Median nerve compression in carpal tunnel caused by a giant lipoma.

A lipoma is a common, benign soft-tissue tumor that rarely arises in the upper limb. When one does occur in the hand, the location of the lipoma can cause nerve compression, which can mimic carpal tunnel symptoms. Magnetic resonance imaging is the visualization modality of choice for diagnosis and surgical planning of lipomas. Surgical resection is recommended to relieve the neurological manifestations of this disease. The surgeon should always suspect liposarcoma first before voluminous, atypical, or recurrent tumors are considered.

Reconstruction of closed rupture of thumb flexor tendon pulleys with a single free palmaris longus tendon graft: a case report and review of literature.

Closed rupture of thumb flexor tendon pulleys is extremely rare. Several techniques have already been described for finger pulley reconstruction. Various techniques based on prior anatomic and biomedical studies have been proposed for thumb pulley reconstruction, in which one or two of the three pulleys are replaced. In the present study, we describe an original technique using a single, free palmaris longus (PL) autograft for thumb pulley reconstruction.

[Long-term functional outcomes of digital ischemia under tourniquet: observations in three cases]. / Résultats fonctionnels à long terme d'ischémies digitales sous garrot : à propos de trois observations.

Digital tourniquet is a quick, simple and reliable method to ensure a bloodless operative field distal to the MP joint. However, a forgotten tourniquet is an exceptional but serious complication related to digital ischemia. Few cases were reported in literature without a long-term outcome. Three digits of three patients, aged 70, 49 and 14 at the time of accident, had a tourniquet left in place for 2 days for the first two and 6 days for the last one. Final assessment was carried out 3, 4 and 16 years respectively after the initial accident. All fingers survived with sequelae such as pain, cold intolerance, dysesthesia, allodynia, joint stiffness and skin and nail trophic disorders. A hypertrophic scar was still visible at the site of the tourniquet. Capillary pulse was normal in all cases. Radiological changes were visible when the tourniquet had been left for more than 2 days. The impact on professional and day life activities was considerable. No surgery for the sequelae was done. Avoiding a missed finger tourniquet requires a suitable tourniquet with a visual reminder and its removal must be considered a crucial part of the surgery.

[Complete wrist denervation: a retrospective study of 27 cases with a mean follow-up period of 77 months]. / La dénervation totale du poignet : une étude rétrospective de 27 cas au recul moyen de 77 mois.

OBJECTIVES: Complete wrist denervation is a palliative operation, which yields still controversial outcomes. The aim of our study is to assess the late outcomes of complete wrist denervation. METHODS: In a retrospective continuous review of 27 complete and isolated denervations of the wrist joint performed by the same surgeon in 27 patients (15 men for 12 women) from 1995 to 2007, the pain (VAS), the function (Dash-score), the range of motion, the strength (Jamar) and the radiological changes were assessed at a mean follow-up period of 77 months (12 to 157). RESULTS: At final follow-up, 12 patients (44%) were completely free of pain and 11 (41%) had little pain, four (15%) had moderate and severe pain. The average time to achieve the complete pain relief was 3 months and 3 weeks. Pain relief was stable over time in 89% of cases. There was a significant improvement in range of motion: 11° flexion/extension; 8° pronosupination. In average, the Jamar grip strength was 85% of the healthy side. The Dash-score was in average 30.4 (22 to 60). The extension of the osteoarthritic surface was observed in 14 patients (52%). Six complications were noted: one complex regional pain syndrome, five neuromas four of which resolved spontaneously. Two patients were re-operated. Eighteen patients were very satisfied (67%), six patients were satisfied (22%) and three patients were moderately satisfied (11%). CONCLUSIONS: Complete wrist denervation is an intervention with few complications indicated in chronic wrist pain of any aetiology.

Is it worth fixing proximal humeral fractures at increased vascular risk?

OBJECTIVE: To evaluate fixation of proximal humeral fractures by anterograde nailing, in terms of fracture reduction, bone healing; osteonecrosis; functional consequences of osteonecrosis and malunion. DESIGN: Prospective, consecutive, multicenter based. SETTING: Academic Trauma Centers; approval was received from the ethics committee of the institutions involved in the study. METHODS: Fifty-one patients were enrolled prospectively, with 31 3-part and 20 4-part displaced fractures (head displacement greater than 45°, tuberosity-head gap greater than 10mm, diaphyseal gap greater than 10mm). A Telegraph™ nail (FH Orthopedics, Heimsbrunn, France) was the fixation device used, introduced through a superolateral transdeltoid approach under fluoroscopic guidance. The assessment included Simple Shoulder Test, absolute Constant score, X-rays every 3 months and CT-scan at final evaluation. Twelve patients died and one was lost to follow-up. Immediate complications included secondary displacement in four patients. RESULTS: There were no infections, no deltoid muscle or axillary nerve damage, and all the fractures united. After a mean follow-up of 24.1 months, malunion was observed in 29% of the remaining 38 patients and osteonecrosis in 32%. Both complications were more frequent and extensive in patients with 4-part fractures. The osteonecrosis area influenced the Constant score, which was 55.8 points when the area was less than 30%, 50.6 points between 30 and 50%, and 38 points when larger than 50%. Head malunion affected the Simple Shoulder Test and the Constant score. CONCLUSION: Nailing may thus be recommended for 3-part fractures, because osteonecrosis is less frequent, more focused, and better tolerated in this sub-group. In contrast, antegrade nailing was not more beneficial than other internal fixation techniques for preventing osteonecrosis or head malunion in patients with 4-part fractures. LEVEL OF EVIDENCE: Level IV: prospective study.

The arthritic wrist. I--the degenerative wrist: surgical treatment approaches.

UNLABELLED: The primary goal in treating a degenerative wrist is to provide pain relief, while maintaining strength and mobility if possible. After failure of the recommended conservative treatment, the choice of approaches can be made from a large collection of techniques, some which are well validated. Partial wrist fusion, particularly the Watson procedure, results in a pain-free wrist in 80% of cases, with 50% of the mobility preserved, good grasping strength and stable results for at least 10 years. Proximal row carpectomy provides similar results if the cartilage on the head of the capitate is preserved and the patient is not involved in heavy manual labour. Complete denervation provides pain relief in almost 80% of cases while preserving motion and strength. This is a safe and effective option, with no age limit, that still allows other procedures to be performed in the future. Total wrist fusion also has its place in revision, and even as first-line treatment, because of the reliable outcome in terms of pain and strength, high satisfaction rates, little to no repercussions linked to the loss of mobility and fewer complications. Other techniques are now available. The partial or complete resection of a carpal bone and placement of an implant is back in vogue because of the availability of pyrocarbon. Such implants are an option in the future for localized osteoarthritis or even diffuse affections, and a useful alternative to more invasive procedures. The use of a rib cartilage graft to partially or completely replace a carpal bone or resurface the radius has promising results in terms of pain reduction and fusion. The role of total joint replacement must be defined relative to the classic, reliable techniques that have long-term outcome data. LEVEL OF PROOF: IV.

Radius graft pedicled on the anterior interosseous artery for recurrent ulnar nonunion.

Recurrent ulnar nonunion challenges the functional prognosis and raises major problems concerning the best therapeutic strategy to follow. The case of a female patient presenting recurrent nonunion of the ulnar diaphysis despite successive treatments is reported. The radius graft pedicled on the anterior interosseous artery from a retrograde approach obtained bone union in 3 months with no functional sequelae. For the first time, we propose a therapeutic alternative calling on a proximally pedicled anterior interosseous flap. This technique can be performed under locoregional anesthesia and does not sacrifice the main artery of the forearm. However, the size of the graft does not entirely compensate for segmentary bone loss. The radius graft pedicled on the anterior interosseus artery is an inventive technique that can solve the problem of difficult ulna nonunions without the disadvantages of vascularized fibula harvesting.

The arthritic wrist. II--the degenerative wrist: indications for different surgical treatments.

For the patient (and the surgeon) the ideal wrist is one that has good mobility, however very often the optimal surgical treatment is one that provides effective pain relief. The patient must be informed of the potential complications and limitations of each procedure. The patient's psychological profile and functional requirements will determine how well he/she adapts to the changes. Also, each surgeon has beliefs and personal experiences that influence the treatment decision and final result. Proximal row carpectomy (PRC) and the Watson procedure are two reference operations for osteoarthritis secondary to scapholunate instability and scaphoid non-union (SLAC and SNAC). Beyond the early complications and drawbacks specific to each, they provide good results that are maintained over time. PRC, which can be performed up to Stage II, is mainly indicated in patients with moderate functional demands, while the Watson procedure is more often done on a patient who performs manual labour, as long as the radiolunate joint space is maintained. Complete denervation is effective in three out of four cases and preserves the remaining mobility. Because of its low morbidity, the procedure can be suggested in patients with a mobile wrist and low functional demands or in older patients, independent of their wrist mobility. Total wrist fusion is not only a rescue procedure. For a young patient who performs heavy manual labour with extensive osteoarthritis and progressive forms of Kienböck's disease, this procedure provides the greatest chance of returning to work and not being socially outcast. The role of osteochondral autografts, implants and wrist prostheses in the treatment arsenal need to be better defined.

[Acute ischemia of the hand, an unknown complication of the hydrogen peroxide irrigation. Case report]. / Ischémie aiguë de la main, une complication méconnue de l'irrigation à l'eau oxygénée. À propos d'un cas.

We report a case of acute transitional ischemia of the hand with acute compartment syndrome of the forearm, following hydrogen peroxide irrigation of a wound. We discuss the physiopathology and management of this complication. Along with numerous related cases of gas embolism, this complication emphasizes the risks of using hydrogen peroxide under pressure, notably in hand surgery.

Proximal row carpectomy: long-term results.

OBJECTIVES: To evaluate long-term clinical outcome of proximal carpectomy. Our assumption was that this intervention should result in long-term benefit, making a wrist painless, mobile, and functional, compatible with social and professional life, whatever the initial etiology of the degenerative wrist. METHODS: We report a continuous single centre retrospective series of 24 patients. Objective (mobility, strength, radiographic evaluation) and subjective (pain, subjective wrist value, functional scores) functions were assessed by an independent observer. Surgery was performed mainly for Kienbock's disease, scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrists. RESULTS: The follow-up lasted 116 months in average, during which pain was improved in all cases; 83% of the patients were satisfied with a mean score of 1.2 on a visual analogue scale (VAS) and 76% subjective wrist value (SWV) (disabilities of the arm, shoulder and hand [DASH]: 31). Wrist flexion-extension arc averaged 76 degrees , and the grip strength equivalent to 78% of the contralateral limb. Radiographic modification developed in 52% without any clinical impact. Three patients required arthrodesis and never felt comfortable with their carpectomy. CONCLUSIONS: Our study shows a long-term efficacy of proximal row carpectomy. This treatment must be considered in the therapeutic arsenal for a degenerative and painful wrist, and it should no longer be regarded as a salvage procedure. Advantages of this intervention are obvious: technical simplicity, short rehabilitation, immediate functionality of the wrist and few complications.

Prognostic factors for the recovery of hand function following trapeziectomy with ligamentoplasty stabilisation.

INTRODUCTION: Numerous procedures are in use to treat trapeziometacarpal osteoarthritis. Most of these techniques impair hand function. In a series of trapeziectomies stabilized by ligament reconstruction with tendon suspension, we investigated whether eventual parameters influenced hand function and dexterity. HYPOTHESIS: Some parameters influence hand function recovery following trapeziectomy combined to ligamento-tendinous stabilization. MATERIALS AND METHODS: This is a continuous, retrospective, single surgeon series; 60 cases of thumb trapeziometacarpal osteoarthritis were treated with trapeziectomy and ligament reconstruction (40 palmaris longus, and 20 half flexor carpi radialis) with no additional metacarpophalangeal (MCP) joint surgery. Besides assessing classical clinical outcome criteria (pain, mobility, force), we analyzed hand function: this was obtained with a questionnaire about different everyday movements. Five types of grip were included in this analysis: spherical, pinch grasp, key pinch, power grip, and precision pinch. RESULTS: Fifty-one trapeziectomies (85%) were evaluated at an average follow-up of 7.5 years (5-11.5). Ninety-four percent of patients had good results for pain. The average Kapandji score for mobility was 9.6 (6-10) with a mean web angle at 36.5 degrees. Hyperextension of the MCP joint occurred in 36 cases and measured an average of 26 degrees (5 degrees-50 degrees). Compared to the contralateral side average strength was 97% with the Jamar dynamometer and 88% for the key pinch. The rate of satisfaction was 96%. Collapse of trapezial height was constant, and at last follow-up, the trapezial index was 50% of its preoperative initial value. The results relative to hand function assessment were good in 58% of patients. The spherical grip was the most difficult to restore. The analysis of the 42% of patients with average or poor hand function showed five prognostic factors for a poor outcome: young age at surgery, persisting postoperative pain, postoperative hyperextension of the MCP joint, reduced postoperative web angle and trapezial space collapse. LEVEL OF EVIDENCE: Level IV. Therapeutic study.

Massive rotator cuff tears in patients younger than 65 years. What treatment options are available?

Management of massive rotator cuff tears is a therapeutic challenge in patients younger than 65 years, particularly if still working. According to our hypothesis, choice of the most appropriate treatment option mainly depends on the patient's functional status and on two predictive factors: height of the subacromial space and fatty muscle infiltration. This is a retrospective, multicenter study of a series of 296 patients younger than 65 years, including 176 males and 120 females with extensive or massive cuff tear. Patients had loss of elevation or external rotation or both in 162 cases. Four types of management of massive rotator cuff tear were performed in this study: anatomical watertight repairs, palliative treatments and partial repairs, watertight repairs using flaps or cuff prostheses and reverse shoulder prostheses. At follow-up, the Constant score (65.6+/-3.4) and active elevation (147.7 degrees +/-32 degrees) had significantly improved. Active external rotation with elbow at the side, and acromiohumeral interval (AHI) were unchanged. Work-related injuries, previous surgeries and complications were correlated with a poorer Constant score. At follow-up, the anatomical repair sub-group had a significantly better Constant score than the three other treatment groups but involved patients with unchanged AHI and a low degree of fatty infiltration of the infraspinatus muscle. The reverse shoulder prostheses sub-group showed better outcomes in terms of function benefits. The presence of a long biceps was correlated with the use of a palliative treatment. In the light of the results and literature, an approach to treatment is suggested related to the functional capacity of patients, the AHI and the degree of fatty infiltration of the infraspinatus and subscapularis muscles.