Orthopaedics

This is an easily recognised condition characterized in the established phase by flexion contracture of one or more of the fingers from thickening and shortening of the palmar aponeurosis. There is a hereditary predisposition. In a predisposed person injury possibly plays a part but its exact significance is uncertain. There is an increased incidence of the disorder among epileptics but this is possibly related to the use of anticonvulsant drugs rather than to an underlying genetic association between the two diseases. The affection is much more common in men than in women. Often both hands are affected. The earliest sign is a small thickened nodule in the mid-palm opposite the base of the ring finger. The area of thickening gradually spreads from this point giving rise eventually to firm cord like bands that extend into the ring finger or little finger or both and prevent full extension of the metacarpophalangeal and proximal interphalangeal joints. The skin is closely adherent to the facial bands and is often puckered. The only effective treatment is by operation. However, that operation is necessary in every case. The contracture that is not progressing rapidly is often better left alone especially in an elderly patient. Operation entails excision of the thickened part of the palmar aponeurosis by painstaking dissection.

This is a syndrome characterized by the compression of the median nerve as it passes beneath the flexor retinaculum. Any space occupying scratch within the carpal tunnel may be responsible. The responsible causes are chronic inflammatory thickening of the tendon sheaths (as in rheumatoid arthritis), osteoarthritis of the wrist, thickening after fracture of the lower end of the radius and myxoedema. The median nerve lies beneath the flexor retinaculum in company with the flexor tendons of the hand. If the available space within this strong-walled tunnel is reduced the nerve is compressed against the flexor retinaculum. The condition is commonest in women in or beyond middle life. The symptoms are sensory and motor. There is tingling, numbness or discomfort in the radial three & half digits and there is a feeling of clumsiness in carrying out fine movements such as those concerned in sewing. A trial may be made of conservative treatment by supporting the wrist for three weeks with a simple splint. When the symptoms arise in pregnancy, relief that lasts until after delivery may be gained by the injection of hydrocortisone alongside the nerve at wrist level. This may be tried also in other cases. If it is unsuccessful full relief is assured by dividing the flexor retinaculum to decompress the nerve. This is a simple operation that may be done either through an open incision by an endoscopic technique.

The term tenosynovitis implies inflammation of the thin synovial lining of a tendon sheath as distinct from its outer fibrous sheath. Like bursitis, tenosynovitis may be caused by mechanical irritation or by bacterial infection. This is caused by excessive friction from over-use. The synovial sheath is mildly inflamed and there are exudates of watery fluid within it. A similar traumatic inflammation may affect the flimsy paratenon surrounding those tendons that are devoid of synovial sheaths. This is termed paratendinitis. The treatments are
I. Rest to the part by appropriate splints.
II. Avoid movements at the joints
III. Bandaging or POP cast.
IV. Thermotherapy US, SWD or TENS
V. Deep friction massage
VI. Difficult cases, hydrocortisone injection
VII. Intractable cases, surgical excision
VIII. Shoe modification, etc
In Infective Tenosynovitis, bacterial infection of a tendon sheath may be acute or chronic. The acute infective tenosynovitis is caused by an organism of the pyogenic group. There is an acute inflammatory reaction in the wall of the sheath with purulent exudates from it. It is an uncommon condition but it is well recognized in the flexor tendon sheaths in the hand. In chronic bacterial tenosynovitis also an uncommon lesion in Western countries, the infection is often tuberculous. The treatment for Infective Tenosynovitis is appropriate antibiotics and Immobilisation for 2-3 months.

Tennis elbow is a common and well defined clinical entity. It is an extra-articular affection characterized by pain and acute tenderness at the origin of the extensor muscles of the forearm. It is believed to be caused by strain of the forearm extensor muscles at the point of their origin from the bone. Although it sometimes occurs after playing tennis other repetitive activities are just as likely to be responsible. Hypothetically is assumed that there is incomplete rupture of aponeurotic fibres at the muscle origin which is a region plentifully supplied by nerve endings. The elbow joint itself is unaffected. The clinical feature is pain at the lateral aspect of the elbow often radiating down the back of the forearm. In mild cases the patient is often willing to await spontaneous recovery once the harmless nature of the affection has been explained. The treatment is unpredictable in its results and no method can be relied upon in every case.
Conservative treatment: Initially, trial may be made of a course of non-steroidal anti-inflammatpry drugs. This method is often successful, bur only if the injection is made precisely into the tender spot.
Operative treatment: If severe disability fails to respond to conservative treatment, operation is well worthwhile. The extensor origin is stripped from its attachment to the lateral epicondyle and allowed to fall back into place.

Patients with serratus palsy may present with pain, weakness, limitation of shoulder elevation and scapular winging with medial transition of the scapula, rotation of the inferior angle toward the mid line and prominence of the vertebral border. Winging of the scapula due to long thoracic nerve palsy is a common diagnosis and should be treated as a significant functional problem. It must be recognized that scapular winging is not simply an aesthetic issue. The Seven muscles attach the scapula (shoulder blade) to the chest wall and help maintain normal scapular control. The muscles are trapezius, levator scapulae, rhomboids major, rhomboids minor, pectoralis minor, omohyoid and serratus anterior. The latissimus dorsi has a small attachment at the base of the scapula but does not significantly contribute to scapular stability. The shoulder blades should act in synchrony with movements of the upper limb. They rotate, protract and retract around the chest wall as you use your arms. About one third of all gross movement affecting the shoulder girdle depends on scapular positioning. The scapulae provide a stable base for upper limb movement. The loss of scapular control can dramatically affect shoulder movement and function.
Scapular winging associated with serratus anterior dysfunction is characterized by prominence of the lower tip of the scapula and loss of scapula protraction during shoulder elevation. Discomfort is usually felt around the scapula and around the back of the shoulders. The flexion is limited (80-120 degrees). If your scapula is winging and you have a strong, symmetric shoulder shrug, a full and supple passive range of motion and positively respond to the scapular stabilization test, chances are your problem is caused by serratus anterior dysfuction most probably secondary to long thoracic nerve palsy.

Many patients seek medical attention for shoulder pain and a common diagnosis given is shoulder bursitis or shoulder tendonitis. The best terminology for these symptoms is impingement syndrome. Impingement syndrome occurs when there is inflammation of the rotator cuff tendons and the bursa that surrounds these tendons. The shoulder is interesting in that several bones, muscles and ligaments contribute to this complex joint. Impingement syndrome or shoulder bursitis occurs when there is inflammation between the top of the humerus (arm bone) and the acromion (tip of the shoulder). In many individuals with this problem, the shape of their bones is such that they have less space than most others. Therefore, small thickenings of the tendons or bursa can cause symptoms. The Common symptoms include:
I. Pain with overhead activities (arm above head height)
II. Pain while sleeping at night
III. Pain over the outside of the shoulder/upper arm
IV. Impingement syndrome and a rotator cuff tear are different problems.
The first step of shoulder bursitis treatment is to decrease the inflammation. This is best done by avoiding the problems that cause inflammation. Inflammation can also be treated with anti-inflammatory medications such as Motrin, Advil, Marcy, Celebrex, Vioxx or one of many others. These all fall within the category of nonsteroidal anti-inflammatory medications.

The hamstring muscle is a group of large & powerful muscles that span the back of the thigh from the lower pelvis to the back of the shin bone. The hamstring is the important muscle that functions to extend the hip joint and flex the knee joint. The hamstring is used in many sporting activities as well as normal daily activities. Sports that commonly cause a hamstring injury are sprinting sports that involve sudden accelerations. These include track and field, soccer and basketball. A hamstring injury can also occur as a result of a direct blow the muscle such as being kicked in the back of the thigh or falling on the back of the thigh. Hamstring contusions are different from pulled hamstrings although they may cause similar symptoms. A pulled hamstring also called a hamstring strain. It is a tear of the hamstring muscle fibers. The symptoms of a pulled hamstring are
Bruising: Small tears within the muscle cause bleeding and subsequent bruising.
Swelling: The accumulation of blood from the hamstring injury causes swelling of the thigh.
Spasm: Muscle spasm is a common and painful symptom of a hamstring injury and difficulty.
Contracting: Flexing the knee is often painful after a pulled hamstring and it can even prevent the patient from walking normally.
Treatment of a pulled hamstring is dependent on the severity of the injury. Because of bleeding and swelling, athletes should stop their activity and rest immediately. An ice pack and compressive bandage can be applied to control swelling.

The three upper limb joints are Shoulder Joint, Elbow Joint and Wrist Joint. The shoulder is a ball and socket joint. The ball portion of the joint consists of the rounded head of the upper arm bone (humerus) and the socket portion is made up of a depression (glenoid) in the shoulder blade. The humeral head (ball) fits into the glenoid (socket) creating the joint that allows you to move your shoulder. The elbow is a hinge joint consisting of three bones. The upper portion of the hinge is at the end of the upper arm bone (humerus) and the lower portion is the top of the two forearm bones (radius and ulna) which are side by side. All three of these bones are in contact with each other. The joint is surrounded and lined by cartilage, muscles and tendons that provide support, stability and ease of movement. Wrist joint is a synovial ellipsoid joint between the distal end of the radius & the articular disc above the scaphoid, lunate and triquetral bones below. The proximal articular surface is adapted to the distal ellipsoid convex surface. The capsule encloses the joint and is attached above to the distal ends of the radius and the ulna and below to the proximal row of carpal bones. The range of motion for Shoulder Joint is shoulder allows for the rotation of the arm in all directions. The range of motion is dependent on the proper articulation of the humeral head upon the glenoid. The elbow joint allows for the extension, flexion and rotation of the arm. The range of motion is dependent upon the proper articulation of the elbow joint.

Soft tissue injuries are not quite ‘soft’ but ‘hard’ in terms of rehabilitation and management. The term soft tissue implies skin, subcutaneous tissue, fascia, muscles, ligaments, tendons, synovium, capsules, nerves, etc. Unlike in fractures the soft tissue injury management is essentially conservative and physiotherapy appears to be the mainstay of treatment. The Mechanism of Injury is
• Direct trauma: Due to fall, RTA, assault, etc. contusion, hematomas, lacerations are some of the examples.
• Indirect trauma: Due to avulsion injuries, muscle pull, ligament sprain, etc. More commonly seen in sport persons
The four broad classifications for STI are Strains, Sprains, Ruptures and Contusions. The features of Features of Intermuscular haematomas are moderate pain, swelling reduces drastically by 48-72 hours, muscle contraction is regained first and due to tracking swelling may be seen at a distance away from the site of injury. The methods of treatment are methods rest to the part., immobilise the affected part with splint, cryotherapy to relieve pain and spasm, pressure bandage to control the swelling and Limb elevation to prevent oedema. The Important Soft Tissue Problems are
Upper Limb
Shoulder
i. Rotator cuff injuries
ii. Supraspinatus tendinitis
iii. Infraspinatus tendinitis
iv. Subscapularis tendinitis
v. Adhesive capsulitis
vi. Tendinitis of the long head of biceps
Elbow
i. Student’s or miner’s elbow
ii. Tennis elbow
iii. Golfer’s elbow
Wrist
i. Ganglion
ii. de Quervain’s disease
iii. Dupuytren’s contracture
iv. Trigger finger
v. Carpal tunnel syndrome
Lower Limbs
Hip and Pelvis
i. Piriformis syndrome
ii. Iliofibial tract syndrome
iii. Glutteal bursitis
iv. Trochanteric bursitis.
Knee and Leg
i. Bursae around the knee
ii. Collateral ligament injury
iii. Cruciate ligament injury
iv. Meniscal injury
v. Quadriceps strain
vi. Hamstrings strain
vii. Calf muscle strain
viii. Patellar tendinitis
ix. Plica syndrome
Ankle and Foot
i. Ankle sprain
ii. Plantar fasciitis
iii. Calcaneal spur
iv. Morton’s neuroma
v. Tendo-Achilles injuries
vi. Tarsal tunnel syndrome

Gout is the clinical manifestation of a disturbed purine metabolism. It is characterized by deposition of uric acid salts especially sodium biurate in connective tissues such as cartilage), the walls of bursae and ligaments. The causes of Gouty Arthritis are susceptible persons an attack may be induced by excessive consumption of purine-rich foods such as liver, kidneys, sweetbreads, shellfish, beer or heavy wines. An attack may also be precipitated by recent injury or operation. The primary fault is an impaired excretion of uric acid by the kidneys. In consequence the level of urate in the plasma is increased, sometimes to 0.5 mmol per litre or more
(normal = 0.1-0.4 mmol per litre (2.0-7.0 mg per 100ml)). The clinical feature is patient is nearly always over 40 and is more likely to be a man than a woman in the ratio of 10:1. The chief clinical manifestations are arthritis and bursitis. In chronic gout several joints may be affected together. They are thickened & nodular and painful on movement. For patients with frequent attacks or with chronic gout especially if the plasma urate level is persistently raised, longterm drug therapy to reduce the plasma urate level may be
equired. The two types of drug available are represented by:
a. probenecid, which paralyses renal tubular reabsorption of urates and thus increases their excretion in the urine
b. allopurinol, which reduces the formation of uric acid by inhibiting the enzyme xanthine oxidase.