De Quervain’s Tenosynovitis, DUPUYTRENS CONTRACTURE, Lateral Epicondylitis, tennis elbow, Cozen's test, golfers elbow, Medial epicondylitis, golfers elbow,

3. Named after a Swiss surgeon, Fritz de
Quervain, who first described the problem in
1895.
De Quervain disease is a stenosing tenosynovitis
of the first dorsal compartment of the wrist
containing Abductor pollicis longus and Extensor
pollicis brevis.
It is characterised by degeneration and fibrosis of
the tendon sheath.

4. Occurs most often in individuals age between 30
and 50 years
It affects women up to six times more often
than men
Is commonly associated with dominant hand.

5. Six fibro-osseous tunnels representing the dorsal
compartments surround the extensor tendons and
function to prevent bowstringing of the extensor tendons.

6. The first dorsal
compartment is
approximately 2 cm
long and is located over
the radial styloid
proximal to the radio-
carpal joint.
The abductor pollicis
longus and the extensor
pollicis brevis tendons
pass through.

7. The APL originates on
the distal third of the
radius and has multiple
slips (2 to 4), with
variable insertions on the
base of the thumb
metacarpal and
trapezium.
The primary function of
the APL is to abduct the
thumb and assist with
radial deviation of the
wrist

8. The EPB originates on
the dorsal surface of the
radius and the
interosseous membrane
and inserts on the base
of the proximal phalanx
of the thumb.
The EPB functions to
extend the
metacarpophalangeal
joint and to weakly
abduct the thumb

9. The etiology is thought to be secondary to repetitive
or sustained tension on the tendons of the first dorsal
compartment
Possible etiologies include
Trauma
Increased frictional forces
Anatomic Variations that include septation of the first
dorsal compartment and the presence of multiple
slips of the APL and, occasionally, of the EPB tendon

10. Biomechanical compression,
Repetitive microtrauma
Inflammatory disease, and
Increased volume states, such as
occurs during pregnancy

11. Resisted gliding of the APL and
the EPB within the narrowed
canal.
Fibroblastic response, resulting in
thickening and swelling of the
compartment.
Degeneration

12. Localized pain along the radial side of the wrist
-Gradual in onset
-Aggravating on grasping and raising objects with
the wrist in neutral rotation.
Localised swelling may be seen.

13. Tenderness along the radial styloid
The Finkelstein test is positive:
(on grasping the patient’s thumb and quickly abducting
the hand ulnarward produces excruciating pain over
the styloid tip)

14. Radial styloid fracture
Scaphoid fracture
Basilar arthritis of the thumb
Radial neuritis

15. Diagnosed is mainly through clinically.
Wrist imaging is required only in the presence of
associated processes such as previous distal
radius or scaphoid fracture, arthritis of the thumb,
and instability of the wrist.

16. Nonsurgical treatment should be the first course
of action for de Quervain disease.
The patient presenting with mild to moderate pain
that does not limit activities of daily living may be
treated with -
 Rest,
 Splinting,
 Nonsteroidal anti-inflammatory drugs or
 Corticosteroid injection.

17. Splinting is an effective
method for resting the
APL and EPB tendons by
immobilizing the thumb
and wrist in a single
position and reducing or
preventing the friction
An ideal splint is a radial
thumb spica extension
splint that holds the wrist
in neutral and the thumb
in 30° of flexion and 30°
of abduction.

19. With the wrist in neutral radioulnar deviation, a rolled-
up towel is placed under the wrist to position it in slight
ulnar deviation
The course of the APL and EPB tendons along the
radial styloid is palpated, and the borders of the first
dorsal compartment are straddled with the opposite
thumb and index finger.

20. A 25-gauge needle is introduced into the tendon
sheath at the level of the styloid, parallel to the
tendons.
The needle is carefully backed out while
maintaining pressure on the plunger of the
syringe.
The injectable medication should flow smoothly and
easily, with both visual and palpable inflation of the
compartment.

21. An additional injection may be offered after a 4-8 week
interval for the patient who has experienced some
improvement with the initial injection.
When pain does not resolve after two
corticosteroid injections and 6 months of
nonsurgical management, then surgical release of
the first dorsal compartment is recommended.

25. Any intra-compartmental septae should be
released and excised.
Anatomic variations of the compartment are the
rule rather than the exception.
Active and free thumb abduction and extension
then can be performed on the awake patient.

26. Postoperatively, thumb and hand motion is
immediately encouraged except for forceful wrist
flexion,which may predispose the tendons toward
subluxation during the first 2 weeks after surgery

27. Radial sensory nerve injury
Incomplete decompression,
Volar subluxation of the tendons

28. DUPUYTRENS
CONTRACTURE

29. A progressive disease of the palmar fascia.
Causes shortening, thickening and fibrosis of
The fasciaand
Aponeurosis of thepalm.
1. The palmar fascia is
continuous with the antebrachial fascia, the deep
fascia of the forearm, and
covers the dorsum of the hand.
thicker in the center of the palm and fingers.
Forms the palmar aponeurosis and digital sheaths.

30. 2. The palmar aponeurosis
covers the soft tissues of the palm and long flexor
tendons.
the longitudinal bands undergo fibrosis, the MCP &
PIP joints get pulled into flexion.
the 4th metacarpal (most commonly affected)
followed by the 5th , 3rd , and 2nd .

31. Unknown.
Have identified a number of risk factors.
Caucasians of Northern European descent (common)
Average age of onset of disease is 60 years old.
More often in men than in women, (6:1)
A strong genetic component.
Trauma, infllamatory response & ischaemia.
Numerous environmental factors have been
purposed..

32. Occurs slowly.
Typically progresses over the course of several years.
Can also develop more rapidly over weeks or months.
Begins with thickening of the skin on the palm.
Resulting in a puckering or dimpled appearance.
The affected fingers being pulled into flexion.
Typically occurs bilaterally.

33. Skin pitting and presence of nodules in Dupuytren disease.

34. Physical Examination
• sites of nodules and bands or
contracted cords
• skin pitting
• degree of skin involvement
Goniometry-the
degree of flexion
contracture
Angle between MCPJ
& PIPJ
Any surgical scarring

36. Hueston tabletop test: If a patient is unable to lay
his palm flat on the table top, the test is positive.

37. ROM : MCP, PIP &DIP
The DASH Questionnaire
The Short Form-36:
A 36 question survey
(evaluation of wrist and
hand function

38. • Simple fasciotomy
• Partial fasciectomy
• Total fasciectomy, and
• Dermofasciectomy.
• Contracture recurrence is common even
after surgery, one should consider the
‘Dupuytren’s diathesis’ before deciding
which surgical procedure would be most
effective for thepatient.
Surgery -
current
mainstay
treatment

39. Within the initial 5 days Post-op
-Info about edema reduction
-ROM exs in uninvolved digits
After 5-7 days Post-op
-Isolated PIP & DIP ROM exs
-Splints between exs

40. Epitheloid sarcoma
Ganglion Cyst
Stenosing tenosynovitis

43. • Lateral Epicondylitis is a common clinical entity
characterized by pain and tenderness at the common
origin of the extensor group muscles of the forearm,usually as
a result of a specific strain, overuse, or a direct bang.
-It is considered a cumulative trauma injury that occurs over
time from repeated use of the muscles of the arm and
forearm, leading to small tears of the tendons (Tendonitis).
-The condition that is commonly associated with playing
tennis and other racket sports, though the injury can happen
to almost anybody.
Lateral Epicondylitis
(tennis elbow)

44. Pathophysiology
• The tendinous origin of extensor carpi radialis
brevis (ECRB) is the area of most pathologic changes.
-Changes can also be found at musculotendinous
structures of the extensor carpi radialis longus,
extensor carpi ulnaris and extensor digitorum
communis.

45. -A tear occurs at the teno-muscular junction, in the tendon,
or at the teno-periosteal junction.
-The resulting inflammation produces exudate in which
fibrin forms to heal the torn tissue.
-Repeated activity causes microtrauma, with subsequent
granulation tissue formation on the underside of the
tendon unit and at the teno-periosteal junction.

46. • The most common cause of Lateral Epicondylitis in
tennis players is a 'late' mechanically poor backhand,
that places excess force across the extensor wad,
that is, the elbow leads the arm.
• Often a history of repetitive flexion-extension or
pronation- supination activity and overuse is obtained
(eg.,twisting a screw driver, lifting heavy luggage with
the palm down).
-Tightly gripping a heavy briefcase is a very common
cause.
-Baseball, golfing, gardening, and bowling can also
cause Lateral Epicondylitis.

47. Clinical Presentation
• At first, the athlete may be aware of only fatigue
and spasm of dorsal forearm muscles related to
unaccustomed activity.
-Then they may note the onset of aching lateral elbow
pain after playing.
-Eventually the pain may become so constant and
severe so as to stop the athlete from further
playing and to interfere with activities of daily
living, such as carrying a briefcase, wringing wet
clothes or even holding a cup of tea.
-Grip becomes weak.

48. Physical Examination
• -Point tenderness over or just distal to the lateral humeral
epicondyle.
• -Tenderness over muscles of dorsal forearm.
• -Pain with resisted wrist extension, finger extension and
resisted radial deviation.
• -Pain with passive stretching of wrist extensors.
• - With long standing symptoms, there is likely to be
considerable atrophy and weakness of extensor muscles
and limitation of passive wrist flexion.
-Accessory movements of the elbow and superior
radio-ulnar joint may be reduced in along term problem.

49. Special tests for Lateral Epicondylitis
• 1) Cozen's test- The patient's elbow is stabilized by the
examiner’s thumb, which rests on the patient's lateral epicondyle.
The patient is then asked to make a fist, pronate the forearm and
radially deviate and extend the wrist while the examiner resists
the motion. A positive sign is indicated by sudden severe pain in
the area of lateral epicondyle of the humerus.
• 2)Mill's test-While palpating the lateral epicondyle, the
examiner pronates the patient's forearm, and flexes the wrist fully
and extends the elbow. A positive test is indicated by pain over
the lateral epicondyle of humerus.
• 3)Maudsley's test- The examiner resists extension of the 3rd
digit of the hand, stressing the extensor digitorum muscle and
tendon. A positive test is indicated by pain over the lateral
epicondyle of the humerus.

51. Investigations
• X-rays are not necessary.
-Rarely, magnetic resonance imaging (MRI) scans may
be used to show changes in the tendon.

52. Treatment
1. Conservative bracing & Rest
2. Passive stretching exercises
3. Ice pack application
4.Extracorporeal Shock Wave Treatment (ESWT)
5.Corticosteroid injections
6.Platelet Rich Plasma Injections
7.Surgery: open debridement & reattachment of tendon.

56. Treatment
1. Conservative bracing & Rest
2. Passive stretching exercises
3. Ice pack application
4.Extracorporeal Shock Wave Treatment (ESWT)
5.Corticosteroid injections
6.Platelet Rich Plasma Injections
7.Surgery: open debridement of PT/FCR, reattachment
of flexor-pronator group.