Surgically Treated Pediatric Hand and Fingers Palmar Wounds Caused by Metal Fences: Analysis Over a 5-Year Period.

BACKGROUND: Hand wounds are frequent in children (31% of hand injuries) and one possible mechanism responsible for profound laceration is metal fences while climbing. These injuries usually require a surgical look to explore soft-tissue damages, but the literature is poor regarding surgical findings and outcomes after this kind of traumatism. The aim of the study was therefore to report a consecutive series of hand and finger wounds caused by metal fences in children, focusing on surgical findings and potential complications. METHODS: All consecutive hand or finger deep wounds caused by metal fences treated between January 2013 and December 2018 were retrospectively reviewed. Inclusion criteria were age below 18 years and a minimum follow-up of 2 years. Complications and surgical revisions were analyzed. RESULTS: A total of 1265 patients were operated for hand or finger deep wounds during the study period, among which 74 were caused by metal fences. The mean age at surgery was 11.3±0.4 years, and the majority of patients were men (80%). Associated injuries were found in 55.4% of the patients including nerves (n=29) or tendons sections/disinsertion (n=6), and sheath (n=16) and pulleys (n=6) tearing. At a mean follow-up of 2.6±0.2 years, 12% of the patients required revision surgery for an irreducible flexion contracture secondary to a contractile scar and consisted of complete scar excision and zigzag flap. Additional tenoarthrolysis was required during the procedure, for 6 patients because of a persisting flexion contracture after excision. CONCLUSIONS: Metal fences surgical palmar wounds in children are impressive lesions by their extended skin damages. Serious associated lesions (collateral pedicle or flexor tendons) were found in 1 case of 3. However, these injuries are not benign and should be carefully monitored clinically during the first postoperative month to look for potential contractile scars that can require revision. LEVEL OF EVIDENCE: Level IV-retrospective cohort study.

Fingertip amputations in children: Atasoy flap's indications and limitations.

INTRODUCTION: The Atasoy flap is considered simple and reliable for covering distal digital defects in adults. Various studies in children have shown more contrasting results, particularly in terms of aesthetics and function. The aim of this study is to evaluate the long-term results of this flap specifically in children, in order to determine its limitations and indications. HYPOTHESIS: The Atasoy flap is reliable and reproducible for coverage of distal digital substance loss up to zone 2 in children. MATERIALS AND METHODS: Fifty-six children who benefited from an Atasoy flap operated on between January 2017 and January 2020 were included. Lesion area, operative technique, postoperative complications (infection, healing difficulties, necrosis), and ultimately nail appearance, cold intolerance or finger pain, finger eviction, extension defect, and final parental satisfaction were analyzed. RESULTS: Forty-nine children were evaluated with a mean follow-up of 18 months (min = 3 months, max = 38 months, SD = 11.3 months). Eighteen children had a hook nail, resulting in 6 of them having their finger excluded. The majority of hook nails were found in zone III and in proximal zone II lesions (12 cases). Eighty-nine percent of children with distal suture fixation to the nail bed (8 children) had this complication. Cold intolerance was present in 9 children. There were no cases of extension failure or early post-operative complications. Final parent satisfaction was 9.1/10 (min = 5, max = 10, SD = 1.3). CONCLUSION: The Atasoy flap in children appears reliable for covering loss of distal digital substance. The main complication is the occurrence of hook nails. Compliance with its indications (transverse substance loss not exceeding the proximal third of zone II) and a precise surgical technique (distal needle fixation without suturing to the nail bed, deep flap lift, non-closure of the donor site) help limit this risk. LEVEL OF EVIDENCE: IV; retrospective study.

Is anterior subcapital shortening osteotomy a reliable and reproducible technique in the treatment of severe slipped capital femoral epiphysis?

INTRODUCTION: Proximal femoral shortening osteotomies are becoming the treatment of choice for severe slipped capital femoral epiphysis (SCFE) to reduce the risk of femoroacetabular impingement. The reported rates of complication seem reasonable, but these are single-operator series with surgeons highly experienced in this technique. The purpose of this study was to assess how surgeon experience impacted the outcomes of anterior subcapital shortening osteotomy (ASSO) in severe SCFE. HYPOTHESIS: The hypothesis was that ASSO is a reproducible technique that is accessible to junior surgeons. MATERIALS AND METHODS: All ASSOs performed for severe SCFE (slipangle > 40°) between 2015 and 2019 were retrospectively reviewed. All osteotomies were performed by surgeons with less than 4 years' experience (senior residents), who were trained by a senior surgeon experienced in this technique (Group 1). The incidence of femoral head avascular necrosis (AVN) and complications were analyzed and compared to a historical control cohort (Group 2). RESULTS: A total of 62 SCFEs (37 unstable and 25 stable) were analyzed. Both groups had similar demographic data and SCFE characteristics. The mean operative times were statistically comparable in both groups. The rates of AVN in unstable SCFEs and in the overall series were comparable in both groups (18.9% vs. 13.3%, p=.55 and 12.9% vs. 9.7%, p=.6). These rates were comparable in the stable forms (4.0% vs. 5.4%; p=1). However, the preoperative MRI in Group 1 showed that 42.8% of unstable hips that developed AVN were already hypoperfused before surgery. The overall rate of complication showed no significant difference between the 2 groups (26% vs. 17%, p=.16). DISCUSSION: Although ASSO is a technically demanding procedure, it is reliable and reproducible. The main risk factor for developing AVN remains the unstable nature of SCFE and not the surgeon's experience. It can be performed by trained junior surgeons, but not in an emergency setting, with the possibility of assistance from a more experienced surgeon. LEVEL OF EVIDENCE: IV; retrospective case study.

Post-traumatic Radioulnar Synostosis in Distal Forearm Fractures in Children: A Report of 2 Cases.

CASES: Two pediatric cases of post-traumatic distal radioulnar synostosis are reported, accompanied by a literature review summarizing evidence on the management of these conditions. Radioulnar synostosis is a rare complication of distal forearm fractures, which impairs upper-extremity function. The numerous surgical procedures that have been described to treat this condition in adults typically involve synostosis resection and an interposition graft to reduce recurrence. The optimal treatment in children has not been established. CONCLUSIONS: Post-traumatic radioulnar synostoses are rare conditions in pediatric patients who can be successfully treated with surgical excision of the synostoses and without the use of interposition grafting.

Upper limb extravasation of cytotoxic drugs: results of the saline washout technique in children.

PURPOSE: Extravasation of cytotoxic vesicant drugs is a surgical emergency (within six hours) since this incident can lead to severe skin and soft-tissue damage. Outcomes after the saline washout procedure have been extensively described in adults, but rarely in children. The aim of this study was to evaluate the outcome of early saline washout procedure for upper limb cytotoxic drug extravasation in children. METHODS: All consecutive children with vesicant drug extravasation were retrospectively reviewed. The saline washout procedure was performed. Cosmetic aspect, residual pain and range of movement were analyzed as well as time to surgery and chemotherapy resumption at last follow-up. RESULTS: Between 2014 and 2018, 13 cytotoxic vesicant drug extravasations occurred (mean age 8 years (sem 5)), including 11 treated by the saline washout procedure. At mean follow-up of 11 months (sem 7), the patients had no or low pain and ranges of movement were fully conserved. Two patients (one within the six hours' delay) had soft-tissue necrosis leading to extensive reconstructive surgery. CONCLUSION: The saline washout procedure is safe and easy and significantly reduces the incidence of extensive skin damage. Early referral to a specialized department is essential. However, the key parameter remains prevention by educating medical staff and nurses about these injuries and by training them for early and urgent management. LEVEL OF EVIDENCE: IV.

External fixation: Role in decreasing postoperative complications of complex syndactyly release - A review of 18 patients.

BACKGROUND: Primary and revision surgery for complete complex congenital syndactyly (CCCS) of the hand carries a risk of complications such as web maceration, which can result in flap or graft loss and alter the final appearance. No consensus emerges from the scant published data on postoperative care after CCCS surgery. The objective of this study was to assess the role for temporary external fixation in stabilising the commissure and facilitating surgical wound care. HYPOTHESIS: Using external fixation after CCCS release facilitates postoperative wound care and decreases the complication rate. MATERIAL AND METHODS: Eighteen patients requiring primary CCCS surgery or revision CCCS surgery due to adhesions or web creep were included in a single-centre retrospective study. After release, an external fixator made of Kirschner pins was installed to temporarily immobilise the inter-phalangeal joints. The dressing was changed every 3 days for 3 weeks, and the external fixator was then removed. The parents and nurses completed questionnaires that used 0-10 point scales to assess ease and duration of dressing changes and perceptions and apprehensions experienced by parents and nurses, as well as pain by patients, during dressing changes. RESULTS: No patient experienced maceration or failure of a graft or flap. Pin site discharge was noted in 1 patient and resolved fully after pin removal. Pain intensity was estimated at 4.2/10 during the first dressing change and 1.3/10 during the last dressing change. In the parents, apprehension was 9.6/10 and 5.1/10 during the first and last dressing changes, and stress was 8.1/10 and 4.1/10, respectively. Dressing change difficulty was rated 1.1/10 at the first and 0.9/10 at the last dressing change. Dressing change duration decreased from 13 to 10minutes. CONCLUSION: These encouraging results support temporary commissure stabilisation by an external fixator to decrease postoperative complication rates and facilitate dressing changes after CCCS release. LEVEL OF EVIDENCE: IV, retrospective observational study.

Infectious flexor hand tenosynovitis: State of knowledge. A study of 120 cases.

INTRODUCTION: Since Kanavel in 1905, knowledge of phlegmon of flexor tendon sheaths of the fingers have evolved over the twentieth century. This serious infection is 20% of infections of the hand and may have adverse consequences for the function of the finger and even beyond, of the hand. Amputation is always a risk. Frequently face this type of infection, we conducted a retrospective study and made an inventory of knowledge in order to consolidate and improve the overall care. MATERIALS & METHODS: The study was retrospective and cross, focused on 120 patients operated on at Hand Surgery Unit, during 4 years. Inclusion criteria were primary or secondary infection of the sheath of the flexor tendons of the fingers.The evaluation focused on clinical and paraclinical perioperative parameters. At last follow, digital mobility (Total Active Motion), the functional score of QuickDASH and the socio-professional consequences were evaluated. RESULTS: The mean age was 40 years, with a male predominance. The hospital stay was 17 days on average (3 days to 80 days). From the classification of Michon, as amended by Sokolow, we found 60 Stage I, 48 stage II, 12 stage III. The Total Active Motion was respectively 240 °, 140 °, 40 °. QuickDASH scores were respectively 20, 56 and 90 out of 100. The time for return to work was 1 month for stage I, 4 months for stage II and 12 months for stage III. DISCUSSION: The long-term functional outcome was generally poor, with stiffness or digital amputation. The poor prognostic factors were: the initial advanced stage of infection, infection beta-haemolytic Streptococcus group A, and delayed surgical management. Smoking was identified as a new risk factor in this disease, as well as diabetes or immunodeficiency. This study confirmed the predominance of Staphylococcus, and scalability of the infection depending on the mode of contamination, and / or type of germ that is to say, scalability schedule for ß-hemolytic streptococci group A chronic and scalability for intracellular bacteria (mycobacteria). CONCLUSION: Any suspicion of flexor hand tenosynovitis should lead to an emergency surgical exploration, not primary antibiotics prescription!

Video-assisted functional assessment of index pollicisation in congenital anomalies.

PURPOSE: Functional results of index pollicisation are usually assessed by the clinical score of Percival. This score is based on elementary hand movements and does not reflect the function of the neo thumb in daily life activities. The aim of this study was to develop a new video-assisted scoring system based on daily life activities to assess index pollicisation functional outcomes. METHODS: Twenty-two consecutive children, operated between 1998 and 2012, were examined with a mean of 77 months after surgery. The mean age at surgery was 34 months. Post-operative results were evaluated by a new video-assisted 14-point scoring system consisting of seven basic tasks that are frequently used in daily activities. The series of tasks was performed both on the request of the examiner and in real-life conditions with the use of a hidden camera. Each video recording was examined by three different examiners. Each examiner rated the video recordings three times, with an interval of one week between examinations. Inter- and intra-observer agreements were calculated. RESULTS: Inter- and intra-observer agreements were excellent both on request (κ = 0.87 [0.84-0.97] for inter-observer agreement and 0.92 [0.82-0.98] for intra-observer agreement) and on hidden camera (κ = 0.83 [0.78-0.91] for inter-observer agreement and 0.89 [0.83-0.96] for intra-observer agreement). The results were significantly better on request than on hidden camera (p = 0.045). The correlation between the video-assisted scoring system and the Percival score was poor. CONCLUSION: The video-assisted scoring system is a reliable tool to assess index pollicisation functional outcomes. The scoring system on hidden camera is more representative of the neo thumb use in daily life complex movements. LEVEL OF EVIDENCE: Level IV.