Anatomical and computed tomography study of the eighth costochondral junction: topography for costochondral graft harvesting.

INTRODUCTION: Costochondral grafts have long been used in maxillofacial reconstruction, but have been little used in trauma and orthopedic cases. This surgical technique requires that a graft be harvested from the thorax in the area of the eighth rib. Pleuropulmonary complications are very rare. Although the harvesting technique is simple, it needs to be demystified. GOAL OF STUDY: This study was performed to define anatomical relationships in the eighth costochondral junction and identify topographical and anatomical landmarks that will make it easier to harvest this structure. METHOD: This was a two-part study. First, an anatomical study was carried out on human cadaver thoraxes to define topographical landmarks and study the anatomical surroundings of the eighth costochondral junction. Second, an imaging study was performed using a database of existing patient computed tomography (CT) scans of the chest and abdomen to confirm the topographical landmarks defined in the first part of the study. The spine was used as a reference for both studies. The location of the eighth costochondral junction was defined relative to the spinal processes along with its location on the lower rib cage hemiperimeter in the transverse plane starting at the corresponding spinous process. RESULTS: The eighth costochondral junction was in line with the spinal process of the twelfth thoracic vertebra in the vast majority of cases and located at two-thirds of the lower rib cage hemiperimeter from the posterior median sulcus, regardless of the patient's chest shape, age and gender. This junction was always located under a single muscle (external oblique) and protected by a thick perichondrium layer, which separates it from the intercostal pedicles, endothoracic fascia and parietal pleura. DISCUSSION: This two-part study has identified reliable landmarks for harvesting of an osteochondral graft at the eighth costochondral junction and, by describing its anatomical surroundings, helps take the mystery out of its harvesting. These landmarks were identified in supine cadavers and in free-breathing patients lying in supine for the CT portion. This position must be used when identifying these landmarks in a patient undergoing costochondral autograft harvesting for cartilage reconstruction.

Dimensions of the trapezium bone: a cadaver and CT study.

PURPOSE: The primary purpose of this study was to define the size of the trapezium bone through measurements on cadaver specimens and CT scans of living subjects. The secondary purpose of this study was to determine if any correlation existed between the size of the trapezium and local anatomical parameters. METHODS: The radio-ulnar length (L), dorsopalmar width (ℓ) and height (h) of the distal surface of the trapezium were measured by two independent observers on 20 cadaver specimens. The same measurements were carried out by two other observers on anonymized CT scans from 18 patients. The inter- and intra-observer agreement was determined using the intraclass correlation coefficient. RESULTS: In the cadavers, the mean length, width and height of the trapezium were 22.8, 15.5 and 15.2 mm, respectively. On the CT scans, these same dimensions were 19.2, 11.4 and 11.6 mm. Inter-observer agreement was statistically significant in both parts of the study. DISCUSSION: The dimensions of the trapezium bone were about 3.33 mm larger in cadavers than on CT scans. These differences can be explained partially by a systematic under-sizing error on the CT scans and the fact that the cartilage layer cannot be directly visualized. CONCLUSION: This study was able to define the dimensions of the trapezium bone. It may be possible to predict the trapezium height from the length of the forearm or the width of the radial epiphysis. Our data can be used to adjust the size of trapezium implants to the dimensions of the patient's bone.

Open volar radiocarpal dislocation with extensive dorsal ligament and extensor tendon damage: A case report and review of literature.

The authors present the case of a patient with a rare combination of open volar radiocarpal dislocation and complete destruction of the dorsal capsule-ligament complex and tendons. The treatment consisted of open reduction and arthrorisis (temporary arthrodesis during 45 days) with four K-wires (radiocarpal and radioulnar). The capsule-ligament complex was fixed with anchors and the extensor tendons were repaired by suturing. A long-arm cast was applied for six weeks. After an 18-month follow-up, the Cooney-modified Green and O'Brien score was 70 and the wrist range of motion was 85°. Dynamic intraoperative X-rays are needed to look for bone or ligament (intracarpal or radioulnocarpal) injuries. Arthrography, arthroscopy or MRI may provide additional information. In cases of stable lesions without intracarpal ligament injuries, conservative treatment may be sufficient. Otherwise, surgical treatment is required, using temporary external fixation or arthrorisis (temporary arthrodesis) associated with anatomic repair of capsular ligaments. The average duration of postoperative immobilization is 6.6 weeks. An external fixator seems to be useful for reduction and for placing optimal tension on repaired ligament repair. Twenty-three cases of volar radiocarpal dislocation are described in published studies. None of them was associated with bone, tendon, skin or capsule-ligament complex injuries. Few studies describe the long-term functional and radiological outcomes of these injuries.

[Distal radius fractures: Which classification is the right one?] / Fractures de l'extrémité distale du radius : quelle classification choisir ?

None of the classification systems for distal radius fractures is ideal. However a validated system to analyze these fractures is available that is based on the "metaphysis, epiphysis, ulna" (MEU) classification and the "patient, accident, fracture" (PAF) system. It makes it possible to understand the injury and select the best treatment.

[Is there any correlation between the strength of pronation and supination of the dominant hand and that of the non-dominant one in right-handed healthy adults: preliminary results]. / Existe-t-il une corrélation entre la force de pronation-supination du côté dominant et celle du côté non dominant chez l'adulte sain droitier : résultats préliminaires.

We searched the existence of a link between the strength of pronation and supination of the dominant forearm and those of the non-dominant one. Ninety-seven volunteers were tested in pronation and supination with an analog dynamometer. Gender, age, dominance, height and weight were recorded. The measurement position was: 90° of elbow flexion, 0° of shoulder abduction, wrist slightly extended and neutral pronation-supination. We took four measurements per patient: strength in pronation and supination, in both the dominant and non-dominant sides. Fifteen subjects were evaluated twice. The left-handed (4) were removed from the statistical analysis. There were 38 men (37 years, 18-66) and 55 women (45 years, 21-71). Torques were higher (P<0.05) in men than in women, higher in supination than in pronation and in the dominant side compared to the non-dominant one (average ratio "non-dominant/dominant": 0.85; σ=0.16). There was a strong correlation between non-dominant hand strength and dominant hand strength (Pearson>0.6). Relating to the 15 subjects evaluated twice, the value of the forces varied during the day, but the ratio "non-dominant/dominant" was constant. The left-handed people were excluded, their values may be different from those of right-handers, as has been shown for grip strength. There was a strength variation during the day, but the ratio "non-dominant/dominant" was constant, making it more relevant intra-individual comparison (non-dominant side versus dominant side) rather inter-individual (based on charts of gender, age, weight and height). In the right-handed, the ratio "strength non-dominant side/dominant" is constant, defining easily in consultation the expected value of recovery of an injured forearm.

Snowblower injuries to the hand.

The aim of this study was to describe the nature and incidence of hand injuries caused by snowblowers, as well as the accident conditions and accident prevention. We conducted a retrospective evaluation over ten consecutive winters. Nine patients were included. All were men with an average age of 49.7 years (17-71). The accidents occurred at home in seven out of nine patients. The machine was running in 50% of the injury events. In most cases, the injuries occurred when the patient tried to unclog snow from the lateral discharge chute. Only four out of the nine patients had read the instructions or received instructions from the salesperson. The dominant hand was injured in 7 out of 9 patients. An average of 2.7 fingers were injured. The longest fingers were most commonly injured: 8 middle fingers, 7 ring fingers, 4 little fingers, 2 indexes and 1 thumb. All the fractures were open. Three patients were operated on several times. In 7 out of 9 cases, the patients had sequelae such as amputation. The mean time off work was 11.4 weeks (3-24). All the patients were experienced snowblower users (9 years and 57th use on average). Snowblower accidents are very mutilating. Prevention must include protected access to blades and better verbal and written safety warnings.

Interest of emergency arthroscopic stabilization in primary shoulder dislocation in young athletes.

INTRODUCTION: The recurrence rate after primary shoulder dislocation in young subjects with high functional demand is close to 75%. The present study assessed the interest of emergency arthroscopic stabilization in this specific population. MATERIAL AND METHODS: A non-randomized prospective study included 31 athletes under 30 years of age with primary anterior shoulder dislocation. Fifteen were offered emergency stabilization; after informed consent, 14 were enrolled in the "emergency stabilization" group. This was compared to a group matched for age, sport and lesion, managed 1 year previously by "non-operative" treatment (n=17), divided into 2 subgroups: "immobilization" and "secondary stabilization". Continuous prospective assessment of recurrence, return to sport and function (QuickDASH, QDsport, Duplay and Rowe scores) enabled comparison between the 3 groups. RESULTS: Mean follow-up was 19 months for the "emergency stabilization" group and 25 months for the "non-operative" group. There were no failures in the "emergency stabilization" group, compared to a 77% rate in the "non-operative" group with onset at a mean 7.5 months and a mean 2.6 episodes of recurrence. Seven (54%) of the failures of non-operative treatment required secondary stabilization. Ninety-three percent of the "emergency stabilization" group, 44% of the "immobilization" group and 71% of the "secondary stabilization" group resumed sport at least at their pre-dislocation level. Mean Quick DASH was 1.46 in the "emergency stabilization" group, versus 15.28 the "immobilization" group (P<0.05) and 16.96 in the "secondary stabilization" group. Mean Duplay and Rowe scores were respectively 92.9 and 95 in the "emergency stabilization" group, versus 59.44 and 61.1 in the "immobilization" group (P<0.05) and 85 and 93.57 in the "secondary stabilization" group. DISCUSSION: Emergency arthroscopic stabilization limits recurrence (Kirkley et al.), with better functional results than for secondary stabilization, lesion "freshness" providing a more favorable environment for labral and ligamentary healing. These encouraging results need confirmation over longer follow-up.

Technical note: How to spare the pronator quadratus during MIPO of distal radius fractures by using a mini-volar plate.

Few surgical approaches have been described that spare the pronator quadratus (PQ) during the treatment of distal radius fractures. The PQ supplies blood to the distal radial epiphysis, helps stabilize the distal radio-ulnar joint, and contributes 21% of pronation strength. Sparing the PQ should result in faster bone union and shorter recovery time. To achieve these goals, we currently use a minimally-invasive volar procedure using a specially-designed short plate (APTUS Wrist 2.5 XS, Medartis(©)). A 20mm incision is made over the fracture line as described by Henry. The PQ is dissected and then detached from the volar side of the radius. Forceps are used to slide the plate under the muscle. The screws are locked after carefully elevating the distal edge of the PQ. A preliminary study of distal radius fracture fixation by this technique was performed in 31 patients. The scar was 26mm in length and the duration of surgery was 34minutes on average. Patients wore a removable brace for 15 days, and passive wrist motion without loading was allowed during the first week. Functional recovery was faster than seen in previously published series. An average Quick DASH score of 10 was achieved by the 10th post-operative week. Although there are no contraindications to this technique, the quality of the reduction is more important than the scar size and desire to spare the PQ. Never hesitate to convert the incision to a classical Henry approach if technical difficulties arise. Our technique seems best suited to patients with high functional demands. It is currently being evaluated in a prospective series.

Fixation of distal radius fractures in adults: a review.

In patients for whom function is a priority, anatomic reduction and stable fixation are prerequisites for good outcomes. Several therapeutic options exist, including orthopedic treatment and internal fixation with pins (intra- and extrafocal), external fixation which may or may not bridge the wrist, and different internal fixation techniques with dorsal or palmar plates using or not, locking screws. Arthroscopy may be necessary in case of articular fracture. In the presence of significant metaphyseal bone defects, filling of the comminution with phosphocalcic cements provides better graft stability. The level of evidence is too low to allow recommending one type of fixation for one type of fracture; and different fixation options to achieve stable reduction exist, each with its own specific complications. With the new generations of palmar plate, secondary displacement is becoming a thing of the past.

[Anatomy and biomechanics of distal radius fractures: a literature review]. / Aspects anatomiques et biomécaniques des fractures du radius distal de l'adulte : revue de la littérature.

Distal radius fractures remain the most frequent fractures in the adult. Associated osteoporosis increases morbidity risk (secondary displacement is the most frequent) and mortality risk (in women older than 60). Severity of the fracture and functional results are related to the bone mineral density. Anatomy has been recently revisited with better description of palmar and dorsal aspects in order to avoid material-related complications. Standard postero-anterior, lateral and oblique radiographs of the wrist show the fracture and the displacement. CT scan is warranted if conventional X-rays are insufficient to show the articular surface. The involvement of the metaphysis (comminution), the epiphysis (articular fracture) and the ulna is different in each case and each fracture is an association of these three components. The MEU classification describes the fracture with sufficient inter-observer reliability and intra-observer reproducibility to be a useful tool for treatment and prognosis. The PAF system is used to propose the most appropriate treatment for each patient. Anatomical reduction and stable fixation are associated with good functional results but in high demanding patients.