Wrist fusion in peripheral paralysis.

In cases of paralysis of the upper limb, wrist fusion is useful in selected indications, especially when there are little to no tendon transfers available to restore finger function and wrist extension. Wrist fusion is particularly useful in the sequelae of brachial plexus lesions and in total paralysis of the radial nerve with hand drop and preserved wrist flexors. Numerous fusion techniques have been proposed. In cases of sequelae of brachial plexus lesions, locking of pronation-supination is associated with the wrist fusion. The use of anatomical plates has dropped the non-union and complication rates.

Management of complex forearm defects: A multidisciplinary approach.

Complex forearm defects with significant damage to, or loss of skin, tendon, muscle, bone and neurovascular structures represent a great challenge for surgeons. The management of such injuries, whether a result of trauma or tumor resection, is focused on preservation of the damaged limb and restoration of hand function. A multidisciplinary approach combining plastic and orthopedic surgical expertise in a coordinated team is proposed to address these challenging cases. The authors have laid emphasis on adequate debridement for wound bed preparation, bone stabilization and reconstruction for a stable bony framework, vascular repair for early revascularization, musculotendinous and nerve reconstruction as well as vascularized tissue coverage on a case-to-case basis to facilitate optimal functional recovery. They also maintain that besides expedient surgical treatment, early mobilization based on an individualized rehabilitation program as well as psychological and socio-professional supports are necessary means of achieving rapid and successful social integration.

Coverage of skin defect due to losses of substance in the elbow.

Skin defects of the elbow follow severe trauma or bone exposure after skin necrosis, osteitis, or management of infected pseudarthrosis. The orthopedic and plastic management of these lesions is fundamental. The authors describe the different clinical frameworks that can lead to bone and/or joint exposure. Before, during or at a distance from bone management (external fixation, internal fixation, temporary cementoplasty, bone graft…), they detail the surgical techniques aimed at covering skin defects of the elbow. The authors review simple skin replacement techniques such as Z-plasties, emphasizing the interest of pedicled flaps of the arm and forearm, as well as muscle or fascio-cutaneous flaps, which are able to cover almost all the elbow skin defects.

Multidisciplinary management of the bone and joint infection complicating treatment of an open fracture of the lower limb.

Bone and joint infections (BJI) of the lower limb can cause functional sequelae and in some cases have an impact on patient's life prognostic. One of the main objectives of multidisciplinary consultation team meetings (MTM) in the treatment of bone and joint infections is to provide an appropriate medical-surgical care, pooling skills of different organ specialists: infectious disease physicians, microbiologists, orthopedic surgeons and plastic surgeons. Treatment is based on aggressive debridement, bone stabilization, adequate antibiotic therapy, long-term coverage of the loss of skin substance and close clinical monitoring. The authors present their multidisciplinary diagnostic and therapeutic approaches to BJI complicating an open fracture at a referent center in the management of complex bone and joint infections.

Soft tissue coverage options around the knee.

Defects around the knee exhibit various etiologies and pose challenges to both orthopedists and plastic surgeons. While a number of reconstructive coverage options are available, flaps are almost always required for complex defects. Many local flaps are easily placed, including muscle and perforator flaps sourced from the thigh to the leg. As the recipient vessels lie deep, free tissue transfers are challenging. Good postoperative management and efficient collaboration between orthopedic and reconstructive surgeons are the keys to successful knee reconstruction, restoring an esthetic contour and preserving joint function.

[Secondary digit reconstruction of mutilated hand]. / La chirurgie secondaire après amputation digitale traumatique.

Traumatic digit amputation generates functional, aesthetic and psychological disabilities. Such post-traumatic consequences call for a rigorous therapeutic approach, aiming at an early secondary surgical procedure - which is ideally to be performed before the patients psychologically recover from their initial trauma. The therapeutic principle consists in improving the global function of the hand, basically aiming at re-creating a quality pollici-digital pinch, ideally thin, stable, sensitive, strong, mobile enough, but also, when possible, at improving the aesthetic aspect of the hand. The therapeutic arsenal includes not only surgical processes using local ressources in order to improve the allocation of the remaining digital capital such as phalangisation, elongating techniques, proximal amputation, digital translocation and redistribution but also remote processes - such as osteoplastic and toe-to-hand transfer techniques. The authors expose their approach and indications of secondary digit reconstruction procedures in mutilated hand. They conclude that a thorough knowledge and mastery of the vast available therapeutic arsenal, a fine and profound analysis of the benefits and downsides of each available surgical technique, a comprehensive acknowledgement of the patient's personal information such as age, gender, profession, dominant hand, status of the mutilated hand, physical and psychological health as well as patient's desire are all necessary in order to define the best therapeutic strategy for each particular case.

Long-term functional outcomes after surgical treatment of nonspecific thoracic outlet syndrome: Retrospective study of 70 cases at a mean of 8 years' follow-up.

Our objective was to study the clinical and functional outcomes after surgical treatment of nonspecific thoracic outlet syndrome (TOS) using a supraclavicular approach. We included every patient with TOS who was treated surgically by the same surgeon at a single hospital between 1999 and 2014 with a minimum follow-up of 4 years. The primary outcome was the overall evaluation of the function by the QuickDASH Score. Secondary outcomes included functional, subjective outcomes, pain levels, and neuropathic features. The clinical outcome of 70 cases was evaluated with a mean follow-up of 8.5 years. The improvement in the QuickDASH Score was significant with an average change of 38 points. Mean pain intensity was reduced postoperatively by 1.6 points from 5.1/10 to 3.5/10. Persistent pain rate at 4/10 or more remained in 56% of cases. These cases were mostly neuropathic. The surgical procedure significantly reduced the number of patients suffering from paresthesia, numbing or weakness. The possibility of sequelae and the persistence of neuropathic pain means the surgical indication should be limited to patients with significant functional disability despite well-conducted rehabilitation. The long-term functional outcomes in patients undergoing TOS was mostly good but could be improved by addressing residual neuropathic pain symptoms.

[Treatment of necrosis of Achilles tendon without tendon reconstruction: About four cases]. / Traitement des nécroses du tendon d'Achille sans reconstruction tendineuse : à propos de quatre cas.

INTRODUCTION: Management of the combined loss of Achilles tendon and skin is difficult. However, these are not exceptional situations after Achilles tendon surgery. Data from the literature are extensive and there is currently no consensus on the technique of tendon reconstruction. CASE REPORTS: We report four cases of purulent necrosis of the Achilles tendon complicating longitudinal incision or suturing of a tendon rupture. After debridement of necrotic tissue, the defect was covered either by a fasciocutaneous perforating flap or a thin skin graft without reconstruction of the underlying tendon. DISCUSSION AND CONCLUSION: The functional results are very satisfactory with good joint mobilities and a resumption of walking without lameness for all patients. Fibrosis can reconstitute a true neo-tendon confirmed on MRI. The advantages are many compared to other methods: a single operating time is necessary, the postoperative management is simple and it avoids certain technical difficulties related to tendon reconstruction. A larger series would be needed to support these results.

Surgical management of closed, isolated proximal phalanx fractures in the long fingers: Functional outcomes and complications of 87 fractures.

Finger fractures are the most common skeletal injuries of the upper limbs. The purpose of this study was to evaluate the functional outcomes and complications after surgical management of isolated, closed fractures of the proximal phalanx (PP) of the hand (thumb excluded). Surgical management was indicated in 87 PP fractures. Fractures were reduced and fixed with pins, screws or a plate. Functional outcomes were assessed through the range of motion (ROM) in flexion-extension, hand and finger strength, and the QuickDASH and PRWHE scores. Fixation was done with pins in 32 cases, screws in 41 cases, and a plate in 14 cases. Rehabilitation was started an average of 1.7 weeks after surgery. There was no significant difference in the functional outcomes based on either fracture type or surgical approach. Nevertheless, the following significant differences were observed: PRWHE score (P=0.017) by injured finger; proximal interphalangeal (PIP) ROM (P=0.037) by fixation type; and grip strength (P=0.019), Quick DASH (P=0.017), and PRWHE (P=0.045) by rehabilitation delay. The most common clinical complications were minor malrotation and cold intolerance. Radiological assessment showed complete union in all cases. Surgical management of PP fractures leads to good functional outcomes, including a satisfactory recovery of finger ROM. The functional recovery of a fractured digit is dependent on the right fixation choice, complete bone union, and early rehabilitation. We suggest using screw fixation to achieve patient satisfaction and optimal functional recovery of closed, isolated PP fractures of the long fingers.

[Traumatic hand injuries in children]. / La main traumatique de l'enfant.

Hand injuries in children are frequent in pediatric emergencies. Epidemiology of hand injuries in children depends on age and social context. The management of these injuries requires experienced pediatrics in order to obtain a functional hand to preserve the potential growth and to reduce the risk of cosmetic sequelae. We will describe the specificities of hand trauma in children and their therapeutic principles.

[Pediatric lower extremity reconstruction]. / Reconstruction des traumatismes complexes des membres inférieurs chez l'enfant.

Lower limb multi-tissular injuries are rare in children but require elaborate surgical care considering the child's growth potential, donor-site morbidity and the psychological consequences for the child and his family. This review outlines the various coverage options, from simple to more complex, developing their principles and their results. Technical features of wound repair of the lower limb in children will be detailed. An efficient and ambitious care can give excellent functional outcomes in children, even when extended, multi-tissue lesions members are involved.

Bilateral fracture of the base of the middle phalanx in a climber: Literature review and a case report.

During climbing, tears of the annular pulley are the most common injuries, while fractures of the dorsal base of the middle phalanx are rare and atypical. Only a few cases have been reported in international literature. The authors present a case of a Salter-Harris type III fracture of the base of the middle phalanx of the middle finger in a young climber and a review of the literature. The patient was a 17-year-old boy who regularly and intensively practiced climbing. He consulted for a non-traumatic history of proximal pain of the interphalangeal joints of the middle fingers. On clinical examination, there was pain on the dorsal surface of the proximal interphalangeal joints, with no decrease in range of motion of the fingers. X-rays showed a Salter-Harris type III, displaced epiphyseal fracture of the dorsal base of the middle phalanx of the middle fingers. Conservative treatment resulted in fracture union and the patient had recovered normal activity of his hand at the 6-month follow-up. Stress fractures are common in athletes like climbers in response to repetitive and prolonged sports. Epiphyseal fractures are the most common injuries in young climbers.

Secondary mobilization of the first dorsal metacarpal artery flap for first web space reconstruction in a child: A case report.

The authors report the case of an iterative mobilization of a skin flap based on the first dorsal metacarpal artery. This flap was initially associated with a toe-to-hand transfer to provide adequate skin coverage in the reconstruction of a post-traumatic thumb defect in a 5-year-old child. More than 8years after initial surgery, this flap was mobilized again for recovery of the first web space opening, which was retracted. This case illustrates the possibility of remobilizing the first dorsal metacarpal artery flap to reduce donor site sequelae in children.

An ultrasound diagnostic aid in hand surgery: observation on a supernumerary muscle in the wrist.

The authors report on a case of dynamic compression of the ulnar nerve in the wrist by a supernumerary hypothenar muscle in a twenty-six-year-old female patient. For eight months, she had been suffering from acroparesthesias in the territory of the ulnar nerve with pain upon effort irradiating into the forearm. The initial clinical examination was rather non-conclusive and the electromyogram found no anomaly. Faced with this dynamic symptomatology, a provisional ultrasonography was performed, revealing a picture of apparent muscular appearance, confirmed on the MRI. Surgical exploration also confirmed the presence of this muscle located between the ulnar artery at the front and the ulnar nerve, which it was pressing against, at the back. It was a supernumerary fascicle of the flexor digiti minimi brevis for which was performed a complete surgical removal. At three months from neurolysis of the ulnar nerve and removal of the muscle, the preoperative symptoms had completely disappeared. This observation reminds us of the primordial role that imaging plays in detecting ulnar nerve compression at the wrist. Although the precision of an MRI as regards the description of supernumerary muscle of the wrist is not discussed, this case emphasizes the interest of ultrasonography.

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.

Cubital tunnel syndrome: comparative results of a multicenter study of 4 surgical techniques with a mean follow-up of 92 months.

BACKGROUND: Cubital tunnel syndrome is the second most frequent entrapment syndrome. Physiopathology is mixed, and treatment options are multiple, none having yet proved superior efficacy. OBJECTIVES: The present retrospective multicenter study compared results and rates of complications and recurrence between the 4 main cubital tunnel syndrome treatments, to identify trends and optimize outcome. MATERIALAND METHODS: Patients presenting with primary clinical cubital tunnel syndrome diagnosed on electroneuromyography were included and operated on using 1 of the following 4 techniques: open or endoscopic in situ decompression, or subcutaneous or submuscular anterior transposition. Four specialized upper-limb surgery centers participated, each systematically performing 1 of the above procedures. Subjective and objective results and rates of complications and recurrence were compared at end of follow-up. RESULTS: Five hundred and two patients were included and 375 followed up for a mean 92 months (range, 9-144 months); 103 were lost to follow-up and 24 died. Whichever the procedure, more than 90% of patients were cured or showed improvement. There was a single case of scar pain at end of follow-up, managed by endoscopic decompression; there were no other long-term complications. None of the 4 techniques aggravated symptoms. There were 6 recurrences by end of follow-up: 1 associated with open in situ decompression and 5 with submuscular transposition. CONCLUSION: Surgery was effective in treating cubital tunnel syndrome. Submuscular anterior transposition was associated with recurrence. In contrast to literature reports, subcutaneous anterior transposition, which is a reliable and valid technique, was not associated with a higher complication rate than in situ decompression. LEVEL OF EVIDENCE: Level IV. Multicenter retrospective.

Extra-articular fractures of the digital metacarpals and phalanges of the long fingers.

Metacarpal and phalangeal fractures of the long fingers are the result of trauma occurring under extremely varied circumstances. As a consequence, the clinical presentation varies greatly, with every bone and joint potentially being involved. Each step of their treatment is crucial, although the benign appearance of these injuries can lead to steps being missed: diagnostic phase with clinical examination and radiographs; therapeutic phase where the most suitable treatment is chosen, which combines mobilization of the digital chains as soon as possible and in every patient; follow-up phase with regular monitoring to detect any complications, especially secondary displacement, and verify that good progress is being made during rehabilitation. The goal of any fracture treatment is to preserve or restore the anatomy, with the emphasis here being on the stability and mobility of the digital chains. The potential progression towards serious functional sequelae (pain, instability or stiffness in hand) and the resulting significant socio-economic repercussions must be at the forefront of a surgeon's mind early on during the initial care of any finger or hand trauma.

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.

Free vascularized fibular graft as a salvage procedure for large clavicular defect: a two cases report.

UNLABELLED: The gold standard technique for treating clavicle non-union is based on cortico-cancellous bone graft harvested from the iliac crest and fixed with a plate. In cases of large clavicular defects, this surgical procedure becomes ineffective and only reconstruction using vascularized bone grafts can be considered. Nevertheless, there are few reports in the literature dealing with this procedure and surgical technique remains unclear. We expose here a technique and results of free vascularized fibular graft for two patients with large clavicular defects. LEVELS OF EVIDENCE: Level IV, technical note.

[Major upper limb trauma: patients' outcomes in 22 cases]. / Macro-amputation du membre supérieur : que sont devenus les patients ? À propos de 22 cas.

In front of a major upper limb trauma, do we need to make everything possible to keep the limb with the risk of facing poor functional outcomes? This study was performed to evaluate and compare long-term functional, psychological and social outcomes following major upper extremity trauma between patients treated with amputation and those who underwent limb salvage. This was a retrospective monocenter cohort study of 22 patients who sustained an upper limb injury requiring either amputation or limb salvage. The characteristics of the patient, trauma and initial take-care were studied. The outcomes of amputation and upper limb salvage were compared by using functional scores (DASH, Chen), autonomy (activities of the everyday life, work, driving, leisure activities), psychological and quality of life evaluation (NHP, EVA, Russel's score). Twenty-two patients were supported. Eleven limb salvages were performed with six secondary amputations. Sixteen patients were reviewed: five with limb salvage and 11 amputees with a mean follow-up of 12 years and 5 months. All patients were autonomous. There were no significant differences between both groups regarding DASH and NHP scores or to work status and driving ability. Russel's score showed that patients with salvaged upper limb were pleased to have kept it and would recommend this treatment. Although the results of upper limb macro-replantation are sometimes disappointing, the satisfaction for these patients to keep their upper limb and their body integrity seems to justify such upper limb salvage when it is technically possible.