undergraduate orthopedic learning

1. Soft Tissue lesions
Dr G.S.Patnaik

2. Tennis elbow

3. Tennis elbow
• Also referred to as lateral epicondylitis
• Defined as an inflammatory condition of the
common extensor origin over the lateral
epicondyle
• Exact eitiology is unknown : probably a chronic
tendinitis of the common extensor origin
• A common problem of the non tennis playing
population too!

4. Tennis elbow
Causes:
• Direct trauma : fall / hit
• Motor vehicle accident
• Work related injury
• Overuse:
– Repetitive lifting, carrying, or performing fine
manipulations of the hand.
• Sudden contraction / stretching of extensor
muscles or repetitive stress:
– Tendinitis
– Small tears
– Microscopic calcification & painful vascular reaction

5. Tennis elbow
Clinical features:
• Adult
• Pain : lateral epicondyle
– After unaccustomed or repetitive activity
– May radiate arm & forearm when severe
• Pain is aggravated by movements like:
– Pouring out tea
– Wringing of clothes
– Turning a door handle
– Shaking hands
– Lifting of weight with the forearm pronated

6. Tennis elbow
Clinical features:
• Tenderness : lateral epicondyle and in the
extensor muscle close to the common extensor
origin
• Elbow flexion & extension : normal

7. Tennis elbow
Clinical features:
Lidocaine injection test
• The patient will be relieved of pain following
injection at the origin of the ERCB tendon
Radiology:
• Usually x-rays are normal occasionally some
calcification may be seen at the common
extensor origin

8. Tennis elbow
Differential diagnosis:
Radial head osteoarthrosis
 X-rays
PIN entrapment neuropathy : PIN syndrome
 Lidocaine injection test:
• Pain relief when the injection is given 4 finger
breadth below the lateral epicondyle, results in PIN
palsy and temporary relief of pain

9. Tennis elbow
Treatment:
• Rest to the part/NSAID’s
• Physiotherapy in the form of coldpac initially
followed by heat therapy
• Bracing to support the part
• Ultrasound-locally
• Plaster immobilisation to ensure rest to the part
• Injections using local anaesthetic & steroids
• Surgery:
• ECRB lengthening or detach the common
extensor origin from the lateral epicondyle

10. Carpal tunnel syndrome

11. Carpal tunnel syndrome
Applied anatomy:
• The carpal tunnel:bony canal : palmar aspect
of the wrist : allows for the passage of the
median nerve to the hand
• The transverse carpal ligament is a thick &
wide ligamentous band attached to the
tuberosity of the scaphoid and crest of the
trapezium radially & to the hook of the hamate
& the pisiform on the ulnar side

12. Carpal tunnel syndrome
Carpal tunnel syndrome (CTS) is a compression
neuropathy, i.e. pinching of the median nerve at
the
wrist
Clinical features:
• More often in women than men – 8 :1
• Common between the ages of 40 and 50
years.
• More frequent in people who tend to do
forceful repetitive types of work

13. Carpal tunnel syndrome
Anatomic factors
• Small carpal canal
• Thick carpal ligament
• Anomalous nerves,
muscles & bursae
Synovitis
• RA / Sero –ve arthritis
• SLE
• Haemophilia
• Gout
Infiltrative disease
• Amyloidosis
• Myxedema
• Acromegaly
Trauma
• #’s, dislocations,
malunions
• Repetitive stress
Tumor / tumor like
• Neuromas
• Lipomas
• Ganglia
• Synovial cysts
Medical / surgical
• AV fistula, arterial
punctures &
catheterisations
Causes:
Miscellaneous
DM,
hemorrhage,
pregnancy,
OC pills,
hypo-
parathyroidism,
idiopathic

14. Carpal tunnel syndrome
Clinical features:
• Wrist pain:
• Numbness and tingling in the
distribution of the median nerve
- lateral 3 1/2 fingers
• Burning pain,“pins and needles”
: at night
• Weakness in grip & feel of
in coordination
• Wasting of the thenar eminence

15. Carpal tunnel syndrome
Clinical features:
Phalen test:
• The patient places the dorsum of both hands
together, then maximally flexes the wrists,
holding the position for one minute
• Reproduction of pain or tingling in the thumb
and/or index finger is a positive test
Phalen test
Reverse Phalen test

16. Carpal tunnel syndrome
Clinical features:
Cuff test:
Compression of the arm for 1 min. with
a sphygmomanometer : sensory changes
along the median nerve distribution
Tinel sign:
• Used to look for entrapment/irritation of the nerve
• The patient's hand is held in a relaxed manner with
the palmar side up. Tap over the course of the nerve,
moving distal to proximal.
• The site at which the patient feels an electric shock
like feeling going along the distribution of the nerve
indicates the region of nerve irritation

17. Carpal tunnel syndrome
Investigations:
• Radiology
carpal tunnel view
• Nerve conduction test
• Electromyography studies
Treatment:
• Nsaid’s
• Wrist splint
• In severe cases where there is evidence
of neurological deficit & in patients who
have increasing symptoms with
functional disability surgery is indicated

18. Choice of treatment

19. Trigger finger
Digital tenovaginitis

20. Trigger finger
Related anatomy:
• Tendons along with the sheath are kept in place
in the hand and the fingers by many fibrous
pulleys for smooth functioning
• Thickening of the tendon sheath:
tendon gets trapped at the
entrance to its sheath & gets
released with a snap on forced
extension of the finger

21. Trigger finger
Thickening occurs:
• Post trauma
• Following unaccustomed activities
• Rheumatoid arthritis
Clinical features:
• Any digit or thumb may be affected
• Ring and middle most common
• Finger clicks on flexion & does not
extend without force : opens with a snap
• A tender nodule felt in the palm in
front of the affected sheath
• Sometimes occurs in the infants : called as infantile
trigger thumb : often mistaken for a dislocation

22. Trigger finger
Treatment:
• Early cases are treated by injection of steroids
carefully at the entrance of the tendon sheath
• Refractory cases are treated by surgery
wherein the pulley is divided so that the tendon
is allowed to glide freely.