From lipomas to toenails: your practical guide to safe, confident minor procedures (Because “minor” doesn’t mean “simple” when it’s your first time)
Date Updated: March 2026
Minor surgery in UK general practice encompasses a range of procedures from simple excisions to joint injections. This guide covers patient assessment, common procedures, red flags, and practical tips for safe practice.
Excisions, wound closure, joint injections, toenail surgery, and more
All local anaesthetic and medication doses checked against BNF/PCDS
Skin cancer, infection, vascular, and nerve injury warning signs
Hydrocolloid, foam, alginate, hydrogel, and antimicrobial options
path: MINOR SURGERY
8 clinical pearls to make you look like a minor surgery wizard
Think 'Wrinkles': Incisions along natural skin tension lines (Langer's lines) heal with less scarring. On face: horizontal on forehead, around eyes/mouth. On trunk: horizontal. On limbs: longitudinal. If unsure, pinch skin - wrinkles show the lines.
For elliptical excisions, length should be 3x the width. This creates 30° angles at the tips, allowing easy closure without 'dog ears'. Too short = puckering. Too long = unnecessary scar.
Quick calc: 1% lidocaine = 10mg/ml. Plain max = 3mg/kg (e.g., 70kg patient = 210mg = 21ml). With adrenaline max = 7mg/kg (70kg = 490mg = 49ml). Always aspirate before injecting to avoid intravascular injection.
Temporal branch of facial nerve (forehead - causes brow ptosis), Spinal accessory nerve (posterior triangle - causes shoulder drop), Digital nerves (fingers - run along sides), Facial artery (nasolabial fold). Know your anatomy!
For epidermoid cysts: excise the entire cyst wall intact. If you rupture it, recurrence rate jumps from 5% to 40%. If inflamed/infected, incise & drain first, then excise 4-6 weeks later when inflammation settled.
Steroid injections take 3-7 days to work (not immediate). Warn patients about post-injection flare (10-20%, settles in 24-48h with ice/paracetamol). Effect lasts 6-12 weeks. Limit to 3-4 per year per joint to avoid cartilage damage.
After avulsing nail, DRY the nail bed thoroughly before applying phenol (moisture dilutes it). Apply 80% phenol for exactly 3 minutes to nail matrix. Neutralise with alcohol. Expect discharge for 2-6 weeks (normal, not infection).
Match dressing to exudate: Dry wound = hydrogel (adds moisture). Low exudate = hydrocolloid. Moderate = foam. Heavy = alginate. Infected = antimicrobial. Cavity = alginate rope. Simple!
Risk stratification approach:
Low-risk procedures (continue anticoagulation):
Higher-risk procedures (consider stopping):
Always weigh thrombotic risk vs bleeding risk. Discuss with patient and consider specialist advice if uncertain.
Systematic approach to evaluating skin lesions and surgical conditions
Asymmetry
One half unlike the other
Border
Irregular, scalloped, or poorly defined
Colour
Varied shades of brown, black, red, white, blue
Diameter
>6mm (pencil eraser size)
Evolving
Changing in size, shape, or colour
Major features (2 points each):
Minor features (1 point each):
A lesion that looks or feels different from the patient's other moles. This simple sign has high sensitivity for melanoma detection. If a lesion stands out as the "ugly duckling" among a patient's moles, consider referral even if other criteria not met.
Common benign lesions encountered in primary care minor surgery. Learn to distinguish them clinically.
Excision if symptomatic, cosmetically concerning, or diagnostic uncertainty. Use careful dissection with flat scissors held parallel to skin surface to avoid damage to surrounding structures.
Rapid growth, hard consistency, fixed to deep structures, >5cm diameter. Subfrontalis lipomas (lie under frontalis muscle, less obvious when eyebrow raised) require specialist referral due to risk of temporal nerve damage.
Excise entire cyst wall intact to prevent recurrence (5% vs 40% if ruptured). If inflamed/infected, incise & drain first, then excise 4-6 weeks later. Score skin with scalpel only, then use small flat dissecting scissors at angle almost parallel to skin surface to carefully dissect each layer until sac visible.
Recurrent infection, diagnostic uncertainty, cosmetically sensitive area
Usually conservative. Excision if symptomatic or diagnostic doubt
Rapid change, bleeding, ulceration, >1cm diameter
Reassure and observe if isolated and asymptomatic (especially in children — high rate of spontaneous resolution). If treatment desired: electrocautery with a fine needle-point tip inserted into the central arteriole produces rapid destruction with excellent results. Cryotherapy is an alternative. Laser treatment available in secondary care for cosmetically significant or multiple lesions.
Multiple spider naevi in an adult — investigate for underlying chronic liver disease before attributing to cosmetic cause. Refer to dermatology for laser treatment if electrocautery not available or lesion is cosmetically prominent.
Curettage and cautery is effective and quick for most lesions. Note that pressure on the lesion during the procedure can be quite painful — warn patient and ensure adequate local anaesthetic. Chemical cautery (silver nitrate) can also induce involution of smaller lesions. Always send excised/curetted tissue for histology — amelanotic melanoma can mimic pyogenic granuloma. Recurrence rate after curettage is higher than after complete excision (~15–40%); if recurrence, consider full excision.
Recurrent lesion after curettage. Lesion on face or near eye. Any doubt about diagnosis — amelanotic melanoma and other vascular tumours must be excluded. Gingival pyogenic granuloma in pregnancy — usually resolves post-partum; refer to oral surgery if persistent.
Complete excision is the treatment of choice. Shave biopsy alone is inadequate — it cannot reliably distinguish KA from invasive SCC. Send all specimens for histology. Do not observe and wait for spontaneous resolution — this is now discouraged due to the risk of under-treating an SCC.
Refer on 2-week wait pathway (NICE NG12) — keratoacanthoma cannot be clinically or histologically distinguished from squamous cell carcinoma with certainty. Treat as suspected SCC until proven otherwise. There is significant regional variation in histopathological diagnosis of KA vs SCC in the UK.
Cryotherapy (liquid nitrogen or nitrous oxide): First-line for isolated thin lesions. One freeze-thaw cycle of 5–20 seconds. For hypertrophic lesions, two cycles may be needed.
Topical treatments (prescribable in primary care):
Curettage and cautery: Suitable for isolated hypertrophic lesions — removes thickened scale and cauterises base.
Refer if: lesion is thickened, indurated, or ulcerated (features of SCC); lesion fails to respond to treatment; diagnosis uncertain. Extensive field change — consider referral to dermatology for photodynamic therapy (PDT) or field-directed treatment planning.
When examining a subcutaneous lump, look for a central punctum (tiny opening). If present, it's almost certainly an epidermoid cyst. If absent and the lump is soft/mobile, think lipoma. If absent and firm/tethered, consider dermatofibroma or other diagnosis. This simple sign has excellent diagnostic accuracy.
Elliptical excision is the gold standard for removing benign and suspicious skin lesions. Proper technique ensures complete removal, good cosmetic outcome, and adequate tissue for histology.
| Area | Considerations |
|---|---|
| Cardiovascular |
|
| Medications |
|
| Pregnancy | Skin surgery is best avoided in pregnancy unless benefits outweigh risks (e.g. suspected skin cancer). Where possible, local anaesthetic should be avoided in the first trimester. |
| Allergies | Ask about: Elastoplast (adhesive tape allergy), antibiotics (for prophylaxis), latex (gloves and surgical couch covering), antiseptic preparations, local anaesthetic (very uncommon — see LA section). |
| General examination | Patients with pre-malignant lesions or suspected skin cancer must have a thorough examination of the skin at the same visit. Know your anatomy — assess lesion depth, proximity to nerves/vessels, and mobility before marking. |
| Patient expectations | Always ask: Is the surgery necessary? What outcome does the patient expect? Discuss risks vs. benefits. Avoid skin surgery on exposed areas immediately before major social occasions. |
Always use topical anaesthetic cream in children before LA injection. Two main options:
Patients who have had MRSA in the past but have since had negative swabs must still be managed as if they have MRSA — false negative swabs are not uncommon.
| Agent | Max dose | Duration | Notes |
|---|---|---|---|
| Lidocaine 1% plain | 3 mg/kg (max 200mg = 20ml) | 30–60 min | Standard choice |
| Lidocaine 1% + adrenaline 1:200,000 | 7 mg/kg (max 500mg = 50ml) | 2–6 hours | Avoid on digits, nose tip, ear lobes, penis |
| Lidocaine 2% plain | 3 mg/kg (max 200mg = 10ml) | 30–60 min | Smaller volume needed |
| Bupivacaine 0.25% plain | 2 mg/kg (max 150mg = 60ml) | 4–8 hours | Longer duration; post-op analgesia |
Early: Perioral tingling, metallic taste, tinnitus, dizziness. Severe: Seizures, arrhythmias, cardiovascular collapse. Always aspirate before injecting. Never exceed max dose. Inject slowly.
Face: The SMAS (Superficial Musculo-Aponeurotic System) lies below the fat. Nearly all critical structures lie deep to the SMAS. Extra care for:
Neck (elderly): External jugular vein may have little covering platysma — use blunt dissection (open scissors from closed position). If vein is cut: pressure + put patient head-down (prevents air embolus). Accessory nerve at Erb's point lies deep to superficial fascia.
Other danger zones: Axilla (brachial plexus branches near surface); upper outer quadrant thigh (lateral cutaneous nerve); lateral popliteal fossa (common peroneal nerve); outer and lower shin (sural nerve — very superficial, commonly used as nerve graft donor).
Lower legs: Avoid excessive skin tension on pre-tibial surface — breaks down easily post-op. Use skin flaps or graft if too large for easy direct closure.
| Location | Deep (absorbable) | Skin (non-absorbable) | Removal |
|---|---|---|---|
| Face | Vicryl 5-0 | Prolene 6-0 or 5-0 | 5–7 days |
| Scalp | Vicryl 4-0 | Prolene 4-0 or 3-0 | 7–10 days |
| Trunk | Vicryl 4-0 | Prolene 4-0 | 10–14 days |
| Arms/Legs | Vicryl 4-0 | Prolene 4-0 or 3-0 | 10–14 days |
| Hands/Feet | Vicryl 5-0 | Prolene 5-0 or 4-0 | 10–14 days |
| Back (high tension) | Vicryl 3-0 | Prolene 3-0 | 14 days |
What to expect: Mild discomfort 2–3 days (paracetamol). Bruising/swelling 1–2 weeks. Scar fades over 6–12 months.
Seek help if: Increasing pain/redness/swelling after 48h; pus or discharge; fever; wound edges separating; excessive bleeding.
A cylindrical cutting tool used to take a core of skin tissue. Mainly used for diagnostic purposes but occasionally as definitive treatment for very small lesions. Sizes range from 3–8mm diameter.
A punch biopsy on a pigmented lesion must only be used if the lesion can be safely removed to include 2mm of normal surrounding skin. If this cannot be achieved, an elliptical excision should be performed instead. Never punch-biopsy a suspected melanoma — refer for excisional biopsy.
A partial biopsy technique used when a larger tissue sample is needed than a punch biopsy can provide, but where full excision is not yet appropriate or possible. Scenarios for this are uncommon — consider whether full excision (with histology) or referral is more appropriate.
Incisional biopsy should be avoided in pigmented lesions. If melanoma is suspected, refer for complete excisional biopsy with appropriate margins — partial biopsy of a melanoma risks sampling error and may make staging inaccurate.
Shave excision removes a proud/elevated skin lesion by cutting horizontally across its base. The main use is for benign lesions that protrude above the skin surface. The operator must be confident the lesion is benign before using this technique — if in doubt, perform a full excision with 2mm margins.
All shave excision specimens must be sent for histology — even when the diagnosis appears clinically certain. Always excise to a 2mm margin if there is any doubt about benignity.
Curettage involves scraping away superficial skin lesions with a curette. Often combined with cautery (heat/chemical) for haemostasis and to destroy residual tissue. Both are claimable under the NHS Minor Surgery Directed Enhanced Service. Suitable for benign superficial lesions only — never use when diagnosis is uncertain, as no histology is obtained from cautery alone.
Three types of cautery are relevant to UK general practice: cryocautery, electrocautery, and chemical cautery (silver nitrate). Operating-theatre-type specialist equipment is outside normal GP scope.
The curette derives its name from the Latin curare (to care for). Bronze curettes have been used in surgery for thousands of years.
Current guidance (including patient.info/PCDS and NICE-referenced sources) states that keratoacanthoma is clinically indistinguishable from squamous cell carcinoma and should be referred on a 2-week wait pathway — not curetted in primary care without prior excisional biopsy to exclude SCC.
Curettage has historically been reported to achieve ~90% cure for carefully selected KA, but this does not negate the diagnostic imperative:
Curettage and cautery has historically been reported as achieving ~90% cure rates for selected BCCs. However, this is not standard primary care practice in the UK. Suspected BCC should be referred. Low-risk BCCs below the clavicle may be excised (not curetted) by GPs with appropriate extended-role competency (GPwER accreditation). When in doubt — refer.
Curettage destroys tissue architecture. Curettings may be sent for cytology but this is non-diagnostic for malignancy. You cannot exclude malignancy from curettage alone. Only use curettage and cautery when you are clinically certain of the diagnosis. Medical records must be meticulous — document the diagnosis, lesion description, and reason for proceeding without excision. If any doubt: excise and send for histology, or refer.
Works by causing cellular lysis after a freeze-thaw cycle. Four techniques are available in primary care:
| Method | Temperature | GP practicality | Notes |
|---|---|---|---|
| Liquid nitrogen (LN₂) | −196°C | Moderately convenient — needs planning | Most destructive. One application usually sufficient. Applied with cotton-wool buds or proprietary spray gun. Can be kept in Dewar flask for ~48 hours. Supply via local hospital or industrial source — arrange dedicated sessions. |
| Nitrous oxide (N₂O) | −89°C | Most convenient — from cylinder, prescribable on FP10 | Less destructive — may need 2–3 treatments 10–14 days apart. More painful than LN₂. Less skill required. |
| Commercial mixtures (e.g. Histofreeze) | −57°C | Convenient, ready to use | Least powerful. Suitable for superficial warts and seborrhoeic keratoses. Less reliable for thicker lesions. |
| Carbon dioxide snow | −78°C | Now rarely used in GP | Largely superseded by LN₂ and N₂O. |
| Lesion | Freeze time | Technique notes |
|---|---|---|
| Viral warts | 15–30 seconds; double 30s for persistent/mosaic plantar warts | Patient pares flat weekly; repeat every 2–3 weeks. Salicylic acid nightly may hasten resolution. Treat 2mm margin of normal skin. |
| Seborrhoeic keratoses | 10–20 seconds (depending on thickness) | Larger lesions may benefit from paring down before freezing. |
| Molluscum contagiosum | 5–10 seconds only | Short time; avoid over-treating in children. |
| Actinic (solar) keratoses | 10–15 seconds | Treat 2mm margin of normal surrounding skin. |
| Bowen's disease | 20–30 seconds | Spray technique preferred. Include 2mm margin. Do not use Histofreeze/cotton bud for Bowen's. |
| Small benign moles | Variable — only if diagnosis certain | If any doubt, excise for histology instead. |
| Skin tags | 5–10 seconds or snip excision preferred |
Silver nitrate sticks chemically destroy superficial tissue. Available as pencils (also sold OTC for shaving cuts) and sticks (long match with black silver nitrate head — preferred for clinical use; very inexpensive).
Chemical cautery of Little's area (Kiesselbach's plexus on the anterior nasal septum) for recurrent idiopathic nosebleeds is a quick, simple procedure well within the remit of GP minor surgery — provided the practitioner has had supervised prior experience.
Evidence (referenced in NICE CKS Epistaxis 2024) suggests 75% silver nitrate is more effective than 95% at two weeks following application. Use 75% sticks where available. Standard silver nitrate sticks sold for clinical use are typically 75% silver nitrate.
0.5% neomycin + 0.1% chlorhexidine cream (Naseptin), applied to the anterior septum BD for 4 weeks, has been shown to be as effective as silver nitrate cautery for anterior epistaxis. It is an appropriate first-line alternative — consider before cautery, especially in those who cannot attend for a procedure. Contraindicated in peanut/soya allergy (contains arachis oil). Alternative: petroleum jelly (Vaseline) applied BD.
Primary closure of traumatic wounds in primary care. Assess carefully — some wounds are better left to heal by secondary intention or require specialist referral.
| Feature | Tissue Adhesive (Histoacryl) | Skin-Strip (Steri-strip) | Suture |
|---|---|---|---|
| LA required | No | No | Usually yes |
| Assistant needed | Sometimes | Sometimes | Recommended |
| Key technique step | Dry thoroughly; hold edges; apply; hold 30 sec | Dry; apply tincture of benzoin; hold edges; apply strips | LA; choose suture material; close in layers; dress |
| Wound washing | Avoid for 5 days | Keep clean and dry | Keep clean and dry |
| Removal | Self-sloughs 5–10 days (do not pick) | Patient removes when they fall away | GP/nurse removes (timing depends on site) |
| Best for | Small, superficial, clean wounds; children; facial lacerations | Superficial, low-tension wounds; children | Deeper wounds; high-tension areas; excisions |
| Not suitable for | Hands, joints, hairy skin, wet wounds, high tension | Hairy areas, high tension, wounds >2cm | Infected/heavily contaminated wounds |
Adapted from Cochrane evidence-based flow diagram comparing minor wound closure techniques.
Faster, more haemostatic. Risk: if one break, entire closure fails. Harder to adjust tension.
Vertical: Excellent eversion; good for thick skin (back, palms, soles).
Horizontal: Fragile skin (elderly); distributes tension.
Technique:
Patient advice: Keep clean and dry. Patient can remove Steri-Strips themselves once wound has healed (usually 5–10 days). Return if any problems.
Not for: Hairy areas, high-tension areas, or wounds >2cm.
Technique (qualified staff):
Post-procedure wound assessment and patient advice:
Not for: Hands, over joints, high-tension areas, or infected wounds.
| Vaccination History | Clean Wound | Tetanus-Prone Wound* |
|---|---|---|
| Fully immunised, last dose <10 years ago | No vaccine | No vaccine |
| Fully immunised, last dose >10 years ago | No vaccine | Booster dose |
| Incomplete or uncertain history | Complete course | Vaccine + immunoglobulin |
*Tetanus-prone: puncture wounds, soil/manure, devitalised tissue, compound fractures, delayed (>6h) surgical intervention.
Not routinely required for clean wounds. Consider for:
First 48h: Keep dry and covered. Elevate if possible. Paracetamol for pain (avoid NSAIDs first 48h).
After 48h: Can shower — pat dry gently. Change dressing if wet/soiled.
Suture removal: Face 5–7 days | Scalp 7–10 days | Trunk/arms/legs 10–14 days
Corticosteroid injections and synovial aspiration are fundamental skills in musculoskeletal medicine. They are used for both diagnosis and treatment of joint, bursal and soft-tissue problems in primary care.
| Finding | Normal | Osteoarthritis | RA / Inflammatory | Septic Arthritis |
|---|---|---|---|---|
| Gross appearance | Clear | Clear | Opaque | Opaque |
| Volume (ml) knee | 0–1 | 1–10 | 5–50 | 5–50 |
| Viscosity | High | High | Low | Low |
| WCC /mm³ | <200 | 200–10,000 | 5,000–75,000 | >50,000 |
| % Polymorphs | <25% | <50% | >50% | >75% |
Send all diagnostic aspirates for: total and differential WCC, culture and sensitivity (gram stain, MC&S), polarised light microscopy (urate/pyrophosphate crystals). Never rely on one test alone — crystal arthritis and infection can coexist.
| Item | Details |
|---|---|
| Skin preparation | Antiseptic solution (povidone-iodine or chlorhexidine), alcohol swabs, 4×4 gauze pads |
| Local anaesthetic | 1% lidocaine (mixed with corticosteroid in same syringe or injected separately) |
| Needles — large joints | 21G (green) for knee, shoulder, ankle |
| Needles — medium joints | 21–23G for elbow, wrist, trochanteric bursa |
| Needles — small joints | 23–25G for fingers, toes, MCP, PIP joints |
| Needles — aspiration | 18G for purulent effusions; 21G for routine knee aspiration |
| Syringes | 3–5ml for injection + anaesthetic; 10–50ml for therapeutic aspiration |
| Miscellaneous | Sterile gloves, forceps (to change syringe without touching needle), specimen containers |
Standard needle lengths work in most patients. Use longer needles (or spinal needles) for large/obese patients. Purulent effusions require 18G or 16G to drain fully. Failure to drain a septic joint fully should prompt urgent referral for washout.
Note: Doses given for methylprednisolone acetate (Depo-Medrone 40mg/ml) as primary reference. For triamcinolone acetonide (Kenalog 40mg/ml), use the lower figure of the range. For periarticular lesions, use methylprednisolone acetate (less skin atrophy risk than triamcinolone).
Hydrocortisone acetate (weakest, shortest-acting) → Methylprednisolone acetate (Depo-Medrone, intermediate) → Triamcinolone acetonide (Kenalog, most potent, longest-acting)
Use the weakest agent adequate for the indication. For superficial periarticular lesions (tennis elbow, De Quervain's), use hydrocortisone acetate — triamcinolone carries a higher risk of skin atrophy and hypopigmentation at superficial sites. Reserve triamcinolone for larger, deeper joints (knee, shoulder) where longer duration is needed.
| Site / Joint | Depo-Medrone (methylprednisolone) | Needle | GP scope |
|---|---|---|---|
| Knee (large) | 20–80mg | 21G | ✓ Routine GP |
| Shoulder / glenohumeral | 40–60mg | 21G | ✓ Routine GP |
| Subacromial bursa | 30–40mg | 21–23G | ✓ Routine GP |
| Elbow (medium) | 20–40mg | 21–23G | ✓ Routine GP |
| Tennis elbow (periarticular) | 10–25mg hydrocortisone acetate (NOT Depo-Medrone — skin atrophy risk) | 23G | ✓ Use cautiously (see note) |
| Olecranon bursa | 20mg | 22G | ✓ Routine GP |
| Acromioclavicular joint | 10–20mg | 23G butterfly or 22G | ✓ Routine GP |
| Wrist joint | 20–40mg | 23G | ✓ Routine GP |
| Carpal tunnel | 20–40mg | 25G | ✓ Routine GP |
| De Quervain's (periarticular) | 20–30mg | 25G | ✓ Routine GP |
| Trigger finger (tendon sheath) | 10–20mg | 25G or 23G butterfly | ✓ Routine GP |
| First CMC joint (thumb base) | 15–30mg | 23–25G | ✓ Routine GP |
| Finger / MCP / PIP joints | 10–15mg | 25–27G | ✓ Routine GP |
| Ankle (medium) | 20–40mg | 22–23G | ✓ Routine GP |
| Subtalar joint | 20–30mg | 22G | ✓ Experienced GP |
| Plantar fascia | 20–30mg | 23G | ✓ Routine GP |
| Trochanteric enthesopathy | 30–40mg | 22G (1.5 inch or spinal for obese) | ✓ Routine GP |
| Anserine bursitis | 20–30mg | 22G | ✓ Routine GP |
| Morton's neuroma | 20–30mg | 22G | ⚠️ Specialist preferred |
| MTP joints | 10–20mg | 22G | ✓ Routine GP |
| Trigger points | 3–5ml 1% lidocaine (NO corticosteroid) | 22G | ✓ Routine GP |
| Hip joint | Diagnostic aspiration only — no dose range given | Imaging-guided | ⚠️ Specialist / imaging guidance required |
The patient should be positioned supine or in a comfortable recumbent position, as fainting (vasovagal) is a real risk. Explain the procedure fully. Have the patient sign consent.
If fluid flow stops, the needle may have clogged with synovial membrane or debris. Rotating the needle, withdrawing slightly, or re-injecting a small amount of fluid will often unclog it. For thick purulent fluid, use 18G or 16G needles.
Indications: RA, psoriatic arthritis, active Bouchard's nodes
Approach: Dorsolateral, digit in semiflexion. Insert 25–27G needle into joint space. Corticosteroid injection produces circumferential distension of the joint.
Precaution: Do not overdistend — fluid tends to back up; maintain firm gauze pressure ≥5 minutes.
Complications: Joint hyperlaxity, capsular calcification (usually inconsequential).
Indications: Trigger finger; flexor tenosynovitis in RA, psoriatic arthritis.
Approach: Just distal to palmar crease of thumb (proximal crease), or distal palmar crease for index/long/ring/little fingers. Needle at 45° distal inclination. Up to 3 injections, 3 weeks apart.
Precaution: Avoid intratendinous injection. Reciprocal needle movement on gentle finger motion indicates tendon engagement — back up by 1mm, free needle, then inject.
Complications: Superficial fat atrophy; tendon rupture is rare but reported.
Indications: Inflammation of abductor pollicis longus and extensor pollicis brevis at radial styloid (positive Finkelstein's test).
Approach: 25G needle aimed at radial styloid. Needle is pulled back 1mm and injection attempted — successful injection distends the sheath distally to the metacarpal base.
Precaution: Do not inject into grossly thickened sheaths (mycobacterial infection may be present). Keep corticosteroid within the sheath.
Complications: Skin hypopigmentation (common); skin atrophy with ecchymosis in elderly.
Indications: All aetiologies except acute (fracture/haemorrhage) and late-pregnancy CTS.
Approach: Wrist extended 30°. Just distal to distal wrist crease, medial to palmaris longus (absent in 25% — use midline if so). Insert 25G needle 1cm deep at 45° distal and lateral inclination.
Precaution: If paraesthesias occur, the median nerve is engaged — withdraw and reposition. Reciprocal movement on finger motion = tendon engagement; reposition.
Clinical pearl: A properly fitted neutral-position wrist splint minimises intracarpal pressure and complements injection therapy.
Indications: Painful OA — "square hand", grating and tenderness at the prominence.
Approach: In the anatomical snuffbox. Joint entered between abductor pollicis longus anteriorly and extensor pollicis longus posteriorly. Thumb flexed across palm to expose joint.
Precaution: Avoid the radial artery (course varies; may encircle the joint line).
Complications: None if radial artery is avoided.
Indications: Acute arthritis (gout, pseudogout most common); RA, sterile synovitis.
Approach: Dorsal, just distal to Lister's tubercle (dorsal distal radius prominence), ulnar to extensor pollicis longus tendon. Wrist slightly palmar-flexed to open the joint.
Precaution: No important neurovascular structures at this entry point.
Indications: Routine dorsal ganglia (highly effective with corticosteroid injection). Ganglia within the carpal tunnel or >3cm should be treated surgically.
Approach: Aspirate ganglia contents first (very viscous, translucent fluid — confirms ganglion). If fluid is different, culture and inspect for crystals.
Precaution: In wrist ganglia, rule out radial artery aneurysm (expansile, pulsatile — distinct from focal pulse of normal adjacent artery).
Indications: Aspiration in acute arthritis; injection in RA, psoriatic arthritis. Elbow held flexed at 90° for all approaches.
Posterior: Palpate depression in midline between two halves of triceps tendon at back of elbow. Needle perpendicular to skin into olecranon fossa.
Inferolateral: Midpoint cleft between olecranon tip and lateral epicondyle. Insert perpendicularly, aiming at joint centre.
Lateral: Radiocapitular joint — from side, just proximal to radial head. Needle passed tangentially between the two bones.
Precautions: No major neurovascular structures at lateral/posterior approaches.
Indications: Diagnosis of effusion; treatment of aseptic bursitis refractory to conservative management. Negative bursal fluid culture required before injecting steroid.
Approach: Lateral through normal skin, aiming at centre of bursa.
Precaution: Taps at tip of bursa may create a chronic leak (skin is maximally stretched here). Medial approach may damage the ulnar nerve. In traumatic/idiopathic bursitis, try conservative management first (avoid leaning on elbow for 3 months).
Complications: Skin atrophy, pain on leaning, septic bursitis (risk of 20mg triamcinolone hexacetonide; lower risk with 20mg methylprednisolone acetate).
⚠️ Current evidence update (NICE CKS 2024): Corticosteroid injection produces good short-term relief (4–6 weeks) but is associated with worse outcomes at 3–12 months compared to physiotherapy or wait-and-see. It is no longer recommended as first-line treatment. Reserve for failed conservative management after ≥6 weeks. Avoid repeated injections — associated with chronic pain and tendon rupture risk.
If injecting: Use short-acting steroid (hydrocortisone acetate) rather than Depo-Medrone — lower risk of skin atrophy. Avoid long-acting preparations. Avoid injecting too superficially (fat necrosis risk).
Approach: At point of maximum tenderness on lateral epicondyle. Pass 23G needle to periosteal contact. Infiltrate with 2–3ml lidocaine. Inject steroid at the tenoperiosteal junction.
Complications: Transient increase in pain in ~40% patients (warn in advance). Repeated infiltrations may result in chronic pain. Avoid subcutaneous injection (fat necrosis, hypopigmentation).
Pathology: Tendinosis of the common flexor origin at the medial epicondyle (pronator teres and flexor carpi radialis most commonly involved). Overuse injury from repetitive wrist flexion and pronation. Accounts for 10–20% of all epicondylitis diagnoses.
⚠️ Current evidence (2024): Like lateral epicondylitis, corticosteroid injection provides short-term relief (<6–8 weeks) but has no proven long-term benefit and may increase recurrence rates. Use only after failed conservative management (rest, physiotherapy, analgesia, counterforce brace).
⚠️ Beware the ulnar nerve — it runs in the cubital tunnel behind the medial epicondyle. Medial elbow injection carries risk of ulnar nerve damage. Do NOT inject the medial compartment of the elbow joint without clear landmarks. Never inject into the nerve (electric-shock sensation = stop immediately).
Position: Patient supine or seated, arm in comfortable abducted position at side, elbow flexed to 45°, wrist supinated.
Approach: Identify point of maximum tenderness on the medial epicondyle (origin of common flexor tendon). Insert 23G needle perpendicular to skin at this point. Advance to bone contact, then withdraw 1–2mm. Inject corticosteroid slowly (peppering technique — fan the needle in multiple passes around the tenoperiosteal insertion).
Precautions: Avoid injecting too superficially (fat atrophy). Stay lateral to the medial epicondyle tip to avoid the ulnar nerve coursing in the cubital tunnel just posterior and medial to it. If paraesthesias occur in the little or ring finger, withdraw immediately — the ulnar nerve has been encountered.
Complications: Ulnar nerve injury (from misplaced injection), post-injection flare (~40% transient pain increase — warn patients), skin atrophy, tendon rupture risk with repeated injections.
Alternatives: Physiotherapy with eccentric loading exercises is the recommended first-line treatment. PRP injection increasingly used for chronic/refractory cases.
Indications: Aspiration in acute arthritis; injection in RA, spondyloarthropathy, early frozen shoulder, OA. Aspiration before injection in acutely inflamed shoulder.
Posterior approach (preferred): Patient sitting with arm relaxed. Palpate posterior acromion margin. Insert needle 1cm below and 1cm medial to posterolateral corner, aiming anteriorly towards coracoid process until bone touched.
Anterior approach: Patient sitting, arm hanging at side, elbow 90°, forearm in sagittal plane. Enter 1cm distal and 1cm lateral to coracoid process. Some lidocaine injected ahead of needle as it advances.
Precautions: Posterior approach preferred — less apprehension, needle farther from neurovascular structures. Watch for vasovagal in susceptible patients. Dry tap may indicate severe synovitis — repeat under fluoroscopic or US guidance.
Indications: Subacromial impingement, calcific tendinitis.
Note: Only ~50% of injections reach the bursal sac even with accurate technique — but results can still be excellent even without direct bursal entry.
Posterolateral approach (most common for GP): Patient sitting or lying. Posterior and lateral aspect of shoulder, inferior to lower edge of posterolateral acromion. Insert needle inferior to acromion at the lateral shoulder and direct toward the patient's opposite nipple — this landmark ensures the needle travels under the acromion into the bursal space. Advance to full needle length. Easy flow indicates bursal location.
Anterior approach: Needle anteroposteriorly flush with inferior acromion surface, 1cm lateral to acromioclavicular joint. Once coracoacromial ligament passed, resistance ceases. Easy flow = bursal location.
Precautions: Chair with armrests; have assistant present (vasovagal risk). Do not inject deeply into rotator cuff tendon.
Indications: Acute arthritis, OA, RA, spondyloarthropathy.
Approach: Needle perpendicular to articular cleft; advance 0.5cm; aspirate or inject to distend joint.
Precautions: AC joint is very narrow with a partial meniscus — procedure is technically demanding. Suspect septic AC arthritis in IV drug users and patients with indwelling subclavian catheters. Do not inject if sepsis suspected.
Indications: Bicipital tenosynovitis. Note: most cases are secondary to subacromial impingement — treat subacromial bursa first; use this injection only if direct tenosynovitis confirmed.
Approach: Palpate bicipital tendon (bicipital groove). Mark on skin. Needle directed superiorly, tangentially to tendon. Inject under low pressure only.
Precautions: Biceps tendon integrity may already be compromised by subacromial impingement. Post-injection rupture risk is real — inject tangentially, not directly into the tendon.
Indications: Diagnostic aspiration for septic arthritis, differentiating septic arthritis from aseptic loosening in prosthetic hip.
Hip joint aspiration is technically demanding and carries significant risk of injuring the femoral neurovascular bundle. Requires imaging guidance (fluoroscopy, US, or CT). This is in the realm of orthopaedics and radiology — refer rather than attempt in primary care.
Note: This condition is better described as gluteal enthesopathy (stress enthesopathy at gluteus medius/minimus insertion), not true bursitis in most cases.
Indications: Trochanteric pain syndrome refractory to conservative management.
Approach: Patient on opposite side. Palpate greater trochanter along femur distally to proximally. Point of maximal tenderness at posterior corner of greater trochanter. Needle inserted vertically to periosteal contact. Infiltrate lidocaine radially (cone 3cm wide, half on bone, half in proximal soft tissue). If pain relieved, infiltrate corticosteroid in same area.
Precaution: Needle must be long enough to reach bone (spinal needle for obese patients).
Clinical pearl: Address the underlying cause (foot pronation, leg length discrepancy, knee/hip/back disorder) for sustained relief.
Indications: Effusion in any aetiology; corticosteroid injection in RA, OA, spondyloarthropathy, crystal-induced synovitis.
Medial approach (preferred for injection with large effusion): Supine, knee extended. Medial patellofemoral approach — aim needle to patellar undersurface mid-distance between upper and lower patellar poles. Medial approach preferred as lateral patellofemoral cleft is narrower and the lateral joint capsule is tougher.
Superolateral approach (alternative — especially useful for effusion): Patient on couch, knee slightly bent. Palpate the superior-lateral aspect of the patella. Mark a point 1 fingerbreadth above and lateral to this site. Clean. Inject LA then corticosteroid at this site directed medially and posteriorly under the patella.
Precaution: In RA, beware superimposed septic arthritis — aspirate first if acutely inflamed. Postpone injection until negative synovial fluid culture is available.
Management: Aspiration or injection of the cyst itself is generally unnecessary. Baker's cysts develop in connecting gastrocnemius-semimembranosus bursae and depend on excessive intra-articular fluid from the knee. Treat the underlying knee disorder — systemic treatment, corticosteroid injection into the knee joint, or surgery (arthroscopic meniscectomy/synovectomy) to address the source.
Indications: Anserine bursitis syndrome — medial knee pain at the pes anserinus (semitendinosus/gracilis/sartorius insertion on anteromedial tibia). Almost always secondary to genu valgum, patellofemoral OA, etc.
Approach: Follow medial border of thigh with knee in semiflexion to where a mark is placed on tibia. Bring knee to extension; insert needle perpendicularly to tibial contact. Infiltrate 3cm area adjacent to periosteum.
Precaution: Paresthesias along medial leg indicate saphenous nerve — reposition needle.
Clinical pearl: Condition will recur unless the primary problem (genu valgum, patellofemoral OA) is addressed. Initiate isometric quadriceps exercises immediately.
Approach: Supine, foot in slight plantarflexion. Seek cleft between tibia and talus by gently flexing and extending the foot. Insert needle vertically medial to anterior tibialis tendon.
Precaution: Avoid the dorsalis pedis artery (lateral to approach).
Indications: As for the ankle (inflammatory arthritis, OA).
Approach: By gently inverting and everting the foot, find soft cleft (sinus tarsi) anterior to lateral malleolus. Insert needle perpendicularly towards tip of medial malleolus. Aspiration of fluid proves articular insertion.
Precautions: None specific. Inject under low pressure.
Indications: Refractory plantar fasciitis after failed conservative management (stretching exercises, footwear modification, insoles, physiotherapy ≥3 months). Per NICE CKS, discuss benefits AND risks before offering injection — plantar fat-pad degeneration and fascia rupture are real risks.
Approach: Medial approach from thinner skin — do NOT approach from the direct plantar surface (thicker skin, more painful, fat-pad damage risk). Patient indicates the tender spot. Enter from the medial side of the heel and direct needle posterolaterally toward the calcaneal insertion. Deposit small blebs of corticosteroid as near to the bony insertion as possible.
Indications: Aspiration for suspected gout (first MTP most common); injection in hallux rigidus, RA, spondyloarthropathies.
Approach: Dorsal, lateral or medial to extensor tendon. Slight passive plantarflexion opens the joint. Attempt aspiration before injection.
Indications: Morton's neuroma (interdigital neuroma).
Approach: Dorsal between metatarsal heads. Needle advanced plantarly ~2cm, through intermetatarsal ligament (tough fibrous resistance). Inject under low pressure. Up to 2 reinjections 2–3 weeks apart.
This procedure should only be performed by those with a thorough knowledge of foot anatomy. Refer to podiatric surgeon or orthopaedics if not experienced.
Indications: Acute cases where pressure on a point or nodule consistently reproduces the patient's pain.
Approach: 22G needle aimed at the tender point or nodule centre, infiltrated radially throughout the indurated area.
Important: Use local anaesthetic ONLY (3–5ml 1% lidocaine or 0.25% bupivacaine) — do NOT inject corticosteroid at trigger points.
Complications: None. Up to 2 reinjections 2–3 weeks apart are allowed.
Pain after the injection: The local anaesthetic wears off after approximately 2 hours — pain will return at this point and may temporarily be worse than before the injection. This is normal. Warn patients explicitly so they are not alarmed.
What to expect: The steroid takes 3–7 days to produce its anti-inflammatory effect. If pain is severe or increasing after 48 hours, seek advice — this could indicate a post-injection flare or, rarely, infection. Facial flushing occurs in up to 40% — transient, settles in 1–3 days (always warn before injecting).
Post-injection flare (~5%): Apply ice to the area for 15 minutes every hour for the first few hours. Continue NSAIDs — they reduce the risk and severity of post-injection flare. Flare usually resolves within 24–48 hours.
Activity: Rest the joint for 24–48 hours. Effect lasts 6–12 weeks. Max 3–4 per year per joint.
Seek help if: Increasing pain, redness, swelling, warmth after 48h; fever; any pain not settling within 48h.
| Complication | Details & Management |
|---|---|
| Infection / Septic arthritis | Risk ~1 in 15,000 procedures. Hot swollen joint + fever post-injection = urgent orthopaedic referral same day. Requires aspiration, IV antibiotics, possible joint washout. Always use aseptic technique. |
| Post-injection flare | Corticosteroid crystal-induced synovitis in ~5% of intra-articular injections. Pain appears several hours after injection, lasts hours to 1 day. Persisting swelling/pain beyond 48h suggests iatrogenic infection — re-aspirate and culture. |
| Facial flushing | Very common (~40% of cases). Transient and inconsequential; resolves in 1–3 days. Always warn patients before injecting — failure to warn is a common source of complaints. |
| Skin atrophy | Frequent with superficial infiltrations and olecranon bursa injections. Cigarette-paper-like skin, recurrent ecchymosis, chronic pressure pain. More likely in elderly. Caused by corticosteroid escaping into subcutaneous tissue — ensure deep injection and correct site. |
| Skin hypopigmentation | Particularly common with De Quervain's injections. May be disfiguring in darker skin. Usually resolves in a few months to 2 years. |
| Tendon rupture | Rare but serious. Risk minimised by avoiding direct injection into the tendon body (inject around, not into). High risk sites: Achilles, patellar, biceps tendons. Athletes with multiple Achilles infiltrations are at particular risk. |
| Corticosteroid arthropathy | Abuse of intra-articular injections may result in a Charcot's-like arthropathy similar to calcium pyrophosphate deposition disease. Avoid excessive frequency. |
| Osteonecrosis | A reported complication of abused articular or soft tissue corticosteroid infiltrations. Rare with appropriate use. |
| Corticosteroid-induced osteoporosis | Patients serially injected for recurrent tendinitis (e.g. tennis elbow) are at enhanced risk during the injection period, particularly if prolonged bed rest or low calcium intake is also present. Intra-articular route has less systemic effect than oral steroids, but risk is not zero with repeated injections. |
| Systemic effects | Transient pituitary inhibition for several days. Serial infiltrations may cause adrenal suppression. Hyperglycaemia in diabetic patients (warn to monitor blood glucose for 48h post-injection). |
Partial or total nail avulsion with phenolisation of the nail matrix is the definitive treatment for recurrent ingrowing toenails. Success rate >95% with proper technique.
What to expect: Discharge from the toe for up to 6 weeks is completely normal — this is the phenol reaction, not infection. Keep area clean and covered.
Activity: Elevate foot 24–48h. Open-toed footwear until healed. Nail bed heals fully in 6–12 weeks.
Seek help if: Increasing pain; spreading redness or swelling; fever; nail spicule growing back into skin.
Choose the right dressing for the wound's exudate level, infection status, and healing stage. Dressings do not heal wounds — they create the optimal environment. Moist wound healing is faster and less painful than dry healing.
| Wound condition | Dressing type | Examples |
|---|---|---|
| Dry / minimal exudate | Hydrogel → adds moisture | Intrasite Gel, Purilon |
| Low exudate | Hydrocolloid → maintains moisture | Granuflex, DuoDERM |
| Moderate exudate | Foam → absorbs excess | Allevyn, Biatain |
| High exudate | Alginate → highly absorbent | Kaltostat, Sorbsan |
| Very high exudate | Alginate + secondary dressing | Kaltostat + gauze pad |
| Infected | Antimicrobial + systemic antibiotics if cellulitis | Aquacel Ag, Iodosorb, Medihoney |
| Cavity wound | Alginate rope → packs cavity | Kaltostat rope |
| Sloughy / necrotic | Hydrogel → autolytic debridement | Intrasite Gel |
| Sutured wound | Non-adherent → protects sutures | Jelonet, Mepitel One |
Mechanism: Occlusive dressing with carboxymethylcellulose — forms gel on contact with exudate. Promotes autolytic debridement.
Mechanism: Polyurethane foam — high absorbency, breathable. Adhesive and non-adhesive versions available.
Mechanism: Derived from seaweed. Gel-forming, haemostatic. Flat sheets or rope for cavities.
Mechanism: 80–90% water. Donates moisture to dry wounds. Promotes autolytic debridement. Cooling effect reduces pain.
| Type | Examples | Key notes |
|---|---|---|
| Silver | Acticoat, Aquacel Ag, Allevyn Ag | Broad-spectrum, sustained release. Grey discolouration temporary. |
| Iodine | Iodosorb, Inadine | Broad-spectrum, rapid action. Avoid in thyroid disease and pregnancy. |
| Honey (medical grade) | Medihoney, Activon | Antibacterial, debriding, deodorising. Good for malodorous wounds. |
| PHMB | Kendall AMD | Broad-spectrum, non-toxic. |
Antimicrobial dressings reduce local bioburden only. They do NOT replace systemic antibiotics when cellulitis or sepsis is present. Review at 2 weeks and stop if infection resolved. Max 2 weeks continuous use.
| Type | Examples | Notes |
|---|---|---|
| Paraffin gauze | Jelonet | Cheap, easy. Can dry and adhere if little exudate. |
| Silicone mesh | Mepitel One | Painless removal. Excellent for fragile skin, skin tears, grafts. |
| Transparent film | Tegaderm | Waterproof, allows inspection. NOT for exuding wounds. |
| Low-adherent pad | Melolin | Absorbent pad with non-stick surface. Needs securing with tape. |
Indications: Sutured wounds, skin grafts/donor sites, minor burns, abrasions, fragile skin (elderly), secondary intention healing.
Four categories of serious warning signs to recognise and act on immediately. Select each tab to review.
Action: Do NOT excise suspected melanoma or SCC in primary care. Refer urgently (2-week wait) for specialist assessment and excision with appropriate margins.
Action: Oral flucloxacillin 500mg QDS for 5–7 days. If systemically unwell, spreading rapidly, or immunocompromised, consider admission for IV antibiotics.
Action: Emergency admission. Call ahead. Requires urgent surgical debridement + IV antibiotics. Mortality 20–30% even with treatment.
Action: Urgent orthopaedic referral same day. Requires joint aspiration (culture, WCC, crystals), IV antibiotics, possible washout. Delay = cartilage destruction.
Action: Do NOT proceed. Refer to vascular surgery. High risk of non-healing, infection, amputation.
Action: Remove all dressings/bandages immediately. Elevate limb. Emergency referral to orthopaedics. Fasciotomy within 6 hours to prevent permanent damage.
Action: Remove tourniquet immediately. Warm digit. If adrenaline used, consider phentolamine injection (alpha-blocker reverses vasoconstriction). Urgent referral if not improving within 30 minutes.
Action: Stop procedure immediately. Document carefully. Most are neuropraxia (temporary) — recover in weeks to months. Refer to hand surgery/neurology if no improvement at 3 months or complete loss of function.
Action: Urgent referral if acute onset with complete loss of function (may need surgical decompression). Routine referral if gradual onset or partial deficit.
Prevention: Know your anatomy. Use landmarks. If patient reports paraesthesia during injection, withdraw and reposition needle immediately.
"If in doubt, don't cut it out."
When faced with diagnostic uncertainty, always err on the side of caution. It's better to refer a benign lesion than to inadequately excise a malignant one. Your patient's safety and your medicolegal protection depend on knowing when to refer.
Remember: Competence is not just about what you can do, but knowing when NOT to do it.
Medicolegal considerations and risk reduction strategies for safe minor surgery practice in UK general practice.
The following areas have higher complication rates and should be approached with caution or referred:
Minor surgery is a valuable skill that improves patient care and job satisfaction. Start with simple procedures, build your confidence gradually, and always prioritise patient safety. Remember: competence comes with practice, but wisdom comes from knowing your limits.
Every expert was once a beginner. Keep learning, keep practicing, and don't be afraid to ask for help.