OA of the base of the thumb

Trapeziectomy

Day of Surgery

• Check circulation, sensation and movement.
• May have a cast in situ dependent on surgeon’s protocol.
• Patient provided with post operative information sheet if they do not already have one.
• Fit note provided for the duration of expected absence if required.

First Review Clinic (7-14 days)

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

Subsequent Review Clinic (4-6 weeks)

• Remove cast if required.
• Re-apply cast if required.
• Encourage ROM
• Reassurance to be given that it will be sore, no damage is being done.
• Don’t force the movement as they will be acute.
• Encourage regular use of analgesia if required.
• Thumb range of motion exercises active and active assisted.

• Scar Care

• Once wound has healed gently massage with an emollient hand cream 3-4 times daily.

• Returning to work
  • Avoid dirty environments and ensure dressing remains dry.
  • Heavy lifting should be avoided for 12 weeks.
• Driving
  • Once feels safe to do so and they feel they are in complete control of the car.  Advice that they may want to check with their insurance company.

• Further review if required, depending on clinical progress.

Trapeziectomy

This information is intended for use with all patients who have had surgical removal of the trapezium bone with or without soft tissue reconstruction.  Most patients, who have undergone this operation, have done so because they are in severe pain and because conservative options have failed.

A number of these patients require minimal intervention, others will require more. To ensure effective and efficient management the clinician should have knowledge of:

• How to actively and passively mobilise
• The frequency of exercise
• The period of time the patient should continue to do their aftercare and exercises.

The patient will usually be referred to therapy, if required, once their cast has been removed.  The time a patient is in cast varies between surgeons.  Please check operation notes or recent clinic letter to confirm this timeframes.

The aim of therapy is to:

• Relieve pain

• Improve thumb position

• Improve active range of movement

• Improve pinch

• Improve grip

• Improve function

Functional outcome measures such as the DASH or quick DASH can be used to record functional outcome if desired.

First Appointment

1.ROM

• Active flexion/ extension of wrist

• Active flexion/ extension of non affected digits

• Active flexion/ extension of IP joint

• Gentle active thumb movement into opposition and circumduction as pain allows.

• Finger abduction and adduction

• Maintain range of movement of elbow and shoulder

2. Exercises

Refer to exercises in the patient information leaflet (reference number to be added once confirmed by medical illustrations).  Remove splint (if patient has been advised to wear one) to perform exercises.  Additional exercises or modified exercises can be issued as determined by assessment and clinical need.

Regularity of exercises to be at therapist discretion, taking into consideration any post surgery inflammation and oedema. Aim for exercises to be done 4 times per day.

3. Education/ Advice

Aims:

• Manage/limit oedema

• Promote good scar management

• Recover function

Hand Care

• Oedema management:

  • Patient is advised to position the forearm in elevation using pillows when sitting/ sleeping.

  • Patient is advised to maintain range of movement of elbow and shoulder regularly.

• Scar management

  • Once the wound is healed and there is no signs of infection, massage of the scar with a non perfumed emollient should begin. Patients should be taught to use circular motions along the scar working distal to proximal to help reduction of oedema.

  • If there is any concern regarding the possibility of infection e.g. foul smell, oozing wound, redness, temperature, increased pain, this must be checked ASAP with a more experienced member of staff, the dressing clinic, a medic or practice nurse.

Function

• Advice on light activities only

Driving

• Patient can return to driving once cast is removed, as pain allows and they feel that they are in complete control of the car. Advise that it is their responsibility to check with their insurance company before returning to driving.

4. Splint

Splinting protocols and the types of splints used vary between hospitals and surgeons, please check local protocols.

A small piece of tubi net can be worn under the splint to absorb perspiration.

If you have any splinting questions or concerns please contact your local hand therapist (refer to details at bottom of page).

Subsequent appointments

All the above advice and exercise is re-iterated and exercises progressed or modified as determined by clinical need and as pain allows.

Exercise progression

Cast removal - regain thumb range of movement and maintain/ regain all other joint range.

Improving range - continue exercise regime and progress onto strengthening as pain allows

12 weeks onward – Return to all activities where possible

Splint

The point at where discontinuation of the splint can commence varies between surgeons, please check local protocol.

Gradual withdrawal of splint for light activities is where you should guide your patient to begin. This can be increased and the patient can then be gradually weaned off the splint as pain allows.

Summary

• Every patient is different. Some will require minimal intervention, others will require more.  Assess and arrange for ongoing therapy, as necessary following local physiotherapy referral protocols.

• This operation is a huge insult on the hand and it can take up to 9 months for the full benefit to be attained.

• Some patients will inevitably encounter unexpected complications. If in doubt or any concerns please contact your local hand therapist.

Problematic Pain

Consult the Pain Service section within Exit Routes  [links to CKP can we link to Exit routes on RDS?] for information and guidelines on diagnosis and management of Complex Regional Pain Syndrome.