[The rheumatoid hand]. / La main rhumatoïde.

Rheumatoid arthritis usually affects the hand (90%). Without treatment, joint damages and deformities lead to loss of the ability to grip, grasp, and pinch, often leaving the patient unable to perform the activities of daily living. Early treatment with DMARDs ± physical therapy is the best way to control the disease and prevent deformity, as well as disability, which often occurs when joints get damaged. Two decades later dramatic advances have been made in the medical therapy of RA with the expanded range of effective disease-modifying antirheumatic drugs. When a patient with RA develops joint damages in the hand or wrist that are unresponsive to medical management and injections therapy, surgical intervention may be necessary. Optimal care involves a team approach among the patient involving rheumatologists, physical therapists and hand surgeons. Patients with RA should be closely monitored in order to detect joint damages necessitating physical therapist or hand surgeon consultation.

Oblique ulnar styloid osteotomy--a treatment for ulnar styloid impaction syndrome.

PURPOSE: We report a series of 5 patients (mean age, 41 y) presenting with ulnar styloid impingement syndrome (USIS) and treated by an oblique ulnar styloid osteotomy. The purpose of the study was to determine whether the osteotomy is an effective method for treating USIS. METHODS: The diagnosis of USIS was made based on a history of ulnar-sided wrist pain supported by clinical and radiological findings. Clinical assessment included provocative tests to differentiate USIS from pain associated with ulnocarpal impaction syndrome. The ulnar styloid length was assessed with a posteroanterior X-ray using the methods of Garcia-Elias and Biyani. The ulnar styloid was deemed excessively long if the ulnar styloid process index was greater than 0.21 or if the overall styloid length was greater than 6 mm. Ulnar variance was recorded. All wrists were assessed by computed tomography arthrography and magnetic resonance imaging studies to rule out any associated soft tissue abnormalities, including ligamentous injuries. Preoperative and postoperative pain levels were recorded using a pain scoring system. RESULTS: Patients were followed up for a mean of 46 months. Before surgery, the mean styloid length was 10 mm, and the ulnar styloid process index was 0.32. The reported pain score was significantly reduced following surgery and all patients, except one, returned to premorbid levels of activity. CONCLUSIONS: Oblique ulnar styloid osteotomy is an effective means of relieving impaction of the ulnar styloid while preserving the integrity of the intrinsic ulnar styloid ligaments. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Bilateral avascular necrosis of the trapezoid.

We present a 5-year follow-up of a patient with bilateral necrosis of the trapezoid that improved clinically and radiographically with nonoperative treatment.

Locked metacarpophalangeal joint of long fingers: classification, definition and treatment based on 15 cases and literature review.

OBJECTIVES: The purpose of this study was to clarify the definition, classification and treatment of the disorder known as the locked metacarpophalangeal (MCP) joint of long fingers, through the analysis of 15 cases and a literature review. PATIENTS AND METHODS: We carried out a retrospective study of 15 patients with locked MCP joint of long fingers, all treated between 1997 and 2007. All patients underwent some imaging investigations including lateral, anteroposterior and Brewerton X-ray examinations. All these patients had been treated by surgery, which allowed us to describe the concerned lesions. RESULTS: The patients were 47 years old on average, 70% of the locks involved the index and the middle finger. Twelve fingers were locked in flexion. In nine of these cases, the cause was a blocking due to a clinging of the radial or ulnar accessory collateral ligament that overlapped a prominent metacarpal condyle or an osteophyte of the metacarpal head. Three fingers were locked in extension due to an imprisonment of a strap of the palmar plate. One patient was lost to follow-up. The remaining 14 patients had an average follow-up of 12.6 months. All recovered normal mobility without any recurrence. CONCLUSION: This study and the literature review show that there are in fact two clinical presentations depending on the etiologies. We suggest a modification of both Posner's definition and Harvey's classification; a new classification should focus on the causes depending on the clinical presentation of the locking, so as to improve the correlation between clinical presentation, etiology and treatment.

[Trapeziometacarpal osteoarthritis]. / Rhizarthrose.

Trapeziometacarpal osteoarthritis, usually defined as arthrosis of the trapeziometacarpal joint, is frequently observed in perimenopausal women and can induce a functional disability, severe in some cases. Most of the time, discomfort is moderate and resolves spontaneously within several months or several years and requires a medical therapy based on analgesics, anti-inflammatory drugs and nocturnal splinting aiming at reducing pain and joint deformity. The spontaneous evolution of the disease leads to joint stiffness in a position of variable deformity of the thumb, with adduction of the trapeziometacarpal joint and compensating hyperextension of the metacarpophalangeal joint allowing to keep a satisfying function despite a decrease in strength and dexterity. However, in the forms of the disease characterized by severe pain and long-lasting progression, a surgical treatment is appropriate since it enables the patients to relieve thumb pain and regain total joint mobility, even though joint deformity is not really corrected. In patients under 70, the most appropriate operation is trapezectomy which, at the cost of a 6-month period until complete recovery is achieved, makes it possible to avoid prosthetic surgery, associated with more uncertain long-term outcomes and risks of wear and loosening. In patients over 70 ans though, in the absence of peritrapezial arthrosis and provided that the trapezium is sufficiently high to constitute an appropriate receptacle for the prosthesis, prosthetic surgery remains an interesting alternative to trapezectomy since it requires a shorter recovery period. The surgical indication needs to be debated on a case-by-case basis; it should only be considered in case of intense pain and not be based on the importance of radiological involvement.

Compression of the median nerve in the proximal forearm by a giant lipoma: A case report.

BACKGROUND: Compression of the median nerve by a tumour in the elbow and forearm region is rare. We present a case of neuropathy of the median nerve secondary to compression by giant lipoma in the proximal forearm. CASE PRESENTATION: A 46-year-old man presented with a six month history of gradually worsening numbness and paresthesia on the palmar aspect of the left thumb and thenar eminence. Clinical examination reveals a hypoaesthesia in the median nerve area of the left index and thumb compared to the contralateral side. Electromyography showed prolonged sensory latency in the distribution of the median nerve corresponding to compression in the region of the pronator teres (pronator syndrome). Radiological investigations were initially reported as normal. Conservative treatment for one month did not result in any improvement. Surgical exploration was performed and a large intermuscular lipoma enveloped the median nerve was found. A complete excision of the tumour was performed. Postoperative revaluation the X-ray of the elbow was seen to demonstrate a well-circumscribed mass in the anterior aspect of the proximal forearm. At follow-up, 14 months after surgery, the patient noted complete return of the sensation and resolution of the paresthesia. CONCLUSION: In case of atypical findings or non frequent localization of nerve compression, clinically interpreted as an idiopathic compression, it is recommended to make a pre-operative complementary Ultrasound or MRI study.

CT-guided percutaneous laser photocoagulation of osteoid osteomas of the hands and feet.

Percutaneous local ablation of osteoid osteoma has largely replaced surgery, except in the small bones of the hands and feet. The objective of this study was to describe the technical specificities and results of computed tomography (CT)-guided percutaneous laser photocoagulation in 15 patients with osteoid osteomas of the hands and feet. We retrospectively examined the medical charts of the 15 patients who were treated with CT-guided percutaneous laser photocoagulation therapy at our institution between 1994 and 2004. The 15 patients had a mean age of 24.33 years. None of them had received any prior surgical or percutaneous treatment for the osteoid osteoma. The follow-up period was 24 to 96 months (mean, 49.93). The pain resolved completely within 1 week. Fourteen patients remained symptom-free throughout the follow-up period; the remaining patient experienced a recurrence of pain after 24 months, underwent a second laser photocoagulation procedure, and was symptom-free at last follow-up 45 months later. No adverse events related to the procedure or to the location of the tumor in the hand or the foot were recorded. CT-guided percutaneous laser photocoagulation is an alternative to surgery for the treatment of osteoid osteomas of the hands and feet.