A Patient's guide to Excision of Lesion from the Upper Limb

Before your operation one of the surgical team will discuss the surgical procedure with you and answer any questions you may have. You will be asked to sign a form giving your consent to the operation. You will also be visited by an anaesthetist to discuss your anaesthetic.

It is important to start deep breathing and circulation exercises as soon as possible after you wake up. If comfortable you can then progress to gentle movement exercises of your joints. Once the anaesthetic has worn off you will be encouraged to mobilise as soon as you are able. This will prevent any post-operative complications. See exercises below.

Smaller Excisions / Excision Biopsies

Unless otherwise instructed, start using your arm normally as comfort allows. It is important to complete the exercises detailed overleaf to maintain/regain joint movement and strength.

Larger / Complex excisions

After your operation you may be required to wear a sling. If this is the case, you will be seen by an Occupational Therapist or Therapy Technician either before or after the operation to discuss post-operative restrictions and show you your exercises. If you do not have a sling, start using your arm normally as comfort allows.

Oedema

To manage post-operative swelling of the upper limb, elevate the affected limb at rest above your heart for at least 24 hours. Repeat elevation after 24 hours if swelling reoccurs.

The following exercises are typically given following this type of surgery however they may vary for each individual. If you don’t have a sling on when you wake up, you CAN commence the exercises without seeing a therapist unless you are told otherwise. Otherwise wait for a therapist or therapy technician to instruct you.

Deep breathing and circulation exercises

Shoulder

• In supine active assisted elevation
• External rotation
• Abduction

	Assist your operated arm to rotate outwards to neutral, in line with your body. Do not go beyond this unless directed to do so by your therapist  or therapy technician. Repeat_______ times. Assist your operated arm into the position shown as comfort allows. Do not go beyond            degrees. Repeat_______ times.
	This is a static exercise and the shoulder should not move. You will be providing gentle resistance from your non-operated arm. Gently push your operated arm outwards against your other hand. Repeat_______ times

Elbow

• Flexion / Extension
• Pronation / Supination

	Lie with your arm supported on a  pillow by your side. Use the other arm to straighten the operated arm down by your side. Ask someone to help if you can. Hold 10 secs. Repeat_______ times.   Sitting up, rest your arm on a pillow. Use your good arm to turn the palm of your hand face down. Hold 10 secs. Repeat_______ times
	Sitting up, rest your arm on a pillow. Use your good arm to turn the palm of your hand face up. Hold 10 secs. Repeat_______ times.

Wrist

•  Flexion
•  Extension
•  Ulnar deviation
•  Radial deviation

Forearm supported on a table with your hand over the edge and palm facing down. Let your hand drop down. Gently assist the movement with your other hand. Hold _______ secs. Repeat_______ times.     Hold the fingers of the hand to be stretched. Gently extend the wrist until you feel the stretching at the inside of the forearm. Keep your elbow straight. Stretch approx. 20 secs. - relax. Repeat_______ times.

Hold fingers and wrist straight. Bend wrist first towards the little finger and then towards the thumb. Repeat_______ times

Hand

• Finger flexion
• Finger extension
• Finger abduction
• Finger adduction
• Thumb full ROM

Wrist and fingers straight. Make a fist. Repeat_______ times.     Make a fist. Straighten fingers. Repeat_________ time

Your Occupational Therapist or Therapy Technician will discuss your personal care activities with you. Depending on your restrictions you may be provided with a Collar and Cuff for showering. Showering is advised as opposed to taking a bath to protect the wound and to avoid weight bearing on your operated arm. Your wound dressing is water resistant however you should avoid direct exposure to water when showering. Please be advised that your balance may be affected while wearing a sling and therefore consider safety aspects when stepping in/ out of the bath/shower or on uneven ground.

You will require loose clothes that preferably button down the front. Avoid clothing with small buttons, hooks and zips. Ladies may find a bra uncomfortable and may prefer to wear a strapless or front-fastening bra. Consider slip-on, easy fitting shoes.

You will usually be allowed to wear your sling over clothes but will need to check this with the team. Always dress your operated arm first and undress it last

Dressing Procedure in a Sling

Sit on the bed and place a pillow(s) under your arm so it is rested in the sling position.

Undo the fastenings at the elbow and wrist. This will release the shoulder strap. You do not need to undo the Velcro on the shoulder strap.

Gently slide out the sling from underneath your forearm by pushing down into the pillows. Keep the operated shoulder as still as possible.

Thread the sleeve onto your operated arm and take the garment as far up to the shoulder as possible. Keep the operated shoulder as still as possible.

You will then be able to put your non operated arm into the sleeve, bringing the garment up and around your shoulders to do the clothing up.

Replace the sling by gently sliding it under your forearm. Replace the fastenings. You may need to lean forward to do up the fastenings. For undressing complete this procedure in reverse.

If you have been provided with a Collar and Cuff for showering use the above procedure for guidance on how to put it on and take it off

If your operated upper limb is supported in a sling then be more careful when ascending / descending stairs to maintain balance. If you are concerned please speak to a member of the therapy team.

You should not attempt to drive until you are out of your sling, your pain has subsided and you feel confident in your own ability. If your ability has been affected you are required by law to contact the DVLA and you may need to inform your insurance company of your operation as your insurance may be invalid.

If you have a smaller excision you may feel able to return to work soon after your surgery dependent on your duties and job requirements. For larger excisions, it is advisable to discuss this with your Consultant at clinic or your GP. Your workplace Occupational Health department can help to identify a safe return to work. Ask your Occupational Therapist if you want to discuss this further.

The ability to return to leisure activities will depend on comfort, range of movement, strength and the procedure undertaken. If you have any specific questions regarding leisure activities, it is advised you discuss them with your therapist or at your post-operative clinic review. If you have any concerns regarding managing routine daily tasks at home, speak to a member of the therapy team.

It is important to remain as physically active as possible while undergoing and after treatment for cancer. This helps to manage side effects of treatment and lowers the risk of any other medical problems. If you have radiotherapy following surgery, it is important to regain as much movement and strength as possible prior to starting radiotherapy. Try to continue your exercises and stretches during radiotherapy and keep as active as possible.

 A surgical clinic appointment will be arranged post-op and this date will be sent to you at home.

Your Occupational Therapist or Therapy Technician will also refer you on for out-patient Occupational Therapy or Physiotherapy if indicated; you can usually choose where this takes place.

Excessive redness or inflammation of the wound must be reported to your GP or local A&E department. Alternatively if you have an allocated Sarcoma Clinical Nurse Specialist you can contact them for advice.

Scars form as a result of the natural healing process of the skin. The scar may stick to underlying tissues and limit movement at that joint. Massage can help soften the scar tissue and make it flatter, paler, cooler and smoother.

Massage can be commenced once all stitches are removed and the wound is closed; normally at about 6 weeks post-surgery. Use an unperfumed moisturising cream or lotion such as E45 or Bio Oil. Massage the scar and any tight/hard areas lying close to the scar for 5-10 minutes 2-3 times per day for optimum results. It may take several months to achieve a flat and movable scar. A scar can take up to 18 months to mature fully.

1. Start with small circles along the length of the scar either with your thumb or first two fingers. Use a firm even pressure.
2. Next, work horizontally across the scar- to and fro in small movements.
3. Then, work vertically along the length of the scar

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