plan for help with transport in the early weeks; driving resumes once you are out of the splint and can manage the wheel, as confirmed at your review. Loaded gripping, lifting and pulling wait until the fusion has united (usually around six to eight weeks) and you are cleared, and are then built up gradually. Most people are back to office or light work by around three months, with heavier or manual work later, on a criterion-based progression judged by Dr Hirpara and your hand therapist rather than the calendar alone. Strength keeps improving for up to a year, and because the worn-out wrist is no longer painful, many people grip more strongly and use the hand more freely than they could before surgery. ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain, wound care and scar management. The phased plan above reflects published outcomes and rehabilitation guidance after total wrist arthrodesis, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your fusion and hand progress. --- ### Wrist Ganglion Excision URL: https://www.cqupperlimb.com/education/rehabilitation/wrist-ganglion-excision/ Region: rehabilitation · rehabilitation An early-motion recovery plan after excision of a dorsal or volar wrist ganglion, using minimal immobilisation then prompt movement of the wrist in every direction to prevent the stiffness that is the most common problem after this operation. This protocol guides your recovery after surgical removal (excision) of a wrist ganglion, a fluid-filled cyst that grows out of the wrist joint, with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist; bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your therapist may adjust the plan depending on how your recovery progresses. If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review. ## What to expect A wrist ganglion is a balloon-like, fluid-filled cyst that is connected by a narrow stalk to the lining of the wrist joint. Most appear on the back of the wrist (a dorsal ganglion); some appear on the front, thumb-side (a volar ganglion). At operation, Dr Hirpara removes the cyst together with its stalk, down to the wrist joint capsule, taking the root as well as the lump, because leaving the stalk behind is the main reason a ganglion can come back. The operation can be done open (through a small incision) or with keyhole (arthroscopic) instruments. Because nothing has been repaired or reconstructed (a cyst has simply been removed), there is no healing tendon or ligament that needs to be protected for weeks. The recovery is therefore an early-motion plan, and its whole purpose is to get the wrist moving promptly: - Stiffness is the most common problem after this operation, far more than the cyst coming back. The wrist that is rested too long after a ganglion excision can lose movement. - So immobilisation is kept to a minimum: a soft dressing, sometimes with a light wrist splint just for comfort, for only a few days up to a week or two. Then you move the wrist early, in every direction. Your fingers, which are not operated on, keep moving fully from day one. Movement of the wrist is opened up as the wound settles, then grip and load are built back gradually. Most people are back to ordinary activity by around four to six weeks. ## Precautions and limitations - Keep your fingers, thumb and elbow moving fully from day one; only the wrist needs any easing-in. - Wear the soft dressing or comfort splint only as long as directed (commonly a few days up to one to two weeks). It is for comfort, not to hold the wrist still for a long time; early movement is the goal here, not rest. - Do NOT soak the wound or get the dressing wet until you are told the wound is sealed; keep it clean and dry. - Hold off on heavy gripping, lifting and load-bearing through the wrist for the first few weeks, and build them back gradually rather than all at once. - If you had a volar (front-of-wrist) ganglion, the cyst can sit close to the radial artery (a pulse you can feel at the front of the wrist); let the rooms know promptly if you notice unusual swelling, coldness or colour change in the hand. - Do NOT drive until you can comfortably control the wheel and are out of any splint, as confirmed at your review. For wound, swelling and scar management, see the practice's wound care guidance. ## Your exercises Kieran Hirpara 4.0 #### Wrist movement (all directions) Gently move your wrist in every direction — bend it back (up), bend it forward (down), and tilt it side to side — moving it as far as is comfortable each way. This is the most important early exercise, because the wrist tends to stiffen after this operation, and moving it early keeps it supple. Do it slowly and stay within comfort; it should not be sharply painful. 10 times in each direction, 4-5 times a day, from the first few days Kieran Hirpara 4.0 #### Forearm rotation (palm up / palm down) Tuck your elbow in at your side and bend it to a right angle. Slowly turn your palm up towards the ceiling, then down towards the floor. Keep the elbow still so the movement comes from the forearm. This keeps the forearm and wrist turning freely while the wound settles. 10 times each direction, 3-4 times a day Kieran Hirpara 4.0 #### Finger movement Make a full, slow fist so the fingertips curl into the palm, then open the hand and straighten the fingers out completely. The fingers are not operated on, so keep them moving fully from day one — this stops the hand stiffening and helps swelling drain away. 10 times, several times a day, from day one Kieran Hirpara 4.0 #### Scar massage Once the wound is fully healed and the dressings are off (usually around two weeks), rub a little plain moisturiser into the scar with your fingertip, using small firm circles for a few minutes. This keeps the scar soft and mobile and stops it sticking to the tissues underneath, which can otherwise hold the wrist back. Do not start this on an unhealed or weepy wound. A few minutes, twice a day, once the wound is fully healed Kieran Hirpara 4.0 #### Grip strengthening A LATER exercise, usually from around three to four weeks once the wound is settled and movement is comfortable. Squeeze a soft ball or therapy putty in your palm, hold for a few seconds, then relax. Build it up gradually. This restores the grip strength that often dips for a few weeks after the operation. 10-15 squeezes, 2-3 times a day, from around 3-4 weeks These are the exercises from your handout. Start them as guided by Dr Hirpara and your hand therapist. The early exercises (wrist movement in all directions, forearm rotation and finger movement) are the heart of this recovery and begin within the first few days, because moving the wrist early is what prevents the stiffness that otherwise follows this operation. Scar massage starts once the wound is fully healed, and grip strengthening is added a little later as comfort allows. None of these should be sharply painful; ease off anything that is. ## Your clinical protocol The rest of this page is the staged clinical protocol for rehabilitation after wrist ganglion excision. This section is to be provided to your hand therapist, and each phase opens with a plain-English explanation of what is happening. This is an excision, not a repair: there is no construct to protect, so the governing principle is minimal immobilisation followed by early active wrist motion in all planes to prevent post-excision stiffness, which is the most common complication after this procedure. Prior to treatment, check the patient's operation report and past medical history, and liaise with the treating surgeon regarding the location (dorsal vs volar), the surgical approach (open vs arthroscopic), the integrity of the dorsal/volar capsule, and any concurrent finding. Dr Hirpara excises the cyst with its stalk down to the joint capsule. For volar ganglia, note the proximity of the radial artery. There is no protected arc and no construct to off-load; the only deliberate restraint is a short window of heavy-grip/load avoidance while the soft tissues settle. ### Phase I — minimal immobilisation and early motion (days 0 to ~14) The first phase protects the wound while getting the wrist moving early. Immobilisation is deliberately brief (a soft dressing, with a light wrist splint for comfort only if needed), and the wrist begins active motion in all directions within the first few days. The systematic-review evidence is that limited immobilisation of two weeks or less, or none at all, does not meaningfully change the outcome, while prolonged rest risks stiffness. For your hand therapist: Education and precautions - Soft dressing, with an optional light wrist splint for comfort only; wean over days, not weeks - No prolonged rigid immobilisation: limit any splinting to ≤2 weeks (commonly a few days) - Keep the wound clean and dry until sealed; full finger, thumb and elbow ROM from day one - Volar cases: be alert to the radial artery; report vascular concerns promptly Management - Wound: surgical dressings as directed; monitor for infection - Oedema: elevation, gentle hand pump, ice as needed - Exercises: active wrist ROM in all planes (flexion/extension, radial/ulnar deviation) within comfort, started in the first few days; active/passive forearm pronation–supination; full active finger and thumb ROM; gentle shoulder ROM Criteria to progress - Wound healing; settling oedema; improving, comfortable wrist arc; splint (if used) discontinued by ~2 weeks ### Phase II — restoring full motion and scar management (weeks ~2 to 4) From around two weeks the dressings are off and the wound is healed. The focus is regaining full, symmetrical wrist movement before stiffness has a chance to set in, and starting scar work so the scar stays mobile and does not tether the wrist. For your hand therapist: Assessments - Active and passive wrist ROM (compare to the other side); forearm rotation; oedema; wound/scar review Education and precautions - Drive towards full wrist ROM in all planes; address any early loss promptly with active and gentle passive work - Begin scar management once the wound is fully healed (massage, silicone/moisturiser, desensitisation as needed) - Light functional hand use encouraged; defer heavy gripping and loading Management - Exercises: progress to full active and gentle passive wrist ROM; continue forearm rotation; commence scar massage and desensitisation; light putty/grip work introduced toward the end of this phase as comfort allows Criteria to progress - Full or near-full pain-free wrist ROM; healed, mobile scar; ready for graded loading ### Phase III — strengthening and return to activity (weeks ~4 to 6 and beyond) Once movement is restored, grip and load are built back gradually. For most patients ordinary activity returns by around four to six weeks; heavier manual demands follow a criterion-based progression. For your hand therapist: Assessments - Grip and pinch strength versus the other side; wrist ROM; response to graded loading; functional/work-specific testing as appropriate Education and precautions - Progress grip and wrist strengthening (putty, ball, graded resistance) as comfort allows - Reintroduce lifting and load-bearing through the wrist gradually; full return guided by symptoms, not the calendar Management - Exercises: progressive grip/pinch and wrist strengthening; graded loading and task-specific work; continue any residual mobility and scar work - Consider discharge once ROM is full, strength is near-symmetrical and function has returned - Consider referral back to the treating doctor if the wrist plateaus stiff, or if a recurrent swelling appears Criteria for return to full activity - Full pain-free wrist ROM; near-symmetrical grip; comfortable with task- and work-specific loading ## Getting back to work and activity Light everyday hand use (eating, writing, light self-care) is encouraged from the start within comfort, and your fingers should be working fully from day one. Desk and light duties are often possible within a few days to a week or so, especially with the dominant hand free; jobs that involve heavy gripping, lifting or repeated forced wrist movement take longer and are built back over the first few weeks. Published series report only a short time off work after ganglion excision (on the order of about two weeks), though this varies with the side operated on and the demands of your job. Because you must be able to comfortably control the wheel and be out of any splint, plan for help with transport in the very early days; driving resumes once you are comfortable and safe, as confirmed at your review. Most people are back to ordinary activity by around four to six weeks, with heavier manual work and sport built back gradually as movement and grip return, judged by how the wrist is doing, not by the calendar alone. ## After your protocol This protocol works alongside the practice's general recovery advice: see managing post-operative pain, wound care and scar management. The phased plan above reflects published guidance after wrist ganglion excision, where the priority is early movement to prevent stiffness; your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your wrist progresses. --- ### Shoulder URL: https://www.cqupperlimb.com/education/shoulder/ Region: shoulder · region-landing Shoulder conditions and the operations that treat them, grouped by theme — each diagnosis sits beside its treatment so you can read the two together. Start with the group that matches the name you have been given, or the one that sounds like your symptoms. ## Understanding your shoulder How your shoulder works Shoulder anatomy overview – bones (clavicle, scapula, humerus) and how they enable wide range of motion. Open → Shoulder Arthroscopy What shoulder arthroscopy is, what it's used for, and how to prepare and recover. Open → ## Rotator cuff & impingement Rotator Cuff Disorders Rotator cuff disorders: common causes of shoulder pain, ranging from mild ache to debilitating injury. Open → Subacromial Impingement and Bursitis Subacromial impingement — causes of shoulder pain with overhead activity, diagnosis, and treatment options. Open → Calcific Tendinitis Calcific tendinitis causes shoulder pain from calcium deposits; treatment ranges from observation to washing out the calcium. Open → Cuff Arthropathy Rotator cuff arthropathy: shoulder arthritis following a long-standing, massive rotator cuff tear and its impact on function. Open → Os Acromiale Patient-facing topic on os acromiale — failed fusion of an acromial ossification centre that may cause shoulder pain and contribute to subacromial impingement. Open → Rotator Cuff Repair Rotator cuff repair reattaches torn tendons to bone, improving pain and function when conservative treatment fails. Open → Revision rotator cuff repair Open → Subacromial Decompression Arthroscopic subacromial decompression for impingement and bursitis — operation and recovery. Open → Suture Anchors and How Repairs Are Held to Bone Open → EnFix Biological Scaffold Open → ## Instability, labrum & biceps Shoulder Instability Shoulder instability — understanding the feeling of looseness, causes, and treatment options. Open → Shoulder Clicking, Popping and Instability Why a shoulder clicks, pops or feels like it slips — from harmless noises to labral tears and instability — what it means, and when it needs attention. Open → SLAP and Biceps Pathology Superior labral (SLAP) tears and disorders of the long head of biceps — assessment and treatment. Open → Biceps Tendinopathy and Long-Head Rupture Front-of-shoulder biceps tendon pain and the "Popeye" long-head rupture — and why the rupture usually needs no surgery. Open → Anterior Shoulder Stabilisation Arthroscopic Bankart repair for anterior shoulder instability — distinct from open Latarjet. Open → Posterior Shoulder Stabilisation Open → Latarjet Procedure Latarjet procedure — bone block transfer for recurrent shoulder instability with glenoid bone loss. Open → Biceps Tenodesis Biceps tenodesis and tenotomy — when, where (suprapectoral vs subpectoral) and what to expect afterwards. Open → ## Arthritis & shoulder replacement Shoulder Arthritis Shoulder arthritis causes pain, stiffness, and reduced range of motion — diagnosis and treatment options explored. Open → Comprehensive Arthroscopic Management (CAM) The Comprehensive Arthroscopic Management (CAM) procedure — a joint-preserving arthroscopic alternative to arthroplasty for glenohumeral osteoarthritis, combining debridement, capsular release, osteophyte excision, microfracture, loose-body removal and axillary nerve neurolysis. Open → Total Shoulder Arthroplasty Total shoulder replacement for severe arthritis — stemless options if rotator cuff is intact. Open → Reverse Shoulder Arthroplasty Reverse shoulder replacement for severe rotator cuff tears and arthritis—when a traditional replacement isn’t ideal. Open → Revision Shoulder Replacement Revision shoulder replacement — addressing failure of prior shoulder replacements with a reverse design. Open → ## Fractures & trauma Clavicle Fracture Clavicle fractures — when conservative management is fine and when fixation is indicated. Open → Proximal Humerus Fracture Proximal humerus fractures — Neer classification, sling management, and surgical options. Open → Pectoralis Major Rupture A chest-muscle tear, classically during a heavy bench press — how to recognise it and why complete tears are usually repaired early. Open → Pectoralis Major Repair Open → Clavicle Fracture Fixation Clavicle fixation (ORIF) — restoring alignment and stability for displaced clavicle fractures. Open → Proximal Humerus Fracture ORIF (Plate and Nail Fixation) Open → Shoulder Arthroplasty for Acute Proximal Humerus Fracture Open → ## Collarbone & AC joint Acromioclavicular Joint Injury (Shoulder Separation) A shoulder separation from a fall on the point of the shoulder — grading, the bump that may remain, and when surgery is needed. Open → AC Joint Osteoarthritis AC joint osteoarthritis causes localized shoulder pain with cross-body movements; treatment ranges from activity modification to surgery. Open → Distal Clavicle Osteolysis Open → Sternoclavicular Joint Disorders Problems where the collarbone meets the breastbone — arthritis, instability and the rare but serious posterior dislocation — and how each is managed. Open → AC Joint Stabilisation Surgical reconstruction for high-grade AC joint dislocation (Rockwood III-VI). Open → Distal Clavicle Excision (Mumford Procedure) A Mumford procedure (distal clavicle excision) removes the small worn outer tip of the collarbone to ease shoulder pain at the AC joint. What the keyhole operation involves and what recovery looks like. Open → ## Frozen shoulder & stiffness Frozen Shoulder Frozen shoulder (adhesive capsulitis) causes pain and stiffness, progressing through freezing, frozen, and thawing phases. Open → Capsular Release for Frozen Shoulder Arthroscopic capsular release frees a stiff shoulder (frozen shoulder) when physiotherapy and injections fail. Open → ## Nerve problems Suprascapular neuropathy Open → Suprascapular nerve decompression Open → Thoracic Outlet Syndrome Compression of the nerves and vessels at the base of the neck — the types, why diagnosis is tricky, and physio-first treatment. Open → ## More shoulder topics Scapulothoracic bursectomy Open → Snapping scapula Open → ## Recovery and rehabilitation Blood Thinners Around Surgery How anticoagulants and antiplatelets work, and why the timing of stopping each before surgery differs — platelet turnover, half-lives and clot risk. Open → Cast and splint care at home Looking after a plaster or splint at home — keeping it dry, elevation, keeping joints moving, and the urgent signs of a too-tight cast. Open → Constipation and gut care after surgery Why constipation is common after surgery (especially with strong painkillers) and how to prevent and manage it. Open → Daily life after hand, wrist or elbow surgery Keeping a hand or wrist dressing dry, elevation to control swelling, and one-handed living after hand, wrist or elbow surgery. Open → Daily life after shoulder surgery Washing, dressing, sleeping and managing day-to-day with the operated arm in a sling after shoulder surgery. Open → Driving After Shoulder and Arm Surgery: When Is It Safe and Legal? After most shoulder surgery, including rotator cuff repair, you usually cannot drive for about six weeks, and not while your arm is in a sling. When it is safe and legal to get back to the wheel after hand, wrist, elbow or shoulder surgery. Open → Eating well for healing Everyday food to support recovery after surgery — protein, energy, healing vitamins, and preventing constipation. Open → Fasting Before Surgery: What You Can Eat and Drink, and Why Why you must stop eating before an anaesthetic, when you can still sip water, and what can happen if you do not fast. The clear fasting rules that keep your stomach empty and your lungs safe during surgery. Open → Flying and travel after surgery Clot risk, cast tightness at altitude, fitness to fly and the practicalities of travelling after upper-limb surgery. Open → Hand therapy basics What to expect from hand therapy, how often you'll go, and what good rehab looks like. Open → Heat vs Ice When ice helps, when heat helps, and how to use either safely on the upper limb. Open → Is my wound infected? How to tell normal healing from a wound infection after surgery — the warning signs and when to seek help. Open → Looking after your wound Dressings, showering, and signs of infection after upper-limb surgery. Open → Managing pain after surgery What pain to expect, how to use pain relief well, and when to call. Open → Melatonin After Shoulder Surgery Why we prescribe melatonin after shoulder surgery, what the trial evidence shows, the dose we use, and what to expect from it. Open → Mind, Stress and Recovery How stress, low mood, anxiety and worry about pain affect recovery and surgical outcomes — and what helps. Open → Preparing for Surgery General checklist for the days before upper-limb surgery — fasting, what to bring, medications. Open → Preventing Blood Clots After Surgery Reducing the risk of deep vein thrombosis after upper-limb surgery — mobilisation, hydration, medication. Open → Returning to sport Phased return to sport after upper-limb surgery, and when contact sport is safe again. Open → Returning to work When you can return to desk, light, and heavy work after upper-limb surgery. Open → Scar Management Massage, silicone, sun protection and the 12-month timeline for surgical scars to soften and fade. Open → Sleep, Pain and Recovery How sleep and pain affect each other, why surgery and shoulder problems disturb sleep, and what helps you rest and recover. Open → Swelling and elevation after surgery Why a hand or arm swells after surgery, how elevation and gentle movement control it, and when swelling is a warning sign. Open → The day of your surgery What to expect on the day of day-case upper-limb surgery, from arrival and meeting the team to waking up and going home. Open → Wearing and Sleeping in an Arm Sling How to sleep in an arm sling, get the sling position right, and look after it after shoulder, elbow or wrist surgery, including whether to keep the sling on overnight. Open → Your shoulder nerve block The nerve block we use for shoulder surgery — how it numbs your arm, why it controls pain so well, and what to expect as it wears off. Open → Your wound check and stitch removal What happens at the post-op wound check, dissolvable vs removable stitches, what removal feels like, and when to seek help sooner. Open → Explore Shoulder in the evidence explorer → --- ### Acromioclavicular Joint Injury (Shoulder Separation) URL: https://www.cqupperlimb.com/education/shoulder/ac-joint-injury/ Region: shoulder · condition A shoulder separation from a fall on the point of the shoulder — grading, the bump that may remain, and when surgery is needed. ## What you're feeling This injury almost always starts with a fall directly onto the point of the shoulder: coming off a bike, a tackle or heavy contact in sport, or a simple trip onto a hard surface. Straight away the top of the shoulder is sore, and over the next day or two a tender lump or step often appears right at the tip, where your collarbone meets the shoulder. The area is painful to touch and to lift the arm, and reaching across your body or overhead can be especially uncomfortable. If you press on the lump, it can feel springy, as if pushing down on the end of the collarbone and feeling it bounce back up, a bit like a piano key. Many people instinctively cradle the arm, because letting it hang drags on the sore joint. This is what people mean by a "shoulder separation", and it is not the same as a dislocated shoulder, where the ball of the shoulder pops out of its socket. ## What's actually happening At the very top of your shoulder there is a small joint where the outer end of the collarbone (clavicle) meets a bony tip of the shoulder blade called the acromion. This is the acromioclavicular (AC) joint. It is held together by ligaments, both the ones around the joint itself and a set of strong ligaments a little lower down (the coracoclavicular, or CC, ligaments) that act like guy-ropes anchoring the collarbone down. A fall onto the point of the shoulder drives the shoulder blade downwards while the collarbone stays put, straining or tearing those ligaments. When only the joint's own ligaments are sprained, the collarbone stays more or less in place. When the stronger guy-rope ligaments tear as well, the collarbone is no longer held down and rides up, which is what creates the visible bump and step. Surgeons grade these injuries by how much damage there is, using a scale called the Rockwood classification, I to VI. Grades I and II are sprains with little or no displacement; grade III sits in between, with a noticeable bump but the shoulder still working reasonably well; and grades IV to VI are the high-grade injuries, where the collarbone is badly out of position. It is worth knowing this is a different problem from a worn-out, arthritic AC joint (wear-and-tear over years) and from a broken collarbone (both of which we cover separately). ## What we can do about it In our clinic, Dr Kieran Hirpara manages this injury by first confirming the diagnosis through a thorough assessment and imaging. The good news is that most AC joint injuries do not need surgery. Low-grade injuries (grades I, II and most grade III) are treated simply. A sling for comfort for a couple of weeks takes the drag off the joint and lets the irritation settle. Once the early pain eases, physiotherapy restores movement and rebuilds the muscles around the shoulder blade and shoulder. People generally regain good, often full, function and get back to work and sport. The one honest caveat is cosmetic: even after everything heals, the bump at the top of the shoulder often stays for good. It looks different from the other side, but it usually does not stop the shoulder working. Surgery is reserved for the injuries that need it. That means the high-grade injuries (grades IV, V and VI), where the collarbone is badly displaced, and the smaller group of lower-grade injuries that stay painful, weak or unstable despite proper rehab, particularly in people who do heavy manual or overhead work, or in serious athletes. An operation reconstructs the torn ligaments to pull the collarbone back down into its proper position and hold it while it heals. We talk through that separately under the AC joint stabilisation procedure. ## What to expect For the great majority of people with a low-grade injury, the story is reassuring. The sharp pain settles within a few weeks, and with physiotherapy the shoulder steadily regains its strength and range. Most return to their normal activities and sport, accepting that the bump may be a permanent reminder of the injury without limiting what the shoulder can do. Even some grade III injuries that look dramatic at first do well without surgery. The injuries that take longer are the high-grade ones, and the low-grade ones that simply don't settle. Here the question is whether reconstruction will give a more stable, stronger, less painful shoulder for the demands you place on it, and the answer depends a lot on your work, your sport and how the shoulder is behaving over the first weeks. There is good evidence that this decision is best made unhurried, giving the shoulder a fair trial before committing to surgery, while not leaving a clearly unstable, high-grade injury indefinitely. ## When to see someone - A fall onto the point of the shoulder that leaves it painful, with a tender lump or step at the top, worth having assessed, both to grade the injury and to rule out a broken collarbone. - An obvious, prominent bump with the arm feeling like it is dragging down: this suggests a higher-grade injury that needs proper assessment. - Pain or weakness that isn't settling after a few weeks of a sling and physiotherapy, especially if you do heavy or overhead work or play sport. - Skin under tension over the bump, a change in skin colour over it, or any sense the bone is pushing hard against the skin: get this looked at sooner. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. An AC joint injury is worth the extra reading because of a mismatch that sits at the centre of every decision about it: the operation reliably corrects what the X-ray shows, and reliably does not change how the shoulder ends up working. ### Surgery fixes the picture, not the outcome High-grade separations look alarming on a film, the collarbone sits visibly proud of the shoulder blade, and it is intuitive that putting it back must be better. Pooling 954 patients with acute high-grade dislocations, there was no clinical difference in functional outcome scores between operative and non-operative management. What did differ ran in both directions: the non-operative group returned to work more rapidly but accepted a poorer cosmetic result, while surgery achieved better radiographic reduction [1]. Narrowing to Rockwood type III, the grade where the argument is genuinely live, a 2025 review of 397 patients found no significant difference in patient-reported or objective function, with surgery improving joint reduction while adding the risk of surgical complications [2]. An earlier review of 646 shoulders reached the same place from a different angle: no significant difference in later arthritis or persistent pain, and a 14% recurrence rate in the surgical group [3]. Three independent bodies of evidence, one conclusion. The deformity is real, it is permanent without surgery, and correcting it does not measurably change what the shoulder can do. ### So the decision is about the bump, not the function That reframing is the practical value of the evidence. If the question is "will surgery make my shoulder work better", the honest answer is that it has not been shown to. If the question is "will surgery remove the step in my collarbone", the answer is usually yes, and for some people, in some occupations and some sports, that matters enough on its own. It is a legitimate reason to operate. It is simply a different reason from the one most people assume they are being offered. ### No technique has won, and one is measurably worse Once a decision to operate is made, the choice of construct attracts a great deal of attention and very little separation. Across 939 patients, subjective outcomes after surgical treatment were comparable for all modalities, but hook plate and K-wire fixation carried the highest complication rates, and the modified Weaver-Dunn the highest rate of unplanned reoperation [4]. Comparing the two techniques most often used today across 399 patients, suture button gave better functional scores and lower pain than hook plate, with no significant difference in operating time, complications or loss of reduction [5]. Reconstruction studies point the same way. In 4,473 patients, biological and synthetic reconstructions produced better functional scores than osteosynthesis [6], and in 1,020 patients anatomic reconstructions performed best, with arthroscopic approaches outperforming open ones [7]. The pattern is that the modern anatomic reconstructions cluster together and the older rigid implants trail. Within the modern group, the differences are small enough that surgeon familiarity is a reasonable basis for choosing. ### One in five has something else going on inside the joint This finding is worth knowing because it is invisible on the films that drive the diagnosis. Pooling 860 patients with surgically treated acute AC joint dislocations, approximately one in five had an associated intra-articular lesion requiring further intervention, most commonly labral or rotator cuff pathology, which is why the authors argue for arthroscopic inspection of the joint even when the reconstruction itself is done open [8]. It also offers an explanation for a frustrating minority of cases: the shoulder that stays painful after a technically sound reconstruction may have had a second injury all along. --- ### AC Joint Osteoarthritis URL: https://www.cqupperlimb.com/education/shoulder/ac-joint-osteoarthritis/ Region: shoulder · condition AC joint osteoarthritis causes localized shoulder pain with cross-body movements; treatment ranges from activity modification to surgery. ## What you're feeling The pain sits right on top of your shoulder, at the small joint where your collarbone meets the highest part of your shoulder blade. It often spreads towards the front of your shoulder or up into the muscle that runs from your neck to your shoulder. Lifting anything heavy brings it on, and lying on that side at night can wake you or make it hard to get comfortable. Pressing directly on that spot usually finds the tenderness. Reaching your arm across your chest, or lifting it right up and out to the side, tends to hurt at the joint. Daily tasks that load the top of the shoulder become awkward: carrying shopping bags at your side, lifting a heavy pan onto the stove, reaching up to a high shelf, or pulling a seatbelt across your body. The ache often flares after activity rather than during it, so a day of lifting or overhead work can leave you sore that evening and the next morning. Night pain on the affected side is common, and some people find they have to sleep on their back or the other side. One thing worth knowing: arthritis at this joint shows up on scans of many people who feel nothing at all. Most joints like this that look worn on an X-ray stay quiet, and a sore shoulder with a worn-looking joint does not always mean the joint is the cause. That is why your surgeon may suggest an injection of numbing medicine into the joint itself. If the pain settles for a short time afterwards, the joint is very likely the source of your trouble. If it does not, the wear on the scan is probably not what is hurting you, and treating it would be unlikely to help. If your shoulder pain is not settling over weeks, is getting worse, wakes you at night, or stops you using your arm or working, see your GP or ask for a specialist review. ## What's actually happening Your shoulder has a small joint where the outer end of your collarbone meets the tip of your shoulder blade. This is the AC joint, short for acromioclavicular joint. It is a moving joint, not a rigid weld. It shifts a few millimetres as your shoulder blade turns and slides during normal arm use, and it lets your shoulder blade and collarbone work as one connected piece. Strong ligaments hold it together, helped by the muscles that cover the top of your shoulder. Inside the joint sits a thin cushioning disc, a little like a gasket between two pieces of bone. From early middle age onwards this disc starts to wear, and the joint surfaces behind it wear with it. That is wear-and-tear arthritis, and at this joint it is very common. The wear usually begins quietly in your twenties and thirties and creeps along over the years. Heavy or repetitive lifting, especially overhead work, speeds it up. So can an old sprain or separation of the joint from a fall, even a mild one that seemed to heal. The catch is that a worn-looking joint does not always hurt. Many people have wear on their scans and no symptoms at all, and most joints that look worn stay quiet. So the pain you feel comes from the joint itself only when the wear, the raw surfaces, or the inflammation around it actually irritate the tissues there. That is why your symptoms sit right on top of the shoulder and flare after loading it. One less common version of this problem is called distal clavicle osteolysis. Here the outer end of the collarbone itself breaks down, with inflammation, small fractures in the bone, and bone loss. It is seen mostly in younger men who do heavy or repetitive lifting, and it leads to the same kind of arthritis in the joint. If wear becomes severe, bony spurs can grow near the joint and press on the tendon that runs under the roof of your shoulder, adding to the trouble. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We confirm what is going on with a careful history, an examination, and imaging where it is needed. For a long-standing problem like this, we usually try non-operative care first and consider surgery only when that has not given enough improvement. The first steps are ones you can take yourself. Resting the joint means easing back on the heavy lifting and overhead work that load the top of your shoulder. Ice can settle a flare-up after a busy day. Physiotherapy aims to settle the irritated joint and build the strength around your shoulder so daily tasks put less strain on it. Give these changes a fair run before judging them, since the ache often flares after activity rather than during it. If self-management is not enough, pain medication and anti-inflammatories can help. Anti-inflammatories are tablets that calm the inflammation in the joint as well as easing pain. We also use injections of cortisone, a strong anti-inflammatory medicine, placed into the joint itself. An injection can serve two purposes: it helps confirm that this joint is the source of your pain, and it can relieve the pain as treatment. About 47 in 100 people who have an injection still have a good result a year later. Surgery comes into the picture when pain persists despite these treatments. The operation removes a few millimetres of bone from the outer end of your collarbone, the half of the worn joint that sits on the collarbone side. With that worn surface gone, the two raw bone ends no longer grind against each other. It can be done through small cuts with a camera, or through a small open incision. If you have had a previous separation of this joint with lasting instability, we will talk that through with you carefully, because it changes how well this operation tends to work. Whether surgery is right for you is a decision we make together, weighing what you want your shoulder to do against what the operation involves. ## What to expect For most people, wear at this joint that shows up on a scan but causes no pain simply stays quiet. Over a seven-year course, 90% of joints like this that were pain-free to begin with never developed symptoms. So if your joint looks worn but does not hurt, there is a good chance it will keep behaving itself. When the joint does hurt, the course varies. Some people find the ache settles with rest, easing back on heavy lifting, and physiotherapy. Others find it comes and goes, flaring after a busy day and easing off when you settle down again. Without treatment, the pain tends to persist or keep returning whenever you load the top of your shoulder, because the wear in the joint does not reverse itself. If non-operative care does not give enough relief, an injection of cortisone into the joint helps some people. About 47 in 100 people who have an injection still have a good result a year later. That means for roughly half of people the relief wears off within the year, and the injection may need repeating or other steps considered. If pain persists despite these treatments, removing a few millimetres of bone from the outer end of your collarbone is an option your surgeon may discuss with you. The aim is to stop the two raw, worn surfaces grinding against each other. Recovery from that operation takes weeks to months, guided by your physiotherapist, and most people find the ache on top of the shoulder eases as the joint settles. What you can realistically expect over the coming months depends on which path you take. With sensible self-management and physiotherapy, many people get back to their normal activities with the ache settled to a level they can live with. If the joint keeps flaring despite a fair trial of these steps, it is worth going back to your GP or asking for a specialist review rather than pushing through the pain. ## When to see someone This is a wear-and-tear problem, not an emergency, so there are no same-day danger signs to watch for with this condition. What matters is whether the pain settles. See your GP if pain on top of your shoulder is not improving after a few weeks of rest from heavy lifting, or if it keeps waking you when you lie on that side. Ask for a specialist review if the ache is getting worse over weeks, stopping you working or using your arm normally, or if lifting and reaching across your body stay painful despite easing back. If your shoulder becomes hot, red, swollen and painful, especially with a fever, that is not arthritis and it needs same-day care at an emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Arthritis of the AC joint is worth the extra reading for an uncomfortable reason: it is extremely common on imaging, it is frequently blamed for shoulder pain, and the evidence that treating it helps is weaker than almost anything else on this site. ### The evidence does not establish that anything works A systematic review of the treatment of primary AC joint osteoarthritis pooled 1,902 patients and reached a conclusion that is rarely stated so plainly: the studies varied in indication, intervention and quality, and did not provide evidence that either non-operative or operative interventions are effective [1]. That is not the same as saying nothing helps. It means the trials that would demonstrate it have not been done to a standard that allows the claim. Distal clavicle excision is a long-established operation performed on the reasonable mechanical logic that removing the worn joint surface removes the pain, but "long-established and mechanically sensible" is not evidence, and it is worth knowing the difference when a decision is being made. ### Adding it to another operation does not improve that operation The most direct test comes from patients having something else done at the same time. Among 208 patients with rotator cuff tears, adding distal clavicle resection did not produce better clinical outcome scores or better range of motion [2]. This matters because that is exactly the circumstance in which the joint is most often resected, the surgeon is already inside the shoulder, the AC joint looks degenerate on imaging, and removing a few millimetres of bone is quick. The evidence says the patient does not measurably benefit. If it is proposed as an add-on to your cuff repair, that is a fair thing to ask about. ### Technique is not the interesting question Open versus arthroscopic resection has been compared repeatedly and the answer is consistent: similar functional and clinical outcomes with either approach across 319 patients [3], with an earlier comparison of 429 patients also favouring neither decisively [4]. When two quite different technical approaches produce the same result, the honest inference is that the technique is not what determines the outcome, patient selection is. ### Why selection is so difficult here The AC joint degenerates in almost everyone with age. It is a small, highly loaded joint with a thin disc that wears early, so a report describing AC joint degeneration on your scan is close to an expected finding after middle age rather than a diagnosis. There is a measurable structural correlate: in symptomatic degenerative AC joints, both the distal clavicle and the acromion are enlarged, whereas in asymptomatic people the relationship between the two is unchanged [5]. That is a useful hint that symptomatic and incidental degeneration differ structurally, but it is a group-level observation, not a test that can be applied to your shoulder. Practically, this is why a diagnostic injection into the joint carries real weight here. If local anaesthetic placed accurately into the AC joint abolishes the pain, the joint is likely the source. If it does not, degeneration on the scan is probably a bystander, and resecting it is unlikely to help, which is the situation the evidence above is warning about. --- ### AC Joint Stabilisation URL: https://www.cqupperlimb.com/education/shoulder/ac-joint-stabilisation/ Region: shoulder · operation Surgical reconstruction for high-grade AC joint dislocation (Rockwood III-VI). ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. The acromioclavicular joint sits at the outer end of your collarbone, where it meets the top of your shoulder. When this joint is badly torn out of place, we call it a high-grade separation. Surgery to hold the collarbone back in its normal position is called AC joint stabilisation. We usually suggest this operation for severe separations, where the collarbone has moved a long way out of place. Without surgery, these injuries often leave ongoing pain and limited shoulder function. For less severe injuries, we usually start with non-operative care such as a sling and gentle exercises. Most people with mild injuries regain full shoulder function within 4 to 6 weeks this way. Surgery comes into the picture when non-operative care has not given enough improvement, or when the injury is too severe for it to work. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We will examine your shoulder and arrange scans to work out how severe the injury is. The aim of this operation is to ease pain, restore stability, and help your shoulder work as it should. Whether surgery is right for you is a decision we make together. ## Before the operation In the lead-up to surgery, we will give you clear instructions to follow. You will need to stop eating and drinking seven hours before your operation. We ask for this so your place on the theatre list can be brought forward if the day runs early. If you take regular medications, bring a written list of everything you use, and we will tell you which ones to pause and when. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing that is easy to get on and off. We already have the scans of your shoulder, such as X-rays, and possibly an MRI or ultrasound, which we use to plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist, who will talk you through the plan for your comfort during the operation. This operation is done under general anaesthetic combined with a regional nerve block. The anaesthetist will meet you before the operation and talk you through both parts. Once you are ready, you will be taken into the operating theatre, where the operation is performed. When it is finished, you will wake up in the recovery area, where nurses will monitor you while the anaesthetic wears off. Once you are stable, you will either move to the ward or go home the same day, depending on the procedure and how your recovery is going. ## What the operation involves The operation is done through one cut that follows the outer end of your collarbone, at the top and front of your shoulder. Through this cut, your surgeon reaches the collarbone and the small bony hook of the shoulder blade beneath it, called the coracoid. The repair is held with a device called the Lockdown. It is a braided synthetic ligament with a loop at each end. Your surgeon passes it around the coracoid and threads it back through itself, then takes it behind the collarbone and fixes it to the front of the bone with a small screw and washer, like a tent peg. This holds the collarbone down in its normal position. Over the following months, your own tissue grows into the braid, so the repair becomes permanent. The cut is closed with stitches, and a dressing goes over the top. You will keep that dressing on for about 10 days. ## After the operation When you wake up, you will be in the recovery ward, and nurses will keep a close eye on you. Your arm will rest in a simple sling for comfort, which comes off for exercises and washing. You can move your hand, wrist, and elbow straight away, and gentle pendulum exercises start immediately. Most patients stay one night in hospital after this operation, though some are able to go home the same day. We will give you pain relief to keep you comfortable, and the nursing team will check on you regularly. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Please arrange for someone to stay with you for the first 24 hours after you get home. You will not be able to drive for at least six weeks; see our guide on Driving after upper-limb surgery. ## Recovery For the first few days your shoulder will be sore and may look puffy around the incision. This settles steadily. Pain relief keeps you comfortable, and resting your arm in the sling eases the pull on the repair. Ice packs, used as your physiotherapist advises, also help. You will move your hand, wrist, and elbow straight away, and gentle pendulum exercises begin immediately. Your physiotherapist will guide you through each stage. At first the exercises are gentle and passive, meaning your arm is moved for you. As healing progresses, you start moving the shoulder yourself, then begin strengthening work once your surgeon is happy with how the repair is settling. The sling stays on between exercises and comes off for washing and for your exercise sessions. Everyday life adjusts around the sling. Sleeping propped up on pillows is often more comfortable early on. You can manage most things at home with your other arm, but you should not lift, push, or reach with the operated arm until your surgeon clears you. Driving waits until your surgeon clears you at your review appointment, and never while you are in a sling; see our guide on Driving after upper-limb surgery. Recovery varies from person to person. Your timeline may differ, and your surgeon and physiotherapist will guide you at each step. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the collarbone can slip partway or fully out of its corrected position. You might notice a bump returning at the top of your shoulder, or a feeling that the joint is loose or shifting when you move. Tell your surgeon at your next review if you notice this. The repair can also fail in ways that only show on scans rather than in how the shoulder feels. Some of these changes never cause trouble and may not need any treatment at all. Your surgeon will keep an eye on them with check-up X-rays. Small breaks in the bone around the repair can happen, sometimes weeks or months later. This usually brings sudden pain and tenderness over the collarbone or near the top of the shoulder. Contact the clinic promptly if this happens. The small screw and washer holding the repair can cause problems, and metal implants used in some techniques can break or shift. A deep, aching pain or a new grinding feeling near the collarbone is worth reporting. Sometimes a further operation is needed to sort out a problem with the hardware. Infection is uncommon but needs quick attention. Watch for redness spreading out from the wound, increasing swelling, warmth, or oozing. A fever with any of these signs means you should call the clinic straight away, or go to the emergency department after hours. Nerve irritation can occur. This may feel like tingling, numbness, or weakness in part of the arm. Some nerve irritation settles on its own without treatment. Mention any new numbness or weakness at your review, or sooner if it is severe. Extra bone can sometimes form in the tissues around the joint as things heal. This may show on scans, and it does not always cause symptoms. If the area feels stiff or achy, bring it up with your surgeon. When a complication does happen, it can sometimes mean one or more further operations to fix it. Outcomes tend to be better when problems are caught early, so please speak up about anything unusual. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems are picked up early when you speak up. Call us if you have a fever, or if the wound becomes more red, swollen, or starts oozing. Call us if you get sudden severe pain over the collarbone or the top of your shoulder. Go to emergency if your calf becomes swollen or painful, or if you become short of breath. Go to emergency if you lose feeling in your arm or hand, or if you cannot move the arm at all. New numbness, tingling, weakness, or a bump returning at the top of your shoulder also deserve a call, even if they seem minor. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Acromioclavicular Joint Injury (Shoulder Separation) page. --- ### How your shoulder works URL: https://www.cqupperlimb.com/education/shoulder/anatomy/ Region: shoulder · anatomy Shoulder anatomy overview – bones (clavicle, scapula, humerus) and how they enable wide range of motion. ## The main parts Your shoulder is made of three bones. The collarbone (clavicle) runs from your breastbone out to your shoulder blade. The shoulder blade (scapula) is a flat bone that sits on the back of your chest and gives 17 muscles a place to attach. The upper arm bone (humerus) has a rounded top, the humeral head, which sits in a shallow socket on the shoulder blade. That ball-and-socket joint (the glenohumeral joint) gives your shoulder the greatest range of motion of any joint in your body. Because the socket is shallow, a ring of soft cartilage around its rim (the labrum) deepens it and helps keep the ball centred. Where your collarbone meets your shoulder blade there is a smaller joint (the acromioclavicular joint), and where it meets your breastbone there is another (the sternoclavicular joint). The sternoclavicular joint is the only true joint linking your arm to the rest of your skeleton. Ligaments, which are strong bands of tissue, hold these bones together. A loose bag of tissue (the joint capsule) surrounds the ball-and-socket joint, and several ligaments inside it tighten only when your arm reaches the ends of its range. They act like checkreins, stopping the ball from sliding too far in any direction. The capsule is normally roomy and relaxed, which is what lets your shoulder move so freely. Muscles and tendons do the moving. Four muscles on the shoulder blade form the rotator cuff, and their tendons wrap around the humeral head, holding it snugly in the socket as you lift and reach. The subscapularis sits at the front, the supraspinatus runs over the top, and the infraspinatus and teres minor cover the back. The big deltoid muscle caps the shoulder from the outside and powers your arm overhead. A tendon from the biceps also runs through the joint, held in its groove by small bands of tissue, and helps steady the shoulder. All of these parts work together. When one of them is injured or worn, the way your shoulder moves and feels can change. ## How it all works together Think of your shoulder as a golf ball balanced on a tee. The ball is the top of your arm bone, and the tee is the shallow socket on your shoulder blade. A golf ball on a tee would roll off, so your body adds helpers. A ring of cartilage around the socket rim makes it a little deeper, and the rotator cuff tendons wrap around the ball and press it gently into the socket as you move. This pressing action is what keeps the ball centred while you reach, lift and throw. The parts move against each other smoothly. The rounded top of your arm bone glides under an arch of bone and muscle above it, and a slippery layer between them lets the surfaces slide without catching. Ligaments around the joint only pull tight when your arm swings to the very ends of its range, like checkreins. In the middle of movement, it is the muscles that hold the ball steady. This teamwork is what lets you do things. You can reach up to a high shelf, grip a jar, turn your palm up to receive change, or swing a racket. The shoulder does not work alone. It depends on good posture and on muscles in your chest, back and arm doing their share, which is why shoulder exercises often involve more than the shoulder itself. Nerves and blood vessels supply all of these working parts. Nerves from the lower neck carry the signals that tell your shoulder muscles when to move, and they also report pain and position. Blood vessels bring oxygen to the muscles, tendons and bone, with several routes feeding the same area so the supply keeps flowing even if one path is squeezed. When all these parts work in step, your shoulder feels effortless. When one part is injured or worn, the others have to work harder, and that is often when pain or stiffness appears. ## Where things commonly go wrong Some parts of your shoulder take more strain than others. Knowing which parts are under the most load helps explain why certain problems are common. The rotator cuff tendons sit in a tight spot. Where the supraspinatus (the tendon over the top) and the subscapularis (the tendon at the front) attach, they cross paths with other soft tissues near the front of the joint. That crowded corner is a common site for tears. If the small bands holding the biceps tendon in its groove are torn there too, the biceps tendon can become unstable and slip. The labrum, the ring of cartilage that deepens your socket, is also vulnerable. It works hardest in the middle of your range of movement, keeping the ball centred. But when you throw overarm, your arm goes up and back into what is called the cocking position. In that position, the edge of the socket presses into the rotator cuff tendons. This pressing can cause tears on the underside of the cuff. Throwers who can rotate their arm back further are more likely to have this happen. The top and back part of the labrum, along with the back of the joint capsule (the loose bag around the joint), are the usual spots for injury in a throwing shoulder. If the shoulder blade and ball-and-socket joint stop moving in step with each other, those same parts can be strained. The acromioclavicular joint (where your collarbone meets the top of your shoulder blade) is usually hurt by a direct knock. A fall onto the point of your shoulder, with your arm held close to your side, is the common cause. The ligaments at that joint are the weakest link when force pushes down on the collarbone. Stronger support comes from the collarbone itself and the joint at your breastbone. Behind them sit very strong ligaments that act as a last line of defence. If those are overwhelmed, the force spreads to where the deltoid and trapezius muscles attach. Everyday work can strain your shoulder too. Forceful effort, awkward postures, repeated movements, vibrating power tools and cold conditions all play a part in workplace shoulder problems. Tasks needing constant arm movement create a steady load on the shoulder. Shoulder muscles tire quickly under that kind of load, and pain can appear within about 1 hour of holding still. ## The bottom line Your shoulder trades stability for freedom. The socket is shallow, so a ring of cartilage deepens it and the rotator cuff tendons press the ball gently into place as you move. That pressing works with your arm in any position, which is why the cuff matters so much. Ligaments only pull tight at the very ends of your range, so in the middle of movement it is the muscles doing the steadying. Where tendons and ligaments cross paths near the front of the joint, the tissues are crowded and prone to tearing. Overarm throwing, direct knocks on the point of the shoulder, and work that loads your arm steadily all place strain on these same structures. --- ### Anterior Shoulder Stabilisation URL: https://www.cqupperlimb.com/education/shoulder/anterior-shoulder-stabilisation/ Region: shoulder · operation Arthroscopic Bankart repair for anterior shoulder instability — distinct from open Latarjet. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a careful history, examine your shoulder, and arrange imaging if it is needed. Shoulder instability means the joint keeps slipping or coming out of place, usually towards the front. We usually try non-operative care first, such as changing your activities and physiotherapy. Surgery is considered when that has not given enough improvement, or when your shoulder keeps dislocating despite it. Anterior shoulder stabilisation is an operation that holds the shoulder joint firmly in place so it stops slipping out at the front. It is typically offered to people who have had repeated dislocations, often after a fall or injury with the arm out to the side and turned outwards. Your surgeon may have suggested it because your shoulder has not settled with other treatment, or because the injury pattern makes further dislocations likely. The aim is a stable shoulder that lets you move, work and play sport without fear of it coming out again. ## Before the operation In the weeks before surgery we arrange any imaging needed to plan the operation, such as X-rays, an MRI or an ultrasound scan. On the day, you will need to stop eating and drinking seven hours before your operation. We ask for seven hours rather than six so your time can be brought forward if the theatre list runs early. Your surgeon will tell you which of your usual medicines to stop and when, so bring a written list of everything you take. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing that is easy to put on over your shoulder. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. This operation is done under general anaesthetic combined with a regional nerve block. The anaesthetist will meet you before the operation and talk you through both parts. You are then taken into the operating theatre, where the operation is performed. When it is finished, you wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves This is a keyhole operation. Your surgeon makes several small cuts around your shoulder, including one at the back, and works with a small camera inside the joint. The camera shows the damaged tissue on a screen. The main problem is a ring of cartilage at the front of the socket that has torn away from the bone. Your surgeon reattaches this ring to the bone using small anchors placed into the socket, with stitches holding the tissue down. If a piece of bone has come away with the tissue, that can be repaired through the same cuts. If a dent in the ball of the joint is catching, your surgeon may also fill it by moving a small piece of nearby tissue into the joint. The cuts are closed with stitches, and a dressing goes over them. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You will wake up in the recovery area, then move to the ward. Nurses will keep your pain comfortable with tablets and adjust them if needed. Your arm rests in a simple sling for comfort, which comes off for exercises and washing. A nurse will show you gentle movements to start, and you will be up and walking the same day. Please have someone stay with you for the first 24 hours. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your shoulder will be sore and swollen, and the skin around it may look bruised. This settles gradually. Keeping your hand and elbow moving within what your sling allows helps, and resting your arm on pillows at night can ease the discomfort. Simple pain tablets, taken as directed, usually keep things comfortable. You will wear a simple sling for comfort. It comes off for your exercises and for washing. A physiotherapist will guide you through gentle movements early on, starting with small pendulum swings and slowly building up as pain allows. Over time the exercises grow to include more active movement, then strength work with resistance. You will do these at home most days, and your physiotherapist will check your progress and adjust the program as you go. Everyday tasks take some planning at first. You will not drive until your surgeon clears you, typically at the six-week review, and our driving guide explains this in more detail. Desk work and light daily tasks come back before heavier jobs. Sport, gym work and manual work wait until the shoulder is strong and your surgeon is happy with your movement and stability. Sleeping upright or on your back with pillows supporting the arm is often more comfortable early on, and most people find side sleeping easier as pain settles. Recovery varies from person to person. Your timeline may differ, and your surgeon and physiotherapist will guide you at each stage. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the shoulder can slip or come out of place again, even after a repair that went well. This may happen years later, often after a fall or during sport. If your shoulder dislocates and will not go back in, go to the emergency department. If it slips out and goes back in by itself, call the clinic so we can see you. Bring it up at your next review even if it settles. Infection is uncommon. Watch the wound for redness that spreads out from it, fluid or pus leaking from it, or a fever. Call the clinic the same day if you notice any of these. Pain that keeps getting worse despite your pain medicines also needs a same-day call. The shoulder can become stiff after surgery. You might notice tightness that limits lifting your arm, reaching behind your back, or getting dressed. Mention it at your review, as early treatment helps movement return. Nerves run close to the shoulder, so they can be irritated during surgery. Numbness and weakness in the first 24 hours after a nerve block are expected. Once the block has worn off, about 24 hours after surgery, call the clinic if your arm, hand or fingers stay numb, or if you cannot move them. Most nerve irritation settles on its own over time. A blood clot is rare but serious. Go to the emergency department if you have swelling or pain in your calf, or shortness of breath or chest pain. These can be signs of a blood clot. The small anchors and stitches used to hold the repair in place can occasionally cause problems, such as a clicking or grinding feeling, or pain from a piece of metal rubbing. Tell your surgeon at review if you notice this. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up early, and we would rather hear about them than have you worry at home. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it. Call us the same day too if your pain keeps getting worse despite your pain medicines. Go to the emergency department if you have swelling or pain in your calf, or shortness of breath or chest pain, as these can be signs of a blood clot. Once your nerve block has worn off, about 24 hours after surgery, call us if your arm, hand or fingers stay numb or you cannot move them. Numbness and weakness in the first 24 hours are expected. If your shoulder dislocates and will not go back in, go to the emergency department. If it slips out and goes back in by itself, call the clinic so we can see you. If you cannot reach us out of hours or on a weekend, go to your nearest emergency department. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Shoulder Instability page. --- ### Biceps Tendinopathy and Long-Head Rupture URL: https://www.cqupperlimb.com/education/shoulder/biceps-tendinopathy/ Region: shoulder · condition Front-of-shoulder biceps tendon pain and the "Popeye" long-head rupture — and why the rupture usually needs no surgery. ## What you're feeling The biceps is the muscle at the front of your upper arm. The long head of its tendon runs up over the top of the arm bone and into the shoulder joint, and this is the part that causes trouble here. The most common complaint is a deep, nagging pain at the front of the shoulder, often a few centimetres below the tip. It can ache when you reach overhead, lift, or carry, and it sometimes radiates down the front of the upper arm. Many people find it hard to point to one exact spot. Because the biceps tendon sits right beside the rotator cuff, this pain very often comes alongside rotator cuff problems, and the two can be difficult to tell apart without an examination. Sometimes there is a more dramatic event. The worn tendon can snap, usually in older people and often with surprisingly little pain. When this happens, the muscle belly drops down the arm and forms a soft bulge that looks like a small ball or a flexed muscle. This is the classic "Popeye" sign. It can be startling to see, but on its own it is rarely as serious as it looks. ## What's actually happening Tendons are tough cords that connect muscle to bone, and like any well-used rope they can fray with time. In biceps tendinopathy, the long head tendon becomes inflamed and worn where it travels through a narrow groove at the top of the arm bone and into the shoulder. That wear is what you feel as the front-of-shoulder pain. Because the tendon shares this crowded space with the rotator cuff, the two often wear together, which is why biceps pain and cuff pain so frequently travel as a pair. If that fraying continues, the tendon can eventually give way completely. When the long head ruptures, the muscle is no longer tethered at the top, so it slides down the arm and produces the Popeye bulge. Here is the reassuring part: the biceps actually has two anchors at the shoulder (the long head and the short head), and the short head stays intact. So when the long head goes, the arm keeps most of its strength, and the change is mainly in appearance. This is an important distinction. A proximal rupture (at the shoulder end) is usually a minor problem. A rupture at the other end of the muscle, at the elbow (a distal biceps rupture), is a very different situation: that one can cause real loss of strength and often needs surgical repair. The bulge can look similar, so it matters which end has actually torn. ## What we can do about it In our clinic, Dr Kieran Hirpara guides patients through a clear pathway that begins with a thorough assessment to confirm the diagnosis. We typically recommend starting with non-surgical care for long-standing issues, reserving surgery only when those measures have not provided enough relief. For biceps tendinopathy, the first steps are simple and non-surgical, and they settle most people: - Activity changes: easing off the overhead and heavy-lifting movements that aggravate it, while keeping the shoulder moving. - Physiotherapy: guided exercises to settle the tendon and rebalance the shoulder, especially when the rotator cuff is involved too. - Anti-inflammatory medication: a tablet to take the edge off pain and inflammation. - An injection: sometimes a corticosteroid injection around the tendon or in the shoulder is used to calm a stubborn flare. Surgery is reserved for ongoing pain that hasn't settled with these measures. When it is needed, there are two main options. The tendon can be cut so it no longer pulls on the sore area (a tenotomy), which often leaves a Popeye bulge but reliably relieves pain. Or it can be re-anchored lower down the arm bone (a tenodesis), which keeps the muscle's normal shape and avoids the bulge but involves a longer recovery. These procedures are frequently done at the same time as rotator cuff surgery, since the two problems so often occur together. For a proximal long-head rupture, the usual advice is no surgery at all. There is little loss of strength, and the bulge is mainly cosmetic. Some younger or more active people, or those bothered by the appearance or by muscle cramping, may choose a re-anchoring procedure, but for most people leaving it alone is the right call. ## What to expect Most biceps tendinopathy improves with patience and the right exercises. It can be slow (a few months rather than a few weeks), but the outlook is good, and the majority avoid surgery altogether. When the biceps problem is part of a wider rotator cuff issue, recovery follows the cuff, and treating both together gives the best result. If you have had a proximal long-head rupture and decided against surgery, you can expect the initial soreness to fade over a few weeks, your strength to return to near normal, and the Popeye bulge to remain as a permanent but harmless reminder. It does not get worse over time, and it does not need to be fixed. ## When to see someone - Front-of-shoulder pain that won't settle, especially with overhead reaching or lifting: worth assessing, as it often signals a biceps or rotator cuff problem that responds well to treatment. - A sudden bulge in the upper arm that comes with weakness: this needs to be looked at to confirm it is the harmless long head at the shoulder and not a tear at the elbow, which is a different injury that may need surgery. - A rupture in a younger or active person: even a proximal one is worth reviewing, both to be sure of the diagnosis and to discuss whether repair is worthwhile for you. - Persistent biceps cramping or aching after a known rupture: usually minor, but can be treated if it troubles you. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Problems with the long head of biceps are worth the extra reading because of an unusual situation in surgery: the standard treatments involve detaching a tendon whose function has never been convincingly demonstrated in a living shoulder, and the evidence says you do not miss it. ### A tendon with an unproven job The long head of biceps runs from the top of the shoulder socket, through the joint, down a groove in the upper arm bone. Because it passes directly through the joint, it has long been assumed to help hold the ball centred in the socket. The evidence for that is weaker than the assumption. Biomechanical studies indicate the tendon contributes to stability of the glenohumeral joint in all directions, but in vivo studies have not established this stabilising effect, and the physiological load required remains unknown [1]. This matters because it explains why the operations work. If the tendon were doing essential stabilising work, cutting it would have consequences. It appears not to. ### Cutting it and reattaching it give the same result The two operations are tenotomy, releasing the tendon and letting it retract, and tenodesis, releasing it and fixing it to the arm bone lower down. Tenodesis is the more involved procedure and is usually presented as the better one. Pooling 650 patients, there was no difference in post-operative functional outcome between tenotomy and tenodesis. The differences that emerged were confined to two things: a Popeye deformity, the muscle belly bunching in the upper arm, and cramping pain in the bicipital groove, both more frequent after tenotomy [2]. An earlier systematic review reached the same conclusion, finding comparably favourable results with the only major difference being the cosmetic deformity [3]. The decision is therefore not really about how well the arm will work. It is about appearance, cramping, and how much surgery you want, which is a more honest framing than "the better operation". ### And within tenodesis, the technical arguments do not separate A good deal of debate concerns where and how to fix the tendon. It does not appear to matter much. Across 707 patients, subpectoral and suprapectoral tenodesis produced similar improvements with no difference in treatment failure, though arthroscopic tenodesis was associated with more stiffness early after surgery [4]. Comparing arthroscopic with open across 476 patients, both gave satisfactory outcomes with no identifiable differences [5]. Laboratory work does show real differences in construct strength, interference screws and more sutures produce stronger repairs, and supra- and subpectoral fixation are biomechanically equivalent once confounders are controlled [6]. That strength does not translate into a measurable clinical gap, which is a recurring pattern in shoulder surgery and worth recognising when a technique is described as stronger. ### Diagnosis is the genuinely difficult part Because treatment options perform similarly, most of the uncertainty sits earlier, in deciding that the biceps tendon is the source of the pain at all. It sits alongside the rotator cuff, and symptoms overlap. Physical examination has been tested against what is actually found at arthroscopy. Performing the uppercut test together with tenderness over the bicipital groove has the highest combined sensitivity and specificity of the known manoeuvres [7]. That is useful precisely because it is a combination, no single test carries the diagnosis. The practical consequence is that a biceps problem is most confidently identified when examination findings, imaging and the pattern of symptoms agree. Where they do not, the tendon may be a bystander, and an operation on it is unlikely to solve the problem. --- ### Biceps Tenodesis URL: https://www.cqupperlimb.com/education/shoulder/biceps-tenodesis/ Region: shoulder · operation Biceps tenodesis and tenotomy — when, where (suprapectoral vs subpectoral) and what to expect afterwards. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your shoulder, and arrange imaging if it is needed to work out what is causing your pain. Biceps tenodesis is an operation that reattaches the long head of the biceps tendon, the tendon at the front of your shoulder, to a new spot on the arm bone. We usually suggest it when simpler treatment such as activity change and physiotherapy has not given you enough improvement, or when you are already having another shoulder operation and the biceps tendon is part of the problem. Most people reach a meaningful improvement between 5 and 8 months after the operation, and by 13 months the results are steady. The aim is to relieve your pain and help your shoulder work normally again. ## Before the operation Before your operation, we plan it around imaging such as X-ray, MRI or ultrasound, which we may have already arranged at your first visit. In the week before surgery, you will get clear instructions from our team. You will need to stop eating and drinking seven hours before your operation. We ask for seven hours rather than a shorter time so your surgery can be brought forward if the theatre list runs early. Tell us about all the medicines you take, including any blood thinners, and bring a written list with you on the day. Some medicines need to be paused before surgery, and we will tell you which ones and when. Arrange for someone to drive you home afterwards. Wear loose, comfortable clothing. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, the doctor who gives your anaesthetic, but most people do not need either. ## On the day On the day of your operation, you come to the hospital's surgical admissions unit. Our team checks you in and gets you ready for theatre. The anaesthetist will meet you before the operation and talk you through both parts. This operation is done under general anaesthetic combined with a regional nerve block. You are then taken into the operating theatre, where the operation is performed. When the operation is finished, you wake up in the recovery area. Nurses watch over you there while the anaesthetic wears off. Once you are stable, you either go to a ward or go home, depending on the operation you had and how your recovery is going. ## What the operation involves This is a keyhole operation. Your surgeon makes a few small cuts around your shoulder, including one at the back, and works with a small camera inside the joint. Through these cuts, the surgeon finds the long head of the biceps tendon, the tendon at the front of your shoulder that has been causing your pain. The surgeon releases the damaged tendon from its worn spot and reattaches it to a new place lower down on the arm bone. It is held there with a small anchor or screw placed into the bone. This gives the tendon a fresh, healthy spot to heal onto, a bit like moving a frayed rope to a stronger part of the post. The tendon stays attached to the bone, so the biceps muscle keeps its shape and strength. If you are having another shoulder operation at the same time, such as a rotator cuff repair, the biceps work is done through the same keyhole cuts while you are already in theatre. Your surgeon will talk this through with you beforehand. At the end, the instruments come out and the small cuts are closed with stitches. The stitches sit under a dressing, which our team will look after with you. You will go home with written instructions about your dressing and your first few days. The exact way the tendon is fixed can vary, and your surgeon chooses the method that suits your shoulder and your situation. What does not change is the goal: the sore part of the tendon is taken out of the joint and anchored to solid bone, so it can settle down and stop hurting. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You will wake up in the recovery ward, where nurses keep an eye on you and give you medicine to keep you comfortable. Your arm rests in a simple sling for support, which comes off for washing and exercises. Please arrange for someone to stay with you for the first 24 hours. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. You can move around the house from day one, but no driving for at least six weeks. Once your surgeon clears you, typically at the six-week review, you can drive again. See Driving after upper-limb surgery for details. ## Recovery For the first few days your shoulder will be sore and may feel swollen. This settles over the following weeks. Pain medicine, rest and ice help keep you comfortable. Your arm rests in a simple sling, which comes off for washing and for your exercises. You can move around the house from day one. Your physiotherapist will guide you through gentle movements at first, then build up your strength as the tendon heals. Strengthening that loads the biceps, such as bending the elbow against resistance or lifting with the arm straight out in front, waits until the tendon has healed firmly. Once your surgeon clears you, typically at the six-week review, you can drive again. See Driving after upper-limb surgery for details. Light daily tasks come back first. You will notice the pain easing as weeks pass, and everyday movements like dressing and reaching become easier. Heavier work, sport and gym activity return later, once your strength and movement have built up and your physiotherapist and surgeon are happy with your progress. Sleep can be uncomfortable at first; sleeping propped up in a chair or on your back often helps until the shoulder settles. Recovery varies from person to person. Your timeline may differ, and your surgeon and physiotherapist will guide you at each step. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Infection is a risk with any operation. You might notice redness that spreads out from the wound, fluid or pus leaking from it, or a fever. Call the clinic the same day if this happens. Most wound infections settle with wound care or antibiotics, but a few need further treatment. Nerves run close to the operating area, so a nerve can be irritated during surgery. This can feel like numbness, tingling or weakness in the arm or hand. Some numbness and weakness in the first 24 hours after your nerve block is expected and normal. Once the block has worn off, at about 24 hours, call the clinic if your arm, hand or fingers stay numb, or if you cannot move them. The shoulder can become stiff after this operation. You might find it hard to reach up, behind your back or out to the side, and movements may feel tight or blocked. Bring this up at your next review, as early movement with your physiotherapist helps loosen it. The screw or anchor holding the tendon can occasionally cause a problem. The tendon can be damaged where it is held, or the repair can fail, which may feel like a sudden pop, new weakness when bending the elbow, or the biceps balling up near the front of your shoulder. The bone of the upper arm can also rarely break near where the implant sits, which causes sudden severe pain, swelling and a change in the shape of the arm. Go to the emergency department if your arm changes shape suddenly or you cannot use it at all. For a pop or new weakness, call the clinic. Some people keep having pain at the front of the shoulder, or cramping in the biceps muscle, even after healing. Mention this at your review. If pain continues, a further operation is sometimes needed. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up in the first few weeks. Knowing what to watch for helps you act early. Go to the emergency department if you have swelling or pain in your calf, or shortness of breath or chest pain. These can be signs of a blood clot. Go also if your fingers or hand turn pale, cold, white, blue or dark, or if your arm changes shape suddenly and you cannot use it at all. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it. Call the same day too if pain keeps getting worse despite your pain medicines. Some numbness and weakness in the first 24 hours after your nerve block is expected and normal. Once the block has worn off, at about 24 hours, call the clinic if your arm, hand or fingers stay numb, or if you cannot move them. If you cannot reach the clinic, out of hours or on a weekend, go to your nearest emergency department. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Biceps Tendinopathy and Long-Head Rupture page. --- ### Calcific Tendinitis URL: https://www.cqupperlimb.com/education/shoulder/calcific-tendinitis/ Region: shoulder · condition Calcific tendinitis causes shoulder pain from calcium deposits; treatment ranges from observation to washing out the calcium. ## What you're feeling Calcific tendinitis means a small build-up of calcium inside one of the tendons of your rotator cuff, the group of tendons that hold and move your shoulder. The pain usually sits on the side or top of your shoulder, over the supraspinatus tendon, which is the tendon most often affected. Lifting your arm out to the side or overhead tends to make it worse, and reaching up to a high shelf or hanging washing can become hard work. The pain often flares at night, especially if you lie on that shoulder, and it can wake you. It may also catch you after activity or first thing in the morning. Some people find the pain comes in bouts, with quieter stretches in between, and it can drag on for months. That long stretch of discomfort can mean time off work and can wear down your quality of life. This condition is most common in women aged between 30 and 60, though it affects others too. The deposit itself is usually between 0.5 and 1.5 cm long, and most are dense rather than fluffy. In about 9% of people more than one tendon is affected, which can spread the pain around the shoulder. One thing worth knowing: a calcium deposit seen on a scan does not rule out a tear in the same tendon. If your pain is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your arm, see your GP or ask for a specialist review. ## What's actually happening Your rotator cuff is a group of four tendons that hold and move your shoulder. They slide through a narrow space under a small bony arch at the top of the shoulder, with a thin fluid-filled cushion between them. Think of the tendon as a rope running through a tight pulley. In calcific tendinitis, part of that rope changes. Cells inside the tendon slowly turn into cartilage-like cells, and calcium starts to settle into the changed tissue. This happens in stages: first the tendon changes, then the calcium forms and sits there, and finally the body breaks the deposit down and absorbs it. The process is active, not simple wear and tear, and it is different from the calcium build-up you might see in an older, worn-out tendon elsewhere. The stage matters because each one feels different. While the calcium is quietly sitting in the tendon, you may have little or no pain. When the body starts absorbing it, the pain often turns severe and sudden, and it can be worst at night. The deposit itself can also cause trouble by its size: as it swells inside the tight space, it can jam against the bony arch above, blocking smooth movement of the arm. That is why lifting your arm out to the side can feel stiff or blocked. The deposit sits most often in the supraspinatus tendon, about 1.5 to 2 cm from where it attaches to the top of the arm bone. That spot explains why the pain sits where it does, and why reaching overhead is the hardest movement. One more thing worth knowing: many people carry these deposits with no pain at all, and only about one third of deposits ever cause symptoms. So the calcium on your scan is a real finding, but whether it is the cause of your pain depends on the stage it is in and how your body is responding to it. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your first visit we take a history, examine your shoulder, and arrange imaging where it is needed. For a long-standing problem like this we usually try non-operative care first and consider surgery when that has not given enough improvement. The first step is simple: change the activities that stir the pain up, and give your shoulder a rest from overhead work. Physiotherapy aims to settle the pain and rebuild smooth, controlled movement in the arm. Give it a fair run before judging it, because this condition can drag on for months. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm, see your GP or ask for a specialist review. Anti-inflammatory medications are a common first-line treatment for the pain. If they are not enough, we can offer procedures that target the deposit itself. One option is shock wave therapy, where sound waves are directed at the calcium from outside the body to break the deposit down. It is noninvasive, meaning nothing pierces the skin, and it is done at a set strength and number of pulses to dislodge the calcium. Another option is ultrasound-guided needling, where a needle is placed into the deposit using ultrasound, a scan that shows live images of the tendon, to break up and draw out the calcium. Both approaches can relieve pain, restore function and clear the calcium. Needling can be repeated if symptoms persist, with at least six weeks between procedures. Surgery comes in when these treatments have not worked. It involves removing the calcium deposit from the tendon, and repairing the tendon as well if it is significantly involved. If your pain has not settled after a genuine trial of the options above, we will talk through whether surgery makes sense for you and decide together. ## What to expect The outlook for calcific tendinitis is, in most cases, a good one. Many people carry these deposits without ever knowing, and only about one third of them ever cause pain. When the deposit does cause symptoms, it has a good likelihood of resolving completely in the long term. Your body can absorb the calcium on its own, and that process is already under way from the moment the deposit forms. That said, the road there is not always quick. Symptoms can drag on for months, and that stretch of discomfort can mean time off work and a real dent in your quality of life. The pain often comes in bouts, with quieter stretches in between, and it can be severe and sudden when your body starts breaking the deposit down. Some deposits settle within months, others take longer, and there is no reliable way to predict exactly how yours will behave. Most people do well without an operation. Conservative care, meaning treatment that does not involve surgery, is the usual first choice, and it brings meaningful improvement for most people: 72% of people treated this way report a good or excellent result, whatever the size or position of the deposit. Shock wave therapy and ultrasound-guided needling both relieve pain and clear the calcium in many people, and both have strong safety records. Needling tends to work best when symptoms have been present for a shorter time and the deposit is smaller. If one of these procedures does not suit your particular deposit, we will talk through the other options with you. Surgery is reserved for people whose pain has not settled after a genuine trial of these treatments. It removes the calcium deposit from the tendon, and it gives a good result in 88.5% of people whose pain has resisted other treatment. Recovery after surgery is gradual: shoulder function improves slowly over the first six months, and most of the gain in comfort and movement builds over that time rather than arriving at once. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm, see your GP or ask for a specialist review. ## When to see someone Most calcium deposits settle on their own, and many cause no trouble at all. But this condition can drag on for months, and it can cost you time at work and wear down your quality of life. See your GP or ask for a specialist review if your shoulder pain is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your arm. Also mention it if the pain feels blocked or jammed when you lift your arm out to the side, as a swollen deposit can physically stop the tendon moving under the bony arch above it. One more thing worth raising: a calcium deposit on your scan does not rule out a tear in the same tendon, so a scan finding alone does not settle the diagnosis. If you cannot reach the clinic out of hours or on a weekend, go to your nearest emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Calcific tendinitis is worth the extra reading because it behaves unlike most shoulder conditions: the deposit is common in people with no pain at all, the body usually dissolves it without help, and the treatment that removes the calcium is not the one that relieves the pain fastest. ### The deposit is a common finding, not automatically a diagnosis A calcium deposit reported on your scan is easy to read as the cause of the problem, because it is visible and the pain is real. The prevalence data complicate that. Among 1,219 adults, deposits were present in 7.8% of people without symptoms and 42.5% of those with subacromial pain syndrome [1]. In a separate series of 302 shoulders, deposits were frequent in the general population and only about one third were painful [2]. So the deposit raises the probability that it is the source, substantially, but roughly one in thirteen painless shoulders has one too. What appears to shift a deposit from silent to symptomatic is partly size and position: the highest likelihood of genuinely symptomatic disease was in women aged 30 to 60 with subacromial pain and a deposit longer than 1.5 cm [1], and pain correlated with location in supraspinatus and with involvement of more than one tendon [2]. ### It usually dissolves, and that shapes everything The natural course is towards resorption, which is why so many treatments appear to work. The clearest illustration comes from a randomised trial in which every patient had needling and lavage and was then randomised to a steroid or saline injection: at twelve months the calcification had resorbed in 83% of the saline group and 74% of the steroid group [3]. Read that carefully, because it contains the counter-intuitive result. The steroid improved pain for six weeks and function for three months, and had no significant effect on whether the calcium disappeared [3]. Pain relief and calcium clearance are separate processes. A treatment can deliver one without the other, and the visible thing on the scan is not the thing driving the symptoms week to week. ### Which is why the non-operative options perform alike If the deposit largely resolves regardless, the treatments are competing to make the interval tolerable rather than to cure. That is what the comparisons show. Across 257 patients, physical therapy, corticosteroid injection and ultrasound-guided barbotage produced similar rates of avoiding surgery [4]. In 239 patients the same three approaches were largely successful, with physiotherapy alone carrying the highest failure rate [5]. Among the procedural options, high-energy shockwave therapy is the most thoroughly studied minimally invasive treatment and has been shown safe and effective in the short to medium term, while ultrasound-guided needling has not been shown superior to an ultrasound-guided subacromial injection [6]. Pooling 1,258 patients, shockwave, needling and arthroscopy all produced good clinical outcomes [7], and barbotage across 908 patients was safe with a high success rate but has never been compared head-to-head against the other major options [8]. ### What surgery adds, stated precisely Surgery is not without an advantage, and the size of it is worth quoting rather than characterising. Pooling 2,352 patients from randomised trials, surgical treatment produced larger improvement in functional scores and comparable pain reduction to non-operative treatment, particularly ultrasound-guided needling, with both routes achieving clinically significant improvement [9]. Among surgical techniques themselves there was no significant difference, and removing the deposit alone performed similarly to removing it plus a subacromial decompression [10]. The function-versus-pain split is the useful detail. If pain is the dominant complaint, the evidence does not clearly favour an operation. If stiffness and loss of function dominate and have persisted, it favours one more. ### The association most often missed Calcific tendinitis is not evenly distributed. In 102 patients, those with an associated endocrine disorder, thyroid disease and diabetes principally, developed symptoms at a younger age, had a significantly more protracted course, and more frequently required surgery [11]. This is worth raising with your GP if your course has been unusually long or began early, not because treating the endocrine condition resolves the shoulder, but because it changes what a realistic timeline looks like. Being told a condition is self-limiting is difficult to reconcile with two years of pain; the endocrine association is one explanation for why the usual reassurance does not fit every case. --- ### Capsular Release for Frozen Shoulder URL: https://www.cqupperlimb.com/education/shoulder/capsular-release/ Region: shoulder · operation Arthroscopic capsular release frees a stiff shoulder (frozen shoulder) when physiotherapy and injections fail. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your shoulder, and arrange imaging if it is needed to confirm the diagnosis. Frozen shoulder causes pain and stiffness because the capsule, the stretchy lining around the joint, becomes inflamed and tight. We usually begin with non-operative care such as physiotherapy, stretching and injections. Surgery is considered when that has not given enough improvement. Capsular release means cutting the tight parts of that lining so the shoulder can move freely again. We suggest it when a steroid injection has not given you enough relief, rather than making you wait a fixed number of months, and it is done as a keyhole operation through small incisions around the shoulder. Most people notice less pain and freer movement soon after surgery, and the operation aims to restore movement, ease pain and return your shoulder to everyday use. ## Before the operation Your surgeon will give you clear instructions in the weeks before surgery. You will need to stop eating and drinking for seven hours beforehand. We ask for seven rather than six so that your operation can be brought forward if the theatre list runs early. Tell your surgeon about all the medicines you take, including blood thinners, because some may need to be paused. Bring a written list of them on the day. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing that is easy to change out of. Imaging such as X-rays, an ultrasound or an MRI scan helps plan the operation and shows the condition of your shoulder. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You then meet the anaesthetist, the doctor who looks after your anaesthetic and pain relief. This operation is done under general anaesthetic combined with a regional nerve block. You will be fully asleep for the operation, and the block (an injection that numbs the nerves supplying the arm before you wake up) provides pain relief for the first 12 to 24 hours after surgery. The anaesthetist will meet you before the operation and talk you through both parts. You are then taken into the operating theatre, where the operation is performed. When it is finished, you wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves Your surgeon does this operation as a keyhole procedure. A few small cuts are made around your shoulder, including one at the back. A thin tube with a small camera goes inside the joint so the surgeon can see the capsule, the tight lining around the joint, on a screen. The tight bands of tissue are then cut to free the shoulder. The surgeon releases the tight parts of the lining, usually starting at the front and top of the shoulder and working down and around as far as the stiffness needs. Cutting one part of the capsule only frees movement in one direction, so the release goes as far as is needed; a less extensive release appears to do at least as well as dividing the whole capsule. Inflamed tissue inside the joint can also be cleaned away. Care is taken near nerves that run close to the bottom of the joint, and the release is done in layers to protect them. Once the tight tissue has been released, your shoulder is gently moved to check the new range of motion. The small cuts are then closed with stitches, and a dressing is placed over them. The aim is simple: cut what is tight so the joint can move freely again. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You wake up in the recovery area, then move to the ward. You may have a simple sling for comfort for the first day or two; there is no repair to protect, so you can use the arm freely. A physiotherapist will show you the movements to start straight away, and you keep doing them through the day. Pain relief is planned before you wake up, so most people find the first day or two manageable. Someone should stay with you for the first 24 hours. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Most people notice a change straight away. The tight, catching pain that made sleep and dressing difficult is often much less from the first days. Your arm will still be sore, and the shoulder may feel bruised and swollen where the work was done. This settles over the first couple of weeks. Keeping up your movements, using the pain relief you have been given, and using the arm freely between exercise times all help. Your days will centre on simple, frequent exercise. A physiotherapist will show you the first movements before you leave hospital, and you repeat them through the day to keep the new motion from stiffening up again. Your physiotherapist then guides your program, building from gentle assisted stretches to movements you do yourself. Any sling is for comfort only, in the first day or two. You can move around the house freely, but wait until your surgeon clears you before driving, typically at the six-week review. Our guide to driving after upper-limb surgery explains this in more detail. As movement returns, everyday tasks come back in stages: reaching behind you, lifting your arm overhead, then returning to work and the activities you enjoy. Recovery varies from person to person, and your timeline may differ. Your surgeon and physiotherapist will guide you at each review. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The small cuts around your shoulder can become infected. Watch for redness that spreads out from a wound, swelling that gets worse, or fluid leaking from the site. A deep, throbbing pain that does not ease with simple painkillers is another warning sign. If you notice any of these, call the clinic rather than waiting for your next visit. Infection caught early usually settles with drainage and a course of antibiotic tablets. Nerves run close to the shoulder, and surgery near them can cause temporary irritation. You might notice tingling, pins and needles, or patches of numbness in the arm. Some people find part of the arm feels weak or slow to respond. These changes are usually temporary and settle on their own over days to months. Mention any new numbness or tingling at your review, or call the clinic if it appears suddenly. The bone and the smooth lining of the joint can be injured during the operation. You would notice this as pain that is different from the usual post-operative soreness, or a clicking or grinding feeling when you move. Bring this up at your next review so it can be checked. The rotator cuff, the group of tendons that help you lift and rotate your arm, can also be affected. This feels like a deep ache at the side of the shoulder, with weakness when lifting your arm or reaching overhead. Simple tasks like getting dressed may feel harder than expected. Tell your surgeon or physiotherapist if this does not improve as expected, so they can examine it and adjust your program. If anything worries you between reviews, call the clinic. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call the clinic straight away if you have a fever, or if redness, swelling or fluid leaking from a wound gets worse. Call us if you notice sudden severe pain, new numbness or tingling, or if you cannot move your arm. Go to emergency if you have calf swelling or pain, or shortness of breath, as these can signal a blood clot. If anything worries you and you are not sure, call us. We would rather hear about it early. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Frozen Shoulder page. --- ### Clavicle Fracture Fixation URL: https://www.cqupperlimb.com/education/shoulder/clavicle-fixation/ Region: shoulder · operation Clavicle fixation (ORIF) — restoring alignment and stability for displaced clavicle fractures. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At a clinic visit we take your history, examine you, and arrange imaging if it is needed. X-rays usually show where the collarbone is broken and how far the pieces have moved. The collarbone (clavicle) can break in its middle third or nearer either end. Many of these fractures heal well without surgery, so we usually start with non-operative care such as rest in a sling and physiotherapy. For adults, we consider surgery when the break is significantly displaced, for example shortened by 2 cm, fully shifted out of place, or broken into several pieces. Surgery may also be suggested if a fracture has failed to heal, or has healed in a poor position. In adolescents, most collarbone fractures are treated without surgery. The operation aims to hold the bone steady so it can join together, ease pain, and restore shoulder strength and movement. ## Before the operation In the days before surgery, we will confirm the plan with you and answer any questions. You will need to stop eating and drinking for seven hours before your operation. We ask for a slightly longer fast than some hospitals so your surgery can be brought forward if the theatre list runs early. If you take regular medications, bring a written list of them and we will tell you which ones to pause. Most people do not need any special tests before this operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing that is easy to change out of. ## On the day You will come to the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist, a doctor who looks after your sleep and pain control during the operation. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. When the operation is finished, you will wake up in the recovery area. Nurses will stay with you and monitor you while the anaesthetic wears off. Once you are stable, you will either move to a ward or go home the same day, depending on the procedure and how your recovery is going. If you are going home, the person you arranged to drive you will take you there. ## What the operation involves This is an open operation done through a single cut over the area of the collarbone that is broken. You will be positioned in a semi-sitting, beach-chair style position on the operating table, with a small pad behind your shoulder to lift it slightly. This gives your surgeon a clear view and a free path to work on the bone. Your surgeon will move the broken pieces back into their normal position and hold them there with a plate and screws. The plate is shaped to follow the natural S-shaped curve of the collarbone, so it sits snugly against the bone. Small screws pass through the plate and into the bone on each side of the break to keep everything steady while it heals. If the bone has broken into several pieces, a small screw may be used to pull a loose fragment back into line before the plate is fitted. If the fracture is near the outer end of the collarbone, your surgeon may add strong stitched supports that run between the collarbone and a nearby bone of the shoulder. These help hold the outer fragment steady while it joins together. If the fracture has failed to heal in the past, your surgeon may also place some extra bone graft material around the break to encourage it to join. Once the bone is held firmly, your surgeon will check that everything is stable and then close the cut with stitches. A dressing goes over the wound before you leave theatre. The whole operation is planned beforehand using X-rays of your collarbone, which show how far the pieces have moved and how many there are. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You will wake up in the recovery area, then move to a ward when you are stable. Your arm will rest in a simple sling for comfort, which comes off for exercises and washing. Nurses will check your pain regularly and give you medication to keep it under control. Someone should stay with you for the first 24 hours after you go home. Keep the sling on when you are up and about, and move around the house in short spells rather than staying still. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your shoulder will be sore and the area over your collarbone will be swollen and may look bruised. This is a normal part of healing. Rest, keeping your arm in the sling, and taking your pain medication as directed will help settle it. Most people find the pain eases steadily over the first couple of weeks as the swelling goes down. Your arm rests in a simple sling for comfort, which comes off for your exercises and for washing. Your physiotherapist will guide you through gentle movements early on, then build up your strength and range of motion as the bone joins. Around the house you can manage light tasks with your other hand, but avoid lifting with the sore arm, reaching overhead, or leaning on it until you are told it is safe. Sleeping propped up on some pillows is often more comfortable at first. As the swelling settles and movement returns, everyday life gets easier. You will be able to dress yourself, write, and use a keyboard well before you can lift anything heavy. Once your surgeon clears you to drive, typically at the six-week review, you can get back behind the wheel; our guide on driving after upper-limb surgery explains what is involved. Return to work and sport depends on what your job or sport involves, and your surgeon will talk you through it as you heal. Everyone heals at their own pace, so your timeline may differ. Your surgeon and physiotherapist will guide you at each review and adjust the plan to suit how you are going. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Infection is the main thing we watch for after surgery. You might notice a deep, throbbing pain that does not ease with simple painkillers, redness that spreads out from the wound, or fluid leaking from it. Sometimes you feel hot and shivery. Tell us straight away if you see any of these signs, as infection needs prompt treatment. The plate and screws sit close to the skin over the collarbone, so they can be felt through it. Some people find the metal rubs or catches, especially when lying on that side or carrying a bag strap across the shoulder. If this irritation becomes bothersome, the hardware can be removed in a later operation. Bring it up at your review rather than putting up with it. Numbness near the scar is common. The small skin nerves around the collarbone are often stretched during surgery, leaving a patch of numbness or tingling below the incision. This is usually something you notice rather than something that limits you, but mention it at your next appointment so it goes on record. Rarely, surgery can affect the bigger nerves or blood vessels under the collarbone. Warning signs include sudden weakness or pins and needles down the whole arm, or the arm looking pale, cold or swollen. These need urgent attention, so go to the emergency department if they come on. The bone itself can sometimes fail to join, or join in a poorer position than hoped. You would notice ongoing pain and weakness at the fracture site that does not improve as expected. Tell us at a review if the shoulder is not settling the way we discussed. Wound problems such as gapping, thickened or tender scarring can occur, and a collection of blood under the wound can cause sudden swelling in the first days. Contact the clinic about any wound concern. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if you have a fever, or if the skin around your wound becomes more red, swollen or starts leaking fluid. Call us if your pain suddenly gets worse or does not ease with your pain medication. Go to emergency if you have calf pain or swelling, or shortness of breath, as these can be signs of a blood clot. Go to emergency if your arm goes numb, feels cold or pale, or you cannot move it. If you are worried about anything at all, call the clinic. We would rather hear about it early. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Clavicle Fracture page. --- ### Clavicle Fracture URL: https://www.cqupperlimb.com/education/shoulder/clavicle-fracture/ Region: shoulder · condition Clavicle fractures — when conservative management is fine and when fixation is indicated. ## What you're feeling A broken collarbone usually happens from a fall onto the shoulder or a direct blow to it. Sport, cycling and road accidents are common causes. The collarbone sits just under the skin at the front of your shoulder, so the break often shows as a lump or a change in shape. If the bone shifts, one piece is pulled up by a muscle in your neck while the weight of your arm pulls the other piece down. That can leave a visible bump along the bone. The pain starts straight away and is usually sharp. You may feel sick or breathless for a few minutes. The shoulder may look swollen and bruised, and the shape may look different to your other side. You will probably not want to move your arm, and simple things like dressing, lifting a bag or sleeping on that side hurt. Most breaks are in the middle of the bone. About 80% happen there, with about 15% at the outer end near the shoulder and 5% at the inner end near the breastbone. In the first days, the pain is worst with movement and at night. Finding a comfortable sleeping position is often the hardest part. Over the next weeks, the pain settles as the bone starts to knit together. The lump where the bone healed may stay, but it usually bothers people less over time. A few warning signs need fast action. Go to the emergency department the same day if the skin over the break is broken or the bone is showing, if your hand or fingers turn pale, cold, white or blue, or if you suddenly lose feeling or movement in your arm after the injury. These are rare, but they need checking straight away. See your GP or ask for a specialist review if pain is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your arm. ## What's actually happening Your collarbone is a slender strut that links your breastbone to your shoulder blade. It is the frame that holds your shoulder out from your chest, so when it snaps, the whole shoulder loses its support. The break usually happens where the bone is narrowest and has the least muscle around it, which is why most breaks are in the middle. Once the bone breaks, muscles take over and pull the pieces apart. A muscle in your neck lifts the inner piece up, while the weight of your arm drags the outer piece down and in towards your chest. Think of a ridge tent pole that has snapped in the middle: the two halves splay apart, and the canvas sags. That is why your shoulder looks dropped and lumpy, and why the arm does not work normally yet. The bone cannot hold the shoulder steady until it has knitted back together. Bone heals by knitting new bone across the break, a bit like glue setting in a joint. This takes weeks, and the pieces need to stay still while it happens. If the pieces sit apart or overlap, the bone may knit in a shortened, angled position. That leaves a permanent bump, and it can shorten the shoulder slightly. Most people still get good function, but some are bothered by the shape or by skin rubbing over the bump. Where the break sits changes the picture. Breaks in the middle usually knit well with a sling and time. Breaks at the outer end, near the shoulder, are different: the broken piece is small and the ligaments that hold it are often torn, so that piece is more likely to fail to heal at all. Breaks at the inner end near the breastbone are uncommon and usually come from bigger accidents. Your surgeon will look at how far the pieces have shifted and talk you through whether rest alone or surgery gives you the better chance of a straight, healed bone. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. The right choice depends on where the bone broke, how far the pieces have shifted, and what your arm needs to do. Some breaks heal well without an operation, and others need surgery soon after the injury, so prompt assessment matters. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. Many breaks are treated without surgery. If the pieces sit close together, we support the arm in a sling while the pain settles, which usually takes 1 to 3 weeks. Once the pain eases, we encourage you to start moving the shoulder, and your physiotherapist guides you as the bone knits. A simple sling is more comfortable than a figure-of-eight bandage, which causes more pain and does not hold the bone in a better position. Breaks at the inner end near the breastbone are almost always treated this way too, with a sling for comfort and shoulder movement kept still for 2 to 6 weeks. Contact sport waits at least 2 to 3 months so the bone can heal fully. Surgery is recommended from the start when the break is severe. If the bone has shortened by 2 cm or more, shifted by its full width, or broken into several pieces, an operation holds the pieces in a normal position while they heal. It also suits some injuries with damage to nerves or blood vessels, and people who need their arm working again quickly. The operation uses a plate shaped to fit the collarbone, held with screws. Surgery makes the bone more likely to heal and lets you use the arm sooner. The choice is genuinely shared: some breaks can heal without surgery, but the bone may knit shorter or angled, leaving a permanent bump. Both paths share the same early weeks. Pain relief keeps you comfortable, and finding a way to sleep is often the hardest part. You protect the arm while the bone knits, then rebuild strength and movement with your physiotherapist at the right stage. ## What to expect Most broken collarbones heal well. With a sling and time, the bone knits across the break over weeks, and the pain settles as it does. Your physiotherapist guides you back into shoulder movement once the early pain eases, then rebuilding strength follows. Daily tasks like dressing and lifting come back gradually as the bone knits. Contact sport waits at least 2 to 3 months so the bone can heal fully. Ninety-five percent of collarbone fractures heal without trouble. Some things can slow or complicate healing. If the bone has shortened by more than 2 cm, there is a higher chance it fails to knit at all, or knits in a shortened position that leaves pain and weakness when you move your shoulder. A break at the outer end of the bone is more likely to fail to heal than one in the middle. The healed bone may also sit angled or shortened, leaving a permanent bump. In children, the bone usually remodels itself and the shape settles. In adults, a slight change in shape usually has to be accepted unless the bump is very noticeable or rubs on the skin. Surgery holds the pieces still in a normal position while they heal, so the bone is more likely to knit and you can use your arm sooner. People who have surgery often get back to work earlier than those who rest the arm. The main trade-off is that surgery carries its own risks. The plate or screws can irritate the skin over the collarbone, and some people have numbness around the scar. A small number of people need another operation to remove the metal once the bone has healed. Overall, about 8 in 100 people who have collarbone surgery have a complication in the first 30 days. Whichever path you take, the shoulder can feel stiff and weak for weeks while you rebuild it. If pain is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your arm, see your GP or ask for a specialist review. ## When to see someone Most broken collarbones are seen soon after the injury, usually at an emergency department or by your GP. Seek urgent care if the skin over the break is broken, if your hand or fingers turn pale, cold, white or blue, or if you suddenly lose feeling or movement in your arm after the injury. These signs need the emergency department the same day. An obvious deformity along the collarbone also needs prompt assessment. Once you have been seen, healing takes weeks. See your GP or ask for a specialist review if pain is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your arm. The same applies if swelling, movement or strength are not improving week on week as the bone knits. If you cannot reach the clinic out of hours or on a weekend, go to your nearest emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Clavicle fracture is worth the extra reading because surgery reliably delivers one thing, union, and the evidence that it delivers a better shoulder is considerably weaker than that. ### Surgery gets the bone to heal; the function difference is smaller The comparison has been done many times, and the results are consistent once read carefully. Across 1,760 patients, surgical treatment of midshaft clavicle fractures produced fewer nonunions, fewer malunions, and an accelerated return to work [1]. But the outcome that matters to most people separates less. In 1,965 patients, surgery led to a greater likelihood of union at one year while not increasing functional scores by amounts patients were likely to consider clinically important [2]. Both statements are true simultaneously, and the distinction between them is the whole decision. Surgery makes the bone heal more reliably and gets you back to work sooner. It has not been shown to leave you with a better shoulder a year later. ### Which makes nonunion risk the thing to estimate If union is the main benefit, then the sensible question is how likely your fracture is to fail to unite without surgery, because that is the risk surgery removes. One factor is quantified and modifiable. Smoking confers a risk ratio of 3.68 for nonunion in displaced middle-third clavicle fractures treated conservatively, and the authors recommend patients be informed of this and offered cessation support [3]. A near-fourfold increase is large enough to change the calculation. For a smoker with a displaced fracture, the non-operative route carries a materially different risk than the same fracture in a non-smoker, and stopping smoking is an intervention available immediately, with no incision. ### The fracture at the outer end behaves differently Fractures at the outer end of the collarbone, near the shoulder, are a separate problem: the fragment is small and the ligaments that would normally hold it are often disrupted, so nonunion rates are higher. Comparing fixation methods across 2,284 patients, hook plates produced significantly lower Constant-Murley scores and higher complication and revision rates than coracoclavicular fixation, with no difference in union rate, while non-operatively treated patients showed good functional outcomes [4]. Two things follow. Among operations, the hook plate underperforms, consistent with what the AC joint literature shows for the same implant. And non-operative treatment of these fractures produces good function despite the higher nonunion rate, which suggests a nonunion here is often better tolerated than the term implies. ### What a malunion actually costs Because surgery's functional advantage is small, it is worth knowing what accepting a malunion means. A clavicle healed short and angled leaves a visible bump and shortens the shoulder girdle slightly. Most people accommodate this without measurable loss. The cosmetic change is permanent and genuine, and for some people it is reason enough. That is a legitimate basis for choosing surgery, it is simply a different basis from expecting the shoulder to work better. --- ### Comprehensive Arthroscopic Management (CAM) URL: https://www.cqupperlimb.com/education/shoulder/comprehensive-arthroscopic-management/ Region: shoulder · operation The Comprehensive Arthroscopic Management (CAM) procedure — a joint-preserving arthroscopic alternative to arthroplasty for glenohumeral osteoarthritis, combining debridement, capsular release, osteophyte excision, microfracture, loose-body removal and axillary nerve neurolysis. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We assess you with a history, an examination, and imaging where needed. For wear-and-tear arthritis of the shoulder, we usually try non-operative care first: changing your activities, physiotherapy, anti-inflammatory medicine, and injections. Surgery is considered when these have not given enough improvement. Comprehensive Arthroscopic Management (CAM) is a keyhole operation that treats the damaged surfaces and soft tissues inside the shoulder joint. It is typically offered to younger, active people who have advanced arthritis but want to keep their own joint and delay a shoulder replacement. Some people with milder arthritis and significant pain may also be suitable. The operation aims to reduce pain and improve how your shoulder moves and works. In studies, 76.9% of people who had this operation still had their own joint at a minimum of 5 years afterwards. We will discuss whether it suits you, and you share in that decision. ## Before the operation Before the day of surgery, your surgeon will give you clear instructions to follow. You will need to stop eating and drinking seven hours beforehand. This allows room to bring your operation forward if the theatre list runs early. Some medicines may need to be paused, and your surgeon will tell you which ones and for how long. Bring a written list of everything you take, including tablets, injections and natural remedies. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing that is easy to put on over your shoulder. Imaging such as X-rays, MRI or ultrasound may be needed to plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will not go to a ward first. The anaesthetist will meet you before the operation and talk you through both parts. This operation is done under general anaesthetic combined with a regional nerve block. You will be fully asleep for the operation, and the block (an injection that numbs the nerves supplying the arm before you wake up) provides pain relief for the first 12 to 24 hours after surgery. You are then taken into the operating theatre, where the operation is performed. You will wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. Because the nerve block can numb part of your arm for the first 12 to 24 hours, you will need someone to drive you home, as set out in the previous section. ## What the operation involves CAM is a keyhole operation. Your surgeon makes a few small cuts, each about 1 cm, around the shoulder. A thin camera and small instruments go through these cuts to work inside the joint. Once inside, your surgeon cleans out the joint. This can include removing loose fragments of cartilage or bone, smoothing the worn joint surfaces, and clearing inflamed tissue. Tight tissue around the joint is released so the shoulder can move more freely. If a nerve at the front of the shoulder is being squeezed by scar tissue, it is freed. If the tendon at the top of the biceps muscle is worn, it is anchored down into the upper arm bone so it can no longer cause pain. Small holes are made in the bone where cartilage is worn away, which encourages new scar-like tissue to grow and cushion the joint. Bone spurs on the lower part of the ball of the joint are trimmed away. The small cuts are closed with stitches and covered with a dressing. You will go home with instructions about caring for the shoulder, and the dressing stays on for about 10 days. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You will wake up in the recovery area, then move to the ward. Your arm may feel numb or heavy for the first 12 to 24 hours because of the nerve block. As it wears off, you may feel some discomfort, and the nurses will give you pain relief to keep this manageable. You will go home with your arm supported in a sling. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Most people can walk around and do light tasks at home straight away. Please arrange for someone to stay with you for the first 24 hours. ## Recovery For the first day or two, your arm will feel numb and heavy from the nerve block. As that wears off, expect some soreness and swelling around the shoulder. Rest, ice packs and the pain relief plan we give you will keep this manageable. Most people find the discomfort settles steadily over the first couple of weeks. You will go home with your arm in a sling. Your physiotherapist will guide you through gentle movements early on, then build up to strength work as your shoulder allows. You can walk around and do light tasks at home straight away, but you will need help with things like dressing and reaching overhead at first. Sleeping upright or propped on pillows is often more comfortable in the early days. Keep the dressing dry and leave it alone; we will review it with you. Recovery happens in stages, and each one is anchored on what your shoulder can do rather than a date on a calendar. As the swelling settles and movement returns, daily tasks become easier. Once your surgeon clears you, typically at the six-week review, you can drive again; see our guide on Driving after upper-limb surgery. Strengthening comes last, once your shoulder tolerates it without a flare of pain. Everyone heals at their own pace, so your timeline may differ. Your surgeon and physiotherapist will check your progress at each visit and adjust the plan if needed. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Keyhole shoulder surgery has a low rate of complications overall. Even so, it helps to know what to watch for in the first weeks. If you already have carpal tunnel syndrome or tendon inflammation in your fingers or hand, tell us before your operation. These conditions make hand and finger problems after surgery more likely. Swelling in the hand can do the same. You might notice tingling, numbness or swelling in your fingers that was not there before. Mention it at your next review, or call the clinic if it gets worse quickly. Stiffness is the most common problem after keyhole shoulder surgery. Your shoulder may feel tight and hard to move, and the tightness may not ease with rest. If simple movements stay painful and restricted after the first couple of weeks, bring it up at your review. Most stiffness settles on its own without another operation. Having arthritis in the same shoulder raises the chance of problems, both soon after surgery and later on. This is one reason we talk through the options with you carefully before deciding on this operation. During keyhole surgery, small tools carry the stitches through the tissue. One of these tools can occasionally break, leaving a small piece inside the joint. You would not usually feel this yourself. It is something your surgeon watches for during the operation and manages there. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most people recover without problems, but some symptoms need urgent attention. Call us straight away if you have a fever, or if the skin around the wounds becomes increasingly red or starts discharging fluid. Go to emergency if you have sudden severe pain, swelling in your calf, or shortness of breath. Call us if your hand or arm loses feeling, or if you cannot move it at all. If you are unsure whether a symptom is serious, call the clinic and we will help you decide. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Shoulder Arthritis page. --- ### Cuff Arthropathy URL: https://www.cqupperlimb.com/education/shoulder/cuff-arthropathy/ Region: shoulder · condition Rotator cuff arthropathy: shoulder arthritis following a long-standing, massive rotator cuff tear and its impact on function. ## What you're feeling Cuff arthropathy is arthritis in the shoulder that develops after a long-standing rotator cuff tear. The rotator cuff is the group of tendons that holds the ball of the shoulder joint centred while you lift your arm. When those tendons are gone, the joint wears in a way it was never designed to, and that wearing is what you are feeling. The pain is usually deep in the shoulder itself, at the point where the ball meets the socket. It tends to sit on the outside of the upper arm as well. Lifting your arm overhead, reaching out to a shelf, or carrying shopping on that side all make it worse. Many people find it flares at night, and lying on that shoulder can wake you. The pain often settles a little once you are up and moving, then builds again after a busy day. Because the cuff is no longer doing its job, the way your arm moves changes too. You may notice weakness rather than just pain: it becomes hard to raise your arm to shoulder height or above, even with help swinging it up. Reaching behind you to do up a necklace, hanging washing, or pulling a jumper over your head can feel awkward or impossible. Some people develop a smooth, rounded bump near the top of the shoulder where the ball has ridden upwards. Over weeks and months, these problems usually build slowly rather than arriving all at once. Simple things like reaching for a seatbelt, pouring a kettle, or getting a coat on can become the hardest part of the day. Some signs need urgent care. If your shoulder becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. If your arm turns pale, cold, white or blue, or you suddenly lose feeling or movement in it, do the same. If your symptoms are not settling, are getting worse over weeks, or are waking you at night, see your GP or ask us for a specialist review. ## What's actually happening A healthy shoulder works like a ball resting in a shallow socket. The rotator cuff tendons wrap around the ball and hold it centred while you lift. Think of them as the guy ropes holding a tent pole steady. When those ropes are gone, the pole leans. In your shoulder, the strong deltoid muscle on the outside of the shoulder still pulls when you lift your arm. With no cuff to hold the ball down and centred, that pull drags the ball upwards. The ball then grinds against the bone above it, the acromion, which is the bony shelf at the top of your shoulder. Those two surfaces were never meant to touch, so they wear each other away. That wearing is the arthritis, and it is why your pain sits deep in the joint and why the ball has ridden up into that rounded bump you may have felt. The wearing also explains the weakness. Lifting the arm depends on the ball staying centred, and yours no longer does. So the effort goes in but the arm does not rise as it should. There is a way around this. A reverse shoulder replacement swaps the ball and socket over: the ball is built onto the socket side and the socket onto the arm side. That change lowers the centre of the joint and gives the deltoid muscle a longer lever to work with, a bit like holding a door handle further from its hinges. The muscle can then lift the arm on its own, without needing the missing cuff tendons. The new joint is also designed so the ball cannot slip out, which keeps things stable as you move. Because the deltoid takes over the work, the shoulder moves differently afterwards. Your shoulder blade does more of the moving than it used to. Most people adapt to this without noticing, and it is part of how the new joint restores movement. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment, which includes your history, an examination and imaging where needed, establishes the diagnosis. The first step is usually non-operative. Changing how you use the shoulder helps: avoiding overhead reaching, lifting with the other arm, and planning tasks so you are not carrying heavy loads on that side. Physiotherapy aims to keep the shoulder moving, build up the muscles that still work, and settle the pain. We usually give this a fair trial over several months before thinking about anything further. Pain medication can help alongside this. Simple pain relievers and anti-inflammatories, which are medicines that reduce swelling and irritation, are the usual starting point. Your GP can guide what is safe for you to take. If these steps have not given enough improvement, surgery may be considered. For cuff arthropathy, the operation is a reverse shoulder replacement, which swaps the ball and socket over so the deltoid muscle can lift the arm without the missing cuff tendons. We will talk through what the operation involves, what it can and cannot do for you, and whether it fits your goals. That decision is one you make together with us, based on your pain, your movement and what matters to you day to day. ## What to expect Cuff arthropathy usually builds slowly over months and years rather than arriving suddenly. Without treatment, the pain and weakness tend to keep getting in the way. The wearing in the joint does not reverse on its own, so most people find their shoulder limits them more over time rather than less. With the right care, the outlook is different. Non-operative treatment such as physiotherapy and simple pain relievers can settle things for a while, and many people manage well with these for months or longer. If surgery is needed, a reverse shoulder replacement has a strong track record for this condition. It reliably relieves pain and restores movement, because the deltoid muscle takes over the work the missing tendons used to do. Most people who were active before surgery are able to return to their activities afterwards, and returning to sport is common. Recovery after surgery takes time and effort. Early, active rehabilitation guided by your physiotherapist is safe and works well, and it can bring earlier benefits than a slower, more cautious approach. Physiotherapy matters beyond the first weeks too: it shapes how much movement you regain and how easily you manage daily tasks months and years down the track. Some people do just as well with a self-directed home programme as with formal supervised sessions, so there is more than one way to do this well. Be realistic about what surgery can and cannot do. A shoulder replaced for cuff arthropathy starts from a worse place than one replaced for straightforward arthritis, so the results tend to be a little less than for those simpler cases. Complications can happen with any shoulder replacement. The most common ones are instability, where the joint moves in a way it should not, and infection. Some complications can be treated successfully if they occur, and revision surgery, where part or all of the replacement is redone, still brings real improvement in pain, movement and function even though results are generally not as good as after a first-time operation. Your own starting point matters. How your shoulder was before surgery is one of the strongest predictors of how it will be afterwards, and we use that to plan your recovery with you. ## When to see someone Cuff arthropathy usually builds slowly, so most people come in when the shoulder starts limiting daily life rather than as an emergency. Ask for a specialist review if your pain is not settling with rest and simple pain relievers, if it is getting worse over weeks, or if it is waking you at night. The same applies if weakness or the rounded bump at the top of your shoulder is stopping you working or using your arm. Some signs need same-day care. Go to an emergency department if your shoulder becomes hot, red, swollen and painful, especially with a fever, or if your arm turns pale, cold, white or blue. Sudden loss of feeling or movement in the arm also needs emergency assessment. If you have already had a shoulder replacement and notice new pain at the base of the acromion, new weakness, or a sudden increase in pain or loss of function, tell us promptly. If you cannot reach the clinic, go to your nearest emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Cuff tear arthropathy and massive irreparable tears are worth the extra reading because the number of operations described for them is itself the most informative fact: when many procedures compete, none is clearly best. ### Everything works a bit, and nothing works clearly better Across 2,000 patients, clinically important treatment effects were seen for all eleven different treatment modalities studied for irreparable posterosuperior cuff tears, with variation in patient characteristics, co-interventions, outcome reporting and follow-up length complicating any sound comparison [1]. A separate review of 3,363 patients found all six non-arthroplasty options produced statistically significant improvements in range of motion and patient-reported outcomes at a year or more, with low revision rates [2]. Eleven modalities, six options, all producing improvement, none demonstrably superior. That pattern usually indicates two things: the natural history includes some improvement regardless, and the studies are too heterogeneous to separate the treatments. ### Improvement early, decline later One finding deserves emphasis because it is easily missed in short-term reports. Across 2,790 patients undergoing superior capsule reconstruction, partial repair, graft interposition and related procedures, there were large initial improvements in shoulder scores for all techniques despite high retear rates, and shoulder scores may decline at mid- to long-term follow-up [3]. So the same operation can look successful at one year and less so at five. When you read that a technique has good results, the follow-up interval matters as much as the number. A 2026 analysis of 4,963 patients attempted to resolve this by ranking treatments on failure rate rather than outcome scores, and while it did not identify a single best treatment, it produced a hierarchy of reliability [4]. Ranking by failure is arguably the more honest measure when early scores converge. ### Why the joint wears out once the cuff is gone The mechanism explains why this is a distinct condition rather than simply a large tear. The rotator cuff holds the humeral head centred in the socket while the deltoid lifts. Without it, the deltoid's pull drives the head upwards against the underside of the acromion. That produces a characteristic pattern: the head rides up on X-ray, the acromion and head wear against each other where they were never meant to contact, and the joint surfaces degenerate secondarily. It is arthritis caused by mechanics rather than by primary joint disease, which is why treating the arthritis without addressing the mechanics does not work. It is also why reverse shoulder replacement solved the problem: it makes the deltoid sufficient without needing a cuff. Where the arthropathy is established, that operation is covered on its own page. ### Reading the outcome figures with the right expectation One caution for interpreting results: outcomes following reverse replacement in this setting are decreased compared with other indications across 6,698 patients [5]. The operation works, but a shoulder replaced for cuff arthropathy should not be expected to match one replaced for straightforward arthritis with an intact cuff, the starting point is worse. --- ### Distal Clavicle Excision (Mumford Procedure) URL: https://www.cqupperlimb.com/education/shoulder/distal-clavicle-excision/ Region: shoulder · operation A Mumford procedure (distal clavicle excision) removes the small worn outer tip of the collarbone to ease shoulder pain at the AC joint. What the keyhole operation involves and what recovery looks like. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. Our assessment, which includes your history, an examination and scans where needed, works out what is causing your pain. For this kind of long-standing joint wear we usually try non-operative care first, such as changing your activities and physiotherapy, and we consider surgery when that has not given enough improvement. This operation removes a small piece of bone from the outer end of your collarbone, the joint where it meets the top of your shoulder. It is offered to people whose pain comes from wear at that joint, or from the bone breaking down after repeated heavy lifting, and only when the ligaments holding the joint steady are sound. Removing that small piece of bone stops the rough surfaces grinding on each other. The aim is less pain and freer movement of your shoulder, and both keyhole and open forms of this operation bring significant pain reduction at 1 year. ## Before the operation Your surgeon will plan the operation using scans you have already had, such as an X-ray, MRI or ultrasound of the shoulder. These show the joint clearly and help decide how much bone needs to be removed. On the day, stop eating and drinking seven hours before your operation. We ask for seven rather than six so you can be brought forward if the theatre list runs early. Your surgeon will tell you which of your usual medicines to skip and which to take. Bring a written list of everything you take. Arrange for someone to drive you home afterwards. Wear loose, comfortable clothing that is easy to get on and off. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. The anaesthetist will meet you before the operation and talk you through both parts. This operation is done under general anaesthetic combined with a regional nerve block. You are then taken into the operating theatre, where the operation is performed. You wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves This is keyhole surgery. Your surgeon makes a few small cuts around your shoulder, including at least one at the back, and works with a small camera inside the joint. The camera shows the joint on a screen, so no large incision is needed to see it. Through these small cuts, your surgeon removes about 5 mm of bone from the outer end of your collarbone. This is enough to stop the rough, worn surfaces at the joint grinding on each other. Your surgeon takes care to remove a controlled amount of bone, enough to relieve pain while protecting the ligaments and capsule that keep the joint steady. Protecting these structures matters, because removing too much bone can leave the collarbone unstable. The small cuts are closed with stitches. A dressing goes over the top, and you keep that dressing on for about 10 days. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. Please arrange for someone to stay with you for the first 24 hours after you get home. You will have pain for the first day or two; we will give you medicine to keep it comfortable, and the shoulder may feel numb for a while because of the nerve block. Numbness and weakness in the first 24 hours after a nerve block are expected. Call the clinic if you cannot feel or move the arm, hand or fingers once the nerve block has worn off, at about 24 hours. Your arm rests in a simple sling for comfort, which comes off for exercises and washing. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first day or two your shoulder will be sore and may feel swollen. The pain medicine we give you keeps this comfortable, and the numbness from the nerve block helps at first too. Resting with your arm supported and doing your exercises gently usually settles the discomfort. Most people find the soreness eases steadily over the first couple of weeks. Your arm rests in a simple sling for comfort. You take it off for your exercises and for washing, and your physiotherapist will show you which movements to start with. These begin gently and build up as the pain settles. You can use your hand for light tasks at home, such as eating or writing, once you feel steady. Avoid lifting anything heavy or pushing through pain. As movement returns, everyday activities get easier. Getting dressed, reaching overhead and sleeping on that side all improve gradually. Sleeping propped up with extra pillows can be more comfortable in the early days. Once your surgeon clears you to drive, typically at the six-week review, you can get back behind the wheel; see Driving after upper-limb surgery for more detail. Desk work and light daily tasks usually come back within 2 to 6 weeks, and heavier activity such as sport or gym work takes longer, from 3 to 6 months. Everyone heals at their own pace, so your timeline may differ. Your surgeon and physiotherapist will guide you at each review. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes pain continues after the operation. This is the most common problem with this surgery. It can happen if slightly too much or too little bone was removed, or if a small piece of bone grows back. If your shoulder still aches the way it did before, or the pain returns after a period of relief, bring it up at your next review. Sometimes a further operation is needed to fix it. Removing too much bone can cause a different problem. The ligaments and capsule that hold the collarbone steady can be disturbed, leaving the joint loose or unstable. You might notice the collarbone feeling like it shifts or clicks, or a sense that the joint is not secure when you move your arm. If the joint was already loose before surgery, this risk is greater. An unstable joint may need further surgery to rebuild the ligaments. Tell your surgeon at your next review if the joint feels loose or moves in a new way. Other problems are uncommon but worth knowing about. These include infection, stiffness, fracture, the joint fusing on its own, and a lasting pain condition called complex regional pain syndrome. Infection signs to watch for are fever, spreading redness around the wound, or fluid or pus leaking from it. Call the clinic the same day if you notice any of these. Pain that keeps getting worse despite your pain medicines also needs a same-day call to the clinic. The joint coming out of place after keyhole surgery has also been reported. If your shoulder suddenly changes shape, drops forward, or feels very painful and unstable after a knock or fall, contact the clinic straight away. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems are picked up early when you tell us about them. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it. Call the clinic the same day too if pain keeps getting worse despite your pain medicines. Go to the emergency department if you have swelling or pain in your calf, or shortness of breath or chest pain. These can be signs of a blood clot. Go to the emergency department as well if your fingers or hand turn pale, cold, white, blue or dark. Call the clinic if you cannot feel or move the arm, hand or fingers once the nerve block has worn off, at about 24 hours. If you cannot reach the clinic, go to your nearest emergency department. ## Where to read more about the condition This page is about the operation itself. The two conditions it treats have their own pages, each covering what the evidence shows about when surgery helps and when it does not: wear at the joint is covered on the AC Joint Osteoarthritis page, and the weightlifter's form, where the end of the collarbone breaks down, on the Distal Clavicle Osteolysis page. --- ### Distal Clavicle Osteolysis URL: https://www.cqupperlimb.com/education/shoulder/distal-clavicle-osteolysis/ Region: shoulder · condition The pain sits at the outer end of your collarbone, right where it meets the top of your shoulder. That spot is called the acromioclavicular joint. It tends to hurt most when you use the arm, especially with pushing, lifting or pressing movements, and it usually settles when you… ## What you're feeling The pain sits at the outer end of your collarbone, right where it meets the top of your shoulder. That spot is called the acromioclavicular joint. It tends to hurt most when you use the arm, especially with pushing, lifting or pressing movements, and it usually settles when you rest. Weight training is a common trigger. Bench pressing and other heavy lifting loads this joint directly, and the pain often builds over weeks of training rather than coming on with one clear injury. Some people notice it after a shoulder injury too, when pain lingers long after the rest of the shoulder has settled. The ache can flare at night or after a session in the gym. Reaching across your body, pressing up from a chair, carrying shopping on that side or pushing a lawnmower can all aggravate it. Because the soreness sits at the very top of the shoulder, it is easy to mistake for a muscle strain at first. This condition can look a lot like other shoulder problems, so scans are used to confirm what is going on. A special X-ray view of the joint, taken on both sides for comparison, and an MRI scan can show changes at the end of the collarbone. Watch for these signs and act on them: Go to the emergency department the same day if your arm becomes hot, red, swollen and painful, especially with a fever. Go the same day if you lose feeling or movement in the arm suddenly after an injury. See your GP or ask for a specialist review if the pain is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your arm. If you cannot reach the clinic, out of hours or on a weekend, go to your nearest emergency department. ## What's actually happening The acromioclavicular joint is a small joint at the top of your shoulder, where the outer end of your collarbone meets a shelf of bone called the acromion. The collarbone acts as the strut that holds your arm away from your chest, and this little joint is one of the places where it connects to the shoulder blade. A tough strap of ligaments underneath keeps the two bones lined up while you lift and press. In this condition, the outer end of the collarbone starts to break down. The medical word for bone breaking down like this is osteolysis. The body normally replaces worn bone with fresh bone, but here the breakdown outpaces the repair, so the bone at the end of the collarbone softens and erodes. The joint above it stays sound; the trouble is confined to the collarbone side. The most common trigger is repeated heavy loading, especially bench pressing and weight training. Each press drives the two bones of the joint into each other, a bit like repeatedly stamping on the same small patch of ground until it wears away. The same process can follow a shoulder injury, where pain lingers for weeks to months after the original knock. Less often, a low-grade infection or a metal plate used to hold the collarbone down after a dislocation can set it off. As the bone erodes, the joint becomes inflamed and swollen, which is why the ache builds over weeks of training and flares at night. The eroded end also loses its smooth fit against the acromion, so pressing, lifting and reaching across your body grind on raw bone. That is the pain you feel at the very top of your shoulder. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. Once we have confirmed the diagnosis with your history, an examination and scans, we work through the treatments in order, starting with the simplest. The first step is changing how you load the joint. Because repeated heavy pressing is what wears the bone down, easing off or swapping the exercises that flare it gives the bone a chance to settle. Physiotherapy aims to settle the inflammation and keep your shoulder strong and moving while you do this. For athletes in season, this approach lets you keep playing while the treatment works. How long this takes depends on whether you can genuinely change the way you train, and we will talk through what that means for your sport or work. Medication is the next layer. Anti-inflammatory tablets, sometimes called NSAIDs, reduce the swelling and ache in the joint. We can also inject a combination of numbing medicine and cortisone, a strong anti-inflammatory, directly into the joint. This injection does two jobs: it confirms the joint is the source of your pain, and it can settle that pain for a period afterwards. If these steps have not given you enough relief, we may talk about surgery. The operation removes a small sliver of bone from the outer end of your collarbone, so the raw, eroded surfaces no longer grind against each other. Only a few millimetres of bone are taken, and if a bone spur is pressing on a nearby tendon we tidy that at the same time. We will go through what the operation involves, what recovery looks like and what it can and cannot change, so you can decide together with us whether it is right for you. ## What to expect For most people, this condition settles once the loading that caused it stops. The bone at the end of your collarbone can rebuild itself when the repeated pressing and lifting eases off. That is the honest catch: the treatment works when you can genuinely change how you train or work. If you keep loading the joint the same way, the pain tends to persist or keep coming back. Recovery without an operation is not a quick fix. The ache builds over weeks, and it usually takes weeks to months of easing off before it settles. Some people notice the pain after a shoulder injury instead, and in that case it can linger long after the rest of the shoulder has healed. If the pain is still there after a reasonable stretch of rest and changed training, that is worth having checked rather than pushing through. If non-operative care does not give you enough relief, surgery is an option. The operation removes a small sliver of bone from the outer end of your collarbone so the raw surfaces stop grinding. People who have this done report less pain and better shoulder movement, and they are generally satisfied with the result. The keyhole version tends to leave less lingering pain than the open version, and people get back to their activities sooner with it. Surgery is not a promise of a pain-free shoulder. A small number of people need another operation later, somewhere between 4% and 10%. That can happen if too little or too much bone was taken, if there was another problem in the shoulder that went unnoticed, or if new bone forms in the joint as it heals. Your surgeon will talk through these risks with you before you decide anything. Whatever path you take, the aim is the same: settle the inflammation, restore smooth movement, and get you back to using your arm without that sharp ache at the top of your shoulder. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm, see your GP or ask for a specialist review. ## When to see someone This condition is easy to mistake for a muscle strain, so it often goes unnoticed at first. See your GP if pain at the outer end of your collarbone lingers after a shoulder injury, once a broken bone or an unstable joint has been ruled out. Ask for a specialist review if the ache keeps building with training, or if it is not settling despite rest and changed loading. Scans can confirm the diagnosis: a special X-ray view taken of both shoulders for comparison, and an MRI that shows swelling deep in the collarbone end. Getting this right matters, because the same pain can come from other shoulder problems, and treatment aimed at the wrong cause will not help. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm, see your GP or ask for a specialist review. If you cannot reach the clinic, out of hours or on a weekend, go to your nearest emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Distal clavicle osteolysis is worth the extra reading because the cause is nearly always identifiable, most people recover without an operation, and the difficult part is whether the loading that caused it can actually be changed. ### The load is usually identifiable, and it is usually the bench press A 2026 scoping review pooled 8 studies covering 483 patients and found bench pressing was the single most common provoking activity at 49.1%, with general weight training a further 24.4% [1]. Pain at the outer end of the collarbone or the acromioclavicular joint was the presenting symptom in 69.9% of patients [1]. The series that first defined the condition found the same pattern: of 46 men diagnosed with osteolysis and no history of acute injury, 45 lifted weights as part of their training [2]. ### Most settle without surgery, but only if the loading actually changes In the pooled review most patients recovered with conservative care, and 16% went on to surgery after conservative treatment failed [1]. A smaller group, 4.4% (3 patients), came to surgery because the disease progressed structurally or because they were unwilling to modify their load for sporting or occupational reasons [1]. That last group is the honest version of the problem: the non-operative treatment works when the provoking activity genuinely stops, and the difficulty is rarely in making the diagnosis. ### When resection is done, little bone is removed and recovery is quick In a series of weight lifters, a limited arthroscopic resection averaging 4.5 mm allowed return to sport at an average of 3.2 days and to the preoperative weight-training programme at 9.1 days, with all patients continuing to train and increasing their loads afterwards [3]. A modern prospective series of 59 patients followed for at least two years reported pain falling from 8.20 to 1.36 out of 10 and SPADI disability from 62.65 to 6.13 by 24 months, with return to sport at 1.72 months and to work at 3.02 months [4]. In the original series, resection was performed in 21 patients and relieved symptoms in all 19 of those who were followed [2]. ### Imaging confirms it; the clinical picture alone does not The review's own conclusion is that the clinical signs and symptoms of this condition were not distinguishable from other shoulder pathologies [1]. MRI was the most frequently used investigation, showing marrow oedema and subchondral fracture at the end of the collarbone, and the authors are explicit that it should be interpreted alongside the examination rather than in place of it [1]. In practice that is why the history — what you lift, how often, and how heavy — carries as much weight as the scan. --- ### EnFix Biological Scaffold URL: https://www.cqupperlimb.com/education/shoulder/enfix-biological-scaffold/ Region: shoulder · device If we used a biological scaffold during your rotator cuff repair, you may have seen the name EnFix on your paperwork and wondered what it is. This page explains it in plain terms: what the scaffold is, the problem it is meant to help with, and, just as importantly, what we do… If we used a biological scaffold during your rotator cuff repair, you may have seen the name EnFix on your paperwork and wondered what it is. This page explains it in plain terms: what the scaffold is, the problem it is meant to help with, and, just as importantly, what we do and don't yet know about it. It is an add-on to a standard rotator cuff repair, not a different operation, and it does not change how you recover. ## The weak spot in a cuff repair A rotator cuff repair reattaches a torn tendon back onto the top of the arm bone. The tricky part is not the stitches: it is getting the tendon to truly heal back onto the bone. Tendon and bone meet at a special junction (your surgeon may call it the footprint, or the enthesis). In nature this is a gradual transition zone that works like a shock absorber, blending the flexible tendon into the hard bone so that load passes smoothly from one to the other. The problem is that, once it is torn, the body does not rebuild that elegant transition zone. It tends to fill the gap with ordinary scar tissue, which is weaker than the original attachment. Sometimes that scar does not fully bridge tendon to bone, and the repair can pull away: a re-tear. This is more likely with larger tears, older tendons, and poorer tissue quality, and most re-tears happen in the first few months after surgery while healing is still getting established. Helping that one spot heal properly is the whole goal. ## What EnFix is EnFix is a small implant placed at the footprint, between the tendon and the bone (not as a patch laid over the top of the repair). The idea is to put helpful biology exactly where healing needs to happen. It is made from demineralised cortical bone fibre, human bone that has been processed so that the hard mineral is removed, leaving the natural fibres and the body's own healing signals behind. It contains no added drugs or chemicals. Because it comes from donated human tissue (an allograft), it is worth knowing that such tissue is carefully screened and processed to remove cells and reduce any risk of infection or rejection; demineralised bone has a long, well-established safety record and is used widely in other areas of surgery, such as the spine. ## What we hope it does The thinking behind EnFix is that it acts as both a scaffold (a natural framework for your own cells to grow into) and a biological signal that encourages those cells to rebuild a proper tendon-to-bone junction rather than plain scar. In short, the hope is that it helps the repair heal more like the original attachment, and so lowers the chance of a re-tear, particularly in the bigger or more difficult tears where healing is least reliable. ## What is known so far It is important to be honest about the evidence, because this is a newer technology. In laboratory and animal studies, repairs supported with this kind of demineralised bone fibre have healed with more organised, more natural tendon-to-bone tissue than repairs without it. Early studies in patients have been encouraging, and our own early results have been promising, but the numbers are still small and the follow-up is still short, so longer follow-up is needed before anyone can say with confidence how much difference it makes. Larger, more formal studies are underway to answer exactly that. We will always be straight with you about this: EnFix is a well-reasoned, biologically sensible addition with promising early signs, not a guaranteed fix. ## What it means for you In practice, using the scaffold: - Adds only a couple of minutes to the operation and uses your existing repair technique: there is no separate procedure and no extra incision. - Does not change your recovery or rehabilitation. Your sling, your movement restrictions, and your physiotherapy are guided by the repair itself, exactly as they would be without it. The scaffold supports healing; it does not replace the need to protect the repair and do your rehab. - Is one part of giving your repair the best chance to heal, alongside the quality of the repair, your own tissue, and how closely you follow your rehab programme. ## When to ask If you are unsure whether a scaffold was used in your repair, or you would like to talk through what it means for your particular tear, just ask at your next appointment and we are happy to go through it. And the usual advice after any cuff repair still applies: contact us if you have increasing pain that your medication isn't controlling, a wound that becomes red, hot or starts leaking, or a fever, and seek urgent care for sudden chest pain or breathlessness. --- ### Frozen Shoulder URL: https://www.cqupperlimb.com/education/shoulder/frozen-shoulder/ Region: shoulder · condition Frozen shoulder (adhesive capsulitis) causes pain and stiffness, progressing through freezing, frozen, and thawing phases. ## What you're feeling Frozen shoulder usually starts as a deep, dull ache that builds over weeks rather than appearing overnight. For most people the pain is the worst part at first, and it is often worst at night. Lying on that side becomes impossible, and broken sleep is one of the most exhausting parts of the whole condition. Then the shoulder starts to lock up. You reach for a seatbelt, or up to a high shelf, or back to a pocket, and the arm simply stops. What makes frozen shoulder different from most shoulder problems is that the stiffness is not just you guarding against pain — the shoulder genuinely will not move, even if someone else lifts your arm for you. Losing the ability to turn your hand outwards, as if opening a door or putting your arm into a sleeve, is the most characteristic sign of all. Most people are between about 40 and 60. Some remember a minor knock beforehand; many have no explanation at all. It is more common if you have diabetes or a thyroid condition, and if you have had it in one shoulder, there is a modest chance of the other one following later. ## What's actually happening Your shoulder joint sits inside a sleeve of tough tissue called the capsule. Normally that sleeve is loose and stretchy, which is what allows the shoulder to move further than any other joint in the body. In frozen shoulder the capsule becomes inflamed and then thickens and contracts, so the sleeve shrinks. The space inside the joint can end up less than half its normal size. Despite the older name "adhesive capsulitis", nothing is actually stuck together inside the joint. There are no glue-like adhesions. The tissue has tightened, which is a genuinely different problem, and it is why some surgeons argue the condition should simply be called a contracture — a tightening — of the shoulder. Why it starts is still not properly understood, and it is honest to say so. There is good evidence that it is not purely a local problem with the shoulder. Studies of inherited risk show that type 1 diabetes genuinely causes frozen shoulder rather than just being associated with it, and that the link runs through blood sugar rather than through weight or mechanical load. The tissue changes look strikingly similar to Dupuytren's disease in the hand, which is why the two often turn up in the same person. ## Being honest about how long it takes You will very likely read that frozen shoulder is self-limiting and resolves completely in around eighteen months to two years. We want to be straight with you: that reassurance is more confident than the evidence supports. The idea that the condition passes neatly through three stages — freezing, frozen, then thawing — comes from a small study published in 1975, in which patients had their arms rested in slings for up to nine months. Unsurprisingly, shoulders treated that way became stiff and then loosened again once movement was allowed. When researchers went back and reviewed all the available studies, they could find no good evidence that untreated shoulders reliably pass through those stages and end up normal. In fact, no study has ever shown people getting back to a measured, genuinely normal range of movement without treatment. What the evidence does show is more useful, and it is this: most of the improvement you are going to get tends to happen early, and then progress slows and levels off. That plateau can be permanent. Depending on which study you read, somewhere between a third and a half of people still have some ache or stiffness several years later, though for most of them it is mild and does not stop them doing what they want to do. None of that means you will not get better. Most people improve a great deal. It does mean that "just wait, it will sort itself out" is not a neutral piece of advice, and that there is a reasonable case for treating the pain actively rather than simply enduring it. ## What we can do about it At Mater Private Hospital Rockhampton, Dr Kieran Hirpara will talk you through the options based on which is bothering you more — the pain or the stiffness — rather than trying to slot you into a numbered stage. A steroid injection into the joint is the single best-supported treatment for the painful phase. Across a very large body of research it is the one treatment that reliably produces a difference in pain and function that patients actually notice, and it works within the first few weeks. Its honest limitation is that the advantage fades after about three months. It buys you comfort, sleep, and the ability to work at the shoulder — it does not cure the tightness. Exercises and physiotherapy are worth doing, with realistic expectations. A simple home exercise programme has measurable value. What may surprise you is that how hard you push makes little difference: a trial comparing firm, end-of-range stretching with gentle, pain-free movement found only small differences, slightly in favour of the firmer approach for some movements, and another study found that people who exercised gently within their pain limits did better — with, reassuringly, no evidence that pushing harder does damage. So work within what you can tolerate. Fighting through severe pain has not been shown to speed anything up. Hydrodilatation, where fluid is injected to stretch the capsule from the inside, is widely used and low-risk. The research on it is genuinely mixed: one review found only small effects on both pain and movement, and others found an early gain in some movements compared with a steroid injection alone that did not last. It is a reasonable option, but we will not oversell it. Manipulation under anaesthetic means moving the shoulder through its full range while you are asleep, to stretch the tight capsule. In the largest trial comparing the main treatments, this came out as the best value option overall. Keyhole capsular release involves surgically dividing the tight capsule under direct vision, rather than stretching it until it tears. Its main advantage is that it tends to be the most durable: across the published surgical series recurrent stiffness after a release is uncommon, whereas after a manipulation a meaningful proportion of shoulders tighten up again and need a second procedure. In the large UK trial, people who had a release were the least likely of the three groups to need any further treatment. Because it is an operation it carries a little more risk than the alternatives and costs more, and you should expect to feel sorer in the first few weeks than someone who had a manipulation — that early difference evens out by around six months. Worth knowing: in that trial, all three approaches ended up within a few points of each other at one year. That is genuinely good news, because it means the decision can be made on what suits you, your other health conditions and your circumstances, rather than on one option being clearly better. How Dr Hirpara usually sequences this. You will not be told to put up with it for a fixed number of months before anything can be offered. In practice he will usually suggest a steroid injection first, because for a lot of people that takes enough of the pain away to get on with life while the shoulder settles. If the injection does not give you adequate relief, he is happy to offer a capsular release from that point — he does not require you to have struggled on for nine or twelve months first. Given how shaky the "it always resolves on its own" reassurance turns out to be, there is little sense in spending a year in pain to find out which way yours will go. ## What to expect If you have an injection, expect the pain to ease over the first week or two. Use that window to keep the shoulder moving. If you have a manipulation or a capsular release, most of the range you are going to regain comes back quickly — usually within the first four to six weeks — and there is generally little further change after about three months. Getting moving early matters, and physiotherapy normally starts within a day or two of the procedure. Most people are back to office-type work within one to three weeks. If you have diabetes, it is fair to expect a slower and slightly less complete recovery than average, and worth knowing that a steroid injection can unsettle your blood sugars for a few days. Tell us if your control is difficult, because it changes what we recommend. Recovery is measured in months, not weeks, whichever route you take. The most useful thing you can do is keep using the arm within comfortable limits and keep your sleep protected. ## When to see someone See your GP if shoulder pain is waking you at night or has not settled with a few weeks of rest, and ask specifically about frozen shoulder if the shoulder is becoming genuinely hard to move rather than just sore. Ask for a specialist review sooner if you cannot turn your hand outwards, if you have diabetes, if the shoulder is affecting your work or driving, or if the pain is severe enough to stop you sleeping. There is no advantage in waiting a long time before getting the pain assessed. Seek prompt medical attention if the shoulder becomes hot, red and swollen, if you feel unwell or feverish with it, if there is significant weakness or numbness in the arm, or if the pain started with a fall or an injury. Those features point away from frozen shoulder and towards something that needs looking at more urgently. ## In more depth Advanced reading: the deeper science (optional) This section goes a step further than you need for your own treatment decisions. It is here because frozen shoulder is one of the conditions where what patients get told and what the research actually shows have drifted apart, and some people would rather see the reasoning than be asked to take it on trust. ### What is actually going wrong in the joint The capsule is a sleeve of collagen around the joint. In frozen shoulder it becomes inflamed and then fibrotic, cells called fibroblasts multiply and lay down dense new collagen, and some of them convert into myofibroblasts, which can actively contract. That is the key difference from ordinary scarring: the tissue does not just thicken, it pulls tight. The joint volume can drop from a normal 10–15 mL to 3–4 mL. The same cell behaviour occurs in Dupuytren's disease in the hand, which is why the two conditions turn up in the same people, and why one shoulder surgeon has argued the condition should simply be renamed a contracture of the shoulder rather than a "capsulitis" [1]. Despite the old name "adhesive capsulitis", surgeons looking inside the joint find no adhesions at all. ### Why the "three stages" story is on shakier ground than it sounds You will read everywhere that frozen shoulder passes through freezing, frozen and thawing phases. That model was proposed in 1975. When researchers went back and traced where it came from, they found the author had mixed up the references for two different earlier papers, and, more importantly, that his patients had their arms rested in slings for up to nine months. A shoulder immobilised that long becomes stiff, and loosens once you let it move. The "stages" may partly describe the treatment rather than the disease. A systematic review that set out to test the model could find no evidence for it, and found the opposite of what it predicts: most improvement happens early and then slows, rather than building to a late thawing [2]. Nor can clinicians reliably agree which stage a given shoulder is in, the people who wrote the standard definition admitted in print that the data to confirm it "are not available". ### The recovery statistic, and why it has two very different answers The often-quoted figure is that 94% of people recover without treatment. That comes from a real study, but it counts only the patients who went untreated and came back for follow-up. Most of the original group either chose treatment or dropped out. Counting everyone, the same data gives roughly 26% [2]. "Recovered" also meant within 10 degrees of the other shoulder, and in some of those patients the other shoulder had been frozen too. The largest long-term follow-up found 41% still had symptoms an average of four years on, and, the part worth knowing, that improvement largely stops after about three years rather than continuing indefinitely [4]. ### It is a whole-body condition, not just a shoulder one A large genetic study found five regions of DNA associated with frozen shoulder and, using a technique that can separate cause from coincidence, showed that type 1 diabetes genuinely causes it rather than merely accompanying it. Being overweight did not, once diabetes was accounted for, the weight association disappeared. That points to blood sugar rather than mechanical load as the driver [5]. ### What the physiotherapy evidence actually says This is the part most worth knowing if you are having, or delivering, physiotherapy. A Cochrane review pooled 32 trials and 1,836 people [6]. Three findings stand out. Against a steroid injection, hands-on physiotherapy comes off worse early on. In the head-to-head trial, six weeks of passive mobilisation and supervised exercise produced 26 points less pain improvement and 25 points less function improvement at seven weeks than a single injection. Judged on whether people felt much improved or recovered, it was 46% for physiotherapy against 77% for the injection, roughly one extra person helped for every four injected instead. By six to twelve months the gap had closed and the difference no longer mattered. How hard you push, how often, and which technique is used appear to make little difference. A 100-patient trial compared firm end-of-range mobilisation against gentle pain-free mobilisation: both groups improved, and the firmer technique did statistically better for some movements (lifting the arm out to the side at three and twelve months, turning it outwards at twelve months), but the authors judged the differences small [18]. A non-randomised study of 77 people found the reverse: at two years, 89% of those who exercised gently within their pain limits had a normal or near-normal shoulder score, against 63% of those given intensive stretching [19]. A 120-patient trial varying the frequency of end-range mobilisation (more than twice weekly, weekly, less than weekly) found differences in abduction of under eight degrees, all statistically indistinguishable from zero. Head-to-head comparisons of technique — anterior versus posterior glide, PNF versus conventional exercise, dumbbells versus bare-handed, were almost all non-significant. Reassuringly, there was also no sign that working at end range does harm. The biggest structural gap: no trial has ever compared manual therapy plus exercise against no treatment at all. So while we can say physiotherapy is not clearly better than an injection, and that the details of how it is delivered do not seem to change much, nobody has actually shown how much of the improvement would have happened anyway. Two useful caveats. The one genuinely high-quality trial in the review looked at physiotherapy after a joint distension, and found it made no difference to pain, function or quality of life, but it did improve how many people rated themselves recovered, and added about 13 degrees of abduction at six weeks, which had faded by six months. And in the big UK trial, the physiotherapy arm was described as including hands-on stretching into the stiff range, yet its own records show manual mobilisation was used in only 11–27% of patients and supervised stretching in a single one. What was actually delivered, and performed as well as surgery at a year, was education, an injection, gentle supervised movement and a home programme. ### How long until it feels better, and does the type of release matter Timing. After a release, the median patient crosses the "this is a real improvement" threshold at about one month, and the "my shoulder is acceptable to me" threshold at about four months [14]. Time off work runs to a median of eight weeks, though the spread is wide, a quarter are back by four weeks, three quarters by thirteen [15]. Manipulation gets movement back faster. That is the honest trade-off against the durability advantage above: manipulation restores range sooner, and release does not really catch up until around the six-month mark, after which the two are indistinguishable on every pooled measure. One small comparison even found manipulation alone finished with the best external rotation [16]. How much capsule to divide is a genuine question, and the answer is "less than you might think". A review pooling 18 studies, 629 patients and 811 shoulders compared three techniques: releasing the front and underside of the capsule only, adding the back of it, or going the whole way round. Its conclusion was that less extensive releases gave better function and pain scores, that adding a posterior release buys early internal rotation which does not last (though it does give a lasting flexion gain), and that a full 360-degree release "may not provide any further benefit". Complication rates did not differ between the three [17]. Two randomised trials of the posterior extension found the same pattern, faster early recovery, no difference by six months. So a bigger operation is not automatically a better one. Doing both together is not the answer. In the only three-way comparison, adding a manipulation to a release produced the highest rate of losing external rotation, 18%, against 7% for manipulation alone and 2% for release alone [16]. ### What the biggest treatment trial actually found A UK trial randomised just over 500 people to structured physiotherapy with an injection, manipulation under anaesthetic, or keyhole surgery. At one year all three landed within a few points of each other, less than the difference a patient would notice [7]. That is genuinely useful news: it means the choice can be made on what suits you and your circumstances, rather than one option being plainly better. Where the three do differ is in how often people need something else afterwards. In that trial, further treatment was needed by 4% after a release, 7% after a manipulation and 15% after physiotherapy [7]. Manipulation came out best on cost per unit of benefit; release cost the most and generated most of the trial's serious complications, though those were rare in absolute terms. ### Manipulation or release — the recurrence question This is where the two operations genuinely separate, and it is the reason a surgeon may steer you towards a release even though the headline outcome scores look the same. A manipulation stretches the capsule until it tears, and the tear does not always go where you would choose. In the largest series, 792 shoulders followed for 17 years — a second manipulation was needed in 17.8%, and in people with type 1 diabetes that rose to 37.9% [9]. The longest follow-up, at an average of 13 years, found 19.2% had needed a repeat manipulation and 31.3% described a recurrence at some point [10]. Two things soften that: nearly all recurrences happen in the first year (after five years the rate is under 2%), and a repeat manipulation works about as well as the first [9][10]. A release divides the capsule deliberately, under vision. Reoperation is markedly less common: a series followed for a mean of five years reported no reoperations in 32 patients, with a single recurrence in someone who did not complete their rehabilitation [11]. The meta-analysis pooling eight studies and 768 patients found the two operations comparable for pain, function and movement (a small long-term pain advantage for release did not reach a clinically important size), with a higher rate of severe complications after release. It noted a higher, though not statistically significant, rate of further steroid injections in the manipulation group, and suggested that over a longer follow-up "the MUA group may experience more recurrences" [8]. Two honest caveats. First, the big manipulation-recurrence studies largely come from one surgeon's practice, so they are not independent confirmations of each other. Second, release is not a full restoration either: one series found the average shoulder score was still about 77 out of 100 two to six years later [12], and in a cohort that excluded diabetics, while almost everyone improved by a meaningful amount, 11–22% still did not consider their shoulder acceptable at six months [13]. So the honest summary is this: for getting the shoulder moving and comfortable, the two are about equivalent, and manipulation is the cheaper way there. For staying that way, the evidence favours release. That difference matters most if you have diabetes, if the shoulder is very stiff, or if you have already had a manipulation that did not hold. --- ### Latarjet Procedure URL: https://www.cqupperlimb.com/education/shoulder/latarjet/ Region: shoulder · operation Latarjet procedure — bone block transfer for recurrent shoulder instability with glenoid bone loss. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your first visit we take a history, examine your shoulder and arrange imaging if it is needed. For a shoulder that keeps dislocating or slipping out of place, we usually try non-operative care first, such as physiotherapy and changes to your activities. Surgery comes into the conversation when those options have not given you enough improvement. The operation suggested for you is called a Latarjet procedure. It moves a small piece of bone from another part of your shoulder blade to the front of your shoulder socket, where it helps hold the joint in place. We offer it when your shoulder has come out of joint more than once, or when there is bone damage around the socket. The main aim is lasting stability, so your shoulder stays put and you can use your arm with confidence. With careful selection of who has the operation, it prevents repeat dislocation in about 99% of cases. ## Before the operation In the weeks before surgery we arrange the scans needed to plan your operation. This usually includes X-rays, and sometimes an MRI (a scan that shows soft tissues) or an ultrasound. On the day, you will need to stop eating and drinking seven hours beforehand. We ask for seven hours so we can bring you forward if the theatre list runs early; your surgeon will confirm your exact time. You may be asked to stop some of your usual medications, and we will give you clear instructions about which ones. Bring a list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing. If you have other medical conditions, you may need blood tests or a review with the anaesthetist (the specialist who keeps you safe and pain-free during the operation). ## On the day You arrive at the hospital's surgical admissions unit, where we check you in and prepare you for theatre. This operation is done under general anaesthetic combined with a regional nerve block. The anaesthetist will meet you before the operation and talk you through both parts. You are then taken into the operating theatre, where the operation is performed. When the operation is finished, you wake up in the recovery area. Nurses stay with you and keep an eye on you while the anaesthetic wears off. Once you are stable, you go to the ward. When you go home, someone must drive you, as you will not be able to drive yourself. ## What the operation involves Your surgeon does this operation as keyhole surgery, also called arthroscopic surgery. A small camera is placed inside your shoulder joint through small cuts around the shoulder, including one at the back. The camera sends a picture of the inside of your joint to a screen, so your surgeon can see and work inside the shoulder without opening it up. The operation moves a small piece of bone from your shoulder blade, called the coracoid, to the front of your shoulder socket. This piece of bone is held in its new position with screws. It acts as a support that stops your shoulder from slipping out of joint towards the front. Because the transferred bone brings a piece of attached tendon with it, it also adds a brace across the front of the joint. At the end of the operation, your surgeon closes the small cuts with stitches and covers them with a dressing. You will wake up in the recovery area with your arm supported in a sling. ## After the operation When you wake up, you will be moved to the recovery ward. Nurses will check on you regularly and give you pain relief as you need it. Your arm will rest in a simple sling for comfort, which comes off for exercises and washing. Most patients stay one or two nights in hospital after this operation. Because you will still be feeling the effects of the anaesthetic, someone should stay with you for the first 24 hours. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. You will be able to walk around on the day of surgery, with help at first. ## Recovery Your shoulder will be sore and swollen for the first few days. This settles gradually over the following weeks. Regular pain relief, rest and ice packs help ease the discomfort. The small cuts around your shoulder heal under the dressing we leave in place for about 10 days. You will go home with your arm resting in a simple sling for comfort. It comes off for your exercises and for washing. Your physiotherapist will guide you through gentle movements at first, then more active exercises as your shoulder settles. You will be able to walk around from the day of surgery, with help at first. Sleep can be awkward with a sore shoulder; many people find resting propped up more comfortable in the early weeks. Around the house, you will need help with tasks that need both hands, such as dressing and cooking, until your arm is ready. Progress comes in stages rather than all at once. Once the worst of the swelling settles, everyday movements feel easier. As your range of motion returns, your physiotherapist will add gentle strengthening. Once your surgeon clears you to drive, typically at the six-week review, you can find more detail in our guide on Driving after upper-limb surgery. Returning to work and sport happens in steps, guided by how your shoulder feels and what your surgeon and physio advise. Recovery varies between individuals. Your timeline may differ, and your surgeon and physiotherapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the shoulder can slip or feel loose again after surgery. You might notice the same sense of the joint shifting that led you here. Tell your surgeon at your next review, or call the clinic sooner if it feels like a full dislocation. The bone graft and the screws holding it can occasionally cause problems. You might feel a click, a catch or a grating deep in the shoulder, or a pain that does not settle the way you expected. Mention this at your review so it can be checked with imaging. Nerves near the shoulder can be irritated during surgery. This might show as numbness, tingling, weakness or a burning feeling in the shoulder, arm or hand. Most of these settle with time. If you notice new numbness or weakness, let the clinic know so it can be watched closely. Infection is uncommon but needs quick attention. Watch for a deep, throbbing pain that does not ease with simple painkillers, redness spreading out from the wounds, swelling that keeps growing, or a fever. Some infections stay close to the skin and settle with antibiotic tablets. Others go deeper and need a return to theatre to wash the area out, along with antibiotics through a drip. If you see any of these signs, call the clinic straight away or go to the emergency department. Pain and stiffness that do not improve can occasionally persist. If your shoulder is not easing as the weeks pass, bring it up at your review so your recovery plan can be adjusted. Arthritis can develop or worsen in the shoulder many years after this operation, though it is usually mild when it happens. You might notice aching, stiffness or grinding that builds slowly over time. Mention any of these changes at a later review. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems after this operation show up in ways you can see or feel. Call us if you have a fever, if the skin around your wounds becomes more red or starts leaking fluid, or if pain suddenly gets much worse. Go to emergency if you have swelling in your calf, shortness of breath, new numbness in your arm or hand, or if you cannot move the arm at all. These signs need checking straight away. If you are unsure, call the clinic and we will guide you. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. The Latarjet is worth the extra reading because it is the clearest trade-off in shoulder surgery: it is the more reliable operation for keeping the shoulder in, and it is the one with more that can go wrong. Deciding between it and a soft-tissue repair means deciding which of those you weight more heavily. ### What it buys Compared directly with arthroscopic Bankart repair, the Latarjet procedure produced a lower recurrence rate, better patient-reported outcomes, and a faster return to sport, while carrying a higher incidence of complications [1]. A long-term comparison of 3,088 patients found the same directional result: lower recurrent instability and lower revision rates after open Latarjet than after arthroscopic Bankart, with comparable rates of moderate-to-severe arthritis between the two [2]. That last detail matters, because the standard worry about the Latarjet is that moving bone and tendon across the front of the joint must accelerate arthritis. On this evidence, at long-term follow-up, it did not, the arthritis rates were similar. ### What it costs Pooling 7,175 patients, the overall complication rate after the Latarjet was 6–7%, with graft-related problems the most common category [3]. There was no significant difference in complication rate between the open and arthroscopic versions of the operation [3]. Six to seven percent is neither trivial nor alarming, and the composition is the useful part: the complications cluster around the transferred bone, its fixation, its healing, its resorption, rather than around the joint itself. That is intrinsic to what the operation does. ### Why it is not simply the better operation If the Latarjet has lower recurrence, an obvious question is why anyone has a Bankart repair. Part of the answer is the complication rate above. The other part is that the soft-tissue options have improved. Across 2,100 patients, adding a remplissage to a Bankart repair reduced instability recurrence compared with isolated Bankart repair without a significant external rotation deficit, and may reduce the risk of reoperation compared with Latarjet [4]. So the real decision is three-way rather than two-way, and it turns on your glenoid bone loss, your Hill-Sachs lesion, your sport and your age, not on which operation has the best headline recurrence figure. ### Do it first, if you are going to do it One finding deserves emphasis because it affects sequencing rather than technique. Pooling 1,571 patients, salvage Latarjet, performed after a failed previous stabilisation — produced inferior outcomes to primary Latarjet in terms of recurrent instability and return to pre-injury sport [5]. The Latarjet is often described as the fallback if a Bankart repair fails. This is evidence that it works less well in that role than when chosen first. For a patient with substantial bone loss and high demands, "try the smaller operation and we can always do the Latarjet later" is a plan with a measurable cost attached. --- ### Os Acromiale URL: https://www.cqupperlimb.com/education/shoulder/os-acromiale/ Region: shoulder · condition Patient-facing topic on os acromiale — failed fusion of an acromial ossification centre that may cause shoulder pain and contribute to subacromial impingement. ## What you're feeling With an os acromiale, the pain usually sits at the front and side of your shoulder, over the bony roof of the joint. Overhead activity makes it worse. Reaching up to a high shelf, hanging washing or lifting something above shoulder height can all set it off. Many people also notice pain at night, and it can wake you when you lie on that side. The pain comes from a small piece of bone at the top of the shoulder that never joined to the rest during growth. When you lift your arm, a muscle pulls on this loose piece and it moves slightly, pressing on the tendon underneath. The junction between the two bone pieces can also be tender to touch, and pressing on it directly can bring the pain on. Day-to-day, you may find your arm feels weak when you lift it out to the side or turn it outward. A painful arc is common: the shoulder hurts partway up as you raise it, then eases as it goes higher. Because the symptoms look so much like wear-and-tear in the tendon under the roof of the shoulder, this condition is easy to mistake for a rotator cuff problem, and it can keep causing pain even after treatment for that. Most people with this bone pattern never feel anything at all. It is often found by chance on a scan done for something else. When it does cause pain, it tends to appear in younger adults, often without any injury, and it is worth suspecting if your shoulder pain has not settled with physiotherapy, rest from sport or an injection. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm, see your GP or ask for a specialist review. ## What's actually happening The bony roof of your shoulder does not form as one single piece of bone. It starts as three separate centres that slowly join together, beginning around age 15 and usually finished by age 25. In about 8% of people, one of these joins never closes. The gap fills with tough, gristle-like tissue instead of bone, leaving a small piece of the roof attached by a flexible link rather than solid bone. Think of it like a plank fixed to a wall with one loose screw. It holds, but it moves a little when you lean on it. The muscle that lifts your arm out to the side attaches to this roof, so every time you raise your arm, that muscle pulls on the loose piece and it flexes slightly. That movement presses down on the tendon running beneath the roof, and the rubbing irritates it. That is why overhead activity hurts and why the pain sits at the front and side of your shoulder. The flexible link itself can also be the problem. It can become tender in its own right, much like a worn joint, and pressing on it brings the pain on. Most people with this bone pattern never feel anything, and it does not appear to cause shoulder pain by itself or make a tendon tear more likely. But when the loose piece starts moving more than usual, either from the way it was formed or after a knock to the area, it can press on the tendon each time you lift. That is what produces the painful arc and night pain described above. Because the loose piece sits right where the tendon lives, the two problems often appear together. If your shoulder has already been treated for a tendon problem and the pain has not settled, this unfused piece is worth checking for, since operating on the tendon alone will not quieten a moving piece of bone above it. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your first visit we take a history, examine your shoulder and arrange imaging where it is needed. The first step is usually changing how you use your shoulder and giving physiotherapy a proper go. Physio aims to settle the irritation under the bony roof and build up the muscles around your shoulder so they cope better with overhead work. Give it a fair trial before thinking about anything further. Pain medication can help you keep moving while that happens. Simple anti-inflammatories, taken as your GP advises, settle the soreness so you can do your exercises comfortably. If pain is not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm, see your GP or ask for a specialist review. When non-operative care has not given enough improvement, we consider surgery. Before that we confirm the diagnosis with plain X-rays, which are almost always enough to show the unfused piece. A view taken from below the armpit shows the shape of the joint and the front of the roof clearly, and it matters because an injury can damage the junction between the two bone pieces. An ultrasound is a simple, accurate way to check the tendon running under the roof, and an MRI scan gives a fuller picture of that tendon and the surrounding soft tissue. The operation we most often offer is a keyhole (arthroscopic) assessment of the joint with a bursectomy, which means clearing inflamed tissue from the space under the roof, then a small open incision for bone grafting and fixation, which means holding the loose piece still so it can join to the rest of the bone. Holding it still lets the two pieces grow together. If the loose piece is small, we may remove it instead of fixing it. Fixing a larger piece needs care, because the muscle that lifts your arm pulls on it constantly and the piece is thin. Sometimes the fragment does not join after fixation, which is called non-union. We will talk through which option suits your shoulder and decide together. ## What to expect Most people with this bone pattern never have any trouble at all, and it needs no treatment. When it does cause pain, the outlook depends on whether the loose piece is stable and whether it is actually the source of your pain. For a painful one, care usually starts without surgery. Changing how you use your shoulder, physiotherapy and simple pain relief settle things for many people. If that has not worked after a fair trial, surgery can lead to a real drop in pain and better shoulder function. When the loose piece is held still and joins to the rest of the bone, people do better on shoulder function measures than when the two pieces stay separate. Surgery is not always the answer, though. In some people with this condition and a tendon tear as well, results after surgery have been mixed, with 53% achieving satisfactory results overall. If it is left alone and it keeps troubling you, the pain usually does not go away by itself. It can also be easy to miss: this condition is worth suspecting when shoulder pain has not settled after treatment, including after surgery for a tendon problem, because operating on the tendon alone will not quieten a moving piece of bone above it. Recovery after surgery is gradual. You will work with your physiotherapist, building movement first and then strength, and overhead lifting will come back slowly over weeks to months. The aim is a shoulder that copes with daily life without the sharp pain on lifting you came in with. If you notice a finger, hand or arm that becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. No GP referral is needed. ## When to see someone Most people with this bone pattern never need care, but see your GP or ask for a specialist review if your shoulder pain is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your arm. Ask for a review sooner if the pain sits at the front and side of the shoulder, is worse with overhead activity, or keeps waking you when you lie on that side. It is also worth a review if the sore spot at the top of the shoulder is tender to press, if your arm feels weak lifting it out to the side or turning it outward, or if the shoulder hurts partway up as you raise it. Younger adults with these symptoms and no injury should be checked for this condition, especially if physiotherapy, rest from sport or an injection has not helped. If a finger, hand or arm becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day; no GP referral is needed. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Os acromiale is worth the extra reading because it is a normal anatomical variant in a meaningful minority of people, usually causes nothing, and is frequently blamed for shoulder pain it is not responsible for. ### What it is, and how common The acromion, the bony roof over the shoulder, forms from several separate centres of bone that normally fuse in the late teens or early twenties. In some people one fails to fuse, leaving a permanent fibrous junction. That is an os acromiale, and it is present from adolescence rather than acquired. Prevalence varies by population. A multicentre study of 6,842 patients found os acromiale is associated with rotator cuff injuries, that prevalence in the Japanese population studied was lower than in non-Asian populations, and that the fragment size tended to be smaller [1]. That association with cuff injury is worth reading carefully. It establishes that the two occur together more often than chance, not that the os causes the tear. The plausible mechanism runs both ways: an unfused fragment moves slightly under deltoid pull, which may irritate the tendon beneath — or the same shoulder mechanics that predispose to cuff disease make an unstable fragment symptomatic. ### Whether it is the source of pain is the whole question Because it is visible, permanent and abnormal-looking on imaging, an os acromiale readily becomes the reported explanation for shoulder pain. Most are silent, and most people who have one never know. What distinguishes a symptomatic one is localised tenderness directly over the fragment, pain reproduced by pressing on it, and, where a diagnostic injection is used, relief specifically from injecting that junction rather than the subacromial space beneath. In the absence of those, the finding is best treated as incidental. The subtypes are conventionally classified by which fusion site is involved [2], which matters surgically because the size of the mobile fragment determines whether it can be excised or must be fixed. ### Why it complicates other shoulder surgery The practical importance of an os acromiale is often less about its own symptoms than about what it does to operations planned for something else. The deltoid attaches to the acromion, so an unfused fragment carries that pull across a mobile junction. Removing bone from the undersurface, as in acromioplasty, thins a fragment that is already unstable, and can convert a symptomless variant into a painful one or produce a nonunion. This is the strongest reason for it to be recognised on pre-operative imaging: not to treat it, but to avoid destabilising it. Where it does require treatment, the choice is between excising a small fragment and fixing a larger one, and fixation across this junction is known to be difficult, the fragment is thin, the deltoid pulls on it continuously, and nonunion rates are appreciable. That difficulty is itself a reason to be confident the os is genuinely the pain source before operating on it. --- ### Pectoralis Major Repair URL: https://www.cqupperlimb.com/education/shoulder/pec-major-repair/ Region: shoulder · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. The pectoralis major is the large chest muscle that pulls your arm across your body. When it tears off the bone or splits along its length, surgery… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. The pectoralis major is the large chest muscle that pulls your arm across your body. When it tears off the bone or splits along its length, surgery means stitching the torn ends back where they belong. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We confirm the tear with your history, an examination, and scans where they are needed. This operation is usually offered to active people with a complete tear who need their full strength for work or sport. Repair gives better recovery of strength than leaving the tear alone, and it also restores the natural shape of the chest. For long-standing tears where the ends cannot be stitched directly, we can rebuild the tendon using donor tissue. Repair works best when it is done soon after the injury, although a later repair is still possible. Most people return to work, with a mean time of 1.6 months, and in a study of serving military personnel, 94% returned to full duty. We will talk through these figures with you so you can decide together what suits your goals. ## Before the operation Once your operation is booked, we will give you clear instructions to follow. You will need to stop eating and drinking seven hours before surgery. We ask for seven hours rather than six so we can bring you forward if the theatre list runs early. Some medicines need to be paused before surgery, and we will tell you which ones apply to you. Bring a list of everything you take, including tablets, drops and natural remedies. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing that is easy to change out of. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. Most people do not need either. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist, the doctor who puts you to sleep and keeps you comfortable during surgery. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. Afterwards, you will wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Once you are stable, you will either move to a ward or go home, depending on the procedure and how your recovery is going. ## What the operation involves The aim of the operation is to stitch the torn tendon back onto the bone of your upper arm, so the muscle can pull properly again. Your surgeon makes a cut over the front of your chest and shoulder to reach the torn ends. The tendon is then stitched back where it tore away, using strong stitches that hold it to the bone while it heals. If the tear happened some time ago and the tendon ends have shrunk, they may not reach each other directly. In that case, your surgeon can rebuild the tendon using donor tissue, or use a sheet of prepared tissue to reinforce the repair. The choice depends on what your surgeon finds during the operation. The cut is closed with stitches and covered with a dressing. ## After the operation When you wake up, your arm will rest in a simple sling for comfort. The sling comes off for exercises and washing. Your team will tell you whether you go home the same day or stay one night in hospital. Nurses will keep you comfortable with pain relief, and the area around the cut may feel sore for a few days. Please arrange for someone to stay with you for the first 24 hours. You can move around the house as you feel able, keeping your arm in the sling. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your chest and shoulder will feel sore and swollen. Pain relief keeps this comfortable, and the soreness settles over the first week or so. Resting with your arm supported helps, and ice packs can ease the swelling. Your arm rests in a simple sling for comfort. It comes off for exercises and washing. Your physiotherapist will guide you through gentle movements at first, then strengthening work as the repair heals. You can move around the house as you feel able, but you will need help with heavier tasks for a while. Sleeping propped up on your back is often more comfortable in the early days. As the swelling settles and movement returns, everyday tasks get easier. Once your surgeon is happy with how the repair is healing, you will gradually build back to lifting, work and sport. Driving comes later, once you are out of the sling and can hold the wheel with both hands and react in an emergency stop, and you are off strong pain medication. Our guide to driving after upper-limb surgery explains this in detail. Recovery varies from person to person. Your timeline may differ, and your surgeon and physiotherapist will guide you at each step. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the repair does not hold and the tendon tears again. You might feel a sudden pop or give way in your chest, with a loss of strength when you push or pull. Tell your surgeon straight away if this happens. Infection can develop around the wound. Watch for redness that spreads out from the cut, warmth, increasing pain, or fluid leaking from the wound. You may feel feverish or generally unwell. Call the clinic if you notice any of these signs, as infection needs prompt treatment. A collection of blood can form under the wound after surgery. This looks like a firm, tender swelling near the cut, and it may feel tight or throbbing. Mention it at your review, or call the clinic sooner if it grows quickly or is very painful. The shape of the chest may not look quite the same afterwards, even when the repair has healed well. Some people notice a slight difference in the contour of the muscle when they look in the mirror or flex. This is usually a cosmetic issue rather than a painful one, so bring it up at your next review if it concerns you. The shoulder can become stiff and painful some weeks after surgery, a condition called frozen shoulder. You may find it hard to reach up, behind your back, or out to the side, and the stiffness can disturb your sleep. Let your physiotherapist or surgeon know, as early treatment helps restore movement. The complications table on this page lists typical rates if you want the specifics. ## When to call us Trust your instincts. If something feels wrong, call us. Call the clinic if you have a fever, or the wound becomes more red, warm or painful, or fluid starts leaking from it. Call us if a swelling near the cut grows quickly or is very painful. Go to emergency if you have sudden severe chest or arm pain, calf swelling or pain, or shortness of breath. Go to emergency if your arm goes numb, changes colour, or you cannot move it. If you feel a sudden pop in your chest with loss of strength, call us straight away. --- ### Pectoralis Major Rupture URL: https://www.cqupperlimb.com/education/shoulder/pectoralis-major-rupture/ Region: shoulder · condition A chest-muscle tear, classically during a heavy bench press — how to recognise it and why complete tears are usually repaired early. ## What you're feeling Most people remember the exact moment. Often it happens during a heavy bench press, just as the bar is being lowered to the chest, and there's a sudden pop or tearing sensation at the front of the shoulder, with a sharp burst of pain. Within a day or two bruising spreads down the front of the arm and across the chest, and the area swells. As the swelling settles, you may notice the shape of your chest has changed. The normal firm fold at the front of the armpit can flatten or disappear, and the muscle itself may bunch up toward the breastbone, looking or feeling different from the other side. Pushing movements feel weak: closing a heavy door, pressing up out of a chair, or bringing the arm across your body into a hug no longer have their usual power. Some of that early weakness is simply pain, but a genuine loss of pushing strength tends to persist. ## What's actually happening The pectoralis major is the big, fan-shaped muscle of the chest. It powers the arm in three main ways: pushing things away from you, hugging the arm across the body, and rotating the arm inwards. The muscle narrows into a strong tendon that anchors onto the upper arm bone (the humerus), near the shoulder. A rupture is a tearing of that muscle-tendon unit, and it most often gives way right at or near where the tendon attaches to the bone. The usual cause is a sudden, forceful stretch while the muscle is contracting hard (exactly what happens at the bottom of a bench press as the weight is lowered). It is far more common in men, particularly active weight-trainers, and anabolic steroid use is a recognised risk factor because it can weaken the tendon. Tears vary. A complete tear pulls the tendon fully off the bone, which is what produces the obvious change in chest shape and the biggest loss of strength. A partial tear, or a tear within the muscle belly itself rather than at the tendon, leaves more of the attachment intact. Which kind you have matters a great deal for how it's best treated. ## What we can do about it In our clinic, Dr Kieran Hirpara leads the assessment for this injury, starting with a detailed history and examination to confirm the diagnosis. For a complete tear in an active person, repair is usually recommended early rather than after a trial of non-operative care, while partial tears are often managed without surgery. The first step is to work out exactly what has torn and where. That's done by examining the shoulder and confirming it with an MRI scan, which shows whether the tear is partial or complete and pinpoints whether it's pulled off the bone or torn within the muscle. For an active person with a complete tear at the tendon, surgery to reattach the tendon to the bone is usually recommended. Repair restores pushing strength and rebuilds the normal contour of the chest, and the evidence is consistent that repaired tendons recover more strength than tears left to heal on their own. The single most important factor here is timing: results are best when the repair is done early, ideally within the first few weeks while the tendon is still healthy and hasn't scarred or pulled back. This is the main reason it's worth being assessed promptly rather than waiting to see how it settles. Partial tears, tears within the muscle belly, and people who are older or have lower physical demands are often managed very well without surgery: a period of rest, then a graded rehabilitation program to rebuild movement and strength. This route restores good day-to-day function, though it usually leaves some loss of peak pushing power compared with a repaired complete tear. Older repairs are still possible if a complete tear is missed early, but they are more demanding and the results are less reliable, which is exactly why early assessment counts. ## What to expect If you have surgery, recovery is measured in months, not weeks. The repair is protected first, typically with a sling for around six weeks and only gentle, guided movement, to let the tendon knit firmly back to the bone. Strengthening is introduced gradually after that, and harder loading is held back deliberately; pushing exercises and bench pressing are usually off the table for six to nine months. Most people are back to everyday activities by around six weeks and to fuller sport or training by four to six months, with strength still improving up to a year out. The pay-off for that patience is good: most people who have an early repair regain strong pushing power, a restored chest shape, and a return to the activities they care about. Those managed without surgery generally settle to solid everyday function too, accepting a little less peak strength. Sticking with the rehab program and not rushing the heavy pressing is what protects the result either way. ## When to see someone - A sudden pop or tearing in the chest or front of the shoulder during lifting or a forceful effort: get it assessed promptly, because the best surgical results come from repairing early. - Bruising spreading down the arm or chest, marked swelling, or a visible change in the shape of your chest or the front fold of the armpit. - Ongoing weakness with pushing or bringing the arm across your body once the initial pain has settled. - Any tearing injury where you're unsure how bad it is: an early scan sorts a partial tear from a complete one, and that decision is time-sensitive. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Pectoralis major rupture is worth the extra reading because it is one of the clearer cases on this site where surgery outperforms non-operative care, and because the complication rate is high enough to be quoted alongside that benefit rather than after it. ### Repair outperforms non-operative treatment Across 664 patients, pectoralis major tendon repair resulted in significantly superior outcomes compared with non-operative treatment, with statistically significant improvements in functional outcome, isokinetic strength and isometric strength, and an associated complication rate of 14.21% [1]. Both halves belong in the same sentence. This is a repair that restores measurable strength that non-operative treatment does not, and roughly one in seven patients experiences a complication. For most tendon injuries on this site the surgical advantage is smaller and the complication rate lower; here both are larger. The strength deficit matters because of what the muscle does. Pectoralis major drives horizontal adduction and internal rotation, pressing movements, bringing the arm across the body. An unrepaired rupture typically leaves a visible deformity and a specific loss of pressing power, which is why the injury is concentrated in, and matters most to, people who lift. ### Where the tear sits determines what can be done Not all pectoralis ruptures are the same injury. A contemporary classification incorporates injury timing, injury location, and standardised terminology for tear extent, proposed specifically to reflect the musculotendinous anatomy and better inform surgical management [2]. The practical distinction is between a tear at the tendon's attachment to the humerus, which repairs well by reattaching it to bone, and a tear within the muscle belly itself, which has no tendon to anchor and is generally managed non-operatively. Between them sits the musculotendinous junction, which is the difficult group. Timing matters for the same reason it does elsewhere: the torn tendon retracts and scars, so a chronic rupture may require grafting rather than direct repair. ### Why the diagnosis is missed early Immediately after the injury the appearance is dominated by bruising and swelling across the chest and upper arm, which obscures the contour change. The characteristic findings, loss of the anterior axillary fold, asymmetry of the muscle on resisted pressing, and a palpable defect, become clearer as swelling settles, by which time the injury may have been labelled a strain. Given that repair is more straightforward acutely, a distinct pop during a heavy press followed by bruising is worth imaging rather than observing. --- ### Posterior Shoulder Stabilisation URL: https://www.cqupperlimb.com/education/shoulder/posterior-stabilisation/ Region: shoulder · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your assessment we take a history, examine your shoulder and arrange imaging if it is needed. Posterior shoulder instability means the top of your arm bone slips or feels like it will slip out the back of the shoulder socket. It is an uncommon problem, and it is often missed at first, which can delay the right diagnosis. For many people we try non-operative care first, such as activity change and physiotherapy. Surgery is considered when that has not given enough improvement, or when your shoulder keeps giving way. We may suggest this operation if your shoulder is painful or unstable despite other treatment, or if the shape of the bone in your socket needs attention. The operation is a keyhole repair that tightens the soft tissues at the back of the shoulder to hold the joint in place. It aims to relieve pain, restore stability and help you return to your usual activities, including sport. ## Before the operation Before your surgery, we will confirm the scans needed to plan your operation. Plain X-rays of the shoulder are often enough on their own. A CT scan gives a clearer picture of the bone in your socket, and an MRI or ultrasound can show the soft tissues such as the labrum and rotator cuff. You will not need every test, only the ones that answer a question about your shoulder. On the day, stop eating and drinking seven hours before your operation time. We ask for seven hours rather than six so your surgery can be brought forward if the theatre list runs early. Your surgeon will tell you which of your regular medicines to skip. Bring a written list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist, the doctor who puts you to sleep and keeps you comfortable during the operation. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. Afterwards you wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and how your recovery is going. ## What the operation involves The most common form of this operation is a keyhole repair. Your surgeon makes two or three small cuts, each about 1 cm, around the shoulder. A thin camera is placed through one cut so the inside of the joint can be seen on a screen. Small instruments go through the other cuts. Inside the shoulder, the surgeon repairs the ring of cartilage at the rim of the socket where it has torn away, and tightens the loose pouch of tissue that lines the joint. This tightening can be done with a stitching method that folds and holds the slack tissue, and it can sometimes be done through a single small cut. The repair is held with small anchors placed into the bone. The small cuts are closed with stitches and covered with a dressing. Some people need more than soft tissue repair. If a piece of bone at the back of the socket is worn or missing, your surgeon may add a small block of bone to rebuild the rim and hold the arm bone in place. This can be done as a keyhole procedure using a guiding frame and small buttons to hold the bone block while it heals. In other cases the angle of the socket itself is corrected. Your surgeon will explain which approach suits your shoulder and why. The position you lie in during the operation, either sitting up slightly or on your side, is chosen by your surgeon for your procedure. ## After the operation You will wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Your shoulder will be sore, and the nurses will give you medicine to keep you comfortable. Your arm will rest in a sling, which protects the repair while it heals. The small cuts around your shoulder are closed with stitches and covered with a dressing. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. A nurse will help you get up and moving, usually within a few hours. Please have someone stay with you for the first 24 hours after you get home. Your team will tell you whether you go home the same day or stay one night in hospital. ## Recovery Your shoulder will be sore and swollen for the first days and weeks. This is normal after a keyhole repair. Rest, ice packs and the pain medicine your team prescribes will ease the discomfort. The swelling settles gradually as the tissues heal. You will wear a sling at first to protect the repair while it heals. Your physiotherapist will guide you through gentle exercises to bring back movement, then strength. At home you can move around, dress yourself and do light tasks with your other hand. You will not lift anything heavy with the sore arm, and you will not push, pull or reach above your head until the repair is ready. Sleeping can be awkward for a while; many people find it easier to sleep propped up in a chair or with pillows behind them. As the soreness fades and your movement returns, you will do more with the arm. Your physiotherapist will add harder exercises as the shoulder allows. When your surgeon is happy with your progress, you will be cleared to drive again. The rules are simple: no driving while you are in a sling, and you must be able to hold the wheel with both hands and react in an emergency stop, off strong pain medicine. Our guide to driving after upper-limb surgery explains more. Returning to sport takes longer than everyday recovery, because the repair needs time to become strong. Your timeline may differ from other people's; your surgeon and physiotherapist will guide you step by step. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The main concern after this operation is that the shoulder becomes unstable again. You might notice the same slipping or giving-way feeling you had before surgery, or a sense that the joint is about to pop out the back. If this returns, bring it up at your next review. Sometimes a further operation is needed to hold the joint in place. If a block of bone was added to rebuild your socket, a few things can occasionally go wrong as it heals. The bone block might not join to your own bone, or the small screws holding it can bend or break. You could feel a sharp catch, new clicking or grinding, or pain deep in the shoulder that does not settle. The block can also shrink or wear away over time, leaving the metal prominent, and the joint can slowly develop wear-and-tear arthritis. Tell your surgeon about any of these changes so they can check the shoulder with scans. The nerves around the shoulder sit close to the area where a bone block is placed. If a nerve is irritated during surgery, you might notice numbness, tingling or weakness in the arm, or trouble lifting the wrist and fingers. Most nerve irritation settles on its own, but report it straight away rather than waiting for your review. A bone block repair can also leave the shoulder stiffer than before. You might find it harder to reach behind your back or lift your arm out to the side. Your physiotherapist will work on this with you, but mention it if movement is not improving. Some patterns of instability, where the shoulder slips during certain movements without a clear injury, do not respond well to surgery. If that sounds like your shoulder, your surgeon will discuss this with you before any operation. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems are picked up early when you tell us about them. Call us if you have a fever, if the wound becomes more red or starts to leak fluid, or if your pain suddenly gets much worse. Call us about numbness, tingling or weakness in the arm, or if you cannot move it. Go to emergency if your calf is swollen or painful, or if you become short of breath. If your shoulder feels like it is slipping out the back again, let us know rather than waiting for your next review. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Posterior shoulder instability is worth the extra reading because it behaves differently from the anterior version most people have heard of, and the difference runs in the direction you would not guess. ### Posterior is the more stable repair, and the harder return A meta-analysis comparing anterior with posterior instability after arthroscopic repair found that patients with anterior instability had higher return-to-sport rates but were more likely to have postoperative instability [1]. Posterior patients were the reverse: the repair held better, but fewer got back to their sport [1]. That is worth sitting with, because it separates two things patients tend to fuse together. "Will my shoulder stay in?" and "will I get back to what I did?" have different answers here, and the second is the harder one. The underlying results for the operation itself are good. A systematic review of 2,307 arthroscopic posterior stabilisations reported good outcomes with high patient satisfaction and low rates of recurrent instability, revision and residual pain [2]. A separate review of 1,047 athletes found high rates of return to sport, and relatively high rates of return to the pre-injury level [3]. Both findings can be true at once, posterior stabilisation is a reliable operation, and it is still a harder road back than its anterior counterpart. ### What predicts failure The most useful recent work is about who does badly. A systematic review of 960 patients identified three risk factors for failure or revision after arthroscopic posterior capsulolabral repair: female sex, reduced glenoid bone width, and preoperative glenoid bone loss greater than 11% to 15% [4]. Equally informative is what did not predict failure: glenoid version, type of sport, labral width and labral version showed no significant effect [4]. Version in particular is often discussed as though it were decisive, and on this evidence it is not. The practical consequence is that the glenoid bone stock deserves proper assessment before surgery. Beyond roughly the 11–15% mark, a soft-tissue repair alone is working against mechanics it cannot fix, and that is the conversation to have before the operation rather than after a failure. ### Why it gets missed Posterior instability rarely presents as a dislocation. It is more often pain with a loaded, flexed arm, a bench press, a push-up, a hand pushing off a chair, with no history of the shoulder visibly coming out. That presentation invites the label of impingement or tendinopathy, and the diagnosis is frequently made late. If you have pain pushing through a flexed arm and it has not responded to treatment aimed at the rotator cuff, posterior instability is worth specifically excluding. --- ### Shoulder Arthroplasty for Acute Proximal Humerus Fracture URL: https://www.cqupperlimb.com/education/shoulder/proximal-humerus-arthroplasty/ Region: shoulder · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. We start with the least invasive options that suit your condition. For many shoulder fractures this means rest, a sling and physiotherapy first. Most… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. We start with the least invasive options that suit your condition. For many shoulder fractures this means rest, a sling and physiotherapy first. Most fractures of this type heal without surgery, and more than 90% join well with non-operative care. But some fractures are badly displaced, meaning the broken pieces have moved apart. In these cases, especially in older patients, surgery may be recommended straight away. This operation is a shoulder replacement designed for fractures. The rounded top of your arm bone is removed and replaced with an artificial joint. It is typically offered to older patients with complex fractures where the broken pieces cannot be reliably held together. Waiting and trying non-operative care first can lead to worse function and more complications, so we may advise operating soon after the injury. The main aim is dependable pain relief. Improving how much you can move and use your arm is a further goal, though results there vary more from person to person. We will discuss all of this with you and decide together. ## Before the operation Before surgery, you will need some scans so we can plan the operation. X-rays of your shoulder come first. Sometimes an MRI (a scan that shows soft tissues such as tendons) or an ultrasound is added. We will tell you exactly which scans you need. On the day, stop eating and drinking seven hours before your operation time. We ask for seven hours rather than six so we can bring you forward if the theatre list runs early. Your surgeon will tell you which of your usual medicines to stop and when. Bring a written list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. The anaesthetist will meet you before the operation and talk you through both parts. This operation is done under general anaesthetic combined with a regional nerve block. You are then taken into the operating theatre, where the operation is performed. Afterwards, you will wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you will go to the ward. ## What the operation involves This is a shoulder replacement designed for fractures. Your surgeon makes a single cut over the area being operated on and works through it to reach the broken shoulder joint. The rounded top of your arm bone, which is the broken piece, is removed. In its place goes an artificial joint made of metal and plastic, a bit like capping a broken stick with a smooth new ball. The surgeon then rebuilds the parts around the new joint. The lumps of bone near the top of your arm bone, where your shoulder tendons attach, are brought back into position and held to the implant with strong stitches. Getting these pieces back in place and healed matters, because they carry the tendons that move your arm. The surgeon also balances the soft tissues around the joint and sets the new parts so the arm sits at its natural length and angle. Once everything is in place, the wound is closed. A fine, self-adhesive mesh is laid over the closed wound first, holding the skin edges together. A liquid skin glue is then painted over the mesh, where it sets to seal the whole thing. This stays on for roughly one to two weeks and then lifts and peels away by itself, so there is nothing to be taken out. ## After the operation When you wake up, you will be in the recovery area, and nurses will keep a close eye on you as the anaesthetic wears off. Most patients stay one or two nights in hospital after this operation. Your shoulder will be sore at first, and we will give you medicine to keep you comfortable. Your arm will rest in a simple sling for comfort, which comes off for exercises and washing. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. A nurse will help you get up and moving soon after surgery. Please arrange for someone to stay with you for the first 24 hours after you go home. ## Recovery Your shoulder will be sore and swollen in the first days after surgery. This is normal and settles gradually. Ice packs, rest and your pain medicine help ease the discomfort. The nerve block from theatre wears off over the first day, so take your medicine before the pain builds. Your arm rests in a simple sling for comfort. It comes off for exercises and washing. Your physiotherapist will guide you through gentle movements early on, and these exercises matter more than anything else you do. Keep them up even when progress feels slow. You can walk around the house from day one, but you will need help with meals, dressing and shopping at first. Sleeping propped up in a chair or with extra pillows is often more comfortable in the early weeks. Milestones come as events, not dates. When the swelling settles, everyday tasks get easier. As your movement returns, you will reach further and lift a little more. Once your surgeon clears you to drive, typically at the six-week review, you can get back on the road; see Driving after upper-limb surgery. Full recovery takes time, and steady effort with your exercises gives you the best chance of a good result. Everyone heals at their own pace. Your timeline may differ, and your surgeon and physio will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Infection is the most serious problem to watch for. It can show up as a deep, throbbing pain that does not ease with simple painkillers, redness spreading out from the wound, or a fever. Tell us straight away if you notice any of these signs. A deep infection needs prompt treatment, so do not wait for your next appointment. The new joint can sometimes come out of place. You would feel a sudden clunk, followed by pain and an arm that will not move normally. If this happens, contact the clinic urgently or go to the emergency department. The artificial parts can loosen over time. This usually builds gradually rather than suddenly. You might notice pain returning after a period of improvement, along with a clicking or grinding feeling in the shoulder. Bring this up at your next review, where scans can check the joint. The bone around the implant can break. This may follow a fall or a knock, and it feels like a new injury with sudden pain and swelling. Go to the emergency department if this happens. Nerve injury around the shoulder is a known risk of this operation. It can cause numbness, tingling or weakness in the arm. Most nerve irritation settles on its own, but tell your surgeon at review if it does not. Stiffness and ongoing pain can develop after surgery. The shoulder feels tight and movement stays limited despite your exercises. Mention this at your review so your physiotherapy plan can be adjusted. The bone fragments around the implant can sometimes fail to heal, or heal in a shifted position. This can leave the shoulder weaker or less steady than expected. Your surgeon will pick this up on your follow-up scans and discuss options with you. Some patients need a further operation later, sometimes years down the track. Reasons include loosening, dislocation, infection or wear of the joint surfaces. Revision surgery is more complex than the first operation and recovery can be slower. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show early signs, and we would rather hear from you than have you wait. Call us if you have a fever, if the skin around your wound becomes more red or starts leaking fluid, or if your pain keeps getting worse instead of easing. Go to emergency if you suddenly cannot feel or move your arm, if you have swelling or pain in your calf, or if you become short of breath. These can signal a blood clot. Sudden severe pain after a fall or a knock also needs urgent care. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Proximal Humerus Fracture page. --- ### Proximal Humerus Fracture URL: https://www.cqupperlimb.com/education/shoulder/proximal-humerus-fracture/ Region: shoulder · condition Proximal humerus fractures — Neer classification, sling management, and surgical options. ## What you're feeling A proximal humerus fracture is a break in the top part of the arm bone, just below the shoulder. It usually happens during a fall, often onto the shoulder or an outstretched arm. The break comes on suddenly, not slowly over time. The first thing you feel is pain at the top of the arm and shoulder. It often starts the moment you fall. The shoulder may swell and bruise over the next day or two, and the bruising can spread down the arm. Your arm may look out of shape if the broken pieces have shifted. You will probably not want to move the arm, and simple things become hard: getting dressed, reaching into a cupboard, carrying a shopping bag, or rolling onto that side in bed. The pain is often worse at night in the early days, and it can be hard to find a comfortable position. Moving the arm hurts at first. Over the first weeks, as the bone starts to heal, the pain usually settles gradually. The shoulder often feels stiff by the time the pain eases, because it has been still. Most of these fractures happen in women over 70, and they are common in bones that have become thin and fragile with age (this is called osteoporosis). If you have broken a bone before, or you break this one, it can point to a higher chance of another fracture in future. That is worth raising with your GP, who can check your bone health. Some breaks are in several pieces, and some shift out of position. Your surgeon works out the pattern from an examination and X-rays, sometimes with a CT scan, which is a detailed scan that shows the bone more clearly. Most of these fractures heal without an operation, and the bone joins in more than 90% of cases treated this way. Watch for a few signs that need same-day care. Go to the emergency department if your hand or fingers turn pale, cold, white or blue, or if you suddenly lose feeling or movement in the arm after the injury. The same applies if the skin over the break is broken, or if bone is showing. ## What's actually happening The top of your arm bone is shaped like a ball that sits in a shallow socket in your shoulder blade. The socket is small, about one third the size of the ball, so the joint moves freely but relies on soft tissue to hold it steady. Four tendons wrap around the ball and press it down while bigger muscles lift the arm. When the bone breaks, that teamwork is disrupted. The break usually happens because the force of a fall drives the arm bone against the socket, which is harder than the bone around it. The bone acts like a hammer hitting an anvil, and it snaps where the bone is weakest. The broken pieces then get pulled by the tendons attached to them. Each tendon pulls its own piece in its own direction, which is why some breaks end up in several shifted pieces. Even when the pieces stay close to where they belong, the shoulder stops working normally for a while. The tendons around the joint need smooth gliding surfaces to work, and swelling and broken bone disturb that. The lining sacs that let tendon glide over bone can thicken and scar, which is one reason the shoulder stiffens. Moving the arm early, once your surgeon says it is safe, helps limit that scarring. The bone heals by knitting back together, the way a broken bone anywhere in the body does. New bone forms across the break and firms up over weeks to months. If a tendon has pulled off with a piece of bone, the tendon heals as that piece knits back into place. The shoulder is forgiving of a slightly crooked heal, because it is not a weight-bearing joint and the surrounding muscles do much of the work. A few patterns change the picture. A break right at the base of the ball can cut off its blood supply, which affects healing. Breaks lower down usually leave the blood supply intact. If the pieces are badly shifted or unstable, or if the ball itself is broken apart, an operation is more likely to be considered. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some breaks heal without an operation, and others need surgery soon after the injury, so prompt assessment matters. We look at how many pieces the bone is in, how far they have shifted, whether the break is stable, and what your arm needs to do. Your own health and how much pain you are willing to put up with are part of that decision too. Many of these fractures are treated without surgery, including some where the pieces have shifted. Non-operative care means a sling to hold the arm still while the bone knits, not a splint or cast. It is not a matter of leaving you alone: we see you regularly and check the break with repeat X-rays to make sure it is healing in an acceptable position. Once your surgeon says the bone is ready, a physiotherapist guides you back into movement in stages, first gentle assisted motion, then active movement as the bone firms up. The bone joins in more than nine in ten cases treated this way, and the average time to solid healing is 14 weeks. There is a 7% chance the bone is slow to join or does not join, and about 5.6% of people treated this way end up needing an operation after all. Surgery is recommended from the outset for some injuries: breaks that are badly shifted and unstable, breaks where the ball of the joint is broken apart, fracture-dislocations where the joint has come out as well, and injuries in younger or more active people whose arm needs to do more. An operation aims to hold the pieces in a better position while they heal, or, for some severe patterns in older patients, to replace the joint. The choice is genuinely shared in some situations: non-operative care may be possible, but the pain along the way or the final position of the shoulder may not be acceptable to you. We will talk through both paths with you before anything is decided. Whichever path you take, the first weeks are similar. Pain control matters early, and we will help you find positions and simple measures that let you sleep and manage daily tasks. You protect the arm while the bone heals, avoiding lifting and sudden movements. Physiotherapy starts at the right stage for your injury, guided by your physiotherapist, and it is the part of treatment you have the most control over. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. ## What to expect The bone knits slowly. For most people treated without surgery, the average time to solid healing is 14 weeks, and the bone joins in more than nine in ten cases. In the first weeks the pain settles gradually, though the shoulder often feels stiff by the time it does. Over the following months, a physiotherapist guides you back into movement in stages, and everyday tasks like dressing and carrying light things return as the bone firms up. If you have an operation, the first weeks look similar: protecting the arm while it heals, then staged movement with your physiotherapist. The shoulder can take months to feel steady again, and stiffness is common along the way. Surgery holds the pieces in a better position while they heal, but it carries its own risks, including a higher chance of needing another operation later. For some severe patterns in older patients, a joint replacement aims for a better long-term result, though recovery from a replacement is its own process. A few things are worth knowing honestly. There is a chance the bone is slow to join or does not join, and some people treated without surgery end up needing an operation after all. A shoulder that heals in a slightly crooked position often still works well, because the joint is not weight-bearing and the surrounding muscles do much of the work. Stiffness is the most common complaint on either path, which is why the movement exercises matter. Recovery from this injury is usually measured in months rather than weeks. Most people regain comfortable daily use of the arm, though some are left with stiffness or aching that persists. If your symptoms are not settling, are getting worse over weeks, or stop you using the arm, see your GP or ask for a specialist review. ## When to see someone Seek urgent care if your arm looks clearly out of shape after the injury, if the skin over the break is broken, if bone is showing, or if your hand or fingers turn pale, cold, white or blue. Sudden loss of feeling or movement in the arm after an injury also needs the emergency department the same day. If you cannot reach the clinic, go to your nearest emergency department. See your GP or ask for a specialist review if the pain is not settling, or if swelling, movement or use of the arm are not improving week on week as the bone heals. Symptoms that get worse over weeks, wake you at night, or stop you working or using the arm also warrant review. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. A broken shoulder in later life is worth the extra reading because it is one of the clearest cases in orthopaedics where the evidence and everyday practice have not agreed, and where the treatment that sounds more serious is not the one that produces the better arm. ### For most older patients, an operation does not improve the result The comparison has been made repeatedly. Pooling 1,743 patients, a systematic review recommended non-operative treatment for the average patient over 65 with a displaced proximal humeral fracture, noting that the pooled effects of observational studies matched those of the randomised trials [1]. An earlier review of 486 patients had already found no demonstrable difference in outcomes between fractures managed surgically and conservatively [2]. This is counterintuitive, because the X-ray of a displaced proximal humerus fracture looks alarming. The bone is in several pieces and clearly out of position. The instinct, the patient's and often the clinician's, is that something so visibly wrong must be put right. What the trials show is that the shoulder is unusually forgiving of imperfect bony position. It is not a weight-bearing joint, the surrounding cuff and deltoid do much of the work, and the fragments are held by soft tissue that keeps a blood supply to them. A shoulder that heals slightly crooked frequently ends up moving and feeling much like one that was fixed, and it gets there without a wound, an implant, or the risks below. ### The trial changed the evidence and not the practice This is the part worth sitting with. PROFHER was the large randomised trial that tested surgery against non-operative treatment for displaced proximal humerus fractures and found no benefit from operating [6]. A study of 116,868 patients then asked whether practice actually changed after it was published. It did not: PROFHER did not significantly impact rates of operative treatment, with no significant change in the rate of operative treatment per year [3]. That is a finding about medicine rather than about your shoulder, and it is a reasonable thing for a patient to know. If you are offered an operation for this fracture, the right question is not whether surgery is ever appropriate, sometimes it clearly is, but what specifically about your fracture and your arm puts you outside the group in whom it has not been shown to help. ### When surgery is chosen, the operation has shifted None of the above means surgery is never right. Head-splitting fractures, fracture-dislocations, open injuries and younger patients with high demands are all different propositions. Where an operation is done in an older patient, the field has moved decisively toward reverse total shoulder replacement. Pooling 228,523 patients, reverse total shoulder arthroplasty offered better functional outcomes and complication rates than hemiarthroplasty, and a more favourable revision profile than plate fixation, in elderly patients with these fractures [4]. The logic is that a reverse replacement does not depend on the tuberosities healing in good position, and tuberosity healing is precisely what is unreliable in an osteoporotic shoulder. It removes the variable that made the older operations unpredictable. ### What actually predicts your recovery Not, mostly, the fracture pattern. A systematic review of 4,323 patients examining biopsychosocial predictors of recovery found that pre-operative functional status, how well the arm and the person were working before the injury, predicts functional recovery [5]. That is worth understanding correctly. It does not mean recovery is a matter of attitude. It means the strongest single predictor of where you end up is where you started, which is an argument for realistic expectations, and for taking the rehabilitation seriously in the months when the shoulder feels stiff and progress feels invisible. --- ### Proximal Humerus Fracture ORIF (Plate and Nail Fixation) URL: https://www.cqupperlimb.com/education/shoulder/proximal-humerus-orif/ Region: shoulder · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your first visit we take a history, examine your shoulder, and arrange imaging if it is needed to work out what is wrong. This operation is called open reduction and internal fixation. It means the broken bone at the top of your arm is moved back into place and held there, usually with a metal plate and screws, or sometimes with a rod inside the bone. We usually suggest it when the break is badly out of place, or when the bone has broken into several pieces, because those breaks rarely stay put on their own. Many shoulder breaks heal without surgery, so we always weigh up both paths with you. For some people, especially those who are otherwise fit and healthy, surgery gives a better chance of keeping the shoulder moving and working well. The aim is simple: a shoulder that is steady, less painful, and able to do what you need it to do. ## Before the operation Once surgery is planned, we will organise the scans needed to map out the break. This usually means X-rays taken from more than one angle, and sometimes a CT scan, which builds a detailed picture of the bone. An MRI scan or an ultrasound may be used if we need a closer look at the soft tissues around the joint, such as the tendons. Most people need no other tests. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, the doctor who looks after you during the operation. In the days before surgery, we will tell you which medicines to pause, and which to keep taking. You will need to stop eating and drinking for seven hours beforehand. We ask for seven hours rather than a shorter time so we can bring your operation forward if the theatre list runs early. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Bring a list of your current medicines, and wear loose, comfortable clothing that is easy to change out of. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist there. This operation is done under general anaesthetic combined with a regional nerve block. The anaesthetist will meet you before the operation and talk you through both parts. You are then taken into the operating theatre, where the operation is performed. Afterwards, you will wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you go to the ward. ## What the operation involves The operation is called open reduction and internal fixation. Open means your surgeon makes one cut over the area being operated on to reach the broken bone. Reduction means moving the broken pieces back into their normal position. Internal fixation means holding them there with metal. Most often your surgeon uses a plate screwed onto the bone; sometimes a rod placed down inside the hollow middle of the arm bone is used instead. Both hold the break steady while it heals. The choice depends on the shape of your break and the quality of your bone. Sometimes a longer plate is used if the break runs further down the arm bone. If the bone is thin, your surgeon may add extra supports to keep the repair solid. Once the bone is lined up and held firmly, the wound is closed with stitches. A dressing goes over the top, and you keep that dressing on for about 10 days. ## After the operation Most patients stay one or two nights in hospital after this operation. You will wake up in the recovery area, then move to the ward. Nurses will check on you regularly and give you medicine to keep you comfortable. Your arm will rest in a simple sling, which comes off for exercises and washing. A nurse will show you how to move around safely before you go home. Someone should stay with you for the first 24 hours after you get home. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Expect some pain and swelling in the first days and weeks. This is a normal part of healing and usually settles as the bone knits. Rest, ice packs, and the pain medicine prescribed for you will help ease the discomfort. Keep your hand, wrist, and elbow moving early, as your physiotherapist will show you. Your arm rests in a simple sling for comfort. It comes off for your exercises and for washing. Your physiotherapist will guide you through gentle movements at first, then build up to stronger exercises as the break heals. Around the house, you can walk, cook simple meals, and manage light tasks with your other hand. Avoid lifting anything heavy with the sore arm, and do not put weight through it until you are told it is safe. Sleep can be uncomfortable at first. Many people find it easier to rest propped up in a chair or with extra pillows. Milestones come as events, not dates. Once the swelling settles, movement usually feels easier. When your surgeon is happy with how the bone is healing, the sling comes off for good. You can drive again once your surgeon clears you, typically at the six-week review; see our guide on driving after upper-limb surgery. As strength returns, you will start reaching overhead and doing more with the arm. Recovery varies from person to person. Your timeline may differ, and your surgeon and physiotherapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the bone does not knit together as it should. You might notice ongoing pain at the break site, or a feeling that the arm is not getting stronger over time. Tell us at your next review if the pain is not settling. The blood supply to the ball of the shoulder joint can sometimes be affected by the injury. If that happens, the joint may become painful and stiff months later, and movement may not improve as expected. Bring this up at your review so we can arrange scans. The metal holding the bone can shift or loosen. You might feel a new click, a grinding sensation, or pain that returns after a good stretch of improvement. Some people feel a screw or plate near the skin. If any of this happens, contact the clinic. Sometimes a small operation is needed to remove or adjust the metal. The tendons around the shoulder can become irritated. You may notice pain when lifting your arm, or catching at certain angles. Mention it at your review. The shoulder can become stiff and tight. Simple movements like reaching behind you may become hard. Early exercises help prevent this, so keep up your physiotherapy and tell your physiotherapist if movement is not improving. Wound problems can occur. Watch for redness spreading out from the wound, fluid leaking, or a deep, throbbing pain that does not ease with simple painkillers. These signs need a call to the clinic straight away. A small collection of blood under the wound can also cause swelling; let us know if it appears. Nerves near the arm can be bruised during surgery. You might notice numbness, tingling, or weakness in the wrist or hand that was not there before. Report this promptly. Blood clots can form after shoulder surgery. Sudden swelling and tenderness in the calf, or shortness of breath, means going to the emergency department. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us straight away if you have a fever, or if the skin around your wound becomes more red, swollen, or starts leaking fluid. Go to emergency if you have sudden severe pain, sudden swelling and tenderness in your calf, or shortness of breath. These can be signs of a blood clot. Call us if your hand or arm goes numb, feels cold, or you cannot move it. New numbness or tingling in the wrist or hand also needs a prompt call. If you are unsure, ring the clinic and we will guide you. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Proximal Humerus Fracture page. --- ### Reverse Shoulder Arthroplasty URL: https://www.cqupperlimb.com/education/shoulder/reverse-shoulder-arthroplasty/ Region: shoulder · operation Reverse shoulder replacement for severe rotator cuff tears and arthritis—when a traditional replacement isn’t ideal. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We assess you by talking through your history, examining your shoulder, and arranging imaging where it is needed. A reverse shoulder replacement is a joint replacement that swaps the usual ball-and-socket arrangement of the shoulder around, so the ball sits where the socket was and the socket sits where the ball was. We usually suggest it when the rotator cuff, the group of tendons that steadies the shoulder, is badly worn or torn, or when other shoulder problems have not settled with non-operative care such as activity change, physiotherapy, splinting or injections. For some injuries, surgery may be recommended straight away. The operation aims to relieve pain and improve how your shoulder moves and works. Clinical benefits are maintained out to 10 years. We will talk through the benefits and risks with you, and the decision is one you make together with us. ## Before the operation Once you and your surgeon have agreed on a reverse shoulder replacement, we will arrange the tests needed to plan your operation. This usually means X-rays of your shoulder, and sometimes a CT scan, which is a detailed scan that builds a three-dimensional picture of the bone. These images help us plan the position of the new joint parts and measure your shoulder carefully before the day of surgery. You will also be asked about your general health, including any past operations on your shoulder, medicines such as steroids, and conditions like osteoporosis, which is thinning of the bones. Please bring a list of your current medications to your appointment. If you take certain medicines, your surgeon may ask you to stop them briefly before surgery. You will need to fast for seven hours beforehand; we ask for a little longer than usual so you can be brought forward if the theatre list runs early. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, the doctor who gives the anaesthetic. ## On the day On the day of surgery you come to the hospital's surgical admissions unit. You are checked in there and prepared for theatre. You do not go to a ward first. This operation is done under general anaesthetic combined with a regional nerve block. The anaesthetist will meet you before the operation and talk you through both parts. You are then taken into the operating theatre, where the operation is performed. When it is finished, you wake up in the recovery area. Nurses watch you there while the anaesthetic wears off. Once you are stable, you move to a ward. ## What the operation involves Your surgeon makes a single cut over the area being operated on to reach the shoulder joint. The worn-out joint surfaces are removed and replaced with new metal and plastic parts. The usual ball-and-socket arrangement is swapped around, so the ball sits where the socket was and the socket sits where the ball was. This is what makes it a "reverse" replacement. The new parts are designed so the strong muscle that caps your shoulder, the deltoid, can lift the arm instead of the worn or torn rotator cuff tendons. During the operation, your surgeon works carefully around the tendons and other soft tissues of the shoulder. If some of these tissues are in good condition, they are stitched back onto the new implant once it is in place. The new parts are positioned and sized using the plan made from your X-rays and scans before the day of surgery. When the new joint is in place, the wound is closed. A fine self-adhesive mesh is laid over the closed wound first, holding the skin edges together. A liquid skin adhesive is then painted over the mesh, where it sets to seal the whole thing. This stays on for roughly one to two weeks and then lifts and peels away by itself, so there is nothing to be taken out. ## After the operation You will wake up in the recovery area, and once you are stable you move to a ward. Nurses check on you there and give you medicine to keep you comfortable. Your arm rests in a simple sling for support; it comes off for exercises and washing. Most patients stay one or two nights in hospital after this operation. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. A physiotherapist will usually see you before you go home to start gentle movements. Please arrange for someone to stay with you for the first 24 hours after you get home. ## Recovery The first days at home are about rest and comfort. Your shoulder will be sore and swollen, and the sling is there to support the arm between exercise times. Simple pain medicine, taken as directed, usually keeps this manageable. The discomfort tends to ease steadily as the weeks pass, and most people find the swelling settles before the stiffness does. Your physiotherapist will guide your exercises, starting with gentle movements and building up as your shoulder allows. The sling comes off for these sessions and for washing. You will be able to do light tasks around the house with your other hand while the operated arm recovers. Sleep can be awkward at first; many people find it easier resting propped up in a chair or with pillows until lying down feels comfortable again. Milestones come as events rather than dates. Once your surgeon clears you to drive, typically at the six-week review, you can get back on the road; our separate guide covers driving after upper-limb surgery. As movement returns, everyday tasks like dressing and reaching become easier. When your physiotherapist is happy with your strength, you can return to the activities you enjoyed before, and most people who were active before this operation get back to those activities afterwards. Recovery varies from person to person. Your timeline may differ, and your surgeon and physiotherapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the new joint can slip out of place. You might feel a sudden clunk, followed by pain and a shoulder that will not move normally. If this happens, contact the clinic straight away or go to the emergency department. Infection can develop around the new joint. Watch for a deep, throbbing pain that does not ease with simple painkillers, redness spreading out from the wound, or fevers. Tell the clinic promptly if you notice any of these signs. Infection is treated in stages, and most infections around a shoulder replacement can be cleared with this approach. The new parts can work loose over time. This usually shows up as pain that returns or worsens, sometimes with a clicking or grinding feeling. Bring this up at your next review so it can be checked with X-rays. Nerves run close to the shoulder, and they can be bruised or irritated during surgery. You might notice numbness, tingling or weakness in the arm. Often this settles on its own, but mention it at your review so it can be tracked. Small breaks in the bone around the new joint, or in the bony point at the top of the shoulder, can happen. You would feel a sharp pain, often after a fall or a heavy push. Contact the clinic if this occurs. A blood clot can occasionally form after shoulder surgery, typically causing sudden swelling and tenderness in the calf. If you notice this, seek medical attention promptly. Some things raise the chance of problems. Men have a higher chance of complications after this operation for a broken upper arm. Having had a previous rotator cuff repair also raises the chance of infection around the new joint. A steroid injection into the shoulder means waiting at least 4 weeks before surgery, and we will plan around that. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems after this operation show up with warning signs you can spot at home. Call us if you notice fever, increasing redness or discharge around the wound, or pain that keeps getting worse instead of easing. Go to emergency if you have sudden severe pain, your shoulder looks out of shape, or you cannot move the arm. Calf swelling with tenderness, or shortness of breath, needs emergency care straight away. Call us too if you lose feeling in the arm or hand, or notice new numbness and tingling that does not settle. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Reverse shoulder replacement is worth the extra reading because it is the operation that solved a problem previously thought unsolvable, a shoulder with no working rotator cuff, and because its characteristic complication is one most patients have never heard of. ### Why reversing the joint works A normal shoulder is a ball on the arm and a socket on the shoulder blade, and it depends on the rotator cuff to hold the ball centred while the deltoid lifts. Where the cuff is gone, a conventional replacement has nothing to stabilise it and the ball simply rides upwards. The reverse design swaps them: the ball is fixed to the shoulder blade and the socket to the arm. That moves the centre of rotation inwards and downwards, which lengthens the deltoid's lever arm and lets it lift the arm on its own. It is a mechanical solution rather than a biological one: it does not repair anything, but makes the remaining muscle sufficient. That also explains the pattern of what it restores. Overhead elevation usually returns well. Rotation depends on muscles the operation does not replace, so reaching behind the back often remains limited, and that should be part of the expectation set before surgery rather than a disappointment after it. ### Where it has displaced older operations For fractures, the shift has been decisive. Pooling 228,523 patients, reverse total shoulder arthroplasty gave better functional outcomes and complication rates than hemiarthroplasty, and a more favourable revision profile than plate fixation, in elderly patients with proximal humerus fractures [1]. An implant detail worth knowing, because it is often raised: comparing standard components with fracture-specific components in reverse replacement for these fractures across 436 patients found no significant differences in clinical outcomes or complication rates [2]. ### The complication to know about The one that matters here is the acromial or scapular stress fracture, the bone above the joint cracking under the increased deltoid tension the design deliberately creates. It is the direct consequence of the mechanism that makes the operation work. A meta-analysis identified the risk factors: patients who sustained these fractures were older with lower BMI, and other risks included osteoporosis, inflammatory arthritis, female sex and previous rotator cuff repair [3]. A separate review found the literature reports these fractures inconsistently, significant discrepancies in how they are defined, diagnosed and counted [4], so quoted rates should be read with caution. Set against that, the short-term picture is reassuring: overall rates of mortality and medical and surgical complications are low in the first 90 days, with only 6% of patients requiring readmission [5]. ### Two things the evidence does not support That the subscapularis must be repaired. Across 267 patients, there were no differences in abduction, internal rotation or external rotation strength after reverse replacement with or without subscapularis repair, though the authors note the literature on strength outcomes is limited [6]. That the indication does not affect the result. It does. At two or more years, Constant scores were significantly higher in patients having reverse replacement for primary osteoarthritis with an intact cuff than for primary osteoarthritis with cuff tears or for secondary osteoarthritis [7]. The same operation gives different results depending on why you needed it, which is worth knowing when you are quoted an average. --- ### Revision rotator cuff repair URL: https://www.cqupperlimb.com/education/shoulder/revision-rotator-cuff-repair/ Region: shoulder · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your shoulder, and arrange imaging where needed. For a long-standing problem we usually try non-operative care first, such as activity change, physiotherapy or injections. Surgery comes into the picture when those steps have not given you enough improvement. A revision rotator cuff repair is a second operation to re-repair a shoulder tendon that tore again or never healed after an earlier repair. We suggest it when pain, night pain, weakness, or stiffness continue despite that earlier treatment. Scans such as an ultrasound or MRI help us check the tendon and the muscle around it before deciding. The operation aims to ease your pain and improve how your shoulder moves and works. Many people keep that improvement at 5 years after surgery. We will talk through the benefits and the risks with you, and the decision is one you make together with us. ## Before the operation Before surgery we arrange scans to plan the operation. These may include X-rays, an ultrasound, or an MRI (a scan that shows the soft tissues around your shoulder in detail). On the day of your operation, you will need to stop eating and drinking seven hours beforehand. We ask for seven hours so we can bring your surgery forward if the theatre list runs early; your surgeon will confirm your exact time. If you take regular medicines, bring a list of them and we will tell you which ones to pause. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing that is easy to put on and take off. If you have other medical conditions, you may need blood tests or a review with the anaesthetist (the specialist who gives your anaesthetic). ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist. This operation is done under general anaesthetic combined with a regional nerve block. You will be fully asleep for the operation, and the block (an injection that numbs the nerves supplying the arm before you wake up) provides pain relief for the first 12 to 24 hours after surgery. The anaesthetist will meet you before the operation and talk you through both parts. You are then taken into the operating theatre, where the operation is performed. When it is finished, you wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves A revision rotator cuff repair is done through keyhole surgery. Your surgeon makes a few small cuts around your shoulder, including one at the back, and works with a small camera inside the joint. The camera shows the torn tendon and the bone it tore away from. The usual plan is to reattach the tendon with small anchors placed into the bone. These anchors hold stitches that pass through the tendon. Anchors are placed in two rows: one row closer to the joint, and a second row further out that pulls the tendon down firmly against the bone where it needs to heal. Depending on what your surgeon finds during the operation, they may use a single row of anchors instead, or a different type of anchor closer to the joint. A soft patch made from biological tissue is often placed under the tendon at the repair site to encourage it to heal back onto the bone. You can read more about this in our page on the EnFix biological scaffold. If the bone where the tendon attaches has worn away, your surgeon may add a small amount of bone graft to rebuild it, so the anchors have something solid to grip. If the tendon is too damaged to reattach, other options such as using a donor tendon to bridge the gap may be discussed with you before or during your care. The cuts are closed with stitches, and a dressing is placed over the wounds. You keep that dressing on for about 10 days. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You will wake up in the recovery area, then move to the ward. Nurses will check on you and give you pain relief as you need it. The nerve block from theatre often keeps the shoulder comfortable for the first 12 to 24 hours, so you may notice little pain at first. Your arm will rest in a simple sling for comfort. You can take it off for washing and for the exercises we show you. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. A nurse will help you sit up, stand, and walk a short distance, usually within a few hours of waking. Please arrange for someone to stay with you for the first 24 hours after you go home. ## Recovery The first days after surgery are about rest and comfort. The nerve block wears off within a day or so, and the shoulder may then ache more than before. Swelling and bruising around the shoulder and upper arm are normal and settle over the following weeks. Ice packs, rest, and the pain relief we prescribe all help ease this. Many people find sleeping upright in a chair or propped on pillows more comfortable at first, as lying flat can put pressure on the shoulder. Your arm rests in a simple sling for comfort. You take it off for washing and for the exercises your physiotherapist shows you. These exercises start gently, with small movements to keep the shoulder from stiffening while the tendon heals. Over time the movements grow bigger and stronger, always guided by your physiotherapist and your own comfort. Day to day, you can walk, move around the house, and use your other arm freely. You will need help with heavier tasks such as lifting, carrying, and reaching overhead until your shoulder is ready. Once the swelling settles and movement returns, everyday activities become easier. Dressing, washing, and light household tasks come back first. Driving waits until your surgeon clears you at your review, typically around the six-week mark; see our guide on Driving after upper-limb surgery for details. Work and sport come back in stages, once your surgeon and physiotherapist agree the tendon has healed well enough. Recovery varies from person to person. Your timeline may differ, and your surgeon and physiotherapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The main thing we watch for is the tendon tearing again. This can feel like pain that returns after it had started to settle, along with weakness when you lift or reach. Most tears that happen again do so within the first six months, so we keep a close eye on your shoulder during that time. If your pain or weakness comes back, tell us early rather than waiting for your next review. Infection is uncommon but needs quick attention. See your GP or go to the emergency department if you notice a deep, throbbing pain that does not ease with simple painkillers, redness spreading out from the wound, fever, or a shoulder that feels hot. Sometimes a repair that has failed can be linked to a low-grade infection that is hard to see. Severe shoulder pain or stiffness that will not settle should always lead to a check for infection, so mention it to us. Not every revision reaches the goal of a pain-free, strong shoulder. Some people find their movement does not improve as much as they hoped, or that stiffness and weakness stay. If the tendon tissue is thin, the tear is large, or arthritis has set in, the result may be less than either of us wants. We will talk honestly with you about what your scans show before you decide. There are also things that raise the risk of the repair failing. Certain antibiotics taken early after surgery have been linked to repairs failing and needing a second operation. If you are prescribed any new medicine in the weeks after your repair, it is worth checking with us or your GP first. Cholesterol problems in your blood can also affect how well the tendon heals, so we take your general health into account when we talk about what to expect. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if you notice a fever, redness spreading from the wound, discharge from the wound, or pain that keeps getting worse. Tell us early if pain or weakness returns after it had started to settle, or if your recovery milestones slip backwards. Go to emergency if you have sudden severe pain, calf swelling, shortness of breath, loss of feeling in your arm, or you cannot move your arm. Most tears that happen again do so within the first six months, so we keep a close eye on your shoulder during that time. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Rotator Cuff Disorders page. --- ### Revision Shoulder Replacement URL: https://www.cqupperlimb.com/education/shoulder/revision-shoulder-replacement/ Region: shoulder · operation Revision shoulder replacement — addressing failure of prior shoulder replacements with a reverse design. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your first visit we take a history, examine your shoulder, and arrange imaging where it is needed. For long-standing problems we usually try non-operative care first, such as activity change, physiotherapy, or splinting, and we consider surgery when that has not given enough improvement. A revision shoulder replacement is a second operation that replaces some or all of the parts of an earlier shoulder replacement. We suggest it when the first replacement is no longer working well, most often because the parts have worked loose, the joint has become unstable, or the socket has worn. Severe pain and stiffness are the main reasons people come to us for this operation. The aim is less pain, better movement, and a steadier shoulder. Revision reverse shoulder replacement has an implant survival rate of 85% at ten years. We will talk through what this operation can and cannot do for you, and decide together whether it is right for you. ## Before the operation Your shoulder will need imaging so we can plan the operation. Plain X-rays from a few angles are usually enough. Sometimes an MRI (a scan that shows soft tissues) or an ultrasound is added. Before the day of surgery, you will get clear instructions from our team. You will need to stop eating and drinking for seven hours beforehand. We ask for seven hours rather than the usual six so you can be brought forward if the theatre list runs early. Bring a written list of all your current medicines, as some may need to be paused. Arrange for someone to drive you home. Wear loose, comfortable clothing. If you have other medical conditions, you may need blood tests or a review with the anaesthetist (the specialist who gives the anaesthetic). ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist. This operation is done under general anaesthetic combined with a regional nerve block. The anaesthetist will meet you before the operation and talk you through both parts. You are then taken into the operating theatre, where the operation is performed. When it is finished, you will wake up in the recovery area. Nurses will monitor you there while the anaesthetic wears off. Once you are stable, you will move to the ward. ## What the operation involves A revision shoulder replacement is an open operation done through a single cut over the area being operated on. Your surgeon works through this one incision to reach the joint. The exact steps depend on why the first replacement failed. Your surgeon may remove some or all of the worn or loose parts and replace them with new metal and plastic surfaces. If the socket bone has worn away, a small bone graft (a piece of bone used to rebuild a missing area) can be packed in so a new socket part can be fitted. Whenever possible, your surgeon will try to fit a new socket component rather than leave it out. If the joint has been unstable, your surgeon may change the design of the replacement to a reverse one, where the ball and socket positions are swapped to make the joint steadier. Sometimes the old cement around the arm-side part is kept and new cement is placed inside it, rather than removing every trace. Once the new parts are in place and checked, the wound is closed. A fine self-adhesive mesh is laid over the closed wound first, holding the skin edges together. A liquid skin adhesive is then painted over the mesh, where it sets to seal the whole thing. This stays on for roughly one to two weeks and then lifts and peels away by itself, so there is nothing to be taken out. ## After the operation You will wake up in the recovery area with nurses watching over you. Once you are steady, you will move to the ward. Most patients stay one or two nights in hospital after this operation. Pain relief is tailored to you, and the nerve block from theatre often keeps the shoulder comfortable at first. Your arm will rest in a simple sling for comfort; it comes off for exercises and washing. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. A physiotherapist may visit to start gentle movements. Please arrange for someone to stay with you for the first 24 hours after you go home. ## Recovery The first days are about rest and comfort. Your shoulder will be sore and swollen, and the nerve block from theatre often keeps it quiet at first. As that wears off, you will feel more of the ache. Pain relief tailored to you, rest, and gentle movement all help. The swelling settles gradually over the early weeks. Your arm rests in a simple sling for comfort. It comes off for exercises and washing. A physiotherapist will guide you through gentle movements early on, then build up your strength and range of motion as your shoulder allows. Around the house, you will need help with heavier tasks at first, but light use of your arm returns steadily. Sleeping upright or propped on pillows is often more comfortable in the early days. Recovery happens in stages rather than all at once. Once your surgeon clears you to drive, typically at the six-week review, you can get back on the road; see our guide on driving after upper-limb surgery. As movement returns, everyday tasks like dressing and cooking become easier. When your shoulder is strong enough, most people get back to work and many return to a sport or activity they enjoy. Many people notice their shoulder keeps improving over the first year. Your timeline may differ from someone else's. Your surgeon and physiotherapist will guide you at each review and adjust the plan to suit how your shoulder is healing. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the new parts work loose or the joint becomes unstable. You might feel a return of the pain you had before, or a new ache that was not there after the operation. Some people notice a clicking, grinding, or clunking feeling, or a sense that the shoulder is shifting out of place. If this happens, bring it up at your next review, or call the clinic sooner if the pain is getting worse. Infection is a risk with any replacement surgery. Watch for a deep, throbbing pain that does not ease with simple painkillers, redness that spreads out from the wound, warmth over the shoulder, or a fever. If you notice any of these, call the clinic straight away. If you feel unwell with a fever or the redness is spreading quickly, go to the emergency department. Sometimes a break can happen in the bone around the new parts, most often picked up on early X-rays after the operation. You would feel sudden sharp pain, worse than the usual postoperative ache, sometimes with a crack or give. Tell your surgeon or the clinic if this happens. Some health conditions and circumstances raise the chance of problems. These include Parkinson disease, poor nutrition before surgery, a fragility fracture (a break from a minor fall) before the operation, previous shoulder surgery, inflammatory arthritis (arthritis caused by an overactive immune system), needing blood-thinning medicine after surgery, and having both shoulders operated on close together. If any of these apply to you, we will factor them into the plan and watch you more closely. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call the clinic if you have a fever, increasing redness or discharge from the wound, or pain that keeps getting worse. Go to the emergency department if you feel suddenly short of breath, have swelling or pain in your calf, or your shoulder pain becomes sudden and severe. Call us straight away if you lose feeling in your arm or hand, or you cannot move it. If in doubt, call us. We would rather hear from you early. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Shoulder Arthritis page. --- ### Rotator Cuff Disorders URL: https://www.cqupperlimb.com/education/shoulder/rotator-cuff-disorders/ Region: shoulder · condition Rotator cuff disorders: common causes of shoulder pain, ranging from mild ache to debilitating injury. ## What you're feeling Rotator cuff pain usually sits at the front or outer side of your shoulder. It can spread down toward the middle of your arm. Lifting your arm overhead, reaching up to a shelf, or lifting something with your arm held out from your body tends to make it worse. Many people notice the pain most at night, and it can wake you or make it hard to sleep on that side. Some people feel it first thing in the morning as well. The pain often starts slowly, without any injury you can point to, especially if you do a lot of overhead work or sport. In other cases it comes on suddenly after a fall or a strain, with pain and weakness straight away. Weakness is a key part of the problem. You might struggle to lift your arm out to the side, hold it up, or turn your arm outward. Everyday jobs like hanging washing, reaching behind you, or lifting a kettle can become hard or painful. The pattern of your symptoms can vary. Some people have mild to moderate pain with overhead movement and only occasional night pain. Others have constant pain, night pain, weakness and stiffness together. If the problem has been there a long time, the muscles around the shoulder blade can lose some bulk, and the joint may feel stiff or grind. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm, see your GP or ask for a specialist review. ## What's actually happening Your rotator cuff is a sheet of four tendons that wrap around the shoulder joint and connect to the top of your arm bone. They work together like the guy ropes holding up a tent. Every time you lift your arm, these tendons pull the ball of the joint firmly into its socket so the arm moves smoothly instead of wobbling. The trouble usually starts in the space above the tendons. A small shelf of bone and a ligament form an arch over the top of the shoulder, and a thin fluid-filled sac sits between the arch and the tendons so they can glide. With repeated overhead movement, or as the tendon ages, the tendons can get squeezed and rubbed under this arch. The tendon fibres fray like a rope wearing against a rough edge. Over time the fraying can become a partial tear, then a tear that goes all the way through. The tendons also have a patch with a poor blood supply, near where they attach to the arm bone. Tissue with little blood flow heals slowly, which is why these tears often do not settle on their own. As a tear grows, the muscle it is attached to can waste away and fill with fat, and the longer a tear is left, the harder it is to repair. The problem sits on a spectrum. It begins with irritation and rubbing under the arch, moves through partial and then full tears, and in long-standing cases ends with the ball riding upwards because nothing is holding it down, wearing the joint away. Tears are graded by size, from small (less than 1 cm) to massive (larger than 5 cm or involving two tendons). Bigger tears tend to cause more weakness and are more likely to need surgery. Sometimes calcium crystals form inside the tendon instead. This can be very painful for a while, but it usually settles by itself. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your shoulder, and arrange imaging where it is needed. Then we work through the options with you. The first step is usually changing how you use your shoulder and giving the tendon time to settle. That means resting from the movements that aggravate it and adjusting work or sport for a while. Physiotherapy is the mainstay of non-operative care. It aims to restore movement in the shoulder, strengthen the muscles that steady your shoulder blade, and build up the rotator cuff itself. A course of 6 to 12 weeks is a reasonable trial. For many people with a full-thickness tear, this approach is enough: non-operative treatment succeeds in 60% of patients, and in 75% after 2 years. Most partial-thickness tears also settle without surgery. Pain relief and anti-inflammatory tablets (NSAIDs) can help you stay active while the tendon settles. A cortisone injection into the space above the tendon can settle pain, though the evidence for it in rotator cuff problems is limited, and we weigh it carefully if surgery is a possibility later. Injections of PRP (a preparation made from your own blood) have not shown a clear benefit in the short term for chronic rotator cuff disease. For calcific tendinitis, where calcium crystals form inside the tendon, there are more options: steroid injection with physiotherapy, shockwave therapy (which directs sound waves at the calcium), ultrasound-guided needle washing of the deposit, or keyhole washing out of the tendon. Surgery enters the picture when non-operative care has not given enough improvement, or when a tear is acute and full-thickness. The standard operation is a keyhole (arthroscopic) repair, where the tendon is stitched back down to the bone using a camera inserted through small cuts. Some tears are better managed with repair, others with tidying up of the tendon (debridement); for partial tears, tears involving more than 50% of the tendon width are usually repaired and smaller ones debrided. We will talk through what your scan and examination show, and decide together whether surgery is the right next step for you. ## What to expect Rotator cuff pain tends to come and go. It often settles for a while, then flares again, and the underlying wear keeps moving slowly over time. In a long-standing tear that is left alone, the joint itself can eventually wear away. Most rotator cuff problems respond well to treatment without surgery, and you have already read how often that works for full-thickness tears. If you go down the non-operative path, improvement usually builds over the first year and then levels off. Many people notice the change as being able to do more with less pain, such as reaching overhead or sleeping on that side again. Your own belief that physiotherapy will help is one of the stronger predictors of whether it does. Pain and how long you have had symptoms do not tell us how severe the tear is, so a painful shoulder does not always mean a large tear, and a quiet one does not always mean a small one. Tears can grow even without symptoms. Among tears causing symptoms, 53% grow larger over at least 6 months, and 48% of those followed for at least 18 months grow. Growth is more likely after age 60, happening in 54% of tears compared with 17% in younger people. Even tears that cause no pain at all grow in about half of cases, typically within about 2.8 years. A tear that grows can become harder to repair later, which is part of why we monitor rather than simply wait. If surgery is the right path, most people improve steadily over the first 6 months after repair, and further gains continue after that. The repaired tendon itself does most of its healing in that first 6 months, which is the window when a repair is most at risk. About 20% of repairs fail and the tendon tears again, and larger tears carry a greater chance of this. Healing is less likely with older age, smoking, diabetes, osteoporosis (thin bones), high cholesterol, or a larger, more retracted tear. For very large, long-standing tears with arthritis already in the joint, treatment aims mainly at pain relief, and results are generally not as strong as for smaller tears. ## When to see someone Most shoulder pain here is a mechanical problem, so the warning signs are about how the pain behaves and what your arm can still do. See your GP if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm. Ask for a specialist review sooner if you notice real weakness, such as being unable to lift your arm out to the side or hold it up, especially after a fall or strain. Night pain combined with weakness after age 65 is a strong pointer to a tear in the cuff, so mention both together. Pain at the front of the shoulder, or pain that came on with no injury at all after months of overhead work, is also worth having examined. If a tear is suspected but the picture is unclear, your GP or specialist can use simple in-room tests, and sometimes a numbing injection into the space above the tendon, to work out whether the tendon is partly or fully torn. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Rotator cuff disorders are worth the extra reading because of one epidemiological fact that reframes every scan report: cuff tears are so common in people without symptoms that finding one does not establish it is causing your pain. ### A torn cuff is a normal finding with age Pooling 6,112 shoulders, the prevalence of rotator cuff abnormalities in asymptomatic people is high enough that degeneration of the rotator cuff should be considered a common aspect of normal human ageing, and high enough to make it difficult to determine when an abnormality is new, or is the cause of symptoms [1]. That is an unusually direct statement from a systematic review, and it should change how a scan report is read. A tear found on your MRI is not automatically the explanation for your pain; it may have been there for years, silently, as it is in a large share of people your age with no shoulder complaint at all. The clinical consequence is that the diagnosis rests on whether the examination and the history match the imaging, not on the imaging alone. It is also why treating the scan rather than the patient is a recognised trap here. ### Surgery helps, and the size of the benefit is the honest part For degenerative full-thickness tears, surgery does outperform the alternatives. Across 677 patients, surgical repair produced significantly improved outcomes compared with either conservative treatment or subacromial decompression alone in older patients, with the authors adding that the magnitude of the difference between surgery and conservative treatment deserves attention [2]. A separate comparison across 269 patients found statistically significant differences favouring surgery in both Constant and pain scores at one year [3]. So repair wins, but the authors of the larger study are careful to flag effect size rather than just direction. A difference can be statistically real and still smaller than what a patient would notice, which is why the choice remains genuine rather than obvious, particularly for someone whose demands are modest or whose tear is unlikely to be repairable. ### Exercise is not a single treatment, and the type appears to matter Non-operative management is usually described simply as "physiotherapy", which obscures a real finding. Comparing seven types of exercise across 947 patients, concentric strengthening training performed best for both shoulder pain and dysfunction, with eccentric strengthening and motor control exercise as alternatives where concentric work is unsuitable [4]. That is worth knowing because it makes "I tried physio and it didn't help" a question rather than a conclusion, what was actually done, for how long, and was it progressive strengthening or a handout of stretches. ### The operation that gets added, and does not need to be Acromioplasty, shaving bone from the undersurface of the acromion, is frequently performed alongside cuff repair on the reasoning that it removes a source of impingement on the repair. The evidence does not support the addition. Across 373 patients, there was no statistically significant difference in subjective outcome after arthroscopic rotator cuff repair with or without acromioplasty at intermediate follow-up [5]. If it is proposed as an addition to your repair, that is a reasonable thing to ask about. --- ### Rotator Cuff Repair URL: https://www.cqupperlimb.com/education/shoulder/rotator-cuff-repair/ Region: shoulder · operation Rotator cuff repair reattaches torn tendons to bone, improving pain and function when conservative treatment fails. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We assess your history, examine your shoulder, and arrange imaging where it is needed to work out what is wrong. Rotator cuff repair is an operation that reattaches a torn shoulder tendon to the bone of your upper arm. A rotator cuff is the group of tendons that holds and moves your shoulder. We usually suggest this operation when the tear is causing pain that wakes you at night, pain with lifting or overhead activity, or weakness that has not settled with non-operative care such as activity change and physiotherapy. For long-standing wear-and-tear tears we try those options first. For a tear caused by a clear injury, surgery may be recommended straight away. The aim is lasting relief of pain and better strength and movement in your shoulder. Surgical repair offers a higher probability of substantial improvement for painful tears over the long term, and we will weigh this up with you as a shared decision. ## Before the operation We will need imaging to plan your repair. This usually includes an X-ray, and often an MRI or ultrasound scan of your shoulder. These scans show the size of the tear, how far the tendon has pulled back, and the state of the muscle. In the days before surgery, follow the instructions our team gives you. Stop taking certain medications only if we tell you to, as your surgeon will give you specifics. Bring a written list of everything you take, including tablets, drops and creams. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing that is easy to put on over your shoulder. Do not eat or drink for seven hours before your operation. We ask for seven hours so your surgery time can be brought forward if the theatre list runs early. If you have other medical conditions, you may need blood tests or a review with the anaesthetist before the day. ## On the day On the day of your operation, you will arrive at the hospital's surgical admissions unit. You will be checked in there and prepared for theatre. You will not go to a ward first. This operation is done under general anaesthetic combined with a regional nerve block. The anaesthetist will meet you before the operation and talk you through both parts. You will then be taken into the operating theatre, where the operation is performed. When it is finished, you will wake up in the recovery area. Nurses will monitor you there while the anaesthetic wears off. Once you are stable, you will either move to a ward or go home, depending on the procedure and how your recovery is going. ## What the operation involves This is a keyhole operation. Your surgeon makes a few small cuts around your shoulder, including one at the back, and works with a small camera inside the joint. The camera gives a clear view of the tear from several angles, so the whole joint can be checked and the tear cleaned up before it is repaired. The repair itself uses two rows of small anchors set into the bone where the tendon normally attaches. The ones nearer the joint are soft suture anchors, made of suture material rather than hard plastic. Their stitches are passed through the torn tendon. Those same stitches are then held further out by a second row of strong medical-grade plastic anchors, and it is this outer row that pulls the tendon down and presses it flat against the bone. Two rows spread the hold over a broad area of tendon rather than gripping it at a single line of points. Often, a biological scaffold is placed under the tendon at the repair site to encourage it to heal back onto the bone. You can read more about this in our section on the EnFix biological scaffold. When the repair is finished, the small cuts are closed with stitches and covered with a dressing. You will go home with that dressing in place, and our team will tell you when it comes off. ## After the operation You will wake up in the recovery area, then move to a ward. Your arm will rest in a simple sling for comfort, and it comes off for exercises and washing. Nurses will check your pain and give you medication to keep it comfortable. Most patients stay one night in hospital after this operation, though some are able to go home the same day. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Someone should stay with you for the first 24 hours. You can start gentle movements as our team directs, and you will be up and walking the same day. You must not drive while you are in a sling. Once your surgeon clears you, typically at the six-week review, you can drive again. Read more in Driving after upper-limb surgery. ## Recovery In the first days and weeks your shoulder will be sore and may feel swollen. This settles gradually. Pain relief and rest help, and most of the discomfort eases as the early weeks pass. Most of your pain relief and improvement in movement happen in the first six months, but things keep getting better for up to two years. Your arm rests in a simple sling for comfort, and it comes off for exercises and washing. Your physiotherapist will guide you through gentle movements first, then strength work as the tendon heals. You can walk and move around at home straight away, but you will need help with things like dressing and carrying. Sleeping can be uncomfortable at first, and many people find it easier to rest propped up. Sleep improves steadily as the shoulder settles. Some milestones happen as events rather than dates. Once your surgeon clears you to drive, you can get back behind the wheel. When your physiotherapist is happy with your movement and strength, you can return to light activities, then heavier ones. Most people are back at work within eight months, though this depends on the type of work you do. Recovery varies from person to person. Your timeline may differ, and your surgeon and physiotherapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The most common problem is that the repaired tendon does not hold. You might notice your shoulder pain or weakness coming back, sometimes after a stumble or a heavy lift. Tell your surgeon at the next review if this happens. Stiffness can develop as the shoulder heals. Your shoulder may feel tight, and you might struggle to reach behind your back or above your head. Most stiffness settles with physiotherapy, so raise it with your physiotherapist or surgeon early rather than waiting. Infection is uncommon but needs quick attention. Watch for a deep, throbbing pain that does not ease with simple painkillers, redness spreading out from the wound, fever, or fluid leaking from the stitches. Contact the clinic the same day, or go to the emergency department if you feel unwell or the redness is spreading quickly. A blood clot in a vein is rare. The signs are sudden swelling and tenderness in the calf. If you notice this, seek medical care straight away. The small anchors holding the tendon can occasionally cause irritation. You might feel a clicking or grinding sensation, or ongoing pain that does not settle. Mention it at your review so your surgeon can assess it. Nerve irritation near the shoulder happens rarely. It can cause tingling, numbness or odd sensations down the arm. Bring it up at your next appointment. Some people keep having shoulder pain after the repair, even when the tendon has healed. If pain persists, your surgeon will examine you and discuss what further options might help. If you have other significant health conditions such as diabetes, or a weakened immune system, mention these at your planning visit. They can affect healing, and we watch these patients more closely after surgery. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems after this operation are uncommon, but a few need quick attention. Call us if you have a fever, if the wound becomes more red or starts leaking fluid, or if your shoulder pain suddenly gets much worse. Go to emergency if you notice swelling or tenderness in your calf, or if you become short of breath, as these can be signs of a blood clot. Call us straight away if your arm feels numb, if you cannot move it, or if tingling down your arm does not settle. If you feel unwell and are worried, trust your instincts and seek care. We would rather hear from you than have you wait. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Rotator cuff repair is worth the extra reading because the factors that best predict your result are largely not surgical, and two of the strongest are things you can act on before the operation. ### Smoking changes the tendon, not just the wound Smoking is mentioned in every consent discussion and usually filed under wound healing. The tendon data are more specific than that. Pooling 73,817 patients, smokers had a significantly higher retear rate after rotator cuff repair, while most clinical scores were similar between smokers and non-smokers apart from a lower Constant score [1]. That combination is the interesting part. The scores look broadly alike, but the repair is more likely to have failed structurally underneath. Smoking is not making the operation feel different; it is making it less likely to hold. The corollary is that the weeks around surgery are the highest-value moment in a lifetime of being told to stop. The tendon is attempting to reattach to bone, and that is a blood-supply-dependent process. ### Deprivation predicts outcome as strongly as biology This is the finding that most changes how the operation should be discussed. In a review of 102,372 patients, social determinants of health, the circumstances people live in, not their tendon anatomy, were associated with worse clinical and patient-reported outcomes after rotator cuff repair, including more postoperative complications and more failed repairs [2]. Rehabilitation after a cuff repair takes months, requires attending appointments, and requires being able to not use the arm. Those are conditions of life as much as decisions. When they are absent the repair does worse, and that is a fact about the treatment pathway rather than a judgement about the patient. If getting to therapy or taking time off work is going to be hard, that belongs in the pre-operative conversation, where the plan can be built around it. ### Stiffness afterwards is common, and the risk factors are not obvious Loss of movement after repair is the complication patients least expect. Pooling 23,257 patients, the available evidence pointed to male sex and increased age as probable protective factors against postoperative shoulder stiffness [3]. Both run against intuition, older shoulders are assumed to stiffen more readily, and that is apparently not what happens here. The practical use is expectation-setting: a younger woman having a cuff repair should be told stiffness is a real possibility for her specifically, and early motion work matters, rather than being reassured with an average. ### What this means for your decision None of this argues against the operation. It argues that the published success rate is an average across people whose smoking status, circumstances and demographics differ from yours, and that your own figure is movable. Stopping smoking, and arranging in advance for the rehabilitation to be attendable, are interventions with evidence behind them, which is more than can be said for most of what patients are asked to worry about. --- ### Scapulothoracic bursectomy URL: https://www.cqupperlimb.com/education/shoulder/scapulothoracic-bursectomy/ Region: shoulder · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment, including your history, an examination and imaging where needed, establishes the diagnosis. Snapping scapula syndrome happens when the shoulder blade grates or clicks as it moves over the ribs. It is usually caused by an inflamed bursa, a thin cushion of tissue between the blade and the ribs, sometimes with a bony prominence at the upper inner corner of the blade. Most people improve without surgery, with physiotherapy, anti-inflammatory medicine, activity change and an image-guided injection into the bursa, usually tried for several months. We suggest this operation when that care has not given you enough improvement. The operation removes the inflamed bursa in the space between the shoulder blade and the ribs, and trims a prominent corner of the blade if one is found. It aims to relieve your pain and improve how your shoulder works. ## Before the operation By this stage you will usually have had scans to plan the operation, such as an X-ray, an ultrasound or an MRI, which shows the soft tissues around your shoulder blade in detail. Your surgeon will give you clear instructions for the day itself. You will be asked not to eat or drink for seven hours before your operation, so we can bring you forward if the theatre list runs early. Bring a list of your current medicines, and tell us about any medicines you take regularly, as some may need to be paused beforehand. Arrange for someone to drive you home afterwards. Wear loose, comfortable clothing that is easy to change out of. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist, the doctor who looks after your sleep and comfort during the operation. This operation is done under general anaesthetic, so you will be fully asleep. At the end of the operation local anaesthetic is injected into the small wounds and the space under the shoulder blade to ease pain as you wake up. A separate nerve block is not usually needed for this operation. The anaesthetist will meet you beforehand and talk you through it. You are then taken into the operating theatre, where the operation is performed. When it is finished, you will wake up in the recovery area. Nurses will stay with you and monitor you while the anaesthetic wears off. Once you are stable, you will either move to a ward or go home, depending on the operation and how your recovery is going. ## What the operation involves This is a keyhole operation. You will usually lie face down, and your surgeon makes a few small cuts along the inner border of your shoulder blade, the side closest to your spine. A thin camera is passed through one of the cuts into the space between the shoulder blade and your ribs. The operation works in this space, not inside the shoulder joint itself. Through the other small cuts, your surgeon removes the inflamed bursa, the thin cushion of tissue that sits between the blade and the ribs. Clearing this tissue gives a clear view of the area. If the upper inner corner of your shoulder blade looks prominent, part of that corner is trimmed back as well. Whether this is needed is decided during the operation, based on what your surgeon finds. At the end, the small cuts are closed with stitches. Local anaesthetic has already been placed in the wounds to ease pain as you wake up. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You will wake up in the recovery area, then move to a ward. Your arm rests in a simple sling for comfort; it comes off for exercises and washing. Nurses will check your pain and give you medicine to keep it comfortable. Some swelling across the back and side of your chest is common in the first day or two. It settles on its own. Please arrange for someone to stay with you for the first 24 hours after you go home. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your shoulder and the area around it will be sore and swollen. The local anaesthetic placed during the operation wears off within hours, so take the pain medicine we give you before it does. Rest, ice packs wrapped in a towel and keeping your hand moving can all ease the discomfort. The swelling across your back and chest settles on its own. You will go home with your arm in a simple sling for comfort. It comes off for your exercises and for washing. Your physiotherapist will guide you through gentle movements at first, then build up to strength work as the soreness settles. Keep the dressing dry and leave it alone until we see you. Everyday tasks come back in stages. You can use your hand for light activities once you feel steady, such as eating, typing and making a cup of tea. Lifting, reaching overhead and heavier housework wait until your surgeon says the healing is far enough along. Once you are out of the sling, comfortable, and can turn the wheel and look over your shoulder without pain, you can drive again. See our page on driving after upper-limb surgery for more detail. Most people find the clicking or grating quiets down as the pain improves, though some noise can remain even when the shoulder feels much better. Recovery varies from person to person. Your surgeon and your physiotherapist will guide your timeline. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the inflamed tissue is not fully cleared, or a rough patch of bone is left behind. If that happens, the catching or grating feeling may continue after your recovery. If the noise or discomfort does not settle the way we discussed, bring it up at your next review. Further treatment can be considered then. Some people keep noticing the shoulder blade moving oddly, even after the wound has healed. You might feel the blade winging out from your back or catching as you reach. If this continues and limits you, tell us at your review so we can assess it. A few people still have symptoms after the operation, such as pain or clicking that does not fully settle. Your shoulder may also not feel as strong or comfortable as you hoped. If your recovery feels slower than expected, raise it with us. We will examine the shoulder and talk through what else can be done. Call the clinic the same day if you have a fever, redness spreading out from a wound, or fluid or pus leaking from it. Also call the same day if pain keeps getting worse despite your pain medicines. Call the clinic if you notice new numbness, or you cannot move the arm, hand or fingers. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up in the first few weeks. Go to the emergency department if you have swelling or pain in your calf, shortness of breath, or chest pain. These can be signs of a blood clot. Go also if your hand or fingers turn pale, cold, white, blue or dark. Call the clinic the same day if you have a fever, redness spreading around the wound, or fluid or pus leaking from it. Call the same day too if pain keeps getting worse despite your pain medicines. Call the clinic if you notice new numbness, or you cannot move your arm, hand or fingers. If you cannot reach us, for example out of hours or on a weekend, go to your nearest emergency department. --- ### Shoulder Arthritis URL: https://www.cqupperlimb.com/education/shoulder/shoulder-arthritis/ Region: shoulder · condition Shoulder arthritis causes pain, stiffness, and reduced range of motion — diagnosis and treatment options explored. ## What you're feeling Shoulder arthritis is wear-and-tear arthritis in the main ball-and-socket joint of the shoulder. The pain usually builds over years rather than arriving suddenly. It sits deep in the shoulder itself, and it tends to come with stiffness that slowly narrows how far you can move the joint. Certain movements and positions make it worse. Reaching up, lifting your arm out to the side, or pushing through the shoulder can all aggravate it. After activity, the ache often settles in. Night is a common flare time, and many people find the shoulder wakes them or makes sleep hard to arrange comfortably. On waking, the joint can feel stiff and slow to loosen. Everyday tasks that need reach become the hard ones. Washing your hair, turning off a light behind you, or getting your arm up and around for dressing can turn into real chores. Weakness often creeps in alongside the stiffness, so lifting and carrying feel less reliable than they used to. The stiffness in arthritis is different from the stiffness of a frozen shoulder, which comes on over weeks to months rather than years. Other conditions can mimic arthritis too, including inflammation from rheumatoid arthritis, which often brings fatigue, pain in other joints, and weight loss along with the shoulder pain and swelling. Your surgeon sorts these apart through your history and examination, sometimes with scans or blood tests. Some signs need faster attention. If the shoulder becomes hot, red, swollen and very painful, especially with a fever, that needs same-day emergency department care, and no GP referral is needed. If shoulder symptoms are not settling, are getting worse over weeks, wake you at night, or stop you using the arm or working, see your GP or ask for a specialist review. If you cannot reach the clinic out of hours or on a weekend, go to your nearest emergency department. ## What's actually happening Your shoulder is a ball-and-socket joint. The ball is the rounded top of your arm bone, and the socket is a shallow dish on your shoulder blade. The socket is naturally small, about a third of the size of the ball it holds. A ring of rubbery cartilage around its rim, called the labrum, deepens the socket so the ball stays put. Covering both surfaces is a smooth, slippery layer of cartilage that lets the two bones glide over each other with almost no friction. In arthritis, that smooth cartilage wears away. Think of it as the shock absorber between the two bones thinning out until the bones start to grind on each other. The body responds by growing extra bone at the joint edges, and these bony spurs add to the stiffness. The lining of the joint can also become inflamed and swollen. Bone-on-bone grinding, spurs, and inflammation together explain the deep ache, the narrowing range of movement, and the night pain you read about above. The wear is not always even. In many arthritic shoulders the ball drifts towards the back of the socket, so the back edge of the socket wears down faster than the rest. The tissues at the front of the joint also tighten over time, which twists the ball further backwards and loads the worn area even more. The tendons around the joint, known as the rotator cuff, are usually still intact in this kind of arthritis, though they can be affected in other forms. Arthritis has several starting points. Most cases have no single clear cause, though a family tendency can play a part. Others follow an old fracture, previous surgery on the joint, repeated dislocations, or inflammatory conditions such as rheumatoid arthritis, where the body's own defence system attacks the joint lining and destroys the cartilage. Whatever the starting point, the end result in the joint is much the same, and it is what drives your symptoms. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your first visit we take a history, examine the shoulder, and arrange imaging where it is needed. X-rays are almost always enough to plan treatment. A CT or MRI scan adds detail in some cases, such as checking the rotator cuff or measuring bone wear before surgery. For mild to moderate arthritis, we usually try non-operative care first. Changing how you use the shoulder helps, so we look at which movements and tasks load the joint and find ways around them. Physiotherapy aims to keep the joint moving and build the strength around it. Anti-inflammatory medicine can settle the ache, and a cortisone injection into the joint can calm inflammation for a period of weeks to months. We give any of these an adequate trial before we talk about surgery, because surgery works better when it follows a genuine attempt at conservative care. Surgery comes into the conversation when non-operative care has not given enough improvement and the pain or stiffness keeps limiting what you can do. The main operation is a shoulder replacement, where the worn surfaces of the ball and socket are resurfaced with artificial parts. Which type we discuss depends on your age, the state of your rotator cuff, and the bone in the socket, and we work through that choice with you as a shared decision. ## What to expect Arthritis does not go backwards. The worn cartilage does not grow back, so the underlying wear-and-tear stays. What changes is how much the shoulder bothers you day to day, and that can be shifted in your favour. Without treatment, the pattern is usually a slow decline over years rather than a sudden collapse. The ache and stiffness tend to build gradually, and the things you noticed earlier, like reaching overhead and sleeping on that side, usually get harder rather than easier. Some people stay steady for long stretches, but the general direction for an untreated arthritic shoulder is downward. With well-managed care, most people do better than that. Keeping the joint moving and building the strength around it, guided by your physiotherapist, can settle symptoms and keep you doing more for longer. Many people manage their arthritis for years without needing surgery at all. If surgery becomes the right answer, shoulder replacement has a long track record for this exact problem. It is the treatment with the most predictable results for easing pain and improving function in advanced arthritis of the shoulder. People typically notice their shoulder working better and their overall health feeling better within a relatively short time after the operation. Strength also improves over the first couple of years, though the tendon at the front of the shoulder does not always return to full normal strength. No treatment is a promise. Most people get real relief, but some are left with stiffness or weakness, and a minority need further surgery down the track. Implants are artificial parts, and they can loosen or wear over time, which is more of a consideration the younger and more active you are. Your surgeon will talk through what a realistic result looks like for your shoulder specifically. One thing worth knowing: if your arthritis is still mild on X-ray, surgery tends to deliver less improvement than it does for severe arthritis. That is not a reason to avoid surgery, but it is a reason to be clear about what you hope to get from it. If your shoulder symptoms are not settling, are getting worse over weeks, wake you at night, or stop you using the arm or working, see your GP or ask for a specialist review. ## When to see someone Most arthritic shoulders can wait for a planned appointment, but some signs should not. If the shoulder becomes hot, red, swollen and very painful, especially with a fever, go to an emergency department the same day. An infection in the joint is time-critical, and no GP referral is needed. The same applies if you cannot reach the clinic out of hours or on a weekend: go to your nearest emergency department. See your GP if the shoulder is not settling, is getting worse over weeks, wakes you at night, or stops you working or using the arm. Ask for a specialist review if pain and stiffness have built over years and are now limiting washing your hair, dressing, or reaching behind you. Some patterns deserve a closer look sooner. Rapid, severe wear can affect older women with shoulder pain that crept up quietly. Severe erosion in someone who has had gout points to gout in the shoulder itself. And if the shoulder is hot and painful with fever, that is the same-day sign described above. Your surgeon will also want to know about neck pain, or numbness and tingling running below the elbow, because these can come from the neck rather than the shoulder. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Shoulder arthritis is worth the extra reading because the main decision, which type of replacement, has recently become a genuine trade rather than a clear answer, and because the trade is different depending on your age. ### Anatomic versus reverse, over 70 An anatomic replacement reproduces the normal arrangement and depends on a working rotator cuff. A reverse replacement swaps ball and socket, letting the deltoid do the lifting, and does not. Historically reverse was reserved for shoulders without a cuff; it is now used far more widely. The comparison in patients aged 70 and over with a competent cuff, across 1,716 patients, splits cleanly. Anatomic replacement provided superior rotational mobility, exceeding the minimal clinically important difference and potentially supporting activities such as dressing and toileting, while reverse offered superior implant survivorship and lower revision [1]. Those are two different currencies. Anatomic buys rotation you would notice day to day; reverse buys durability. Neither dominates, which is why this is now a discussion rather than a default. ### Reverse carries more early complications in this setting The durability advantage comes with a near-term cost when reverse is used for ordinary arthritis. Across 8,846 patients, an increased rate of early complications was observed with reverse compared with anatomic for primary glenohumeral arthritis, instability, scapular fracture, infection and all-cause complications, with no difference in revision rate at that follow-up [2]. Read alongside the survivorship finding above, the pattern is that reverse trades a higher chance of an early problem for a lower chance of a late one. Which matters more depends heavily on how many years the implant needs to last. ### Replacing the socket as well as the ball A hemiarthroplasty replaces only the ball, leaving the worn socket. It is a smaller operation and avoids the glenoid component, which is the part most prone to loosening over time. The evidence does not favour it. In patients with primary glenohumeral osteoarthritis and an intact cuff across 1,317 patients, total shoulder arthroplasty is favoured over hemiarthroplasty in clinical outcome, risk of revision, and post-operative complications [3]. The explanation is that the worn socket keeps generating pain against the new ball. Avoiding the glenoid component avoids one long-term failure mode by accepting a shorter-term one. ### For younger patients the calculation changes entirely Under about 60, every option is unsatisfactory in a specific way, and this is honestly reflected in the literature rather than resolved by it. A replacement will very likely need revising within a lifetime, and revision shoulder surgery is substantially harder than the first operation. Joint- preserving options, arthroscopic debridement, capsular release, removing osteophytes, do not halt the arthritis but can defer replacement, which for a young patient is a coherent goal in itself. ### One finding for anyone who has had instability surgery Arthritis after shoulder stabilisation is common on imaging and mostly silent. Following arthroscopic Bankart repair, the prevalence was 60% for any arthritic change and 28% for moderate-to-severe change, yet it is generally asymptomatic, with no significant correlation identified with the established risk factors [4]. If you have had a stabilisation and a later scan reports arthritis, that finding is common, usually not the source of symptoms, and not on its own a reason to act. --- ### Shoulder Arthroscopy URL: https://www.cqupperlimb.com/education/shoulder/shoulder-arthroscopy/ Region: shoulder · operation What shoulder arthroscopy is, what it's used for, and how to prepare and recover. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your shoulder, and arrange imaging where it is needed. That assessment tells us what is wrong inside the joint. For long-standing problems we usually try non-operative care first. This can mean changing activities, physiotherapy, or injections. Surgery comes into the conversation when those steps have not given you enough improvement. For some structural problems, such as a torn tendon or an unstable shoulder, we may recommend surgery straight away. Shoulder arthroscopy is a keyhole operation. A small camera is placed inside the joint, and instruments are passed through small incisions around the shoulder. It lets us see and treat problems such as labral tears, rotator cuff tears, and biceps tendon damage in one sitting. The aim is less pain, better movement, and a steadier shoulder. ## Before the operation In the days before surgery, we will confirm which scans are needed to plan your operation. This may be an X-ray, an MRI, or an ultrasound. You will get clear instructions about your medications. Some may need to be paused for a short time. If you take blood thinners or have diabetes, tell us early so we can plan around them. On the day, bring a list of everything you take, including tablets, injections and supplements. Wear loose, comfortable clothing that is easy to put on over a bandaged shoulder. Arrange for someone to drive you home afterwards, as you will not be able to drive that day. You will need to stop eating and drinking seven hours before your operation. We ask for seven hours so we can bring your surgery forward if the theatre list runs early. If you have other medical conditions, you may need blood tests or a review with the anaesthetist before the day. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist, the doctor who gives the anaesthetic and looks after you during the operation. This operation is done under general anaesthetic combined with a regional nerve block. You will be fully asleep for the operation, and the block (an injection that numbs the nerves supplying the arm before you wake up) provides pain relief for the first 12 to 24 hours after surgery. The anaesthetist will meet you before the operation and talk you through both parts. After that, you are taken into the operating theatre, where the operation is performed. When it is finished, you will wake up in the recovery area. Nurses will stay with you and monitor you while the anaesthetic wears off. Once you are stable, you will either move to a ward or go home. Which of these happens depends on the procedure you had and how your recovery is going. ## What the operation involves Shoulder arthroscopy is a keyhole operation. Your surgeon makes a few small incisions around your shoulder, including one at the back, and passes a small camera into the joint. The camera sends a picture of the inside of your shoulder to a screen, so your surgeon can see the joint surfaces, the labrum (a rim of cartilage around the socket), and the rotator cuff tendons directly. Fluid is pumped in to hold the joint open and keep the view clear. What happens next depends on what is found. A torn labrum can be reattached to the bone. A torn rotator cuff tendon can be stitched back onto its attachment on the arm bone using small anchors set into the bone. Loose or damaged tissue can be trimmed away, and inflamed tissue or bone spurs pressing on the tendon can be removed. Because the camera can be moved to look from different angles, your surgeon can check the whole joint and treat more than one problem in the same operation. At the end, the instruments are taken out and the small incisions are closed with stitches. Your shoulder is covered with a dressing, which stays on for about 10 days as described in the recovery section. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You will wake up in the recovery area, then move to a ward for the night. Your arm will rest in a simple sling for comfort, which comes off for exercises and washing. The first 24 hours matter most for pain control, so we will keep on top of it with your pain medicines. Numbness and weakness in the arm are expected while the nerve block wears off, usually within about 24 hours. If you cannot move the arm, hand or fingers, or you have numbness once the block has worn off, call the clinic. Someone should stay with you for the first 24 hours. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery The first day or two after surgery are when pain is at its strongest, so keep on top of your pain medicines from the start. The nerve block from theatre will wear off, and as it does you may feel a dull ache in the shoulder. Some swelling around the shoulder and upper arm is normal and settles as the days pass. Rest, ice and your prescribed pain relief all help ease this early discomfort. Your arm rests in a simple sling for comfort, which comes off for your exercises and for washing. Your physiotherapist will guide you through gentle movements, then build up to strength work as your shoulder allows. You can use your hand and wrist for light tasks such as eating and writing once you feel able. Avoid lifting with the operated arm until your surgeon or physiotherapist says it is safe. Sleeping upright or propped on pillows is often more comfortable in the early days, and many people find it easier to sleep in a recliner or with extra pillows behind the back. Recovery varies from person to person, so your timeline may differ from someone else's. Your surgeon and physiotherapist will guide you at each review. Once the swelling settles and your movement returns, everyday tasks become easier. You will not drive until your surgeon clears you, typically at the six-week review; see Driving after upper-limb surgery for the full rules. Returning to work, sport and the gym happens in stages, guided by how your shoulder feels and what your surgeon and physiotherapist agree you are ready for. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Infection is uncommon after keyhole shoulder surgery. It can show as a fever, redness that spreads out from the wound, or fluid or pus leaking from it. Call the clinic the same day if you notice any of these. Pain that keeps getting worse despite your pain medicines is also a reason to call the clinic the same day. A blood clot is rare but serious. Go to the emergency department if you have swelling or pain in your calf, or shortness of breath or chest pain. These can be signs of a blood clot. Stiffness can develop after some shoulder operations, and the shoulder can sometimes freeze. You may notice the shoulder tightening up and losing movement, especially reaching behind your back or out to the side. Bring this up at your next review, as early treatment helps. Nerves run close to the shoulder, and they can occasionally be irritated or injured. You might feel numbness, tingling, or weakness in the arm, hand or fingers. Numbness and weakness in the first 24 hours after a nerve block are expected. Call the clinic if you have numbness, or cannot move the arm, hand or fingers, once the block has worn off (about 24 hours). If you cannot reach the clinic, go to your nearest emergency department. If you had surgery to steady a shoulder that dislocates, the shoulder can sometimes slip or dislocate again. You may feel the shoulder shift, give way, or slide out of place. Tell your surgeon at review, or call the clinic if it happens sooner. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most recoveries go smoothly, but some signs need quick action. Go to the emergency department if you have swelling or pain in your calf, or shortness of breath or chest pain. These can be signs of a blood clot. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it. Call the clinic the same day too if your pain keeps getting worse despite your pain medicines. Call the clinic if you have numbness, or cannot move the arm, hand or fingers, once the nerve block has worn off (about 24 hours). If you cannot reach the clinic, go to your nearest emergency department. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Rotator Cuff Disorders page. --- ### Shoulder Clicking, Popping and Instability URL: https://www.cqupperlimb.com/education/shoulder/shoulder-clicking-popping-and-instability/ Region: shoulder · condition Why a shoulder clicks, pops or feels like it slips — from harmless noises to labral tears and instability — what it means, and when it needs attention. ## What you're feeling A shoulder that clicks or pops is worth taking seriously when the noise comes with other feelings. You might notice a sense that the joint is slipping or shifting where it should not, or a feeling of looseness that never quite settles. Some people feel the shoulder is unstable during sleep, or feel pain when carrying heavy objects such as shopping bags. Throwing can become difficult, and pain or weakness may spread down the arm with tingling in it. The pain usually sits deep in the shoulder itself. It often flares after activity, especially anything with the arm raised and turned outwards, or when you hold objects with your arms at your sides. Resting usually eases it, but the clicking and the feeling of looseness can stay. Reaching overhead, lifting, and throwing are the tasks people most often find hard. If the shoulder has actually come out of joint before, the pain afterwards can be severe, with the muscles around it gripping in spasm. A few signs need action rather than waiting. If your shoulder dislocates and will not go back in, go to the emergency department. If it slips out and goes back in by itself, call the clinic so we can see you. Also seek same-day emergency care if your arm suddenly loses feeling or movement after an injury. If symptoms are not settling, are getting worse over weeks, or wake you at night, see your GP or ask for a specialist review. One more thing worth knowing: repeated dislocations raise the risk of arthritis in the shoulder over time. After a stabilising repair, any arthritis that develops is usually mild and often causes no symptoms at all. ## What's actually happening The shoulder is the body's most mobile joint, and that freedom comes from its shape. The socket is shallow, about one-third the size of the ball it holds. Picture a golf ball resting on a saucer rather than sitting in a cup. A ring of soft cartilage around the rim, called the labrum, deepens the socket by about 50%. Even with it, the socket is only around 9 mm deep from top to bottom and 5 mm from front to back. Because the fit is loose, the shoulder relies on soft tissue to hold it centred. The capsule, a loose sleeve around the joint, works with ligaments that tighten only at the extremes of movement. In the middle ranges, your rotator cuff and biceps muscles do most of the work, pressing the ball gently into the socket. It is less like a hinge and more like a team of guy ropes all pulling in different directions to keep a tent pole upright. Instability happens when that team loses its grip. The labrum can tear away from the rim, or the capsule and ligaments can stretch out, often after a dislocation or after years of repeated strain from throwing or overhead work. Once the ropes slacken, the ball can slide forwards, backwards or downwards before it is caught again. That sliding is the click or pop you feel, and the sense of slipping or looseness described above is the same problem making itself known. Some people are loose-jointed by nature, and in them the whole capsule can be too stretchy, which is why the feeling of instability can appear without any injury at all. When the shoulder has actually dislocated, the ball can dent as it levered over the rim, and that dent makes further slipping more likely. Repeated dislocations also raise the risk of arthritis over time, though after a stabilising repair any arthritis that develops is usually mild and often causes no symptoms. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. For most people, that means physiotherapy before anything else. Physiotherapy aims to strengthen the rotator cuff, the group of muscles that holds the ball centred in the socket, and to retrain the shoulder blade and the shoulder's sense of where it sits in space. For loose-jointed shoulders that slip in several directions, physiotherapy is tried for 6 to 9 months before surgery is considered. Around 20% of people still find their shoulder unstable after that, and surgery becomes an option for them. Surgery is not offered to people who can deliberately make their shoulder slip out, or who have not yet tried physiotherapy. If the shoulder has slipped out of joint after a single injury, the arm may be held still in a sling for a short period, followed by physiotherapy. We may also ask you to change activities that strain the shoulder, such as heavy lifting or throwing, while the muscles settle. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your first visit we take a history, examine the shoulder, and arrange imaging where it is needed. Plain x-rays usually give us most of what we need, including a special view taken with the arm raised that shows whether the ball sits centred in the socket. Scans such as MRI, which shows soft tissue like the labrum and rotator cuff, are used when they will change the plan. If physiotherapy has not given enough improvement, surgery may be considered. The aim of a stabilising operation is to repair the torn labrum or tighten the stretched capsule so the ball stays centred in the socket. Some shoulders need a repair done through keyhole surgery, others need an open operation, and the choice depends on what is found in the joint, including how much bone has been lost from the socket rim. We will talk through which approach suits your shoulder, and the decision is one you make together with us. ## What to expect Instability rarely settles on its own and then stays settled. For some people the feeling of looseness comes and goes, flaring after activity and easing with rest. For others, once the shoulder has slipped out of joint, it tends to keep happening. Each new episode can stretch the soft tissues further, which is why the problem often gets worse rather than better when it is left alone. Without treatment, the outlook depends on the type of instability. Loose-jointed shoulders managed with physiotherapy often improve, though some people still feel unstable afterwards. Shoulders that slip out after an injury are more likely to keep doing so. Repeated dislocations also raise the risk of arthritis over time, as covered above. With a stabilising repair, most shoulders stay centred. After keyhole repair for instability that keeps coming back, 25 of 29 shoulders had excellent results and 2 more were good, with 1 shoulder slipping out again over 2 to 3 years. That one shoulder settled after further keyhole surgery. For shoulders that slip in several directions, results are more mixed: some repairs hold well, while in others the shoulder kept slipping and the operation did not achieve its aim. Shoulders with a large tear all the way around the socket rim are harder to stabilise, and about 19% of people still felt instability 2 years later, with about 8% needing another operation. Recovery is gradual rather than instant. The shoulder is held still for a short time, then physiotherapy guided by your physiotherapist rebuilds strength and control. Most people keep their movement: in one group, 61% kept motion identical to their other arm and the rest lost only a small amount of outward rotation. Sticking closely to the physiotherapy plan matters, because the repair can fail if the shoulder is pushed too hard too soon. If a repaired shoulder keeps slipping, further surgery is possible and often helps. If you have already had a stabilising repair and now notice clicking without any feeling of giving way, that noise alone is usually not a sign the repair has failed. ## When to see someone Some signs need care straight away. If your shoulder dislocates and will not go back in, go to the emergency department. If it slips out and goes back in by itself, call the clinic so we can see you. If you cannot reach the clinic, go to your nearest emergency department. Seek same-day emergency care if your arm suddenly loses feeling or movement after an injury. See your GP or ask for a specialist review if symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using the arm. Ask for a review if clicking comes with a feeling of the joint slipping or giving way, weakness that is more than pain, or catching that physically blocks movement. Pain in a young shoulder after an injury is worth checking even if it never felt like it came out. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Clicking and popping in the shoulder is worth the extra reading because it is a symptom rather than a diagnosis, and because the single most useful thing to establish is whether the noise comes with a sense that the joint is moving where it should not. ### Noise on its own is usually not the problem A shoulder that clicks, snaps or grinds without pain, without weakness and without a feeling of giving way is common and generally does not indicate damage. Tendons move over bony ridges, the capsule folds and unfolds, and gas can move within the joint fluid. None of that requires treatment. The reason this matters is that a noise is alarming out of proportion to its significance, and imaging a painless clicking shoulder will frequently find something, an age-typical labral fray, a partial cuff change, that then gets blamed for it. The rotator cuff literature makes this concrete: cuff abnormalities are common enough in people without symptoms to be considered a feature of normal ageing, which makes it genuinely difficult to know whether a finding is new or causative [1]. ### The question that separates the groups What changes the assessment is whether the noise is accompanied by a sense of the joint shifting, slipping or giving way, apprehension when the arm is raised and rotated outwards, an episode of the shoulder coming out, or a persistent feeling of looseness. That combination points towards instability, which is a structural problem with its own evidence, its own decision points and its own treatments, the balance of bone loss against soft tissue, whether a Hill-Sachs lesion engages, and the choice between repair, remplissage and bone transfer. Those are covered in depth on the shoulder instability page rather than repeated here. The second combination worth recognising is noise with true weakness or visible wasting, which points away from the joint surface entirely and towards the rotator cuff or a nerve problem. ### Why painless clicking after a stabilisation is different again If you have had instability surgery, a shoulder that clicks is a common source of worry. Worth knowing: arthritic change following arthroscopic Bankart repair is present in 60% of shoulders for any change and 28% for moderate-to-severe change, and it is generally asymptomatic, with no significant correlation identified with the established risk factors [2]. So a mechanical noise in a previously stabilised shoulder, without instability symptoms, is more often a reflection of a joint that has been through something than a sign of failure. ### What is actually worth reporting Three features change the assessment and are worth mentioning specifically: a sense of the joint moving or giving way; genuine weakness rather than pain-limited effort; and locking or catching that physically blocks movement rather than merely making a sound. Clicking without any of those, in a shoulder that works, is the situation in which the most useful intervention is an explanation rather than an investigation. --- ### Shoulder Instability URL: https://www.cqupperlimb.com/education/shoulder/shoulder-instability/ Region: shoulder · condition Shoulder instability — understanding the feeling of looseness, causes, and treatment options. ## What you're feeling Shoulder instability means the ball of your shoulder joint moves more than it should within its socket. Sometimes it slips partway out, which is called subluxation. Sometimes it comes fully out, which is a dislocation. Some people notice this after a fall or injury. Others have loose shoulders that have always felt unreliable, without any single injury to point to. The pain is often felt deep in the shoulder itself, at the front or the back depending on which way the joint slips. Some people feel a vague ache rather than a sharp pain, and some feel tingling or pins and needles down the arm. You might notice a clicking or popping sensation, or a feeling that the shoulder is about to slip when you lift your arm out to the side or above your head. Throwing can be hard, and pain during the wind-up phase of a throw is common. The shoulder often misbehaves at night. Many people find sleeping on that side uncomfortable, and the shoulder can feel loose or shift position during sleep. Carrying heavy objects, such as shopping or a young child, can bring on pain. Lifting things overhead, like reaching for a high shelf, is another common trigger. Everyday tasks can become harder in quiet ways. Reaching behind you, hanging washing, or pulling something off a top shelf might make you brace or hesitate. If you play sport, you may have lost confidence in the shoulder during tackles, swimming strokes, or overhead shots. Some people start avoiding positions that feel risky, like holding the arm out wide and turned outward. If your shoulder has fully dislocated, the muscles around it often go into spasm and the pain is severe until the joint is put back. If your shoulder slips back in on its own, or feels loose without ever fully dislocating, the problem can be subtler. Either way, these symptoms are worth taking seriously, because they tell your surgeon a great deal about what is happening inside the joint. ## What's actually happening Your shoulder is built for movement more than for strength. The socket is naturally shallow, about one-third the size of the ball it holds. Think of a golf ball resting on a tee rather than sitting inside a deep cup. That shape lets your arm reach in every direction, but it also means the joint relies on soft tissues to stay put. The main soft-tissue stabiliser is a ring of firm cartilage around the rim of the socket, called the labrum. It works like a raised lip or bumper on the edge of a shallow dish, deepening the socket by 50% and giving the ball something to rest against. Around that ring sits a capsule, a loose sleeve of tissue, with thickened bands that act like guy ropes holding the joint in place. The muscles of the rotator cuff add another layer of control by keeping the ball centred as you move. Instability happens when these restraints stop doing their job. In some people the capsule is loose all round, which is why the shoulder slips in more than one direction. In others, an injury stretches or tears the labrum and capsule at the front or the back, so the bumper no longer holds the ball. Repeated slipping can wear the labrum further. A dislocation can also dent the smooth surface of the ball where it strikes the socket rim, and in some shoulders the rim of the socket itself loses bone, leaving even less for the ball to sit against. Each of these changes makes the joint easier to slip and harder to trust. This is why the symptoms you feel match the direction of the problem. If the front of the joint is affected, lifting your arm out wide and turned outward lets the ball slide forward. If the back is affected, reaching forward or across your body can push it backwards. When the whole capsule is loose, the shoulder can shift in several directions, including downward, which explains the tingling and the feeling of the joint dropping. The clicking you notice is often the labrum or capsule catching as the ball moves within the socket. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment, which includes your history, an examination, and imaging where needed, establishes the diagnosis. For most shoulder instability, we start with physiotherapy. A physiotherapist guides you through exercises that strengthen the rotator cuff, the group of muscles that keeps the ball centred in the socket. The program also trains the muscles around your shoulder blade and retrains your sense of where the arm is in space, which is called proprioception. For shoulders that are loose in several directions without a single injury, physiotherapy is the main treatment, and about 80% of people improve with it. We usually ask you to give it a fair go over 6 to 9 months before thinking about surgery. If your shoulder slipped out after an injury, a short period in a sling, typically 3 to 7 days, lets things settle before rehabilitation begins. For a first-time dislocation towards the back of the joint, the arm is held still for 1 to 2 weeks with the elbow at your side, then therapy starts. Simple pain relief and anti-inflammatory medicine can help in the early days, and changing activities that provoke the shoulder is part of the plan. Surgery comes into the picture when physiotherapy has not settled things, or when your symptoms keep interfering with work or sport. It is also worth knowing that in young athletes who dislocate, instability often returns without surgery, so we may discuss operating sooner rather than later. Before any operation we examine the shoulder carefully and use scans to check the labrum, the joint surfaces, and whether any bone has been lost from the socket rim. The type of surgery depends on what is found. Many shoulders are suited to keyhole repair of the torn labrum and capsule. If a good amount of bone has worn off the socket rim, or if a dent in the ball is large, we may recommend a procedure that adds bone to the front of the socket to restore its depth. If your shoulder slips in more than one direction and you can deliberately make it dislocate, surgery is generally not advised, and physiotherapy remains the mainstay. Any operation is a shared decision between you and us, made once you understand the options. ## What to expect Shoulder instability rarely settles on its own once it has started. For some people it comes and goes, with quiet stretches between episodes of slipping. For others, especially younger people, it becomes a pattern that repeats. In patients under 22 who dislocate, 70% go on to have further instability, and half of them eventually need surgery to hold the joint steady. A history of repeated episodes is the strongest predictor that the shoulder will keep slipping without treatment. Leaving it alone carries real risks beyond the slipping itself. Each new episode can wear away more bone from the rim of the socket, damage the smooth surface of the joint, and make any later operation more involved. Over the long term, two-thirds of people who dislocated developed wear-and-tear arthritis in that shoulder within 25 years, whatever their age. That is why we take even a first dislocation seriously rather than waiting to see what happens. With well-managed care, the outlook is often steadier. Physiotherapy is the mainstay for loose shoulders, and most people under 40 who give it 6 months are treated without surgery. When surgery is needed, it aims to restore stability and let you trust the shoulder again. Athletes can generally return to play once strength and movement have come back. After surgery for instability towards the back of the joint, 90% of athletes were back playing sport at 3 years, and 67% returned at their previous level. Heavy work and contact sport usually wait until 6 months after that type of repair. Honesty matters here, because no treatment removes risk completely. After keyhole repair at the front of the shoulder, 30% of shoulders had further instability by midterm follow-up, and about one third had at least one redislocation over 8 to 10 years. Stiffness can occur if the capsule is tightened too much, though it is uncommon. For shoulders loose in several directions, instability returns in 7% of cases with either keyhole or open surgery. These figures are not meant to discourage you. They are the realistic picture we use, together with your age, your sport, and your scans, to work out the plan that gives your shoulder its best chance of staying put. ## When to see someone See your GP promptly if your shoulder has dislocated and will not go back in, or if you cannot turn your arm outward or lift it after an injury. Ask for a specialist review if the shoulder keeps slipping, if episodes are becoming easier to trigger, or if a first dislocation happened during sport. Go to an emergency department if you notice numbness, tingling or weakness in the arm after a dislocation, as the nerves running past the joint can be stretched or pressed. Seek review too if pain and looseness are disturbing your sleep, limiting your work, or stopping you from throwing, lifting overhead, or carrying things. If your shoulder feels unreliable without any injury, that is still worth assessing rather than waiting for it to worsen. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Shoulder instability is worth the extra reading because the decision that matters is not really "operate or not" — it is which operation, and that turns on a measurement of bone rather than on how the shoulder feels. ### Bone loss is the variable that decides A soft-tissue repair reattaches the torn labrum and tightens the capsule. It cannot replace missing bone from the front of the socket, and once enough of that rim is gone the shoulder can slide out over the defect no matter how well the soft tissue is repaired. A systematic review of 19,307 patients identified the established risk factors for recurrence after arthroscopic Bankart repair: younger age, glenoid bone loss, and off-track Hill-Sachs lesions, with contact and competitive sport, number of fixation devices and sex also commonly reported [1]. "Off-track" is worth translating. The Hill-Sachs lesion is the dent punched into the back of the humeral head as it dislocates over the socket rim. Whether it matters depends on whether it stays in contact with the glenoid through range, on-track, or falls off the edge and engages. It is the interaction between the two defects, not either alone, that predicts failure. ### What the bigger operation buys, and what it costs Where bone loss is significant, transferring bone solves the problem the repair cannot. Compared directly, the Latarjet produced a lower recurrence rate, better patient-reported outcomes and faster return to sport than arthroscopic Bankart repair, while carrying a higher complication rate [2]. A long-term comparison of 3,088 patients found lower recurrent instability and revision after open Latarjet, with comparable arthritis rates between the two [3], which addresses the usual objection that moving bone across the joint must accelerate wear. The cost is quantified: pooling 7,175 patients, the overall complication rate after Latarjet was 6–7%, mostly graft-related, with no significant difference between open and arthroscopic versions [4]. ### The middle option The choice is not binary. Across 2,100 patients, adding a remplissage, filling the Hill-Sachs defect with capsule and tendon so it cannot engage, reduced recurrence compared with isolated Bankart repair without a significant loss of external rotation, and may reduce reoperation compared with Latarjet [5]. That matters for throwing athletes and anyone whose sport depends on the last few degrees of external rotation, where the traditional worry about stabilisation has always been trading instability for stiffness. ### Read the outcome literature sceptically Two findings should temper any confident number quoted to you. A review of 19,156 patients concluded that a large proportion of studies reporting Bankart repair outcomes are of low methodological quality and low level of evidence [6]. And access is not evenly distributed: across 43,054 patients, minority race or ethnicity, public insurance, lower income and greater social deprivation all reduced the likelihood of undergoing Bankart repair, with public insurance also associated with longer waits [7]. Some of the variation in published outcomes reflects who reached surgery and when, not what the operation does. --- ### SLAP and Biceps Pathology URL: https://www.cqupperlimb.com/education/shoulder/slap-biceps-pathology/ Region: shoulder · condition Superior labral (SLAP) tears and disorders of the long head of biceps — assessment and treatment. ## What you're feeling The pain from a SLAP tear sits deep inside the shoulder, at the top of the joint. You may not be able to point to one sore spot on the outside. It often starts after a fall or a sudden pull on the arm, or it can creep in slowly, which is common in people who throw overhead, such as cricketers or baseball pitchers. Many people notice a deep ache during or after overhead activity. Some describe the arm going dead or heavy when they reach up, along with tiredness or a catching feeling. If the biceps tendon itself is the problem, you might feel clicking or snapping as you lift your arm overhead. A torn tendon that has snapped can leave a visible lump on the front of the upper arm, often called a Popeye sign. Day to day, the things that hurt are the ones that load the top of the shoulder: reaching up to a high shelf, lifting a heavy bag, throwing a ball, or working with your arm above shoulder height. The pain tends to flare after activity rather than first thing on waking. Your strength and movement are often still there, which is part of why this problem gets mistaken for other shoulder conditions. One thing worth knowing: a SLAP tear rarely travels alone. In most cases it comes with another problem in the same shoulder, such as wear in the rotator cuff or a labral tear. That is one reason the pain can feel vague and hard to pin down, and why your surgeon will examine the whole shoulder rather than one spot. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm, see your GP or ask for a specialist review. ## What's actually happening Your shoulder is a ball-and-socket joint. Around the rim of the socket sits a ring of soft cartilage called the labrum, which works a bit like a rubber gasket that deepens the socket and keeps the ball seated. The tendon of the long head of the biceps anchors straight into the top of that ring, so the two are one continuous structure. When the top of the labrum tears, it takes part of the biceps anchor with it. That is what a SLAP tear is: a tear at the top of the gasket where the biceps attaches. The tear usually comes from force. A fall on an outstretched arm, a sudden yank on the arm, or the repeated strain of throwing can peel the top of the labrum back off the rim of the socket, the way a label peels away from a jar. In people who throw overhead, the shoulder tightens at the back over years of play. That tightness tips the ball slightly up and back during the throwing action, twisting the top of the labrum every time. The same strain also runs down the biceps tendon itself, which can become inflamed, frayed, or unstable so that it clicks or snaps in its groove at the front of the shoulder. These problems explain the symptoms you read about above. The deep ache comes from the torn labrum and the irritated tendon at the top of the joint. The catching and clicking come from the torn edge moving as you lift your arm. And because the biceps helps steady the ball in the socket, a tear there can leave your arm feeling weak or dead during overhead work. SLAP tears are also graded by how far the tear extends, from fraying of the rim through to a tear that splits the labrum and runs down into the biceps tendon itself. The higher grades, where the biceps tendon is torn as well, tend to be the ones where treating the biceps rather than repairing the labrum becomes the more likely plan. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your visit we take a history, examine the shoulder, and arrange scans where they will help. Scans of the labrum and biceps are not perfect, so we read them alongside your story and your examination rather than on their own. Most SLAP tears get a proper trial of non-operative care first. That means rest from throwing or other overhead sport, anti-inflammatory medicine, and physiotherapy. The physio programme aims to strengthen the rotator cuff and the muscles around the shoulder blade, and to stretch the tight structures at the back of the shoulder. In people who throw, part of the work is fixing faults in the throwing action itself, because that is often what keeps loading the tear. Give this care a minimum of 3 months before judging it. Many people settle with it, and if the first course falls short, a second course aimed at the specific problems found can still help. High-level athletes can often keep competing and finish their season while this is going on. If physiotherapy alone has not settled things, we may offer a cortisone injection into the shoulder joint or into the groove where the biceps tendon runs. Cortisone is a strong anti-inflammatory. It can ease pain and help work out whether the tear is truly the source of it, and for some people it settles symptoms enough that surgery is not needed. Surgery comes into the conversation when symptoms persist after 3 months of non-operative treatment. The plan depends on your age, how active you are, what the tear looks like, and what else is going on in the shoulder. For some tears, especially in younger, active people, the labrum is repaired back to the socket. For others, particularly people over 30 with lower physical demands, treating the biceps tendon works better: the tendon is released from the torn labrum and reattached lower down the arm, or simply released. Which option suits you is a decision we make together, weighing what each involves. If a cyst in the shoulder is pressing on a nerve, surgery is considered sooner, because waiting can leave lasting weakness. ## What to expect Without treatment, the deep ache at the top of your shoulder usually keeps flaring after overhead work rather than settling on its own. Rest from throwing, anti-inflammatory medicine and physiotherapy settle things for many people, and the earlier sections of this page cover that care in detail. If the first course falls short, a second course aimed at your specific problems can still help. If surgery is the path you take, the outlook depends on your age, your activity and what else is going on in the shoulder. Most people return to their previous overhead activities after repair of the tear. For people under 50 with a tear alongside a rotator cuff problem, results and return to activity tend to follow a steady course. It is honest to say the picture is not perfect. Some people who have the labrum repaired need further surgery later. In one long-term group of young military patients, 40% of those who had a repair went on to have the biceps tendon treated instead, while none of those who had the biceps treated first needed a revision. Overall, about 10 in 100 people who have an isolated labrum repair need another operation later, and that is often because a second problem in the shoulder has come to light. Age over 40, smoking, obesity and irritation of the biceps tendon itself all raise the chance of needing revision surgery. There are also things worth knowing if you are weighing up your options. Simply trimming the torn tissue without repairing it tends to lose its effect: pain relief that helps most people at a year helps fewer by two years, and fewer than half are back to their previous level of sport at that point. For people with high physical demands who have both a tear and biceps irritation, combining a repair with biceps treatment has been linked to worse results than treating one problem on its own. Which option suits you is a decision your surgeon makes with you, based on your age, your sport and the tear itself. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm, see your GP or ask for a specialist review. ## When to see someone See your GP or ask for a specialist review if your deep shoulder ache is not settling after a few weeks of rest from overhead activity, or if it keeps flaring every time you throw, lift above shoulder height, or reach up. Ask sooner if your arm goes dead or heavy when you lift it overhead, if you notice new clicking or snapping at the front of the shoulder, or if the arm feels weak in a way that stops you working or playing sport. If a lump has appeared on the front of your upper arm after an injury, or your shoulder has started catching or giving way, that is also worth a review. There is no emergency attached to this condition, but the sooner the shoulder is examined, the sooner you and your GP can settle on a plan. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. SLAP tears are worth the extra reading because they are the shoulder diagnosis where both the clinical tests and the scan are least reliable, and because the operation that has become preferred is not the one that repairs the tear. ### The examination test does not carry the diagnosis The Active Compression (O'Brien) test is the manoeuvre most associated with SLAP lesions. Assessed across 3,091 patients, it has both limited screening and limited confirmation ability, and the authors state plainly that they do not advocate for its use in clinical decision making [1]. That is about as negative a conclusion as a diagnostic review issues, and it applies to the test most often quoted as positive in referral letters. ### And MRI cannot rule one out Imaging is better but incomplete. Across 2,916 patients, MRI showed moderate sensitivity with excellent specificity and accuracy, making it valuable for confirming a SLAP lesion, while it cannot definitively rule one out, with arthroscopy remaining the reference standard [2]. Put the two findings together and the practical position is: a positive MRI is informative, a negative one is not conclusive, and the examination adds little either way. This is the main reason SLAP tears are over-diagnosed in shoulders whose pain has another cause, and why treating an incidental superior labral finding is a recognised error, particularly in older shoulders where fraying at that site is an expected age change. ### Tenodesis has overtaken repair, on grounds worth understanding Where an isolated type II tear is genuinely symptomatic, two operations compete: repairing the labrum back to the socket, or detaching the biceps tendon and reattaching it lower down, removing the pull that stresses the torn labrum. Across 881 patients, SLAP repair and biceps tenodesis are both acceptable as index treatment, with repair still the most commonly performed but tenodesis equally efficacious and an attractive alternative [3]. A decision analysis across 908 patients went further: tenodesis is preferred over repair on greater expected value, with meta-analysis showing more frequent favourable outcomes [4]. The mechanical logic is that repair restores the anatomy but leaves the biceps pulling on a healing repair, which in an older or stiffer shoulder frequently produces persistent pain and loss of external rotation. Tenodesis abandons the anatomy and removes the deforming force. Outcomes have favoured removing the force. The exception is the young overhead athlete, where sacrificing the biceps anchor is a bigger functional decision and repair retains a role. ### Why the biceps and the labrum are one topic The long head of biceps attaches directly to the superior labrum, they are continuous. A tear at that junction is therefore simultaneously a labral injury and a biceps anchor injury, which is why an operation on the biceps treats a labral lesion, and why symptoms overlap so completely with biceps tendinopathy that the two are often indistinguishable clinically. --- ### Snapping scapula URL: https://www.cqupperlimb.com/education/shoulder/snapping-scapula/ Region: shoulder · condition Snapping scapula means you hear or feel a grating, clicking or snapping sound from your shoulder blade as it moves over your chest wall. Doctors sometimes call it "washboard syndrome", because the sound can feel like a wheel running over a washboard. The noise itself is common… ## What you're feeling Snapping scapula means you hear or feel a grating, clicking or snapping sound from your shoulder blade as it moves over your chest wall. Doctors sometimes call it "washboard syndrome", because the sound can feel like a wheel running over a washboard. The noise itself is common. About a third of people with no symptoms at all have some grating from the shoulder blade. On its own, without pain, it needs no treatment. What usually brings people to see someone is pain. It sits around or under the shoulder blade, often near the inner edge closest to your spine. It tends to worsen with overhead activity, reaching up or across your body, and it can show up as reduced performance at sport. The pain comes from an inflamed bursa, the thin fluid-filled cushion that lets the shoulder blade glide smoothly over the ribs, or from the shape of the bone itself. The chest wall acts like a sound box, so the noise you hear is louder than the movement causing it. The pain can make everyday tasks hard. Lifting a heavy pan onto a high shelf, hanging washing on a line, or reaching for a seatbelt can all set it off. Some people notice it most after activity rather than during it. It can be severe enough to disturb sleep or stop you using your arm normally. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm, see your GP or ask for a specialist review. ## What's actually happening Your shoulder blade is designed to glide. It sits on your chest wall, separated from it by a thin layer of slippery, fatty tissue that works like a gasket between two moving surfaces. Four joints work together to move your shoulder, and about two-thirds of the movement comes from the ball-and-socket joint itself, with the remaining third coming from the shoulder blade sliding over the ribs. When that glide is smooth, you never notice it. The problem in snapping scapula is that something disturbs this glide. Sometimes it is the shape of the bone: the inner edge of the shoulder blade may be angled or curved towards the ribs more than usual, so it sits closer to the chest wall than it should. Sometimes it is a small lump of extra bone on the blade. Often it is the muscles around the blade working unevenly, so the blade does not track smoothly as you move. Any of these can make the blade rub or catch instead of gliding. The rubbing irritates the cushion between the blade and the ribs. That cushion, called a bursa, is a thin fluid-filled sac that works like a shock absorber between bone and soft tissue. When it becomes inflamed it thickens and becomes tender, and that is the pain you feel under or around the shoulder blade. The friction can also cause a reactive thickening of the tissue itself, the body's response to repeated rubbing. This explains the symptoms described above. The noise comes from the roughened surfaces moving over each other, and the chest wall amplifies it like a sound box. The pain comes from the inflamed cushion, not from the noise itself. That is why the two problems are treated differently, and why treatment focuses on calming the inflammation and retraining the muscles that control the blade. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic, we take a history, examine your shoulder and arrange imaging where it is needed to work out what is causing the noise and the pain. Most people settle without an operation, so treatment starts without surgery. The first step is a physiotherapy programme to strengthen the muscles that control your shoulder blade, along with stretching of muscles that have become tight. Changing the activities that bring the symptoms on also helps. Give this a proper trial of 3 to 6 months before thinking about anything further. If pain persists, medicine can help settle the inflammation. Anti-inflammatory tablets, the same kind many people take for muscle aches, are part of this stage. We can also offer an image-guided injection of steroid and local anaesthetic into the bursa under your shoulder blade. This does two jobs: it calms the inflamed cushion, and it confirms that this is where your pain is coming from. Surgery is considered only when pain continues after several months of these treatments and they have not given you enough improvement. The operation is keyhole surgery, done through small cuts with a camera. It removes the inflamed bursa between your shoulder blade and your ribs. The upper inner corner of your shoulder blade is trimmed only if it is found to be prominent during the operation. Most people's pain improves substantially after surgery, but some clicking often remains. We will talk through what surgery could mean for you and decide together whether it is the right step. ## What to expect Most people settle without an operation. Treatment starts with physiotherapy to strengthen the muscles that control your shoulder blade, anti-inflammatory medicine and changing the activities that bring the symptoms on. Give this a proper trial of 3 to 6 months. Many people find their pain eases over this time and never need surgery. If pain continues after several months of these treatments, surgery may be considered. Keyhole surgery removes the inflamed bursa between your shoulder blade and your ribs, and trims the upper inner corner of the blade only if it is found to be prominent. Most people's pain improves substantially after surgery. Some clicking often remains, because the treatments that help pain mostly fix the pain, not the noise. Complete relief of every symptom is not the usual result. Without treatment, symptoms can persist and may be severe enough to disturb sleep or stop you using your arm normally. The condition can be difficult to recognise and treat, so it is worth getting a clear diagnosis early rather than waiting for it to settle on its own. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm, see your GP or ask for a specialist review. ## When to see someone The noise alone is not a reason to worry. About a third of people with no symptoms at all have some grating from the shoulder blade, and on its own it needs no treatment. What matters is pain. See your GP or ask for a specialist review if you have pain around or under the shoulder blade that is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your arm. Also ask for a review if the pain is severe enough to disturb sleep, if your performance at sport has dropped, or if overhead activity such as reaching up or across your body brings the pain on. Snapping scapula can be hard to recognise, so a clear diagnosis early is worth having. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Snapping scapula is worth the extra reading because the noise and the pain are two different problems, and the treatments that help mostly fix the second one, not the first. ### The noise is common; the pain is the problem Grating from the shoulder blade is not, on its own, a sign of disease. A classic review of the condition cites an early study that found scapular crepitus in 31% of 100 people with no symptoms at all [1]. What turns the noise into a condition is pain, usually from an inflamed bursa: the thin, fluid-lined layer of tissue that lets the shoulder blade glide over the ribs. Shape plays a part. In an imaging study, people with a scapula that curves forward along its inner border (a concave shape with a positive "medial scapula corpus angle") had a 12-fold higher risk of snapping scapula [2]. That measurement turned out to be less useful than it first looked: a later study found that the same angle varies considerably with the direction it is viewed from, so it is not reliable enough to diagnose the condition on its own [3]. In a cadaver model, the most important bony feature was how far the inner part of the scapula sat forward towards the ribs [4]. ### Most people settle without an operation In a series of 30 shoulder blades in 28 patients treated with a specific muscle-strengthening programme, 14 (50%) did well with the exercises alone and 6 (21%) needed only anti-inflammatory medicine as well, so 71% reached a good result or better on the study's own grading without surgery [5]. The longest follow-up comes from Finland. Twelve people who had open surgery and 9 who were treated without it were reassessed a mean of 22 years later. Pain with exertion was low in both groups: 0.8 out of 10 after surgery and 1.5 out of 10 without it, a difference too small to be sure was real (p = 0.357) [6]. Pain improved promptly after surgery in 7 of 12, but in the long run both routes ended in much the same place. An injection of local anaesthetic and steroid into the bursa does two jobs: it treats the inflammation and it tests whether the bursa is really the source of the pain. In one UK pathway, 74 of 94 patients were still troubled after physiotherapy and had an ultrasound-guided injection; 55 had a good initial response, which lasted in 17 [7]. Among the 42 operated patients who were followed up, those who had responded well to the injection improved more after the operation than those who had not [7]. A larger American series followed for at least five years did not find the same link [8], so a poor response to an injection does not rule surgery out. ### What surgery achieves, and what it does not The largest long-term series followed 66 people for 5 to 15 years after keyhole removal of the bursa and trimming of the corner of the shoulder blade. The average shoulder score rose from 56.7 to 87.2 out of 100, pain fell from 5.2 to 1.4 out of 10, and 77.6% reached an improvement large enough to notice. Of the 42 who played sport, 38 (90.5%) went back to it and 31 (73.8%) returned at or close to their previous level. Eight (12.1%) needed a further operation [8]. Another series of 74 shoulder blades had a similar rate of further surgery (8 of 74) and found that older patients, people who had had symptoms for longer, and people with lower scores for mental wellbeing before surgery tended to do less well [9]. Complete resolution is the exception. A systematic review of 203 operated shoulders found 42 (20.7%) were completely better, 139 (68.5%) were improved but still had some symptoms, and 22 (10.8%) had a poor result [10]. A 2026 review of 464 patients reached the same overall conclusion: both non-operative and surgical treatment relieve pain, but the mechanical symptoms, the clicking and grating, often do not go away completely [11]. ### Is the bone worth removing? Trimming the upper inner corner of the shoulder blade is the traditional part of the operation, so it is a surprise that it may add little. One centre compared 24 people who had the bursa removed alone with 32 who also had the corner trimmed. Final pain scores (3.4 and 2.8 out of 10, p = 0.351) and shoulder scores (75.8 and 76.5, p = 0.895) were the same, and clicking was still present in 58% and 59% [12]. The operation was shorter without the bone work: 37.5 against 61.2 minutes [12]. The groups were followed for different lengths of time and were not randomised, so this is not the last word, but it is why the decision to trim the bone is made during the operation rather than in advance. --- ### Sternoclavicular Joint Disorders URL: https://www.cqupperlimb.com/education/shoulder/sternoclavicular-joint-disorders/ Region: shoulder · condition Problems where the collarbone meets the breastbone — arthritis, instability and the rare but serious posterior dislocation — and how each is managed. ## What you're feeling The sternoclavicular joint is the small joint at the front of your chest where the inner end of your collarbone (clavicle) meets your breastbone (sternum). You can feel it as the little bump just below the base of your neck, a couple of centimetres out from the midline. It is easy to overlook until something goes wrong with it. Problems here tend to show up in one of a few ways. Some people notice a deep ache or tenderness right over that bump, often with a bit of swelling, that gets worse when they reach overhead, lift, push, or lie on that side. Others feel the joint click, slip or shift with certain movements, sometimes with a visible lump that comes and goes. And occasionally the trouble starts with a sudden injury (a fall onto the shoulder, a tackle, or a car accident), followed by pain, swelling and a change in the shape of the joint. How it feels depends a lot on which of these is going on, and we sort that out below. ## What's actually happening The sternoclavicular joint is the only true bony joint connecting your whole arm and shoulder to the rest of your skeleton. Everything your arm does is anchored back to your chest through this one small joint, which is why it is built tough, wrapped in strong ligaments. A few different things can affect it. Arthritis (wear of the joint surfaces) is the most common problem. The smooth cartilage thins over time, the joint can swell, and it aches with use. This is seen most often in middle-aged women, frequently without any injury at all, and on its own it is a nuisance rather than a danger. Atraumatic instability means the joint slips or partly pops out of place without a real injury, usually because the ligaments are naturally loose. It is most common in young, flexible (hypermobile) people, and the clavicle most often shifts forwards (an anterior slip), which you may see as a lump that appears when you move a certain way. Traumatic dislocation happens when a strong force pushes the collarbone fully out of the joint. If it pops forwards (anterior), it is painful and looks abnormal but is rarely dangerous. The one that matters most is the posterior dislocation, where the collarbone is driven backwards, behind the breastbone, into the space holding the windpipe, the swallowing tube and the large blood vessels of the chest. This is rare, but it can be serious. More on that in the last section. ## What we can do about it Our approach is guided by Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We then begin with a thorough assessment to confirm the diagnosis. For long-standing issues, we usually start with non-operative care and only consider surgery if this does not provide enough relief. The good news is that most sternoclavicular problems settle without surgery. For arthritis and for anterior (forward) instability, the first-line plan is non-operative and usually works well: modifying the activities that aggravate it, simple pain relief and anti-inflammatory medication, and physiotherapy to settle the joint and build supporting muscle. If a painful arthritic joint is still troublesome after a fair trial of this, a steroid injection into the joint can calm it down and also help confirm the joint is the source of the pain. Surgery is the exception, not the rule. It is reserved for selected people whose pain or instability does not settle despite proper non-operative treatment. Depending on the problem, that might mean stabilising the joint (rebuilding the ligaments to hold the collarbone in place) or, for stubborn arthritis, trimming away the worn end of the collarbone to take the painful surface out of the equation. These are considered carefully, because the joint sits right next to important structures in the chest. A posterior dislocation is the situation that can't wait. It usually needs an urgent reduction (putting the joint back into place), and because of what lies behind the joint this is often done in an operating theatre with a chest or vascular surgeon on standby, just in case. ## What to expect For arthritis and for the common forward instability, the outlook is reassuring. With activity changes, physio and time, the great majority of people get comfortable enough to get on with normal life, and many never need anything more than that. Flexible joints often quieten down as the surrounding muscles get stronger and you learn which movements to avoid. When surgery is needed, it can be very effective for the right person, but recovery takes patience: a period of protecting the joint followed by a staged return to activity over several months. Your surgeon will talk you through the specific plan for your situation. A posterior dislocation treated promptly usually does well once the joint is safely back in place. The thing that matters is speed: get it assessed and reduced early. ## When to see someone See your doctor if you have: - Ongoing pain, swelling or tenderness over the joint at the front of the chest that isn't settling, or a lump that keeps slipping in and out. - A joint that feels unstable or repeatedly pops out with certain movements and is limiting what you can do. - Pain after an injury to the front of the shoulder or chest, especially if the joint looks or feels out of shape. Treat this as an emergency: call an ambulance or go straight to your nearest emergency department if, after a heavy blow or high-energy injury to the shoulder or chest, you have: - Difficulty breathing, a feeling of pressure or choking, or a change in your voice. - Trouble or pain on swallowing. - Swelling, colour change, coldness or pins-and-needles in the arm, or a weak pulse on that side. These can be signs of a posterior dislocation pressing on the windpipe, the swallowing tube or the major blood vessels behind the breastbone. It is uncommon, but it needs urgent hospital assessment. Do not wait to see if it settles. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Sternoclavicular joint problems are worth the extra reading because one variant of them is a genuine emergency that can look unremarkable from the outside, and because the window in which the simplest treatment works is measured in hours. ### Posterior dislocation is the one that matters The sternoclavicular joint sits at the base of the neck where the collarbone meets the breastbone. Directly behind it lie the great vessels, the trachea and the oesophagus. An anterior dislocation pushes the collarbone forwards, producing a visible lump. It looks dramatic and is usually benign. A posterior dislocation pushes it backwards, towards those structures, and produces little to see externally, sometimes only a subtle hollow. The appearances are the inverse of the seriousness. Symptoms pointing to a posterior dislocation are difficulty swallowing, shortness of breath, a change in voice, or congestion of the veins in the arm or neck. Any of these after an injury to the front of the shoulder warrants immediate assessment. Plain X-rays are unreliable at this joint and CT is generally required. ### The 48-hour window Where a posterior dislocation is identified, the collarbone can often be pulled back into place without opening the joint. Across 140 adolescent patients, closed and open methods have both proven highly effective, and closed reduction is most effective when attempted less than 48 hours after the initial injury [1]. That is a specific, actionable number. Beyond about two days the soft tissues begin to organise around the displaced bone and closed reduction becomes progressively less likely to succeed, turning a brief manoeuvre into an open operation next to the great vessels. This is the strongest argument for early imaging rather than watchful waiting when the mechanism fits. Because of that proximity, reduction of a posterior dislocation is customarily performed with a cardiothoracic team available, not because it usually goes wrong, but because the consequences if it does are immediate. ### Reconstruction for instability works, and the technique does not decide it For recurrent or chronic instability, the joint is reconstructed with a tendon graft. Across 164 patients, reconstruction led to significant improvements in patient-reported outcomes and return to activity with a low complication rate, and, usefully, this held regardless of technique, including unicortical versus bicortical drilling and allograft versus autograft [2]. Where several technical variants perform alike, the sensible reading is that achieving a stable construct matters more than how it is achieved. ### Arthritis here is treatable and under-recognised Degenerative change at this joint is a genuine and often overlooked cause of pain at the base of the neck, particularly in middle-aged women, and it is frequently attributed to the neck itself. Surgical treatment across 107 patients is a safe procedure offering good pain reduction and a high rate of satisfaction, though the literature does not establish whether open or arthroscopic surgery is preferable [3]. The practical point is that a persistent, well-localised tenderness exactly over this joint is worth pointing out specifically, since it is a small target that is easy to overlook when the complaint is described as shoulder or neck pain. --- ### Subacromial Decompression URL: https://www.cqupperlimb.com/education/shoulder/subacromial-decompression/ Region: shoulder · operation Arthroscopic subacromial decompression for impingement and bursitis — operation and recovery. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic visit, we take a history, examine your shoulder and arrange imaging if it is needed. This rules out other causes of shoulder pain, such as a frozen shoulder or a torn tendon. Subacromial decompression is an operation that makes more room in the space above the rotator cuff, the group of tendons that move your shoulder. It is offered when your pain matches the pattern of impingement, where the tendons are pinched as you lift your arm, and when non-operative care has not given enough improvement. That care usually includes changing activities, physiotherapy and injections. We will suggest surgery only after looking at your examination and scans together with you. Where it is used for the right reasons, most people, 70% to 75%, find the operation helps. The aim is less pain when you lift your arm and better use of your shoulder. ## Before the operation Once surgery is planned, a few simple preparations help the day go smoothly. Your surgeon will already have the scans needed to plan the operation, such as X-rays, an MRI or an ultrasound. Do not eat or drink for seven hours before your operation. We ask for seven rather than six so you can be brought forward if the theatre list runs early. If you take regular medicines, bring a written list of them and ask your surgeon whether any should be paused beforehand. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing that is easy to change out of. If you have other medical conditions, you may need blood tests or a review with the anaesthetist before the day. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will then meet the anaesthetist, the doctor who looks after your anaesthetic and pain relief. This operation is done under general anaesthetic combined with a regional nerve block. The anaesthetist will meet you before the operation and talk you through both parts. When everything is ready, you are taken into the operating theatre and the operation is performed. Afterwards, you wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. They will check your shoulder, your comfort and your recovery from the anaesthetic. Once you are stable, you either move to a ward or go home, depending on the operation you had and how you are recovering. How long people usually stay is set out in 'After the operation'. ## What the operation involves Subacromial decompression is a keyhole operation. Your surgeon makes a few small cuts around your shoulder, including one at the back, and works through them with a small camera and slim instruments. The camera lets your surgeon see the space above the rotator cuff, the group of tendons that move your shoulder, on a screen. Once inside, your surgeon removes some swollen tissue called bursa and shaves away a small piece of bone from the underside of the acromion, the bony shelf above the tendons. Removing this bone and tissue makes more room, so the tendons are no longer pinched when you lift your arm. This part of the operation is called acromioplasty. If your surgeon finds anything else that needs attention, such as a torn tendon, they will discuss that with you beforehand. When the work is finished, your surgeon washes out the shoulder and closes each small cut with stitches. A dressing goes over the wounds, and it stays in place for about 10 days. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You will wake up in the recovery area, then move to a ward for the night. Your arm rests in a simple sling for comfort; it comes off for exercises and washing. Nurses will help you manage any pain with medicines. Someone should stay with you for the first 24 hours after you get home. If you had a nerve block, your arm may feel heavy or numb at first; this is expected and wears off within about 24 hours. Call the clinic if numbness or weakness lasts once the block has worn off. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery Your shoulder will be sore and swollen for the first few days. The swelling settles gradually over the following weeks, and the pain eases as it does. Medicines prescribed by your care team, ice packs and rest all help in the early days. Your arm rests in a simple sling for comfort; it comes off for exercises and washing. You will start gentle exercises soon after the operation, guided by your physiotherapist. These keep the shoulder from stiffening while the tissues heal. Everyday tasks such as dressing, eating and typing at a desk are usually manageable early on. Lifting anything heavier than a cup of tea, or reaching above shoulder height, waits until your shoulder is ready. Sleeping can be uncomfortable at first; many people find it easier propped up in a chair or with pillows behind them. Once the swelling settles and your movement returns, daily activities feel more natural. You can drive once your surgeon clears you, typically at the six-week review; see our guide on Driving after upper-limb surgery. Return to work, sport and heavier activity is gradual, and your surgeon and physiotherapist will tell you when each step is safe. Recovery varies between individuals. Your timeline may differ from the typical ranges shown in the table above, and your surgeon and physio will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes new bone forms where the small piece of bone was shaved away. This can feel like the old pinching pain coming back, with a catching or grinding feeling when you lift your arm. If that happens, bring it up at your next review. The shoulder can also become stiff and painful, with movement that will not loosen up even with gentle exercises. Tell your physiotherapist or call the clinic if this does not improve. Occasionally the pain turns out to come from something else, such as a torn tendon or arthritis in a nearby joint. If your shoulder still aches much as it did before, once the early healing has settled, we will look at the original diagnosis again with you at your review. Rarely, a blood clot can form. Go to the emergency department if you have swelling or pain in a calf, or sudden shortness of breath or chest pain. These can be signs of a blood clot. Call the clinic the same day if you have a fever, redness spreading out from a wound, or fluid or pus leaking from it. Call the clinic the same day too if pain keeps getting worse despite your pain medicines. Call the clinic if numbness or weakness in your arm, hand or fingers lasts once the nerve block has worn off, at about 24 hours. Numbness and weakness in the first 24 hours are expected. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up early, so it helps to know what to watch for. Go to the emergency department if you have swelling or pain in a calf, or sudden shortness of breath or chest pain. These can be signs of a blood clot. Call the clinic the same day if you have a fever, redness spreading out from a wound, or fluid or pus leaking from it. Call the clinic the same day too if pain keeps getting worse despite your pain medicines. Call the clinic if numbness or weakness in your arm, hand or fingers lasts once the nerve block has worn off, at about 24 hours. Numbness and weakness in the first 24 hours are expected. If you cannot reach the clinic, go to your nearest emergency department. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Subacromial Impingement and Bursitis page. --- ### Subacromial Impingement and Bursitis URL: https://www.cqupperlimb.com/education/shoulder/subacromial-impingement/ Region: shoulder · condition Subacromial impingement — causes of shoulder pain with overhead activity, diagnosis, and treatment options. ## What you're feeling The main symptom of subacromial impingement is pain at the front of your shoulder. It often shows up when you lift your arm, reach overhead, or use the arm away from your body. Many people also notice weakness in the shoulder and arm. The pain tends to follow a pattern. It can flare during a "painful arc", a band of movement where lifting your arm hurts, roughly between 40 and 120 degrees out to the side or in front of you. Outside that band, the movement is often easier. Night pain is common, and the shoulder can ache after activity or on waking. Tasks that become hard include hanging washing, reaching a high shelf, or lifting a kettle. Your shoulder usually keeps a normal range of motion, meaning you can still move it through its full arc even though parts of that arc hurt. Tenderness over the front of the shoulder is common. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your arm, see your GP or ask for a specialist review. Other shoulder problems can feel similar, including frozen shoulder, a full-thickness rotator cuff tear (a tendon torn all the way through), and instability (a shoulder that slips or feels loose). A careful assessment sorts out which of these you have. ## What's actually happening Your shoulder sits under a bony arch. The arch is made of the acromion, a shelf of bone on top of the shoulder, joined to another bone at the front by a ligament. Sliding through the gap beneath that arch are your rotator cuff tendons, the group of four tendons that hold the ball of the joint centred as you move, and a small fluid-filled cushion called the subacromial bursa. The bursa works a bit like a gasket, letting the tendons glide smoothly under the bone instead of rubbing on it. In this condition, that cushion becomes inflamed and swollen, and the tendons can thicken as well. A thicker tendon takes up more of the narrow space under the arch, so there is less room to glide. That fits with what you feel: pain at the front of the shoulder when you lift your arm, worst in the painful arc described earlier, because that is exactly when the space under the arch is at its tightest. The space is narrowest when your arm is lifted to about 90 degrees, roughly level with your shoulder. It is worth knowing that some rubbing between the arch and the tendons happens in every shoulder, even healthy ones. The pressure simply rises with certain movements, like reaching out to the side or behind you. There is also debate about whether the shape of the bone above the tendon is truly the cause, since the link between bone shape and tendon problems has not been settled. Many specialists now describe this condition as subacromial pain syndrome, which names where it hurts rather than claiming to know why. Because of this, treatment usually starts without an operation, with exercise and other non-surgical measures. Surgery to shave bone from the underside of the arch, called subacromial decompression, may be offered to a small group of selected patients whose pain has not settled. It is honest to say that trials comparing this operation against a sham procedure, where the surgeon looks inside the shoulder but does not remove any bone, found little added benefit from the bone removal itself. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your first visit we take a history, examine your shoulder, and arrange imaging where it is needed. For a long-standing problem like this, we usually try non-operative care first and consider surgery only when that has not given enough improvement. The first step is changing how you use the arm and building shoulder strength with a physiotherapist. The aim is to settle the irritated tissue and restore comfortable movement, not to push through pain. Give this a fair trial over several months before judging it. Adding a large dose of shoulder strengthening on top of your usual care does not improve results, so steady, well-guided exercise is what counts. Pain medicine and anti-inflammatories can help you keep moving while the exercises do their work. We do not use cortisone injections for this condition. If pain still limits you after a genuine trial of non-operative care, we discuss surgery. The operation is a subacromial decompression, which shaves bone from the underside of the arch to give the tendons more room, and removes the inflamed bursa at the same time. The decision is one you make together with us, weighing what the operation involves against what it can and cannot change. ## What to expect For most people, this condition settles with time and steady exercise rather than surgery. Give non-operative care a fair trial over several months before judging it. Many people improve enough to get back to their normal activities without an operation. If the pain has not settled after a genuine trial of exercise and other non-surgical measures, surgery may be discussed, but the trials comparing it against a sham procedure found little added benefit from the bone removal itself. Recovery after this condition is managed, not rushed. Most people who have the operation are back at work within 6 weeks, and more than 90% manage to return to driving within 4 weeks, though you should not drive for at least six weeks after shoulder surgery and only once your surgeon has cleared you. Most people also return to their former sports, including 90% of those in overhead sports and all of those in sports that spare the shoulder or involve contact. Subjective shoulder function takes almost 3 months on average to recover. The coracoacromial ligament, the strap of tissue under the arch, can re-form relatively quickly after surgery but takes time to regain strength. If the condition is left alone, some people continue to have pain that comes and goes, particularly with overhead activity. Specific exercise treatment can reduce the need for surgery, with results maintained after 10 years. Results are slower and overall poorer for people with a whiplash injury. A partial rotator cuff tear found at surgery may not need to be addressed, as both groups had a similar final outcome. ## When to see someone Most shoulder pain here is not an emergency, but a few signs need fast attention. Go to an emergency department the same day if your arm becomes hot, red, swollen and painful, especially with a fever, or if your fingers or hand turn pale, cold, white or blue. The same applies if you suddenly lose feeling or movement in the arm after an injury. See your GP if the pain is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your arm. Ask for a specialist review if simple measures have not helped after several months, or if the pattern sounds like the painful arc described earlier. A specialist assessment can also rule out other causes, such as a rotator cuff tear or frozen shoulder, before any decisions are made. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Subacromial impingement is worth the extra reading because it is the shoulder condition where surgery has been tested against a placebo operation, twice, in large randomised trials, and the result changed practice worldwide. ### Two trials that compared the operation against pretending to do it Most surgical evidence compares one operation with another, or with no treatment. Very rarely, a trial compares an operation with a sham, the patient is anaesthetised, the arthroscope is inserted, nothing is decompressed, and neither patient nor assessor knows which was done. That design removes the placebo effect of having had surgery, which is substantial. The CSAW trial randomised 313 patients three ways: arthroscopic subacromial decompression, investigational arthroscopy only, and no treatment. Both surgical groups did better than no treatment, but the difference was not clinically important, and decompression offered no extra benefit over arthroscopy alone [1]. The FIMPACT trial reached the same conclusion independently. In patients with impingement syndrome, arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy at 24 months [2]. Two well-conducted trials, two countries, the same answer: the part of the operation that removes bone is not the part producing the improvement. Whatever benefit people experienced came from something the sham procedure also delivered. ### What that does and does not mean It does not mean the pain is imagined, or that nothing helps. It means the mechanical explanation — that a bone spur is rubbing on the tendon and shaving it away fixes the problem, is not supported as the mechanism of benefit. That has consequences for how the condition is framed. The term "impingement" itself embeds the mechanical theory, which is why much of the literature has shifted to "subacromial pain syndrome": a description of where it hurts rather than an unproven claim about why. ### So what is left Non-operative treatment carries the weight, and the comparative evidence is mixed enough to be worth reading carefully. In a network analysis of 3,643 patients, arthroscopic decompression with acromioplasty and physical therapy showed better outcomes across pain, patient-reported measures and range of motion, while corticosteroid injection showed poor outcomes in all three domains, with the authors recommending physical therapy for patients with significant symptoms [3]. Set against the sham-controlled trials, the reasonable synthesis is that structured exercise is the core treatment; injection may relieve pain in the short term but does not perform well over the longer horizon; and surgery has not been shown to add anything beyond what inserting a camera adds. ### Where surgery still has a role None of this applies to a genuine, repairable rotator cuff tear, which is a different diagnosis with its own evidence, covered on the rotator cuff page. The trials above concern shoulders with pain attributed to impingement, not shoulders with a torn tendon. Distinguishing the two is the reason careful assessment matters more here than the choice of operation. --- ### Suprascapular nerve decompression URL: https://www.cqupperlimb.com/education/shoulder/suprascapular-nerve-decompression/ Region: shoulder · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. The suprascapular nerve runs through small channels at the back of the shoulder. When something presses on it there, it can cause a… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. The suprascapular nerve runs through small channels at the back of the shoulder. When something presses on it there, it can cause a dull, aching pain and weakness in the shoulder muscles. This operation, called nerve decompression, eases that pressure so the nerve can recover. Most people with this problem are first treated without surgery. That usually means physiotherapy, anti-inflammatory medicine, and changing activities that stir up the pain. We consider this operation when those measures have not given enough improvement, or when the nerve is being squeezed by something such as a ganglion cyst, a band of tissue, or a bone spur. Surgery may also be suggested if your pain or weakness is getting worse. Before recommending it, we confirm the diagnosis with a careful history, an examination, and tests that check how the nerve is working. The aim of the operation is simple: less pain and better strength and function in your shoulder. Many people return to sport and their usual activities after this operation. We will talk through whether it is the right choice for you, together. ## Before the operation Before your operation, you will need some scans and tests to plan it. These usually include an X-ray, an MRI scan (a scan that shows detailed pictures of soft tissues), and sometimes an ultrasound. You may also have a test that checks how well the nerve is working. In the seven hours before your operation, do not eat or drink anything. We ask for seven hours rather than six so your operation time can be brought forward if the theatre list runs early. Bring a list of all your current medicines. Some medicines may need to be paused, and your surgeon will tell you which ones and when. Arrange for someone to drive you home afterwards. Wear loose, comfortable clothing. If you have other medical conditions, you may need blood tests or a review with the anaesthetist (the doctor who gives the anaesthetic). ## On the day On the day of your operation, you will come to the hospital's surgical admissions unit. You will be checked in there and prepared for theatre. You will then meet the anaesthetist, the doctor who gives the anaesthetic. This operation is done under general anaesthetic combined with a regional nerve block. The anaesthetist will meet you before the operation and talk you through both parts. You will then be taken into the operating theatre, where the operation is performed. When it is finished, you will wake up in the recovery area. Nurses will monitor you there while the anaesthetic wears off. Once you are stable, you will either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves This operation is done through keyhole surgery. Your surgeon makes a few small cuts around your shoulder, including one at the back. A thin tube with a tiny camera goes in through one of the cuts, so your surgeon can see inside the shoulder on a screen. The suprascapular nerve runs through small channels at the back of your shoulder. A band of tissue crosses over the nerve at these points, like a strap over a tunnel. During the operation, your surgeon releases that band so the nerve is no longer squeezed. If a ganglion cyst (a fluid-filled sac) is pressing on the nerve, your surgeon removes it as well. The camera also lets your surgeon look around the rest of the shoulder and treat any other problems found there. The small cuts are closed with stitches. A dressing goes over the wounds, and you will keep that dressing on for about 10 days. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You will wake up in the recovery area, then move to the ward. Nurses will check on you and give you medicine to keep you comfortable. Your arm will rest in a simple sling, which comes off for washing and exercises. Someone should stay with you for the first 24 hours. Numbness or weakness in the arm during this time is expected while the nerve block wears off. If numbness or weakness lasts beyond that, call the clinic. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your shoulder will be sore and may feel swollen. This settles gradually. Simple pain medicine and rest ease the discomfort. Your arm rests in a sling for comfort, and it comes off for washing and for your exercises. Your physiotherapist will guide your rehabilitation. Early on, this means gentle movements to keep the shoulder from stiffening. As the pain settles, the exercises build up to restore strength. The sling comes off for good once your physiotherapist and surgeon agree your shoulder is ready. Day to day, you can do light tasks around the home as soon as you feel able. Avoid lifting anything heavy or pushing through pain. Sleep can be awkward at first; some people find it easier propped up in a chair or with pillows. You will not drive until your surgeon clears you, typically at the six-week review. Our guide to driving after upper-limb surgery explains this in more detail. Once the swelling settles and movement returns, everyday activities feel more natural. Strength comes back gradually as the nerve recovers, and this continues over many months. Most people notice the pain easing first, then function improving as they work through rehabilitation. Recovery varies from person to person. Your timeline may differ, and your surgeon and physiotherapist will guide you at each step. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The nerve being operated on can sometimes be irritated further. If you notice new numbness, tingling or weakness in your shoulder, arm or hand once the nerve block has worn off (about 24 hours), call the clinic. Numbness and weakness in the first 24 hours after a nerve block are expected. The blood vessels and veins near the nerve are close to the operating area. Your surgeon identifies and protects them during the operation. If you notice swelling or a firm, tender lump near one of the small wounds after you go home, call the clinic. A collection of blood under the wound can occasionally happen after surgery. This feels like a swollen, tender spot that may look bruised. If the swelling keeps growing or the pain keeps getting worse despite your pain medicines, call the clinic the same day. The wound itself needs watching. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it. This operation is done through keyhole surgery, which carries a limited risk. The open form of this operation also has a low rate of problems. Releasing the nerve safely takes skill, and your surgeon has trained specifically in this area. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up early, and we would rather hear from you than have you worry at home. Call the clinic if you notice numbness, or you cannot move your arm, hand or fingers, once the nerve block has worn off (about 24 hours). Numbness and weakness in the first 24 hours are expected while the block wears off. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it. Call us the same day too if your pain keeps getting worse despite your pain medicines. Go to the emergency department if you have swelling or pain in your calf, or shortness of breath or chest pain. These can be signs of a blood clot. Go also if your fingers or hand turn pale, cold, white, blue or dark. If you cannot reach us, out of hours or on a weekend, go to your nearest emergency department. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Suprascapular neuropathy page. --- ### Suprascapular neuropathy URL: https://www.cqupperlimb.com/education/shoulder/suprascapular-neuropathy/ Region: shoulder · condition Suprascapular neuropathy means the nerve that supplies two of your shoulder muscles is being stretched or squeezed. It usually shows up as pain, weakness, or both. The pain tends to sit at the back of the shoulder, near the top corner of the shoulder blade, and it is often a… ## What you're feeling Suprascapular neuropathy means the nerve that supplies two of your shoulder muscles is being stretched or squeezed. It usually shows up as pain, weakness, or both. The pain tends to sit at the back of the shoulder, near the top corner of the shoulder blade, and it is often a dull ache rather than a sharp stab. Overhead activity can make it worse, so things like reaching to a high shelf, hanging washing, or throwing a ball for the dog may flare your symptoms. Some people notice catching, locking or clicking in the shoulder as they move. Night-time ache that disturbs sleep is common with shoulder problems generally, and if pain is waking you at night or not settling over weeks, see your GP or ask for a specialist review. When the nerve has been irritated for a long time, the muscles it supplies can waste away. You might notice a hollow or dip below the spine of the shoulder blade at the back, or that your arm tires quickly when held out to the side. Weakness with lifting your arm and turning your forearm outward is typical. Some people have this wasting with very little pain, which is why it often goes unnoticed for a while. Daily tasks that need strength or reach become harder: lifting a kettle, pulling a jumper over your head, or holding a phone to your ear for long. If your symptoms are getting worse over weeks or stopping you from using your arm, that is worth a review rather than waiting it out. There is one urgent sign to know about. If your arm, hand or fingers become hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. ## What's actually happening The suprascapular nerve is a small nerve that runs across the back of your shoulder blade and supplies two of your shoulder muscles. It travels a winding route, passing through two narrow gaps where the tissue above it is tight, like a cable running under a strap. At the first gap, near the top of the shoulder blade, a ligament crosses over the nerve. Further along, at the second gap near where the shoulder meets the blade, another band of tissue lies over it. Because the nerve is squeezed through these narrow spots, anything that crowds the area can press on it. A fluid-filled sac, called a ganglion cyst, can grow from a tear in the rim of cartilage around the shoulder socket and squash the nerve along its path. The ligament over the first gap can also harden with bone, or the gap itself can be unusually narrow, leaving less room for the nerve. A large collection of blood near the shoulder blade can do the same. The nerve can also be stretched rather than squeezed. Repeating overhead actions, like serving a tennis ball or spiking a volleyball, pulls on the nerve as the arm goes up and back. A long-standing rotator cuff tear can have the same effect, because when the tendon pulls away, the muscle shifts and tugs on the nerve where it is held under that strap. So can a sudden injury that yanks the shoulder back while the head turns the other way. Whatever the cause, the result is the same. The nerve stops carrying its signals properly, so the two muscles it supplies, which lift your arm and turn your forearm outward, weaken and can waste away. That is why the pain at the back of your shoulder and the weakness you noticed in the section above are happening. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic visit, we take a history, examine your shoulder and arrange scans where they are needed to confirm the diagnosis. Most people start without surgery. You rest the shoulder and change the activities that flare your symptoms, such as repeated overhead work. Anti-inflammatory tablets can settle pain in the short term. Physiotherapy aims to keep your shoulder moving freely and to strengthen the muscles around the shoulder blade, including the ones that hold it steady against your ribs. We usually give this approach a fair trial of at least 6 months before thinking about surgery, unless there is a clear cause pressing on the nerve or the muscle at the back of your shoulder has already started to waste, in which case we keep that trial short, no more than 3 months, so the nerve is not damaged for good. If these steps have not given you enough relief, surgery may be considered. The operation releases the tight band of tissue pressing on the nerve, giving it more room. It is done through small cuts using a camera, or occasionally through a small open cut. We will talk through whether it suits your shoulder and decide together. After surgery, your arm rests in a simple sling for comfort, and gentle pendulum exercises start straight away. You see us again at 1 week to check your strength and begin physiotherapy with your physiotherapist, starting with assisted movements and muscle-tightening exercises. Resistance work and overhead activity begin somewhere between 4 and 8 weeks after the operation. ## What to expect For most people, this condition starts without surgery. Resting the shoulder, changing the activities that flare your symptoms, anti-inflammatory tablets and physiotherapy are the usual first steps. With this approach, pain often settles and the shoulder can work normally again. If the nerve stays squeezed, surgery to release the tight band of tissue pressing on it can relieve pain and allow normal shoulder function to return. Recovery takes months rather than days. Strength in the two affected muscles builds back slowly, and guided exercises with your physiotherapist protect the shoulder while it recovers. Where the muscles have wasted, that hollow at the back of the shoulder blade usually improves as the nerve recovers, though some wasting can remain even once the pain has gone. If a large rotator cuff tear is part of the picture, repairing the torn tendon, even partly, can take the stretch off the nerve and let it recover along with your shoulder function. Left alone, an irritated nerve does not always settle by itself. Long-standing pressure on a nerve can lead to lasting changes in the muscles it supplies, so symptoms that are not settling over weeks are worth a review rather than waiting them out. If your symptoms are getting worse, waking you at night, or stopping you from using your arm, see your GP or ask for a specialist review. ## When to see someone See your GP or ask for a specialist review if you have pain at the back of your shoulder that is not settling over weeks, or weakness lifting your arm or turning your forearm outward. Ask sooner if the hollow below your shoulder blade is visibly wasting, or if you have a dull ache with catching, locking or clicking in the shoulder, which can point to a tear in the rim of cartilage around the socket. A nerve problem like this is worth checking with a nerve test rather than waiting it out, because long-standing pressure can leave lasting changes in the muscles. If your arm, hand or fingers become hot, red, swollen and painful, especially with a fever, go to the emergency department the same day. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Suprascapular neuropathy is worth the extra reading because the same nerve appears in two quite different roles, as a cause of shoulder pain and weakness, and as a target for pain relief, and the evidence for the two is very different in quality. ### Decompression works, with a caveat about attribution Where the nerve is compressed, releasing it is effective. Across 730 patients, suprascapular nerve decompression significantly improves patient-reported outcomes, is non-inferior to similar procedures performed without decompression, and is associated with high rates of return to sport and relatively low rates of adverse events [1]. The phrase doing the work there is "non-inferior to similar procedures without decompression". The nerve is frequently released during an operation done for another reason, a cuff repair, or removal of a ganglion at the shoulder blade, so attributing the improvement to the decompression itself is difficult. It helps, and it does not make the accompanying procedure worse. ### Why the level of compression changes the picture The nerve passes through two narrow points as it wraps around the shoulder blade, and which one is involved determines the presentation. Compression at the suprascapular notch, higher up, affects both supraspinatus and infraspinatus, producing weakness in lifting and external rotation along with pain. Compression at the spinoglenoid notch, further along, affects only infraspinatus, producing external rotation weakness and visible wasting in the hollow below the spine of the shoulder blade, often with little pain. The isolated-wasting presentation is the one that gets missed, because it does not hurt much. The commonest cause at that level is a ganglion cyst arising from a labral tear, which means finding this pattern should prompt a search for the cyst and the tear behind it, since treating the cause addresses the nerve. ### As a pain block, the evidence is thinner than its use suggests The same nerve is widely blocked with local anaesthetic for shoulder pain, both after surgery and in chronic conditions. Reviewing physical harms across 4,142 patients, the block carries a low risk of physical harm, but the authors note heterogeneity in the intervention and low-quality evidence, and call for better assessment and reporting of harms [2]. "Low risk of harm on low-quality evidence" is a specific and limited claim. It supports the block being reasonably safe; it is not a statement about how well it works, and it should not be read as one. ### The distinction worth carrying away Two things share this nerve's name and should not be conflated. A neuropathy is a structural problem where the nerve is compressed and can often be decompressed, with wasting and weakness as its signature. A nerve block is a symptomatic treatment that interrupts pain signalling from the joint and changes nothing structural. Weakness and visible wasting point to the first. Pain alone, without those findings, usually points elsewhere, and a block that relieves it is providing analgesia rather than confirming a diagnosis. --- ### Suture Anchors and How Repairs Are Held to Bone URL: https://www.cqupperlimb.com/education/shoulder/suture-anchors/ Region: shoulder · device A suture anchor is a small device that holds stitches into bone. It solves a problem that stitches alone cannot: you can sew soft tissue to soft tissue, but you cannot sew soft tissue to bone. The anchor provides something for the stitches to hold on to. ## What is it A suture anchor is a small device that holds stitches into bone. It solves a problem that stitches alone cannot: you can sew soft tissue to soft tissue, but you cannot sew soft tissue to bone. The anchor provides something for the stitches to hold on to. Almost every repair in the shoulder uses them. When a rotator cuff tendon is reattached, when a torn labrum is put back onto the rim of the socket, when a ligament is reattached after a dislocation — in each case an anchor is placed into the bone and its stitches are passed through the tissue and tied down. The anchor is not what holds the repair together in the long run. It holds the tissue still against the bone for the weeks it takes the two to knit together biologically. Once healing has happened, the join is living tissue, not hardware. ## What it's made of Anchors have been made from several different materials over the years, and the field has moved through them in a fairly clear sequence. The earliest were metal — usually titanium. They held extremely well but stayed in the bone permanently and showed up on every X-ray afterwards, which made later imaging harder to interpret. Bioabsorbable anchors followed, made from polymers designed to dissolve over a few years. The intention was sound, but some of the early materials broke down unpredictably and could leave a cavity in the bone or provoke inflammation. PEEK — a strong medical-grade plastic — is widely used now. It does not dissolve, but it does not show up on X-ray and its stiffness is closer to bone than metal is. All-suture anchors are the newest, and are now in widespread use in the shoulder. There is no rigid body at all: a small sleeve of suture material is passed into a narrow hole and then tightened so that it bunches up and grips inside the bone. The hole needed is considerably smaller than for a solid anchor, so much less bone is removed. The stitches themselves have changed as much as the anchors. Modern sutures are braided from an extremely strong polyethylene fibre, and are now stronger than the tendon they hold. ## How your surgeon uses it Anchors are used in several quite different shoulder operations, and what the surgeon is trying to achieve is not the same in each. ### Rotator cuff repair Here the job is to hold a broad, flat tendon down onto an equally broad area of bone — the footprint — so the two can knit together across that whole surface. There is more than one reasonable way to arrange this, and practice differs between surgeons. A single-row repair places one line of anchors along the edge of the bone where the tendon should sit. A double-row or suture-bridge construct adds a second row further down the bone, so the stitches from the inner row are carried outwards and tensioned over the tendon, pressing a broad surface flat against the bone rather than holding it at a few points. The second arrangement is thought to favour healing, and it does produce fewer retears on follow-up scans — but as the evidence below sets out, that advantage shows up more reliably on the scan than in how shoulders actually feel. Which is used depends on the size and shape of the tear, the quality of the bone and tendon, and the judgement and training of the individual surgeon. ### Labral repair The labrum is a rim of cartilage around the edge of the shoulder socket. It is not being held onto a flat surface but reattached to the edge of one, so the anchors are smaller and are placed around the rim of the socket, usually three or four of them, with the stitches passed around the labrum to draw it back against the bone. This is the repair done for shoulder instability after a dislocation, where the labrum has been torn off the front of the socket. The socket is small and the bone is thin, so anchor size and how much bone each one takes up matter more here than almost anywhere else in the shoulder — which is part of why all-suture anchors have been taken up readily for this operation. ### Biceps tenodesis (loop and tack) Sometimes the long head of biceps tendon is detached from inside the joint and reattached to the arm bone a little lower down. The requirement is different again: not spreading a tendon over a surface, and not restoring a rim, but holding one cord-like tendon securely at a single point while it heals into the bone. One straightforward way to do this is often called loop and tack. A stitch is passed around the tendon and locked onto itself, so it grips the tendon like a noose rather than relying on the thread pulling through tendon fibres. That loop is then tacked down to the bone with a single small anchor. The alternative approach wedges the tendon into a drilled socket with a screw. Loop and tack avoids drilling a socket of that size, so less bone is removed, and the grip on the tendon comes from the looped stitch rather than from compression against a screw. ### A note on knots In any of these repairs, the stitches may be tied in knots, or held by a locking mechanism built into the anchor so that no knot is needed. Both are in routine use, and the evidence does not favour either. ## What to expect The anchors stay in. They are not removed once healing is complete, and they do not need to be. Removing them would mean another operation and would take bone with them. They will not set off airport scanners. All-suture and PEEK anchors contain no metal at all. Even titanium anchors are far too small to trigger a walk-through detector. You can have an MRI. Anchors in current use are MRI-safe. Metal anchors can cause a local blur on the image near the anchor, which is one of the practical advantages of the newer materials — the scan is easier to read if your shoulder ever needs imaging again. They are not what limits your recovery. The anchor is secure from the moment it is placed; it is the tendon-to-bone healing that takes months, and that is what your sling and rehabilitation timeline are protecting. Recovery follows the timeline of the operation itself, so see the page for your specific procedure. Occasionally an anchor can loosen or pull out, most often in soft bone. This is uncommon, and it is one of the reasons the choice of anchor is matched to the quality of your bone. ## What the evidence says The honest summary is that anchors work well and that the differences between the various types and techniques are smaller than the amount written about them would suggest. All-suture anchors hold as well as solid anchors in testing and in patients, while removing less bone — which is the main reason for the shift towards them. Comparisons of the newer suture tapes against conventional round sutures have not shown a clear clinical advantage, despite a sound theoretical case for them. Tying knots and using knotless designs give much the same result. Double-row repairs do appear to improve the chance of the tendon healing to bone on a follow-up scan, but that has not translated into a clear difference in how shoulders feel and function. That gap between what the scan shows and what the patient reports is a recurring theme in shoulder surgery. The materials story is the one place where the evidence is genuinely one-sided: the early bioabsorbable anchors produced meaningfully more problems than what replaced them, which is why they are largely no longer used. If you want the detail — how anchors developed, what the sutures are actually made of, and how all this compares with the older technique of passing stitches through tunnels drilled in the bone — that is in the section below. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Anchors are worth the extra reading because they are the clearest example in shoulder surgery of engineering outrunning biology: over four decades the fixation has become far stronger, and the thing that fails has moved each time, from the stitch, to the anchor, to the tendon itself. ### The problem anchors solve Sewing tendon to tendon is straightforward. Sewing tendon to bone is not, because bone will not hold a stitch, the thread simply cuts through the surface. The original solution was transosseous repair: drill tunnels through the bone and pass the sutures through them, so the thread is anchored around a bridge of solid bone rather than gripping its surface. Done open, this was the standard for decades and it worked. Arthroscopy is what displaced it. Through keyhole portals you cannot reliably drill and thread a tunnel across a piece of bone you can only see from one side. The anchor exists because it lets a surgeon achieve fixation from a single direction, through a portal, not because it was shown to be better than tunnels. That distinction matters, because the comparison has since been done. Biomechanically, anchor fixation produces less gap formation under cyclic loading than transosseous repair, with no significant difference in ultimate load to failure [1]. And now that arthroscopic techniques have been developed to recreate bone tunnels without an implant, the clinical comparison is available too: arthroscopic transosseous repair gives comparable clinical and structural outcomes to anchor repair, its only measured advantage being slightly better recovery of abduction [2]. So the tunnel was never really beaten. It was made impractical by the shift to keyhole surgery, and it is now partly returning. ### Four generations of anchor Metal. The first anchors were titanium or stainless steel, and they held superbly. Their drawbacks were downstream: they stay in the bone permanently, and they scatter on later imaging, which matters in a joint likely to be scanned again. Bioabsorbable. Polymer anchors designed to dissolve over a few years followed, and the shift was rapid and near-total, a 2007 review describes a major shift from metallic to bioabsorbable anchors, attributing it to higher complication rates with metal [3]. That verdict did not entirely survive contact with the polymers themselves. The early poly-L-lactic-acid materials degraded slowly and unpredictably, and could provoke inflammation, leave a fluid-filled cavity in the bone, or shed fragments into the joint. The more measured assessment a few years later was that bioabsorbable anchors remain safe and reproducible, with complications amounting to a fraction of the total implanted, while emphasising that meticulous insertion technique is what keeps them that way [4]. Both reviews stress the same specific point: the anchor must be sunk below the level of the cortex, because a proud anchor abrades whatever passes over it [3]. PEEK. A high-performance thermoplastic that is radiolucent, non-degrading, and closer to bone in stiffness than metal is. It is now the standard solid-anchor material, and is worth a section of its own below. All-suture. The current generation abandons the rigid body entirely. A sleeve of suture material is passed through a small drill hole and then tensioned so that it deforms and locks against the inner wall of the bone. Across the design generations the raw numbers improved sharply, newer anchors showed markedly increased load-to-failure strengths, with the important caveat that an anchor which fails by pulling out at low load risks becoming a loose body inside the joint [5]. ### What PEEK actually is Polyether ether ketone is a semi-crystalline thermoplastic from the polyaryletherketone family. It is not a plastic in the everyday sense: it is used in aerospace and in spinal implants, it melts around 340°C, it tolerates repeated steam sterilisation, and it is chemically inert in the body. Three properties explain why it displaced both metal and the early absorbables as a solid-anchor material. It is radiolucent. PEEK does not show on X-ray and produces no scatter on CT or MRI. A shoulder repaired with PEEK anchors can be imaged afterwards and read cleanly, a genuine advantage in a joint that may well be scanned again. Its stiffness is close to bone. PEEK's elastic modulus is in the region of cortical bone, where titanium's is roughly ten times higher. A very stiff implant in less stiff bone concentrates stress at the interface; matching the modulus more closely spreads it. It does not degrade. Unlike the absorbable polymers it replaced, PEEK does not break down, so there is no resorption phase during which the anchor weakens or the body reacts to its breakdown products. ### What PEEK does to bone, which is not nothing The natural assumption is that an inert, non-degrading material provokes no biological response. The imaging evidence complicates that. Perianchor cysts, fluid-filled cavities in the bone immediately around the anchor, occur with every anchor type. Comparing all-suture, bioabsorbable and PEEK anchors across 213 repairs, cysts formed in 10.8% of cases overall, with no significant differences between the three materials in clinical scores, retear rates or perianchor bone reaction [6]. A more granular comparison is less flattering to PEEK. Across 73 repairs, despite both being non-absorbable, all-suture anchors produced less osseous reaction than PEEK, with the authors concluding that anchor choice should weigh not only initial fixation strength but the post-operative biological response [7]. The reassuring part is what those cysts appear to mean. Around PEEK anchors specifically, cyst formation stabilises by six months and shows no association with functional scores or with retear [8]. So this is a radiographic finding rather than a clinical problem, which matters mainly because it will be reported on your scan and can look alarming. Where it does have consequences is revision. Anchorless transosseous repair, which leaves no implant at all, avoids peri-implant cyst formation entirely, and the authors argue the real advantage is in the prospect of additional surgery, where undisturbed bone gives more options [9]. That is the same bone-stock argument that drives the move to all-suture anchors, arrived at from a different direction. ### Why all-suture anchors won on bone, not on strength The intuition is that a soft anchor must be weaker than a solid one. It is not. All-suture anchors have similar or better mechanical properties than regular anchors, with a low-profile design that preserves bone tissue, and clinical series show satisfactory results with low complication rates [10]. The real argument for them is the hole. A solid anchor needs a socket sized to its body; an all-suture anchor needs a hole roughly half the diameter. In the greater tuberosity, where the bone is often soft, and where a revision may one day need somewhere fresh to place fixation, how much bone was removed the first time is a genuine consideration. The clinical evidence supports using them where it matters most. Double-row suture-bridge cuff repair using all-suture anchors for the medial row produced similar excellent outcomes to the same repair using solid medial-row anchors [11]. They are not free of the cyst phenomenon either, around 40% of patients after double-row suture-bridge repair with all-suture anchors, with a low anchor insertion angle and a large mediolateral tear identified as risk factors [12]. That insertion-angle finding is a technical point with a practical edge: how the anchor is aimed is something the surgeon controls. ### The suture became the strongest part, and that moved the problem The less visible revolution is in the thread. Modern sutures are braided from ultra-high-molecular- weight polyethylene, the FiberWire class of materials, and the result is a suture substantially stronger than the tissue it passes through. This solved one problem and created another. Repairs no longer fail by the suture snapping. They fail by the suture cutting through the tendon, like cheese wire, which is why so much design effort has gone into spreading the load rather than increasing strength further. Flat suture tape is the direct response: a wider footprint against the tendon means lower pressure per unit area for the same tension. The theory is sound and the laboratory agrees. The patients do not, quite: although biomechanically superior, suture tapes showed similar retear rates and postoperative function to conventional round sutures [13]. That is worth sitting with, because it is the same pattern as the anchor comparisons. Once fixation is strong enough, making it stronger stops changing the outcome, the limiting factor has become the biology of tendon healing to bone, which no implant addresses. ### Configuration: where the remaining differences are Single-row repair places one line of anchors at the tendon edge. Double-row and suture-bridge constructs add a second, more lateral row, compressing a broad area of tendon against bone. Across the evidence, double-row and suture-bridge repairs have lower retear rates than single-row repair in most tear-size categories, with no difference between double-row and suture bridge [14]. Knot-tying versus knotless designs show no significant difference in retear rates [15]. ### Two ways a repair fails, and only one of them is fixable This is the most consequential thing in this section, and it is rarely explained to patients. A cuff repair that fails does not simply "fail", it fails in one of two patterns, and they have very different implications. Type 1 is failure at the footprint. The tendon pulls off the bone where it was reattached, at the repair site itself. The tendon substance remains intact and still reaches the bone. Type 2 is failure at the medial row, the tendon tears through at the suture line where the medial anchors hold it, typically at or near the musculotendinous junction, while the tendon attached to the footprint remains healed to the bone. On MRI this looks paradoxical: a well-healed footprint with a defect medial to it. The original description of these patterns compared techniques directly. Suture bridge better preserved the cuff tissue repaired to the insertion site than single-row did, but the retears that did occur with suture bridge were mainly at the musculotendinous junction, whereas single-row tended to fail directly at the footprint [16]. Imaging work after double-row repair found the same signature: complete tearing around the medial-row anchors with a well-repaired tendon on the footprint [17]. So the stronger construct did not abolish failure. It relocated it. Pooled across techniques, double-row and suture-bridge repairs increase the risk of medial cuff failure, and the authors note that technique modifications can reduce it [18]. Why Type 2 is the worse problem. Two reasons, and the second is the one that matters most. Functionally, it does worse: in a series of 373 repairs with a retear rate of 15.6%, type 2 failures showed significantly inferior functional outcomes [19]. Anatomically, it is much harder to revise. A Type 1 failure leaves a tendon of full length that has simply detached, there is tissue to grasp, mobilise and reattach. A Type 2 failure has destroyed tendon substance at the medial row, so what remains is a shorter, often retracted tendon with the good, healed portion of it still fixed to the bone laterally. Revision then means working with less tendon than the original operation had, and pulling what is left further across a gap it cannot comfortably reach. In some cases direct repair is no longer possible at all, and the conversation moves to reconstruction, tendon transfer or reverse replacement. That asymmetry is the reason technique modifications aimed specifically at reducing medial-row strain — avoiding over-tensioning, medial knot placement, and how the medial row is loaded, receive the attention they do. Not because Type 2 is common, but because it forecloses options. ### One construct, named To make this concrete, one specific construct: Dr Hirpara uses a medial row of all-suture anchors — the JuggerKnot (Zimmer Biomet), placed at the articular margin, with the sutures carried laterally and secured by a lateral-row anchor, the Quattro (Zimmer Biomet), in the tuberosity. Other surgeons use different implants and different configurations, and this is offered as an illustration of the reasoning rather than as a recommendation. The logic follows everything above. The medial row goes where bone quality is poorest and where sparing bone matters most, so a soft anchor with a small hole is used. The lateral row sits in better bone and takes the tensioning load, so a solid anchor is used. It is a construct assembled from the specific strengths of two generations of technology rather than a preference for either. --- ### Thoracic Outlet Syndrome URL: https://www.cqupperlimb.com/education/shoulder/thoracic-outlet-syndrome/ Region: shoulder · condition Compression of the nerves and vessels at the base of the neck — the types, why diagnosis is tricky, and physio-first treatment. ## What you're feeling Thoracic outlet syndrome usually shows up as an arm that just isn't quite right. You might notice an ache through the shoulder, the side of the neck and down the arm, along with numbness, pins-and-needles or tingling, often in the ring and little fingers. The arm can feel heavy, weak or clumsy, so you fumble things or your grip tires quickly. A very typical clue is that the symptoms get worse when your arm is up or overhead (hanging out washing, reaching to a high shelf, driving, or carrying a bag on your shoulder) and ease again when you rest the arm down. Some people get headaches at the back of the head as well. Less commonly, the problem is with the blood vessels rather than the nerves. If a vein is squeezed, the whole arm can suddenly swell, feel heavy and take on a bluish tinge. If an artery is squeezed (which is rare), the hand may go pale, cold and painful. These vascular patterns matter, because they need to be looked at quickly (see the last section). ## What's actually happening To get from your neck to your arm, the nerves and blood vessels have to pass through a narrow gap at the base of the neck, between your collarbone, your first rib, and the scalene muscles of the neck. This gap is the "thoracic outlet". When it becomes too tight, those structures get compressed, and that pressure is what produces the symptoms. There are three types, depending on what is being squeezed. Neurogenic TOS (pressure on the nerves, the brachial plexus) is by far the commonest, making up the great majority of cases; this is the aching, numbness, tingling and weakness pattern. Venous TOS involves the main vein and causes the swollen, heavy, bluish arm, sometimes with a clot. Arterial TOS is rare and involves the artery, causing the pale, cold hand. A few things make the space tighter. Some people are born with an extra rib in the neck (a cervical rib) or a tight fibrous band. Posture also matters: rounded, drooping shoulders close the space down, as do bulky or tight neck and chest muscles, which is why the condition is more common in people who do repetitive overhead work or sport. A previous neck or collarbone injury can also be the trigger. ## What we can do about it At Mater Private Hospital Rockhampton, Dr Kieran Hirpara leads our approach to this condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate, and begin with a thorough assessment to confirm the diagnosis. For long-standing symptoms, we usually start with non-operative care and consider surgery only if that does not provide enough relief. The good news is that for the common, neurogenic type, the first-line treatment is physiotherapy, not surgery. A targeted programme to open up the thoracic outlet does the heavy lifting: correcting posture, strengthening the muscles that hold the shoulder blade back and down, releasing tight neck and chest muscles, and learning to avoid the arm positions that pinch. This settles symptoms for most people, and it's worth giving it a genuine, several-month effort. Surgery is reserved for two situations. The first is the vascular types (venous or arterial), where decompression is usually needed and is the main treatment. The second is neurogenic TOS that hasn't settled despite a proper trial of physiotherapy and is genuinely interfering with life. The operation decompresses the outlet, typically by removing the first rib (and any extra cervical rib) and releasing the scalene muscles, to give the nerves and vessels room. It can be done through the armpit, above the collarbone, or with keyhole assistance. For selected patients it works well. ## What to expect TOS can be a tricky diagnosis. There's no single test that proves it. The diagnosis is mostly clinical: your story plus examination tests that put the arm in provoking positions. Scans and nerve studies are often used as much to rule out commoner causes (like carpal tunnel at the wrist, cubital tunnel at the elbow, or a neck/disc problem) as to confirm TOS itself. So part of the process is patiently sorting out where your symptoms are really coming from, and the answer isn't always clear-cut. For the neurogenic type, most people improve with posture and physiotherapy and never need an operation, though it can take months and needs you to keep the habits going. When the vascular types or stubborn neurogenic cases do come to surgery, decompression relieves symptoms for most carefully selected patients, with recovery over several weeks. Because TOS sits at the most proximal point of the nerve pathway (higher up than carpal tunnel at the wrist or cubital tunnel at the elbow), it's sometimes just one piece of the puzzle, and the plan is tailored to you. ## When to see someone - A sudden, swollen, heavy or bluish arm: this can mean a vein is blocked or clotted and needs urgent assessment, the same day. - A pale, cold, painful hand, or fingers that change colour: a possible arterial problem and a reason to seek urgent care. - Numbness, tingling, weakness or clumsiness in the arm or hand that is persisting, worsening, or interfering with work, sleep or daily tasks. - Wasting (loss of muscle bulk) in the hand, or symptoms that keep coming back despite a good trial of physiotherapy: worth a specialist opinion. - If you've been told you have a cervical rib and are getting arm symptoms, worth having it assessed. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Thoracic outlet syndrome is worth the extra reading because it splits into forms that could hardly be more different, one objectively demonstrable and occasionally limb-threatening, the other diagnosed largely on clinical judgement, and almost all the controversy attaches to the second. ### Three conditions sharing one name The thoracic outlet is the narrow space between the collarbone and first rib through which the nerves to the arm and the main artery and vein all pass. Compression there produces three distinct syndromes. Venous and arterial TOS are vascular problems. They are uncommon, they are objectively demonstrable on imaging, and they can be urgent, a clotted subclavian vein producing a swollen blue arm, or arterial compression producing a cold hand and, in the worst case, emboli. Nobody disputes these exist or that they need treating. Neurogenic TOS accounts for the great majority. Here the nerves are compressed, producing aching in the shoulder and arm, numbness typically along the little-finger side, and symptoms worsened by holding the arms overhead. The difficulty is that in most cases there is no test that confirms it — nerve conduction studies are frequently normal, and imaging shows no lesion. Contemporary reviews respond to this by distinguishing vascular and objectively verifiable forms of neurogenic TOS from the rest [1], which is a careful way of acknowledging that the remainder rest on clinical judgement. ### Why that distinction drives everything Where the diagnosis can be objectively demonstrated, treatment decisions follow the usual logic. Where it cannot, two failure modes arise: people with genuine compression go years without a diagnosis because their tests are normal, and people whose arm pain has another cause undergo a substantial operation that cannot help them. Both errors are well recognised, which is why the standard of proof before surgery is set higher here than for most compressions, and why a prolonged trial of physiotherapy, addressing posture, the scalene muscles and shoulder girdle mechanics, precedes any operation for the neurogenic form. ### What is removed, and the evidence on how Surgery decompresses the outlet by removing the first rib, dividing the scalene muscles, or both. Comparing approaches across 2,010 patients, Disabilities of the Arm, Shoulder and Hand and Derkash scores were significantly better following rib-sparing scalenectomy, and higher complication rates were reported after first rib resection [2]. Against that, longer-standing series argue for the combined operation. Across 532 patients, a combined transaxillary first rib resection with transcervical scalenectomy was described as the most complete decompression with a better rate of symptom improvement and lower recurrence [3], and recurrence was reported at 5% to 10% when the combined procedure was used as the primary operation [4]. The two positions are not fully reconcilable from the published data. The more recent comparative analysis favours doing less; the large single-surgeon experience favours doing more, on the grounds that incomplete decompression is what drives recurrence. What both agree on is that recurrent TOS is a considerably harder problem than the first presentation, so getting the initial decision right matters more than the choice of technique. ### The practical implication Given a diagnosis that is often clinical, an operation whose optimal extent is contested, and a recurrence problem that is difficult to salvage, this is a condition where a second opinion before surgery is reasonable rather than adversarial, particularly for the neurogenic form without objective confirmation. --- ### Total Shoulder Arthroplasty URL: https://www.cqupperlimb.com/education/shoulder/total-shoulder-arthroplasty/ Region: shoulder · operation Total shoulder replacement for severe arthritis — stemless options if rotator cuff is intact. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment, including your history, an examination and imaging where needed, establishes the diagnosis. For wear-and-tear problems like arthritis (the smooth cartilage covering the joint wears away), we usually try non-operative care first: activity change, physiotherapy, and splinting. We consider surgery when that has not given enough improvement. Total shoulder arthroplasty means shoulder joint replacement: the worn surfaces of your shoulder joint are removed and replaced with artificial parts. We suggest it when shoulder pain and stiffness limit your daily life and other treatment has not helped enough. The operation aims to relieve pain and improve how your shoulder moves and works. Pain is relieved in approximately 90% to 95% of all patients undergoing this operation. Over 80% of shoulder replacements last more than 10 years, and 75% last more than 20 years. Shoulder replacement is considered as safe as other major joint replacements. We will talk through your options with you and decide together whether this operation suits your shoulder and your goals. ## Before the operation Your surgeon will plan your operation using X-rays of your shoulder, and sometimes an MRI (a scan that shows soft tissues) or an ultrasound (a scan using sound waves). These pictures show the shape of the joint, the amount of wear, and the condition of the tendons around it. That detail helps your surgeon choose the right replacement parts for your shoulder. In the days before surgery, you will be given clear instructions to follow. You will need to stop eating and drinking seven hours before your operation. This longer gap lets us bring you forward if the theatre list runs early. Some medications may need to be paused, and your surgeon will tell you which ones and when. Bring a written list of everything you take, including tablets, drops and natural remedies. Arrange for someone to drive you home, as you will not be able to drive yourself. Wear loose, comfortable clothing that is easy to put on and take off. If you have other medical conditions, you may need blood tests or a review with the anaesthetist (the doctor who gives the anaesthetic) before the day of surgery. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist before the operation and talk through the plan with them. This operation is done under general anaesthetic combined with a regional nerve block. The anaesthetist will meet you before the operation and talk you through both parts. You are then taken into the operating theatre, where the operation is performed. When you wake up, you will be in the recovery area. Nurses will monitor you while the anaesthetic wears off. Once you are stable, you will move to the ward. If you are going home, the person you arranged to drive you will take you there. ## What the operation involves Your surgeon makes a single cut over the front of your shoulder to reach the joint. Through this opening, they remove the worn-out joint surfaces: the rounded ball at the top of your arm bone and the shallow socket it moves against. These are replaced with artificial parts made of metal and plastic, fitted to match the shape of your own joint. One tendon in front of the joint, the subscapularis (a muscle-tendon unit that helps rotate your arm inward), is gently moved aside to give access, then repaired back into place at the end. Your surgeon takes care throughout to protect the soft tissues around the joint and to position the new parts accurately. Once the new parts are in place and the tendon is repaired, the wound is closed. A fine self-adhesive mesh is laid over the closed wound first, holding the skin edges together. A liquid skin adhesive is then painted over the mesh, where it sets to seal the whole thing. This stays on for roughly one to two weeks and then lifts and peels away by itself, so there is nothing to be taken out. ## After the operation When you wake up, you will be in the recovery area, then move to the ward. Most patients stay one or two nights in hospital after this operation. Your arm will rest in a simple sling for comfort. It comes off for exercises and washing. Pain control is planned for you before you leave theatre, and your care team will keep checking how you are feeling and adjust things as needed. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. A physiotherapist will usually see you on the ward to start gentle movements. Please arrange for someone to stay with you for the first 24 hours after you go home. ## Recovery Everyone's recovery follows its own path, and your timeline may differ. Your surgeon and physiotherapist will guide you at each visit. In the first days and weeks, expect some pain and swelling around the shoulder. This settles gradually for most people. Your care team will plan pain relief before you leave hospital and adjust it as needed. Many people manage well with a simple, non-opioid pain plan. Keeping your arm in the sling between exercises helps with comfort. Rest, gentle movement as your physiotherapist shows you, and following the plan will ease the discomfort. A physiotherapist will usually see you on the ward to start gentle movements. At home, you will keep doing these exercises as directed. The sling comes off for exercises and washing. You will need help with some daily tasks at first, such as dressing, since the operated arm will be limited. Sleep can be disturbed early on, but most people find their sleep improves as the shoulder settles. Movement and strength return in stages. As the swelling settles and your movement grows, everyday tasks become easier. Once your surgeon clears you to drive, typically at the six-week review, you can get back behind the wheel. See our guide on Driving after upper-limb surgery. Returning to work and sport depends on your job, your activities and how your shoulder is healing. Your surgeon and physiotherapist will talk you through what is safe at each stage. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Infection is the most serious problem to watch for. It can show up as a deep, throbbing pain that does not ease with simple painkillers, redness that spreads out from the wound, or a fever. Tell the clinic straight away if you notice any of these signs. Some infections appear months later, so mention anything unusual at your reviews, even if it seems minor. A clot can form in a vein after this operation. This may cause sudden swelling and tenderness in the calf. If a piece of that clot travels to the lungs, you might feel sudden breathlessness or chest discomfort. Go to the emergency department if this happens. The nerves around the shoulder can be stretched or bruised during surgery. You might notice numbness, tingling or weakness in your arm or hand. Many of these recover fully, some only partly. Mention it at your next review so it can be tracked. A fracture near the new joint is uncommon but can happen, either during the operation or afterwards. You would feel sharp pain and lose the ability to move the arm normally. Call the clinic if this occurs. The artificial parts can loosen over time. This usually feels like a return of pain, sometimes with a clicking or grinding feeling in the shoulder. Bring this up at your review, as scans can show what is happening. The shoulder can also become stiff or unstable, or the new parts can come out of place. You would notice a sudden loss of movement, or a feeling that the joint has shifted. Contact the clinic promptly. If you have had shoulder surgery before, some of these risks are higher. Your surgeon will discuss this with you before the operation. The complications table on this page lists typical rates if you want the specifics. ## When to call us Trust your instincts. If something feels wrong, contact us. Call the clinic if you have a fever, increasing redness or discharge from the wound, or pain that keeps getting worse. Go to emergency if you have sudden swelling in your calf, shortness of breath, or chest discomfort. These can be signs of a clot. Call us straight away if you lose feeling in your arm or hand, or you cannot move it at all. Most problems are easier to sort out early. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Shoulder Arthritis page. --- ### Wrist URL: https://www.cqupperlimb.com/education/wrist/ Region: wrist · region-landing Wrist problems grouped by theme — carpal tunnel, tendon problems, fractures, ligament injuries, arthritis and ganglions — with each condition beside the operation that treats it. ## Understanding your wrist How your wrist works Wrist anatomy – understanding the radius, ulna, and carpal bones is key to understanding wrist function. Open → Wrist Arthroscopy Diagnostic and therapeutic wrist arthroscopy — what it is, when it's used, and recovery. Open → ## Carpal tunnel & nerve compression Carpal Tunnel Syndrome Carpal tunnel syndrome causes hand numbness, tingling, and weakness—diagnosis and treatment options explained. Open → Carpal Tunnel Release Carpal tunnel release surgery relieves median nerve compression—when it’s needed and what to expect. Open → ## Tendon problems De Quervain's Tenosynovitis Patient-facing topic on De Quervain's tenosynovitis (first dorsal compartment) — diagnosis, conservative management, and indications for de Quervain's release. Open → De Quervain's Release De Quervain’s release surgery widens the tendon sheath to relieve pain from thumb tendon inflammation. Open → ECU Tendinopathy and Snapping ECU Open → Intersection Syndrome An overuse tendon problem of the back of the forearm, often confused with de Quervain's — its causes, and how rest, splinting or injection settle it. Open → ## Fractures Distal Radius Fracture Distal radius fractures — assessment, casting, and indications for surgical fixation. Open → Distal Radius ORIF Open reduction and volar plate fixation of the distal radius — operation, recovery, rehabilitation. Open → Distal Radius Malunion (and Corrective Osteotomy) When a wrist fracture heals in a poor position — the problems it causes and how a corrective osteotomy realigns the bone. Open → Scaphoid Fracture Scaphoid fractures — recognition, the high non-union risk, casting and percutaneous/open fixation. Open → Scaphoid Fixation Percutaneous and open compression-screw fixation of scaphoid fractures. Open → Hook of Hamate Fracture Open → Hook of Hamate Excision Open → Carpal Fractures Other Than the Scaphoid Open → ## Ligament & TFCC injuries Wrist Ligament Injuries Wrist ligament injuries—common causes, symptoms, diagnosis, and treatment options (conservative vs surgery). Open → Scapholunate Ligament Injury A tear of the key ligament linking two wrist bones — how it is diagnosed, why it matters, and the repair or reconstruction options. Open → TFCC Injury TFCC injuries — pain on the ulnar side of the wrist, often with clicking, and treatment options. Open → Ulnar-Sided Wrist Pain and Ulnar Impaction Pain on the little-finger side of the wrist from the ulna grinding against the wrist bones, and how shortening it relieves the pressure. Open → Distal Radioulnar Joint Surgery Open → ## Arthritis & salvage surgery Wrist Osteoarthritis Wrist osteoarthritis — understanding symptoms, non-surgical options, and when wrist replacement might be considered. Open → SLAC and SNAC Wrist SLAC/SNAC wrist – understanding pain from arthritis at the wrist, often after injury. Open → Kienböck's Disease Kienböck’s disease — progressive wrist pain from lunate avascular necrosis; diagnosis and treatment options. Open → Partial Wrist Fusion Patient-facing topic for four-corner and capitolunate (two-corner) fusion of the wrist — joint-preserving alternative to total wrist fusion that retains some bending motion. Open → Total Wrist Fusion Wrist fusion permanently joins wrist bones to relieve pain from arthritis or injury. Open → Proximal Row Carpectomy A wrist salvage operation for an arthritic wrist (SLAC/SNAC) that keeps useful movement — how it works, recovery, and how it compares with fusion. Open → ## Ganglions Wrist Ganglia Wrist ganglia are common, fluid-filled lumps – often painless – and this page covers observation, aspiration, and excision. Open → Wrist Ganglion Excision Ganglion excision — when to consider surgery, arthroscopic vs open approaches, and expected recovery. Open → ## Recovery and rehabilitation Blood Thinners Around Surgery How anticoagulants and antiplatelets work, and why the timing of stopping each before surgery differs — platelet turnover, half-lives and clot risk. Open → Cast and splint care at home Looking after a plaster or splint at home — keeping it dry, elevation, keeping joints moving, and the urgent signs of a too-tight cast. Open → Constipation and gut care after surgery Why constipation is common after surgery (especially with strong painkillers) and how to prevent and manage it. Open → Daily life after hand, wrist or elbow surgery Keeping a hand or wrist dressing dry, elevation to control swelling, and one-handed living after hand, wrist or elbow surgery. Open → Daily life after shoulder surgery Washing, dressing, sleeping and managing day-to-day with the operated arm in a sling after shoulder surgery. Open → Driving After Shoulder and Arm Surgery: When Is It Safe and Legal? After most shoulder surgery, including rotator cuff repair, you usually cannot drive for about six weeks, and not while your arm is in a sling. When it is safe and legal to get back to the wheel after hand, wrist, elbow or shoulder surgery. Open → Eating well for healing Everyday food to support recovery after surgery — protein, energy, healing vitamins, and preventing constipation. Open → Fasting Before Surgery: What You Can Eat and Drink, and Why Why you must stop eating before an anaesthetic, when you can still sip water, and what can happen if you do not fast. The clear fasting rules that keep your stomach empty and your lungs safe during surgery. Open → Flying and travel after surgery Clot risk, cast tightness at altitude, fitness to fly and the practicalities of travelling after upper-limb surgery. Open → Hand therapy basics What to expect from hand therapy, how often you'll go, and what good rehab looks like. Open → Heat vs Ice When ice helps, when heat helps, and how to use either safely on the upper limb. Open → Is my wound infected? How to tell normal healing from a wound infection after surgery — the warning signs and when to seek help. Open → Looking after your wound Dressings, showering, and signs of infection after upper-limb surgery. Open → Managing pain after surgery What pain to expect, how to use pain relief well, and when to call. Open → Melatonin After Shoulder Surgery Why we prescribe melatonin after shoulder surgery, what the trial evidence shows, the dose we use, and what to expect from it. Open → Mind, Stress and Recovery How stress, low mood, anxiety and worry about pain affect recovery and surgical outcomes — and what helps. Open → Preparing for Surgery General checklist for the days before upper-limb surgery — fasting, what to bring, medications. Open → Preventing Blood Clots After Surgery Reducing the risk of deep vein thrombosis after upper-limb surgery — mobilisation, hydration, medication. Open → Returning to sport Phased return to sport after upper-limb surgery, and when contact sport is safe again. Open → Returning to work When you can return to desk, light, and heavy work after upper-limb surgery. Open → Scar Management Massage, silicone, sun protection and the 12-month timeline for surgical scars to soften and fade. Open → Sleep, Pain and Recovery How sleep and pain affect each other, why surgery and shoulder problems disturb sleep, and what helps you rest and recover. Open → Swelling and elevation after surgery Why a hand or arm swells after surgery, how elevation and gentle movement control it, and when swelling is a warning sign. Open → The day of your surgery What to expect on the day of day-case upper-limb surgery, from arrival and meeting the team to waking up and going home. Open → Wearing and Sleeping in an Arm Sling How to sleep in an arm sling, get the sling position right, and look after it after shoulder, elbow or wrist surgery, including whether to keep the sling on overnight. Open → Your shoulder nerve block The nerve block we use for shoulder surgery — how it numbs your arm, why it controls pain so well, and what to expect as it wears off. Open → Your wound check and stitch removal What happens at the post-op wound check, dissolvable vs removable stitches, what removal feels like, and when to seek help sooner. Open → Explore Wrist in the evidence explorer → --- ### How your wrist works URL: https://www.cqupperlimb.com/education/wrist/anatomy/ Region: wrist · anatomy Wrist anatomy – understanding the radius, ulna, and carpal bones is key to understanding wrist function. ## The main parts Your wrist is a small, busy joint. It is made of eight little bones arranged in two rows. The row closest to your forearm holds the scaphoid, lunate, triquetrum and pisiform. The row closest to your hand holds the trapezium, trapezoid, capitate and hamate. These bones do not move as one solid block. The row near your hand is fairly rigid. The row near your forearm is more mobile, and each bone in it has its own small movements. Together they let your wrist bend, straighten and swing side to side. The two long bones of your forearm meet these small bones. The radius, on the thumb side, connects with the scaphoid and lunate. The ulna, on the little finger side, sits a little further back and does not touch the triquetrum directly. A soft cushion of tissue called the triangular fibrocartilage complex (TFCC) sits between them. The bones are held together by strong straps called ligaments. Some ligaments tie the small bones to each other. Others run from the forearm bones to the wrist bones. The front of the wrist has the strongest ligaments, because they hold everything in place as you move. Muscles and tendons make your wrist move. Tendons are the cords that join muscle to bone. On the back of your wrist, tendons straighten the wrist and pull it toward the thumb or little finger. On the front, tendons bend the wrist. When you grip something, straightening your wrist helps your fingers and thumb work properly. If the wrist cannot straighten, gripping becomes very hard. All of these parts share the load. When you push through a neutral wrist, most of the force goes through the radius and a smaller share goes through the ulna. The ligaments and the shape of the bones keep the whole arrangement steady. If a bone or a ligament is injured, that balance can be lost, and the small bones can tilt out of position. Knowing how the parts fit together makes it easier to understand what happens when one of them is hurt. ## How it all works together Think of your wrist as a team of small parts that share one job. The two rows of bones work like a hinge and a swivel at once. When you bend or straighten your wrist, both the joint near your forearm and the joint between the two rows take a share of the movement. When you swing your hand toward your thumb or little finger, the mobile row near your forearm shifts and turns to keep the motion smooth. The scaphoid acts as a link that steadies this row while the rest of the wrist moves around it. What holds it all steady while it moves? The ligaments. Some strap the small bones to each other, and others run from your forearm bones down to the wrist. They guide the bones along their paths and stop them sliding out of place. The shape of the bones helps too. The front of the wrist is slightly hollow, which makes it steadier when bent forward than bent back. This teamwork is what lets you do everyday things. You can turn your palm up to hold a bowl, grip a rail, or reach up to a shelf. Your hand moves against a steady forearm, and the wrist passes the force through. Nerves and blood vessels run through the same tight space. Two main arteries, the radial and the ulnar, bring blood to your hand. They join together in arches in your palm, so if one is squeezed or injured, the other can often keep the hand supplied. Nerves carry the signals that let you feel and move. The radial nerve works the muscles that straighten your wrist and fingers. The ulnar nerve works some of the small muscles inside your hand. Because everything sits close together, a problem in one part, such as a swelling or a torn ligament, can press on or disturb the parts beside it. ## Where things commonly go wrong The parts that take the strain are the ones closest to the action. The end of the radius, the forearm bone on your thumb side, takes most of the load when you fall onto your hand. That is why breaks here are among the most common fractures seen in emergency departments. Older bones that have lost density break more easily, so a simple fall from standing can be enough. The break pattern depends on how the injury happened, and sometimes the crack runs into the joint itself. A break at the outer corner of the radius, near the thumb, can also strain the ligament that ties the scaphoid to the lunate, because the crack line reaches into that joint. The small bones and their straps can be injured too. The scaphoid acts as a link that steadies the mobile row, so if it breaks, or if the strap tying it to the lunate tears, that row can lose its anchor. The wrist can then fold in on itself, a bit like a hinge that buckles under load. The lunate and triquetrum normally move together as one unit. When the ligaments holding them are disrupted, those bones can tip into abnormal postures that surgeons call VISI or DISI, meaning the lunate tilts toward the palm or the back of the wrist. The cushion of tissue on the little finger side, the triangular fibrocartilage complex, and the joint between the two forearm bones can also be a source of trouble. A strong twisting injury or a break near that joint can pull it out of line. Rheumatoid arthritis, a condition where the body's own inflammation wears away joints, often targets the wrist. The inflamed lining swells, softens the cartilage and stretches the ligaments, so the wrist can change shape over time. Because so many parts sit close together, an injury to one can disturb its neighbours. Swelling or a shifted bone can press on the nerves that run through the wrist. That is why a careful examination looks at feeling, circulation and tenderness in specific spots, and checks how the forearm joint behaves when you turn your palm up and down. ## The bottom line Your wrist is built from eight small bones in two rows, tied together by strong straps called ligaments. The row near your forearm moves more than the row near your hand, and the scaphoid acts as the link that keeps the mobile row steady. Most of the load you push through your wrist travels down the radius, the forearm bone on your thumb side, which is why that spot is where breaks most often happen. On the little finger side, a soft cushion of tissue and the joint between your two forearm bones let your palm turn up and down. When one part is hurt, the parts beside it can be affected too, because everything sits close together in a small space. --- ### Carpal Tunnel Release URL: https://www.cqupperlimb.com/education/wrist/carpal-tunnel-release/ Region: wrist · operation Carpal tunnel release surgery relieves median nerve compression—when it’s needed and what to expect. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your hand, and arrange imaging or nerve tests if they are needed. Carpal tunnel syndrome happens when a nerve in your wrist is squeezed, causing tingling, numbness and pain in your hand. We usually begin with non-operative care such as splinting, hand therapy or injections. Surgery is considered when those treatments have not given enough improvement. The operation is called a carpal tunnel release. It eases pressure on the nerve by cutting a tight band across the wrist. Significant improvements in symptom severity and hand function may be expected after this operation regardless of age, other medical conditions, or workers' compensation status. We will discuss the options with you and decide together whether surgery is right for you. ## Before the operation Your surgeon will give you clear instructions, but here is what to expect. You will need to stop eating and drinking seven hours before surgery. We ask for seven hours rather than six so you can be brought forward if the theatre list runs early. Bring a list of your current medications, and tell your surgeon about any blood thinners, as some may need to be paused beforehand. Arrange for someone to drive you home afterwards. Wear loose, comfortable clothing with sleeves that are easy to remove. Some imaging, such as an X-ray, MRI or ultrasound, may be needed to plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, but most people do not. ## On the day On the day of surgery you come to the hospital's surgical admissions unit. Staff there check you in and prepare you for theatre. You then meet the anaesthetist, the doctor who gives the anaesthetic and looks after you during the operation. This operation can be done under local anaesthetic (an injection that numbs just the area of surgery, with you awake) or under general anaesthetic (fully asleep). Most people choose local: recovery is quicker and you can go home soon after. If you'd prefer to be asleep, that's also a reasonable choice; discuss it with your surgeon and anaesthetist. You are then taken into the operating theatre, where the operation is performed. Afterwards you wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Once you are stable you either go home or spend a short time on the ward, depending on the procedure and how you are recovering. ## What the operation involves The operation is called a carpal tunnel release. Your surgeon makes a single cut over the area being operated on, at the wrist and palm. Through this cut, your surgeon reaches the tight band of tissue that forms the roof of the carpal tunnel, a narrow channel in your wrist that the nerve passes through. Cutting that band opens the tunnel and takes pressure off the nerve. The band itself does not need repairing; it heals with more room inside for the nerve. The cut is closed with stitches. A bulky padded bandage is then wrapped around your hand and wrist. You will keep this dressing on for about 10 days, as described in the next section. The operation itself is short, and you go home the same day. Your surgeon will explain the steps again before you sign the consent form, and you can ask questions at any point. ## After the operation You will wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Your hand will be in a bulky padded bandage, and we will give you pain relief to keep you comfortable. This is a day case, so you will go home the same day. Please arrange for someone to stay with you for the first 24 hours. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Keep your hand raised when resting, and use it gently for light tasks as soon as you feel able. Most people are back to driving within one to two weeks, once the wound is comfortable and they can grip and turn the wheel without protecting the operated hand. See Driving after upper-limb surgery. ## Recovery For the first few days your hand will be sore and swollen, and the padded bandage will feel bulky. Keep your hand raised when you are resting, as this eases swelling and discomfort. Simple pain relief is usually enough. Many people do not need strong pain medication at all after this operation. You will use your hand gently for light tasks as soon as you feel able. The dressing stays on until we see you, and once it is off you can wash and shower normally. Your stitches come out at your follow-up visit. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby will guide your exercises and make a splint if you need one for comfort. Gentle movement helps the nerve settle, so you will be using your hand more as the weeks pass. As the swelling settles, you will notice tingling and numbness easing and your grip returning. Once you can grip and turn without pain, everyday tasks feel normal again. Timely release of the pressure on the nerve allows sensation and function in the hand to return. If your symptoms were present in both hands, we can discuss operating on both at the same visit. Recovery varies from person to person. Your timeline may differ, and your surgeon and therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Infection. A wound infection can look like redness spreading out from the cut, warmth, or oozing fluid. You might feel a deep, throbbing pain that does not ease with simple painkillers, or you might develop a fever. If you notice any of these, call the clinic the same day. If you feel unwell or the redness is spreading quickly, go to the emergency department. Some things can raise the chance of infection, such as a steroid injection into the wrist shortly before surgery or certain health conditions. We will talk through anything relevant to you before the operation. Wound problems. Sometimes the wound edges take longer to heal or open slightly, or blood collects under the skin and causes swelling. You might see the stitches pulling apart or notice a firm, tender lump near the cut. Mention this at your follow-up visit, or call the clinic sooner if it looks worse. Nerve irritation. The nerve being released sits close to the operating area, so it can be bruised or irritated during surgery. This usually feels like new tingling, numbness or pins and needles in the hand, or a patch of skin that feels different to before. Most nerve irritation settles with time, but some changes can last. Tell your surgeon at the next review if you notice new numbness that is not improving. Symptoms that come back or do not fully settle. Occasionally the pressure on the nerve is not fully relieved, or the tunnel tightens again over months or years. You might notice the original tingling, numbness or night pain returning. If this happens, bring it up at your review. Further surgery is sometimes needed, and your surgeon will arrange tests to find out why. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most people recover without problems, but some signs need urgent attention. Call us if you have a fever, increasing redness or discharge from the wound, or pain that keeps getting worse. Call us if you notice new numbness in your hand that is not improving, or you cannot move your fingers. Go to emergency if you have sudden severe pain, calf swelling or pain, or shortness of breath. When in doubt, call the clinic and we will guide you. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Carpal Tunnel Syndrome page. --- ### Carpal Tunnel Syndrome URL: https://www.cqupperlimb.com/education/wrist/carpal-tunnel-syndrome/ Region: wrist · condition Carpal tunnel syndrome causes hand numbness, tingling, and weakness—diagnosis and treatment options explained. ## What you're feeling Carpal tunnel syndrome happens when the nerve running from your wrist into your thumb, index and middle fingers gets squeezed as it passes through a narrow tunnel in your wrist. The tingling and numbness usually sit in the thumb, index and middle fingers. Many people also feel pain in the hand, and sometimes the symptoms spread beyond those fingers. The classic pattern is tingling and numbness that wake you at night. Symptoms often flare when you wake in the morning too, and they can come on after you have been using your hand a lot. Shaking your hand or letting it rest may settle the tingling for a while. As the squeezing continues over months or years, the numbness can become constant, and the muscles at the base of your thumb can waste and weaken. That weakness shows up in everyday tasks. Turning a key, holding a phone, gripping a saucepan handle or doing up buttons can get harder. You may find yourself dropping things you would normally hold onto, because your grip is not as reliable and your fingers feel clumsy. A few things raise the chance of this happening. Repeating the same hand movements often, and carrying extra body weight, both increase the risk. It is also more common in women and becomes more frequent through middle age. Some health conditions are linked with it too, including pregnancy, menopause, thyroid problems, kidney failure and diabetes. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## What's actually happening Think of your wrist as a short tunnel with a floor of small bones and a tough band of tissue forming the roof. Nine tendons and one nerve, the median nerve, share that space. The tunnel has no give, so when anything takes up extra room inside it, the nerve is the softest thing in there and it gets squeezed first. The squeezing can come from either side. Sometimes the tunnel itself narrows, for example when your wrist is bent for long stretches. Sometimes the contents swell, from fluid changes, inflammation or wear in the lining around the tendons. Either way, the pressure inside the tunnel climbs. At first it comes and goes, often at night or when your wrist is held still doing things like reading or driving. Over time the pressure can stay high all the time, and that is when the numbness stops coming and going and settles in. This explains the pattern you have just read about. Pressure is highest when the wrist is bent right back or right down, which is why symptoms flare in fixed positions and wake you at night. The nerve carries feeling for the thumb, index and middle fingers, so that is where the tingling sits. As the squeezing continues, the nerve struggles to pass signals, feeling fades and the thumb muscles, which the nerve also powers, weaken and waste. Doctors describe this condition as mild, moderate or severe, based on how much the nerve is affected. With mild or moderate compression, feeling usually returns once the pressure is relieved. When compression has been severe for a long time, some numbness and weakness can remain even after treatment, because the nerve itself has been damaged. The aim of any treatment is the same: take the pressure off the nerve. For many people that starts with simpler measures, and when those are not enough, surgery opens the roof of the tunnel so the nerve has room again. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your visit we take a history, examine your hand and arrange imaging or nerve tests if they are needed to confirm the diagnosis. For a long-standing problem like this, we usually try non-operative care first and consider surgery when that has not given enough improvement. The first steps are things you can do yourself. Changing how you use your hand, resting it more often, and wearing a splint, especially at night, all take pressure off the nerve. Hand therapy teaches nerve and tendon gliding exercises, which help the nerve move smoothly through the tunnel. These simple measures work well for mild and moderate symptoms, and they are worth trying early and giving a fair go. The longer the nerve has been squeezed, the less well these measures tend to work. If splinting alone is not enough, a cortisone injection into the tunnel can settle the inflammation around the nerve. It often works well at first, and about 45% of people still have relief months later, especially those who respond well to the first injection. Combining the injection with splinting reduces symptoms and helps nerve function more than the injection alone. Another option is platelet-rich plasma, or PRP, an injection made from your own blood that can relieve pain and improve how the hand works. We will talk through which of these suits you. When these measures have not given enough relief, surgery is the next step. Carpal tunnel release cuts the tight band forming the roof of the tunnel, which opens up space and takes the pressure off the nerve straight away. It relieves symptoms better than splinting, and operating earlier gives a better chance of a full recovery. We will discuss the operation with you fully on its own page, and any decision is one we make together. ## What to expect Carpal tunnel syndrome rarely stays still. For some people the symptoms settle on their own, and early, mild symptoms can often be managed without surgery. For many others the tingling and numbness keep coming back, and over months or years the numbness can become constant. If the squeezing has been severe for a long time, some numbness and weakness can remain even after treatment, because the nerve itself has been damaged. How well treatment works depends a lot on where you start. The severity of your symptoms when you first come in is the most important factor in how much relief you can expect. People with mild or moderate symptoms find their daytime numbness and tingling settle sooner than people with severe symptoms. Age is not a barrier: older people improve at the same rate as younger people, and nobody should be turned away from treatment because of their age. After surgery, the improvement is steady rather than instant. Symptoms and hand function keep improving for up to 12 weeks. Over the third to sixth months, as feeling and strength return, sleep improves too, because the night-time tingling that wakes you settles down. Relief is the usual result: 97% of people get complete or partial relief of their symptoms. Some symptoms do persist in a small number of people, and a small number come back later, sometimes after a long stretch of being symptom free. If that happens, further surgery can still improve hand function and quality of life. A few other things shape the outlook. Diabetes does not change the result: people with diabetes improve just as much as people without it. People with metabolic syndrome, a cluster of conditions including high blood pressure and high blood sugar, recover more slowly at first, but by a year after surgery their symptom relief and hand function are similar to everyone else's. Some people develop the same problem in the other hand over time, so keep an eye on both hands. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone Most of the time, carpal tunnel syndrome is not an emergency. The signs that matter are the ones you have already read about: tingling and numbness in the thumb, index and middle fingers, often worse at night. See your GP if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand. Ask for a specialist review if simple measures like a splint have not helped after several weeks, or if the numbness has become constant or the muscles at the base of your thumb are wasting. Go to an emergency department if a hand or arm becomes hot, red, swollen and painful, especially with a fever, or if your fingers turn pale, cold, white or blue, or if you suddenly lose feeling or movement in your hand. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Carpal tunnel syndrome is worth the extra reading because it is the most reliably successful operation in hand surgery, which makes the three situations where it behaves differently the ones actually worth understanding. ### Diabetes changes less than you would expect Patients with diabetes are frequently told their result will be worse, and it is a reasonable thing to assume: diabetes damages nerves, and this is a nerve operation. The evidence does not support it. Pooling 2,869 patients, there was no significant difference in improvement across essentially all outcomes after carpal tunnel release between diabetic and non-diabetic patients, the single exception being sensory conduction velocity, an electrical measurement rather than something you would notice [1]. The honest framing is that diabetes may affect the nerve's baseline, but it does not appear to stop decompression from working. The authors' own conclusion is that better diabetic neuropathy care is what deserves attention, not withholding an operation that helps. ### Three ways to do it, and why this practice does the oldest one The carpal tunnel can be released through an open incision, endoscopically through one or two small portals, or percutaneously with a needle-sized blade guided by ultrasound. All three cut the same structure, the transverse carpal ligament, and the argument between them is about the first few weeks, not about whether the numbness resolves. Open versus endoscopic has been compared repeatedly. Pooling randomised trials across 1,596 patients, the two were similar in relief of symptoms, but endoscopic release produced better recovery of function and earlier return to work, and was safer across the measured complications [2]. Ultrasound-guided release is the newer arrival, and it is the one you are most likely to meet in advertising, usually described as "incisionless" and offered in rooms under local anaesthetic rather than in an operating theatre. Two things are worth knowing before that framing does your thinking for you. It is not literally incisionless, there is still a small puncture, and the published trials measure it as a shorter incision, not the absence of one. And the evidence, while genuinely encouraging, is thinner than the confidence of the marketing suggests. The pooled analysis of randomised trials rests on three studies and 221 patients: function scores favoured ultrasound guidance, and patients returned to normal activities 20.8 days earlier than after open release [4]. Two large 2026 comparisons matched on patient characteristics — 356 patients against open release [5] and 372 against endoscopic [6] — found it safe and effective, needing less anaesthetic, using fewer opioids afterwards and leaving patients happier with the wound, though it took longer to perform than either alternative. Improvements have held out to six years [7]. The honest counterweight rarely appears in the advertising, and it is mostly about who is holding the probe. A 2025 Innsbruck series described patients who needed a second, open operation after an ultrasound-guided release, for incomplete division of the ligament, nerve injuries and arterial injuries [8]. The detail that matters is the operator. Of the fourteen, the original procedure had been done by radiologists in eleven, by a general surgeon in one, and by experienced hand surgeons in two. What happened next differed accordingly. In one of the two hand-surgeon cases, an artery was caught during the release; the bleeding was recognised immediately, the surgeons converted to an open operation on the spot, stopped it, finished the release, and the patient had no further trouble. In the general-surgeon case, the woman had numbness from the moment she woke up, was given two cortisone injections that did nothing, and came back nine months later needing the median nerve rebuilt with three sural nerve grafts. That is the argument for experience in one comparison: not that complications never happen to skilled operators, but that a skilled operator recognises one and can rescue it in the same sitting. Be careful how much weight you put on that series, though, because it has been publicly contested and partly corrected. A high-volume interventional radiology group replied that its central recommendation was "not supported by the data provided", the series reported no denominator, no total number of procedures and no comparison rate, so it cannot be turned into a risk. That group has performed more than 2,000 of these releases under a standardised protocol, and pointed out that even if all eleven radiologist cases had needed revision, that would be a revision rate below 5 per 1,000 [10]. The original authors then conceded that three of those cases had been misclassified and were not examples of incomplete release at all, describing it as "a critical error in both the data and its interpretation" [10]. Where the two sides agree is the useful part, and it is worth stating plainly: this operation should be done by someone with real expertise in nerve ultrasound working to a standardised technique, with hand-surgical help immediately available if something has to be converted to an open procedure partway through. The learning curve is roughly 30 procedures before operating time settles [9]. If you are considering it, those are the fair questions to ask, how many the operator has done, to what protocol, and what happens if it has to become an open operation today rather than in nine months. On the safety comparison the marketing leans on hardest, the pooled complication rate was 7.1% for ultrasound guidance against 5.6% for open release, a difference whose confidence interval ran from 0.04 to 15.10 [4]. That interval is so wide it tells you almost nothing. "No difference in complications" here means "nobody has yet measured this well enough to say". Dr Hirpara performs open carpal tunnel release. The reason is the thing open surgery uniquely offers: the ligament and the nerve are seen directly, the release can be confirmed complete under vision, and any anatomical variation, an extra muscle belly, an unusual branch of the nerve, is dealt with as it is found rather than worked around. It needs no special equipment, and it remains the technique of choice for revision surgery and for unusual anatomy whichever approach a surgeon normally favours. The trade is real and you should hear it stated plainly: the evidence above suggests you would probably get back to work sooner after an endoscopic or ultrasound-guided release. What the evidence does not suggest is that you would end up in a different place. If a faster return matters more to you than direct vision of the nerve, that is a legitimate preference, and it is worth raising at your appointment rather than deciding from a website. ### The nerve that still hurts afterwards may not be the one that was released This is the finding most worth carrying away. In a cohort of 7,867 patients undergoing surgery for nerve compression, approximately 3% underwent decompression of a different nerve in the same arm within a year [3]. Three percent is small in absolute terms and large in what it implies. Nerve compression is frequently not a single-site problem: the same person can have median nerve compression at the wrist and ulnar nerve compression at the elbow, and the symptoms overlap enough that one can mask the other. When the hand is still not right after a technically successful release, the question is not always "did the operation fail", sometimes it is "was there a second site all along". The authors specifically note that patients with both carpal and cubital tunnel syndrome may benefit from simultaneous decompression [3]. ### Why the operation works so well The mechanics are unusually simple, which is much of the explanation. The carpal tunnel is a closed space with a rigid floor of carpal bones and a tough transverse carpal ligament as its roof. Pressure inside it rises, the median nerve is the softest structure present, and it suffers. Dividing the ligament converts a closed compartment into an open one and the pressure falls immediately. That is why relief of night pain is often nearly instant while numbness takes months: the compression stops the day of surgery, but the nerve then has to repair itself, and nerve recovers slowly and from the top down. Persistent numbness at six weeks is usually a nerve healing on schedule rather than an operation that did not work. --- ### De Quervain's Release URL: https://www.cqupperlimb.com/education/wrist/de-quervains-release/ Region: wrist · operation De Quervain’s release surgery widens the tendon sheath to relieve pain from thumb tendon inflammation. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. De Quervain's release is an operation that opens the tunnel of tissue around two thumb tendons at the wrist, so the tendons can glide without catching. We usually offer it when other treatments have not given you enough relief. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your wrist, and arrange imaging if it is needed to confirm the cause of your pain. For this condition, non-operative care usually comes first. That means a cortisone injection, which is the preferred initial treatment, often with a splint and hand therapy. A single cortisone injection relieved symptoms in 82% of patients, with over half remaining symptom-free for at least 12 months. Repeat injections can also work well. Surgery is considered when injections and splinting have not settled your pain, or when your symptoms are severe enough to affect daily life. The operation aims to relieve pain and let you use your thumb and wrist normally again. ## Before the operation Your surgeon will confirm the diagnosis at your appointment, usually with a gentle wrist examination and, if needed, imaging such as an X-ray, ultrasound or MRI scan to plan the operation. Most people need nothing more before surgery day. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. On the day, stop eating and drinking seven hours beforehand; we ask for this so your operation can be brought forward if the theatre list runs early. Your surgeon will tell you which of your usual medicines to skip. Bring a written list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing with a sleeve that slides up past your wrist. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You then meet the anaesthetist. This operation can be done under local anaesthetic (an injection that numbs just the area of surgery, with you awake) or under general anaesthetic (fully asleep). Most people choose local: recovery is quicker and you can go home soon after. If you'd prefer to be asleep, that's also a reasonable choice; discuss it with your surgeon and anaesthetist. You are then taken into the operating theatre, where the operation is performed. Afterwards you wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves The operation is called a release of the first dorsal compartment. That is the tunnel of tissue on the thumb side of your wrist that squeezes two tendons as they pass through it. Your surgeon makes a small cut over that tunnel, on the thumb side of the wrist, and opens the tunnel so the tendons can glide freely. Sometimes one of the two tendons sits in its own separate space within the tunnel, divided off by a wall of tissue. If your surgeon finds that during the operation, they open that space as well, so both tendons are freed. Once the tendons glide without catching, your surgeon closes the cut with stitches and covers it with a dressing. You keep the dressing on for about 10 days, as described in the section after this one. The whole operation is a short, focused procedure on a small part of your wrist. You will go home the same day with instructions on caring for the wound. ## After the operation You wake up in the recovery area, where nurses keep an eye on you while the anaesthetic wears off. This is usually a day case, so you can expect to go home the same day, although occasionally patients stay overnight. Someone should stay with you for the first 24 hours. Your wrist will have a dressing over the stitches, and we leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. You can move your fingers, thumb and wrist as comfort allows, and most people use their hand for light tasks straight away. Many people feel relief within the first day or two. ## Recovery Many people notice relief within the first day or two, once the tight tunnel has been opened and the tendons can glide. Some soreness and swelling around the wound is normal in the early days. Resting with your hand raised on a pillow eases this, as does gentle movement of your fingers, thumb and wrist as comfort allows. You can use your hand for light tasks straight away. Keep the dressing clean and dry, and leave it on until we review it. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Your hand therapist will guide you through simple exercises so the tendons keep gliding smoothly, and will make a splint for you if one is needed. As the swelling settles, everyday activities become easier. You will find your grip and thumb movement return gradually. Once you can grip and turn a steering wheel without protecting your hand, and the wound is comfortable, you can usually drive again; see our page on Driving after upper-limb surgery. Work and other activities can resume as your comfort and strength allow. Recovery varies from person to person. Your timeline may differ, and your surgeon and hand therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the tight tunnel is not fully opened, or a tendon slips out of its groove as it glides. You might notice the same catching or pinching feeling you had before the operation, or a snapping sensation at the base of your thumb when you move it. If that happens, bring it up at your next review. Further surgery can rebuild the tunnel and hold the tendons in place if they keep slipping. The nerves that give feeling to the back of your hand and thumb run close to the tunnel. If one is irritated during surgery, you may notice tingling, numbness or a sharp, electric feeling in your thumb or the back of your hand. Most of these feelings settle, but tell your surgeon if they do not, or if they seem to be getting worse rather than better. Recovery can also take longer than you hoped. Some people find the soreness and stiffness linger for weeks rather than days, and this can be frustrating. If your wrist is still painful after a reasonable time, or the relief you expected has not arrived, raise it at your review appointment so we can look at what is going on. Occasionally a cortisone injection given before surgery does not work as well as expected, and the pain continues. If that has been your experience, it does not mean anything has gone wrong with your wrist. It simply means the next step, surgery, is the right one for you. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most people recover without problems, but some symptoms need urgent attention. Call us if you have a fever, if the wound becomes more red or starts to leak fluid, or if your pain suddenly gets much worse. Go to emergency if you have swelling or pain in your calf, or shortness of breath. Call us straight away if your hand or thumb goes numb and stays that way, or if you cannot move your fingers or thumb. When in doubt, call us. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the De Quervain's Tenosynovitis page. --- ### De Quervain's Tenosynovitis URL: https://www.cqupperlimb.com/education/wrist/de-quervains-tenosynovitis/ Region: wrist · condition Patient-facing topic on De Quervain's tenosynovitis (first dorsal compartment) — diagnosis, conservative management, and indications for de Quervain's release. ## What you're feeling De Quervain's tenosynovitis is a problem with two tendons at the thumb side of your wrist. The tunnel they run through becomes swollen and tight, so the tendons gliding through it hurt. You feel soreness and tenderness on the thumb side of your wrist, near the bony bump at the base of the thumb. There is often swelling over that same spot. Certain movements make the pain worse. Bending your wrist towards your little finger, gripping firmly while bending the wrist towards the thumb side, or pinching your thumb and index finger together can all set it off. Everyday tasks that use these movements become hard: lifting a kettle, turning a door handle, picking up a small child, wringing out a cloth, or using scissors. Some people notice a gritty feeling under the skin when they press on the sore spot. Most people find the pain flares with use and settles with rest. It can be worse after a busy day using the hand. Some people notice it first thing in the morning or during the night. A small number of people (about 1 in 100) find their thumb catches or locks as well as hurting. This is worth mentioning, because it can change which treatments work well. When to seek help See your GP or ask for a specialist review if the pain is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your hand. Go to the emergency department the same day if your hand or arm becomes hot, red, swollen and painful, especially with a fever. This could be an infection that needs same-day care, and you do not need a GP referral. Also go the same day if your fingers or hand turn pale, cold, white or blue, or if you suddenly lose feeling or movement after an injury. If you cannot reach the clinic, for example out of hours or on a weekend, go to your nearest emergency department. ## What's actually happening Two tendons move your thumb away from your hand and straighten it. They run side by side through a narrow tunnel on the thumb side of your wrist. The tunnel has a firm roof that holds the tendons close to the bone, like a guide loop holding two ropes in place. The problem is that the tendons and their tunnel become inflamed. The swollen lining takes up room inside an already tight space, so the tendons rub as they slide. That friction causes more swelling and more pain, and the tunnel itself can narrow over time. The blood supply through this narrow passage is poor, which makes it harder for the irritation to settle on its own. Some people are built with an extra wall inside the tunnel, splitting it into two separate passages. This matters because both tendons need room to glide. If one tendon sits in its own sealed-off passage, that passage can stay tight even when the main tunnel is treated. This explains what you're feeling. The sore spot on the thumb side of your wrist is the tunnel itself. The pain with gripping, pinching and lifting is the tendons pulling through the narrowed space. Pinch and thumb strength can drop because the tendons cannot glide freely. The gritty feeling some people notice is the roughened tendon surface moving under the skin. When the thumb catches or locks as well as hurting, the narrowing has become severe enough to trap the tendon briefly. This is a more advanced form of the same problem, and it is worth flagging early because it changes which treatments work well. The pain here can also come from neighbours of the tunnel rather than the tunnel itself: arthritis at the base of the thumb, irritated tendons further up the forearm, or a superficial nerve crossing this part of the wrist. These need different treatments, which is why the exact source of the pain matters. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. We usually begin with changes to how you use your hand, and hand therapy to settle the irritation and ease the load on the tendons. A splint that holds your thumb and wrist still can rest the tendons and reduce the friction that is causing the pain. Give these steps a fair go before moving on, and let us know if things are not improving. The treatment with the strongest evidence for this condition is a cortisone injection. Cortisone is an anti-inflammatory medicine that calms the swelling inside the tunnel. A single injection relieves symptoms in 82% of people, and over half of those stay symptom-free for at least 12 months. Using ultrasound to guide the injection can improve the result, and it also helps us confirm exactly what we are treating. Combining the injection with a splint that holds the wrist still works better than the injection alone. If your symptoms come back, a second injection is still a reasonable option rather than a sign that injections have failed. If you have diabetes, a single injection is less likely to succeed than it is for other people, but each further injection keeps working as well as the one before. Most people will not need surgery. We consider it when non-operative care has not given enough improvement, or when the thumb catches and locks as well as hurting, which tends not to settle on its own. The operation releases the tight roof of the tunnel so the tendons can glide freely again. It is a small operation with its own page describing what it involves. ## What to expect For most people, this condition does not disappear on its own quickly. Most people who develop it still have symptoms a year later if nothing is done, and the pain tends to flare with use rather than fade steadily away. A small number of people (about one in three) will eventually need surgery within two years, and most of those who do need it reach that point within the first year. The outlook with treatment is good to report honestly. A single cortisone injection settles symptoms completely in 70% of people, and a further 10% are cured by a second injection. Together, injections succeed 73.4% of the time within two injections. When surgery is needed, it works well: 88% of people are fully satisfied afterwards, and the operation cures the problem in 91% of cases. What recovery feels like depends on which path you take. After an injection, the soreness usually eases over days to weeks as the swelling inside the tunnel settles. After surgery, the tendons glide freely again, and improvement generally comes earlier with the keyhole (endoscopic) method than with the open method. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she directs your therapy and makes any splint you need. Some things are worth knowing upfront. If you have diabetes or metabolic syndrome (a cluster of health problems that includes high blood pressure and weight around the middle), injections are less likely to succeed for you than for other people. How you think about the condition matters too: people who expect the worst tend to report more pain and less function, so it helps to have accurate expectations rather than fears about what this condition means. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone Most of the warning signs for this condition are already covered in the first section above: pain that is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your hand. If any of those describe you, see your GP or ask for a specialist review. One sign deserves a second mention here. If your thumb catches or locks as well as hurting, tell whoever you see. This form of the problem tends not to settle with rest or splinting alone, and it changes which treatments work well, so it is worth flagging early rather than waiting to see if it fades. The same advice applies if the pain sits slightly away from the usual spot, for example further up the forearm or over the base of the thumb. Several other conditions can mimic this one, and they respond to different treatments. A careful examination sorts out which one you have. Go to an emergency department the same day if your hand or arm becomes hot, red, swollen and painful, especially with a fever, or if your fingers turn pale, cold, white or blue. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. De Quervain's tenosynovitis is worth the extra reading because of a small anatomical variant that accounts for much of the dissatisfaction after an operation that is otherwise reliable, and because the best non-operative result comes from combining two treatments rather than choosing between them. ### The combination beats either part The first dorsal compartment holds two tendons in a tunnel at the thumb side of the wrist. Treatment aims to settle inflammation in that tunnel and reduce the load passing through it. A network meta-analysis of 823 patients concluded that corticosteroid injection with a short duration of immobilisation remains the primary and effective treatment, with extracorporeal shockwave therapy a secondary option [1]. Looking at the components directly, combined orthosis and corticosteroid injection approaches are more effective than either intervention alone [2]. That is a more specific instruction than "try a splint, then an injection if it fails". The evidence supports doing both together, with the splint worn for a defined short period after the injection. ### A second injection is still worth having Where symptoms return, the reflex is to conclude injections have failed and to move to surgery. The data across a large cohort say otherwise: although the success rate decreases with multiple injections, repeat injections have a high rate of success and are a viable clinical option [3]. Declining success with repetition is expected. But a lower success rate is not the same as futility, and a second injection remains a reasonable step rather than a delaying tactic. ### The variant that explains most surgical disappointment Release of the first dorsal compartment is effective, and where it disappoints there is usually a specific reason. Dissatisfaction can result from incomplete release, tendon subluxation, nerve injury, or simply the duration of recovery, and an unidentified and unreleased extensor pollicis brevis subsheath is a discrete source of dissatisfaction [4]. This deserves unpacking because it is the single most useful fact in this section. In a substantial proportion of people the compartment is not one tunnel but two, with the extensor pollicis brevis tendon running in its own separate sheath alongside the other. A release that opens the main compartment and stops leaves that second sheath intact, and the tendon inside it still compressed. The wrist is opened, the operation is completed as described, and the symptoms persist. It is also why the two other listed causes matter: releasing too widely allows the tendons to subluxate out of the groove with wrist movement, producing a painful snap, and the superficial branch of the radial nerve crosses immediately over the operative field. The compartment must be opened completely but not excessively, with a nerve in the way, which is why an apparently minor operation warrants the same care as a larger one. ### Not everything at the radial wrist is de Quervain's Pain in this region has a differential worth knowing, because the treatments differ: arthritis at the base of the thumb, intersection syndrome a few centimetres further up the forearm, and radial nerve irritation can all produce pain in overlapping territory. A localised tenderness directly over the compartment, with pain reproduced by ulnar deviation of the wrist with the thumb tucked in the palm, is what points to the tendon sheath rather than to its neighbours. --- ### Distal Radius Fracture URL: https://www.cqupperlimb.com/education/wrist/distal-radius-fracture/ Region: wrist · condition Distal radius fractures — assessment, casting, and indications for surgical fixation. ## What you're feeling A distal radius fracture is a break in the end of the radius, the larger of the two bones in your forearm, just above the wrist. It usually happens when you fall onto an outstretched hand. Some breaks come from a harder impact, but the simple fall is the common story. It is one of the most common breaks seen in emergency departments, and it is especially common in older women, because bones can thin after menopause. You will usually feel pain straight away, and your wrist will swell. There is often bruising. If the bone has shifted, you may see a change in the shape of your wrist. The classic pattern is a bump on the back of the wrist and a hollow in front, which doctors call a dinner-fork deformity because the wrist looks like a fork held upside down. Sometimes there is no obvious change in shape at all, just tenderness in one spot and pain when you try to move the wrist. In the first days, the pain is often there even when your hand is still, and it can be worse at night. Moving your fingers or turning your wrist will hurt. Keeping your hand raised helps limit the swelling, and moving your fingers early helps prevent stiffness. Most of the early pain settles over the first few weeks as the bone starts to knit. Some things need urgent attention. If broken skin appears over the fracture, if bone is showing, or if the deformity is obvious, go to the emergency department the same day. The same applies if your fingers or hand turn pale, cold, white or blue, or if you suddenly lose feeling or movement in the hand. Nerve irritation near the wrist can cause numbness or tingling in the fingers, and this needs to be checked promptly. If your symptoms are not settling, are getting worse over weeks, or are waking you at night, see your GP or ask for a specialist review. If you cannot reach the clinic out of hours or on a weekend, go to your nearest emergency department. ## What's actually happening The radius is the larger of the two forearm bones, and the distal radius is its wide end, the part that forms half of your wrist joint. When you fall on an outstretched hand, the force bends this end of the bone until it snaps. The break can sit in one clean line, or it can splinter into several pieces. It can also push out of place, which doctors call displacement. If the broken pieces stay lined up, the bone is described as undisplaced. Think of the wrist end of the radius like the top of a table leg that has snapped and tilted. The tabletop, your hand, no longer sits level on it. If the pieces can be eased back into line and held there while they knit, the surface becomes level again. If they cannot be held, the hand keeps sitting on a slope, and the wrist may stay stiff, weak or sore long after the break itself has healed. Bone heals by knitting: new bone forms across the break, slowly bridging the pieces together. That knitting needs the pieces held still, which is what a cast or an operation provides. The trouble is that this end of the radius is naturally thin-shelled, so it bends and crumbles rather than snapping cleanly, and some breaks are hard to hold in line. A break that was badly out of position to begin with is the one most likely to slip back, which is why a cast treated wrist is checked with X-rays again in the first couple of weeks. The force of the injury can also strain the soft parts around the bone. The ligaments that hold the small wrist bones together, and the gristle pad deep in the wrist joint, can be sprained or torn at the same time. This happens in about half of these fractures. It is one reason a wrist can keep troubling you even once the bone itself has knitted, and why your surgeon looks past the bone when planning your treatment. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. The right choice depends on how the bone has broken, whether the pieces have shifted, and whether they are likely to stay put. It also depends on you: your age, your health, and what you need your wrist to do. Some breaks heal well without an operation, and others need surgery soon after the injury, so prompt assessment matters. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. Many breaks are stable or only slightly out of place, and these usually do well without surgery. We hold the wrist still in a splint or cast while the bone knits. If the pieces have shifted, they can often be eased back into line first, with numbing medicine around the break, and then held in a cast. A wrist treated this way is checked with X-rays again at 7 days and again at 14 days, because a break that has been set can slip in the cast. The bone usually knits in about 5 weeks, and the cast comes off so movement can begin. From there, your therapist guides you back to using the hand in stages. Surgery is recommended from the outset when the break is unstable or badly out of position, when the broken pieces step into the joint surface, when the skin is broken, or when the injury has also damaged nerves or ligaments. It aims to hold the pieces in the right position while they knit, so the wrist surface stays level. The choice is genuinely shared in some situations: a cast may be possible, but the wrist may end up sitting on a slope, and that final shape may not be acceptable to you. We will talk through both paths with you before anything is decided. Whichever path you take, the first weeks share the same basics. Keep the hand raised to limit swelling, and keep your fingers moving early so they do not stiffen. Pain medicine in the early days is part of the plan, and most people treated without surgery do not need strong pain medicine beyond the first days. Protect the wrist while it knits, and start therapy at the right stage, not before the bone is ready and not long after. ## What to expect Most people find the worst of the pain settles within the first two months. By six months, most people have little pain and little trouble using the wrist. Recovery does not stop there, though. It keeps improving for years, and wrist function can still be measured as restored a decade later. Recovery follows one of three paths. About 69% of people recover quickly, about 23% recover slowly, and about 8% do not fully recover. Older age and thinner bones slow recovery in the first year. A harder injury, such as a fall from height or a road crash, also slows recovery over the first six months. Having surgery within two weeks of the injury is linked with better long-term function than waiting longer. If your wrist is held in a cast, the bone usually knits in about 5 weeks, as covered earlier. If you have surgery, the pieces are held with a small metal plate and screws while they knit. Both paths aim for the same thing: a wrist that moves, grips and carries your daily loads without pain. Long-term results between the two are broadly similar, though people who have surgery can take longer off work than people treated in a cast. Some things can slow you down or complicate the picture. The break can heal in a poor position, which doctors call a malunion. This is more common in older people, and it can leave the wrist stiff, weak or sore, and change its shape. A badly tilted bone end also loads the wrist joint unevenly, which can wear it down over years. Stiffness in the fingers and forearm is common if the hand is not kept moving early. Rarely, the bone fails to knit at all. Nerve irritation near the wrist can cause numbness or tingling, and a tendon can occasionally fray where it rubs against a plate or screw. If your symptoms are not settling, are getting worse over weeks, or are waking you at night, see your GP or ask for a specialist review. If you cannot reach the clinic out of hours or on a weekend, go to your nearest emergency department. ## When to see someone Seek urgent care if you have broken skin over the fracture, bone showing, or an obvious change in the shape of your wrist. The same applies if your fingers or hand turn pale, cold, white or blue, or if you suddenly lose feeling or movement in the hand. Numbness or tingling in the fingers also needs prompt checking, because it can mean a nerve is squeezed near the wrist. See your GP or ask for a specialist review if pain is not settling, or if swelling, movement or grip are not improving week on week as the bone knits. Recovery from a broken wrist is a long process, so small gains week by week are what you are watching for. If you cannot reach the clinic out of hours or on a weekend, go to your nearest emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. A broken wrist is worth the extra reading because it is the fracture where the gap between what looks right on an X-ray and what a patient actually notices is widest, and because the commonest operation for it has a higher complication rate than most people are told. ### Surgery improves function, but by how much matters Pooling 2,254 adults, operative treatment of distal radius fractures improved the medium-term DASH score and grip strength compared with non-operative treatment, with no difference in overall complication rate [1]. That is a genuine result in favour of surgery, and it should be read alongside its own size. The DASH is scored out of 100, and the differences in this literature are typically modest — real, measurable, and often smaller than patients imagine when they hear "surgery gives a better result". It is a difference in the quality of the recovery rather than the difference between a working wrist and a useless one. ### The plate has its own complication profile The volar locking plate is the standard fixation, and it is very good. It is not free. A meta-analysis restricted to high-quality studies found an overall complication rate of 30.8% after volar locking plate fixation, and noted the technique may be associated with more hardware-related complications than previously reported [2]. That figure needs context rather than alarm: it counts everything, including minor and self-resolving problems, not 30.8% disasters. But it is the honest denominator, and it is higher than the impression given by "a plate and screws, then straight to moving your hand". Removal is a related question with a clean answer. Across 3,690 patients there was a strong positive correlation between how often surgeons removed hardware and how often complications were reported, and the authors concluded that routine removal is not justified in the absence of plate-related problems [3]. A plate that is not causing trouble should generally be left alone. ### The ulnar styloid fracture you were told about probably does not matter Most people with a distal radius fracture also break the tip of the ulna, and it is often mentioned as though it were a second, worrying injury. Pooling 1,403 patients, a concomitant ulnar styloid fracture did not affect the outcomes of the distal radius fracture, and the authors advise caution before electing to fix it [4]. So if that fragment was pointed out on your X-ray, its presence alone is not a reason for additional surgery, and not a reason to expect a worse result. ### What actually predicts a poor outcome Not the ulnar styloid, and not the surgeon's choice of implant so much as the fracture's own behaviour. Where a fracture is managed in a cast, the risk factors for it slipping again after reduction include initial complete displacement and other markers of an unstable pattern — the fracture that was badly out of position to begin with is the one most likely to drift back. That is why a wrist treated in plaster is X-rayed again at one and two weeks. The check is not bureaucratic; it is the window in which a slipping fracture can still be dealt with easily. --- ### Distal Radius Malunion (and Corrective Osteotomy) URL: https://www.cqupperlimb.com/education/wrist/distal-radius-malunion/ Region: wrist · condition When a wrist fracture heals in a poor position — the problems it causes and how a corrective osteotomy realigns the bone. ## What you're feeling You broke your wrist some time ago (perhaps from a fall onto an outstretched hand) and it healed. But it has not gone back to normal. The wrist may look slightly bent, crooked or shorter than the other side, sometimes with a visible bump on the back. More than the look, it often does not work the way it used to: the grip feels weak, the wrist is stiff, and turning your palm up and down (as if turning a key or a doorknob) can be awkward or painful. Many people notice an ache on the little-finger side of the wrist (the side away from the thumb) that flares with twisting, leaning on the hand, or heavier tasks. Some feel a clunk or instability when rotating the forearm. A few develop pins and needles in the thumb and fingers if the healed position crowds a nerve at the wrist. These are all signs that the bone did not heal in quite the right shape. ## What's actually happening The distal radius is the larger of the two forearm bones, on the thumb side, right at the wrist. When it breaks and then heals in a poor position, we call that a malunion: the bone is solidly healed, just in the wrong shape. The most common pattern is that the end of the radius tilts backwards (toward the back of the hand) and the bone settles shorter, so it no longer lines up properly with the neighbouring ulna bone. That small change in shape has knock-on effects. A shorter, tilted radius throws off the grip mechanics, so power drops. It also unbalances the joint where the two forearm bones meet near the wrist (the DRUJ), which is the joint that lets you rotate your forearm, making rotation stiff or sore. And because the radius has dropped, the ulna can effectively sit too "long," pressing on the small bones and cartilage on the little-finger side and causing that ulnar-sided pain. If the break ran into the joint surface itself and healed with a step, the cartilage wears unevenly and can lead to arthritis over time. ## What we can do about it At Mater Private Hospital Rockhampton, Dr Kieran Hirpara leads our upper-limb team in managing these wrist injuries. We typically begin with non-surgical care, but if pain or stiffness persists, we consider surgery after a thorough assessment of your history and imaging. Not every crooked-healed wrist needs surgery. If the deformity is mild and you are managing well, hand therapy, activity changes, a supportive splint and simple pain relief are entirely reasonable, and we often start there. When the deformity is significant and it is genuinely limiting you (pain, weak grip, restricted rotation) the operation that fixes the underlying problem is a corrective osteotomy. In plain terms, the surgeon carefully re-cuts the bone at the site of the old fracture, swings it back into the correct alignment, and holds it there with a metal plate and screws. Where the bone is opened up to restore length, the gap may be filled with bone graft (your own bone, donor bone, or a bone-substitute material), though with modern plates many corrections now heal reliably without a graft. If the little-finger-side bone is the main problem, the surgeon may instead (or also) shorten the ulna to take the pressure off that side. These days the operation is often planned in advance on a 3D computer model of your own wrist, and the surgeon may use a custom-made guide so the cut and the realignment match the plan precisely; this is especially useful when the break went into the joint surface. ## What to expect It helps to know up front that this is a bigger undertaking than the original fracture surgery: the surgeon is reshaping healed bone rather than simply fixing a fresh break, so recovery is more involved and takes longer. The bone needs to knit in its new position, which typically takes a couple of months, and the plate is usually left in place. The good news is that, for the right wrist, the gains are real and lasting: studies consistently show improved pain, better grip and better forearm rotation, and patients generally report being satisfied years later. Correcting the shape early, before the joint and surrounding ligaments have adapted to the bad position, tends to give the best result. It is not a guarantee of a perfectly normal wrist, and if arthritis has already set in the benefit is more limited, but for a symptomatic malunion this operation reliably makes the wrist work better than it did. ## When to see someone - A wrist that healed crooked and stays painful, weak or stiff months after a fracture; it is worth having the alignment assessed, because correcting it earlier generally works better. - Pain on the little-finger side of the wrist that flares with twisting or leaning on the hand, especially with a clunky or restricted forearm rotation. - Worsening loss of grip or rotation, or trouble with everyday tasks like turning keys, pouring, or using tools. - Pins and needles or numbness in the thumb and fingers after a wrist fracture; a nerve may be irritated and should be checked. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Distal radius malunion is worth the extra reading because the corrective operation has a clear technical answer that is only recently established, and because the decision to do it at all rests on function rather than on how the X-ray looks. ### The approach determines the reoperation rate Correcting a malunion means cutting the healed bone, restoring its alignment, and holding it with a plate. That plate can be placed on the front of the radius or on the back, and the choice has been treated as a matter of preference. The comparison across 403 patients does separate them. Anterior plating was associated with fewer reoperations, 9% versus 28%, and less hardware removal, 3% versus 18%, with comparable major complications at 5% and 6%. The authors advise that surgeons should be fully aware of the increased risks of dorsal plate fixation after corrective osteotomy [1]. The mechanism is anatomical rather than technical. On the back of the wrist the extensor tendons run directly over the bone with almost nothing between them and a plate, so hardware there is prominent, irritating, and frequently removed, and in the worst case can wear a tendon through. On the front, a layer of muscle separates the plate from the flexor tendons. Note what did not differ: major complications were the same. The advantage is in avoiding a second operation for hardware, not in avoiding disaster. ### Why the X-ray does not decide it A malunited distal radius healed in a poor position is visible on any film, and the deformity looks like something requiring correction. The measurements, how much the joint surface tilts, how much the radius has shortened, are what a follow-up report emphasises. But the deformity itself is not the complaint. What people present with is loss of forearm rotation, loss of grip, pain at the ulnar side of the wrist, or an appearance that bothers them. The link between the radiographic numbers and those symptoms is loose, particularly in older patients, where substantial deformity is often well tolerated. That is why corrective osteotomy is considered for symptoms and function, not for the appearance of a scan. A wrist that works acceptably, in a person whose demands it meets, does not need correcting because the angles are wrong. ### What the operation is actually correcting Two consequences drive most symptomatic malunions. The first is loss of forearm rotation. When the radius heals short or tilted, it no longer rotates truly about the ulna, and turning the palm up becomes restricted, the movement needed to carry a tray, take change, or turn a key. The second is ulnar-sided pain from relative lengthening. The radius shortens as it collapses, so the ulna becomes comparatively long and is driven against the carpal bones, producing an impaction problem as a secondary consequence of the fracture. This is treatable either by restoring the radius to length or by shortening the ulna, and which is appropriate depends on how much of the deformity sits in each bone. Understanding those two mechanisms explains why correction is often worth considering even years after the original injury: it is addressing an ongoing mechanical problem, not repairing an old fracture. --- ### Distal Radius ORIF URL: https://www.cqupperlimb.com/education/wrist/distal-radius-orif/ Region: wrist · operation Open reduction and volar plate fixation of the distal radius — operation, recovery, rehabilitation. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your wrist, and arrange imaging if it is needed. That assessment tells us whether the break is unstable or has moved into the joint, which is when surgery is usually advised. The operation is called open reduction and internal fixation. In plain terms, it means the broken bone is put back into its normal position and held there with a small metal plate and screws. For most wrist fractures of this type, a plate on the palm side of the wrist is the usual method. Non-operative care, such as a cast or splint, is often tried first for less severe breaks. When the bone is unstable or has shifted, surgery may be recommended straight away, because a cast may not hold the pieces in place. The aim is a wrist that heals in a good position, so you can move your hand and get back to your normal activities sooner. ## Before the operation On the day of your operation, you will need to stop eating and drinking seven hours before your operation time. We ask for seven hours rather than six so your operation can be brought forward if the theatre list runs early. Your surgeon will tell you which of your regular medicines to skip on the day, and which to take as usual. Bring a written list of everything you take, including tablets, drops and anything from the chemist. Arrange for someone to drive you home afterwards, as you will not be able to drive yourself. Wear loose, comfortable clothing with a sleeve that is easy to remove. To plan the operation, we use X-rays taken from several angles. Sometimes a CT scan (a detailed X-ray) or an MRI scan (a scan that shows soft tissues such as ligaments) is needed as well. If you have other medical conditions, you may need blood tests or a review with the anaesthetist before the day. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist there. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. Afterwards you will wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you will either go to a ward or go home, depending on the procedure and your recovery. ## What the operation involves The operation is done through a cut on the palm side of your wrist. Through this opening, your surgeon moves the broken pieces of bone back into their normal position. A small metal plate is then shaped to fit the bone and held in place with screws. The plate sits on the front of the wrist bone, where there is a layer of tissue between it and the tendons that work your thumb and fingers. Sometimes the joint surface itself needs a closer look. In that case, your surgeon may use a thin instrument with a tiny camera to check inside the joint while the bone pieces are being lined up. This helps confirm the joint surface is smooth and even before the plate is fixed. Once the bone is held firmly, your surgeon checks the position with X-rays taken during the operation. The wound is then closed with stitches, and a dressing is placed over the top. The plate and screws stay in your wrist permanently. They hold the bone steady while it heals, like an internal splint. In some fractures, extra support is needed. If the bone is broken into several pieces, your surgeon may add a second plate on the back of the wrist, or use a bone graft to fill gaps and help the bone knit together. You will go home with the dressing intact. We ask you to keep it dry and leave it in place for about 10 days, when you will see us again to have the wound checked. ## After the operation When you wake up, you will be in the recovery ward, where nurses keep a close eye on you as the anaesthetic wears off. Your wrist will be wrapped in a soft dressing, and we will give you pain relief to keep you comfortable. You can usually get up and move around soon after, and someone from the nursing team will help you the first time. Because the anaesthetic can make you unsteady for a while, please have someone stay with you for the first 24 hours after you go home. Most patients stay one night in hospital after this operation, though some are able to go home the same day. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your wrist will be sore and swollen, and this is normal. Rest, keeping your hand raised on pillows, and the pain relief we give you will ease the discomfort. The swelling usually settles over the following weeks, though it can take a while to go down completely. You will go home with a soft dressing rather than a cast, so most people find everyday life easier than they expected. You can get up and move around straight away, and you can use your other hand for dressing, eating and washing. Keep the dressing dry. Hand therapy is an important part of your recovery: you will see Ruby Doolan at Extend Rehabilitation, our hand therapist, who will guide your exercises and make a splint for you if you need one. Moving your fingers early helps stiffness and supports healing. As the weeks pass, you will notice the swelling easing and movement returning. Your therapist will show you exercises to build up your grip and get your wrist bending again. You can do light activities at home once you feel steady, but avoid lifting anything heavy or putting weight through your wrist until we tell you it is safe. You will not drive while your wrist is healing; once the dressing is off and your surgeon has cleared you, driving can resume, and our page on driving after upper-limb surgery explains more. Everyone heals at their own pace, so your timeline may differ. We will see you along the way and guide you through each stage. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the metal plate or screws cause irritation. You might feel a sharp ridge under the skin, or a rubbing sensation when you move your wrist. If this bothers you, bring it up at your next review. The tendon that straightens your thumb can occasionally fray and snap. You would notice this suddenly: you cannot lift your thumb up straight, and the back of the thumb feels slack. This usually happens around 3 months after the operation, sometimes without any warning pain. If your thumb stops working in this way, contact the clinic promptly. The nerve that gives feeling to your thumb, index and middle fingers can become irritated. You might notice tingling, pins and needles, or patches of numbness in those fingers. Mild symptoms are common and often settle. Mention any numbness that is not improving at your review appointment. Infection in the wound is uncommon but needs quick attention. Watch for a deep, throbbing pain that does not ease with simple painkillers, redness spreading out from the wound, warmth, or fluid leaking through the dressing. If you see any of these, call the clinic straight away, or go to the emergency department if it is after hours. Occasionally the bone shifts before it has healed, or the healing is slow. You might feel a fresh grinding or clunking in the wrist, increasing pain, or the wrist giving way. Tell us at your review so we can check the position with an X-ray. Some wrists stay stiff or tender after healing. You may find turning your hand, bending the wrist back, or gripping harder than expected. Hand therapy and the exercises your therapist gives you are the main treatment for this. Smoking and nicotine in any form, including patches and gum, raise the chance of several of these problems, including wound infection, slow healing and further surgery. It is worth stopping before your operation if you can. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems give warning signs. Call us if you have a fever, or the wound becomes more red, warm or leaks fluid. Call us if pain keeps getting worse despite simple painkillers. Go to emergency if you notice calf swelling or pain, or sudden shortness of breath, as these can signal a blood clot. Go to emergency if your fingers go numb and stay that way, or you cannot move them at all. If your thumb stops lifting straight, contact the clinic promptly. When in doubt, call us. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Distal Radius Fracture page. --- ### Distal Radioulnar Joint Surgery URL: https://www.cqupperlimb.com/education/wrist/druj-hemiresection/ Region: wrist · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a history, examine your wrist, and arrange imaging where it is needed to work out what is causing your pain. The distal radioulnar joint is the joint between the two bones of your forearm, just above the wrist. Surgery on it is suggested when that joint is worn, unstable, or damaged after an injury, and it is causing pain on the little-finger side of your wrist, trouble turning your forearm, or weaker grip. For long-standing problems we usually try non-operative care first: activity change, physiotherapy or hand therapy, and splinting. Surgery comes into the picture when those steps have not given you enough improvement. Some injuries to this joint are unstable from the start, and for those we may recommend surgery straight away. The aim of the operation is to ease your pain and let you turn your forearm and use your hand with more comfort and confidence. ## Before the operation Once your surgery is booked, we will give you clear instructions to prepare. You will need to stop eating and drinking seven hours before your operation. We ask for seven hours rather than a shorter time so your place on the theatre list can be brought forward if the day runs early. If you take regular medicines, bring a written list of them to hospital, and we will tell you which ones to pause and when. Most people do not need any extra tests beforehand. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, the doctor who gives your anaesthetic. Please arrange for someone to drive you home afterwards, and wear loose, comfortable clothing on the day. ## On the day On the day of your operation you come to the hospital's surgical admissions unit. There you are checked in and prepared for theatre. You will meet the anaesthetist, the doctor who looks after your anaesthetic. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. Afterwards you wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Once you are stable you either go to a ward or go home, depending on the procedure and how your recovery is going. ## What the operation involves There is more than one way to operate on this joint, and the right one for you depends on what is wrong with it. If the joint has come out of place after a wrist fracture, your surgeon will put the bones back into their correct position and hold them there while they heal, sometimes with a cast. If the joint is worn and painful, your surgeon may remove part of the bone at the end of the forearm bone on the little-finger side of your wrist. This is done through a cut over the back of the wrist, on the little-finger side. Removing that worn bone surface stops the two forearm bones grinding on each other when you turn your forearm. If the joint is loose rather than worn, your surgeon can rebuild the ligaments that hold it together. Ligaments are the strong bands of tissue that connect one bone to another. This is done using a piece of tendon, the tissue that joins muscle to bone, woven through small holes in the bones to act like a new strap holding the joint in place. This is only possible when the joint surfaces themselves are still healthy. If the whole joint is badly worn, your surgeon may replace it. The damaged bone at the end of the forearm bone is removed and replaced with an artificial joint made of metal, and sometimes plastic parts as well, so the two forearm bones can move smoothly against each other again. At the end of the operation your surgeon closes the cut with stitches and covers it with a dressing. You will wake up with your hand and wrist bandaged, and the dressing stays on for about 10 days. ## After the operation When you wake up you will be in the recovery area, and nurses will check on you as the anaesthetic wears off. Your hand and wrist will be bandaged, and you may have a sling to rest your arm. We will give you pain relief to keep you comfortable; tell the nurses if your pain is not settling. You can get up and move around as soon as you feel able, and someone should stay with you for the first 24 hours. Your team will tell you whether you go home the same day or stay one night in hospital. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your wrist will be sore and swollen, and the little-finger side may throb, especially at night. Keeping your hand raised on pillows, even while you sleep, helps the swelling settle. The pain relief we give you works best when you take it regularly rather than waiting for the pain to build. You will leave hospital with your arm bandaged and resting in a sling. The dressing stays on for about 10 days, and we will change or remove it when we see you. Your rehabilitation after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she will guide your exercises and make any splint you need. Early on, the exercises are gentle and focus on keeping your fingers, elbow and shoulder moving. As healing progresses, the exercises work on turning your forearm and building your grip back up. Day to day, you will need help at first with tasks that need two hands, like dressing, cooking and carrying things. Once the swelling settles and movement returns, everyday activities get easier. When you can grip without pain and turn your forearm comfortably, you will find you can do more with your hand. If driving is part of your recovery, you must not drive while in a sling or splint, while on strong pain medication, or unless you can hold the wheel with both hands and react in an emergency stop. See our guide on driving after upper-limb surgery. Everyone heals at their own pace, and your timeline may differ. Your surgeon and your hand therapist will guide you at each step. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. If part of the end of your forearm bone has been removed, the remaining stump can sometimes shift or press against nearby structures. You might feel a sharp or grinding pain on the little-finger side of your wrist when you turn your forearm, or a sense that something is catching. Bring this up at your next review. Some people notice the wrist is less painful but stiffer afterwards, with less bending forwards. If turning your forearm feels limited, your shoulder often takes over without you realising, so the difference in daily life may be small. Mention any movement you are unhappy with at review. If this joint was injured along with a wrist fracture, the joint can slip out of place early on, sometimes within the first two weeks. This is easy to miss. Watch for new pain, swelling or a change in the shape of your wrist, and tell the clinic if you notice these. A tear in the cartilage cushion on that side of the wrist, left untreated, can leave the joint feeling loose. You might notice clicking, a shift or clunk when you load the wrist, or weaker grip. If the joint stays loose and painful despite other treatment, further surgery is sometimes needed, but many people improve with time and do not need another operation. Ulnar-sided wrist symptoms often keep improving for up to a year after fracture surgery. For a long-standing wrist deformity present since youth, the joint can gradually become worn or unstable over time. In severe cases, the tendons that straighten the fingers can wear through from rubbing over a prominent bone, causing sudden loss of the ability to straighten one or more fingers. If a finger will not straighten, contact the clinic promptly. As with any wrist operation, bones can be slow to heal or fail to join, and the area where bone was removed can become unstable and painful. Persistent pain at the back of the wrist should be raised at review. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if you have a fever, or the skin around your wound becomes more red, swollen or weepy. Call us if your pain suddenly gets worse, or new pain or swelling appears in your wrist in the first two weeks. Tell us if a finger will not straighten, or your wrist feels loose, clicks or gives way. Go to emergency if you have calf swelling or pain, shortness of breath, chest pain, numbness in your hand, or you cannot move your arm or fingers. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. The distal radioulnar joint is worth the extra reading because it is the joint in the wrist we are worst at measuring, the one most often blamed prematurely, and the one where waiting is most often the right answer. ### We cannot reliably measure the problem Instability of this joint is diagnosed largely by feel, the examiner shifts the ulna against the radius and forms an impression. A 2025 review of assessment strategies concluded plainly that reliable, quantifiable methods for analysing distal radioulnar joint instability remain an unmet need, and that developing them is essential to improving management [1]. That has a direct consequence for you. When the diagnosis rests on a subjective test, the threshold for calling a joint unstable varies between examiners, and so does the threshold for operating on it. A second opinion here is not distrust; it is a reasonable response to a test with known limits. ### Most ulnar-sided pain after a wrist fracture settles This is the single most useful finding for anyone with a painful wrist after a distal radius fracture. A comprehensive review concluded that most ulnar-sided wrist problems following distal radial fractures can be treated non-operatively initially, typically for over a year, in anticipation of substantial improvement with time [2]. A year is longer than most people expect to be told to wait, and the temptation to intervene earlier is strong on both sides of the consultation. The exception named in the same review is important and specific: early marked subluxation of the joint that physically blocks forearm rotation does need addressing rather than observing [2]. So the default is patience, with a defined reason to abandon it. ### When salvage is needed, the choice is finer than it looks If the joint is destroyed and non-operative management has genuinely failed, the classic options are the Darrach procedure, removing the end of the ulna, and the Sauvé-Kapandji, which fuses the joint and creates a gap more proximally to allow rotation. A systematic review comparing them found comparable satisfaction regardless of the underlying pathology, with similar improvement in range of motion, strength and overall function [3]. The difference was in the reoperation rate, which was higher with the Sauvé-Kapandji [3]. That is a clean discriminator. Where two operations produce the same result, the one requiring fewer further operations has the advantage, though the Sauvé-Kapandji retains a role where preserving the ulnar support of the carpus matters, which is precisely why it was devised. ### Ulnar impaction is a different problem with its own answer Ulnar-sided pain from the ulna being relatively too long, ulnar impaction syndrome, is treated by shortening the load path, either by cutting and shortening the ulnar shaft or by arthroscopically removing the dome of the ulnar head. A meta-analysis of 311 patients found both effective, with the arthroscopic wafer procedure showing fewer complications and a lower reoperation rate [4]. The shaft osteotomy involves a plate, a healing bone and the possibility of the osteotomy failing to unite; the arthroscopic procedure avoids all three. Where the anatomy suits it, that is a meaningful difference. --- ### ECU Tendinopathy and Snapping ECU URL: https://www.cqupperlimb.com/education/wrist/ecu-tendinopathy/ Region: wrist · condition This is pain on the little-finger side of the back of your wrist — the side your watch strap sits nearest if you wear it low. It is usually worst when you turn your palm upwards and bend the wrist towards your little finger, which is exactly what happens in a tennis backhand, a… ## What you're feeling This is pain on the little-finger side of the back of your wrist — the side your watch strap sits nearest if you wear it low. It is usually worst when you turn your palm upwards and bend the wrist towards your little finger, which is exactly what happens in a tennis backhand, a golf swing, or wringing out a cloth. There are two versions of the problem, and many people have a bit of both. An irritated tendon. The pain is a dull ache along the tendon, sometimes with swelling you can feel, and it hurts to push the wrist back against resistance. It tends to build over weeks with repeated use rather than starting in one moment. A tendon that slips out of its groove. Here you get a distinct snap, click or clunk as you rotate the forearm — often something you can demonstrate yourself, and often something you first noticed after a specific incident, like the club catching the ground or a hard backhand. It can feel alarming, as though something is giving way. ## What's actually happening The tendon involved is the extensor carpi ulnaris, usually shortened to ECU. It runs from the muscle in your forearm down the little-finger side of the wrist, sitting in a shallow groove in the end of the ulna — the forearm bone on that side. A small sleeve of tissue, its own private tunnel, holds it in that groove. That groove is genuinely shallow, averaging only about a millimetre and a half deep, so the sleeve does most of the work of keeping the tendon in place. If the sleeve is torn or stretched — usually by a forceful twist with the palm turning up and the wrist bent — the tendon can ride up out of the groove and snap back in. If instead the tendon and its lining become irritated and thickened from repeated loading, it becomes painful to glide, which is the tendinopathy version. An important thing to know, because it changes how the tests should be interpreted: a certain amount of tendon movement is completely normal. When researchers examined 755 people with no wrist symptoms at all, about 1 in 15 had a snapping ECU, and nearly half of those had the tendon visibly leaving its groove on ultrasound — with no pain and no problem. A snap on its own is not proof that anything is wrong. ## What we can do about it At Mater Private Hospital Rockhampton, Dr Kieran Hirpara will base the diagnosis mainly on the examination rather than on a scan, and it's worth explaining why. Scans need careful interpretation here. In a study of more than 4,000 wrist MRIs, changes in the ECU tendon showed up in around one in eight scans, including in people having the scan for something else entirely. If you take an abnormal-looking ECU on MRI and ask how often that person actually has ECU trouble, the answer is only about 6% of the time. An MRI is genuinely useful for ruling out other causes of pain on that side of the wrist — a cartilage tear, for instance — but a mark on the tendon is not by itself the answer. Ultrasound is often more helpful, because we can watch the tendon move in real time while you reproduce the snap. Most people get better without surgery. Treatment usually starts with modifying the activity that provokes it and a period in a splint or cast. For a tendon that is slipping out of its groove, the position matters: the wrist is usually held with the forearm turned palm-down and the wrist slightly cocked back, for around four to six weeks, because that is the opposite of the position that lets the tendon escape. A steroid injection into the tendon sheath is a reasonable next step for the irritated-tendon version. In the best study available, 13 patients with a confirmed diagnosis all got some relief, 10 of them complete relief, and none went on to need surgery — with most still comfortable four to five years later. A useful early signal: if the first injection settles things completely, that tends to last. If it only half-works, it more often leaves some residual ache. We do limit injections to a maximum of about three, and we are more cautious in throwing and racquet athletes, because there is a concern — not proven with numbers, but reported — that repeated steroid around this tendon may contribute to it eventually tearing. Surgery is reserved for people whose instability keeps causing pain despite a proper trial of casting, usually assessed at around two months. The operation rebuilds or reinforces the sleeve that holds the tendon in the groove. Several techniques exist and all report good results. ## What to expect Recovery from the non-surgical route depends on how irritable things are. Athletes with a mild problem are often back within two to three weeks; more severe cases take six to eight weeks; and a complete slip treated in a cast can take five to six months before returning to a demanding sport like tennis. After surgery, expect around four to six weeks in a cast or splint with the forearm held palm-down, then a gradual return of movement, strengthening from about two months, and sport-specific work at three to four months. Published series report people returning to their previous activity at around two and a half to three and a half months. Two honest points about the surgery. First, essentially every published series reports that the snapping does not come back — but the one study that scanned people afterwards found the tendon still sitting out of its groove in about half of them, even though they were happy and scoring well. In other words, the operation reliably relieves symptoms, but it does not always put the anatomy back exactly where it was. Second, the gains in grip strength and range of movement are small; the operation is done for pain and for the snapping, not to make the wrist stronger. Complications are uncommon but real: numbness or a tender spot from irritation of a small skin nerve on the back of the wrist, stiffness, and rarely a persistent pain syndrome. If your snapping doesn't hurt, it probably doesn't need fixing. People with a painless snapping ECU generally carry on at a high level with taping and monitoring alone. ## When to see someone See your GP if pain on the little-finger side of the wrist has not settled after a few weeks of easing off the activity that brings it on, or if it is limiting your sport or work. Ask for a hand surgery opinion if the wrist snaps or clunks painfully when you turn your forearm, if the pain followed a specific twisting injury, or if you have already tried rest, a splint and an injection without lasting benefit. Seek prompt attention if the wrist becomes hot, red and swollen, if you develop numbness or weakness in the hand, or if you felt a sudden give-way with immediate loss of strength — that last one can indicate the tendon itself has torn. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Extensor carpi ulnaris problems are worth the extra reading because both of the findings that usually confirm the diagnosis — an abnormal signal on the scan, and a tendon that snaps as the wrist turns, occur commonly in people with no symptoms at all. ### An abnormal MRI here means less than it appears to The ECU tendon runs in a groove on the back of the ulna at the little-finger side of the wrist. When someone has pain there and the scan reports signal change in that tendon, the conclusion looks obvious. The data undercut it. Reviewing 4,301 wrist MRIs, ECU signal changes are common and often asymptomatic, and such changes are uncommonly associated with symptomatic tendinopathy, resulting in a low positive predictive value [1]. Low positive predictive value is the operative phrase. It means that among all the wrists showing this finding, only a minority have it as the cause of their pain. The scan cannot carry the diagnosis on its own, it has to agree with tenderness in exactly that location and pain reproduced by resisted movement in the right direction. ### And the snapping is common in people who are fine The second confirmatory sign is a tendon that visibly or audibly snaps out of its groove as the forearm rotates. Examining an asymptomatic population of 755 people, ECU snapping was found at a prevalence that makes it unreliable as a marker of pathology on its own [2]. The practical reading is that snapping the patient has noticed, in a wrist that also hurts in that precise spot, is meaningful. Snapping found incidentally on examination of a wrist that hurts elsewhere is probably a normal variant. Taken with the MRI finding, the pattern is consistent: this tendon produces abnormal-looking results in ordinary wrists. Diagnosis here depends more on the correlation between findings than on any one of them. ### Which matters because the ulnar wrist has many possible sources The ECU sits immediately alongside the TFCC, the distal radioulnar joint and the pisotriquetral joint, all of which produce pain in the same small area. Attributing that pain to an abnormal-looking ECU tendon is easy and, given the figures above, frequently wrong, which is the main reason to be careful before treating it as the culprit. ### Conservative treatment is the mainstay, and it works Where the diagnosis is sound, the treatment is unglamorous. A combination of conservative measures and rehabilitation can render patients symptom-free and allow return to desired activities [3]. Two features specific to this tendon shape the rehabilitation. Because it is loaded by forearm rotation combined with ulnar deviation, the position of a golf swing, a racquet stroke, or lifting a heavy pan, activity modification here means changing the direction of loading rather than simply resting. And because the tendon sits in a subsheath that can be stretched or torn, allowing it to subluxate, immobilisation is often positioned in pronation with the wrist extended, which holds the tendon in its groove while the sheath heals. --- ### Hook of Hamate Excision URL: https://www.cqupperlimb.com/education/wrist/hook-of-hamate-excision/ Region: wrist · operation Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. The hook of hamate is a small bone in your wrist, on the little-finger side of your palm. Removing the broken piece of this bone is called a hook of… ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. The hook of hamate is a small bone in your wrist, on the little-finger side of your palm. Removing the broken piece of this bone is called a hook of hamate excision. We usually try non-operative care first, such as a cast or splint, and consider surgery when that has not given enough improvement. For some acute fractures, surgery may be recommended straight away. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment, including your history, examination and imaging where needed, establishes the diagnosis. This operation aims to relieve pain and restore normal hand function. It is often offered to athletes who grip tightly, such as baseball players. Return to play was documented for 94.5% of patients. Many are back to sport between 5 and 7 weeks after surgery. We will discuss whether this operation suits you, and decide together. ## Before the operation Before surgery, you will need some imaging so we can plan the operation. This may include an X-ray, an MRI scan (a scan that shows bone and soft tissue in detail) or an ultrasound. Most patients need nothing else. If you have other medical conditions, you may need blood tests or a review with the anaesthetist (the doctor who gives your anaesthetic). Please bring a list of all your current medications to your appointment. Your surgeon will tell you which medications to stop before surgery and when. Do not eat or drink for seven hours before your operation. We ask for seven hours rather than six so we can bring you forward if the theatre list runs early. Arrange for someone to drive you home afterwards. Wear loose, comfortable clothing on the day. ## On the day You will arrive at the hospital's surgical admissions unit. There, staff will check you in and prepare you for theatre. You will then meet the anaesthetist, the doctor who gives your anaesthetic. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. After that, you will be taken into the operating theatre, where the operation is performed. When it is finished, you will wake up in the recovery area. Nurses will monitor you there while the anaesthetic wears off. Once you are stable, you will either go to the ward or go home. Which of these happens depends on the procedure and on your recovery. ## What the operation involves Your surgeon makes a single cut in your palm, on the little-finger side near the base of your hand, directly over the hook of the hamate. The hook is a small curved piece of bone that sits deep in your palm. Through this cut, your surgeon carefully finds the ulnar nerve and artery, two important structures that run right beside the hook, and keeps them safe throughout the operation. Next, your surgeon frees the broken piece of bone from the soft tissue attached to it and removes it. The remaining edge of the bone is then smoothed so your tendons can glide over it without catching. The tendons that bend your fingers run close to this bone, and a rough edge can irritate them, so smoothing it matters. Your surgeon then closes the cut with stitches. A dressing goes over the wound, and we will tell you when it comes off. The operation itself is straightforward from your point of view: you are asleep, the broken piece is taken out, and you wake up in recovery with a padded dressing on your palm. ## After the operation When you wake up, you will be moved to the recovery ward, where nurses will check on you and keep you comfortable. We will give you pain relief to keep things settled, and most people find the discomfort is mild and settles over the first few days. Your hand will have a padded dressing on it, and you can move your fingers gently soon after the operation. This is usually a day case, so you can expect to go home the same day, although occasionally patients stay overnight. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Please arrange for someone to stay with you for the first 24 hours after you get home. ## Recovery Most people find the pain in their palm settles steadily once the broken piece of bone has been removed. The discomfort is usually mild and eases over the first few days. Some swelling and tenderness around the wound is normal. Resting your hand, keeping it raised when you can, and taking the pain relief we give you will help. You will go home with a padded dressing on your palm. Keep it clean and dry, and leave it on until we see you. You can move your fingers gently soon after the operation, and gentle movement helps as things settle. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she will guide your exercises and make any splint you need. At home, you can do light daily tasks with the operated hand once you feel comfortable, but avoid heavy gripping, lifting and sport until your therapist and we clear you. The milestones are simple ones. Once the wound is comfortable and you can grip and turn a steering wheel without protecting your hand, driving is usually fine again; see our page on driving after upper-limb surgery. As the swelling settles and your grip strength returns, you can build back up to manual work, sport and the gym. The final result comes when your pain and strength stop improving. Recovery varies from person to person. Your timeline may differ, and we and your hand therapist will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The main thing we watch for is a problem with the wound itself. This might look like redness that spreads out from the cut, or the area feeling warmer than the skin around it. Some fluid or clear ooze on the dressing can also be a sign. If you notice any of these, call the clinic rather than waiting for your next visit. Pain that does not follow the usual pattern is another thing to flag. The discomfort after this operation is usually mild and settles over the first few days. A deep, throbbing pain that does not ease with simple painkillers, or pain that gets worse instead of better, is worth a phone call. Tell us what you feel and when it started, and we will see you sooner if needed. Because the nerves and blood vessels run close to the bone being removed, changes in feeling or colour in your little finger and ring finger matter too. Numbness, pins and needles, or fingers that look pale or bluish should be reported straight away. Call the clinic during working hours, or go to the emergency department if this happens at night or on a weekend. Some tenderness and swelling around the wound is normal in the early days. But swelling that suddenly increases, or a hand that feels tight and firm rather than just puffy, should be checked. Bring it up with us as soon as you can. If anything about your recovery feels wrong to you, trust that instinct and contact us. It is always easier to check a small worry early than to manage a bigger one later. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if you have a fever, or the wound becomes more red, warm or oozy. Call us if pain suddenly gets much worse. Go to emergency if you have calf swelling or pain, or shortness of breath. Go to emergency if your little finger or ring finger goes numb, changes colour, or you cannot move your fingers. If anything feels wrong, trust that feeling and contact us. --- ### Hook of Hamate Fracture URL: https://www.cqupperlimb.com/education/wrist/hook-of-hamate-fracture/ Region: wrist · condition A hook of hamate fracture happens in a moment. The usual cause is a direct blow to the palm side of your hand, near the base of your little finger. This injury is common in baseball players and golfers, where a bat, club or racquet presses hard into that spot. A sudden force… ## What you're feeling A hook of hamate fracture happens in a moment. The usual cause is a direct blow to the palm side of your hand, near the base of your little finger. This injury is common in baseball players and golfers, where a bat, club or racquet presses hard into that spot. A sudden force through the ligaments and tendons of the palm can also cause it. Straight away, you feel pain on the palm side of your hand, at the base near your little finger. The spot is tender to touch. In most acute fractures, this tenderness is present every time. Pushing or pulling with your hand hurts, so gripping a doorknob, holding a coffee mug or twisting a jar lid becomes difficult. You may notice swelling. The pain is sharp at first, then settles to a deep ache. The first days and weeks can be frustrating. Your hand hurts when you use it, and the ache can disturb your sleep early on. This injury is rare, and it often does not show up on standard wrist x-rays. That means it can be missed at first, especially when the x-rays look normal. If your symptoms match this pattern, a special x-ray view or a CT scan can find the fracture. A CT scan is very accurate for this injury. Some warning signs need urgent care. Go to the emergency department the same day if your hand or arm becomes hot, red, swollen and painful, especially with a fever. Go the same day if you have broken skin over the injury, bone showing, or an obvious deformity. Go the same day if your fingers or hand turn pale, cold, white or blue, or if you suddenly lose feeling or movement. See your GP or ask for a specialist review if your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand. If you cannot reach the clinic after hours or on a weekend, go to your nearest emergency department. ## What's actually happening Deep inside your wrist, on the palm side, sits a small curved bone called the hamate. It has a little hook of bone pointing forward into your palm. That hook is a anchor point for some of the ligaments and muscles that move your little finger, and your finger tendons glide right against it when you grip. When you fall onto your hand or swing a bat, club or racquet, that hook takes the strain. A single hard hit can crack it. Repeating the same swing thousands of times can also wear it down until it breaks, the way a paperclip snaps after being bent back and forth. This bone is small, and only about 2% of wrist bone fractures happen here. The hook has a poor blood supply, and that matters. Bone needs blood to knit back together, like any other tissue. The hook also moves when you grip, because the tendons pressing on it keep the broken ends shifting. A fracture that keeps moving, with little blood flow, often struggles to heal. Doctors call this a nonunion, meaning the bone never knits. If the broken pieces sit in their normal position, the bone can still knit if the hand is kept still early on. If the pieces have shifted apart, or the fracture is found late, simple healing becomes less likely. In that case, treatment usually means either holding the bone together with a small screw, or removing the hook altogether. Removing it sounds drastic, but the hand copes well without this small hook, and many people return to their sport at their previous level. One more thing worth knowing. The rough, unhealed edge of a broken hook sits right against your finger tendons. Over time it can fray them, like a rope rubbing on a sharp rock. If a tendon snaps, the broken hook is removed and smoothed so the tendon can work again. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some hook of hamate fractures heal without an operation, and others need surgery soon, so prompt assessment matters. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic, we take a history, examine your hand, and arrange imaging where it is needed. Because this fracture often hides on standard x-rays, we may use a special x-ray view or a CT scan to see it clearly. If the broken pieces sit in their normal position and the fracture is found early, we may hold your hand still in a splint or cast so the bone can knit. We keep an eye on healing with repeat imaging, and your hand therapist, Ruby Doolan at Extend Rehabilitation, makes any splint you need and guides your return to movement at the right stage. Athletes sometimes choose to keep playing with the fracture and deal with the unhealed piece later, and we will talk through what that means for you. If the pieces have shifted apart, or the fracture is unstable, we may recommend surgery from the start. One option is removing the hook of bone, which lets you return to your sport relatively quickly. Another is holding the bone together with a small screw, which we may suggest for younger patients to preserve grip strength. We aim to protect the nearby nerve and blood supply during any of these operations. The choice between these paths is genuinely shared: sometimes a splint could work, but the pain or the final position of the bone may not suit your hand or your sport. Whichever path you take, the early weeks look similar. We will help you manage the pain, and you protect your hand while it heals. Hand therapy with Ruby starts at the right stage, so your grip and movement come back safely. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## What to expect Healing depends on where you are in the story. If your fracture is found early and the pieces sit in their normal position, keeping your hand still in a splint or cast gives the bone its chance to knit. If the fracture is found late, or the pieces have shifted, the bone may never knit on its own. In that case, surgery usually means either a small screw to hold the bone together or removing the hook altogether. If you have surgery to remove the hook, most people are back to their sport relatively quickly. For high-level amateur athletes, surgery allows return to sport at their preinjury performance level, with normal hand function on testing, less pain, and satisfaction with the result. One professional bowler had satisfactory hand function 2.5 months after the hook was removed. Early and late surgery both lead to return to preinjury levels of activity. Holding the bone together with a screw can also work well, with few problems afterwards, and repair of an unhealed fracture can preserve grip strength and relieve pain completely. Recovery is a gradual return, not a switch. Your hand will ache at first, and the ache settles over weeks. Grip strength comes back as the hand is used again, guided by your hand therapist. Daily tasks like holding a mug or turning a key get easier as the tendons stop being irritated by the broken piece. There are honest risks worth knowing. The hook has a poor blood supply, so slow or failed healing is the main concern. If the bone does not knit, the rough edge can rub on your finger tendons. Tendon rupture in the little finger has happened anywhere from 6 months to 25 years after the original injury, and grip strength afterwards averaged 83% of the other hand. If a tendon does snap, the broken hook is removed and smoothed so the tendon can work again. Surgery itself carries a low risk of minor complications. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone Seek urgent care if you have an open wound over the injury, bone showing, or an obvious deformity. Go the same day if your fingers or hand turn pale, cold, white or blue, or if you suddenly lose feeling or movement. These signs need an emergency department, not a waiting room. For everything else, start with your GP. Ask for a specialist review if the pain is not settling, or if swelling, movement or grip are not improving week on week as the bone heals. This injury hides on standard x-rays, so a normal first result does not rule it out. A CT scan finds it 95% of the time, and getting the diagnosis early protects your grip and your tendons later on. --- ### Intersection Syndrome URL: https://www.cqupperlimb.com/education/wrist/intersection-syndrome/ Region: wrist · condition An overuse tendon problem of the back of the forearm, often confused with de Quervain's — its causes, and how rest, splinting or injection settle it. ## What you're feeling Intersection syndrome causes pain and swelling on the back and thumb side of your forearm, a little way above the wrist (roughly a hand's breadth up from the bony bump on the back of your wrist). It is not pain in the wrist joint itself, but higher up, where the muscles of the forearm cross over one another. The pain is usually worse when you bend your wrist back or move your thumb, and it often comes on after a spell of repetitive activity: rowing, weightlifting, racquet sports, gardening, or a lot of keyboard or wrist-heavy work. Many people notice swelling over the sore area, and some feel or even hear a soft creaking, squeaking or grating when they move the wrist, as if something is rubbing. This is sometimes called a "wet leather" sound. ## What's actually happening On the back of your forearm, two sets of muscles cross over one another like an X. One set runs out to your thumb; the other runs down to power the wrist. At the point where they cross, a few centimetres above the wrist, the tendons slide back and forth past each other inside their smooth sheaths. When you do a lot of repetitive wrist movement, that crossing point gets irritated and inflamed. The lining of the tendon sheaths swells, friction builds up, and the tissues become tender and puffy, causing the pain, the swelling and the creaking. It is an overuse problem, not an injury from a single accident, and it is not the same as de Quervain's, a related thumb-side tendon problem that sits lower down, right at the wrist. Intersection syndrome sits higher. The good news is that the irritated tissue settles down well once the rubbing stops, and the condition does not cause lasting damage in most people. ## What we can do about it Dr Kieran Hirpara guides our approach to managing this condition in our clinic. We start with non-operative care and consider surgery only if symptoms persist despite these measures. Almost everyone gets better without surgery. The mainstays are: - Resting the aggravating activity: the single most important step. Easing off the rowing, lifting or repetitive task for a few weeks lets the inflammation settle. - A wrist splint that holds the wrist slightly bent back. This rests the crossing tendons and is often worn for a few weeks. - Anti-inflammatory tablets or gels (NSAIDs) to calm the pain and swelling. - Ice over the sore area after activity. If things don't settle with those measures, a corticosteroid injection into the tendon compartment (often guided by ultrasound for accuracy) usually brings the inflammation down. For the small number of people whose symptoms keep returning despite all of this, a minor operation to release and clean out the irritated tendon sheath is very effective. It is rarely needed. ## What to expect Most people settle within a few weeks to a couple of months once they rest the activity and use a splint. The outlook is excellent: this is a condition that genuinely gets better, and it does not tend to leave any lasting weakness or stiffness once it has calmed down. The main thing that brings it back is returning to the same heavy or repetitive activity too quickly. Easing back in gradually, and where it applies looking at technique or equipment (for example oar grip in rowers, or bar grip in the gym), helps keep it away for good. ## When to see someone - Pain and swelling on the back of the forearm that doesn't settle after a couple of weeks of rest and a splint. - A creaking or squeaking over the area, or pain that flares every time you go back to your sport or work task. - Symptoms that keep coming back despite resting, worth assessing, as an ultrasound-guided injection may help. - Any fever, hot red skin, or rapidly worsening swelling: see a doctor promptly, as that points to something other than simple overuse. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Intersection syndrome is worth the extra reading mainly because of what it is confused with, it sits a few centimetres from de Quervain's tenosynovitis, is treated differently, and the evidence distinguishing them is genuinely small. ### Where it is, and why that is the whole diagnosis Two muscles running to the thumb cross over the two wrist extensor tendons about four to eight centimetres above the wrist, on the back of the forearm. Friction at that crossing point produces pain, swelling and sometimes an audible or palpable creaking as the wrist moves. The location is the diagnosis. De Quervain's is tender at the wrist itself, over the bony prominence at the thumb side. Intersection syndrome is tender noticeably further up the forearm. Both are provoked by thumb and wrist movement, and both can produce swelling, but the point of maximal tenderness separates them, and it does so reliably enough that imaging is often unnecessary. ### What distinguishes the two populations The direct comparison is small, 80 patients, but informative. Intersection syndrome occurred more frequently in men and in the dominant hand than de Quervain's disease, both across all patients and when peripartum women were excluded, and patients with intersection syndrome presented with a much shorter duration of symptoms [1]. Each of those fits the mechanism. Intersection syndrome is a friction injury from repetitive resisted wrist extension, rowing, weight training, racquet sports, heavy manual work, so it favours the dominant side and an occupationally exposed group. The shorter symptom duration reflects that it tends to arise after an identifiable change in activity rather than accumulating insidiously. The de Quervain's contrast is instructive in the other direction: excluding peripartum women changed the comparison, which underlines how strongly that condition is associated with the postnatal period — an association intersection syndrome does not share. ### Treatment, and an honest statement of the evidence Management is conservative in the great majority: relative rest from the provoking movement, a thumb-spica-style splint, anti-inflammatory measures, and correction of the technique or workload that caused it. Corticosteroid injection into the affected space is used where that fails, and surgical release of the second compartment is reserved for the small number who do not settle. The evidence base for that sequence is thin. The literature consists largely of case series and descriptive reports; there are no trials comparing the options, and the largest comparative study available is the 80-patient series above [1]. The treatment ladder rests on mechanism and clinical experience rather than on demonstrated superiority, which is worth stating plainly rather than implying a firmer foundation than exists. What that means practically is that the strongest thing anyone can offer here is the diagnosis itself. Because the condition is self-limiting once the provoking load is removed, correctly identifying the site, and therefore the movement to modify, does most of the work. --- ### Kienböck's Disease URL: https://www.cqupperlimb.com/education/wrist/kienbocks-disease/ Region: wrist · condition Kienböck’s disease — progressive wrist pain from lunate avascular necrosis; diagnosis and treatment options. ## What you're feeling The pain of Kienböck's disease sits in the middle of the back of your wrist, over a small bone called the lunate. It often appears without any injury at all, though some people remember a knock or repeated strain beforehand. The back of the wrist may also look swollen. Your wrist may feel stiff, and your grip may be weaker than usual. The pain tends to flare with gripping, twisting and loading the wrist, such as carrying shopping, turning a jar lid or pushing up from a chair. Resting the hand usually settles it. Daily tasks that need a firm grip or a bent-back wrist, like using a hammer, wringing out a cloth or holding a steering wheel for long stretches, can become hard or uncomfortable. Kienböck's disease usually shows up between the ages of 30 and 40. It is uncommon in older people, though when it does appear later in life it is more often in women, and in the hand they use most for heavy work. In older people the pain can be quiet or easy to miss, which sometimes delays the diagnosis. The condition usually gets worse slowly over time if left alone, and it can move faster than doctors once thought. Over years it can lead to wear-and-tear arthritis in the wrist. For that reason, your other wrist should also be checked and X-rayed, because the disease can affect both sides. See your GP or ask for a specialist review if the pain is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your hand. Go to your nearest emergency department if you cannot reach the clinic after hours or on a weekend. ## What's actually happening Your wrist is built from eight small bones arranged in two rows. The lunate sits in the middle of the back row, tucked between its neighbours and the end of your forearm bone. It has no muscles attached to it, so it simply moves as the bones around it move. The lunate also has a fragile blood supply. Small vessels enter the bone at each end, and in some wrists only one route brings blood in. When that supply is interrupted, the bone tissue dies. Doctors call this osteonecrosis, which means bone death from lack of blood. This is the core problem in Kienböck's disease. Why the supply fails is not fully settled. A single injury is usually not to blame. The disease often begins gradually, without any fall or accident at all, and problems with blood flow into and out of the bone seem to matter more than wear and tear. Some wrists are also shaped in a way that loads the lunate more heavily than others, which may set the scene. Once the bone is weakened, the consequences follow. The lunate normally acts as a small shock absorber, sharing the load that passes through your wrist every time you grip or push. A dead bone cannot carry that load well. It hardens, then cracks and collapses under pressure. As it loses height, the bones above it sink down, the small joints of the wrist fall out of line, and the ligaments holding everything together get slack. That collapse is what produces the pain, stiffness and weak grip described earlier. Doctors describe the condition in stages, from hardened but intact bone, through collapse of the lunate, to arthritis across the whole wrist. Earlier stages may settle with rest and splinting alone. Later stages, where the bone has collapsed or the joint surfaces are worn, are the ones more likely to need surgery. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment, which covers your history, an examination and imaging where needed, establishes the diagnosis. For earlier stages, we usually begin with non-operative care. This means changing how you use your wrist, wearing a splint or cast to hold it still, and hand therapy. For children and teenagers under 15, we recommend holding the wrist still for at least 6 weeks, then keeping a close eye on it with repeat X-rays, CT and MRI scans. Some wrists settle with this alone, and the condition can run a mild course in some people. When non-operative care has not given enough improvement, we consider surgery. The aim of most operations is to take load off the lunate so it is protected while it heals, or to rebuild the wrist so the worn surfaces are bypassed. In the earliest stages, a keyhole procedure called core decompression relieves pressure inside the bone. Another option is shortening the forearm bone, called a radial shortening osteotomy, which shifts load away from the lunate. A vascularised bone graft moves a small piece of living bone, with its blood supply intact, into the lunate to help it heal. For wrists where the lunate has collapsed substantially or wear-and-tear arthritis has developed, salvage options include removing the row of damaged bones, called a proximal row carpectomy, fusing some of the wrist bones together, or a full wrist fusion. We will talk through which option suits your wrist and your stage, and decide together. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she directs your rehabilitation and makes any splint you need. See your GP or ask for a specialist review if the pain is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your hand. Go to your nearest emergency department if you cannot reach the clinic after hours or on a weekend. ## What to expect Kienböck's disease usually moves slowly, but it does tend to move. Left alone, the lunate can keep breaking down, and the condition can end in arthritis across the whole wrist. It can also progress faster than doctors once thought, and the smooth surface of the lunate can wear away early on. That said, not every wrist follows the same path. Some people have the disease without any pain at all, and X-ray changes do not always match how the wrist feels. A wrist can look worse on a scan while feeling better, which is why your symptoms and what your hand can do matter more than the pictures. With treatment, the outlook is steadier. Earlier stages often settle with rest, a splint or cast, and changing how you use your wrist. Children and teenagers respond well to non-operative care. Where surgery is needed, the aim is honest: operations are offered to reduce pain and keep your wrist moving, not to promise the lunate will be saved. Radial shortening osteotomy gives decade-long improvement in 75% of patients, and its effect is maintained for more than 10 years. Vascularised bone grafting and core decompression also show results that last a long time. For wrists where the lunate has collapsed or arthritis has set in, removing the row of damaged bones or fusing the wrist can still give a wrist that works, though grip strength and comfort vary from person to person. If it is left alone, the likely story is gradual worsening: more stiffness, a weaker grip and pain that flares with loading the wrist. Some wrists stay mild for years. Others do not. Because the course is hard to predict, this condition is worth keeping an eye on rather than ignoring, even when the pain is tolerable. There are no emergency signs specific to Kienböck's disease itself, but if your hand ever becomes hot, red, swollen and painful, especially with a fever, go to your nearest emergency department the same day. See your GP or ask for a specialist review if the pain is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your hand. ## When to see someone See your GP or ask for a specialist review if you have pain in the middle of the back of your wrist that is not settling, is getting worse over weeks, wakes you at night, or stops you working or using your hand. The same applies if the back of your wrist is swollen, your grip feels weaker than usual, or your wrist is stiff and hard to move. These signs matter because the condition tends to progress, and earlier review keeps more options open. Ask for a specialist review too if you are over 60 and have wrist pain that is vague or easy to miss, since the diagnosis is often overlooked in older women. There are no emergency signs specific to Kienböck's disease itself, but if your hand ever becomes hot, red, swollen and painful, especially with a fever, go to your nearest emergency department the same day. If you cannot reach the clinic after hours or on a weekend, go to your nearest emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Kienböck's disease is worth the extra reading because of an uncomfortable finding that runs through its literature: the operations performed for it improve symptoms without clearly changing what the disease does to the bone. ### Surgery relieves pain; it has not been shown to alter the disease The most direct comparison available followed patients long-term after radial osteotomy against those treated non-operatively. Radial osteotomy was not superior to non-operative treatment in terms of disease progression by Lichtman stage, but it did produce better outcomes for pain and range of wrist motion [1]. Read that as two separate claims, because it is. The operation helps how the wrist feels and moves. It has not been demonstrated to stop the lunate collapsing. A later long-term comparison of non-operative treatment against vascularised bone grafting reached a similarly measured conclusion [2]. This is the single most useful thing to understand before consenting to surgery here. If an operation is offered as a way to save the lunate, that framing is ahead of the evidence. If it is offered as a way to reduce pain and preserve motion in a wrist that hurts now, that is supported. ### Why the radiographs and the symptoms drift apart Kienböck's is defined radiologically, the Lichtman stages describe sclerosis, then collapse, then carpal disintegration, and it is natural to assume the pictures track the pain. They frequently do not. Wrists progress radiologically while feeling better, and wrists hurt persistently at early stages. That mismatch is why "the X-ray looks worse" is not by itself a reason to operate, and why serial imaging is a poor way to decide. The decision belongs to symptoms and function. ### The operations are numerous, which is itself informative Radial shortening, capitate shortening, vascularised bone grafting, core decompression, partial fusions, proximal row carpectomy, the number of described procedures is large. A systematic review of capitate shortening osteotomy is among the more recent additions [3]. In surgery, a long list of competing operations for one condition is usually a sign that none of them is decisively better. That is the honest reading here, and it explains why two reasonable surgeons may propose different procedures for the same wrist without either being wrong. The unifying logic behind most of them is mechanical: reduce the load passing through the lunate, either by shortening the radius so the ulna carries more, or by shortening the capitate so less force is transmitted down onto the lunate. They are attempts to unload a bone whose blood supply is failing, not attempts to restore that blood supply, with the partial exception of vascularised grafting, which tries to do both. ### What this means for you Three practical consequences. Watchful waiting is a legitimate option rather than a failure to act, particularly if pain is tolerable. The purpose of any operation should be stated in terms of symptoms, not stage. And because no procedure has separated itself from the others, being told why this operation suits your wrist, your ulnar variance, your stage, your demands — matters more here than in most of hand surgery. --- ### Carpal Fractures Other Than the Scaphoid URL: https://www.cqupperlimb.com/education/wrist/other-carpal-fractures/ Region: wrist · condition These injuries usually happen in a fall onto an outstretched hand, a direct blow to the wrist, or a sudden heavy load through the hand. Some people feel or hear a snap or click at the moment of injury. High-energy impacts, like a fall from height or a road crash, can break more… ## What you're feeling These injuries usually happen in a fall onto an outstretched hand, a direct blow to the wrist, or a sudden heavy load through the hand. Some people feel or hear a snap or click at the moment of injury. High-energy impacts, like a fall from height or a road crash, can break more than one of the small wrist bones at once. Straight away, the wrist hurts. There is usually swelling and bruising around the injured area. The pain tends to sit in one spot you can point to, and pressing on that spot is the most reliable sign something is wrong. Moving the wrist, gripping, or pushing through the hand makes it worse. If the injury is more severe, the wrist may look obviously out of shape, and you may not want to use the hand at all. In the first days to weeks, the pain is often there at rest and can wake you at night. Everyday tasks that load the wrist, like pushing up from a chair, carrying shopping, or turning a door handle, hurt. The pain usually settles gradually as the bone heals, though it can stay sore with gripping or twisting for some time. One thing worth knowing: these breaks are easy to miss. They are uncommon, and the small bones overlap each other on plain X-rays, so a normal X-ray does not always rule one out. Some of these fractures, like those of the trapezium or trapezoid, are hard to see on standard images at all. If your wrist is still painful after an injury, your surgeon may arrange a scan such as an MRI or CT to look more closely. Some warning signs need urgent care. Go to the emergency department the same day if your hand or arm becomes hot, red, swollen and painful, especially with a fever, or if fingers or the hand turn pale, cold, white or blue, or if you suddenly lose feeling or movement after the injury. If symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using the hand, see your GP or ask for a specialist review. ## What's actually happening Your wrist is not one joint. It is a small cluster of eight bones sitting in two rows between your forearm and your hand. The bones in each row are tied together by strong straps of tissue called ligaments, and the whole cluster moves as a linked system when you bend, straighten or turn your wrist. When one of these bones breaks, or the ligaments holding the rows together tear, that linked system stops working smoothly. The wrist loses its normal rhythm, so loading it hurts and gripping feels weak or unreliable. Most of these breaks happen in a fall onto an outstretched hand. The force funnels down through the hand into one small bone, and that bone cracks. Sometimes the force tears ligaments instead of, or as well as, breaking bone. The triquetrum, on the little-finger side of the wrist, is the one that breaks most often. The others, the lunate, capitate, trapezium, trapezoid and pisiform, break far less often. Think of the wrist like a stack of building blocks held together with rubber bands. If one block cracks but stays in place, the stack can still hold weight while the crack knits back together. Bone heals this way: the two edges grow new bone across the gap, slowly firming up over weeks. But if a block shifts out of line, or the rubber bands holding the stack together are torn, the stack can no longer line itself up. The bones may slide in ways they were never designed to, and that is what causes lasting trouble if it is not corrected. This is why the pattern of the break matters. A clean break that has not shifted can often settle in a cast while it heals. A break that has moved out of place, or one with torn ligaments beside it, may need surgery to hold the pieces still while they knit. Getting the picture early matters too, because some of these injuries are easy to miss at first and cause more trouble later if they go untreated. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some of these breaks heal without an operation, and others need surgery soon after the injury, so prompt assessment matters. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a history, examine your wrist, and arrange imaging where it is needed to work out which bone is broken and whether it has shifted. If the break is stable and the pieces have not moved out of place, we will usually treat it without surgery. That means a splint or cast to hold the wrist still while the bone knits, often for about 4 weeks for some of these injuries. We may check healing with repeat imaging along the way. As comfort allows, you start gentle stretches and movement to keep the wrist from stiffening up. A hand therapist guides this staged return to movement and makes any splint you need. Surgery is recommended from the outset when the broken pieces have shifted, when the wrist bones or ligaments are unstable, or when the injury pattern needs the bones held precisely while they heal. High-energy injuries that break several bones or tear ligaments often fall into this group. The aim is to realign the bones and hold them still so they can heal in the right position. Sometimes there is a genuine choice: a break can heal in a cast, but the pain or the final position of the bone may not suit your work or sport, and we will talk that through with you. Whichever path you take, the first weeks are about comfort and protection. Pain relief keeps you comfortable while the swelling settles. You keep to the splint or cast and the plan until we confirm on X-ray that the bone has healed, even if the wrist starts to feel better before that. Hand therapy at the right stage helps you regain movement and strength without loading the injury too soon. ## What to expect Healing is measured in weeks and months, not days. For some of these breaks, the wrist can feel better and work well long before an X-ray shows the bone has fully knitted. Keep to the splint or cast and the plan until we confirm on X-ray that the bone has healed, even if your wrist feels fine. If your break is healing in a cast or splint, the bone usually knits over several weeks. One reported case of a scaphoid and trapezium break together showed the bones united after six weeks, with full wrist and thumb movement and normal grip by sixteen weeks. As the weeks pass, the pain settles first, then movement and strength return with hand therapy. Most people get back to daily tasks as comfort allows, and heavier work or sport comes later once the bone is solid. If you have surgery, the bone still needs time to knit, but the pieces are held still while they do. Recovery stretches over months. In one case of a combined scaphoid and lunate fracture, both bones healed with wrist movement and grip strength preserved at 10 months after surgery. Another complex injury around several wrist bones left a fair result, scoring 75 out of 100 on a wrist function scale at four years, while a similar injury scored 85 out of 100 at two years. A trapezoid fracture treated without surgery left the patient pain-free with full wrist motion at 12 months. Most isolated breaks like these heal well. Things that can go wrong include the bone failing to knit, knitting in a poor position, or the wrist going on to stiffen. These risks rise when several bones or ligaments are injured at once, which is why the pattern of your break shapes the plan. If a break is missed or treatment is delayed, the bone may fail to heal, lose its blood supply, or the wrist bones may become unstable. That is why we check healing along the way and ask you to come back if symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using the hand. ## When to see someone Seek urgent care if your wrist looks obviously out of shape, if there is broken skin over the injury, or if you suddenly lose feeling or movement in your hand after an injury. These injuries can also come with nerve or blood vessel trouble, so numbness, tingling, or a hand that turns pale or cold needs same-day assessment. See your GP or ask for a specialist review if the pain is not settling, or if swelling, movement or grip are not improving week on week as the bone heals. Because these breaks are easy to miss on a first X-ray, a wrist that stays sore after an injury deserves a closer look. Early scans can pick up what plain images miss, and prompt review helps avoid the slower-healing and instability problems that come with a delayed diagnosis. --- ### Partial Wrist Fusion URL: https://www.cqupperlimb.com/education/wrist/partial-wrist-fusion/ Region: wrist · operation Patient-facing topic for four-corner and capitolunate (two-corner) fusion of the wrist — joint-preserving alternative to total wrist fusion that retains some bending motion. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment, including your history, an examination and imaging where needed, establishes what is causing your wrist pain. A partial wrist fusion joins together only the damaged wrist bones, leaving the healthy joints moving. We usually suggest it when wear-and-tear arthritis is limited to part of the wrist, and often after other treatments such as hand therapy, splinting, anti-inflammatory medicine or injections have not given enough relief. The aim is to remove the worn joint surfaces that hurt, while keeping as much wrist movement, grip strength and stability as we can. Total wrist fusion is kept for exceptional circumstances. Whether this operation suits you depends on which joint surfaces are affected, and we will talk that through with you as a shared decision. ## Before the operation Before surgery, you will need some imaging so we can plan the operation. This usually includes X-rays, and sometimes an MRI scan, which uses a strong magnet to show the wrist bones, ligaments and joint surfaces in detail. On the day, stop eating and drinking seven hours before your operation. We ask for seven hours rather than six so your time can be brought forward if the theatre list runs early. Bring a written list of your current medicines and wear comfortable clothing with a loose sleeve. Arrange for someone to drive you home afterwards. If you have other medical conditions, you may need blood tests or a review with the anaesthetist, the doctor who gives the anaesthetic. ## On the day You will arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist, the doctor who gives the anaesthetic. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. When it is finished, you wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves A partial wrist fusion is done through one cut over the back of your wrist. Through this cut, your surgeon reaches the small wrist bones that form the worn-out joint. The damaged joint surfaces are cleared away so healthy bone can grow together. The bones that are causing your pain are then joined to each other. Small metal screws hold them in the right position while they heal, and the surgeon packs bone around the joint to help it knit. Which bones are joined depends on where your arthritis is. If one damaged bone is beyond repair, it may be taken out and the remaining bones joined in its place. The healthy joints next to the fusion are left alone so your wrist keeps some movement. Once the bones are held firmly, the wound is closed with stitches and covered with a dressing. The dressing stays on for about 10 days, and your surgeon will tell you when it comes off. ## After the operation You will wake up in the recovery area, where nurses watch you closely while the anaesthetic wears off. Most patients stay one night in hospital after this operation, though some are able to go home the same day. Your wrist will be supported in a splint or cast, and we will give you medicine to keep you comfortable. If you had a nerve block, your hand may feel numb or heavy for the first 24 hours; this is expected. Once it wears off, call the clinic if you have numbness or cannot move your fingers. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Please have someone stay with you for the first 24 hours. ## Recovery For the first few days your wrist will be sore and swollen, and your hand may feel stiff. This settles gradually. Keeping your hand raised on pillows, even while you sleep, helps the swelling go down. The medicine we give you keeps you comfortable while the worst of the soreness passes. Your wrist will be supported in a splint or cast while the bones knit together. Your hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she will guide your exercises and make any splint you need. Early on, the focus is on gentle movement of your fingers, elbow and shoulder so they do not stiffen while the wrist rests. As the weeks pass, your therapist will add exercises to build grip strength and, once the fusion has healed, to regain whatever wrist movement is safe for you. Everyday tasks take some planning at first. You will need help with shopping, cooking and anything that needs two hands or a firm grip. Most people find sleeping easiest with the arm propped on pillows rather than lying on it. You cannot drive until the cast is removed and your surgeon clears you; see our page on driving after upper-limb surgery. Recovery varies from person to person. Some wrists settle quickly, others take longer to feel strong and comfortable. Your surgeon and your hand therapist will guide you at each visit and let you know what to expect next. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Sometimes the bones do not knit together as planned. You might notice a deep, aching pain in the wrist that does not settle, or a grinding feeling when you move. If the pain keeps getting worse despite your pain medicines, call the clinic the same day. Otherwise, bring it up at your next review. If the bones still will not join, further surgery may be needed to help them heal. The metal screws used to hold the bones can sometimes cause trouble. A screw may shift position, or press on nearby skin or tendons. You might feel a sharp edge under the skin, a clicking feeling, or pain over the metal. Most hardware never needs to come out, but if it keeps hurting, a small operation to remove it can help. Mention this at your review. Rarely, the wrist can develop carpal tunnel syndrome after surgery. This feels like tingling, numbness or burning in the fingers, worse at night. Tell your surgeon if this happens, as a small release operation can treat it. Infection is uncommon but needs quick attention. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it. Some wrists stay painful even after the bones have joined well. A few people find the wrist still aches with activity, or that they need regular pain medicine. If this happens, your surgeon will talk through the options with you, which can include further surgery. Very occasionally, a partial fusion does not relieve the pain and the whole wrist is later fused instead. This is a bigger operation that removes all wrist movement, but it usually takes away the pain. The complications table on this page lists typical rates if you want the specifics. ## When to call us We would rather hear from you than have you worry at home. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it, or if pain keeps getting worse despite your pain medicines. Go to the emergency department if you have calf swelling or pain, shortness of breath or chest pain, as these can be signs of a blood clot. Go to the emergency department if your fingers or hand turn pale, cold, white, blue or dark. Once the nerve block has worn off, after about 24 hours, call the clinic if you have numbness or cannot move your arm, hand or fingers. If you cannot reach us out of hours or on a weekend, go to your nearest emergency department. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Wrist Osteoarthritis page. --- ### Proximal Row Carpectomy URL: https://www.cqupperlimb.com/education/wrist/proximal-row-carpectomy/ Region: wrist · operation A wrist salvage operation for an arthritic wrist (SLAC/SNAC) that keeps useful movement — how it works, recovery, and how it compares with fusion. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take your history, examine your wrist and arrange imaging where needed to work out what is causing your pain. For a long-standing problem like wrist arthritis, we usually try non-operative care first: changing how you use your hand, hand therapy, and splinting. We consider surgery when that has not given you enough improvement. This operation is called a proximal row carpectomy. It means removing two or three of the small bones on the thumb side of your wrist that have been worn down by arthritis. It is typically offered for wear-and-tear arthritis of the wrist, including a pattern called scapholunate advanced collapse, and for advanced Kienböck disease, where one of the small wrist bones loses its blood supply. We recommend it when the smooth cartilage on the remaining wrist surfaces is still healthy, which we check on your scans. The aim is to relieve your pain while keeping your wrist moving. Most people keep useful wrist motion and grip strength, and many return to work. ## Before the operation Before your operation, we ask you to stop eating and drinking seven hours before your operation time. We ask for seven hours rather than six so your surgery can be brought forward if the theatre list runs early. Your surgeon will tell you which of your usual medications to stop and when, and it helps to bring a written list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing on the day. Most people need no other preparation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. We use X-rays and MRI scans of your wrist to plan the operation and check the health of the cartilage we rely on. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist, who looks after your anaesthetic and pain relief. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief; the anaesthetist will discuss this with you on the day. You are then taken into the operating theatre, where the operation is performed. When it is finished, you wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Once you are stable, you either go to a ward or go home, depending on the operation and how your recovery is going. ## What the operation involves Your surgeon makes a single cut over the back of your wrist, in line with your arm. Through this cut, your surgeon reaches the wrist joint and removes the two or three small bones that have been worn down by arthritis. This leaves a new, simpler joint between your wrist and forearm, where healthy cartilage on the remaining surfaces takes over the job of the removed bones. One important part of the operation is protecting a strap of tissue that runs across the wrist and helps hold it steady. Your surgeon keeps this strap intact, because it supports the wrist as it heals and moves. The cut is then closed with stitches. A dressing goes over the top, and this stays on for about 10 days. ## After the operation You wake up in the recovery area, then move to a ward. Most patients stay one night in hospital after this operation, though some are able to go home the same day. Nurses will keep you comfortable with pain relief, and you can tell them at any time if your pain is not controlled. Your wrist will be in a soft dressing. You may also have a sling, or a half plaster along the front of your forearm; some people have one or both, some have neither. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. You can get up and walk around as soon as you feel steady. Please arrange for someone to stay with you for the first 24 hours. ## Recovery For the first few days your wrist will be sore and swollen, and the back of your hand may feel bruised and tight. Rest, keeping your hand raised on pillows, and the pain relief you have been given all help. The swelling usually settles gradually over the following weeks. You may go home with a sling, a half plaster along the front of your forearm, both, or neither. Whichever you have, you can get up and move around as soon as you feel steady. You will use your non-operated hand for washing, dressing and meals, and you will need help with heavier household jobs at first. Keep the dressing dry and intact until we review it. Hand therapy starts soon after surgery with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she guides your exercises and makes any splint you need. Early on, the focus is gentle movement and settling the swelling. As pain eases, your exercises build towards gripping, lifting and using your hand for daily tasks. Many people notice the wrist moves more freely and daily activities feel easier as the weeks pass. Once you can grip and use your hand without pain, you can take on more: desk work and light tasks first, then heavier work, sport and gym activity later in your recovery. If you want to drive, wait until you are out of any sling or plaster, can hold the wheel with both hands and make an emergency stop, and are off strong pain medication. See our guide on driving after upper-limb surgery. Recovery varies from person to person. Your timeline may differ, and we will guide you along the way. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. This operation avoids some problems other wrist operations carry. Because no bones are joined together, the bones cannot fail to heal. You also will not need another operation to take out any metal, because none is put in. Overall, this operation carries fewer surgical problems than the main alternative, a partial wrist fusion. The main thing to watch over the years is wear-and-tear arthritis in the part of the wrist that is left. You might notice aching or stiffness that slowly builds again, or a grinding feeling when you move the wrist. If this happens, bring it up at your next review. If arthritis in that joint becomes painful enough, further surgery can be considered, including stiffening the whole wrist. Grip strength after this operation is usually somewhere between 60 and 80% of what a normal wrist has. Most people find this is enough for daily tasks, but it is worth knowing before you plan a return to heavy work. Some problems need quick action. Go to the emergency department if your fingers or hand turn pale, cold, white, blue or dark, as this can be a sign of a circulation problem. Call the clinic the same day if you have a fever, if redness spreads out from the wound, or if fluid or pus leaks from it. Call the clinic the same day too if your pain keeps getting worse despite your pain medicines. If you cannot reach the clinic, out of hours or on a weekend, go to your nearest emergency department. Numbness or weakness in the first 24 hours after a nerve block is expected and is not a problem. Once the block has worn off, call the clinic if your hand stays numb or you cannot move your fingers. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems after this operation are rare, but a few signs need quick action. Go to the emergency department if you have swelling or pain in your calf, or shortness of breath or chest pain, as these can be signs of a blood clot. Go to the emergency department too if your fingers or hand turn pale, cold, white, blue or dark. Call the clinic the same day if you have a fever, if redness spreads around your wound, or if fluid or pus leaks from it. Call the clinic the same day as well if your pain keeps getting worse despite your pain medicines. Once your nerve block has worn off, usually within about 24 hours, call the clinic if your hand stays numb or you cannot move your fingers. If you cannot reach the clinic, out of hours or on a weekend, go to your nearest emergency department. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the SLAC and SNAC Wrist page. --- ### Scaphoid Fixation URL: https://www.cqupperlimb.com/education/wrist/scaphoid-fixation/ Region: wrist · operation Percutaneous and open compression-screw fixation of scaphoid fractures. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. The scaphoid is a small bone near the base of your thumb, on the thumb side of your wrist. Scaphoid fixation means holding the broken bone still with a small screw so it can heal. We usually suggest it when the break has shifted out of place, or when the bone is slow to heal or has failed to heal at all. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic visit we take a history, examine your wrist and arrange scans if they are needed. A cast is often tried first for breaks that have not shifted. Surgery may be recommended straight away for some injuries, and it is also considered when a cast has not given enough healing. The aim is a wrist that heals well, moves well and bears load without pain. ## Before the operation In the days before surgery we confirm the plan with you and check which scans are needed. Most people will already have had X-rays, and some will need an MRI or ultrasound scan so we can see the break clearly before we operate. You will be given instructions about fasting: no food or drink for seven hours before your operation time. We ask for seven hours rather than a shorter period so that we can bring you forward if the theatre list runs early. Some medications may need to be paused, and we will tell you which ones and when. Bring a list of everything you take. Arrange a lift home, as you will not be able to drive yourself. Wear loose, comfortable clothing. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You come to the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You meet the anaesthetist, who reviews your health and answers any last questions. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. You wake up in the recovery area, where nurses watch over you while the anaesthetic wears off. Your wrist may be supported, and you may feel some discomfort as the numbness settles. Once you are stable, you either go to a ward or go home the same day, depending on the procedure and how your recovery is going. Because you have had a general anaesthetic, you will need your arranged lift home and should rest for the remainder of the day. ## What the operation involves There are two ways we can reach the broken bone, and we choose the one that suits your fracture. For a break that has not shifted out of place, we can use a percutaneous approach. This means the screw is passed through the skin without a formal cut. For a break where the pieces need to be seen and moved back into line, or where a bone graft is being added, we make a single cut over the wrist and work through that. Once we can see the bone, we hold the fracture with a screw passed down the length of the scaphoid. The screw squeezes the broken pieces together so they cannot move while they heal. Where the break is old, has not healed, or has lost bone, we add a bone graft to fill the gap and encourage healing. Where the blood supply to the broken piece is poor, we can use a vascularised bone graft instead. This is a small piece of bone moved with its own blood vessels still attached, so it brings a fresh blood supply with it. We choose between these options based on what your scans show. We close the wound with stitches. You will have a dressing over the wrist, and we ask you to leave it in place for about 10 days. ## After the operation Most patients stay one night in hospital after this operation, though some are able to go home the same day. You will wake up in the recovery ward, where nurses keep an eye on you while the anaesthetic wears off. Your wrist will be supported in a splint or cast, and there will be a dressing over the wound. Pain is usually manageable with simple measures, and we will make sure you are comfortable before you leave. You can move around as soon as you feel able, though take it gently for the first day or two. Please arrange for someone to stay with you for the first 24 hours after you get home. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. ## Recovery For the first few days your wrist will be sore and may be swollen. Simple pain relief and rest usually settle this. Keeping your hand raised when you are sitting or lying down helps the swelling go down. The discomfort eases steadily as the days pass. Your wrist will be in a splint or cast, so you will need help with some daily tasks at first. Dressing, cooking and carrying things with one hand take a little planning. You can move around the house as soon as you feel able, though take it gently for the first day or two. Once the dressing comes off at your review, your hand therapist Ruby Doolan at Extend Rehabilitation will guide your exercises and fit any splint you need. Hand therapy helps your wrist regain movement and grip strength as the bone heals. You will not drive while the cast is on. Once the cast is removed and your surgeon clears you, you can read more on our page about driving after upper-limb surgery. You can return to work and other activities as your wrist allows, building up gradually. Heavier tasks and sport come back once the bone has healed and your grip feels strong without pain. Everyone heals at a different pace, and your timeline may differ from what we describe. Your surgeon and your therapist will guide you at each review, and will let you know when it is safe to do more. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The main thing we watch for is the bone failing to heal, or healing much more slowly than expected. You might notice a deep, aching pain in the wrist that does not settle the way a healing break usually does, or tenderness in the same spot near the base of your thumb. Some people feel a grinding sensation when they move the wrist or put weight through the hand. If the bone has not joined after a reasonable time, we will see it on your scans and talk through the next steps with you. A break that is not treated for four weeks or longer is harder to heal, and breaks near the end of the bone closest to the forearm are the hardest of all. This is why we ask you to come in promptly if you injure your wrist, and why we keep a close eye on how your healing is progressing. If you have surgery for a bone that failed to heal, we may use a graft with its own blood supply to bring fresh blood to the area. Problems from this type of graft are uncommon. The main one worth knowing about is a patch of numbness or pins and needles on the back of the thumb side of the wrist, which in most cases is temporary. If you notice this, mention it at your next review. If the bone cannot be saved, some people go on to have the broken pieces removed and the remaining wrist bones joined together. This settles pain for many people, and the result holds up over many years rather than wearing off. If you notice pain that is getting worse rather than better, new swelling, or a wrist that will not bear load, contact our clinic rather than waiting for your next appointment. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if your pain is getting worse instead of better, or if new swelling will not settle. Call us if you notice redness, warmth or discharge around the wound, or if you feel feverish. Call us if your fingers or thumb become numb, tingly or pale, or if you cannot move them. Go to emergency if you have sudden severe pain, calf swelling or pain, or shortness of breath. If your cast feels too tight, or your wrist pain does not ease the way a healing break usually should, contact our clinic rather than waiting for your next appointment. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Scaphoid Fracture page. --- ### Scaphoid Fracture URL: https://www.cqupperlimb.com/education/wrist/scaphoid-fracture/ Region: wrist · condition Scaphoid fractures — recognition, the high non-union risk, casting and percutaneous/open fixation. ## What you're feeling A scaphoid fracture usually happens when you fall onto your outstretched hand, or during sport. The scaphoid is a small bone on the thumb side of your wrist, just below the base of your thumb. The break often comes from a low fall from standing height, though in men it more often follows a harder impact such as sport or a car crash. Some people feel nothing more than a sharp pain at the moment of injury. Straight away, the thumb side of your wrist hurts. There may be swelling and bruising on that side. The spot just below the base of your thumb, a small hollow called the anatomical snuffbox, is often tender to press. Your wrist may feel stiff, and it may hurt to bend it fully, to lean on it, or to load it in extreme positions. Pinching your thumb and index finger together, or pushing along the length of your thumb, can also hurt. These signs can be surprisingly subtle. The swelling in that hollow may be slight, and some people can still move the wrist well enough to think it is only a sprain. That is part of why scaphoid fractures are missed. Up to 30% to 40% do not show on the first X-rays, and some are only confirmed when the wrist is examined and imaged again, most often at 10 to 14 days after injury. Over the first days to weeks, pain is usually worst early on. Moving the wrist, gripping, or pushing up from a chair on that hand will hurt. Night-time aching is common in the first days. The pain generally settles as healing begins, though tenderness in that hollow below the thumb can linger into the second week. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. If you cannot reach the clinic, go to your nearest emergency department. ## What's actually happening The scaphoid is a small, curved bone on the thumb side of your wrist. It sits inside the wrist joint itself, and it links the two rows of small bones that make up your wrist. Think of it as the connector between the front and back of a train: when it is whole, both halves bend and straighten together smoothly. When it breaks, the two halves of your wrist can start moving out of step with each other. Most breaks happen across the middle of the bone, called the waist. That is where the bone takes the biggest bending force when your wrist is forced backwards in a fall. About 70% to 80% of scaphoid fractures happen at the waist. The rest happen closer to your forearm or closer to your thumb. This bone has an unusual blood supply. Blood flows into it from the far end, near your thumb, and travels backwards along the bone. A break can cut off that supply to the piece of bone nearer your forearm. Without blood, that piece struggles to heal. This is why where the break sits matters so much, and why some fractures are treated differently from others even when they look similar on an X-ray. Bone heals by knitting back together, the same way a broken arm does. New bone forms across the break until the two pieces are one again. But the pieces must be held still and well supplied with blood for that to happen. If the break is shifted out of place, or if the two pieces move against each other as you use your wrist, the bone may not knit. If it does not knit, the wrist can slowly wear down over years, because the two rows of bones keep working out of step. That is the mechanical problem in a nutshell: a broken connector in a joint that depends on it. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some scaphoid fractures heal well without an operation, and others need surgery soon after the injury, so prompt assessment matters. We look at where the break sits, whether the pieces have shifted out of place, and what your hand needs to do for work and sport. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. If your break is stable or has barely moved, a cast or splint is often the right choice. It holds the bone still while it knits, and we check healing with repeat imaging along the way. Breaks that are found within 6 months of the injury can still heal with casting alone, even when the diagnosis came late. Once the bone has knitted, a hand therapist guides your return to movement, stage by stage. One caution from the evidence: anti-inflammatory pain tablets taken within the first month have been linked to a higher chance of the bone failing to knit, so we will talk with you about pain relief that does not interfere with healing. Surgery is recommended from the outset for some injuries, not as a fallback. Breaks near the end of the bone closest to your forearm often fail to knit in a cast, operating on them heals them far more reliably. Breaks where the pieces have shifted, or where the bone is unstable, are also treated surgically so the pieces are held in the right position while they heal. A small screw holds the bone still from inside, which lets some people stop wearing the cast sooner and get back to work faster, around 7 weeks sooner on average. For others the choice is genuinely shared: a stable break can heal in a cast, but that means more weeks in a cast and a slower return to work, and surgery carries its own small risks. We weigh those trade-offs together. Whichever path you take, the first weeks look similar. Pain relief keeps you comfortable while the bone starts to knit. Protecting the wrist means following the immobilisation plan closely, because movement between the broken pieces is what stops healing. Hand therapy with Ruby Doolan at Extend Rehabilitation begins at the right stage, once healing is secure enough. She directs your exercises and makes any splint you need. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## What to expect Healing depends on where the break sits and how soon treatment starts. Fractures treated within 4 weeks of injury knit more reliably than those treated later, and breaks treated more than 31 days after the injury have a higher chance of failing to knit. In a cast, the bone is held still while new bone forms across the break. With surgery, a small screw holds the pieces together from inside, and some people stop wearing the cast sooner and return to work around 7 weeks sooner on average. For stable breaks that have barely moved, both paths can lead to a wrist that works well, and there is no proven long-term advantage of one over the other. The first weeks are much the same either way. Your wrist is protected, pain settles gradually, and you avoid loading the hand. As the bone knits, a hand therapist guides your return to movement and grip, stage by stage. Most people are back at daily tasks before they are back at heavy work. Sport comes last, once healing is confirmed and strength has returned. If the bone knits, virtually all wrists end up with a good outcome, even if the bone heals in a slightly altered shape. The main thing that can go wrong is slow or failed healing, called nonunion. This happens in more than 10% of fractures treated with surgery, and it is more likely when treatment starts late or when the break is near the end of the bone closest to your forearm. If the bone does not knit, the wrist can slowly develop wear-and-tear arthritis over years. Among people whose unhealed fractures were never treated, arthritis had developed in 97% of those injured five years or more earlier. A healed fracture can also re-break: one documented case re-fractured within 7 months of healing. Stiffness is common while the wrist is held still, and it usually improves with therapy once the bone is secure. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. If you cannot reach the clinic, go to your nearest emergency department. ## When to see someone Seek urgent care if your wrist is obviously out of shape, if there is an open wound over the injury, or if your fingers turn pale, cold, white or blue. Sudden loss of feeling or movement in the hand after an injury also needs the emergency department the same day. For most scaphoid injuries the picture is quieter, and that is exactly the trap. The wrist may still move, and the swelling can be slight. If your pain is not settling, or if swelling, movement or grip are not improving week on week as healing progresses, see your GP or ask for a specialist review. Symptoms that get worse over weeks, wake you at night, or stop you working or using your hand also deserve a proper look. If you cannot reach the clinic, go to your nearest emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Scaphoid fracture is worth the extra reading because where the break sits along the bone matters more than almost any other feature, and because the argument for operating is not the one most people assume. ### Position on the bone changes the risk sevenfold The scaphoid receives most of its blood supply through vessels entering near its far end, so blood travels backwards along the bone towards the proximal pole. A fracture across the waist interrupts that supply to everything beyond it. The consequence is quantified. Amalgamating published series, 34% of acute proximal scaphoid fractures progress to nonunion when managed non-operatively, and the relative risk of nonunion for these fractures is 7.5 compared with more distal fractures treated the same way [1]. That is why two fractures which look similar on a film can carry entirely different recommendations. A distal fracture in a cast has a strong chance of healing. A proximal pole fracture treated identically fails to unite in about a third of cases. ### Surgery lowers the nonunion rate but does not improve the destination For the common waist fracture, comparing surgery with cast treatment produces a result worth reading carefully. Surgery gave a nonunion rate three times lower, a quicker return to function, and transiently better grip strength and range of movement, but was associated with more complications. There were no significant differences in pain, tenderness, cost or functional outcome [2]. So the operation buys reliability of union and speed of recovery, at the cost of surgical complications, and the two groups converge on the same place. That makes it a decision about how much a faster, more certain path is worth to a particular person, a manual worker or an athlete weighs those months differently from someone who can accommodate a cast. ### Diagnosis is where most of the harm is avoided Because a missed scaphoid fracture is the one that becomes a nonunion, the diagnostic pathway matters. Anatomical snuffbox tenderness was the most sensitive clinical test, and combining tests improved the post-test probability of fracture, which can be used to limit unnecessary immobilisation, hospital visits and imaging [3]. That last clause is the useful one. Combining examination findings is not only about catching fractures; it also identifies the people who can safely stop wearing a cast, which is why a structured reassessment is worth attending even when the wrist feels better. ### For an established nonunion, the fancier graft is not the better graft Where a fracture has failed to unite, the standard treatment is bone grafting, and a vascularised graft, one brought with its own blood supply, is intuitively superior. The evidence does not support that. Current evidence suggests vascularised bone grafting does not yield significantly superior results to non-vascularised grafting in scaphoid nonunion, though the authors note potential selection bias reduces certainty [4]. The union figures are close: 84% for vascularised and 80% for non-vascularised grafts, with considerable variation between reports attributable to patient, fracture, treatment and study-design factors [5]. Since vascularised grafting is the longer and more technically demanding operation, that near-parity is worth knowing. Selection bias runs in a particular direction here, vascularised grafts tend to be used for the harder cases, so the comparison likely understates them. But it does not support choosing one as routinely better. --- ### Scapholunate Ligament Injury URL: https://www.cqupperlimb.com/education/wrist/scapholunate-injury/ Region: wrist · condition A tear of the key ligament linking two wrist bones — how it is diagnosed, why it matters, and the repair or reconstruction options. ## What you're feeling Most people first notice this after a fall onto an outstretched hand, the classic catch-yourself fall that also breaks wrists. There is pain on the back of the wrist, usually a little towards the thumb side, and it tends to be worse when you push, grip, or bear weight through the hand: doing a push-up, pressing up out of a chair, opening a heavy door, lifting a kettle. The wrist often feels weak and unreliable. Some people describe a click, clunk or catching sensation when they move it a certain way, as though something inside is shifting. There may be a bit of swelling, and the spot right on the back of the wrist between two of the small wrist bones is often tender to press. Early on it can be easy to brush off as a sprain that "just won't settle", and that is exactly the trap: the ligament involved does not heal on its own. ## What's actually happening Your wrist is a cluster of eight small bones held in precise alignment by short, strong ligaments. One of the most important is the scapholunate ligament, which ties together two of those bones (the scaphoid and the lunate) in the middle of the wrist. It works like the keystone that keeps the whole carpus moving as a coordinated unit. When that ligament is torn, the two bones lose their link. The scaphoid tips forward and the bones start to drift out of their normal alignment. At first this may only show up when the wrist is stressed in a certain position (a "dynamic" problem); over time the gap can become fixed (a "static" problem). The reason we take this seriously even when the pain is modest is the long game: a wrist whose bones no longer line up correctly wears unevenly, and over a span of years that abnormal loading can grind down the cartilage and lead to a specific pattern of wrist arthritis. Treating the ligament early is really about heading that off. ## What we can do about it Dr Kieran Hirpara is an upper-limb surgeon at Mater Private Hospital Rockhampton who guides how we manage this condition in our clinic. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. That lets us start with a thorough assessment of your history, examination, and imaging. Because a recent tear can often be repaired directly, we aim to assess a new injury promptly; older injuries are managed differently, as described below. The right treatment depends a lot on how long ago the injury happened and whether the bones still line up, which is why getting an accurate diagnosis matters. We usually combine an examination with X-rays (sometimes special "stress" views taken while you clench your fist), and often an MRI. The most reliable way to see the ligament directly is a wrist arthroscopy (keyhole camera surgery), which doubles as both the definitive diagnosis and, in many cases, the treatment. - Recent injuries where the ligament can still be repaired are the best scenario. The torn ligament is stitched back down (increasingly through keyhole techniques), sometimes reinforced with nearby tissue, and the bones are held in position with temporary wires while it heals. - Older injuries where the ligament can no longer be simply repaired, but the bones can still be coaxed back into line, are usually treated by rebuilding the ligament. Surgeons use a strip of one of your own tendons, or nearby tissue, woven into place to restore the link and pull the scaphoid back upright. - Long-standing injuries where the bones are stiff in a bad position, or arthritis has already set in, are past the point of repair or rebuild. Here we shift to salvage operations that aim to give you a strong, much less painful wrist, by fusing or removing selected small bones, accepting some loss of movement in exchange for durable comfort. Mild, incidental cases that aren't causing trouble can sometimes simply be watched, with hand-therapy to build up the muscles that help stabilise the wrist. ## What to expect This is a wrist injury that rewards being caught early. When a fresh tear is repaired or a reducible one is rebuilt, the goal is a stable, comfortable wrist that lets you return to most activities, though it is normal to lose a little of the extreme range of movement, and recovery is measured in months, not weeks. After surgery you can expect a period in a cast or splint while the repair takes, followed by a structured hand-therapy programme to regain movement and strength. Wires, if used, are usually removed in the rooms after several weeks. The honest part: no operation makes the wrist exactly as it was, and results are generally better the sooner the injury is treated. If you have reached the salvage stage, the trade-off is real but worthwhile: far less pain and a wrist you can rely on, at the cost of some stiffness. What matters most is matching the operation to your particular injury, which is a conversation worth having properly. ## When to see someone - A wrist that stays painful, weak or "clicky" more than a few weeks after a fall, especially pain on the back of the wrist with pushing or gripping. Don't assume a stubborn "sprain" is harmless. - You've broken your wrist (a distal radius fracture) and the wrist remains sore or unstable after the bone has healed. These ligament injuries often travel together and can be missed. - A persistent clunk, catch or sense of the wrist giving way. - Known scapholunate injury with new or increasing pain, or swelling that won't settle: worth reassessing before it progresses. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Scapholunate ligament injury is worth the extra reading because it is the wrist injury where the gap between how serious the problem is and how good the solutions are is widest, and the literature says so plainly. ### Why a small ligament matters so much The scaphoid and lunate sit side by side in the first row of carpal bones, bound by a short interosseous ligament. They are shaped to want to rotate in opposite directions under load, the scaphoid to flex, the lunate to extend, and the ligament is what holds them together against that tendency. When it fails, the two bones separate and rotate away from each other. Because the whole carpus moves as a linked system, that changes how load crosses the wrist, and the altered contact progressively wears the joint in a recognised sequence, the scapholunate advanced collapse pattern. This is the crucial point for a patient: an untreated complete tear is not a stable situation that either settles or does not. It is the first stage of a predictable arthritic process, and that is what justifies attention to an injury which may not be especially painful at the outset. ### The reconstructions have not been separated For chronic injury, many operations exist, which is itself informative. Comparing techniques for chronic scapholunate interosseous ligament disruption across 978 patients, tenodesis reconstruction produced significantly improved scapholunate gap and angle relative to capsulodesis on radiographic measures, with the existing data showing some benefit for tenodesis [1]. But radiographic improvement is not the same as clinical superiority, and the broader review is blunt. For chronic non-arthritic scapholunate dissociation across 342 patients, heterogeneity in data collection, a lack of comparative studies and short follow-up meant no conclusion regarding the superiority of any single technique was possible, with the authors calling for longer-term comparative studies and natural history studies [2]. ### The missing natural history is the real gap That last request is unusual and worth dwelling on. Asking for natural history studies means the field does not reliably know what happens to an untreated scapholunate injury, how many progress to arthritis, over what timescale, and which ones. Without that, the benefit side of the equation cannot be quantified. We know the arthritic sequence occurs; we do not know the proportion in whom it does, or how fast. Any statement that reconstruction "prevents arthritis" is therefore an extrapolation from mechanism, not a demonstrated outcome. Two things follow. Timing matters, a ligament repaired early, while the tissue is still repairable and the bones still reduce, is a different proposition from a reconstruction years later. And a recommendation here rests more on the individual findings than on trial evidence, because the trial evidence to appeal to does not yet exist. ### Where the process has already advanced Once arthritis has developed, the reconstructive question closes and a salvage decision opens instead, most commonly between removing the proximal row of carpal bones and fusing four of them. Those options, and the evidence comparing them, are covered on the SLAC/SNAC wrist page rather than here. --- ### SLAC and SNAC Wrist URL: https://www.cqupperlimb.com/education/wrist/slac-snac-wrist/ Region: wrist · condition SLAC/SNAC wrist – understanding pain from arthritis at the wrist, often after injury. ## What you're feeling The pain sits on the thumb side of your wrist, in the middle of the joint rather than at the edges. It tends to build over years rather than arrive all at once. Many people with wrist pain go a long time without a clear cause, because this kind of arthritis does not always show up on ordinary x-rays early on. Certain movements bring the pain on. Loading the wrist with the hand bent back, such as pushing up from a chair or getting out of a pool, presses the worn surfaces together. Gripping and twisting together is another common trigger: turning a doorknob, wringing out a cloth, or using a screwdriver. Rest usually settles it, though the ache can wake you at night or grumble on waking before it loosens up. As the wear spreads, everyday tasks get harder. You may notice a weaker grip when carrying shopping, pouring a kettle, or opening a jar. Bending the wrist back to lean on your hand, or taking your full weight through it, becomes uncomfortable. Some people lose the smooth snap of wrist movement and start avoiding anything that loads the hand at an angle. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## What's actually happening Your wrist is built from eight small bones arranged in two rows. The row closest to your forearm acts like a cushion between your forearm and your hand, spreading load and smoothing out movement. A strong strap of ligament, the most commonly injured ligament in the wrist, holds two of those bones together so the row can work as one unit. SLAC wrist starts when that strap is damaged, usually from an old injury. The two bones it held together drift apart. One of them, the scaphoid, changes the way the whole row moves, and the load that used to spread evenly now concentrates on one small part of the joint. SNAC wrist follows the same path but begins with a broken scaphoid that never healed, which uncouples the rows in a similar way. That concentrated load wears away the smooth cartilage covering the bone ends, the same wear-and-tear arthritis you can get in a knee. The worn surfaces grind when you load the wrist, which is the pain you feel pushing up from a chair or twisting a screwdriver. As the wear spreads from the thumb side towards the middle of the wrist, grip weakens and movement stiffens. The condition is described in stages, and the stage depends on which joint surfaces the wear has reached. Early on it is confined to the outer edge of the wrist. Later it reaches the joint in the middle of the hand. That matters because surgery is chosen to match the stage: where one key joint is still healthy, removing the worn row of bones can work, and where wear has spread further, fusing some of the remaining bones into a single block is used instead. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We assess your history, examine your wrist, and arrange imaging where it is needed to work out the stage of wear. For a long-standing problem like this, we usually try non-operative care first and consider surgery when that has not given enough improvement. The first step is changing how you load the wrist. Pushing up from a chair, wringing a cloth and using a screwdriver press the worn surfaces together, so adjusting those tasks takes pressure off. A splint can hold the wrist still while you work or sleep. Hand therapy aims to keep the wrist moving and build the strength around it. We usually give this a fair trial over weeks to months before thinking about surgery. Pain medication can help alongside this. Simple anti-inflammatories settle the ache when you use the wrist more than usual. We will talk through what suits you and your other medicines. When these steps no longer give enough relief, surgery is considered. The aim is to remove the worn joint surfaces that cause the pain while keeping as much useful wrist movement as possible. Where one key joint is still healthy, removing the worn row of bones lets the wrist work with a new, smoother contact. Where wear has spread further, fusing some of the remaining bones into a single block gives a stable, load-bearing wrist. Both are motion-preserving choices, and the trade between movement and strength is a shared decision we make with you. If wear is too widespread for either, total wrist fusion is reserved for exceptional circumstances, and joint replacement can be an alternative where it suits the patient. ## What to expect This is a long-standing form of wear-and-tear arthritis, so it does not settle quickly on its own. Left alone, the pain tends to build over years as the wear spreads from the outer edge of the wrist towards the middle. Grip weakens and movement stiffens as it goes. Non-operative care can ease the ache over weeks to months, but it manages the symptoms rather than stopping the wear. With treatment, the outlook depends on how far the wear has spread and which operation suits your stage. Where one key joint is still healthy, removing the worn row of bones can give durable results. Where some bones are fused into a single block, most wrists heal solid and carry load without the grinding pain. Hand therapy starts early after surgery, sometimes within the first week, to keep stiffness down, and the wrist is held still for about two months while the bones join. Improvement keeps coming after that: some people continue to gain wrist function for more than 3 years after treatment. It is honest to say that not every wrist settles completely. Some bones do not join after a fusion, which may need further surgery. The metal used to hold a fusion can also cause pain on the back of the wrist, and occasionally it needs removing. A small number of people who have had one of the motion-preserving operations still need a total wrist fusion later if pain persists. And in some wrists, pain lingers even though the bones have joined well. Warning signs after any wrist surgery need fast action. If your finger, hand or arm becomes hot, red, swollen and painful, especially with a fever, go to the emergency department the same day; no GP referral is needed. The same applies if your fingers or hand turn pale, cold, white or blue, or if you suddenly lose feeling or movement. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone This condition builds slowly, so most warning signs are about change rather than sudden danger. See your GP if your wrist pain is not settling with rest and adjusting how you load it, or if it is getting worse over weeks. Ask for a specialist review if the pain wakes you at night, stops you working, or your grip keeps weakening and everyday tasks keep getting harder. After any wrist surgery, some signs need same-day care. Go to the emergency department if your finger, hand or arm becomes hot, red, swollen and painful, especially with a fever. The same applies if your fingers or hand turn pale, cold, white or blue, or if you suddenly lose feeling or movement. If you cannot reach the clinic out of hours or on a weekend, go to your nearest emergency department. There is no emergency sign of the arthritis itself. The reason to be seen is that the wear spreads over time, and the options that keep the most movement work best before it reaches the middle of the wrist. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. SLAC and SNAC wrist are worth the extra reading because the choice between the two standard salvage operations is a genuine trade, one gives more movement, the other more strength, and the most recent pooled evidence has begun to favour one of them overall. ### Two operations, two different compromises Once the carpus has collapsed into the arthritic pattern, the joint surfaces cannot be restored, so both operations remove the arthritic contact rather than repair it. Proximal row carpectomy removes the entire first row of carpal bones, letting the head of the capitate sit in the socket the scaphoid and lunate vacated. Four-corner fusion removes the scaphoid and fuses the remaining four bones into a single block. Comparing them directly across 240 patients, the compromise is explicit. Four-corner arthrodesis gave significantly greater radial deviation and grip strength as a percentage of the opposite side, while proximal row carpectomy produced better flexion, extension and total flexion-extension arc, along with a lower overall complication rate [1]. That maps onto how each is constructed. Fusing four bones into a block preserves the attachments that drive grip but eliminates motion between them. Removing a row shortens the carpus and creates a new, more mobile joint, at the cost of the strength that came from the removed structures. ### The larger pooled analysis favours carpectomy More recent and much larger evidence has shifted the balance. Across 3,174 patients with SLAC and SNAC wrists, proximal row carpectomy resulted in better outcomes and a lower complication rate than four-corner fusion [2]. The complication difference is the more reliable part of that comparison, and it has a mechanical explanation: four-corner fusion has to achieve union across four bone surfaces, and nonunion, hardware problems and the need for removal are complications that carpectomy simply does not have available to it. Reviewing the fusion variants themselves does not rescue the difference. Comparing two-corner with four-corner arthrodesis, the techniques showed similar outcomes and complications despite the theoretical advantage of the smaller fusion, so both remain reasonable [3]. ### Where the decision still goes the other way The pooled result does not make carpectomy universally correct. It depends on the head of the capitate and the corresponding surface of the radius being undamaged, because those two surfaces become the new joint. Where arthritis has already reached the capitate, a more advanced stage of the same process, carpectomy has nothing sound to articulate against, and fusion becomes the option. Age and demand matter too. A younger, heavier-using wrist may favour the strength that fusion preserves, accepting the higher complication rate. ### When both have been exhausted If salvage fails, or arthritis is too widespread for either, the remaining options are total wrist fusion and total wrist replacement. Both are effective at relieving pain and improving grip, with comparable complication rates of 17% and 19% respectively, with functional improvement observed after arthroplasty, but robust long-term data on replacement still lacking [4]. That parity is worth knowing because fusion and replacement are often presented as radically different propositions. They differ in what they leave you with, rather than in how often they go wrong: a strong, painless, immobile wrist versus a mobile one with a replacement you may well outlive, meaning further surgery later. --- ### TFCC Injury URL: https://www.cqupperlimb.com/education/wrist/tfcc-injury/ Region: wrist · condition TFCC injuries — pain on the ulnar side of the wrist, often with clicking, and treatment options. ## What you're feeling The pain sits on the little-finger side of your wrist, the ulnar side. It often flares when you load that side: pushing up from a chair, gripping a jar, or turning a doorknob while holding something heavy. Twisting motions like wringing out a cloth or using a screwdriver can also set it off. Some people notice the wrist feels unsteady, as if it might give way, or that it clunks when the forearm rotates. Others have pain that lingers without any clear cause on scans, which is common with this part of the wrist. The ache can be worse after activity and may bother you at night or when you first wake up. Day to day, tasks that need a firm grip and a twist become hard: opening a stuck lid, carrying a heavy bag of shopping on that side, or leaning on your hand to stand from a low seat. Work that involves tools or repeated strain on the wrist can keep the pain going. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## What's actually happening Inside your wrist, on the little-finger side, there is a structure called the triangular fibrocartilage complex, or TFCC. Think of it as a shock absorber with ropes attached. The shock absorber is a disc of tough, slippery cartilage that sits between the end of your ulna, the forearm bone on that side, and the small bones of your wrist. The ropes are ligaments that anchor that disc to the ulna and steady the joint where the two forearm bones meet at the wrist. The TFCC does two jobs at once. It cushions load travelling through the ulnar side of your wrist, and it holds that forearm joint together while you turn your palm up and down. That dual role explains the two patterns you read about above. When the cushion part is torn, loading that side hurts: pushing up from a chair, gripping, twisting. When the ropes are torn away from their anchor point on the ulna, the joint itself loses its stay, so the wrist feels as if it will give way or clunks as the forearm rotates. The second pattern matters more, because the ligament part is what holds the joint together. There is one more thing worth knowing about this spot. Only the outer rim of the TFCC has a blood supply, roughly the outer 10% to 40% of it. The inner part gets almost none. Blood is what brings healing, so tears near the rim have a real chance of mending, while tears in the middle tend not to heal on their own. That is also why a tear here can keep aching: the damaged tissue sits in a place where the body struggles to repair it, and every grip or twist keeps loading it. So the pain, the clunking and the giving way are not separate problems. They are what happens when a cushion-and-stay structure that takes load with every movement of your hand is no longer doing both of its jobs. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At that first visit we take a history, examine your wrist, and arrange imaging where it is needed to work out what is torn. Some TFCC tears settle without an operation. A splint can hold the wrist still and take load off the sore spot while the outer rim, the part with a blood supply, has a chance to mend. Hand therapy aims to settle the pain and rebuild strength and grip so the wrist copes with daily loads again. We usually give this a fair stretch of weeks before judging whether it is working. Pain tablets and anti-inflammatories can help you keep moving while the tear settles. They do not repair the tissue, they make the days more comfortable. If the pain or the clunking still limits you after that, we talk about surgery. The standard first step is keyhole surgery, called wrist arthroscopy. The surgeon looks inside the joint through small cuts using a tiny camera, which is the most accurate way to confirm a TFCC tear and check the ligaments and joint surfaces at the same time. Some tears can be tidied or repaired through those same small cuts. Where the cushion has worn and the little-finger side of the wrist is overloaded, a procedure can shave a small amount off the end of the ulna to take pressure off that side. The choice between tidying up the tear, repairing it, or rebuilding it with a tendon graft depends on where the tear sits and how long it has been there. This is a shared decision. We lay out what each option involves and what it can and cannot change, and you decide what fits your wrist and your life. ## What to expect For many people, a TFCC tear settles with time and the right care. Tears near the outer rim, where the blood supply is, have a real chance of mending on their own or with a splint. Tears deeper in the cushion tend not to heal by themselves, but the pain can still ease once the wrist is rested and loaded less. Recovery is gradual rather than sudden. Most people notice the ache fading over weeks rather than days, and grip and twisting strength return as the wrist settles. If you have keyhole surgery for an isolated tear on that little-finger side, the average time back at work is 5.5 weeks. Athletes can take longer to return to their sport, especially if there are other injuries on that same side of the wrist. One pattern worth knowing: if the end of the ulna has been pressing into the wrist and causing pain, that pain tends to come back once you return to sport. If the tear is left alone, the outlook depends on which part is damaged. A rim tear may quieten down. A tear in the middle, or one where the ligament ropes have come loose, often keeps aching with every grip and twist, because that tissue sits where the body struggles to repair it. The giving-way feeling can stay too. Surgery does not promise a pain-free wrist. People who had keyhole surgery for long-standing wrist pain improved on average by about 50% at one year, and most still had some pain and stiffness at that point. What surgery does well is confirm exactly what is torn and repair what can be repaired, which usually means less pain and a wrist that copes with daily loads again. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone Most TFCC tears are not emergencies. A few situations are. Go to an emergency department the same day if your wrist becomes hot, red, swollen and painful, especially with a fever, because that points to an infection needing same-day care. The same applies if your fingers or hand turn pale, cold, white or blue, or if you suddenly lose feeling or movement in the hand after an injury. For everything else, timing is about persistence rather than speed. See your GP if wrist pain on the little-finger side has lasted more than 3 months and has not settled with rest, splinting or hand therapy. Ask for a specialist review sooner if the wrist feels unsteady, gives way or clunks when you turn your palm up and down, since that suggests the ligament part of the TFCC has torn loose. Pain that keeps you from working, wakes you at night, or leaves scans clear while the ache continues is also worth a specialist opinion, because this spot often needs a closer look than scans alone can give. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Triangular fibrocartilage complex injury is worth the extra reading because the technique debates that dominate discussion have not separated, while one detail of the post-operative regime, which attracts far less attention, appears to matter. ### What the structure actually does The TFCC is a disc of cartilage with a surrounding sling of ligaments, sitting between the end of the ulna and the carpal bones. It performs two jobs at once: it cushions load transmitted across the ulnar side of the wrist, and it stabilises the joint between the two forearm bones at the wrist — the distal radioulnar joint. That dual role explains why injuries here present in two distinct ways. A tear affecting mainly the disc produces pain on load, pushing up from a chair, gripping and twisting. A tear detaching the deep fibres from their attachment on the ulna, the foveal insertion, produces instability, with the sense that the wrist gives way or clunks when the forearm rotates. The second matters more, because the ligamentous attachment is what holds the joint together. ### MRI is accurate, with a qualification worth knowing Diagnosis rests substantially on imaging. Across 1,298 patients, the overall accuracy of MRI was acceptable, and for peripheral tears the pooled accuracy was relatively high, with MRI using appropriate parameters described as an ideal method for diagnosing the different tear types [1]. The qualification is in the word "peripheral". MRI performs best at the outer, better-vascularised part of the complex, which is where repairable tears sit. Central and degenerate tears, and the precise state of the foveal attachment, are harder to characterise, which is why examination findings and sometimes arthroscopy carry weight alongside the scan. ### The technique comparisons do not separate Two operative debates recur, and neither has resolved. For the common peripheral, ulnar-sided tear, a systematic review of 240 patients found a lack of high-quality evidence to draw firm conclusions on arthroscopic versus open repair, and no scientific evidence to suggest superiority of one technique over the other [2]. For foveal repair, comparing suture anchor with transosseous suture across 904 patients, both achieved improvement in functional outcomes, pain and grip strength with a low reoperation rate — though the range-of-motion comparison remained inconclusive [3]. The consistent message is that the repair needs to restore the attachment; the hardware used to achieve it has not been shown to change the result. ### The post-operative detail that does appear to matter Here the evidence is more discriminating, and it is practically useful. Comparing immobilisation regimes after foveal TFCC repair across 288 patients, post-operative immobilisation may benefit more from restricting forearm rotation than from restricting elbow motion, and the additional restriction of elbow flexion and extension has not shown a consistent advantage [4]. This follows directly from the anatomy. The repaired structure is loaded by rotation of the forearm, not by bending the elbow, so the splint needs to control the palm turning up and down. An above-elbow cast is often used to enforce that indirectly by preventing the elbow rotating, and this evidence suggests the elbow component is not the part doing the work. For a patient, six weeks in a brace that leaves the elbow free is a substantially different experience from six weeks in a cast above it. --- ### Ulnar-Sided Wrist Pain and Ulnar Impaction URL: https://www.cqupperlimb.com/education/wrist/ulnar-sided-wrist-pain/ Region: wrist · condition Pain on the little-finger side of the wrist from the ulna grinding against the wrist bones, and how shortening it relieves the pressure. ## What you're feeling Pain on the little-finger side of the wrist (the ulnar side) is very common, and it has several possible causes. This page is about the most important mechanical one: a condition called ulnar impaction (also known as ulnocarpal abutment). The pain tends to sit deep on the outer edge of the wrist, towards the back of the hand. It is often worse when you grip firmly, twist your forearm, or bend the wrist towards the little finger, so everyday actions like opening a jar, turning a key, using a screwdriver, wringing out a cloth, or leaning on the hand to push up out of a chair can all set it off. Many people also notice a click or a clunk in the wrist with certain movements, and the wrist can ache after a day of heavy use. Putting weight through the wrist (in a plank, a push-up, or pushing a heavy door) is a classic aggravator. It usually builds up gradually rather than starting with a single injury, though it can follow a wrist fracture. ## What's actually happening Two forearm bones run up to the wrist: the radius (thumb side) and the ulna (little-finger side). For the wrist to work smoothly, the ends of these two bones should sit at roughly the same level. In ulnar impaction, the ulna is relatively too long compared with the radius, a condition doctors call positive ulnar variance. Some people are simply born with a slightly long ulna. In others it develops later: most often when a broken wrist heals slightly shortened, leaving the radius a touch shorter than it was and the ulna effectively standing proud. Whatever the cause, that little bit of extra length means the end of the ulna grinds against the small wrist bones it sits next to (the lunate and the triquetrum) every time you load the wrist. In between those bones sits a cushion of cartilage called the TFCC (the triangular fibrocartilage complex), which acts as a shock-absorber. Repeated abutment slowly wears this cushion down, can tear the TFCC, and over time bruises and even forms small cysts in the bone underneath. That wear-and-tear process is what produces the pain, the clicking, and the loss of comfort with gripping and twisting. (We have a separate page on TFCC injuries, which often go hand-in-hand with this condition.) ## What we can do about it Dr Kieran Hirpara leads our upper-limb service at Mater Private Hospital Rockhampton, where we manage ulnar-sided wrist pain through a clear pathway. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. We begin with a thorough assessment to confirm the diagnosis, and for long-standing issues, we always try non-operative care first before considering surgery. The good news is that most people settle with non-operative treatment, and that is always where we start. Calming it down. The first steps are simple: modify the activities that load the ulnar wrist (especially heavy gripping, twisting and weight-bearing) for a while, wear a wrist splint to rest the joint, and use anti-inflammatory medication to settle the pain and swelling. Sometimes a steroid injection into the joint helps break the cycle of inflammation. Confirming the diagnosis. Alongside treatment we usually take X-rays to measure exactly how the two bones line up (sometimes with a special "grip" view that exaggerates the impaction), and often an MRI to look at the cartilage, the TFCC and the bone underneath. Occasionally a keyhole look inside the joint (arthroscopy) is used to confirm what is going on and treat it at the same time. If it persists. When good non-operative treatment hasn't settled things, the aim of surgery is to take the pressure off the ulnar side of the wrist. The most established option is an ulnar-shortening osteotomy, where the surgeon removes a small slice of the ulna to bring it back to the right length and holds it with a small plate while it heals. A less invasive alternative in selected cases is an arthroscopic "wafer" procedure, which shaves a small amount off the very end of the ulna through keyhole surgery. Both work by stopping the bone from grinding against the wrist. ## What to expect For most people, ulnar impaction is a problem we can get on top of. Non-operative measures settle a large proportion of cases, and the symptoms ease once the joint is no longer being repeatedly overloaded. When surgery is needed, shortening the ulna is a reliable operation, and studies that have followed patients for many years report good, lasting pain relief and high satisfaction. The bone needs time to heal, so there is a recovery period of some weeks in a splint or cast while the osteotomy unites, followed by a gradual return to gripping and loading. The main things to be aware of are that the bone occasionally takes longer than expected to knit, and that the small plate can sometimes be felt under the skin and is occasionally removed once everything has healed. Overall, the great majority of people return to their everyday activities with the pain resolved. ## When to see someone - Ulnar-sided wrist pain that won't settle over a few weeks, or that keeps coming back with gripping and twisting. - Pain that follows a previous wrist fracture, especially if the wrist has never felt quite right since. - A persistent click, clunk or catching on the little-finger side of the wrist, particularly with weight-bearing. - Pain that is stopping you doing your job or your daily activities. This is the point at which it is worth looking into what is driving it and what can be done. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Ulnar-sided wrist pain is worth the extra reading because it is a location rather than a diagnosis, several distinct problems share the same small area, and because for the commonest of them, the newer and smaller operation now has better complication figures than the established one. ### Why this corner of the wrist is difficult Within a few centimetres sit the TFCC, the distal radioulnar joint, the extensor carpi ulnaris tendon and its sheath, the pisotriquetral joint, the lunotriquetral ligament, and the point where the ulna meets the carpal bones. Each can generate pain in the same place, several commonly show abnormalities on imaging in people without symptoms, and more than one can be involved at once. That is why assessment here leans harder on precise localisation and provocation testing than elsewhere in the wrist, and why a scan reported as showing several abnormal structures is a common and unhelpful outcome. It is also why less common causes, midcarpal impaction, for instance, are periodically described as overlooked contributors [1]. ### Ulnar impaction: the mechanical problem with a mechanical fix The commonest structural cause is ulnar impaction, the ulna sitting slightly long relative to the radius, so the carpal bones are driven against its end with grip and with the forearm turned palm down. Over time this wears the TFCC and the cartilage of the bones it abuts. The treatment shortens the ulna, either by cutting and shortening the shaft, or by removing a wafer of bone from its end, which can be done arthroscopically. Pooling 956 patients, the arthroscopic and open wafer procedures may be viable alternatives to the more popular ulnar shortening osteotomy, though clinical superiority had not been established at that point [2]. More recent data have moved further. Comparing the arthroscopic wafer procedure with ulnar shortening osteotomy across 311 patients, both were effective, but the wafer group showed fewer complications and a lower reoperation rate, leading the authors to describe it as potentially the superior alternative [3]. ### Why the osteotomy accumulates complications The reason is not that the operation is poorly done. Shortening the shaft requires cutting a bone, holding it with a plate while it heals, and accepting that it may not heal. A pooled review of 1,423 patients specifically examined nonunion, finding no difference between transverse and oblique osteotomies, and concluding the choice between the two should therefore not be made on nonunion risk [4]. The wafer procedure avoids that category of problem entirely by removing bone from the end rather than dividing the shaft. There is no fracture to unite and usually no plate to remove later, which is where the difference in reoperation rates comes from. The trade-off is that the wafer procedure removes a limited amount of bone and requires the distal radioulnar joint to be sound, so shortening the shaft remains necessary where more correction is needed or that joint is also involved. ### The practical consequence for a patient Because several structures can be responsible, a treatment aimed at the wrong one will not work regardless of how well it is performed. This is the region where a diagnostic injection, targeted imaging, and occasionally arthroscopy earn their place before a decision, and where a specific diagnosis, rather than "ulnar-sided wrist pain", is what should be reached before an operation is planned. --- ### Wrist Arthroscopy URL: https://www.cqupperlimb.com/education/wrist/wrist-arthroscopy/ Region: wrist · operation Diagnostic and therapeutic wrist arthroscopy — what it is, when it's used, and recovery. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your appointment we take a careful history, examine your wrist, and arrange imaging where it is needed to work out what is causing your pain. Wrist arthroscopy is an operation that uses a small camera inside the wrist joint to look closely at the joint surfaces and soft tissues. We usually suggest it when wrist pain has lasted more than 3 months, has not settled with non-operative care such as activity change, hand therapy, splinting or injections, and when scans and examination have not given a clear enough answer. It may also be recommended after a fracture or a ligament injury, to check the joint surfaces and soft tissues and to treat some problems in the same sitting. The operation can also help with stiffness, some types of arthritis, and long-standing ligament trouble. People who had the operation for persistent wrist pain improved on average by about 50% at one year, though most continued to have some pain and disability. The main aim is less pain, better movement and a steadier wrist, decided together with you. ## Before the operation Your surgeon will give you clear instructions before the day, and we cover the practical points here. You will need to stop eating and drinking from seven hours before your operation. We ask for seven hours rather than the usual six so your operation can be brought forward if the theatre list runs early. Bring a list of your current medications, and your surgeon will tell you if any need to be paused beforehand. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing. Imaging such as an X-ray, MRI or ultrasound helps plan the operation, and this is usually arranged at your appointment. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day On the day of your operation, you present to the hospital's surgical admissions unit. You are checked in there and prepared for theatre. You will then meet the anaesthetist, the doctor who looks after your anaesthetic and pain relief. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. When it is finished, you wake up in the recovery area. Nurses monitor you there while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves Wrist arthroscopy is a keyhole operation. Your surgeon makes a few small cuts around the wrist, and a small camera goes through one of them so the inside of the joint can be seen on a screen. During the operation your arm is held steady and your fingers are gently suspended in soft finger traps, with a steady pull on the wrist that opens up the joint and creates room to work. Salt water flows through the joint to keep the view clear. Once the camera is inside, your surgeon can look closely at the joint surfaces and the soft tissues, including the cartilage lining the bones and the ligaments that hold the small wrist bones together. What happens next depends on what is found. Loose pieces of cartilage or bone can be removed. Inflamed tissue lining the joint can be trimmed away. A cyst or a thickened band of tissue can be dealt with. Torn ligaments, including the triangular cartilage on the little-finger side of the wrist, can be trimmed or repaired. If a bone is broken, the pieces can be lined up precisely under the camera and held with screws or pins while they heal. If the wrist has become stiff after an injury or a previous operation, tight tissue can be released to free it up. At the end, the small cuts are closed with stitches. A dressing goes over the wrist, and your hand is usually supported in a bandage or splint. The dressing stays on for about 10 days, and we will tell you how to care for the wounds in the meantime. ## After the operation You will wake up in the recovery area, where nurses watch you as the anaesthetic wears off. This is usually a day case, so you can expect to go home the same day, although occasionally patients stay overnight. Your wrist will be in a dressing, and your hand may be supported in a bandage or splint. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Pain relief is planned for you before you go home; take it as directed. If you had a nerve block, numbness and weakness in the first 24 hours are expected. Once it wears off, at about 24 hours, call the clinic if your fingers stay numb or you cannot move them. Ask someone to stay with you for the first 24 hours. Call the clinic the same day if you have a fever, spreading redness around the wound, fluid or pus leaking from it, or pain that keeps getting worse despite your pain medicines. Go to the emergency department if your fingers or hand turn pale, cold, white, blue or dark, as this can be a circulation problem. Keep your hand raised when resting to help swelling settle. Most people move around the house normally from the day of surgery; you do not need bed rest. ## Recovery For the first few days your wrist will be sore and swollen, and your fingers may feel stiff. Keeping your hand raised when resting helps the swelling settle. Take your pain relief as directed, and expect the discomfort to ease steadily as the days pass. Most people move around the house normally from the day of surgery. You will need someone to handle heavy lifting and driving at first. Once any splint comes off and you can hold the wheel comfortably, you can drive again; our page on driving after upper-limb surgery explains this in more detail. The dressing stays on for about 10 days, and we will check the wounds when we see you. Hand therapy is a big part of getting your wrist moving again. Your rehabilitation is with Ruby Doolan at Extend Rehabilitation. Ruby is a hand therapist: she will guide your exercises and make any splint you need along the way. Early on, the focus is gentle movement and controlling swelling. As the wrist settles, the exercises build up to gripping, lifting and using your hand for everyday tasks. Recovery follows a step-by-step pattern, and coordinated movement between the wrist and fingers keeps improving as the weeks go by. How quickly you return to work, sport or the gym depends on what was found and repaired inside your wrist, and on your job and hobbies. Your timeline may differ from someone else's; we and your therapist will guide you at each stage. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. Infection is uncommon after this operation, but it matters when it happens. Call the clinic the same day if you have a fever, spreading redness around the wound, or fluid or pus leaking from it. Call the clinic the same day too if pain keeps getting worse despite your pain medicines. In a severe infection deep in the wrist, further surgery is sometimes needed, and this is very rare. The finger traps that hold your fingers during the operation can leave your finger joints sore afterwards, or bruise the soft tissue or small nerves in a finger. This settles on its own in most cases. Bring it up at your next review if a finger is still sore or feels odd. Fluid used to fill the joint during the operation can occasionally leak into the tissues of the forearm. Watch for swelling in the forearm that builds up quickly, along with tightness and pain that keeps growing. Call the clinic straight away if you notice this. Nerves near the wrist can be irritated or injured during the operation. You might notice numbness, tingling or a patch of skin that feels different once the nerve block has worn off, at about 24 hours. Numbness and weakness in the first 24 hours after a nerve block are expected. Call the clinic if numbness lasts beyond that, or if you cannot move your fingers or hand once the block has worn off. If you cannot reach the clinic, go to your nearest emergency department. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most people recover without problems, but it helps to know what to watch for. Call the clinic the same day if you have a fever, spreading redness around the wound, fluid or pus leaking from it, or pain that keeps getting worse despite your pain medicines. Call the clinic if your fingers stay numb or you cannot move them once the nerve block has worn off, at about 24 hours. Go to the emergency department if your calf swells or is painful, if you become short of breath or get chest pain, or if your fingers or hand turn pale, cold, white, blue or dark. These can be signs of a blood clot or a circulation problem. If you cannot reach the clinic, go to your nearest emergency department. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Wrist Ligament Injuries page. --- ### Total Wrist Fusion URL: https://www.cqupperlimb.com/education/wrist/wrist-fusion/ Region: wrist · operation Wrist fusion permanently joins wrist bones to relieve pain from arthritis or injury. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment, including your history, an examination and imaging where needed, establishes the diagnosis. Wrist arthritis causes pain, weakness of grip and sometimes a wrist that will not stay steady. For many people, non-operative care comes first: activity change, hand therapy, splinting or injections. We suggest a total wrist fusion when those steps have not given you enough improvement. The operation joins the wrist bones together so they heal as one solid piece. This stops the painful rubbing between worn joint surfaces. It is usually offered for severe wear-and-tear arthritis after injury, or for a wrist damaged by rheumatoid arthritis that has become unstable or deformed. It may also be considered if a previous wrist replacement has failed. The aim is a stable, strong wrist with much less pain, so you can use your hand with confidence. ## Before the operation Your surgeon will plan the operation using imaging of your wrist, such as X-rays or an MRI scan. MRI uses a strong magnet to take detailed pictures and can show problems that plain X-rays miss. You will get clear instructions about your medicines before surgery. Some medicines may need to be paused for a short time, and your surgeon will tell you which ones and for how long. Stop eating and drinking seven hours before your operation time. We ask for seven hours rather than six so you can be brought forward if the theatre list runs early. Arrange for someone to drive you home afterwards. Bring a list of your current medicines with you. Wear loose, comfortable clothing. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You will meet the anaesthetist there. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. You wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. ## What the operation involves Your surgeon makes a single cut over the back of your wrist. Through this opening, they reach the worn joint surfaces between the small wrist bones and the end of the forearm bone. They remove the remaining smooth cartilage from these surfaces, along with any hardened bone, so that fresh, bleeding bone is exposed on both sides of each joint to be joined. This raw-on-raw contact is what allows the bones to heal together as one solid piece. Your surgeon then lines the bones up in a functional position and holds them still while they heal. A shaped metal plate is fitted across the back of the wrist and fixed to the bones with screws. The plate holds everything in place so the bones cannot shift while they knit together. In some cases, your surgeon may add a small amount of extra bone graft to help the healing. Once the bones are secure, your surgeon closes the cut with stitches and applies a dressing. ## After the operation You will wake up in the recovery area with nurses watching over you while the anaesthetic wears off. Your wrist will be supported in a splint or cast, with a dressing over the wound. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Pain relief is planned for you before you leave hospital, and the nurses can adjust it if you are uncomfortable. You will be able to get up and walk around on the day of surgery, using your other hand for support. Most patients stay one night in hospital after this operation, though some are able to go home the same day. Please arrange for someone to stay with you for the first 24 hours after you get home. ## Recovery For the first few days your wrist will be sore and swollen. This settles gradually. Keeping your hand raised on pillows, even at night, helps ease the swelling and discomfort. Take the pain relief that has been planned for you rather than waiting for the pain to build. Your wrist will be in a splint or cast while the bones heal together. You will use your other hand for everyday tasks such as dressing, eating and washing. You can move around the house and do light activities, but you must not drive while your wrist is immobilised. Once the cast or splint is removed and your surgeon clears you, driving can begin; our page on driving after upper-limb surgery explains this in more detail. Hand therapy starts soon after surgery and helps prevent stiffness in your fingers, wrist and forearm. Your hand therapist, Ruby Doolan at Extend Rehabilitation, will guide your exercises and make any splint you need. Starting gentle movement early helps you regain useful motion sooner and often means fewer therapy visits overall. Because the wrist bones are joined, that part of your wrist will no longer bend. Most people adapt well and manage their daily activities with some new habits. Your forearm can still turn, so many tasks remain comfortable. Once the bones have healed and your grip feels strong, you can build back up to work and other activities. Everyone heals at their own pace, so your timeline may differ. Your surgeon and your hand therapist will guide you at each step. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The metal plate and screws hold the bones still while they heal. Sometimes this hardware causes discomfort or shifts slightly. You might feel a sharp edge under the skin, or a nagging ache over the plate that simple painkillers do not settle. If this bothers you, mention it at your next review. The hardware can be removed once the bones have healed. Occasionally the wrist bones do not knit together as planned. This is called a nonunion. Many people with this problem feel nothing at all, and it causes no symptoms. If the gap does cause pain that will not settle, your surgeon will discuss the options with you at review. The nerve that runs through the middle of the wrist can become compressed by swelling after surgery. This is called carpal tunnel syndrome. You would notice tingling, pins and needles or numbness in your thumb, index and middle fingers, often worse at night. Tell your surgeon if this happens. It can usually be treated with a small operation to release pressure on the nerve. Problems with wound healing can happen. Watch the skin around your dressing for spreading redness, increasing warmth, oozing or an unpleasant smell. A wound that is not settling may need treatment. If you notice these signs, contact the clinic promptly rather than waiting for your next appointment. Tendons, the cords that connect muscle to bone, can occasionally be irritated or torn near the wrist. You might notice sudden weakness, for example a finger that will not straighten properly, along with swelling or tenderness on the back of the hand. Bring this to your surgeon's attention early. If you have had a previous wrist replacement that failed, a fusion done afterwards can still settle things down, though recovery may be a little slower than after a first-time fusion. The complications table on this page lists typical rates if you want the specifics. ## When to call us Most problems show up in the first few weeks. Call us if you have a fever, or the skin around your wound becomes more red, warm or oozing. Call us if your pain suddenly gets worse, or if you notice tingling or numbness that was not there before. Go to emergency if your calf is swollen and painful, or if you become short of breath. Go to emergency if you cannot feel or move your hand or fingers at all. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Wrist Osteoarthritis page. --- ### Wrist Ganglia URL: https://www.cqupperlimb.com/education/wrist/wrist-ganglia/ Region: wrist · condition Wrist ganglia are common, fluid-filled lumps – often painless – and this page covers observation, aspiration, and excision. ## What you're feeling A wrist ganglion is a fluid-filled lump that grows from a wrist joint or tendon sheath. It is not a growth that turns into anything harmful. Many people notice it first as a smooth bump on the back of the wrist, though it can also appear on the palm side. It may feel firm, and it can change in size over time. The lump itself is often painless. When there is pain, it tends to sit deep in the wrist, near the lump, and it often worsens with activity. Tasks that bend or load the wrist, such as pushing up from a chair, carrying shopping bags, or gripping a heavy pan, can make it ache. Some people find the wrist feels weaker or stiffer than usual, which can make typing, writing, or opening jars harder. Because the lump sits close to nerves in the wrist, a ganglion can sometimes press on them. This may cause tingling, numbness, or weakness in the hand. If you notice any of these nerve symptoms, it is worth having the wrist reviewed sooner rather than later, as the nerve needs relief from that pressure. If the lump or pain is not settling, is getting worse over weeks, or is stopping you from using your hand or working, see your GP or ask for a specialist review. ## What's actually happening A ganglion grows from a small, one-way valve in the lining of your wrist joint. Fluid that normally lubricates the joint gets pushed out through this valve but cannot flow back. It collects in a sac under the skin, and that sac is the lump you can see and feel. The lump is connected to the joint by a thin stalk, which is why it can change size as the joint makes more or less fluid. Most ganglions grow from the scapholunate ligament, a short strap of tissue that holds two of the small wrist bones together. It works a little like a gasket between them. The lining around this strap becomes irritated, often after a mild sprain or repeated strain, and that is where the fluid leaks from. This also explains why the ache sits deep in the wrist rather than on the skin: the problem is at the joint itself, not in the lump. The lump's position explains the rest of your symptoms. On the back of the wrist it usually sits directly over that ligament, close to the tendons that straighten your fingers. On the palm side it often grows near the main artery and the nerves that run into your hand, which is why tingling or numbness can happen when the cyst presses on them. Some lumps are small and hidden, only appearing when the wrist is bent forward, yet they can still cause deep pain. It is worth knowing that ganglia are common. Many people have them without any symptoms at all, and they are found on scans of painless wrists more often than you might expect. Having one does not mean anything is wrong with the structure of your wrist joint itself. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment, with your history, an examination and imaging where needed, establishes the diagnosis. Because a ganglion is harmless, doing nothing is a reasonable first step. Many ganglia go away on their own. Between 28% and 58% of wrist ganglia settle without any treatment. In children under 10, ganglia usually sit on the palm side of the wrist, and between 69% and 79% shrink away by themselves within 12 to 18 months. Watching and waiting, sometimes with a splint for comfort, suits most children with a hand or wrist ganglion. If the lump is bothersome, we can drain it with a needle. This is called aspiration. Drawing the fluid out removes up to 85% of ganglia when it is done one, two or three times. Some fluid often returns afterwards, because draining empties the lump but leaves the valve that made it. Even so, 74% of people are satisfied after aspiration and simple advice about the lump. Draining first also keeps an operation as a later choice rather than the first move. A hidden ganglion on the back of the wrist, one that causes deep pain but cannot be seen, is usually managed first without surgery, with the wrist held still and steroid injections into the joint lining. When these steps have not given enough relief, surgery can remove the ganglion. The operation takes out the lump and its stalk, the thin connection to the wrist joint, because leaving the stalk behind makes the lump more likely to return. It can be done as an open operation or with keyhole surgery through small portals. We will talk through which suits your wrist, and you decide together with us whether surgery is worth it for you. ## What to expect Many wrist ganglia change over time rather than staying the same. They can shrink, swell, or come and go. Some settle on their own: about 40% of wrist ganglia decrease over the first 6 years after they are first assessed, and between 39% and 42% of ganglia on the back of the wrist go away without any treatment at all. In young children, most hand and wrist cysts resolve by themselves, usually within a year. If yours is not causing much trouble, waiting is a reasonable choice, and the lump will not turn into anything harmful if you leave it alone. Treatment changes the odds. Draining the lump with a needle empties it, but most ganglions come back after aspiration, because the valve that made the lump is still there. Surgery that removes the lump and its stalk has a much lower chance of recurrence: about 10% of wrist ganglia return after surgery, and between 3% and 12% return after open removal of a ganglion on the back of the wrist. Most people who have surgery find their symptoms settle. Some pain can linger afterwards, though, especially if your work or sport needs forceful bending back of the wrist. If surgery is the path you take, recovery is usually straightforward. Your hand is wrapped in a bulky bandage and raised to keep it comfortable at first, and wrist movement starts early, within the first 2 weeks after palm-side ganglion surgery. Moving the wrist soon matters: stiffness is uncommon but can happen if early motion is not encouraged. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation, and she will guide your exercises and make any splint you need. A firm or tender spot where the lump was can persist for up to 3 weeks after keyhole surgery on the palm side, and massaging that spot as instructed helps it settle. Scars are part of any operation, and curved incisions near the wrist creases tend to heal with more attractive scars. If a treated lump or your symptoms are not settling, or they are getting worse over weeks, see your GP or ask for a specialist review. ## When to see someone Most wrist ganglia are harmless, and many settle on their own, so a lump alone is not an emergency. See your GP or ask for a specialist review if the lump or pain is not settling over weeks, is getting worse, or is stopping you from working or using your hand. Ask sooner if you have tingling, numbness or weakness in the hand, as that suggests the cyst is pressing on a nerve. Go to an emergency department if your hand or fingers turn pale, cold, white or blue, or if you suddenly lose feeling or movement in the hand after an injury. These are rare with a ganglion, but they need same-day care. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Wrist ganglia are worth the extra reading because the choice is genuinely between accepting a recurrence risk and accepting an operation, and the numbers behind that trade are clear enough to decide on. ### Aspiration recurs; excision does not, as often The two active treatments are drawing the cyst out with a needle, and removing it surgically along with its stalk. Pooling 2,239 patients, open surgical excision offers a significantly lower chance of recurrence than aspiration. Arthroscopic excision has produced promising results, but comparative trial data are limited and have not demonstrated its superiority [1]. The mechanism explains the difference. A ganglion is not a free-floating sac of fluid; it connects by a stalk to the underlying joint capsule, and the joint keeps producing the fluid. Aspiration empties the reservoir and leaves the source, so refilling is a common outcome rather than a treatment failure. Excision aims to trace and remove the stalk at its origin. ### Keyhole and open removal perform alike Where excision is chosen, the approach has been compared directly. Across 910 patients, arthroscopic and open approaches have comparable outcome profiles for recurrence and complications, with the authors calling for standardised, adequately powered studies [2]. That places the decision on secondary grounds, scar, surgeon familiarity, and whether other intra-articular pathology needs inspecting at the same time, rather than on recurrence risk. ### Nobody agrees on what to do afterwards, and it may not matter A small, honest finding. A systematic review and survey of hand surgeons found them divided on whether to immobilise the wrist after dorsal ganglion excision, and in terms of functional outcome there is no compelling data to suggest one strategy is superior [3]. It is worth knowing that instructions varying between surgeons here reflects genuine equipoise rather than one of them being wrong. ### The strongest argument is often for doing nothing None of the above establishes that a ganglion should be treated. These are benign cysts. They frequently fluctuate in size, and a proportion resolve without any intervention. They do not turn into anything else. That reframes the decision. The reasons to treat are pain, interference with wrist movement or grip, pressure on a nearby nerve, or a size that genuinely bothers the person, not the existence of the lump. Given that aspiration carries a meaningful recurrence rate and excision carries the risks of an operation on a joint capsule, watchful waiting is a legitimate first position, and one worth stating explicitly rather than treating as a failure to act. The exception is a ganglion causing nerve symptoms, numbness, weakness, or pain radiating into the hand, where the cyst is compressing a structure that does not tolerate it indefinitely, and watchful waiting is no longer the low-risk option. --- ### Wrist Ganglion Excision URL: https://www.cqupperlimb.com/education/wrist/wrist-ganglion-excision/ Region: wrist · operation Ganglion excision — when to consider surgery, arthroscopic vs open approaches, and expected recovery. ## Why this operation has been suggested Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. A wrist ganglion is a fluid-filled lump near the wrist joint. Removing it is called excision. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your visit we take a history, examine your wrist and arrange imaging if it is needed. Most wrist ganglions are first treated without surgery. We usually try activity change, hand therapy, splinting or draining the lump with a needle. Surgery comes next when those steps have not given you enough improvement. About 40% of wrist ganglions shrink on their own over the first 6 years, so waiting is often reasonable at first. Draining the lump with a needle usually does not stop it coming back, while surgical removal has about a 10% recurrence rate. The operation aims to remove the lump and ease your pain so your wrist works well again. ## Before the operation Most people need little preparation. You will be told not to eat or drink for 7 hours before surgery. We ask for 7 hours rather than the usual 6 so you can be brought forward if the theatre list runs early. Your surgeon will tell you which medicines to stop and when, and you should bring a list of everything you take. Arrange for someone to drive you home afterwards, and wear loose, comfortable clothing. Imaging such as an X-ray, ultrasound or MRI scan may already have been done to plan the operation. If you have other medical conditions, you may need blood tests or a review with the anaesthetist. ## On the day You arrive at the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You meet the anaesthetist there. This operation is done under general anaesthetic. You will be fully asleep for the operation. Some patients may also have a regional nerve block for post-operative pain relief; the anaesthetist decides on the day based on your individual circumstances. You are then taken into the operating theatre, where the operation is performed. You wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery. Most people go home the same day. If you do go home, someone must drive you, as arranged before surgery. You will be given instructions about caring for your wrist and about your follow-up visit before you leave. ## What the operation involves The operation removes the ganglion, which is the fluid-filled lump, along with the small stalk that connects it to the wrist joint. Removing that stalk matters, because leaving it behind makes the lump more likely to grow back. Where your surgeon works depends on where the lump sits. For a lump on the back of the wrist, the operation is done through two or three small keyhole cuts, each about 1 cm long. A thin camera is passed into the wrist joint so the surgeon can see inside and remove the lump and its stalk. For a lump on the palm side of the wrist, the operation is done through one open cut over the lump. The surgeon carefully separates the lump from nearby structures. On the palm side, the lump often sits close to an artery that supplies blood to the hand, and sometimes wraps around it, so this part of the operation is done slowly and gently. Your surgeon will also check beforehand that blood flow to your hand is healthy through both of its main arteries. Once the lump is out, the cuts are closed with stitches. A dressing goes over the top, and you keep that dressing on for about 10 days. Your surgeon will encourage you to start moving your wrist early, within the first 2 weeks after surgery, because gentle movement helps prevent stiffness. ## After the operation This is usually a day case, so you can expect to go home the same day, although occasionally patients stay overnight. Someone should stay with you for the first 24 hours. You may feel some pain around the cuts; simple pain relief usually settles it. Keep your hand raised on a pillow when resting to ease swelling. You can move around the house as soon as you feel steady, and gentle wrist movement is encouraged early. We leave the dressing on for about 10 days; please do not take it off before then unless we tell you to. We change or remove it when we see you. Most people are driving again within two to three weeks, once they can hold the wheel comfortably. ## Recovery For the first few days your wrist will be sore and a little swollen around the cuts. Simple pain relief usually settles this, and keeping your hand raised on a pillow helps the swelling go down. The discomfort eases steadily over the first couple of weeks. You will keep the dressing on for about 10 days, and we change or remove it when we see you. Gentle wrist movement starts early, within the first 2 weeks, because moving soon helps prevent stiffness. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Your hand therapist will guide your exercises and check your movement and grip as they return. You can move around the house as soon as you feel steady, and you will use your hand for light tasks as comfort allows. As the swelling settles, everyday activities become easier. Once you can grip without pain, you will find writing, eating and dressing feel normal again. Driving usually resumes within two to three weeks, once the wound is comfortable and you can hold the wheel comfortably; see our page on driving after upper-limb surgery. Most people are back at their usual work and activities as movement and strength return. Recovery varies between individuals, so your timeline may differ. Your surgeon and your hand therapist will guide you at each visit, and you can expect steady improvement as your wrist settles. ## What can go wrong Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early. The lump can grow back after surgery. You might notice the same soft bump returning near your wrist, sometimes weeks or months later. If you see or feel it coming back, bring it up at your next review. Your surgeon can talk you through the options if it needs further treatment. Some people are left with pain in the wrist after the operation. This is more likely if your wrist was painful before surgery, or if your job or sport needs strong, forceful bending back of the wrist. The pain can feel like a deep ache that flares with activity and does not fully settle with simple painkillers. Some people also find their hand does not work as smoothly as they hoped, with grip or daily tasks feeling harder than before. If pain or weakness lingers past the early healing period, tell your surgeon at review so hand therapy or other steps can be considered. Injury to the tendons that straighten the fingers is a rare problem during keyhole surgery on the back of the wrist. You would notice this as trouble straightening one or more fingers, or a finger that hangs lower than the others. If you cannot straighten a finger properly, contact the clinic straight away. For a lump on the palm side of the wrist, there are rare problems linked to where the lump sits near an artery that supplies blood to the hand. Warning signs include a hand that looks pale, blue or cooler than usual, or numbness and tingling that will not settle. If you notice any of these, go to the emergency department rather than waiting. The complications table on this page lists typical rates if you want the specifics. ## When to call us Call us if you have a fever, or the skin around your cuts becomes more red, swollen or starts leaking fluid. Call us if your pain keeps getting worse instead of easing, or if you cannot straighten a finger. Go to emergency if your hand turns pale, blue or feels cold, if you lose feeling in your hand, or if you cannot move it. Also go to emergency if you have calf swelling or shortness of breath. ## Where to read more about the condition This page is about the operation itself. The condition it treats, including what the evidence shows about when surgery helps and when it does not, is covered in more detail on the Wrist Ganglia page. --- ### Wrist Ligament Injuries URL: https://www.cqupperlimb.com/education/wrist/wrist-ligament-injuries/ Region: wrist · condition Wrist ligament injuries—common causes, symptoms, diagnosis, and treatment options (conservative vs surgery). ## What you're feeling A wrist ligament injury usually follows a fall onto an outstretched hand, a twist, or a heavy load through the wrist. The pain can sit on the thumb side of the wrist, or on the little-finger side, depending on which ligament is hurt. Some people feel a click or a clunk when they move the wrist sideways. The wrist may feel weak, and grip strength can drop. Swelling often appears over the injured area, and it can be worse if some time has passed since the injury. Certain movements tend to stir the pain up. Bending the wrist towards the little finger, twisting the forearm, or loading the wrist with your body weight can all make it worse. Rest and keeping the wrist still often settle it. In the first days after an injury, moving the wrist is usually limited by pain. After a longer time, the wrist may still move normally but hurt at the end of the range, or grind slightly. Daily tasks that need a firm grip or a loaded, bent wrist become the hard ones. Pushing up from a chair, carrying shopping bags, turning a door handle under load, or catching yourself when you slip can all send pain through the wrist. Some people notice the wrist is stiff on waking, or aches after using it. Pain that wakes you at night, or that will not settle over weeks, is worth having looked at. Watch for a few warning signs. Go to the emergency department the same day if your hand or fingers turn pale, cold, white or blue, if you suddenly lose feeling or movement in the hand after an injury, if the skin is broken over the injury with bone showing or an obvious deformity, or if the hand becomes hot, red, swollen and painful, especially with a fever. You do not need a GP referral for that. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using the hand, see your GP or ask for a specialist review. If you cannot reach the clinic after hours or on a weekend, go to your nearest emergency department. ## What's actually happening Your wrist is a small, busy joint. Eight small bones sit between your forearm and your hand, arranged in two rows. Ligaments, which are strong bands of tissue, hold these bones together and keep them moving as one unit. When you fall onto your hand or twist the wrist hard, one of these ligaments can stretch or tear. Two ligaments do most of the work of holding the two rows together. One joins the scaphoid and lunate bones on the thumb side. The other joins the lunate and triquetrum bones on the little-finger side. If one of these tears, the bones it was holding start to move separately instead of together. That is why your wrist can click or clunk, and why it feels weak or gives way under load. There is also a cushion of tough, rubbery tissue on the little-finger side of the wrist, called the triangular fibrocartilage complex. Think of it as a gasket between the two forearm bones and the small bones of the wrist. It cushions the joint and keeps everything steady when you twist your forearm. A tear here causes pain on that side, often with a catching feeling. Some ligaments sit outside the joint and some inside it. The ones outside act like guide ropes holding the bones in place from a distance. The ones inside knit the bones of each row directly to each other. A tear in either type lets the bones drift out of line. Over time, bones that move the wrong way can wear against each other and the joint can become stiff and sore. The wrist also has a limited blood supply to some of these small bones, which is one reason some ligament injuries are slow to settle and worth assessing early. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, matches the treatment to your specific injury. Some wrist ligament injuries heal without an operation, and others need surgery soon after the injury, so a prompt assessment matters. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At the clinic we take a history, examine your wrist, and arrange imaging where it is needed to work out which ligament is hurt and how far it has torn. Some injuries settle without surgery. A mild stretch of a ligament can be treated with a cast that holds the wrist still while it heals. A fresh tear of the cushion of tissue on the little-finger side can also be managed first with a splint and anti-inflammatory medicine, which eases pain and swelling. Hand therapy aims to restore strength and movement, and gentle use of the hand for light daily tasks helps once healing allows it. Surgery is considered when the ligament has torn right through, when the small bones of the wrist have shifted out of line, or when an injury is found soon after it happened and needs to be repaired before the wrist stiffens. Many of these operations are done through keyhole surgery, where a small camera is placed inside the wrist to see the injury directly and repair it. Some tears need a small open incision instead, and long-standing tears may need a tendon graft to rebuild the ligament. We will talk through which option suits your injury, and decide together on the plan. After any operation, your rehabilitation is hand therapy, not physiotherapy. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation. Ruby directs your exercises and makes any splint you need during recovery. ## What to expect The outlook depends on how badly the ligament is torn and how soon it is treated. Some mild injuries settle with rest and a splint or cast over weeks. Others keep causing pain and weakness until they are properly assessed and repaired. A wrist that is left with torn ligaments can stay unstable, and the bones can drift out of line and wear against each other over the years. Recovery is gradual rather than sudden. In the first weeks the wrist is often stiff and weak, and everyday tasks like carrying shopping or pushing up from a chair can still stir the pain. Over the following months, movement and grip strength usually return bit by bit. After surgery to rebuild a torn ligament on the thumb side of the wrist, people typically regain about 44 degrees of bending forward and 58 degrees of bending back, and grip strength around 88% of the other hand. Some people notice finger extension stays poor for more than 3 months after an injury around the base of the hand, even when the wrist itself recovers quickly. It is worth being honest about what treatment can and cannot do. After a reconstruction for a long-standing tear, the wrist is steadied and made more comfortable, but it is not returned to being a normal wrist. Most people get a wrist that works for daily life with less pain and better strength. If surgery is delayed for years and arthritis has already set in, the results of rebuilding are generally poorer than when it is done earlier, so it pays not to wait too long. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. If you cannot reach the clinic after hours or on a weekend, go to your nearest emergency department. ## When to see someone Some wrist ligament injuries are emergencies, and some are slow-burning problems that still deserve an early appointment. Go to an emergency department the same day if your hand or fingers turn pale, cold, white or blue, if you suddenly lose feeling or movement in the hand after an injury, if the skin is broken over the injury with bone showing or an obvious deformity, or if the hand becomes hot, red, swollen and painful, especially with a fever. You do not need a GP referral for that. A badly swollen, painful wrist after a fall needs checking promptly even when you can still move it, because some serious injuries hide on ordinary X-rays. See your GP or ask for a specialist review if pain is not settling over weeks, is getting worse, wakes you at night, or stops you working or using your hand. The same applies if the wrist keeps clicking or clunking, feels weak under load, or gives way when you carry things. If you cannot reach the clinic after hours or on a weekend, go to your nearest emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Carpal ligament injuries are worth the extra reading because they include the wrist injury most often missed in an emergency department, one where the bones have visibly dislocated and the X-ray can still be read as normal. ### The perilunate dislocation and why it is missed The carpus is a ring of ligaments around the lunate. A high-energy fall can rupture that ring sequentially, so the rest of the carpus dislocates around a lunate that stays in place, or, further along the same spectrum, the lunate itself is extruded forwards. It is missed because of how it appears on a standard film. On the front-facing view the bones remain roughly in their normal outline and simply lose their orderly arcs; the dislocation is obvious only on the side view, where the lunate tips out of line with the radius and capitate. In a swollen, painful wrist after a fall, with attention on excluding a distal radius fracture, that side view can be under-scrutinised. The consequence of missing it is serious and time-dependent: the carpus stays dislocated, the ligaments scar in the wrong position, and the blood supply to the lunate is at risk. ### Operative treatment, and the question of the nerve Where an acute perilunate injury is treated surgically, the technique comparison across 880 patients found closed techniques may produce a smaller post-operative scapholunate gap and better wrist flexion-extension and functional scores than open surgery, though the authors are careful to note these findings may reflect different cohorts in terms of injury severity, leaving the causal relationship uncertain [1]. That caveat is important. Less severe injuries are more amenable to closed treatment, so a comparison of this kind partly measures which injuries were selected rather than which technique is better. A second question is what to do about the median nerve, which runs immediately in front of the displaced lunate and is often compressed acutely. There is a lack of consensus, arising from few studies with small samples, with the authors proposing carpal tunnel release only where median nerve symptoms are present at the time of surgery [2], rather than routinely. ### The instability that is not from an injury at all Not every unstable wrist has been damaged. Palmar midcarpal instability occurs in people with generally lax ligaments, where the carpus clunks as the wrist moves from a neutral position into ulnar deviation, often without any injury preceding it. The evidence for treating it non-operatively is limited to case reports and expert opinion, but proprioceptive awareness and neuromuscular rehabilitation show promise on the basis of analogous evidence in other joints, and are recommended as the first approach [3]. That reasoning by analogy is worth flagging as exactly that. It is, however, mechanically coherent: where ligaments are constitutionally lax, the muscles crossing the joint are the only remaining means of controlling it, and training their timing is the available intervention. This also explains why surgery is approached cautiously here, tightening ligaments in someone whose tissue is lax everywhere tends not to hold. ### The rest of the picture Scapholunate ligament injury, the commonest and most consequential of the carpal ligament problems, is covered on its own page, as is the arthritic pattern that follows an untreated one. Lunotriquetral injury, the equivalent tear on the little-finger side, produces ulnar-sided pain and a clunk, and is discussed alongside the other causes of pain in that region. --- ### Wrist Osteoarthritis URL: https://www.cqupperlimb.com/education/wrist/wrist-osteoarthritis/ Region: wrist · condition Wrist osteoarthritis — understanding symptoms, non-surgical options, and when wrist replacement might be considered. ## What you're feeling Wrist osteoarthritis is wear-and-tear in the joint. The smooth surface that lets the small wrist bones glide wears thin, and bone starts to rub on bone. The pain usually sits on the back or the thumb side of the wrist, and it can be hard to pin down exactly which spot it comes from. The pain tends to flare with use. Gripping, twisting a jar lid, turning a key, pouring from a kettle or leaning on your hand to push up from a chair can all set it off. Many people notice it after activity rather than during it, and some find it wakes them at night or aches first thing in the morning before it loosens up. As the joint stiffens, everyday tasks get harder. Loading the wrist, for example when you rise from a low chair or get out of bed, can hurt. Fine hand movements that need a stable, comfortable wrist become slow or awkward, and you may find yourself avoiding tasks you used to do without thinking. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. If you cannot reach the clinic, for example out of hours or on a weekend, go to your nearest emergency department. ## What's actually happening Your wrist is built from eight small bones in two rows. They work together as one smooth-moving system, and the row closest to your forearm acts a bit like a cushion between your hand and your arm. When you lean on your wrist or grip something hard, most of that load passes through the forearm side of the joint, and a large share of it funnels through the two bones nearest the thumb. In wrist osteoarthritis, the smooth gliding surface between these bones wears away. Bone then presses on bone, and the joint loses its even, rolling motion. The bones nearest the thumb are often where this starts, so pain with gripping, twisting and leaning on your hand follows from the wear itself. Wear also changes how the wrist shares out its work. As one bone shifts out of its normal position, the surface it glides on gets smaller and the load concentrates on a narrower strip of joint. That is why a wrist that once absorbed force evenly can now flare with everyday tasks. Stiffness sets in as the joint surfaces and their supporting ligaments lose their free glide. The wrist also depends on soft tissues that steady the small bones while they move. Ligaments are strong bands that hold bones together, and a folded cushion of tissue sits on the little-finger side of the joint to keep the forearm bones turning smoothly when you rotate your hand. When arthritis and wear disturb this arrangement, the wrist can no longer spread load and move at the same time as well as it used to. That is the problem your symptoms come from, and it is what treatment aims to settle. ## What we can do about it Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. Our assessment takes in your history, an examination, and imaging where it is needed. The first step is usually care you can do yourself. Changing how you use the wrist, easing off the tasks that set the pain off, and letting it settle over weeks rather than days all help. Hand therapy aims to keep the wrist moving and to build the strength around it so everyday loads hurt less. A splint can hold the wrist still during flares or during heavier work. We usually give these measures a fair trial before talking about anything further. Pain relief is the other mainstay. Simple pain medication and anti-inflammatories, taken as your GP advises, can settle flares and make activity more comfortable. Anti-inflammatories target the swelling and irritation inside the worn joint as well as the pain itself. If these steps have not given you enough improvement, surgery becomes part of the conversation. For advanced wear, the two options are fusing the wrist, which joins the bones so they no longer grind, or replacing the joint to keep some movement. Neither is automatically the right answer; the choice depends on your age, your work, and what you want the wrist to do. We will talk through both with you and decide together. ## What to expect Wrist osteoarthritis is a long-term condition. The wear in the joint does not reverse itself, so without treatment the pain usually keeps coming back with use, and stiffness tends to build slowly over months and years. Some people have quiet stretches between flares, but the underlying wear stays. The good news is that most people get real relief once the wrist is managed well. Settling the flares with rest, a splint, simple pain relief and hand therapy often makes everyday tasks comfortable again. Many people carry on for years with these measures alone. If surgery is needed later, both fusing the wrist and replacing it reliably settle pain and improve grip strength. Fusion is a durable option, and people are on the whole very satisfied with the results. Replacement keeps some movement, but it carries a higher rate of complications over time, mainly loosening of the implant, so the choice depends on your age, your work and what you want the wrist to do. Recovery after surgery takes patience. Early movement with a hand therapist helps you regain useful wrist and forearm motion sooner, with fewer therapy visits. Hand therapy after surgery is with Ruby Doolan at Extend Rehabilitation; she directs your therapy and makes any splint you need. Over the first weeks and months, pain and disability improve steadily, and grip strength becomes more dependable. Be aware that no operation restores entirely full wrist function, and a fused wrist gives up its movement in exchange for strength and comfort. Surgery also carries honest risks. Complications after wrist fusion happen often enough that you should know about them, most often because the bones have not fully knitted together or because the metalware causes irritation, and sometimes a further operation is needed to remove the plate. If a joint replacement wears out or loosens years down the track, converting it to a fusion is a safe and effective salvage. Your surgeon will talk through all of this with you before any decision is made. If your symptoms are not settling, are getting worse over weeks, wake you at night, or stop you working or using your hand, see your GP or ask for a specialist review. ## When to see someone Wrist osteoarthritis is a wear-and-tear problem, so the warning signs are about pain and function rather than danger. See your GP or ask for a specialist review if your wrist pain is not settling with rest and simple measures, if it is getting worse over weeks, if it wakes you at night, or if it stops you working or using your hand. Ask sooner rather than later if stiffness is building and everyday tasks like gripping, twisting a jar lid or leaning on the wrist have become hard or painful. A routine check-up often does not find the cause of wrist pain on its own, so it is worth describing exactly when the pain flares and what you can no longer do. If you cannot reach the clinic, for example out of hours or on a weekend, go to your nearest emergency department. ## In more depth Advanced reading: the deeper science (optional) This section goes further than you need for your own treatment decisions. Wrist osteoarthritis is worth the extra reading because it contains one of the clearest examples in hand surgery of a sensible-sounding idea that made outcomes worse, and because the choice between fusing and replacing the joint is closer than it is usually presented. ### Cutting more nerves makes the result worse, not better Wrist denervation treats pain without altering the joint. The nerve branches carrying pain sensation from the wrist capsule are divided, leaving the joint mechanically unchanged. It preserves movement and does not preclude anything later, which makes it an attractive option. The commonest version divides the posterior interosseous nerve alone. Since the anterior interosseous nerve also supplies the capsule, dividing both should logically give more complete relief. It does not. Across 325 patients, anterior plus posterior interosseous neurectomy does not offer greater advantages compared with isolated posterior neurectomy, and, more strikingly, the combined procedure seems to be associated with a paradoxical increase in the failure rate [1]. An intervention that does more and achieves less is worth pausing on. Whatever the mechanism, the finding is a caution against reasoning from anatomy to outcome, which is exactly the kind of reasoning that makes the combined operation sound better. The broader evidence for denervation itself is encouraging but soft: a trend towards positive outcomes for pain relief, return to work and satisfaction, with heterogeneity across the literature and a call for standardised outcome reporting [2]. ### Fusion and replacement are closer than they sound For advanced arthritis, the two definitive options are presented as opposites: fuse the wrist and lose all movement, or replace it and keep some. The evidence puts them nearer together than that framing suggests. Across 961 patients, both wrist arthrodesis and wrist arthroplasty were effective at alleviating pain and improving grip strength, with comparable complication rates of 17% and 19%, functional improvement was observed after arthroplasty, but robust long-term follow-up data for replacement were lacking [3]. A network meta-analysis of 359 patients found replacement significantly improved DASH, pain and PRWE scores against pre-operative values in both inflammatory and non-inflammatory arthritis [4]. So both work, and both carry roughly a one-in-five complication rate. The real difference lies in what each leaves you with and how it fails. A fusion is durable and predictable, and its failure mode is nonunion, a defined problem with a defined solution. A replacement preserves motion, and its failure mode is loosening over years, in a joint at the end of a long lever with limited bone stock for revision. The long-term data gap is the honest limitation, and it is the reason age and demand weigh so heavily: a wrist replacement needs to outlive the person's need for it. ### Union rates after fusion are reliable Where fusion is chosen, the technical variations do not appear to matter much. Across 3,517 patients, there was no difference in union or complication prevalence between total wrist arthrodesis techniques, or between different treatments of the carpometacarpal joint, though the authors note the included studies were of low quality with high heterogeneity, limiting confidence [5]. ---