Atypical schwannoma of the median nerve. A case report.

Schwannomas of the hand are very rare tumors and represent less than 3% of all soft tissue tumors in the hand. These tumors share clinical, epidemiological and imaging characteristics with the other soft tissue and peripheral nerve tumors; thus, it can be difficult to make a preoperative diagnosis. Here we report the case of a 48-year-old woman who presented with a schwannoma arising from the palmar branch of the median nerve. The tumor measured 54 × 41 x 52 mm and was located in the thenar eminence. The first hypothesis was a vascular tumor. After surgery and histological analysis, the final diagnosis of an atypical schwannoma was established. The presence of shared immunohistochemical characteristics with cellular histiocytoma and myoepithelial tumors forced us to adopt an aggressive follow-up protocol. As of the last follow-up at 9 years, the patient had good clinical outcomes and no recurrence. This case highlights the difficulties encountered in clinical practice to diagnose such tumors.

Patient-accident-fracture (PAF) classification of acute distal radius fractures in adults.

There is not enough evidence in the literature to support the use of any classification system for distal radius fractures (DRF) in adults. However, there is a need for identification of more homogeneous groups of patients with DRF so that the extent of preoperative workup and sophistication of treatment would best match the needs of the patient. The authors propose an innovative method to analyse and stratify acute DRF in adults. A one-page chart includes criteria related to the patient (P), the energy of the accident (A) and the pathology of the fracture (F). Analysis of the pathology includes not only the distal radius itself but also the associated ulnar and carpal lesions. Radiological suspicion of associated carpal of distal radio-ulnar joint ligamentous injuries is included in the analysis. The preliminary results of the use of this chart in 1610 consecutive adult patients (16-102 years) with unilateral acute DRF are presented. A total of six homogeneous groups of patients are described, and the relevance of this classification regarding the therapeutic options is discussed.

Treatment of intra-articular fracture of distal radius fractures with fluoroscopic only or combined with arthroscopic control: A prospective tomodensitometric comparative study of 40 patients.

BACKGROUND: Considering articular distal radius fractures treated with volar plate, we hypothesized that articular radio-carpal displacement was better reduced with arthroscopic control than with only fluoroscopic control. METHODS: Forty patients with similar articular radius fracture (type C according to AO classification) and high functional needs were treated with volar plate fixation. They were divided in two comparative groups: 20 patients in Fluoroscopic group and 20 patients in Arthroscopic group. Pre and postoperative radiographs and tomodensitometric images were analysed by an independent observer. We evaluate extra and intra-articular displacements according to "Patient Accident Fracture" classification. RESULTS: We observed a better reduction of the radio-carpal step-off and gap in the arthroscopic group, with a statistically significant difference (p<0.05). The index of postoperative intra-articular reduction was better in the fluoroscopic group (5.5) than in the arthroscopic group (2.2) with a significant difference (p<0.05). CONCLUSIONS: According to these results, arthroscopy is useful to perform a better articular radio-carpal reduction in distal radius fracture. LEVEL OF EVIDENCE: Level 3.

Hemi-arthroplasty for distal radius fracture in the independent elderly.

INTRODUCTION: The authors report their experience with hemi-arthroplasty in irreparable fresh distal radius fracture in independent elderly patients as first-line treatment (12 fractures in 11 women; mean age, 74 years) or in second line after clinically disabling primary failure (4 fractures in 4 women; mean age, 78 years). RESULTS: In the 12 primary surgeries, at a mean 32 months' follow-up, there were no complications requiring implant ablation; mean pain score was 1/10, flexion-extension 62°, Lyon Wrist score 75%, and Patient-Related Wrist Evaluation (PRWE) 22 points. In 2 of the 4 secondary surgeries, at a mean 24 months' follow-up, there were no complications requiring implant ablation; mean pain score was 2.5/10, flexion-extension 62°, Lyon Wrist score 58%, and PRWE 50 points: i.e., slightly poorer results than in primary surgery. CONCLUSION: Salvage of complex fracture in independent elderly patients by hemi-arthroplasty, whether primary or secondary to failure, seems to be a considerable progress, to be confirmed in larger series.

[What is the role of primary or secondary hemiarthroplasty for distal radius fractures in independent elderly patients?] / Quelle place pour l'hémiarthroplastie en urgence ou en secondaire pour fracture de l'extrémité distale du radius du sujet âgé autonome ?

The authors report their experience with wrist hemiarthroplasty for acute irreparable distal radius fractures in independent elderly patients (12 women, mean age 76years) and following failed initial treatment in the same population (5 women, mean age 75years). The first 11 cases have a mean follow-up of 30months. No complications requiring implant removal were reported. At follow-up, the mean VAS for pain was 1/10, the mean flexion-extension arc was 60°, the Lyon Wrist score was 73 % and the PRWE (Patient-Related Wrist Evaluation) was 22 points. The five patients who had secondary procedures and were reviewed at mean of 16months' follow-up did not require implant removal but there was one complete forearm rotational ankylosis with ossification. At follow-up, the mean VAS for pain was 3/10, the mean flexion-extension arc was 56°, the Lyon Wrist score was 65 % and the PRWE was 45 points. The authors believe that hemiarthroplasty is a useful salvage procedure for irreparable wrist fractures in the emergency room and after failed initial treatment in active elderly patients.

[Radiological analysis of acute distal radius fractures and clinical outcomes]. / Analyse radiologique des fractures fraîches de l'extrémité distale du radius et évaluation clinique des résultats.

Radiological analysis of acute distal radius fractures (DRF) begins with the initial AP and lateral X-ray views. A CT scan is very often indicated. In addition to the three standard planes, 3D reconstructions are mandatory. We recommend not only AP views of the distal facets of the radius but also a complete 3D view in the surgical position. The distal ulna and carpus should also be analyzed. We describe the radiological sequence and the criteria used. These criteria are recorded in the one-page PAF chart, since they all impact the treatment choice. Clinical outcomes of DRF treatment are rarely addressed in the literature. We review the most commonly used clinical scores and describe the one that we use currently.

[Patient-Accident-Fracture (PAF) classification of distal radius fractures]. / Classification Patient-Accident-Fracture (PAF) des fractures fraîches de l'extrémité distale du radius.

Despite the huge amount of literature devoted to acute distal radius fractures, there is currently no consensus as to treatment recommendations. There is no universally accepted anatomical classification other than the three main categories of the AO classification. The authors believe that the only way to improve this field is to stratify the patients according to their general health and functional needs. They propose a new classification system that they have used since 2009 and demonstrate its therapeutic, epidemiological and teaching values.

[Incidence of distal ulna fractures associated with distal radius fractures: Treatment options]. / Incidence des fractures de l'extrémité distale de l'ulna associées aux fractures de l'extrémité distale du radius (processus styloïde ulnaire). Nos choix thérapeutiques.

Fractures of the neck and/or head of the ulna or distal ulna fracture (DUF) other than ulnar styloid fractures can occur in combination with distal radius fractures (DRF). This combination can have a significant influence on the treatment and prognosis since it causes the entire distal forearm to be unstable. In a series of 1279 consecutive unilateral DRFs, we found an associated ulnar neck fracture in 5.9% of cases, ulnar head and neck fracture in 1.6%, and isolated ulnar head fracture in 1.4%. Overall, 9% of cases in this study had a DUF with a DRF. The frequency of extra-articular "A" (11%) and intra-articular "C" (9%) DRFs according to the AO classification was about the same. There were no cases of DUF combined with partial "B" DRF. There was a correlation between combined DUF with DRF and the patient's group in the PAF classification. DUF are more frequently associated with DRF in elderly patients. Specific distal ulnar locking plates were recently introduced and they may be a useful adjunct to distal radius locking plates when treating patients with combined DUF and DRF.

[Complications of volar locking plates used to treat distal radius fractures]. / Complications des plaques antérieures verrouillées pour fractures fraîches de l'extrémité distale du radius.

About 10 years after volar locking plates were introduced to treat acute distal radius fractures, several papers have reported short-term complications. The aim of this paper was to report our complication rate over a 2-year period and to compare it to the literature. We found similar complication rates despite different classification systems. Because of the prospective nature of our study, we were able to demonstrate that extra-articular and/or intra-articular scores exceeding 8 points on a 12-points scale were statistically associated with more complications, irrespective of the patient's overall health and age.

[Chronic ulnar wrist pain in adults: diagnosis and treatment principles]. / Douleur chronique du compartiment médial du poignet chez l'adulte : diagnostic et principes du traitement.

Adult patients with chronic ulnar wrist pain often seek medical advice. There are a number of diagnoses for chronic ulnar-sided wrist pain. A sound diagnostic strategy is therefore of paramount importance. Patient's history, clinical examination and high quality standard radiographs are the most important part of this strategy. Sophisticated investigations should only be performed to focus on solid clinical hypotheses. The palmar and dorsal aetiologies of ulnar wrist pain are considered as well as their treatment principles.

[Acute carpometacarpal joint dislocation of the long fingers: study of 100 cases]. / Luxations carpométacarpiennes fraîches des doigts longs. Étude à propos de 100 cas.

OBJECTIVES: The authors report clinical and radiological results of carpometacarpal dislocations treated in emergency over a period of 7 years (2002-2009). Mechanisms of injury and diagnosis pitfalls are specified, and treatment options are discussed. METHODS: A retrospective study of 100 carpometacarpal dislocations was performed. Most commonly trauma was a punch (56%). In half the cases, lesions were located only within the fifth ray. Carpal or metacarpal fractures were associated in a majority of cases (88%). Surgical treatment was carried out in all cases either by closed reduction and percutaneous pinning (60%), or by open reduction and internal fixation (40%). The mean follow-up was 5 months. Anatomic reduction of dislocation, consolidation and reduction of associated fractures were analysed on the last follow-up x-rays. Evaluation tools were pain score, range of motion and grip strength. RESULTS: Radiological criteria were satisfactory in 68% of cases. Non-satisfactory X ray criteria were mainly associated with closed reduction and percutaneous pinning. At final follow up, 81% of the patients were pain-free and had recovered complete range of motion. In 16% of patients pain was only found during grip strength test. CONCLUSIONS: Carpometacarpal luxations are not as rare as suggested by literature. Early diagnosis and treatment are essential for the prognosis. Increasing indications of a scan enable better analysis by identifying all injuries. Open reduction by which allows the treatment of all associated injuries must be promoted.

Prospective study of a new total wrist arthroplasty: short term results.

We present early results (average 32 months follow-up, minimum 12 months) of a prospective study of the ReMotion™ total wrist arthroplasty in a series of 20 wrists (19 patients) with end-stage arthritic wrists (of whom 13 were rheumatoid). Overall there were no intra-operative complications, dislocations or reoperations. We observed one carpal and one radial loosening--both in rheumatoid patients. Neither was symptomatic enough to warrant reoperation. In the rheumatoid group of 13 wrists there was an average of 41% clinical score improvement. According to the Meuli score there were seven excellent, five good and one poor result. In the non-rheumatoid group of seven wrists there was an average of 27% clinical score improvement. According to the Meuli score there were two excellent, two good, two fair and one poor result. In the short term follow-up of this series, the ReMotion™ total wrist arthroplasty provided better results and less devastating complications than the old generation total wrist arthroplasties. Longer follow-up is needed to validate these early results.

[Intra-articular sub-periosteal osteoid osteoma of the triquetrum. Case report]. / Ostéome ostéoïde sous-périosté du triquetrum en situation intra-articulaire. A propos d'un cas.

We report a case of subperiosteal osteoid osteoma of the triquetrum located into the piso-triquetral joint space. Such a variant at this particular location is very rare. The diagnosis was delayed for six years. A bloc resection of the tumour was followed by complete recovery.

"PAF" analysis of acute distal radius fractures in adults. Preliminary results.

There is not enough evidence in the literature to support the use of any treatment in distal radius fractures, mainly because of the heterogeneous aspects of most series. There is a need for more standardized analyses of distal radius fractures that should allow the identification of more homogeneous groups of patients. The authors propose a novel synthetic method to analyse acute distal radius fractures in adults. A one-page chart includes criteria related to the patient (P), the energy of the accident (A), and the characteristics of the fracture (F) along with associated ulnar and carpal lesions. The preliminary results of the use of this chart in 258 consecutive patients are presented. Four homogeneous groups of patients are described and the principles of their treatment are discussed.

[Analysis of acute distal radius fractures with the articular sagittal index (ASI)]. / L'index sagittal articulaire (ISA) pour l'analyse des fractures fraîches du radius distal.

Displacements of articular fragments are not always visible on initial radiographs of acute distal radius fractures. Despite the wide use of CT scan, it may be useful to know a simple index that could suggest an articular displaced fracture from the initial standard radiographs. The authors describe an articular sagittal index (ASI) of the distal radius and provide reference values from a study of 100 healthy volunteers. An increase of the ASI index suggests a displaced articular distal radius fracture with possible impaction.

Clinical evaluation of two bilateral hand allotransplantations at six and three years follow-up.

We report a six and three years follow-up clinical evaluation of two bilateral hand allotransplantations from brain-dead multi-organs donors performed in two young adult traumatic hand amputees. Lifelong immunosuppressive treatment included tacrolimus, mycophenolate mofetil and prednisolone. In both patients, early complications were observed but were successfully treated. At follow-up, clinical results allow useful hand function in both patients, by far superior to what can be provided by current myoelectric prostheses. Although the long-term risks-benefits ratio of bilateral hand transplantation is still unknown, these two cases demonstrate that this new treatment is feasible. Further experimental and clinical research is needed to better delineate its role in the future of hand surgery.

[Testing of pronation and supination strength in the outpatient setting: a preliminary study]. / Evaluation de la force de pronosupination à la consultation: étude préliminaire.

Dynamometric studies of grip strength are widely used in clinics. We present a clinic dynamometer that can be used to measure pronation and supination moments while the subject being tested is holding a cylindrical handle in neutral pronosupination. One hundred volunteers without any previous history of upper extremity injury were tested in pronation and supination in order to provide a database of strength values and to study variations with respect to sex, age, dominance, weight and height.

Three-dimensional in vivo displacements of the shoulder complex from biplanar radiography.

The goal of this study was to adapt roentgen photogrammetry to in vivo studies of shoulder skeletal motion during arm elevation in the scapular plane. Numerous in vitro and in vivo studies have been published describing shoulder bone movements. They involve plain radiographic measurements and utilize a three-dimensional (3D) approach. Measurements are either direct using pins implanted in bones, or indirect recording points on medical images. Roentgen photogrammetry locates points in space from two projections obtained from two different radiographic incidences. The technique has been applied in vivo by implanting metallic balls in bones. However, to be used as a standard clinical procedure, the technique must be adapted to be less invasive. In vivo photogrammetric reconstruction of known points in 3D space requires that the subject is strictly motionless between the successive radiographic exposures or that the exposures are obtained simultaneously. Methods used in this study were developed to allow subsequent exposures to be used for analysis. Numerical tools have been developed to align the two projections of a point in 3D space which have moved slightly between two successive exposures. The standard photogrammetric technique is completed by geometric modeling of the shoulder complex and humerus, and by the control of their mutual proximity at the level of joints. Bones are modeled as a set of simple volumes linked together using geometric shapes described by shape parameters. The coincidence between real bone contours and radiographic projections of the modeled bone gives the values of the shape parameters and the accurate location in space. Results focus on two different topics: errors related to the use of roentgen photogrammetry with successive exposures, and results obtained by applying roentgen photogrammetry to the in vivo shoulder complex. Results describing shoulder bone and joint displacements are presented for comparison with previously published results. The technique of roentgen photogrammetry can successfully be applied to patients. The radiographic protocol is simple, and data can be obtained easily and quickly from the digitized films. The data obtained from asymptomatic shoulders compared favorably with published values. Future research will focus on comparisons between kinematics of the symptomatic and asymptomatic contralateral limbs in volunteers.

[Primary Swanson metacarpophalangeal joint arthroplasty in major hand traumas. A report of two cases at 14 years follow-up]. / Arthroplasties métacarpophalangiennes en urgence par implant de Swanson dans les traumatismes pluritissulaires complexes de la main. A propos de deux cas revus a 14 ans.

In major hand injuries, destroyed joints may be treated by joint transfer, arthroplasty or fusion with or without temporary external fixation. Four immediate digital metacarpophalangeal joint Swanson implants in two patients with amputation or devascularizated near-amputation were reviewed with a 14 years follow-up. No infection was noted. Prostheses were stable with a 31 degrees active range of motion and grip strength was 42% of the opposite side. Functional results were "useful" with patients satisfaction. In one patient, heavy manual worker, implants were replaced fourteen years after trauma because of recent pain on one joint and implants fragmentation. The other patient was painless. Immediate Swanson arthroplasty in major hand injuries may be an alternative in metacarpophalangeal joints destruction.