1. Degenerative Tendon Disease of The Elbow & Hand Presenter: Demy Faheem Dasril Moderator: dr. Syaiful Anwar Hadi, SpOT (K) Presenter: Demy Faheem Dasril Moderator: dr. Syaiful Anwar Hadi, SpOT (K)

2. Degenerative Tendon Disease Introduction  Usually in weight-bearing joint  More frequent in upper limb Introduction  Usually in weight-bearing joint  More frequent in upper limb

3. Pathogenesis Local necrosis extending into a tendon / joint capsule Local necrosis  calcified (dystrophic calcification) Inflammation Degeneration Weaken structure Pathological tear Local necrosis extending into a tendon / joint capsule Local necrosis  calcified (dystrophic calcification) Inflammation Degeneration Weaken structure Pathological tear

4. Bicipital Tendinitis and Tenosynovitis  Degenerative changes in the tendon of the long head of the biceps muscle  chronic inflammation of synovial sheath within the bicipital groove  Anterior pain aggravated by active supination  Yergason sign (+)  Degenerative changes in the tendon of the long head of the biceps muscle  chronic inflammation of synovial sheath within the bicipital groove  Anterior pain aggravated by active supination  Yergason sign (+)

5. Treatment  Local rest  arm sling  Analgetic  Surgical : tendon is divided  bicipital groove  Local rest  arm sling  Analgetic  Surgical : tendon is divided  bicipital groove

6. Rupture of The Biceps Tendon  Types:  Proximal : more common  Distal : less common  Types:  Proximal : more common  Distal : less common

7. Proximal Type  Pre-existing degenerative changes  Weaken structure  Contraction : Active flexion  Rupture  Sign & symptoms:  Immediate pain  ‘Go away’ sensation  Pre-existing degenerative changes  Weaken structure  Contraction : Active flexion  Rupture  Sign & symptoms:  Immediate pain  ‘Go away’ sensation

8. Distal Type Less common Weakness of supination & flexion ‘Ball’ more proximal  proximal type Surgical repair is indicated

9. Degenerative Tendon Disease of The Elbow  Tennis Elbow  Golfer’s Elbow  Tennis Elbow  Golfer’s Elbow

10. Tennis Elbow  Lateral epicondylitis due to pathology in ECR tendon  Pathogenesis is unclear : flexion + extension of elbow  backhand movement  Premature degeneration : origin of the forearm extensor muscle  humerus lateral epicondyle  Lateral epicondylitis due to pathology in ECR tendon  Pathogenesis is unclear : flexion + extension of elbow  backhand movement  Premature degeneration : origin of the forearm extensor muscle  humerus lateral epicondyle

11. Clinical Examination  Pain : grasping, dorsiflexion  extensor muscle  Pain over the lateral aspect of the elbow  Radiating pain to distal  Cozen sign (+)  Pain : grasping, dorsiflexion  extensor muscle  Pain over the lateral aspect of the elbow  Radiating pain to distal  Cozen sign (+)

12. Treatment  Local rest  spontaneous resolution within 6-12 weeks  Local heat  Physiotherapy  NSAID  Steroid injection  Surgery  abn origin of ECRB is excised  Local rest  spontaneous resolution within 6-12 weeks  Local heat  Physiotherapy  NSAID  Steroid injection  Surgery  abn origin of ECRB is excised

13. Golfer’s Elbow  Medial epicondylitis  Less common  Pain : grasping, elbow flexion  flexor muscle  Pain over the medial aspect of the elbow on resisted elbow flexion  Medial epicondylitis  Less common  Pain : grasping, elbow flexion  flexor muscle  Pain over the medial aspect of the elbow on resisted elbow flexion

14. Treatment  Local rest  Local heat  Physiotherapy  NSAID  Steroid injection  Local rest  Local heat  Physiotherapy  NSAID  Steroid injection

15. Degenerative Tendon Disease in The Wrist & Hand  De Quervain’s Tenovaginitis Stenosan  Digital Tenovaginitis Stenosan (Trigger Finger)  Dupuytren’s Contracture  De Quervain’s Tenovaginitis Stenosan  Digital Tenovaginitis Stenosan (Trigger Finger)  Dupuytren’s Contracture

16. De Quervain’s Tenovaginitis Stenosan  Influenced common fibrous sheath : APL and EPB tendon  Repeated forced and movement : typing, gripping  Thickening  constriction  Influenced common fibrous sheath : APL and EPB tendon  Repeated forced and movement : typing, gripping  Thickening  constriction

17.  Women >> men  Wrist pain  radiates : proximal and distally  Exacerbated by ulnar deviation  Local tenderness : radial styloid  Finkelstein test (+)  Women >> men  Wrist pain  radiates : proximal and distally  Exacerbated by ulnar deviation  Local tenderness : radial styloid  Finkelstein test (+)

18. Treatment  Steroid injection  Immobilisation of the thumb : splint  Surgical : division of the inflammed and stenotic tendon sheath  Steroid injection  Immobilisation of the thumb : splint  Surgical : division of the inflammed and stenotic tendon sheath

19. Digital Tenovaginitis Stenosan (Trigger Finger)  Flexor tendon (deep and superficial) enclosed by common tendon sheath  If thickening : stenosis  disturbed gliding movement  Tendon become large proximally  repeated movement  Flexor tendon (deep and superficial) enclosed by common tendon sheath  If thickening : stenosis  disturbed gliding movement  Tendon become large proximally  repeated movement

20.  Finger can be flexed actively and extended passively  ‘Snapping phenomenon’  Nodular enlargement in the flexor tendon  Finger can be flexed actively and extended passively  ‘Snapping phenomenon’  Nodular enlargement in the flexor tendon

21. Treatment  Immobilization in extension  Steroid injection  Surgical : division of fibrous sheath  Immobilization in extension  Steroid injection  Surgical : division of fibrous sheath

22. Dupuytren’s Contracture  Progressive fibrous tissue contracture of the palmar fascia  ulnar side  Affects the MCPJ and PIPJ  Men > 50 years old  Frequently bilateral  Progressive fibrous tissue contracture of the palmar fascia  ulnar side  Affects the MCPJ and PIPJ  Men > 50 years old  Frequently bilateral

23. Treatment  Surgical : excision of all abnormal palmar fascia  Post operative : early mobilization  Surgical : excision of all abnormal palmar fascia  Post operative : early mobilization

24. Thank You