SOFT TISSUE AFFECTIONS OF UPPER LIMB

HAND

DUPUYTREN’S CONTRACTURE• A benign proliferative disorder characterized by nodular

hypertrophy and contractures of the superficial palmer fascia(palmer aponeurosis).

• Epidemiology & genetics– autosomal dominant – 5-7th decade of age,M>F– European population.

• Pathophysiology – Proliferation of myofibroblasts – cytokines mediated

• Associated conditions– HIV, alcoholism, diabetes,phenytoin therapy,tuberculosis.

PRESENTATION Nodular thickening in the palm,puckered surface Pain Flexion contracture of MCP and PIP joints Dorsal knuckle pads thickened-Garrod’s pads. Similar nodules may be seen on the sole of foot-Ledderhose’s

disease. High rate of recurrence.

DIAGNOSIS-differentiating featuresSkin contracture –previous laceration is usually obvious Tendon contracture-finger deformity changes with wrist position.

TREATMENT

• Nonoperative– range of motion exercises, injections

• indications– may be attempted but condition will not spontaneously resolve

• modalities– early efficacy seen with injections of clostridial collagenase into

Dupuytren's cords » causes lysis and rupture of cords

• Operative– surgical resection/partial fasciectomy/Z-plasties.

• indications– MCP flexion contractures > 30°– PIP flexion contractures

– Skin graftig/amputaion/joint fusion

TRIGGER FINGER• It is a Stenosing tenosynovitis caused by inflammation of the flexor

tendon sheath• Epidemiology

– more common in diabetics– ring finger most commonly involved

• Mechanism– caused by entrapment of the flexor tendons at the level of entrance to its

sheath– On forced extension tendon passes the constriction with a snap.

• Associated conditions– diabetes mellitus– rheumatoid arthritis– amyloidosis

ANATOMY• Flexor pulleys of finger • Muscles

– FDP – FDS

• Symptoms– finger clicking– pain at distal palm – finger becoming "locked in flexed position

• Physical exam– Tender nodule can be felt infront of MCP joint– Click may be reproduced at the site by alternatively flexing and

extending the finger.

TREATMENT• Nonoperative

– night splinting, activity modification, NSAIDS• indications

– first line of treatment– steroid injections

• indications– best initial treatment for fingers

• technique– Single injection– Recurrent triggering in diabetics and young patients need second injection

• Operative– surgical debridement and release of the A-1 pulley

• indications– in cases that fail nonoperative treatment

– release of A1 pulley and 1 slip of FDS (usually ulnar slip) • indications

– pediatric trigger finger– Rheumatoid arthritis

MALLET FINGER

• A finger deformity caused by disruption of the terminal extensor tendon distal to DIP joint– the disruption may be bony or tendinous

• Epidemiology• usually occur in the work environment or during participation in sports• common in young to middle-aged males and older females• long, ring and small fingers of dominant hand

Mechanism of injury• traumatic impaction blow

– usually caused by a traumatic impaction blow (i.e. sudden forced flexion) to the tip of the finger in the extended position.

– forces the DIP joint into forced flexion

• Presentation– primary symptoms

• painful and swollen DIP joint following impaction injury to finger – often in ball sports

• Physical exam– inspection

• fingertip rest at ~45° of flexion

– motion• lack of active DIP extension

• RADIOGRAPH– findings

• usually see bony avulsion of distal phalanx • may be a ligamentous injury with normal bony anatomy

TREAMENT• Nonoperative

– extension splinting of DIP joint for 6-8 week– maintain free movement of the PIP joint – worn for 6-8 weeks– avoid hyperextension– begin progressive flexion exercises at 6 weeks

• Operative – indications

» subluxation of DIP joint » >50% of articular surface involved» >2mm articular gap

– surgical reconstruction of terminal tendon– chronic injury (> 12 weeks) with healthy joint– tendon reconstruction has a high complication rate (~ 50%)

– DIP arthrodesis– painful, stiff, arthritic DIP joint

KIENBOCK’S DISEASE• Ischaemic necrosis of lunate bone leading to limited and painful wrist

movements.

– incidence• M>F ,age group 20-40 years

– risk factors• history of trauma

• Pathophysiology• biomechanical factors

– ulnar negative variance » leads to increased radial-lunate contact stress

– repetitive trauma

• anatomic factors– geometry of lunate– vascular supply to lunate

» patterns of arterial blood supply » disruption of venous outflow

• Presentation – dorsal wrist pain

• usually activity related• +/- wrist swelling• tenderness over the lunate

– range of motion• decreased flexion/extension arc• decreased grip strength

Imaging • Radiograph

– Lunate sclerosis– Fragmentation– Collapse of lunate,proximal migration of capitate,fixed scaphoid rotation– Radiocarpal arthritis

• CT– most useful once lunate collapse has already occurred

• MRI– best for diagnosing early disease

Treatment• Nonoperative

– immobilization, NSAIDS• Cast for 6-12 weeks reduces pain and mechanical stress.

• Operative– vascularized bone graft– Radial shortening lunate sclerosis– Radial dome osteotomy

– Proximal row carpectomy – Scaphocapitate fusion fragmentation,collapse

– Scapho-trapezium-trapezoid fusion

– Wrist fusion radiocarapal arthritis– Total wrist arthroplasty

De Quervain’s Disease• Reactive thickening of the sheath around the extensor pollicis

brevis and abductor pollicis longus within the first extensor comparment.

• Epidemiology– common in

• woman ,30-50 years• racquet sports

• Pathophysiology– causes include

• idiopathic• overuse

– golfers and racquet sports

• post-traumatic• postpartum

• Presentation– radial sided wrist pain– Sometimes visible swelling over radial styloid

• Physical examination– Finkelstein maneuver-pathognomonic sign• ulnar deviated wrist with thumb clenched in fist causes

pain• tenderness at the level of radial styloid• Hitch-hiker’s sign-resisted thumb extension is painful.

Treatment• Nonoperative– rest, NSAIDS, thumb spica splint, steroid injection• indications

– first line of treatment

• technique– steroid injections into first dorsal compartment

• Operative– surgical release of 1st dorsal compartment • indications

– severe symptoms and nonoperative management has failed

GANGLION CYSTS• A mucin-filled synovial cyst caused by either

– trauma– mucoid degeneration– synovial herniationIncidence

• it is the most common wrist swelling (60-70%)• Young adults

Location• dorsal carpal (70%)

– originate from Scapho-lunate articulation

• volar carpal (20%)– originate from radiocarpal or STT joint

• volar retinacular (10%)– originate from herniated tendon sheath fluid

• Pathophysiology– filled with fluid from tendon sheath or joint– no true epithelial lining

• Presentation– painless lump– cosmetic problem

• Physical exam• Firm and well defined,non tender• transilluminates • Does not move with the tendons• Occasionally a ganglion can be the cause of compression of deep branch of ulnar

nerve.

Imaging • Radiographs

– normal• MRI

– indications• not routinely indicated• shows well marginated mass with homogenous fluid signal intensity

• Ultrasound– useful for differentiating cyst from vascular aneurysm– may provide image localization for aspiration while avoiding artery

Treatment -Non operative• Reassurence –often disappears spontaneously• Aspiration

-Operative• Surgical resection –severe symptoms/nerve compression• Recurrence is usual.

CARPAL TUNNEL SYNDROME• Most common compressive neuropathy

– pathologic (inflamed) synovium most common cause of idiopathic CTS– risk factors/associated factors

• female sex• obesity• pregnancy• hypothyroidism• rheumatoid arthritis• advanced age• chronic renal failure• smoking• alcoholism• menopause

• Pathophysiology– mechanism

• precipitated by– exposure to repetitive motions and vibrations– certain athletic activities

» cycling» tennis» throwing

– space occupying lesions (e.g., gout)

Anatomy• Carpal tunnel defined by

– scaphoid tubercle and trapezium radially– hook of hamate and pisiform ulnarly– transverse carpal ligament palmarly (roof)– proximal carpal row dorsally (floor)

• Carpal tunnel consists of – nine flexor tendons– one nerve (median nerve)

Presentation – numbness and tingling in radial 3-1/2 digits– pain and paresthesias that awaken patient at night– Clumsiness and weakness

• Physical exam – inspection may show thenar atrophy – Durkan's test

• is the most sensitive test to diagnose carpal tunnels syndrome• performed by pressing thumbs over the carpal tunnel and holding pressure for 30 seconds.

– onset of pain or paresthesia in the median nerve distribution within 30 seconds is a positive result.– Phalen test

• wrist volar flexion for ~60 sec produces symptoms• less sensitive than Durkin compression test

– Tinel's test• provocative tests performed by tapping the median nerve over the volar carpal tunnel

-Electrodiagnostic tests

Treatment • Nonoperative

– NSAIDS, night splints, activity modifications• indications

– first line of treatment

• modalities– night splints (good for patients with nocturnal symptoms only) – activity modification (avoid aggravating activity)

– steroid injections• indications

– adjunctive conservative treatment

• outcomes– 80% have transient improvement of symptoms (of these 22% remain symptoms

free at one year)

• Operative– Surgical division of transverse carpal ligament

• indications– failure of nonoperative treatment (including steroid injections)

Tennis Elbow • Also called lateral epicondylagia-pain and tenderness over the lateral

epicondyle due to overuse injury leads to inflammation involving common extensor origin

• Epidemiology– incidence

• most common cause for elbow symptoms in patients with elbow pain• Common in tennis players ,even more common in persons performing similar activities

involving foreceful repititive wrist extensions.

• Pathophysiology– mechanism

• occurs in activities with repetitive pronation and supination with elbow in extension• common in tennis players (backhand implicated)

– pathoanatomy• usually begins as a microtear of the origin of ECRB • may also involve microtears of ECRL and ECU

– pathohistology• microscopic evaluation of the tissue reveals

– Fibrocartilagenous metaplasia – Microscopic calcification

• Anatomy • Muscles

– muscles that insert on lateral epicondyle include • extensor carpi radialis brevis-main pathological tendon • extensor carpi radialis longus • extensor carpi ulnaris • extensor digitorum • extensor digiti minimi • anconeus

Presentation • Symptoms

– pain with resisted wrist extension– pain with gripping activities– decreased grip strength

• Physical exam– palpation & inspection

• point tendernes over lateral epicondyle– neuromuscular

• may have decreased grip strength• neurological exam helps to differentiate from radial tunnel syndrome.

– provocative tests • exacerbation of pain at lateral epicondyle when

– resisted wrist extension with elbow fully extended– resisted extension of the long fingers– maximal flexion of the wrist

• Diagnosis– diagnosis is primarily based on symptoms and physical examination

Treatment

Nonoperative– 90% of the tennis elbow will resolve spontaneously in 6-12

months.– activity modification, ice, NSAIDS, physical therapy, ultrasound

indications– first line of treatment

• techniques– tennis modifications (slower playing surface, more flexible racquet, lower string

tension, larger grip)– counter-force brace (strap)– steroid injections (up to three)– stretching of extensors

Operative– release and debridement of ECRB origin

• indications– if prolonged nonoperative treatment (9-12 months) fails

Golfer’s Elbow • Also called medial epicondalgia-pain and tenderness over the medial

epicondyle due to overuse injury leads to inflammation involving pronator origin.

• incidence• 3 times less common than lateral epicondylitis• dominant extremity in 75% of cases

• Pathophysiology– mechanism

• found in activities that require repetitive wrist flexion/forearm pronation– common in golfers, pitchers, racquet sports, plumbers

– pathoanatomy• micro tears

– pronator teres (PT) and flexor carpi radialis (FCR) are most affected• Associated conditions

– ulnar neuropathy• inflammation may affect ulnar nerve

– ulnar collateral ligament insufficiency

Anatomy• Flexor-pronator mass includes

-Pronator Teres (median n.) – Flexor Carpi Radialis (median n.) – FDS (median n.) – Palmaris Longus (median n.) – Flexor Carpi Ulnaris (ulnar n.)

• Presentation– pain over medial epicondyle

• worse with wrist and forearm motion

• Physical exam– tenderness over the origin of PT and FCR at the medial epicondyle– provocative tests

• pain with resisted forearm pronation and wrist flexion

Treatment • Nonoperative

– rest, ice, activity modification, bracing, NSAIDS, corticosteroid injections

• Operative– open debridement of PT/FCR, reattachment of flexor-pronator group

• indications– up to 6 months of nonoperative management that fails in

compliant patient– symptoms severe and affecting quality of life.– Preserve the medial collateral ligament– Preserve the antebrachial cutaneous nerve to prevent post

operative neuroma formation.

Olecranon Bursitis• Olecranon bursitis also informally known as elbow bump/student's

elbow/popeye's elbow/Cilento's Disgrace/baker's elbow is a condition characterized by pain, redness and swelling around the olecranon, caused by inflammation of the olecranon bursa.

• Due to continual pressure or friction over olecranon or infection of bursa• Inflammation,increased secretions cause swelling of bursa.• Gout –commonest non-traumatic cause• Also associated with Rheumatoid arthritis• Xrays shows soft tissue shadow with calcification.

Presentation• Symptoms include swelling in the elbow,

which can sometimes be large enough to restrict motion

• Pain• redness and shiny skin due to infection may

leads to discharging sinus

Treatment

• Non-operative treatments• icing, a firm compression bandage, and avoidance of the

aggravating activity.• NSAIDs• aspiration of the excess bursa fluid with a syringe

(draining of the bursa)• Corticosteroid injection• In case of infection, the bursitis should be treated with

an antibiotic• Surgical treatments -Chronically inlarged bursa needs to be resected.

Frozen Shoulder • Also known as adhesive capsulitis,defined as progressive pain and stiffness of

the shoulder which usually resolves spontaneously after about 18 months• Middle age,40-60 years usually• Pathoanatomy

– soft tissue scarring and contracture or osseous change

– essential lesion involves the anterior capsule,coracohumeral ligament and rotator interval

– Fibroblastic proliferation of capsular tissue seen on biopsy • Associated conditions

– associated with• diabetes • hyperthyroidism• dupuytren’s contracture • previous surgery (lung and breast)• prolonged immobilization• extended hospitalization• hyperlipidaemia• cardiac disease

Anatomy• Capsuloligamentous structures

– function• contribute to stability of the glenohumeral joint• act as check reins at extremes of motion in their nonpathologic state

– include the glenohumeral ligaments • Rotator interval

– a triangular region between the anterior border of supraspinatus and the superior border of subscapularis

– contains the SGHL and coracohumeral ligament

Presentation• characterized by gradually increasing pain• stiffness increases when pain tends to subside• slight wasting• cardinal feature is stubborn lack of active and passive motion in all directions

Imaging• Radiographs

– findings• disuse osteopenia• concomitant osteoarthritis, calcific tendinitis, or hardware indicating prior surgery

• MR arthrogram– loss of axillary recess indicates contracture of joint capsule

Diagnosis- differentials• -infection• -post-traumatic stiffness• -diffuse stiffnes• -reflex sympathetic dystrophy

The diagnosis of frozen shoulder is clinical resting on two characteristics • painful restriction of movement in the presence of normal x-rays• A natural progression through three successive phases— Stage one: freezing/painful stage, 6 weeks to 9 months,patient has a slow onset of pain. As the

pain worsens, the shoulder loses motion.Stage two: frozen/adhesive stage is marked by a slow improvement in pain but the stiffness

remains,4-9months.Stage three: thawing/recovery, when shoulder motion slowly returns toward normal. This generally

lasts from 5 to 26 months.

Nonoperative– Pendulum exercises– manipulation under anesthesia (MUA)– Corticosteroid injections – Saline infusion under pressure

Operative-arthroscopic surgical release

• indications– only after extensive therapy has failed ( 3-6 months)

• surgical techniques– arthroscopic lysis of adhesions (LOA)– arthroscopic rotator interval release will increase ER

» when ER at the side is limited, the most likely diagnosis is contracture of the rotator interval, including the superior glenohumeral and coracohumeral ligaments

Rotator Cuff Syndrome • Comenest cause of pain around the shoulder

is a disorder of the rotator cuff.Comprise of at least 4 conditions--Supraspinatus impingement syndrome and

tendinitis-Rotator cuff tears-Acute calcific tendinitis-Biceps tendinitis/rupture

Impingement syndromeShoulder impingement has been defined as

compression and mechanical abrasion of the supraspinatus as they pass beneath the coracoacromial arch during elevation of the arm.

Rotator Cuff Muscles--supraspinatus-infraspinatus-subscapularis-teres minor

Pathology • Impingement position-abduction,slight flexion and internal rotation• Site of impingement is also the critical area of diminished vascularity in

the supraspinatus tendon about 1 cm proximal to its insertion into the GT.• Rotator cuff compressed as it comes in contact with anterior edge of

acromian process and the taught coracoacromial ligament.

• Other factors which may predispose to repetitive impingement

-osteoarthritic thickening of acromioclavicular joint

-osteophytes on the anterior edge of the acromion

-swelling of the cuff/subacromial bursa in gout,rheumatoid arthritis etc.

-hooked acromion(type III) -Thickened coracoacromial ligament-subacromial bursitis.

Presentation

1- Pain-It is exacerbated by overhead or above the shoulder activities. A frequent complaint is night pain, often disturbing sleep, particularly when the patient lies on the affected shoulder. The onset of symptoms may be acute, following an injury, or insidious, particularly in older patients, where no specific injury occurs. In the acute stage, there is a painful arc of abduction between 60 and 120 degrees increased with resistance at 90 degrees.

2-Tenderness along anterior edge of acromian process3- Loss of motion : Prolonged capsulitis.4- weakness and inability to raise the arm may indicate that the rotator

cuff tendons are actually torn.

Physical exam– impingement tests• Neer impingement sign

Passive flexion, abduction and internal rotation of arm causes pain

• Neer impingement test– positive if a subacromial lignocaine injection relieves pain

associated with passive forward flexion >90°

• Hawkins test– positive if internal rotation and passive forward flexion to

90° causes pain

• Radiographs– recommended views

• true AP of the shoulder – useful in evaluating the acromiohumeral interval

» normal distance is 7-14 mm

• 30° caudal tilt view– useful in identifying subacromial spurring

• supraspinatus outlet view– useful in defining acromial morphology

– findings• common radiographic findings associated with impingement

– proximal migration of the humerus as seen in rotator cuff tear arthropathy – traction osteophytes– calcification of the coracoacromial ligament– cystic changes within the greater tuberosity– Type III-hooked acromion

• MRI– useful in evaluating the degree of rotator cuff pathology

TreatmentNonoperative– Elimination of aggravating activity– Physiotherapy/active exercises– NSAIDS– Steroidal injections

• Operative– acromioplasty • indications

– subacromial impingement syndrome that has failed a minimum of 4-6 months of nonoperative treatment

– OPEN/ARTHROSCOPIC ACROMIOPLASTY