SEMINAR ON AFFECTIONS OF THE

SOFT TISSUES

BY:- Dr. KRISHNA MURTHY T

DEPARTMENT OF ORTHOPEDICS
Dr.B R AMEDKAR MEDICAL COLLEGE
Affections of the soft tissues

 CARPAL TUNNEL SYNDROME- 5 mark question

 MALLET FINGER
 TRIGGER FINGER-3 mark question/5 mark
 DEQUERVAIN’S DISEASE-5mark/ 3 mark question
 TENNIS ELBOW-3 mark/ 5 mark
 GOLFER’S ELBOW-3 mark
 CARPAL TUNNEL SYNDROME

 It is also called as Tardy

median nerve palsy.

DEFINITION:
It is a compressive
irritation syndrome of the
median nerve as it traverses
the carpal tunnel.
ANATOMY:
The carpal tunnel is a
cylindrical cavity
connecting the volar
forearm with palm.
Contents :
1.Tendons of flexor
digitorum superficialis and
flexor digitorum profundus in a
common sheath .
2. Flexor pollicis longus
tendon in an independent sheath
.
3. Median nerve.
Pathophysiology :
It is caused by
compression neuropathy of
median nerve at wrist because of
hypertrophy or oedema of flexor
synovium.
 SEX : M : F – 1 : 5
AGE : Common age of onset is between 40 – 50 years of age.

FACTORS INVOLVED IN PATHOGENISIS OF CTS :

1 Anatomical : a) size of carpal tunnel
b) bony abnormalities of carpal bones.
c) Acromegaly
d) Flexion or exension of wrist.
2. In contents of canal : a)Colles and scaphoid fractures.
b)scaphoid rotatory subluxation
and lunate volar dislocation.
c) post traumatic arthritis
d) musculo tendinious variants
 e) Aberrant muscles of palm and hand
f) Local tumours
g) persistent medial artery
h) Hypertrophic synovium and haematoma.
3. Physiologic :
a) Neuropathic : DM, Alcoholism, double crush syndro
-me.
b) Inflammatory : RA, gout ,non specific tenosynovitis,
infections, ganglion.
c)Alterations of fluid balance : pregnancy , menopause ,
eclampsia, hypothyroidism
renal failure, long term
haemo dialysis, obesity,
LE, pagets, amyloidosis
scleroderma.
CLINICAL FEATURES :
Symptoms :
 Paroxysms of pain, paraesthesias
and numbness occur in the area
of distribution of median nerve
particularly at night.
 Patient is awakened after few hours of
sleep by pain which is burning, aching,
or pricking and pins and needles and
numbness in one or both hands.
 Pain may radiate to inner aspect of
forearm or to shoulder.
 Uselessness of wrist and swelling of
fingers.
 Acute attack subsides within
few mins to an hour and
relieved by dangling the arm
over the side of the bed, shaking
the arm or rubbing of hand.
 Tingling may develop during
day often precipitated by
certain manual activities.
 Sensory impairment in
distribution of median nerve.
 Wasting of thenar muscles and
decreased grip strength.
Signs :
 Wrist flexion( PHALENS TEST ):
Patient is asked to actively
place the wrist in complete but unforced
flexion. If tingling and numbness are
produced in median nerve distribution of
hand within 60 seconds then the test is +ve.
It is most sensitive
provocative test with specificity of 80
percent.
 Tourniquet test :
A pneumatic BP cuffis
applied proximal to elbow and inflated
higher than systolic BP. If paresthesia and
numbness develops in the region of median
nerve distribution of hand then the test is
+ve.
 Percussion test ( TINELS SIGN ) :
Tapping median nerve at wrist produces
tingling sensation,test is +ve.
 Compression test :Direct pressure exerted over median nerve
for 30 secs at wrist. If symptoms appear then test is +ve and
disappear after the release of pressure.
 2 point discrimination test : Loss of 2 point discrimination test or
abductor pollicis brevis has high specificity.
 Flick sign : shaking or flicking one’s hand for relief during maximal
symptoms.

DIFFERENTIAL DIAGNOSIS : 1. Tendonitis

2. Tenosynovitis
3. Nerve compression by
cervical disc herniation.
4. Thoracic outlet syndrome
TREATMENT :
 Conservative
 Surgical
 Conservative treatment :
a. Rest, ice , heat.
b. immobilisation
with CT splint.
c. NSAID’S
d.corticosteroids, prednisolone for 8
days starting with 40 mg for 2 days and
tapering by 10 mg every 2 days.
Surgical :
Indications :
1.Failed conservative
2.thenar atrophy
3.Sensory loss
Surgical release of carpal tunnel :
Division of flexor retinaculu
-m and transverse carpal ligame
-nt.
1.Mini open surgical release.
2.Endoscopic release.
3.Percutaneous balloon carpa
-l tunnel plasty.
 MALLET FINGER
(BASEBALL FINGER OR DROPPED
FINGER)

Definition :

Ii is an injury of extensor
digitorum tendon of the
fingers at DIP joint due to
hyperextension of the tendon
resulting in flexion deformity
of DIP joint.
 It usually occurs when a
ball,while being caught hits an
outstreched finger and jams it.
 Most commonly involved fingers
are middle and ring fingers and
more commonly seen in men.
 AETIOLOGY :
1. Forceful blow to the tip of
finger causing sudden flexion.
2. Hyperextension injury with
fracture dorsal tip of distal
phalanx.
 Mechanism of injury :
1.It affects the DIP joint and arises
as a result of closed injury on
the extensor mechanism near its
insertion into distal phalanx.
 Therefore,as an extensor tendon
injury,the mallet finger is a
characteristic flexion deformity of
DIP joint which occurs as a result of
disrupted continuity of the extensor
tendon over DIP joint.
 Normally,the terminal portion of
extensor mechanism that crosses the
DIP joint in midline dorsally is
responsible for active extension of
distal joint,but a flexion force on the
tip of extended finger will jolt the
DIP joint into flexion. It results in
1.stretching or tearing of tendon.
2.Avulsion of tendon at the
insertion on dorsal lip of distal
phalanx base.
Symptoms :
1.Pain,swelling and bruising of finger tip.
2.Dropping of finger tip.
3.Haematoma beneath the nail
4.Detachment of nail from beneath the
skin fold at the base of nail.
5.The end of finger is bent and cant be
straightened voluntarily. The DIP
joint can be straightened easily with
the help from other hand.
6.If DIP joint gets stuck in a bent
position and PIP joint (middle
knuckle) extends, the swan neck
deformity occurs.
Diagnosis :
1.Plain x rays,PA and lateral of DIP
joint of affected finger.
2.X rays are used to differentiate
between bony injury and a
tendnious mallet injury and reveal
any associated metaphyseal , shaft
or tuft fractures of distal phalanx.
3.Lateral x ray reveals volar
subluxation of distal phalanx.
Management :
a) Conservative
b) Surgical.
Conservative :
1. Continious DIP joint
extension splinting with a
moulded polythene (stack)
or alluminium splint (6-8
weeks) followed by 6 weeks
of night time splinting.
If the splint is removed
and allowed the finger to
bend, the process is
disrupted and must start all
over again
2.In case of old injuries,
splintage for 8-12 wk to see
for drooping and if not
surgery.
Complications of splinting :
Dorsal skin necrosis over DIP joint due to excessive
pressure of splint.
Alternatively, K- WIRE fixation of DIP joint in
extension with wire cut of beneath the skin can be
done. It should be left in place for 6 weeks followed
by 2 weeks of night splinting.
Surgery :
Indications :
1.Failure of conservative treatment
2. Too much drooping of finger.
3. Associated fractures with open injuries.
 TRIGGER FINGER
(stenosing tenosynovitis or locked
finger)
Definition :
It is an inflammation of
synovial sheath that encloses
the flexor tendons of the thumb
and fingers. It may result from
enlargement of tendon itself or
narrowing of 1st annular pulley.
Age: above 40 years
Sex : common in females
Pathophysiology :
 Normally,the tendons of
fingers glide back and forth
under a restraining pulley.
 Thickening of flexor tendon
sheath causes restriction of
normal gliding mechanism.
 A nodule may develop on the
tendon causing it to get stuck
at the proximal edge of A1
pulley.
 When the patient is attemptin
to extend the digit,difficulty is
met.
 With more forceful attempts to
extend the digit, it classical
-ly snaps open with significant
pain at the distal palm and into
proximal aspect of affected digit
 Less commonly, the nodule is
restricted distally to A1 pulley
resulting in difficulty flexing the
digit.
 Commonly affected- middle or
ring fingers and thumb.
 TYPES- a)Congenital
b)Acquired.
Symptoms :
 Painful snapping sensation (triggering) in
the affected fingers.
 Inability to extend finger smoothly.
 Locking of finger while bending.
 Tenderness over the tendon, usually at the
base of finger or palm.
 Soreness in affected fingers.
Conservative :
 Rest- brace or splint in mild
cases.
 Medications-local
injections of
corticosteroids about the
tender area in palm or
into the synovial tendon
sheath.
Complications of steroid injections-
Infection, bleeding,
tendon rupture, atrophy
of subcutaneous fat,
digital nerve injury.
Surgical treatment :
Indications- 1. failure to
respond to 2-3 injections of
corticosteroids.
2. A congenital nodule on FPL
tendon not responding to
injections.
 Trigger finger release
DEQUERVAIN’S DISEASE
 It is also called as
stenosing tenosynovitis of
1st dorsal compartm
-ent.
 Contracture of the
palmar aponeurosis.

 It is named after swiss

surgeon Fritz de
Quervain who first
identified it in 1885.
Definition :
It is a chronic constr
-ictive tenosynovitis affect
-ing the Abductor pollicis
longus and extensor poll
-icis brevis tendons of the
thumb at the wrist within
the fibro osseous sheath of
1st dorsal compartment at
level of radial styloid.
Age : Adults 30-50 years
Sex :F:M- 10:1
Aetiology :
 Idiopathic
 Overuse of wrist like
grasping, pinching,
squeezing may lead to
tenosynovitis.
 It may be associated
with Rheumatoid
arthritis.
Clinical features :
Symptoms :
 Pain over the thumb side of
the wrist, gradual or
sudden, located at 1st dorsal
compartment at wrist. It
may radiate down the
thumb or up the forearm.
 Swelling along the APL &
EPB tendons.
 Tenderness .
 Thickening of fibrous
sheath.
Signs :
FINKELSTEIN’S TEST :
Tenderness can be elicited
at the tip of styloid by
sudden ulnar deviation of
flexed hand with the
thumb tucked inside the
palm.
 Most pathognomic
objective sign but not
diagnostic.
 Test is also +ve in 1st
carpometacarpal arthritis,
Warenberg’s syndrome.
Treatment :
It depends upon the severity of
problem.
 period of activity modification.
 Complete rest of wrist.
 Ice
 Phsiotherapy
 NSAIDS
 Wrist splint (Thumb spica splint ) :
3-6 weeks
wrist in neutral,
Thumb CMC-45 deg palmar and
radial abduction
Thumb MCP- 10 deg flexion
Thumb IP- don’t immobilize.
More serious cases or failure of initial treatment may
require cortisone injection to reduce inflammation
into tendon sheath.
IN rare cases, surgery is recommended.
Surgery : -
Surgical release of 1st dorsal compartment.
Indications :
 Failure of conservative mangement.
 Persistence of pain.
TENNIS ELBOW

 It is also called as
lateral epicondylitis.
 Definition :
It is a degenerative
disorder affecting the
tendinious origin of common
wrist extensors where the
outer part of elbow becomes
painful and tender usually
as a result of specific strain
or overuse.
Aetiology :
 Epicondylitis –this is due to
single or multiple tears in the
common extensor origin,peri
-ostitis, angiofibroblastic
proliferation of ECRB.
 Inflammation of adventitious
bursa b/w common extensor
origin and radiohumeral jt.
 Calcified deposits within the
common extensor tendon.
 Painful annular ligament is due
to hypertrophy of synovial
fringe between radial head and
capitulum.
Mechanism of injury :
 Due to the above aetiological
factors,the damage consists of
small tears in part of tendon & in
muscle coverings.
 After the initial injury heals,
these areas often tear again
resulting in haemorrhage, rough
granulated tissue and calcium
deposits.
 Collagen and protein leak out
causes inflammation resulting in
ischaemia due to pressure.
 This causes slow healing of
tendons.
Pathophysiology :
 Stage 1 – Acute inflammation
but no angioblastic invasion.
Patient complains of pain
during activity.
 Stage 2 –Chronic inflammati
-on with some angioblastic
invasion. Pain both during
activity and rest.
 Stage 3 – Chronic
inflammation extensive
angioblastic invasion. Pain at
rest, night pain, and pain
during daily activities.
Clinical features :
Symptoms :
 Recurring pain on the outer aspect of
upper forearm, radiating down the
arm towards wrist.
 Pain intensified by grasping or
twisting motions.
 Tenderness at epicondylar ridge,
lateral epicondyle, lower edge of
capitellum anteriorly, laterally over
radio humeral interval, circumference
of radial head.
 Weak grasp and dropping of objects
with forearm pronated.
 TREATMENT
Conservative therapy :

Goal : Decrease inflammation and pain, promote tissue

healing, retard muscle atrophy. During acute stage of
injury, either medial or lateral elbow is affected. RICE
regimen should be employed.

REST
ICE
COMPRESSION
ELEVATION
Rest – avoiding further overuse
and not absence of activity.
Absolute rest should be
avoided as it causes muscle
atrophy and decreases blood
supply retarding healing
process.
Ice- it decreases inflammation,
slows local metabolism and
helps to relieve pain.
Compression and elevation-
To assist venous return and
minimise swelling.
Physiotherapy : It
is the next
phase of treatment.
Application of heat in
form of moist
compresses or short
wave diathermy used.
 Strengthening and
Stretching
excercises :
 Radiation therapy :
Three treatments
of 200 rads in air to
each of 3 fields, ant,
post and lateral may
cure the symptoms.
 Mills manoeuvre :
This is a final option
before surgery. About 10
% of cases don’t
respond to conservat
-ive line of treatment. In
them, a forceful
extension of fully flexed
and pronated forearm
after injection may be
attempted.
Surgery :---
Indications :
 Severe pain for 6 weeks
 Marked and localised tenderness.
 Failure to respond to restricted
activity or immobilisation for atleast
2 weeks.
Techniques :
 Percutaneous release of epicondylar
muscles
 Bossworth technique of excision of
proximal portion of annular
ligament, release of origin of
extensors, excision of bursa and
excision of synovial fringes
 GOLFER’S ELBOW
 It is also called as medial
epicondylitis.
 Definition :
It is a condition where
the inner part of elbow
becomes painful and
tender, usually as a
specific strain, overuse
or a direct trauma.
Symptoms :
 Pain on the bony bit
on the inside of the
elbow.
 Weakness in the
wrist.
 Pain on the inside of
the elbow.
 Pain when the wrist
flexion is resisted.
 Pain on resisted wrist
pronation .
TREATMENT :
 Ice the injury for 2 days (20 mins upto 6 times a day )
 Rest.
 After 2 days, apply heat and use a heat retainer.
 A number of braces and supports are also available to help
reduce the load on the elbow enabling it to heal.
 Apply ultrasound or laser treatment.
 Prescribe anti inflammatory medication.
 Use sports massage techniques.
 Give a steroid injection.
 Surgical repair of medial flexor origin similar to that of the
tennis elbow.
Rest is a very important
component in the healing
of this injury. It may heal
quickly within 2 weeks
but one could suffer with
this problem for longer.
When the symptoms
have settled down, it is
essential that one fully
rehabilitate and
strengthen the elbow.
THANK YOU