Shoulder Surgery Information for Patients

Peter Campbell - Shoulder Surgeon Shoulder Surgery Information for Patients

e have put this information booklet together aspects before making a decision, please arrange for you to assist you in understanding your another appointment by ringing the office. Wup coming operation. After you leave the office it is easy to be confused by all the information you have just received from Mr Campbell and his staff. There will be information that you have forgotten or questions that you forgot to ask. We hope this booklet helps you to better understand shoulder anatomy, what your operation involves, what to expect after your surgery, possible complications from having surgery and a general anaesthetic and an estimate of how much your surgery and hospital stay will cost. Please retain this booklet as it has relevant information for you for your post operative management. If after reading this booklet you wish to discuss any

Shoulder Anatomy And Functions

he shoulder joint is the most mobile joint in the body. To enable this Tdegree of mobility there is a large round ball (the head of the humerus) at the Collar Bone Acromioclavicular (A/C) Joint upper part of the arm and small flat socket (Glenoid) which is part of the shoulder blade. This is like a golf ball sitting on a Acromion golf tee. From a purely bony point of view this arrangement is inherently unstable. Shoulder Blade To confer stability to the shoulder the (Scapula) soft tissues that are attached around the shoulder joint have an integral function.

Coracoid Process To move the shoulder joint there are two groups of muscles. The first group of Humerus muscles are the prime movers and these are the large muscles that are attached to and move the arm bone. As the arm bone Glenoid moves another series of smaller muscles which all come from the shoulder blade act as guide ropes which hold the ball of the joint firmly against the socket no matter what position the arm is placed in. (scapula) arises a bony process Front which is called the spine of the Deltoid shoulder blade or scapula and it curves around to form the bony overhang of the shoulder. This is called the acromion. The collarbone (clavicle) joins on to the acromion and this joint between the acromion and the collarbone is known as the AC joint.

Pec Major The muscle arising from the deep surface of the shoulder blade is called the subscapularis and it inserts onto the front part of the arm bone just below the ball of the joint. The muscle that arises from above the spine is called the supraspinatus and the muscle that arises from below the spine Back Deltoid is called the infraspinatus. All of these tendons meld together as they attach to the bone around the ball of the shoulder joint. They form a cuff of tissue around the ball of the shoulder joint.

The anatomists who originally studied this part of the body thought that their main function was to rotate the arm so all of these muscles and tendons have been grouped together as the rotator cuff. As previously mentioned their main function though is not to rotate the arm but to maintain the ball firmly Latissimus Dorsi against the socket as the shoulder joint moves.

Anatomy and Functions All of these muscles and muscle which drapes over the their attachments are named shoulder joint and the latissimus You will note on the diagrams that anatomically and most of these dorsi which is the large muscle the tendons will have to move as names are derived from Latin. arising from the back which is the shoulder moves below the These muscles will be named in the climbing muscle. bony overhang of the shoulder the illustrations so that when you called the acromion and beneath see their names written in x-ray The muscles from the shoulder a ligament which connects the reports or any other investigations blade, are the pulleys and guide acromion to another bone at the or in operative reports you will ropes which hold the ball against front of the shoulder joint called understand what is being referred the socket and are named the coracoid process. Between to. The large muscles which are according to which part of the this bony arch and the tendon the prime movers of the shoulder shoulder blade they arise from. sits a lubricating sack called the joint are the pectoral muscles bursa. This is a normal structure at the front of the chest, deltoid At the back of the shoulder blade and it is present to allow the

2 Front Infraspinatus Back

Subscapularis Teres Minor

Rotator Cuff Tendons

Coracoacromial Ligament Anatomy and Functions and Anatomy

Supraspinatus

Infraspinatus

Subscapularis tendon to slide under this hard the movement of the arm. There across your body or back behind surface. This bursa is often is a second much smaller joint your body the joint slides. The injured or becomes thickened where the collarbone joins on acromioclavicular joint can be and inflamed with various to the bony overhang of the injured and it also can suffer problems of the shoulder and this shoulder and this is called the arthritis like any other joint. is called bursitis. AC joint. This joint also moves Disorders of the acromioclavicular but nowhere near as much as the joint are common and are a There are two joints around the shoulder joint itself. common cause of shoulder pain. shoulder region. The first is the They may occur in isolation or main joint which is the ball and Every time you lift your arm the in combination with the other socket joint which is otherwise collarbone rotates and there common shoulder conditions known as the glenohumeral joint. is movement at this joint and which are listed overleaf. This is the joint which produces every time you bring your arm

Acromioclavicular Bursa on top of Joint & Capsule Tendons

Coracoacromial Ligament

3 Shoulder Problems

Impingement decreases the subacromial space common ways of tearing the causing more pain and catching rotator cuff tendon are: One of the rotator cuff tendons when you use your arm. called the supraspinatus tendon 1. Frequent repetitive use of passes directly underneath Bony spurs also form on the your arm above shoulder height. the acromion and attaches to underside of the acromion. These This is common in trades people the top of the humerus. The spurs also causes catching and and manual workers. Over time space between the tendon irritation of the tendon and bursal and with repetitive rubbing the and the acromion is called the sack. Once again the end result is tendon begins to weaken and subacromial space and contains painful catching and decreasing eventually becomes worn. In a fluid filled sack called a bursa. range of motion of the shoulder some people this results in a This bursa acts as a lubricant for in any above shoulder activities. partial or full thickness tear of the tendon to move under the The surgical solution for this one or more tendons. acromion when you move your problem is an operation called arm. In some people the space an ACROMIOPLASTY OR SUB 2. A traumatic injury such between the tendon and the ACROMIAL DECOMPRESSION. as a fall onto your shoulder. The overhanging acromion is narrow. impact pulls the tendon off the The rotator cuff tendons and the Rotator Cuff Tear insertion point at the top of the adherent bursa can catch or be humerus. pinched when you raise your Tears in one or more of the arm. This can result in the bursal rotator cuff tendons are common 3. A degenerate tear which tissue becoming thickened and and there are different types or occurs over time. As we get inflamed. This then places more degree of tears to the rotator older so do our tendons and like pressure on the cuff tendons and cuff tendons. The three most many other areas in our body our

Supraspinatus Clavicle

Hole in Tendon Spur Common Shoulder Problems

Infraspinatus

Bursal Sack

Teres Minor Acromion

4 tendons lose their strength and Soft tissues surrounding flexibility. This natural process of wear and tear on the tendons can Glenoid eventually lead to a partial or full thickness hole in the tendon.

Instability

An unstable shoulder is precisely that, a shoulder joint that is loose and dislocates either completely Glenoid or partially. The capsule that (without Labrum) surrounds the ball and socket joint and various ligaments help stabilise and keep the shoulder Labrum torn off Glenoid Shoulder Blade (Scapula) Problems Shoulder Common joint normally aligned. Shoulder becoming detached from the produce pain and a feeling of instability is most commonly instability. caused by two different socket or (glenoid). The second category of patients present with problems. The first is post In some patients when they traumatic. This category includes generalised looseness of the joint. These people have flexible repeatedly dislocate their people that have had excessive shoulder they can damage force applied to their shoulder joints throughout their body and have had this all their life. People the bone along the side of the such as a tackle in a football glenoid, as well as tear off the game resulting in a dislocated with loose joints often develop problems with the shoulder labrum. To restore stability to this shoulder. This type of injury injury, surgery in the form of a results in the ligaments becoming where their shoulder starts to become excessively loose in one bone grafting procedure needs stretched and a stabilising to be performed. structure called the labrum or more directions and starts to Acromioclavicular joint Acromioclavicular (A/C) Joint arthropathy

The acromioclavicular or A/C joint is where the end of the clavicle (collar bone) meets the acromion. Strong ligamentous Humerus tissue and a capsule surrounds the joint. The end of the clavicle and the acromion is covered in cartilage to enable the two bones to slide and rotate against each other. When you move your arm this joint always moves. It is common to experience pain and problems from this joint. Most of these problems occur from arthritis or wear and tear of the cartilage in the joint, dislocation of the joint or fractures of the clavicle.

Subscapularis Tendon Biceps Tendon

5 Types of Shoulder Surgery

ACROMIOPLASTY & DECOMPRESSION

An acromioplasty is keyhole surgery and involves reshaping the under surface of the acromion to decompress the rotator cuff tendons below. This allows the tendons to move freely under the acromion and prevent the painful catching of the tendon. The inflamed bursal tissue will also be removed and the bursa will regrow as a normal bursa from the remnants left behind.

EXCISION AC JOINT ARTHROSCOPIC STABILISATION

Surgery This is an arthroscopic operation in which Stabilisation is an operation in which any of the inflamed tissue between the bones is the injured structures in the shoulder joint are removed and 7 to 10mm of bone from the repaired back to bone and the joint which is end of the collar bone is removed. The stretched is tightened back to normal tension. stabilising capsule of the joint and the stabilising ligaments around the joint are left intact and there is no loss of strength of the shoulder. The gap is filled in with scar tissue which becomes a spacer so that no matter what position the shoulder is placed in, in future the two bones will not rub against each other and cause pain.

6 Types of Shoulder Surgery

ROTATOR CUFF REPAIR

Involves reattaching the torn rotator cuff tendons back onto the bone. This is done by placing anchors with suture material into the bone and stitching the suture through the tendon and tying the tendon down onto the bone. At the same time an Acromioplasty will be performed to remove all inflamed bursa and reshape the under surface of the acromion so there is more space for healing to occur in. Surgery

LATARJET (OPEN STABILISATION)

This is an open operation, not keyhole surgery. It involves a piece of bone being removed from the corocoid process and transplanted to the glenoid to replace the bone that is deficient. The bone block is fixed to the glenoid with a metal screw and the soft tissues repaired inside the block using anchors. Soft Tissue Repair Anchors for Soft Stump of Coracoid Tissue Repair

Coracoid Graft

Conjoint Tendon Attached Muscles

7 Surgical Complications and Risks

our shoulder condition is neither life nor shoulder surgery. At any time before your surgery limb threatening but the complications if you wish to discuss further any of these potential Yof surgery (albeit extremely rare) can be complications before proceeding please do not both life or limb threatening. The following lists hesitate to contact Mr Campbell’s rooms and outline the most frequent post operative events discussion will be undertaken. You are under no and the rare but possible complications of shoulder obligation at any time to proceed with surgery. surgery. These lists are not totally inclusive but Unless you are satisfied that any issues that you may do discuss the most common adverse outcomes. have with the possible risks of surgery have been You must be aware of these adverse events and adequately discussed with you do not proceed. possible complications if you decide to undertake Common risks and associated events:

n this list we have included a Pain on movement can persist Sore throat. number of conditions which for many weeks following The anaesthetists will place a I occur after any surgical the surgery and the expected breathing tube to control your operation and a number of outcomes and course of these airway during your operation. common but usually short lived will be discussed with you. This can produce a sore throat phenomenon that can also which may persist for the first occur. day after surgery. Nausea and vomiting. Nausea and vomiting are common Dental damage. Pain. after a general anaesthetic. It With the passage of an airway Unfortunately all shoulder surgery does vary from person to person by the anaesthetist there is a is associated with a significant and it also varies from operation possibility of damage to the amount of post operative pain. to operation. teeth. Please discuss this with The things that are done to try your anaesthetist on your pre- and minimise your pain in the operative visit and he will post operative period are: Leakage from wounds. explain the manoeuvres he will Large volumes of fluid are undertake to minimise this risk. • At the time of surgery a local pumped into the shoulder during anaesthetic block is placed into surgery to assist with vision using Pain and bruising at the the nerve which supplies most the arthroscope. As a result the intravenous site. of the sensation to the shoulder shoulder becomes swollen with The anaesthetist will place an joint. fluid. After the surgery this fluid intravenous line into a vein in leaks out of the skin punctures. I your opposite arm. This is to • Local anaesthetic is instilled encourage my patients to spend administer the various anaesthetic into the operative area. the first post operative night in agents necessary to maintain the hospital so that this leakage is into anaesthetic. A number of these • Whilst an inpatient if injections hospital sheets and mattresses agents from a chemical point are necessary for pain these will and pillows and not your own of view are quite irritable to the be administered. at home. Your wounds and Surgical Complications and Risks surface of the vein. This may dressings will usually have to be result in some inflammation and • On discharge from hospital changed the following morning some superficial clotting in these you will be supplied with strong because of leakage. Once the veins. Once the intravenous oral pain killing medication to try wounds have been redressed the catheter has been removed and make you as comfortable as leakage does not tend to be an there may be an area of pain or possible. The most severe pain ongoing problem. bruising at the intravenous site. is for the first 48 hours after the This will settle with time. surgery.

8 Bruising around the wound. contribute to shoulder pain. If Although your surgery may Ulnar nerve numbness. this is the case the tendon will be done predominantly The nerve that supplies the little be released inside the shoulder arthroscopically there is usually finger and the finger beside it joint and it will slide out of the bone reshaped internally. passes near the surface at the shoulder joint. In approximately This will have some bleeding elbow. For the same reason four in ten people in which this associated with it. This bleeding because of swelling and also is done there is a change in will track down with gravity and because of having the arm resting the shape of the muscles of the at five to seven days post-surgery in a sling there is often temporary upper arm. This does not result bruising may actually come out at numbness and/or tingling in in a loss of strength or function distant sites like the upper chest these fingers due to a degree of and is purely cosmetic. or the mid arm portion. This is a compression of the nerve at the normal occurrence and will also elbow. Once again this usually The next list is of RARE BUT be resorbed with time. settles with time. POTENTIALLY SERIOUS risks of Risks and Complications Surgical surgery. As a result of swelling around the Patches of numbness in the shoulder because of the surgery forearm. Infection. there is a relative interference There can be various patches of Any operation where the skin with blood coming back from the tingling and/or slight decrease in is penetrated to enter a joint entire arm in the veins and from sensation in the forearm because runs the risk of infection. This tissue fluid coming back from of swelling and also the position infection is usually caused by the arm in the lymphatic vessels. of the arm at the time of surgery. organisms that normally live This will result in a generalised This is usually a transient affair on the skin. To reduce the risk increase in the volume of the and does settle in the immediate of infection at the time of your arm. This is not usually visually post operative period. shoulder surgery a number of apparent but can produce things are done. transient problems or short-lived Change in biceps problems in the arm. These are: appearance. • The antiseptic solution that The next common possible the skin is soaked in binds to the Swelling and stiffness of sequelae after surgery is a change keratin protein in the skin and fingers. in the shape of the upper arm. has a long acting action against The fingers often become swollen The biceps muscle in the front of the common skin organisms. and stiff and it is important to the arm comes from two tendons keep the fingers moving. around the shoulder. One of the • At the time of your anaesthetic tendons arises from above the you will be given one dose of Carpal Tunnel Syndrome. shoulder joint but passes through intravenous high dose antibiotics The nerve that supplies sensation the shoulder joint before it enters which are effective against the to some of the fingers passes into the arm. As it sits in the common skin organisms. through the wrist and this is called shoulder joint it can be damaged a carpal tunnel. There is often a and injured and it does often • The standard surgical sterile short-lived tingling and technique is employed to reduce numbness in the thumb the risk of infection. and index and middle The infection rate for fingers as a result of shoulder surgery in swelling in this area. If my practice is 0.04%. you have suffered any If an infection does carpal tunnel syndrome occur this will have to before your shoulder be treated surgically. surgery, this is to be Infection always expected in the post requires further surgery operative period. In in the form of washing most cases this is short out the infection and lived and settles as the removing any foreign swelling settles. material. It often also

9 requires the use of high dose known vascular disease the machines it enables us to directly intravenous antibiotics for up to swelling as a result of the surgery monitor your brainwave function six weeks after the onset of the can produce clotting in the and be absolutely sure that you infection. Once the infection is artery but this does not damage are fully anaesthetised. If you eradicated this then will require the artery and in most cases this are still concerned by this you further surgery to repair the can be cleared either by catheter need to discuss this with your primary problem. As previously techniques and/or open surgery anaesthetist prior to surgery. stated the infection rate following by a vascular surgeon. This is a shoulder surgery in my practice very uncommon complication. Heart attack and/or stroke is very low. This is a potential risk for people Sudden death from who have known heart and/or Stiffness of the shoulder. anaesthesia. vessel disease. Every effort will Everybody who has shoulder This is usually as a result of an be made to ensure you are as fit surgery will have a relative allergic reaction to the anaesthetic and healthy as possible before degree of stiffness in the post agents. The incidence in our any surgery is undertaken. operative period. This can persist society for people undergoing up to two to three months post- elective shoulder surgery is Pulmonary embolus. surgery. In approximately 3% of estimated to be 1 in 80,000 to Pulmonary embolus occurs patients having shoulder surgery 100,000 people. To try and when a blood clot forms in a vein. this stiffness is much more put this risk into context and This vein is usually one of the severe and can result in a frozen compare them with other risks deep veins in the pelvis. A part shoulder. This does not last of modern living, recent statistics of this blood clot can then break forever but it does prolong the from the UK have shown that the off and float up to the heart and recovery period. It makes what risk for any individual in any one then be pumped out from the is already a frustrating period year of dying in a traffic accident heart to the brain and/or lungs. of time even more frustrating is 1 in 5,000. The risk of dying This can result in varying levels of because of the time taken. in an accident in the home is 1 problems which in a worst case in 10,000 and the risk of being scenario could lead to sudden Failure of repair. murdered is 1 in 80,000 to collapse and death. Pulmonary If the rotator cuff is repaired the 100,000. It can be seen from embolus can happen to anyone success rate is approximately these statistics that the risk of at any place at any time. There 90% to 92%. Failures usually dying from anaesthesia is very is an increased incidence at the occur when the tissue is of poor low. time of surgery and this is more quality or if the tears are massive common with surgery in the and longstanding. Awareness. pelvis and/or lower limb. The Many patients are rightfully risk following shoulder surgery Damage to the major artery concerned with waking up in is less because there is no forced and/or nerves the middle of their operation. bed rest post surgery and you These pass in front of the With shoulder surgery drug can walk around immediately shoulder. In the worst case paralysis is not used so that you scenario, damage, could lead to are breathing spontaneously loss of the arm. The positioning even though your airway is of the operating portals and the controlled. If the anaesthetic operating position is such that was to get light we would be

Surgical Complications and Risks the major artery and/or nerves aware of that by movement of are not placed at risk. In an yourself on the operating table. older age group who have Also with modern anaesthetic

As mentioned, this list is not fully comprehensive but it does cover what I consider to be the major known risks of surgery or those which have the worst case outcome. If you would like to discuss these risks or any other concerns it is absolutely essential that you have these adequately explained to you before you embark upon surgery. You can contact Mr Campbell’s rooms at any time if you have any concerns or wish to discuss these further.

10 On The Day Of Your Surgery

n the day of your surgery if you DO NOT there will ask you some questions such as your have an appointment with Mr Campbell name and what surgery you are having. O to sign a consent form please report directly to Admissions (located opposite Western From there you will be wheeled on your bed to the Orthopaedic Clinic.) They will take care of your operating room and met by the anaesthetist and admission procedures. an anaesthetic nurse. They will assist you onto the operating table and proceed to place ECG monitors Upon arriving on the ward the nurses will assist on your chest, blood pressure cuff on your arm, you in getting ready for theatre. This will involve and an oxygen probe on your finger. After this a admission questions and having your blood pressure, drip will be placed into your hand or arm, and you pulse and temperature taken. Your anaesthetist will will shortly fall asleep from an anaesthetic drug visit you in the ward prior to surgery. We cannot injected into the drip. give you an exact time that you will go to theatre. We will always admit you some hours early. This Once surgery is completed you will be taken to is in case of any unforseen changes such as other the recovery ward on your bed and the nurses

patients’ surgery being cancelled. Please bring a will monitor you whilst you wake up. This usually InformationGeneral book or magazine with you. takes around 1/2 hour. Once you are awake and comfortable you will be transferred back to your When it is time for you to come to theatre you will room in the ward. You will be away from your bed be escorted to the operating suite and will have a in the ward for about 2.5 to 3 hours, if you wish to short wait on your bed in a waiting room. A nurse inform relatives who are waiting for your return.

11 Intra and Post Operative Pain Management

lease discuss your pain management with Unfortunately, strong painkillers can cause your anaesthetist. nausea or vomiting in some people. You will P be given anti-sickness medicines with your There are several inpatient phases following anaesthesia and on the ward. You should try to surgery. Our aim is for you to be as comfortable reduce the amount of Targin and Oxcycodone as possible within the safety limits of the drugs. used after the first 3-4 days, depending upon your level of pain. You can continue the Panadol Surgery Osteo (and Celebrex if given) for longer. During surgery your anaesthetist will give you pain relieving drugs with the aim of making you This is our standard regime and suits most comfortable when you wake from surgery. people. Some medical conditions will require alterations to this combination. Your anaesthetist At the end of the surgical procedure local will discuss this with you if this applies. If pain is anaesthetic is injected into your shoulder joint still a problem then the Acute Pain Service will and around the skin incisions. be asked to adjust a pain relief plan specifically for you. In the recovery room if you still have pain the nurses will give you pain relieving medication Discharge into your intravenous drip. They will ensure that On discharge from hospital you will have at you are comfortable before you are transferred least FOUR days supply of oral medication. to the ward. In recovery or on the ward if you You will need to make an appointment to see have pain inform the nurses. your GP to review pain management and to get another prescription if needed. I WOULD After surgery STRONGLY RECOMMEND YOU PRE BOOK On the ward you will have been prescribed a THIS APPOINTMENT WHEN YOU SET THE combination of medications for pain control. DATE FOR YOUR SURGERY.

Some are to be taken REGULARLY and some AS Sleeping position NEEDED. It is very difficult to get comfortable in the first few weeks after surgery. If you have access to a REGULAR: recliner or arm chair you will find it easier to get Panadol Osteo. (Two tablets three times daily) some sleep in a semi sitting position. and Targin (twice daily) provide background pain relief and should be continued for 3-4 days. Ice Packs They are most effective if taken this way. If you I strongly recomend the use of ice packs

Post Operative Information Operative Post are not having any repair or stabilisation then especially after excercise. you may also be given Celebrex (twice daily). The simplest ice pack is a bag of frozen peas wrapped in a tea towel. It is essentital that Movicol be taken regularly (twice daily) to prevent constipation. Drink It is normal for you to have pain in your shoulder plenty of water. after surgery, but we have endeavoured to reduce this as much as possible for you. AS NEEDED: If you experience severe pain despite these regular drugs then you can also take Oxycodone 5-10mg up to every 4 hours.

12 Use Of Your Sling

recommend the use of a sling following motor vehicle in this period of time while you shoulder surgery. Initially following the are wearing a sling. If you were to drive and I surgery the arm will be painful and the sling you had to react in an emergency situation you does help support the shoulder itself. If you have will either damage your surgery or you will not had a repair of the rotator cuff or of the lining be able to react in time and you may have a of the joint as in shoulder reconstruction the collision or some form of accident. If this was sling is an important part of the post operative the case you might find that your insurance rehabilitation course. It will be discussed with company may not cover you and the police you in detail in the post operative visit how long may consider that you are driving in a culpable you will need to wear the sling for. In general manner. terms though a number of points can be made. Thirdly if you are out and about where there Post Operative Information The times when you must wear a sling are – are a lot of people around you should wear the sling as it gives them a signal that you have had In bed at night if you have had a repair or something done and they tend to give you a reconstruction. Under the influence of pain wider berth than they might otherwise do. killing medications your dreams tend to be more exotic than normal and you can fling your arms There are many things you will be able to do around and hurt yourself if you do not have the around the house or in a controlled environment sling on. out of the sling as well and these will be discussed with you in your post operative visit. The second time you must wear the sling when in any form of transport, that is plane, train or automobile. For this reason you cannot drive a

13 The Day After Surgery

r Campbell or a member of his team will visit you in your room to see how Myou are feeling and ensure you are comfortable to be discharged that morning. The findings at surgery will be discussed.

The nursing staff will assist you with showering and change your dressing on your shoulder. The dressings will be waterproof so you can bathe normally at home. They will give you your discharge medications to take home with you. You will have a post operative handout on your performed surgery and what to expect during your first week post-surgery. The nurses will instruct you on how to put the sling on and off.

Once home if there is anything that you find confusing in the information sheets please do not hesitate to ring Mr Campbell’s rooms and his staff will help you. Could you please arrange for someone to pick you up from hospital late morning. You will not be able to drive yourself home. Post Operative Information Operative Post

14 Post Operative Regimes

our post operative information and management will be specific to what was found and treated at the time of surgery. Listed below is a brief overview of the postoperative management for Ythe different types of shoulder surgery performed. You will be given detailed instructions specific to your surgery on the first post operative day.

Rotator Cuff Repair

• Sling for six weeks.

• No driving for six weeks. Post Operative Information • Return to work will be determined by job requirements and your recovery rate.

Acromioplasty +/- AC Joint Excision:

• Sling for comfort. • Driving when comfortable and confident. • Return to work when comfortable.

Stabilisation:

• Sling for four weeks. • No driving for four weeks.

WARNING You cannot drive a motor vehicle when your arm is in a sling. Even though you physically can do this (especially automatic vehicles) if you are involved in an emergency, you would not be able to react appropriately. If you were involved in an accident your insurance company may not cover you and you could be charged with culpable driving.

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