If you are a patient at Spire Shawfair Park Hospital, Matthew will perform your surgery. 

Rings, jewellery, watches and nail polish

You should remove any rings, jewellery, watches and nail polish from the arm being operated on. Leaving these in place can increase the risk of problems such as infection, pain and swelling. If you cannot remove a ring, you should make contact with a jeweller to cut it off for you.

Fasting/nil by mouth

If your operation is to be performed under general anaesthesia, you will need to fast beforehand. This means no food or milky drinks for at least six hours before surgery, and no water for two hours beforehand. Small sips of water may be allowed, for example to take medication.

Please provide a full list of your medications so that Matthew, and your anaesthetist if needed, can give you the right advice. Most medicines can be continued as normal, and only a small number need to be stopped before surgery.

Although Aspirin can often be continued ahead of surgery, some blood thinners may need to be stopped in advance (discuss this with Matthew at your appointment).

Biologic medications for inflammatory types of arthritis (such as Etanercept, Rituximab and Filgotinib) will usually need to be stopped in the weeks before surgery and not restarted until your wound has healed at around day 14. Your rheumatology team will be able to advise you on when to stop this medication. Non-biologic rheumatological medications such as Methotrexate and Sulfasalazine can usually be continued alongside your surgery.

Most hand and wrist operations are carried out as a day case, so you will not usually need to stay in hospital overnight. In some cases, such as more complex procedures or if surgery takes place later in the day, it may be better for you to stay overnight so your pain and recovery can be monitored. Matthew will let you know if this is likely for your operation.

Matthew performs operations under local, regional and general anaesthesia and will advise you on the likely anaesthesia for your procedure.

Anaesthesia involves the use of medications (called anaesthetics) to prevent pain during surgery. Even if you have a general anaesthetic, Matthew will also use local anaesthesia around the surgical area to help keep you comfortable when you wake up. The effect of local anaesthetics can vary, but pain relief usually lasts between two and eight hours depending on the type used.

After surgery, you will be cared for by the nursing team, and by the anaesthetic team if required. While in hospital, you will be given the pain relief you need, and you will also be provided with medication to take home with you. It is normal to need regular pain relief for several days after surgery. More complex procedures, particularly those involving bones, joints or the wrist, often require pain relief for at least a few weeks.

Matthew will administer a local anaesthetic at the site of your surgery to numb the area. Regional and general anaesthesia are carried out by an anaesthetist, a doctor who specialises in anaesthetic techniques. If you have certain medical conditions, such as heart disease or breathing problems, you may need an additional assessment with an anaesthetist to check which type of anaesthetic is safest for you and to discuss any specific risks.

Local anaesthesia

Local anaesthesia uses an injection of local anaesthetic medication in the region of your surgery to numb a small area of your hand or finger. Local anaesthesia is administered using a small needle, and the numbing effect usually occurs within a few minutes. The numbing effect helps to avoid the feeling of pain, but the feeling of pressure and movement is usually maintained. You remain awake for the procedure (unless it is combined with other anaesthetic techniques such as sedation or general anaesthesia).

Some operations performed under local anaesthesia will also require a tourniquet to be applied to your arm or your finger (a tourniquet is a pressure device that reduces blood flow at the site of surgery). 

Arm tourniquets can be painful, and Matthew often utilises the Wide Awake Local Anaesthetic No Tourniquet (WALANT) technique, which permits some hand operations (like surgery for carpal tunnel syndrome to be performed under local anaesthesia without a tourniquet. Matthew co-authored the UK national guidance on Wide Awake Hand Surgery for the British Society for Surgery of the Hand (BSSH).

Examples of operations that are commonly performed under local anaesthesia include those for carpal tunnel syndrome, trigger finger, De Quervain’s syndrome and some finger operations.

You do not need to fast when local anaesthesia is the only type of anaesthetic being used (fasting is when you avoid eating or drinking before your operation).

Regional anaesthesia

Regional anaesthesia (also known as a block) uses an injection of local anaesthetic medication further up your arm (variably at the area around your upper arm, shoulder and armpit). It aims to switch off the nerves that transmit pain and often temporarily affects your ability to move or control your arm (requiring a sling). It is reserved for more complex surgeries and requires the expertise of an anaesthetist (a medically trained specialist in anaesthetic techniques). 

Regional anaesthesia is sometimes combined with sedation or general anaesthesia. Sedation relaxes you to a point where you may sleep, but you can wake up to communicate if needed.

Examples of operations that can be performed under regional anaesthesia include those for thumb base arthritis (trapeziectomy), cubital tunnel syndrome and some wrist operations.

You may need to fast before regional anaesthesia, especially if there is a chance it could be combined with sedation or a general anaesthetic. Fasting (sometimes called ‘nil by mouth’) means no food for at least six hours before surgery, and no water for the two hours before. Small sips of water may be allowed, for example to take medication.

General anaesthesia

General anaesthesia makes you unconscious and insensitive to pain. It is reserved for more complex surgeries and requires the expertise of an anaesthetist (a medically trained specialist in anaesthetic techniques). It is sometimes combined with regional anaesthesia.

Examples of operations that can be performed under general anaesthesia include thumb base arthritis surgery, cubital tunnel surgery and most wrist operations.

You will need to fast if you are having a general anaesthetic. This means no food for at least six hours before surgery, and no water for the two hours before. Small sips of water may be allowed, for example to take medication.

You should wear comfortable clothing on the day of your surgery. Most hand and wrist operations are performed as a day case, meaning you can go home on the same day. If you are expected to stay overnight, it’s a good idea to bring a wash bag with your toiletries, plus slippers and a dressing gown.

You will need to wait for surgery after your arrival at the hospital. To pass the time, it is advised that you bring some reading materials, such as a book or tablet device.

You should avoid bringing any valuables to the hospital. Jewellery should be removed in advance from the hand or wrist being operated on (including rings, bracelets, watches and any piercings).

On the day of your surgery, Matthew will meet you on the surgical ward to go over the surgical plan again. He will give you the chance to ask any questions to make sure your complete understanding. He will explain what to expect after the operation, including how long you might be in bandages or a cast and whether you’ll need hand therapy (physiotherapy). He will also go through the benefits and possible risks of the surgery and ask you to sign a consent form. A marker pen will be used to draw an arrow on your skin near the site of the planned surgery.

If you are having a general or regional anaesthetic, a consultant anaesthetist will review you as well. If your surgery is under local anaesthetic only, Matthew or an anaesthetist will give the injection while you are in the operating theatre, lying comfortably with your arm supported. Your name and date of birth will be checked several times on the ward and in the theatre before your surgery.

After the operation, you will return to the surgical ward directly if you have had a local anaesthetic, or via the recovery area if you have had a general anaesthetic. Matthew will aim to see you on the ward before you go home to confirm your first follow-up appointment and any further care instructions.

Elevation

Elevating your hand above the level of your heart (situated at the mid-level of your chest) for the first 24-48 hours will help to reduce swelling and unnecessary pain. Using your operated hand to touch the opposite shoulder is usually the most effective way to elevate it. When lying flat (such as at night) it is recommended that you support your arm (including the hand, forearm and elbow) on a pillow placed across one side of your chest. Arm slings generally fail to elevate the hand sufficiently but are sometimes used if you have had a regional anaesthetic block (a local anaesthetic injection around the nerves near the shoulder).

Wounds

After surgery, you should keep your skin wounds clean, dry and covered for at least 12-14 days. This helps them heal properly and reduces the risk of infection. Wounds are closed with sutures (stitches) that may need removing after 10-15 days, although some sutures are absorbable and will fall away on their own over a few weeks. It’s normal for healing wounds to feel itchy.

Matthew and the nursing staff will advise when your wound can be left uncovered and when it can safely get wet. You should avoid soaking the wound until it is watertight, usually around two weeks after surgery. You can use a plastic cover or bag (without holes) over your bandages or cast to protect it from water, or waterproof arm protectors such as those made by LimbO.

When the wound is first exposed to water, keep contact brief, like washing hands or showering, rather than soaking in a bath. During the first week of water exposure, dry the wound gently to avoid irritation. If the wound heals well, normal exposure to water is usually safe by around two and a half weeks, unless your arm is in a plaster cast.     

Plaster casts

If plaster or synthetic (resin) casts are to be used, they should be kept clean and dry for the duration of their use. Casts made of Plaster of Paris will lose their shape and support if exposed to water. If water enters beneath a cast, the dressings will fail and the skin will become soft (macerated), malodorous and risk wound issues like infection.

Splints

If splints are to be used, they should be kept clean and dry for the duration of their use. If water enters beneath a splint, the skin may become soft (macerated), malodorous and risk wound issues like infection. Some splints can be removed to permit skin care and drying, but you should discuss this with Matthew or your hand therapist (physiotherapist) first.

After surgery, your first follow-up appointment will usually be scheduled at around two weeks, typically between day 12 and 15. This appointment will involve checking your surgical site and removing any sutures (stitches). For some operations, absorbable sutures may be used, which do not need removal, though they may sometimes be trimmed. Even with absorbable sutures, a wound review is still needed to make sure your skin has healed properly and is healthy.

Depending on the type of surgery performed and your recovery, further appointments may also be required. Matthew will advise on the expected number and timing of appointments following your surgery.

Pain after surgery can sometimes affect your sleep. It’s important to take painkillers regularly in the days following your operation. Elevating your hand above heart level, for example by resting it on the opposite shoulder, can help reduce swelling and pain. When lying flat or in bed, support your arm (including the hand, forearm and elbow) on a pillow placed across one side of your chest. Sleeping on your side can make it harder to keep your hand elevated.

Your skin wound will usually heal in the first 10-14 days following surgery, and you must keep the site of surgery and any dressings dry and clean during this time. Skin wounds that are kept dry and clean will heal quickly and with a reduced risk of infection when compared to wet wounds. Any plaster or synthetic (resin) casts should also be kept clean and dry to avoid skin irritation or failure of the cast.

When bathing or showering, keep your hand or arm away from the water. You can use a plastic cover or bag without holes over your bandages or cast to protect them. Alternatively, waterproof arm protectors made by LimbO and other manufacturers can be used.

Matthew will advise on the expected timeframes and confirm when your skin is sufficiently healed to get wet, for example when washing your hands or showering. A review of your surgical site is usually scheduled around two weeks after surgery.

The need for hand therapy (physiotherapy) after surgery depends on the procedure performed. Some operations, such as those for carpal tunnel syndrome or trigger finger, usually do not require formal hand therapy, though Matthew will suggest simple exercises to aid recovery and prevent stiffness. Other procedures, like surgery for Dupuytren’s disease or certain wrist conditions (for example scaphoid non-union, arthritis or ligament injuries), often require routine hand therapy. Some operations, such as a trapeziectomy for thumb base arthritis, may require hand therapy in some cases. Matthew will advise based on your expected recovery and any symptoms, such as pain or stiffness.

Complications after hand surgery are uncommon, but they can still happen. The most common effects of surgery include temporary pain, swelling or bruising around the surgical site. You should also expect one or more skin scars.

Alongside the general risks of surgery outlined below, there will be additional risks specific to your operation. These additional risks will be discussed during your consultation and will also be included in your out-patient letters and correspondence.

All complications are significant events, but most can be treated successfully to minimise their long-term effects. Around 1 in 2000 patients can experience a major complication that can be life-threatening or result in long-term or permanent loss of function of the hand or arm.

General risks (most hand operations will include these risks):

Infection

Infection is a rare but serious complication, affecting about 1 in every 100 patients, and requires urgent medical attention. Signs include redness, swelling, increasing pain, fever and loss of function, such as difficulty moving the hand. If you notice these symptoms, contact your GP, attend Accident & Emergency or seek urgent medical advice.

Infections are treated with antibiotics and, in rare cases, a further operation may be needed to clean the wound. Infection can sometimes lead to significant loss of function. To reduce the risk, a dose of antibiotics is sometimes given at the start of surgery, particularly for procedures involving joints or bones.

Occasionally, redness may appear around the sutures due to normal inflammation, which usually settles after the stitches are removed and does not require treatment.

Bleeding

Persistent bleeding is occasionally seen after surgery and is more common in patients taking blood thinning medication like Aspirin, Clopidogrel or Apixaban. Some operations may result in mild bloodstaining of the surgical dressings in the first hour or so and this will usually settle with hand elevation and localised pressure. A change of dressing is occasionally required and rarely a second operation to stop the bleeding.

Pain

Pain and tenderness at the site of surgery is expected in the weeks and few months following surgery. Painkillers will often be advised or prescribed at the time of your surgery, with many operations requiring only simple painkillers (like Paracetamol or Ibuprofen) and others requiring stronger or opiate-based medications (like Codeine Phosphate or Co-Codamol). Very rarely, a chronic (longer-term) pain syndrome can develop that can be difficult to treat (see Complex Regional Pain Syndrome).

Wound issues and dehiscence

Skin wounds should be kept clean, dry and covered for at least 10-14 days after an operation, which will allow satisfactory wound healing and reduce the risk of infection. Pressure at the site of surgery should be avoided so that the skin can heal. If one or more of the sutures fail, the wound can gap and remain open (termed dehiscence). If open partially, the wound will be kept covered and allowed to heal, with some widening of the scar to be expected. The risk of wound dehiscence is increased in those with poorly controlled diabetes or when using walking aids, like a frame or stick.

Scars

Surgical wounds heal with scars, which can be tender at first. Scars usually become less tender within two to three months and less red over 6-12 months. Rarely, scars may remain tender for longer. Scars over joints, like the wrist, can take longer to settle.

Scars are often numb because tiny nerve endings in the skin are cut during surgery. This numbness can be permanent but usually does not cause problems. Sometimes scars can become raised or lumpy, known as hypertrophic scars, which can affect appearance and, rarely, cause stiffness. These lumpy scars usually soften and settle over 6-12 months, but not always. Once healed, massaging scars with a moisturiser can help improve their appearance and sensation.

Stiffness

You will be advised when it is safe to start moving your hand and fingers after surgery. It is important to move them, particularly fingers that are not in a dressing, cast or splint, to prevent stiffness and maintain range of movement.

As your skin and deeper surgical wounds heal, scar tissue forms. This tissue can stick to structures such as tendons and nerves, which may limit movement. Early movement helps these structures glide properly and reduces stiffness.

For fingers not covered by dressings, exercise them by making a full fist and then straightening them fully, repeating this 10 times every 30 minutes. Some patients may also require hand therapy (physiotherapy) after surgery.

Altered grip strength

Many operations in the hand and wrist may affect grip and pinch strength, especially during the recovery phase in the months following surgery, and sometimes long-term. Sometimes reduced grip strength is expected, including after carpal tunnel decompression and trapeziectomy for thumb base arthritis. If plaster casts or splints are to be used, reduced grip strength will be common in the weeks and months after their use due to the rest and reduced muscle activity during immobilisation.

Nerve, artery or tendon injury

There is a small risk of injury to arteries, nerves and tendons during hand and arm surgery. Scars are often numb afterwards because tiny nerve endings at the skin surface are cut, which usually does not cause problems. Some bleeding during surgery is expected from small blood vessels and will stop during or shortly after the procedure.

Major nerve damage is rare. More commonly, nerves may be stretched or bruised, which can cause temporary changes in sensation or occasional weakness. Permanent nerve damage or complete division of a nerve is extremely rare but can result in long-term pain, numbness and reduced function. Rarely, nerve injury can be caused by an arm tourniquet.

Major artery injury is also rare. In very rare cases, a blood vessel may be damaged, requiring further surgery to repair it or stop bleeding, and in extremely rare circumstances could affect the blood supply to a finger or thumb. Arterial injury can also very rarely be caused by a tourniquet.

Tendon damage is very rare and can usually be repaired surgically, though it may sometimes lead to stiffness or reduced function.

Complex Regional Pain Syndrome (CRPS)

Although very rare, around 1 in 2,000 patients may experience this severe pain syndrome in the weeks following a hand operation. This serious complication causes severe pain (out of proportion to that expected), increased sensitivity, swelling and stiffness in the hand. It is treated with physiotherapy and medical therapy (including neuropathic-type painkillers) and can take up to two years to improve. The cause of CRPS is not well understood and long-term pain and disability is common. 

Compartment syndrome

This is very rarely seen following hand surgery and is a consequence of swelling within muscle compartments of the hand and arm that can lead to irreversible nerve and muscle damage if not diagnosed and treated promptly. Typical symptoms include severe pain (out of proportion to that expected) in the hours following surgery that does not respond to strong painkillers. It can also cause pins and needles in the hand and fingers. The treatment is further surgery under a general anaesthetic to release the pressure within muscle compartments with the wounds closed several days later. Permanent disability of the hand and arm is expected following this condition. Compartment syndrome can very rarely be caused by an arm tourniquet.

Blood clots

Deep vein thrombosis (DVT) occurs when blood occupying the veins of the leg thickens and clots, and is usually due to lack of movement. These clots can detach and travel in the blood stream to the heart and lungs (termed a pulmonary embolus or PE) and can be life-threatening. For this reason, all patients having a general anaesthetic will require compressive stockings and sometimes a mechanical compression device attached to the lower limbs (calves) to promote blood circulation and prevent stasis. DVT and PE is extremely rare after hand surgery (it is far more common after lower limb surgery), and is seen in around 1 in 10,000 patients. The risk of blood clots will increase with the duration of surgery under general anaesthetic, with dehydration, and if there is a personal or family history of blood clots (please inform Matthew if this applies to you).