Correction of ulnar claw hand and Wartenberg's sign.

Ulnar claw hand usually occurs when the ulnar nerve is damaged distally. Claw hand deformity is characterized by metacarpophalangeal hyperextension and interphalangeal flexion, making it impossible to oppose the fingers and thumb. Bouvier's test is used to guide the procedure. Palliative surgery requires prior preparation of paralytic hands. In case of a positive Bouvier's test, Zancolli's lasso technique is preferred because of its effectiveness. Capsuloplasty with anteroposterior transosseous fixation is used if the bone is strong enough and when flexor digitorum profondus muscle is inactive and does not allow flexor digitorum superficialis tendon transfer. In case of a negative Bouvier's test with interphalangeal extension deficit of 45° of less, direct interossei muscle restoration techniques by active transfers are performed. If the interphalangeal extension deficit is more than 45°, proximal interphalangeal arthrodesis is indicated. Wartenberg first described actively irreducible abduction of the little finger. Wartenberg's sign is seen when ulnar paralysis occurs, and during ulnar nerve regeneration. Treatment of isolated Wartenberg's sign consists of re-routing the extensor digiti minimi. Among the other techniques, Belmahi's "tie lasso" is preferred when flexible claw hand is associated with Wartenberg's sign.

Adaptive Proximal Scaphoid Implant (APSI): 10-year outcomes in patients with SNAC wrists.

Radioscaphoid arthroplasty with the Adaptive Proximal Scaphoid Implant (APSI®) is an attractive treatment alternative in the short and medium term for patients with early scaphoid non-union advanced collapse (SNAC) wrist. The purpose of our study was to determine the long-term outcomes of this implant in SNAC wrists. All patients who received the implant from October 2002 to October 2010 were included. A clinical and radiographic study was performed. Our case series included 39 patients, of which 33 were contacted, with a mean follow-up of 10 years (5.8-13.4). Most of the patients had stage-1 SNAC wrist (95%). There were nine complications (27%), seven of which required reoperation: implant dislocation (44%) or progression of the carpal degeneration (33%). Ninety-six percent of patients contacted were satisfied or very satisfied with their surgery (although 21% needed a second surgery) with a Mayo Wrist Score of 80/100 and a Patient-Rated Wrist Evaluation of 17.5/100. Wrist strength was 86% of the contralateral side. Flexion-extension range was 101° and pain assessed using a visual analog scale was at 1.2 (0-6). We report satisfactory and lasting results with the APSI®, similar to those of scaphoid excision with four-corner fusion and proximal row carpectomy. Hence, the APSI® is a reliable alternative for treating osteoarthritis in SNAC wrists.

[Surgical management of the thumb with intrinsic palsy]. / Stratégie thérapeutique dans les paralysies des muscles intrinsèques du pouce.

The long term disability resulting from paralysis of the muscle that control the thumb depends largely of the management (surgical and physiotherapic) of these problems that must be considered in the context of functional disability, and so it is possible to consider specific tendon transfers to improve opposition. This work dealt with paralysis of the thenar muscles. It is helpful to treat such a problem to consider restoring of the anteposition, rotation and adduction of the first metacarpal. In paralysis of the abductor pollicis brevis (APB) and opponents pollicis (OP) it is possible to use as a motor transfer the tendon of extensor pollicis brevis (EPB) or extensor indicis proprius (EPB) or occasionally by palmaris longus (PL). When the flexor pollicis brevis is paralysed, transfer of the flexor sublimis ot the third or the ring finger is used as described by Bunnel. When all thenar muscles are paralysed is very important to assess the range of movement of the trapeziometacarpal joint as well as the presence of any contracture of the first web space. The stability of the metacarpophalangeal and interphalangeal joints must be assessed with pinch grip between thumb and index finger. Careful preoperative assessment of remaining function allows accurate diagnosis and thus what tendon transfer is possible and what other procedure are necessary like arthrodesis of the MP joint, opening of the first web, or stabilization of the IP. The management of these problems is difficult and many factors must be taken into consideration like age, aetiology and experience of the surgeon.

[Flexor digitorum superficialis tendon transfer for intrinsic paralysis in leprosy]. / Transfert tendineux palliatif utilisant le Flexor Superficialis Digitorum dans les paralysies intrinsèques d'origine lépreuse.

A follow up study was performed in the rehabilitation centre for patients with leprosy in Hôchiminhville - Vietnam. All patients had claw-hand deformity due to ulnar and median nerve intrinsic paralysis. Thirty-two affected hands (128 long fingers) were included in the study. A Bunnel-Littler tendon transfer procedure was performed using a four-tailed graft of the flexor digitorum superficialis of the third finger. Clinical evaluation included anatomical measurements of interphalangeal and metacarpal joints in complete extension and in the intrinsic position. In the open hand assessment, 48.5% reported good results, 14.8% medium results and 36.7% poor results. With the hand in the intrinsic position, 53.9% achieved good results, while 33.6% achieved medium results and poor in 12.5%. Poor functional outcome is related to a failure of this procedure and seems to be due to extensor tendon laxity, with or without stiffness of the interphalangeal joints. There were many anatomical deformities (27.3%) found at the time of follow up, notably boutonniere (51.4%) and mallet finger deformities (31.4%) The fourth and fifth fingers had the worst results. We have therefore decided to change our protocol for claw-hand correction and use the Bouvier test in deciding on our surgical indications. Preoperative physiotherapy is absolutely necessary to reduce stiffness of the interphalangeal joints.

[Dorsal cutaneous adipofascial flaps of long fingers]. / Les lambeaux cutanés a pédicule adipofascial de la face dorsale des doigts longs.

We report a series with the adipofascio cutaneous flap of the dorsal aspect of long fingers used with an anterograde or retrograde pedicle. Thirty flaps were performed in 29 patients with a mean age of 43 years, 16 cases in emergency and 13 cases secondary for the treatement of traumatic sequelae. The adipofascial pedicle was retrograde for 22 flaps and anterograde for 8 flaps. The donor site was adjacent of the cutaneous defect in 21 cases or at a distance in 9 cases. Transcient veinous congestion was observed in 2 cases. No necrosis was reported. A second surgery of plasty was performed in 1 case for a cutaneous bulk. The quality of the cutaneous coverage gave any functional discomfort and was evaluated very satisfying. These flaps have an important adaptabily of utilization depending on the localisation and the size of the cutaneous defect as well as the quality of its surrounding skin. The homodigital feature of these flaps avoids the disadvantages of the dorsal hand flaps or the heterodigital flaps. Due to their anastomotic vascularisation, these flaps are reliable and therefore can be recommended for the treatment of dorsal cutaneous defects of long fingers less than 2.5 cm.

Neurolysis of the common peroneal nerve in leprosy. A report on 22 patients.

Thirty-two operations on the common peroneal nerve for leprous neuritis are reported. A combined medical and surgical approach to treatment is recommended, and the technique of operation is described. Recovery of motor power was satisfactory but depended on many factors, including the duration of the neuritis, the extent of the compression, the immunopathological status of the patient and the efficacy of medical treatment. The main indication for neurolysis is hyperalgesic neuritis. The only contraindication is painless long-standing paralysis; in this condition the degree of neural fibrosis prevents any hope of improvement.

Return-to-work interval and surgery for carpal tunnel syndrome. Results of a prospective series of 233 patients.

AIM OF THE STUDY: To evaluate the connection between the type of patient insurance and the time taken to return to work after carpal tunnel surgery. PATIENTS AND METHODS: Two hundred and thirty-three patients in full-time work were operated on for carpal tunnel syndrome between 1 January and 30 June 1998. They were divided into three groups: independent workers (n=87), wage earners in the private sector (n=90) and civil servants (n=56). Four categories were defined: manual workers, non-manual workers, patients with social security insurance and patients with workers compensation. The average return-to-work interval after surgery for each of the groups was evaluated and compared group by group. RESULTS: For independent workers the average time off work is 17 days, for those in the private sector it is 35 days, and for civil servants it is 56 days. Patients with social security insurance were off work for 32 days and those with workers compensation for 49 days. DISCUSSION: The comparison shows significant differences with regard to social security insurance: the return-to-work interval in civil servants is larger than for private sector workers, and this is higher than in independent workers. The difference between patients with workers compensation and those with social security insurance is 17 days and significant. There is a significant difference between manual and non-manual workers in independent and private sector workers. There is no significant difference between the sub-groups in the civil servants. These cross references enable us to work out the influence that social security status has on the return-to-work time following surgery.

[Plate thermography in the evaluation of idiopathic carpal canal syndrome. Apropos of 32 cases]. / Apport de la thermographie en plaque dans l'évaluation du syndrome du canal carpien idiopathique. A propos de 32 observations.

During a period of eight months thirty-two cases (twenty-two unilateral and five bilateral) of idiopathic carpal tunnel syndrome were studied at the Saint-Louis Hospital, Paris, France. The patients were found to benefit from the use of the preoperative technique, thermography in addition to routine clinical exams and complementary exams such as radiographs and E.M.G. The period of intervention was from the fifteenth day through the second and thirds months. By comparing the clinical and functional results before and after surgical treatment through the use of images from patients in the same condition, it can be concluded that the use of this simple technique can provide valuable information and is harmless in the care of idiopathic carpal tunnel syndrome. It is demonstrated that thermography permits: the ability to foresee the action of treatment; the ability to survey the effects of treatment and therefore obtain a valuable prognosis; and finally, a method of deciding on other acrosyndromes.

[X-ray computed tomographic analysis of structural changes of the carpal bones, after section of the anterior annular ligament]. / Analyse tomodensitométrique des modifications structurales du carpe, après section du ligament annulaire antérieur.

Computed tomography analysis was conducted in 29 patients with 34 carpal canal syndromes to determine structural modifications of the wrist during the immediate preoperative period and two and three months after operation. The carpus was analyzed at 3 levels of the section: proximal at the entrance orifice of the canal, median and distal at the orifice of exit, with the wrist at rest and then in maximum active flexion and extension. Results showed that the increase of canal caliber (and therefore the decrease in local increase in pressure) continued during the second and third postoperative months, at rest as well as in flexion or extension. It appears, further, that opening of the canal does not alter structural organization of wrist bones or ligaments, the increases in caliber obtained varying in the same sense whatever the position of the wrist or the level of the section.

[Cervical myelography and x-ray computed tomography in arm paralysis of traumatic origin]. / Myélographie et tomodensitométrie cervicales dans les paralysies du membre supérieur d'origine traumatique.

Results of cervical myelography by the lumbar approach were compared with those of CT scan imaging after subarachnoid metrizamide by the lumbar route, in 16 patients operated upon for post-traumatic cervical spine lesions. Examination in each patient included the last four cervical and first thoracic roots on the injured side, making a total of 80 roots. Lesions detected by myelography and CT scanning are described, comparison of semiologic data with gross findings at operation showing poorer diagnostic accuracy for myelography (86%) than for myelography and a CT scan combined (97%). Sensitivity of the former varied between 70 and 90%, depending on whether doubtful forms were classed as normal or pathologic, but was lower than that of the CT scan (96%). This also applied to specificity (90% as against 96%) and diagnostic accuracy (86% to 90% as against 97%). Combining myelography with a CT scan after subarachnoid contrast injection provides complementary very precise data allowing improved therapeutic results.

[Appearance of the normal knee by MRI using a surface antenna]. / Aspect du genou normal en I.R.M. avec antenne de surface.

NMR imaging of the knee using a surface aerial provides remarkable anatomical detail of this joint without the need for invasive procedures or stressful positioning. Results of the use of this technique on seven normal knees confirmed the precise anatomical details provided, with direct visualization of the femorotibial interline and particularly of the cruciate ligaments, menisci and cartilages. This method allows a new diagnostic approach to the knee, especially for traumatic or tumoral lesions, and greater efficacy of treatment.

[Blount's disease: a review of 8 cases (author's transl)]. / Maladie de Blount: revue de huit cas.

The authors have reviewed eight cases of infantile tibia vara. All were treated operatively. Five patients were young children (less than 5 years old); they were treated by a single osteotomy into valgus and lateral rotation. Three children were older at the time of surgery. The deformity recurred in all of them and a second operation was required of elevation of the lateral tibial plateau and lateral epiplysiodesis. The authors emphasise the need for early correction of deformity to produce better mechanical function of the knee and balanced epiphyseal growth.

[Measurement of carpal tunnel pressures in the idiopathic carpal tunnel syndrome without motor deficit]. / Mesures des pressions intra canalaires dans le syndrome du canal carpien idiopathique non déficitaire.

The pressure in the carpal tunnel was measured in ten patients suffering from purely painful carpal tunnel syndrome. Five normal individuals were also investigated as controls. It was shown that the pressure was always high in involved patients. A rise of pressure on flexion and extension of the wrist was much greater in patients than in controls. It is concluded that true compression plays the main role in carpal tunnel syndrome. A localised tenosynovitis was constantly found at operation. It was responsible for the rise of pressure inducing a functional ischaemia of the nerve.

[Acetabular fracture with intrapelvic luxation following an epileptic attack. Apropos of 2 cases including 1 bilateral case]. / Fracture du cotyle avec luxation intra-pelvienne au décours d'une crise comitiale. A propos de 2 cas dont 1 bilatéral.

The authors have observed 3 acetabular fractures following epileptic fits in two patients. One case was bilateral with an anterior displacement on one side and a posterior one on the opposite side. The second case, which was unilateral, showed a central displacement and a transverse fracture of the acetabulum. Both cases were treated conservatively. The first had a relatively good result after 6 months, and the second died after 10 days.

[Results of emergency repair of wounds of palmar collateral nerves of the fingers]. / Résultats de la réparation en urgence des plaies des nerfs collatéraux palmaires des doigts.

A group of 107 patients with 110 injured digital nerves was studied one year after microsurgical nerve suture. Return of sensibility was tested within the autonomous zones for the nerve. Four tests were used to appreciate the results: pain, Tinel sign, Weber two point discrimination test, the return of the sensibility appreciated by the patient himself. At follow-up, 86 per cent of the patients were found without pain, 75 per cent without Tinel sign, 68 per cent achieved a two point discrimination test of < or = 7 mm, 18 per cent were found with a discrimination test value of 9 mm or more. 93 per cent were satisfied or very satisfied. Of the factors studied, the patient's age at the time of nerve suture was found to be directly related to the return of sensibility as tested by two point discrimination test. Although the return of sensibility following nerve suture in adults is not as good as in children, primary suture of the nerve is worthwhile, a protective sensation is better than an anesthetic digit, and the incidence of painful neuroma is very minimal. The findings in the present study indicate that the nerve suture gives better results that the nerve graft.

[Computed tomographic study of the anatomical modifications of the wrist brought about by section of the anterior annular ligament]. / Exploration tomodensitométrique des modifications anatomiques du poignet entraînées par la section du ligament annulaire antérieur.

The authors have analysed the action of sectioning the transverse carpal ligament by computerised tomography in 19 patients (22 wrists) with carpal tunnel syndrome. Three cuts were studied-proximal, middle and distal, the wrist being either straight, flexed or extended. The study was done pre-operatively and three months after division of the ligament. The study demonstrated the reconstruction of a new ligament which was more lax and expanded anteriorly, despite the fact that the patient wore a plaster cast for two weeks after operation, the wrist being maintained straight. The calibre of the carpal tunnel showed an increase of between 7 p. 100 and 44 p. 100 after the operation and this increase was not related to any alteration in bone topography, which was unchanged. Thus, the role of the ligament in the permanency of shape of the anterior concavity of the wrist skeleton is questionable. The flexor tendons could expand anteriorly, thanks to the laxity of the new ligament.

[Current management of hand leprosy]. / La prise en charge actuelle des mains lépreuses.

Leprosy, a chronic infectious disease caused by mycobacterium leprae affects an estimated 700,000 persons each year. Clinically, leprosy can be categorized as paucibacillary or multibacillary disease. Leprosy is important largely because of the deformities, disabilities and handicap it causes in a proportion of those affected by the disease. There are surgical procedures and techniques to correct or limit the deterioration of these conditions. In the past these surgical procedures were only performed in special institutions for treating leprosy and their complications. However, with the widespread use of multidrug therapy (PCT) and the consequent reduction in the prevalence of leprosy, there is progressive integration of the care of people affected by leprosy into the general health services. Surgery, as in intervention in the management of leprosy and its complications is used in patients who are already under anti-leprosy treatment, or after the have completed it satisfactorily. Therefore, preventive surgery like nerve decompression and corrective surgery should not be practiced in places where there is no leprosy program. This paper describes the nerve decompression for preventing paralytic deformities. Procedures for correction of claw deformity of finger and thumb resulting from ulnar or combined ulnar and median nerve paralysis, so commonly seen in leprosy-affected persons are given separately. In order to carry out these procedures, many involving tendon transfers with or without tendon grafting, the surgeon has to be well versed in the structural and functional anatomy of the hand and should training in hand surgery. Furthermore, supportive physiotherapy and if possible, occupational therapy services for pre and post-operative management of the hand should be available. If the corrective procedures are carried out in the absence of any of these requirements, the venture is bound to result in failure, worsen the hand disability as well as make any subsequent correction very much more difficult.

[Professional absenteeism and surgery for carpal tunnel syndrome. Results of a prospective series of 233 patients]. / Interruption professionnelle et chirurgie des syndromes du canal carpien. Résultats d'une série prospective de 233 patients.

AIM: The aim of our work was to evaluate the influence of the type of patient's insurance ant the return to work interval after carpal tunnel release. MATERIAL AND METHODS: An prospective analysis of 233 patients (18-65 years old, full time workers) undergoing a carpal tunnel release between January and June 1998 was conducted to determine the interval between surgery and return to work. For statistical analysis we used the Ms Works and Status software package. The mean return-to-work intervals were determined for the following and compared for three groups. Group 1: independent worker, n = 87; group 2: wage earner, n = 90; group 3: civil servant, n = 56; and 4 others subgroups: manual workers, n = 164; non manual workers, n = 69; patients with social security insurance, n = 191; patients with workers compensation, n = 42. RESULTS: For the patients in group 1 the average return to work was 17 days (11 days for non manual workers, 29 days for manual workers). In group 2, the average was 35 days (21 days for non manual workers, 42 for manual workers). In group 3 the average was 56 days (49 days for non manual workers and 63 days for manual workers). The statistical analysis showed the civil servant took significantly longer to return to work than independent workers or wage earner (p < 0.05). The work related patients took significantly longer than patients covered by social security. The effect of occupational han (manual versus non manual) use was clear in the group 1 and 2, but there was no difference in the group 3. DISCUSSION: Our study of 233 patients demonstrated significant difference between independent workers, wage earners, and civil servants in term of return-to-work intervals. In comparing manual and non manual workers, we found a significant difference in group 1 and 2, but in civil servants group non difference were found. We cannot explain these findings on medical grounds.

[Treatment of piso-triquetral pain by excision of the pisiform: report of fifteen cases]. / Traitement des douleurs piso-triquétrales par exérèse du pisiforme: à propos de 15 cas.

INTRODUCTION: Piso-triquetral joint could be painful and pisiformectomy can be the best procedure if conservative treatment have failed. The aim of this retrospective study was to evaluate clinical and functional results of pisiformectomy. MATERIAL AND METHOD: Thirteen patients with pisiformectomy were included in this retrospective study, 2 of them have bilateral procedure (n = 15). An ulnar neuropathy was associated in four cases. The average follow-up was 31.5 month. Professional traumatic injuries were the most common etiology. Surgical procedure was the same for all patients. Patients were reviewed clinically and subjective results were evaluated with an analogic scale (Eva). RESULTS: No postoperative complications were found. At the maximal follow-up, result was excellent for 12 cases, good for 2 cases and fair for one case. Analogic evaluation pain at maximal follow-up was 0.8 points compared to 6.4 points preoperatively (p < 0.001). Wrist range of motion was improved. DISCUSSION: Etiologies of piso-triquetral disorders were large and dominated by traumatic or microtraumatic injuries. Pisiformectomy is the best procedure if conservative treatment have failed. There is no place for piso-triquetral arthrodesis considering pisiformectomy's good results. Nevertheless, it's important to know that piso-triqueral disorder could be included in an authentic loco-regional disorder.