Recovery from injury and surgery
Because we have such high demands on our hands and they are in constant use, it generally takes longer to recover than what you may think! Hand function is incredibly complex and intricately balanced so the goal for most injuries and surgery is to decrease pain and regain function; some ongoing symptoms are usually to be expected.
Most hand and wrist injuries take roughly 3 to 6 months to recover but whenever possible hand use begins early. By 6 to 8 weeks most everyday tasks should be possible with the injured hand. In many conditions, the hand continues to improve for up to 12 months.
Patient age
Children are more capable than adults of making a ‘complete recovery’ due to their amazing ability to remodel bone and soft tissues as well as their cerebral adaptability. Unfortunately, recovery is slower as we get older and less likely to be complete, particularly when it comes to soft tissue injuries. For example, in the elderly, microsurgical nerve repairs are unlikely to result in good nerve function no matter how nicely they are performed.
Bone healing
With fractures (or corrective osteotomy), bone healing time stays roughly the same once you are an adult, but the bone does lose density as we age; this increases the risks of surgery, particularly with regard to loss of fixation (fracture moving or settling during the healing process).
Bone is a living substance and is actually very good at healing itself, particularly in the hand and wrist where the blood supply is excellent. Surgery aims to improve the fracture position (correct anatomy) and speed up or make more reliable the healing and recovery to optimize the result. That being said, it is usually the associated soft tissue injury (ligaments etc.) that take the longest time to settle and cause ongoing symptoms. The length of recovery is directly related to the extent of the injury. In other words, severe and high energy injuries take much longer to heal.
Stiffness
Some stiffness is inevitable after hand and wrist injuries and surgery. After injury, scar tissue is produced, not only to heal injured structures but to protect from further injury and control pain. This leads to stiffness but it can impair function. It is important to understand that surgery also creates scar tissue and therefore can contribute to stiffness.
The degree of stiffness is directly related to the severity of the injury and the age of the patient. Genetics are also important; if you are ligamentously lax (flexible) then you may recover more movement. Hand therapy to encourage early motion is also important but with some injuries motion may be limited to allow tissues to heal. Dr Schick and your hand therapist will guide you to find the balance between early movement and immobilization to protect the injury and/or surgical repair enough to allow healing and this balance varies for different people and injuries based on the above.
Strength
People are always concerned about the lack of strength after hand and wrist injuries and/ or surgery but this is largely unfounded. With recovery the pain settles and strength returns. The aim of early rehabilitation is generally to regain motion. Strengthening exercises are only started once most of the soreness has settled. This is at 6 to 8 weeks post injury at the earliest. Trying to strengthen (eg. with a “squeezy ball”) soon after a painful injury or surgery is counterproductive and will risk further injury to healing structures.
Surgical wound care
There is a lot of variability between surgeons regarding post operative care of hand and wrist wounds. To minimize problems such as infection or wound breakdown, I base my advice on evidence and experience, while making things as comfortable and easy as possible for the patient.
Wherever possible I use dissolving sutures (vicryl rapide or subcutaneous monocryl) to avoid the need for removal. Sutures that do require removal (nylon) are still required in some parts of the hand and you will be advised at the time of surgery regarding this.
Dressings
After wound closure, a bulky non-stick dressing is used, combined with casts or splints were appropriate. The aim of the dressing is to place some compression on the wound/ surgical area and contain the small amount of wound bleeding that always occurs. It should be comfortable and not too tight. It is important the dressing +/- cast will allow use of any non injured digits; it is as small as possible while achieving the above.
The initial dressing will remain on for anything between 3 days to 3 weeks based on the type of injury and surgery. The dressings need to remain dry; use a taped plastic bag when showering and try to avoid heavy sweating. If the dressing becomes wet it should be changed in the rooms or by your hand therapist ASAP.
For conditions that require early finger mobilization (finger fractures or tendon repairs) you will see a hand therapist at day 3 to 5 post op to remove dressings, carefully clean the wounds and make protective (thermoplastic) splints.
For other conditions, dressings will remain on until the first post op review at roughly 1 week. For smaller procedures (eg. carpal tunnel and trigger releases) I am usually happy for you to remove your own dressings on day 5; at this stage normal (gentle) hand washing with soap and water is the best way to clean your wound. Pat dry the area well afterwards and then reapply a light dressing.
From 2 weeks, non perfumed moisturizer can be massaged into the wound twice daily; this decreases sensitivity and allows the scar to settle more quickly.
Antibiotics
A single dose of intravenous antibiotics is given at the time of surgery. There is no indication for ongoing (oral) antibiotics except for contaminated or infected non surgical wounds and then in most instances a 5 day course is adequate. Minor post operative wound infections may require antibiotics and you should contact the rooms if concerned. Some inflammation and bruising is common and reassurance is often all that is required. More serious deep infections are rare but usually require surgical washout (antibiotics will not cure these).
Wound cleaning
Although normal hand washing (and thorough drying) is good for wounds, submerging the wound (eg. bath, pool or the sea) can lead to infection if the wound isn’t completely sealed. This means the wound should look completely healed without any bleeding or moist spots. Time for this varies, but 3 weeks post surgery is usually safe and generally I would not recommend submerging the wound before this. If you are a keen swimmer and are not sure about your wound; please email a photo to the rooms and we can advise.
Scar management
When wounds are sutured the wound edges are everted to achieve optimal wound healing and the best scar possible. This results in the scar looking slightly raised until it matures which takes about 12 months. The scar will also be slightly red during this period and becomes pale only after maturity. With subcutaneous sutures (wrist wound closure) there may be some small lumps along the length of the wound; these are the interrupted deep sutures and resorb over time. Massage with moisturizer (non perfumed) helps the scar to settle and decreases scar sensitivity. Silicone is another good option; this can be bought from the chemist as an adhesive sheet then cut into narrow strips to cover the scar.
Pain syndromes (CRPS)
Only about 1% of patients with hand injuries and/ or surgery will develop a significant Complex Regional Pain Syndrome (CRPS). Mild CRPS is more common and cannot always be distinguished from normal post op pain and sensitivity.
Pain syndromes are much more common in patients that suffer from depression or anxiety. For elective surgery, this may be able to be addressed by your GP preoperatively. Evidence (in the literature) and experience has shown that the CRPS rate is also much higher in work cover or 3rd party claims, as well as with any ongoing legal action regarding the injury. Previous pain syndromes significantly increase the risk and any combination of these factors make some degree of CRPS quite likely.
It is important to understand that some wound and hand sensitivity is normal after an injury and it is only when this becomes severe (eg. disturbing sleep) that CRPS becomes a concern. Severe CRPS can result in a stiff useless hand; it should firstly be recognized and then treated early and aggressively.
When CRPS develops pain more severe than expected is usually seen early after injury or surgery. This pain is worse than expected from the injury and is combined with hypersensitivity and often an intolerance of casts or splints. There are skin colour changes, excessive swelling and stiffness gets worse over time instead of improving.
The best treatment for CRPS is prevention!
My approach is…..
If a pain syndrome is developing post injury then treatment is a combination of nerve pain medication and intensive hand therapy. Treatable conditions (such as carpal tunnel syndrome) need to be excluded or treated if present.
If becoming more severe, then pain team input (including a pain specialist doctor and psychologist) will be required.
Most hand and wrist injuries take roughly 3 to 6 months to recover but whenever possible hand use begins early. By 6 to 8 weeks most everyday tasks should be possible with the injured hand. In many conditions, the hand continues to improve for up to 12 months.
Patient age
Children are more capable than adults of making a ‘complete recovery’ due to their amazing ability to remodel bone and soft tissues as well as their cerebral adaptability. Unfortunately, recovery is slower as we get older and less likely to be complete, particularly when it comes to soft tissue injuries. For example, in the elderly, microsurgical nerve repairs are unlikely to result in good nerve function no matter how nicely they are performed.
Bone healing
With fractures (or corrective osteotomy), bone healing time stays roughly the same once you are an adult, but the bone does lose density as we age; this increases the risks of surgery, particularly with regard to loss of fixation (fracture moving or settling during the healing process).
Bone is a living substance and is actually very good at healing itself, particularly in the hand and wrist where the blood supply is excellent. Surgery aims to improve the fracture position (correct anatomy) and speed up or make more reliable the healing and recovery to optimize the result. That being said, it is usually the associated soft tissue injury (ligaments etc.) that take the longest time to settle and cause ongoing symptoms. The length of recovery is directly related to the extent of the injury. In other words, severe and high energy injuries take much longer to heal.
Stiffness
Some stiffness is inevitable after hand and wrist injuries and surgery. After injury, scar tissue is produced, not only to heal injured structures but to protect from further injury and control pain. This leads to stiffness but it can impair function. It is important to understand that surgery also creates scar tissue and therefore can contribute to stiffness.
The degree of stiffness is directly related to the severity of the injury and the age of the patient. Genetics are also important; if you are ligamentously lax (flexible) then you may recover more movement. Hand therapy to encourage early motion is also important but with some injuries motion may be limited to allow tissues to heal. Dr Schick and your hand therapist will guide you to find the balance between early movement and immobilization to protect the injury and/or surgical repair enough to allow healing and this balance varies for different people and injuries based on the above.
Strength
People are always concerned about the lack of strength after hand and wrist injuries and/ or surgery but this is largely unfounded. With recovery the pain settles and strength returns. The aim of early rehabilitation is generally to regain motion. Strengthening exercises are only started once most of the soreness has settled. This is at 6 to 8 weeks post injury at the earliest. Trying to strengthen (eg. with a “squeezy ball”) soon after a painful injury or surgery is counterproductive and will risk further injury to healing structures.
Surgical wound care
There is a lot of variability between surgeons regarding post operative care of hand and wrist wounds. To minimize problems such as infection or wound breakdown, I base my advice on evidence and experience, while making things as comfortable and easy as possible for the patient.
Wherever possible I use dissolving sutures (vicryl rapide or subcutaneous monocryl) to avoid the need for removal. Sutures that do require removal (nylon) are still required in some parts of the hand and you will be advised at the time of surgery regarding this.
Dressings
After wound closure, a bulky non-stick dressing is used, combined with casts or splints were appropriate. The aim of the dressing is to place some compression on the wound/ surgical area and contain the small amount of wound bleeding that always occurs. It should be comfortable and not too tight. It is important the dressing +/- cast will allow use of any non injured digits; it is as small as possible while achieving the above.
The initial dressing will remain on for anything between 3 days to 3 weeks based on the type of injury and surgery. The dressings need to remain dry; use a taped plastic bag when showering and try to avoid heavy sweating. If the dressing becomes wet it should be changed in the rooms or by your hand therapist ASAP.
For conditions that require early finger mobilization (finger fractures or tendon repairs) you will see a hand therapist at day 3 to 5 post op to remove dressings, carefully clean the wounds and make protective (thermoplastic) splints.
For other conditions, dressings will remain on until the first post op review at roughly 1 week. For smaller procedures (eg. carpal tunnel and trigger releases) I am usually happy for you to remove your own dressings on day 5; at this stage normal (gentle) hand washing with soap and water is the best way to clean your wound. Pat dry the area well afterwards and then reapply a light dressing.
From 2 weeks, non perfumed moisturizer can be massaged into the wound twice daily; this decreases sensitivity and allows the scar to settle more quickly.
Antibiotics
A single dose of intravenous antibiotics is given at the time of surgery. There is no indication for ongoing (oral) antibiotics except for contaminated or infected non surgical wounds and then in most instances a 5 day course is adequate. Minor post operative wound infections may require antibiotics and you should contact the rooms if concerned. Some inflammation and bruising is common and reassurance is often all that is required. More serious deep infections are rare but usually require surgical washout (antibiotics will not cure these).
Wound cleaning
Although normal hand washing (and thorough drying) is good for wounds, submerging the wound (eg. bath, pool or the sea) can lead to infection if the wound isn’t completely sealed. This means the wound should look completely healed without any bleeding or moist spots. Time for this varies, but 3 weeks post surgery is usually safe and generally I would not recommend submerging the wound before this. If you are a keen swimmer and are not sure about your wound; please email a photo to the rooms and we can advise.
Scar management
When wounds are sutured the wound edges are everted to achieve optimal wound healing and the best scar possible. This results in the scar looking slightly raised until it matures which takes about 12 months. The scar will also be slightly red during this period and becomes pale only after maturity. With subcutaneous sutures (wrist wound closure) there may be some small lumps along the length of the wound; these are the interrupted deep sutures and resorb over time. Massage with moisturizer (non perfumed) helps the scar to settle and decreases scar sensitivity. Silicone is another good option; this can be bought from the chemist as an adhesive sheet then cut into narrow strips to cover the scar.
Pain syndromes (CRPS)
Only about 1% of patients with hand injuries and/ or surgery will develop a significant Complex Regional Pain Syndrome (CRPS). Mild CRPS is more common and cannot always be distinguished from normal post op pain and sensitivity.
Pain syndromes are much more common in patients that suffer from depression or anxiety. For elective surgery, this may be able to be addressed by your GP preoperatively. Evidence (in the literature) and experience has shown that the CRPS rate is also much higher in work cover or 3rd party claims, as well as with any ongoing legal action regarding the injury. Previous pain syndromes significantly increase the risk and any combination of these factors make some degree of CRPS quite likely.
It is important to understand that some wound and hand sensitivity is normal after an injury and it is only when this becomes severe (eg. disturbing sleep) that CRPS becomes a concern. Severe CRPS can result in a stiff useless hand; it should firstly be recognized and then treated early and aggressively.
When CRPS develops pain more severe than expected is usually seen early after injury or surgery. This pain is worse than expected from the injury and is combined with hypersensitivity and often an intolerance of casts or splints. There are skin colour changes, excessive swelling and stiffness gets worse over time instead of improving.
The best treatment for CRPS is prevention!
My approach is…..
- Education and reassurance
- Adequate pain relief from the start
- Local anaesthetic infiltration or a regional block are used
- the anaesthetist will provide a script for strong pain killers if needed
- simple analgesia (panadol and anti-inflammatories) can be added to this if there is no contraindication
- ice packs (dry gel pack) and elevation should be used for the first 5 days or so
- Use the hand as normally as possible
- Within the confines of splints or dressings
- Avoid heavy lifting (eg. more than a cup of tea or coffee)
- Vitamin C 500mg (one tablet) daily for 6 weeks. There is some evidence (at least for distal radius fractures) that this decreases the risk or severity of CRPS.
If a pain syndrome is developing post injury then treatment is a combination of nerve pain medication and intensive hand therapy. Treatable conditions (such as carpal tunnel syndrome) need to be excluded or treated if present.
If becoming more severe, then pain team input (including a pain specialist doctor and psychologist) will be required.
