Early vs late surgical treatment of radial instability of the thumb metacarpophalangeal joint. A retrospective cohort study.

There is no clear evidence in the literature whether treating thumb radial collateral ligament (RCL) injury in the acute phase improves outcome. The purpose of the present study was to compare the clinical and radiological results of RCL repair in acute and chronic settings. Fourteen patients were included. Clinical range of motion (ROM) of the thumb, Kapandji score and radiological parameters were compared pre- and post-operatively to the contralateral uninjured thumb (control group) to evaluate the results of the surgical technique. Patients were then divided into two groups according to early versus late repair and outcomes were compared between the two groups and the control group. Preoperatively, mean spontaneous angle between first metacarpal (M1) and proximal phalanx (P1) (spontaneous M1P1 angle), ulnar stress M1P1 angle, ROM and Kapandji score differed significantly between injured and uninjured sides. Postoperatively these parameters for the injured side improved, reaching values similar to those on the uninjured side, especially with acute phase treatment; late treatment also tended to provide clinical improvement in ROM, Kapandji score and ulnar stress angle, but with significant improvement only for spontaneous deviation of the thumb. This study showed the late and immediate repair of the RCL of the thumb both gave good results, with slightly better outcome with acute phase repair. LEVEL OF EVIDENCE: Therapeutic, Level III.

Non rheumatoid closed rupture of extensor carpi ulnaris tendon. Report of a case in a professional athlete.

A rare case of closed, non-rheumatoid rupture of the extensor carpi ulnaris tendon, that occurred in a professional tennis player, is presented. The authors describe the diagnostic problems and the treatment. They discuss the anatomical particularities of the area, the probable pathological mechanisms that lead to the lesion and the best ways of dealing with the problem.

Osteoblastoma of the carpal scaphoid frequency and treatment.

A rare case of osteoblastoma of the carpal scaphoid is presented. Review of the literature revealed two more cases that have been previously reported. The authors present the diagnostic difficulties and the treatment which was applied: proximal row carpectomy and tendon transfers for wrist stabilization. Treatment options, according to the literature, also include scaphoidectomy and tumor curettage with bone grafting.

[A case of simultaneous luxation of the metacarpophalangeal and interphalangeal joints of the thumb]. / Un cas de luxation simultanée des articulations métacarpophalangienne et inter-phalangienne du pouce.

A rare case of simultaneous dislocation of the interphalangeal and metacarpo-phalangeal joints of the thumb is reported. The displacement was first reduced conservatively and the ligaments of the metacarpo-phalangeal joint repaired surgically at a later date. The result was satisfactory.

[Carpal tunnel syndrome and pseudarthrosis of the scaphoid. Apropos of 2 cases]. / Syndrome du canal carpien et pseudarthrose du scaphoïde. A propos de deux cas.

Two cases were seen in elderly patients in which a carpal tunnel syndrome was present in association with an ununited scaphoid fracture. The carpus had remodelled and the lunate was dorsi-flexed. Its upper end bulged into the tunnel and was the cause of the nerve compression. It was aggravated by associated osteoarthrosis. The two cases were treated surgically by neurolysis and division of the carpal ligament and partial resection of the lunate to restore the normal concavity of the carpus.

[Tendinitis of the long palmar muscle tendon. Physiopathology and results of surgical treatment. Apropos of 28 cases]. / La tendinite du grand palmaire. Physiopathologie et résultats du traitement chirurgical. A propos de 28 cas.

The results of a 27 cases of flexor carpi radialis tenosynovitis, operated between 1984 and 1992 and followed for an average of 30 months, are reported. This study confirms the female predominance of this disease (25 women for two men) and its development mainly after the age of fifty. Pain along the course of the tendon is a constant sign, frequently associated with dysaesthesia in the territory of the palmaris brevis branch of the median nerve as well as synovial swelling. Surgery was indicated because of failure of apparently correctly conducted medical treatment. The technique consists of synovectomy and resection of all sources of irritation of the tendon in its sheath. The development of trapezium or scaphoid osteophytes is a common cause of irritation. The functional result obtained was good or excellent in 22 cases. This study confirmed the existence of a close relationship between the development of flexor carpi radialis tenosynovitis and the presence of external osteoarthritis of the carpus, as this combination of lesions was observed in 20 of the 27 cases. Carpal osteoarthritic lesions appear to be responsible for the great majority of cases of flexor carpi radialis tendinitis observed in women over the age of 50 years. Following failure of medical treatment, surgical treatment is effective provided it includes treatment of any osteoarthritic lesions present.

[Carpal tunnel syndrome. Cosmetic incision (author's transl)]. / Syndrome du canal carpien. Incision esthétique.

The median nerve compressed in the carpal tunnel can be released by an incision in the "line of life", a natural fold along the axis of the third metacarpal bone. By sectioning the carpal tunnel in the palm of the hand, on the cubital side of the median nerve, division of the external branch and of the sensory cutaneous rami of the nerve can be avoided. Hypertrophic scars are prevented. The part of the carpal tunnel situated in the forearm can be freed by a subcutaneous incision if needed, but compression at that level is much less frequent than in the palm of the hand.

[When should peripheral nerves be grafted? (author's transl)]. / A quel moment doit-on greffer une plaie des nerfs périphériques?

In the presence of peripheral nerve damage, the only acceptable procedure is suture without tension, carried out under excellent conditions of fascicular approximation. In the case of loss of substance, immediate or secondary suture should never be performed. In the experience of "S.O.S. Main" secondary suture has led to the most disastrous results. Nerve graft, as an emergency, is legitimate in the case or reimplantations, in view of the high degree of technical competence of the teams, and the experience acquired. Deffered nerve graft is envisaged at about the end of the second month:--either in the absence of suture,--or in the absence of recovery. When there is any doubt, further examination at the 4 th or 5 th month ensures that treatment is not delayed too long. At all events, examinations must be repeated every two months in order to study nerve regrowth and to determine the need for possible though difficult reoperation if it stops.

[Replantations and devascularization. VBS (Vessel-Bone-Skin) emergencies]. / Réimplantations et dévascularisation. L'urgence V.O.P. (Vaisseau--Os--Peau).

The reimplanting activity initiated by Professor Raymond Vilain at Boucicaut Hospital in 1972 allowed emphasizing that, in addition to the reimplantation of a completely severed segment, there existed a parallel activity including microsurgical steps, bone surgery and skin plasties, all of which were gathered under the term of VBS, or Vessels-Bone-Skin, emergencies. Other terms are used (stage 3 fracture with vascular involvement, stage 4 fracture) for the same ultra-emergent pathology, in which many diagnostic problems as to the significance and extent of ischemia are associated with therapeutic issues. The results of an operation performed by one surgeon possessing all the desirable skills and working in a specialist Center allowed demonstrating that the quality of the results was such as could be hoped for: an overall survival rate of about 60%, little second surgery, blood consumption lower than 10 bottles per patient in average. These data represent the major progress made in 15 years. However, the rescuing staff must still be made aware of the importance of diagnosing devascularization in a context of multiple injuries: a VBS emergency involves limbs in which bony continuity, and sometimes even a skin bridge, may still be preserved. The vascular problems cannot be solved without resorting to the microanastomosed flap techniques. Lastly, the staff in charge of this kind of problems must treat upper limbs as well as lower limbs. Utmost surgical strictness is essential to avoid the major complication of such surgery: not only local failure threatening the functional results, but also the vital risks inherent in the reimplantation of a large limb segment. Reimplantation of an autologous limb has largely demonstrated its superiority over prostheses, even the most sophisticated ones.

[Treatment of recurrent Dupuytren's disease by scalar incision and firebreak graft]. / Traitement des récidives de la maladie de Dupuytren par incision scalaire et greffe "coupe-feu".

We report our experience of the use of a scalar type incision associated with a total skin graft in the treatment of recurrences of Dupuytren's contracture. This is not an original technique, but one described by Hueston in 1984, which consists of a "Fire Break" skin graft after a simple transverse incision of recurrent Dupuytren's contracture. We attribute the absence of recurrence with this graft to the impossibility of the disease to affect the thin tissue between the skin graft and the underlying tendons. Our series is composed of 25 patients, all male. The majority of these patients had undergone surgery on a single occasion before treatment of recurrences with an average time interval of seven years. In a great majority of cases the little finger was deformed and generally severely (stage III or IV). All of our patients were reviewed with a mean follow-up of 28 months after surgery, and we did not observe any recurrences under the graft. In this series, which remains too small and too recent, 67% of cases presented an acceptable result with nearly complete extension and satisfactory grasp. We do not apply this technique to the treatment of all cases of recurrent Dupuytren's contracture, but we reserve it preferentially for elderly patients, operated on several occasions for ulnar fingers especially the little finger, in digital or digito-palmar forms in which the deformity predominates on the proximal interphalangeal joint with marked digital infiltration.

Yersinia enterocolitica tenosynovitis. The first case.

We describe a case of tenosynovitis of tibialis posterior due to Yersinia enterocolitica occurring after injury by a plant thorn in a 55-year-old man. The illness was chronic with 2 recurrences in spite of antibiotic treatment. Full recovery was obtained only after surgical intervention. Our patient's chronic course was fostered by the persistence of thorn fragments in the infected area and the exceptionally pathogenic character of the isolated colony of Yersinia.

[Paronychia, the general practitioner, the surgeon and antibiotics (author's transl)]. / Le panaris, le praticien, les antibiotiques, et le chirurgien.

Antibiotic therapy for paronychia has seen its day. It is indicated only rarely and justified only when on the day following infection or during the next few days there are signs of regional or systemic spread. The surgical treatment of infections of the hand is not difficult but should be known, if not learned. A paronychia which has been opened but not cured should be reoperated upon rapidly. An "old" paronychia is a major catastrophe: small fistula, great damage. No surgical quarter for evil organisms!