This document discusses soft tissue lesions, including tennis elbow, carpal tunnel syndrome, and trigger finger. For tennis elbow, it describes the causes as overuse or repetitive stress injuries, clinical features such as lateral epicondyle pain aggravated by certain motions, and treatments including rest, bracing, injections and surgery. Carpal tunnel syndrome is defined as median nerve entrapment at the wrist. It lists causes such as medical conditions and repetitive stress. Clinical features include numbness and tingling in the median nerve distribution. Trigger finger is caused by thickening of the tendon sheath which results in the finger getting trapped and snapping on motion. Injection of steroids or surgery to divide the pulley may treat trigger finger.

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.