The thyroid gland produces hormones and is one of the endocrine glands, placed in the anterior neck just below the voice box and is the source of the hormone thyroxine. The thyroid hormones are secreted into the blood and are important in controlling the metabolism and contribute to the normal function of all the body’s cells. The thyroid gland can produce and store more thyroid hormone than the body needs at any period and so a patient may not need to take thyroid replacement hormone if only a proportion of the thyroid gland is removed.

If the whole thyroid gland is excised then the patient will need to take tablets for thyroxine replacement throughout their life. The size of four small rice grains, the minute parathyroid glands adhere to the thyroid gland and secrete a hormone called parathyroid hormone. Parathyroid hormone is closely involved in the blood regulation of calcium concentrations, which promotes good health and the maintenance of a healthy skeletal structure. During the thyroid removal operation the surgeons take care not to affect the parathyroid glands but the secretions of the glands can be altered.

Thyroidectomy is the removal of the thyroid gland, either a total thyroidectomy or partial removal, called a sub-total thyroidectomy, hemithyroidectomy or lobectomy. There are several reasons for removing all or part of the thyroid gland. Overactivity of the thyroid gland is the main reason, known as hyperthyroidism or Graves’ disease or when goitre occurs with an enlarged thyroid. Goitres are removed either because they are causing pressure on the windpipe or gullet, are causing breathing or swallowing problems or they may look unsightly.

Patients are maintained in an unconscious state during the thyroidectomy by a general anaesthetic and monitored by an anaesthetist. The surgeon makes a neck incision using the normal creases in the neck just above the breastbone and the cuts are typically made symmetrically. The incisions heal well and the scar that remains afterwards becomes so inconspicuous that eventually it becomes almost invisible. A small drain tube in the neck can ensure that fluid does not collect in the wound which enhances wound healing and the tubes are removed in a day or so. The typical hospital stay is two to four days.

No food is usually taken for six hours before operation and then only clear fluids until two hours before operation. The anaesthetic will be given through an injection in the arm with the operation taking one to two hours. Stitches under the skin may not need to be removed or the surgeon may use skin stitches or clips which do need to be removed after two to three days. Most people go home two to four days after operation although this varies with how people feel, and they will need to be collected and taken home by a relative. The amount of pain suffered after the operation varies greatly with some discomfort commonly around the neck.

There are various post-operative risks and many of them are rare. Infection can occur in the wound and if it develops redness and soreness then antibiotic treatment is prescribed. Wound reopening and exploration to remove any accumulated pus is also rarely required. Bleeding in the wound can occur, leading to a haematoma which necessitates wound exploration and washing out, with a one in fifty chance of this occurring. Patients will have some bruising and also swelling around the wound area caused by the bleeding under the wound.

A check of the vocal chords will be performed on all patients before surgery and operating very close to the larynx and the nerves which supply it is discussed with the patient. The nerves can lose partial function if they are bruised during surgery and weakness and hoarseness of the voice can be affected as the nerves control vocal chord movements. It may take months for the voice to recover and in rare, severe cases the nerve can be permanently altered. It is very rare for both nerves to be affected and a serious complication as the ability to speak is lost and a tracheotomy in the trachea is necessary to maintain breathing.

A fall on the outstretched hand (FOOSH) is a common occurrence and often results in a Colles’ fracture, a fracture of the distal inch of the radius and ulna next to the wrist. Treatment is immobilisation in a splinting material such as Plaster of Paris for five to six weeks to allow healing of the bony fragments, followed by a variable period of rehabilitation depending on the severity of the fracture. The hand is extremely important functionally so the period in plaster is kept to a minimum to allow quick restoration of normal hand use, although a wrist splint can be used for a week or so, particularly in cases where there is significant pain on activity.

Once the hand is released from the Plaster of Paris the physiotherapist will check the healing process is progressing normally. Palpation of the fractured area firmly should cause no significant tenderness or pain, hand colour should be normal and there should be no excessive swelling of the area. Muscle wasting is common after immobilisation but should not be too great. The ranges of movement of the limb, while restricted in some planes, should not be severely reduced in many planes. Pain should not be severe or widespread nor come on with all movements of the wrist and hand.

Range of movement exercises are the first line of treatment for a physiotherapist, teaching exercise performance every two hours. Many colles’ fractures do very well simply with regular end range exercise practice and do not need more sophisticated treatments. The physiotherapist checks any restrictions in shoulder and elbow movement then records the forearm rotations, supination and pronation, which are important functionally. The physiotherapist will then assess wrist flexion and extension, finger flexion and extension and thumb movements. Most commonly restricted movements are supination and wrist extension.

After the plaster comes off the wrist often feels vulnerable, partly because the plaster is seldom left on until the bone is entirely healed to prevent the onset of complications due to immobilisation. Physiotherapists may give the patient a futura type brace, a fabric brace with Velcro straps and a metal piece for the underside of the wrist to stiffen it. This is not meant to keep the wrist immobilised further but to support the wrist while the patient is performing functional activities and then to be removed for light activities and regular exercise performance.

If the progress of the joint is not as expected then the physiotherapist can use joint mobilisation techniques to restore the gliding and sliding movements of the joint. Accessory movements are small movements performed passively on another person and can be done to the midcarpal, radiocarpal and distal radio-ulnar joints. The physiotherapist will hold one side of the joint firmly as they passively move the other side of the joint, either gently and repetitively or more forcefully at the end range of where the joint will allow, pushing against the restriction. The joint can also be placed in the stiff position while the mobilisations are performed.

Strengthening the wrist occurs with a gradual increase in functional activities but joining a hand class can instruct the patient in practicing the large variety of small movements that the hand can perform and needs to strengthen for optimum hand function. Repetitive work at pieces of apparatus can strengthen and harden the hand to turning, twisting, pulling, grasping and fine work with the thumb and index finger. This can move on to work with weights or functional activities if the person needs to return to manual labour or another job requiring upper limb strength.

In some cases a pain syndrome can develop in the hand with tight swelling, poor joint motion, high pain and hypersensitivity, at which time a doctor’s opinion is needed to exclude complications with the fracture such as non-union. Painkillers and contrast bathing are treatments for the pain, with self massage used for swelling and desensitising techniques for the abnormal sensibility. The patient should be clear that they have to go through significant pain to get their hand better again.

Osteoarthritis (OA) is the commonest joint degeneration condition in the world, resulting in huge amounts of pain and suffering, work loss, expense and disability. Ageing of western developed populations, soon to be followed by some developing countries such as China, will place an increasing burden on medical services as the occurrence of OA rises steadily with age. There will be an increasing need to provide medical and physiotherapy treatment for OA over the next 50 years and for many thousands of people this will involve joint replacement.

Of all medical interventions, joint replacement has one of the highest increases in quality of life, transforming a person’s mobility, outlook and independence. Developed in the 1960s to a level where mass treatment was feasible, total hip replacement has matured into a predictable and successful treatment for OA with very good results stretching to 15 years and beyond. Conservative treatments are the mainstay of management of OA but once it becomes severe hip replacement is the only option.

Total hip replacement involves removal of the arthritic joint surfaces and their replacement with metal and plastic components. The top of the femur, the ball of the hip joint, is removed and the socket is reamed out to make it bigger to accept the new part. Cement is pressurized into the bony areas and a steel alloy femoral component with a ball and stem is inserted down the femur and a plastic cup of ultra high density polyethylene into the socket. The metal-plastic interface allows very low friction and wear, ensuring a long life for the joint.

On return from operation the physiotherapist will check the patient’s operative record, medical observations and assess the patient. Initial physio treatment consists of checking respiratory status and the muscle power and feeling in the legs to exclude nerve injury. Exercises are given to restore normal movement although an epidural can cause loss of movement in the legs and delay progress. The physiotherapist will then mobilise the patient with an assistant, taking care of the hip precautions, stand them up and walk them a short distance with elbow crutches or a frame.

Hip flexion, knee extension, buttock and calf exercises are practiced whilst in bed to reactivate the leg muscles and pump the blood around the limb. Routine analgesia is very useful as reduced pain allows easier exercising and mobilising. Patients can now go to the toilet, wash and dress and walk about the ward with a helper if needed, at least three times a day to get their confidence. When sitting, correct height chairs are vital and patients should avoid having their feet up on a stool.

After hip replacement patients require instruction and correction to achieve a normal walking pattern, develop muscular power and improved function. Physiotherapists teach the appropriate gait at the time, often starting with “step to” where the patient moves the walking aid, steps the operated leg forwards and steps up to it with the other leg, a stable and safe pattern. Progression is to ‘step through” where the unaffected leg steps beyond the other in an approximation of a normal walking pattern. Patients often progress naturally then to a gait where they move both the crutches and the affected leg forward at the same time and start to walk in a fully natural pattern.

Six weeks or so after the operation the patient will have a good gait, have reasonable muscle power and be able to do most functional activities such as a walk, climb stairs and ride in a car. They may then move on to a stick if stability or balance is difficult or the person is very old. Patients can now return to normal activities but need to maintain the hip precautions: Avoid crossing the legs in sitting. Don’t stand on the affected leg and rotate. Don’t flex the hip suddenly or above 90 degrees, such as by sitting in a low chair, sitting down too fast, crouching or leaning forward quickly to the feet. If an infection develops, for example chest, teeth or bladder, then the doctor should be informed as infections can settle in an artificial joint.