Proximal row carpectomy in emergency.

Proximal row carpectomy (PRC) is a well-accepted procedure for the treatment of early post-traumatic degenerative disease of the wrist. Much less frequently, PRC has been advocated as an emergency procedure for irreparable fracture-dislocation of the wrist. Our objective was to compare the results of PRC in patients having undergone this procedure in the two contexts. We conducted a retrospective analysis of the clinical and radiographic results of six patients treated by emergency PRC as compared to six patients who underwent elective PRC. The mean follow-up was 36 months. Both the patient's satisfaction and the grasp of the wrist joint were significantly better in patients who underwent PRC emergency as compared to those having undergone elective PRC. Quick DASH score, radiographic results, and return to work were also more favourable in these patients, but the difference between the two groups was not significant. This study confirms that PRC is a valuable salvage technique indicated in early posttraumatic wrist collapse. Moreover, when performed in emergency, the procedure shows even better subjective and objective results, allowing a majority of patients to return to their previous job.

Diagnosis of occult scaphoid fracture with high-spatial-resolution sonography: a prospective blind study.

BACKGROUND: Evaluation of diagnostic accuracy of high-spatial-resolution sonography (HSR-S) in occult scaphoid fractures. PATIENTS AND METHODS: HSR-S was performed in 24 patients with clinically suspected fracture and normal radiographs. Three levels of clinical suspicion were considered (high, intermediate, and low). Three levels of sonographic suspicion were defined on the basis of cortical interruption, radiocarpal effusion, and scapho-trapezium-trapezoid effusion. Three positive criteria were interpreted as being highly indicative of fracture. Data from sonograms were compared with computed tomography (CT) scans. RESULTS: CT scanning demonstrated a fracture of the scaphoid in five patients. The global sensitivity of HSR-S for detection of occult scaphoid fracture was 100% and the specificity 79%. All patients with demonstrated occult fracture had a high sonography index of suspicion. A high sonography index of suspicion was correlated with 100% sensitivity, specificity, positive predictive value, and negative predictive value. CONCLUSION: HSR-S is a reliable, available, and cost-effective method in early diagnosis of occult fractures of the scaphoid. The presence of three defined criteria is required to assess the diagnosis.

Influence of fracture pattern on consolidation after metacarpal plate fixation.

INTRODUCTION: Consolidation problems may complicate plate fixation of metacarpal fractures. It was our clinical impression that the fracture's morphology and the patient's occupation may influence this complication. METHOD: Retrospective study on 104 extra-articular metacarpal fractures. Time to union, presence of consolidation problems and time to return to work were correlated with fracture pattern (transverse/non-transverse), presence of soft tissue injury, type of patients and type of plate. RESULTS: Twelve patients (15%) experienced consolidations problems: 8 patients within the transverse fracture pattern group (29.6%) and 4 patients (7.4%) within the non-transverse fracture group. The difference was significant (P = 0.01). Manual workers were found to be more likely than non-manual workers to have consolidation problems (p < 0.01) in both groups of fractures. There was no correlation between consolidation problems and hand dominance (P = 0.76), soft tissue injury (P = 0.24) or type of plate (P = 0.34). DISCUSSION: We found a significant correlation between fracture patterns, patients' profession and consolidation problems. Despite technical advances in plate design, management of such fractures by plating remains fraught with complications, demands meticulous handling of soft tissue and does not allow for technical error.

Proximal fractures of the fifth metacarpal: a retrospective analysis of 25 operated cases.

The clinical and radiological outcomes of 25 surgically treated fractures of the proximal third of the fifth metacarpal were retrospectively analysed. Many different methods of osteosynthesis were used. At follow-up after a mean of 3.3 years, 15 of 25 patients had no pain. Most patients regained a nearly full range of motion in the adjacent joints and more than 90% of the contralateral grip strength. X-ray signs of degenerative arthritis in the metacarpohamate joint were observed in 10 of 25 patients. Pain was found to be directly correlated with the presence of degenerative changes.

[Osteosynthesis of distal radius fractures by by flexible intramedullary nailing (Geneva experience)]. / Ostéosynthèse des fractures du radius distal par embrochage souple centro-medullaire (l'expérience genevoise).

In 1949 Leslie Rush described a new method of management of Colles' fractures by means of a rigid medullary nail. Claude Py in 1969 followed this concept but used two flexible intramedullary pins. After briefly recalling the biomechanical principle and operating technique, the authors outline their series of 39 extra- and intra-articular fractures (10 males and 29 females) operated between March 1995 and April 1996 with an average follow-up of 6.5 months (1.5-14.5 months). The radiological and functional results are discussed: 55% of the cases showed good anatomical reduction whereas 59% achieved a satisfactory functional result. The advantage of this operating technique lies in its simplicity. Nevertheless, considerable experience is necessary owing to the relatively high complication rate (secondary displacement, tendon or nerve lesions, reflex sympathetic dystrophy). However, this method requires only a limited amount of time and remains a good indication for extra-articular and simple articular fractures. In the case of severe posterior comminution, the use of cancellous bone graft can help to prevent secondary dorsal impaction and its repercussion on distal radio-ulnar function.

[Replacement of flexor digitorum profundus tendons by transfer of flexor superficialis tendons. An anatomical study]. / Remplacement des tendons fléchisseurs profonds des doigts longs par transfert des tendons fléchisseurs superficiels. Etude anatomique.

To date, the functional results of surgical treatment of flexor tendons lesions, particularly secondary repair, usually remain disappointing. However, experience has shown that tendon transfers, particularly for restoration of thumb flexion, constantly gives good results. In this anatomical study, the hands of 3 fresh cadavers were dissected in order to study the length of superficial flexor tendons prior to advancement on the same finger to replace the deep flexor or their transfer to adjacent long fingers in the case of destruction of both flexor tendons. The authors observed that, with the exception of the superficial flexor of the little finger, the other 3 superficial flexors can be used for advancement or transfer, either alone or associated with proximal elongation according to Rouhier's technique. The advantages and disadvantages of this method are discussed and compared with other deep flexor repair techniques (free graft, vascularized graft).

[Psychogenic spastic hand]. / La main spastique psychogène.

Twelve patients seen over a 8-year period with psychogenic spasms of the hand are reported. Six elderly patients presented with extrinsic flexion of the two or three medial fingers with sparing of the thumb and index. Six other patients had various hand attitudes following coincidental but not causal trauma to the upper extremity. Because of the differences in clinical presentation, age of patients and coincident trauma in some cases, the former patients were characterized as type I psychogenic spasms and the latter as type II. A major recurrent depression was the commonest psychiatric diagnosis (DSM-III-R, Axis I) with a concurrent dependent or borderline personality (DSM-III-R, Axis II). The diagnosis of psychogenic spasm of the hand is a diagnosis of exclusion, that requires a multidisciplinary approach including surgeon, neurologist, psychiatrist and rehabilitation therapist. Electromyographic studies are used to rule out a neurological or muscular etiology of the condition. Surgical treatment was uniformly unsuccessful and is probably contraindicated. Only one patient had a nearly complete spontaneous recovery.

[Ulnar nerve compression syndrome of the elbow. Analysis of 50 operated cases]. / Le syndrome de compression du nerf cubital au coude. Analyse de 50 cas opérés.

This is a retrospective review of 50 elbows (44 patients) treated operatively by simple decompression (seven cases), decompression with epitrochlectomy (13 cases), and anterior transposition (30 cases) for compression neuropathy of the ulnar nerve at the elbow. We performed a superficial transposition in five cases, an intramuscular transposition in 13 cases, and a deep submuscular transposition in 12 cases. The mean follow-up was three years and two months. The overall results show cure or improvement in 78% of cases, no changes in 20% of cases, and one case with subjective worsening. The postoperative result was inversely proportional to the initial degree of the neuropathy. The cases related to trauma obtained a better result.

Open dislocation of the trapezoid.

Isolated dislocation of trapezoid is rare. We report here a new case of open dorsal dislocation of the trapezoid following a high energy crush injury of the left hand in a factory worker. It was associated with multidigital mutilation and metacarpal fractures.

[Palmar dislocation of the metacarpophalangeal joint of the thumb. Apropos of a case initially treated by bilateral ligament suture with tendon reinforcement surgery]. / La dislocation palmaire de la métacarpo-phalangienne du pouce. A propos d'un cas traité d'emblée par suture ligamentaire bilatérale avec plastie tendineuse d'appui.

We report a case of complete palmar dislocation of the metacarpophalangeal joint of the thumb with simultaneous rupture of the radial and ulnar collateral ligaments. This highly unstable condition needs a reliable augmentation ligamentoplasty which was achieved with a free palmaris longus tendon graft. This type of transosseous plasty reinforces the collateral ligaments at their anatomical sites. The 7 month end-results is promising: the metacarpophalangeal joint remains perfectly stable and painless in spite of a slight residual stiffness which causes no discomfort to the patient.

[Cicatrization of tendon injuries]. / La cicatrisation des plaies tendineuses.

In the digital canal, the tendon healing has a double origin: the extrinsic one, where the synovial sheet and the paratendinous tissues (paratendon) are invading the tendon wound, permitting the growth of the fibroblasts; the latter produces collagen fibres, which constitute the tendinous callus; the intrinsic one, where the proper cells of the tendon from the epitenon (epitenocytes) and of the endotenon (endotenocytes), also produce fibroblasts, which is a source of collagen fibres. The experimentation has shown, on one hand, that the preservation of the synovial sheet, and, on the other hand, that early mobilisation, as far as the tendon suture has been protected, enhance the intrinsic type of cicatrisation against the extrinsic one, and sofare the functional result.

[Fractures of the clavicle and secondary lesions of the brachial plexus]. / Fractures de la clavicule et lésions secondaires du plexus brachial.

The fractures of the clavicle are fundamentally minor and usually will heal by simple immobilization. When the trauma is severe, the fracture may cause a lesion of the subclavicular neuro-vascular bundle. However, if the lesion is limited it may appear clinically only a few days after the accident. In other cases, whether the clavicular fracture heals or not, the bone lesion may produce a hypertrophic callus. This phenomenon will cause a narrowing of the costo-clavicular outlet and a compression of the neurovascular bundle which will provoke a real TOS. The authors present 16 cases of clavicular fractures, two of which having had early neurovascular complications and the 14 others a late phenomenon of costo-clavicular syndrome. The pathogenesis of the lesions, the principles of treatment and the results are discussed.

[Stress syndrome of the fingers related to rock climbing]. / Le syndrome de surcharge digitale lié à l'escalade sportive.

In addition to the well-known common trauma in the practice of rock climbing, free climbing at top level has given rise to a new specific pathology affecting the flexor apparatus of the fingers. The cases of 23 top level climbers (performance level 6a to 8a) have been reviewed. 1/3 of them had severe pain in their fingers caused by traction movements. 1 climber out of 4 were referred to us for the above symptomatology. The diagnosis was either tendinitis or tenosynovitis, and the treatment was always conservative. Understanding the pathogenesis of the conflict between tendon and pulley movements will permit partly to cure these lesions, but our aim should be to prevent them.

[Heterotopic ossification and ulnar nerve compression syndrome of the elbow. A report of two cases]. / Para-ostéo-arthropathie et syndrome compressif du nerf cubital au coude. A propos de deux cas.

Heterotopic ossification is a well known complication in patients after longterm coma following CNS trauma. The association of heterotopic ossification and a nerve compression syndrome situated near the calcifications is less common. The authors present 2 CNS traumatised patients who secondarily developed the association of heterotopic ossification of the elbow with a compressive syndrome of the ulnar nerve. Although heterotopic ossification does not appear to be the direct cause of the nerve compression, it certainly promotes compression it because of the flexion it causes.