Soft Tissue Swelling

(Hand & Knee)

M. Afiq Izzuddin bin Rossli
1001336000

Scenario 9b
Patient presented with stiffness of hand and finger
Differential diagnosis ?
1. Trigger Finger
2. Dupuytrens contracture

1) Trigger Finger (Digital

tenovaginosis)
Flexor tendon become trapped by thickening at the
entrance to its sheath, causing the finger to bend
(trigger finger)
Secondary nodule can develop on the tendon.
Underlying cause is unknown, but commonest in patient
with Diabetes.
People with RA can also developed the synovial
thickening or intra-tendinous nodules which also cause
the triggering.

Clinical Feature:
Thumb, ring and middle fingers most commonly affected; sometimes
several fingers are affected.
Patient notices a click as the finger is flexed; when the hand is
unclenched, the affected finger initially remains bent at the PIP joint but
with further effort it suddenly straightens with a snap (triggering).
Tender nodule can be felt in front of the MCP joint and the click may be
reproduced at this site by alternately flexing and extending the finger

Infantile Trigger Thumb

Parents sometimes notice that
their baby or infant cannot
extend the thumb tip.
The diagnosis is often missed, or
the condition is wrongly taken
for a dislocation.
Very occasionally the child grows
up with the thumb permanently
bent.

Treatment
In adults, early cases may be
cured by an injection of
corticosteroid.
Recurrent triggering up to 6
months later occurs in over 30
per cent of patients particularly
younger patients and those with
diabetes, who may then need a
second injection.
Refractory cases need operation
In babies it is worth waiting until
the child is about 3 years old, as

2) Dupuytrens contracture
A nodular hypertrophy and
contracture of the
superficial palmar fascia
(palmar aponeurosis).
Autosomal dominant trait
Most common in people of
European (especially
Anglo-Saxon) descent.
Males > females;

Clinical features
Nodular thickening in the palm.
Gradually extends distally to
involve the ring or little finger.
Pain.
Often bilateral. The palm is
puckered, nodular and thick. If the
subcutaneous cords extend into
the fingers they may produce
flexion deformities at the MCP and
PIP joints

Management
Operation is indicated if the
deformity is a nuisance or
rapidly progressing..
Surgery does not cure the
disease, it only partially
corrects the deformity.
Night splinting for a few months
may reduce recurrence.
Skin grafting severe skin
involvement, strong family
history, young patient.
Amputation or joint fusion
severe, recurrent disease in

Scenario 9c
45years old lady present with the swelling at the left
popliteal fossa. Shes a known case of Rheumatoid
Arthritis.
Differential diagnosis ?

Knee Swelling (Introduction)

Other than injury, knee also prone to a number of
disorder which present essentialy as swelling
Swelling of the knee is often painless until the tissue
become tense and causing pain.
Swelling of the knee can be divided into 4 big group of:
1.
2.
3.
4.

Swelling of the entire knee joint

Swelling in front of the knee joint
Swelling at the back of the knee joint
Bony sweeling

1) Swelling of the entire joint

1) Acute swelling of the entire swelling
a)
b)
c)
d)
e)
f)

Post-Traumatic Haemarthrosis
Bleeding Disorder
Acute Septic Arthritis
Traumatic Synovitis
Aseptic Non-Traumatic Synovitis
Gouty Arthritis

2) Chronic swelling of the joint

g) Arthritis
a) Osteoarthritis
b) Rheumatoid Arthritis
c) Tuberculous arthritis

b) Synovial Disorder

2) Swelling in front of the Joint

1. Pre-patellar Bursitits (Housemaid Knee)
2. Infra-patellar Bursitis (Clergymans Knee)
3. Pes-Anserinus (Deep Bursitis)
Bursitis
. function of the bursa is to facilitate movement of tendons and muscles
over bony prominences.
. Excessive frictional forces from overuse, trauma, systemic disease
(e.g., rheumatoid arthritis, gout), or infection may cause bursitis.

Pre-patellar Bursitis
It is a Fluctuant swelling confined to the front of the patella and
the joint itself
The swelling due not to pressure but constant friction between
skin and bone.
Mainly occur in workers who do not use the protective knee pads

Infra-patellar Bursitis (Clergymans

Knee)
Swelling below the patella and suprficial to the patellar
ligament, more distally swelling compare to pre-patellar
bursitis.
Occur in people who kneeling more uprightly.

Pes-anserinus (Deep Bursitis)

Its an inflammation of the sartorius bursa located over the
medial side of the tibia just below the knee and under the
conjoint tendon and is manifested by pain on climbing stairs.

Treatment of Bursitis
1) Uninfected Bursitis
1. Firm bandaging
2. Rest & Avoid kneeling
3. Aspiration (if needed)

2) Infected Bursitis
4. Rest & avoid kneeling
5. Antibiotic
6. Aspiration/Excision (if needed)

3) Swelling at the back of the knee

joint
1) Popliteal Cyst (Bakers Cyst)
) Bulging of the posterior capsule and synovial herniation may
produce a swelling in the popliteal fossa Painless Lump
) Incidence: Older people > young
) Location: Midline of the knee or below of the joint
) More likely to be caused by RA & OA

Treatment:
Occasionally the cyst may rupture, causing the synovial contents
spill into the muscle planes causing Pain & swelling of the calf
(This can be mistaken as DVT)
1) Aspiration (may needed to resolve the swelling)
2) Injection of hydrocortisone
3) Excision not advised!
(because recurrence in common, unless the underlying condition is
treated)

2) Semi-Membranous Bursa
Bursa between the semimembranous and the medial head of
gastrocnemius may becaome enlarged and causing Painless
Lump behind the knee
Location: Slightly to the medial side of the midline and most
conspicuous with
knee straight
The lump is fluctuant and
painless
Mx: Recurrence is common and
the bursa is self-limiting

4) Bony Swelling around the knee

Knee is relatively superficial joint, any bony swellings of
distal femur and proximal part of tibia are often visible
and palpable
Most common condition is Osteochondromata

Thank you