[Coverage of dorsal distal skin defects of the digits. Techniques and indications]. / Couverture des pertes de substance cutanée distales des doigts. Techniques et indications.

Distal dorsal skin defects of the digits could be considered as a surgical entity. The coverage of this area is challenging according to the following points: the proximity of the distal interphalangeal joint, the thinness of the extensor apparatus and the vicinity of the nail. Among the numerous flaps described, the homodigital turnover pedicled flaps appear the most effective option rather than cross-finger flaps.

[Interest of using muscle flaps in the coverage of small ankle and distal leg defects]. / Intérêt de l'utilisation des muscles locaux dans la couverture des petites pertes de substance de la cheville et du quart distal de jambe.

The author reports his experience and the interest in using small pedicled muscle flaps in the coverage of small cutaneous size defects around the ankle and the distal leg. In such defects, the bad cutaneous status often precludes the use of fasciocutaneous flaps, and the use of wider muscle pedicled flaps or even free flaps is excessive. Because of their small sizes, the muscles used in our series, often considered as accessories, appear very useful.

[Hemosiderotic fibrohistiocytic lipomatous lesion: a new entity you must remind]. / Tumeurs fibrolipomateuses hémosidérotiques: une nouvelle entité à ne pas méconnaître.

Fatty tissues lesions are the most frequent of both benign (lipoma) and malignant tumor (liposarcoma) of soft tissues in the adult. We here describe the case of female patient having a fatty tissue mass of the ankle corresponding to an hemosiderotic fibrohistiocytic lipomatous lesion (HFHLL). This very rare tumour of recent description is specific of the ankle/foot area of the middle age women. These lesions are always benign and frequently recur following incomplete resection. This tumor may have invasive local growth and metastases have not been described so far. We describe the anatomopathologist's key points of their diagnostic. We discuss the main differentials diagnosis and treatment.

[Our experience about ten end-to-side sensitive nerve sutures at the hand]. / Notre expérience de dix sutures latéroterminales de nerfs sensitifs de la main.

Ten traumatic nerve defects at the palm or digit level were treated by end-to-side (ETS) neurorrhaphy. The technique included removal of an epineurial window on the donor nerve and coaptation of the sharply cut distal end of the injured nerve by epineurial stitches under microscope magnification. At final follow-up, the static two-point discrimination test scored at an average of 9.1 (range, 6-12) mm on the repaired nerve, compared to an average of 4.6 (range, 4-6) mm on the contralateral uninjured control side. The moving two-point discrimination test scored at an average of 7 (range, 4-10) mm on the repaired nerve compared to an average of 2.6 (range, 2-4) mm on the control side. This short series showed ETS neurorrhaphies are effective and give comparable results with those of nerve grafts or vein conduits, but worse than direct repairs.

End-to-side neurorrhaphy for defects of palmar sensory digital nerves.

Ten traumatic nerve defects at the palm or digit level were treated by end-to-side (ETS) neurorrhaphy. The technique included removal of an epineurial window on the donor nerve and coaptation of the sharply cut distal end of the injured nerve by epineurial stitches under microscopic magnification. At final follow-up, the static two-point discrimination test (2 pd) scored at an average of 9.1 mm (range, 6-12 mm) on the repaired nerve, compared to an average of 4.6 mm (range, 4-6 mm) on the contralateral uninjured control side. Moving 2 pd scored at an average of 7 mm (range, 4-9 mm) on the repaired nerve compared to an average of 2.6 mm (range, 2-4 mm) on the control side. This short series showed that ETS neurorrhaphies are effective and give comparable results with those of nerve grafts or vein conduits.

["Opération Smile" missions in Mongolia]. / Missions "opération sourire" en Mongolie.

We report our experience of plastic surgery of the face, limbs and burns in Mongolia. This country is three times as huge as France and has got 2,4 millions of inhabitants of whom almost one million live in the capital city Oulan-Baator, where sanitary and weather conditions are very tough for a large part of the population. The main observed and treated pathologies were sequellae of nerves and vessels lacerations, sequellae of complex hand injuries, sequellae of leg traumas, face, neck and limb burns, lips and palate clefts and pressure shores. The training of Mongol surgeons is far from good in the fields of skin coverage, digits reconstruction, treatment of nerve and vascular injuries and management of burns. Pedicled radial antebrachial, posterior interosseous, inguinal, sural, saphenous and lower limb muscular flaps were performed and taught. Microsurgery is still starting up. Thus we performed the first second toe transfer to reconstruct an amputated thumb. Some clinical cases are presented. This French-Mongolian cooperation should continue in order to match between both countries the knowledge and use of standard techniques in plastic surgery.

[Patient-rated wrist questionnaire: preliminary report on a proposed French version of a North American questionnaire designed to assess wrist pain and function]. / Auto-évaluation de la douleur et de la fonction du poignet. Proposition d'une version française d'un questionnaire nord-américain et essai préliminaire.

We present a French translation of a North American self-assessment questionnaire (Patient Rated Wrist Questionnaire or PRWE). This questionnaire was developed by Joy MacDermid and members of the IWI (International Wrist Investigators). Three years were needed to establish the specific items and questions to get a valid and reliable questionnaire. It includes 5 questions on pain and 10 questions on function. All the questions were rated on a 0-10 scale. The questionnaire provides several scoring options with a total of 100. MacDermid assessed the responsiveness of three questionnaires (DASH, SF-36 and PRWE) in 59 patients after distal radius fractures. Standardised response means (SRM) were calculated to indicate responsiveness. The PRWE was the most responsive. The French version was evaluated on 20 patients. All the questions were understood. The mean writing time was 5 minutes (3 min - 7 min).

[Island bone graft from the second metacarpal to the first metacarpal]. / Greffe vascularisée en îlot du deuxième métacarpien pour allongement du premier métacarpien.

We report a case of reconstruction of the first metacarpal by using an extended vascularized bone graft taken from the distal part of the second metacarpal. Following a gunshot injury, a 57 year-old man presented with a thumb amputated at the interphalangeal joint level and an index finger amputated at the metacarpophalangeal joint level. After lengthening of the first metacarpal over a six weeks period, the bone gap was filled using a vascularized 2.4 cm-length piece of the second metacarpal. This graft was vascularized by the dorsal vascular network of the first web space. At two months, the bone fixation was removed. At five months, the bony integration was complete.

[The DASH questionnaire. French translation of a trans-cultural adaptation]. / Le questionnaire DASH. Adaptation française d'un outil d'évaluation international.

The DASH (Disability of Arm-Shoulder-Hand) is a self-administered questionnaire developed in 1994 by representatives of the Institute for Work & Health (IWH) and the American Academy of Orthopaedic Surgeons (AAOS). It measures the physical disability and symptoms for all upper limb disorders in a heterogeneous population and for acute as well as chronic disorders. The original american version has been already tested for reliability and validity. Interest in the DASH was raised by several European publications. It appeared that the DASH could provide a common measure for upper extremity physical disability in Northern America and European countries. For this cross-cultural adaptation, we followed the guidelines developed by the Institute for Work & Health and American Academy of Orthopaedic Surgeons. Five translations and two "back-translations" were compared, aiming to semantic, idiomatic, experimental and conceptual equivalence. The final version has been tested in 223 patients presenting a variety of traumatic or non traumatic disorders. 208 questionnaires (93%) were valid because there was less than 4 missing answers. This final version has been proposed to American Academy of Orthopaedic Surgeons in order to be endorsed as an official translation. This could improve assessment for international studies by establishing standard measures.

[The supramalleolar flap. Our experience in 35 cases]. / Le lambeau supramalléolaire latéral. Notre expérience de 35 cas.

The authors report 35 cases of use of the supramalleolar flap described by Masquelet et al. in 1988. In 27 cases, the arterial blood supply was in a mixed (anterograde and retrograde) fashion since the perforating branch of the peroneal artery was spared. In eight cases the arterial blood supply was in a retrograde fashion due to the location of the skin loss. As described by Valenti et al. In 1991, the authors recommend the use of a distal subcutaneous pedicled to avoid skin grafting over the tendons at the distal part of the lag. In main cases of anterograde blood supply the superficial peroneal nerve could be spread. In 33 cases the plastic result was assessed as satisfactory. The coverage of the weight-bearing portion of the heel was done two times with no satisfactory result. Coverage of the medial malleolus area, Achilles tendon and dorsal skin of the foot represent the main indications and the best results. Five times, a venous congestion was observed with three cases of partial necrosis of the flap. The use of a large subcutaneous pedicle did not always prevent such venous problems, though this technical aspect improves the vascular reliability of the flap. The main local alternative is the distal pedicled sural flap that needs to divide the sural nerve and not allows coverage as distal as the supramalleolar flap. Except the distal coverage of the foot, the indications of these previous both flaps are similar. In case of foot coverage, the medial plantar flap based on the lateral plantar vascular bundle, as described by Martin et al. in 1991, is the other one local alternative. Free flaps are indicated for extensive skin losses, or when a poor distal vascularity of the leg does not allow reliability of distal pedicled flaps.

[Non-articular malunions of the distal radius: evaluation and techniques of correction]. / Les cals vicieux extra-articulaires du radius distal: evaluation et techniques de correction.

Malunion remains the most common complication following fracture of the distal radius. Deformities can be observed in all three planes with displacement in dorsal or palmar tilt, translation, shortening and axial rotation. Preoperative evaluation requires a comparative analysis with clinical, radiological and scanographic assessment. The functional consequences affect the radiocarpal and distal radio-ulnar joints and the carpus. Biomechanical aspects include changes in pressure forces on the distal radius and ulna, and displacement of the centers of rotation. If present, associated lesions should be evaluated. The degree of clinical acceptance depends on each patient, but generally functional outcome is closely correlated with the anatomic result. Limits of radiological acceptance should be defined at 20 degrees dorsal tilt, 5 degrees radial inclination, and a - 4 mm distal radio-ulnar index. Corrective osteotomy is performed on the radius, with or without a complementary ulnar procedure. Closing wedge and re-orientation osteotomies are no longer used. Opening wedge osteotomy with or without lengthening is preferred, generally with an access on the same side as the sagittal tilt. The osteotomy should be performed just above the distal radio-ulnar joint. A temporary external fixator provides the best way to check peroperative corrections. Bone grafts may be harvested from the radius or the iliac crest. Pins and cast are sufficient to immobilize the dorsal tilt corrections. In case of volar tilt, an internal plate fixation is best. Depending on the status of the distal radio-ulnar joint, a conservative (shortening osteotomy, wafer procedure) or non-conservative (Darrach-Moore, Kapandji-Sauvé.) procedure should be performed on the ulna. If needed, associated lesions of the carpus must be treated. Surgical correction is mainly indicated in case of a functionally unacceptable deformation, but should be discussed if the radiographical limits have been overrun. The goal of such corrective procedures is to recover anatomical restitution.

[Hand injuries caused by self-made bombs. Observations and reconstructoin techniques. Report of 7 cases]. / Lésions de la main par explosifs artisanaux. Observations et techniques de reconstruction. A propos de sept cas.

The authors report on their experience of sodium chlorate bomb injuries of the hand observed in seven boys. The thumb was damaged in all cases. This digit was amputated in five cases, was totally saved in one case and partially saved in another case. In four cases, the preservation of damaged tissues in the emergency procedure allowed a secondary reconstruction of the thumb, thus making it possible to achieve a prehensile and sensitive hand. In these former four cases, a posterior interosseous flap was performed to ensure the primary or secondary skin coverage. In two cases, the major lesions necessitated an amputation at the radiocarpal level. In one of these two cases, coverage of the amputated stump by a free gracilis muscle flap made it possible to minimize the level of amputation and to wear a functional prosthesis. Sodium chlorate bombs are made with an unstable chemical mixture. These reactives provoke high-energy injuries with a short range of dispersion. The damages depend on the prehensile mode, which explains why the thumb and the index finger are always injured. These blast injuries were limited to the hand and the skin coverage could be done with a distally based posterior interosseous flap. In spite of the impressive lesions observed in such young patients, a conservative attitude could be taken in an emergency situation with the aim to perform further reconstructive procedures.

[Temporary external fixation in the correction of non articular mal-unions of the distal radius]. / Le fixateur externe temporaire dans la correction extra-articulaire des cals vicieux du radius distal.

PURPOSE OF THE STUDY: The authors reviewed 21 cases of extra articular malunions of the distal radius treated by osteotomy, temporary external fixation, then osteosynthesis. Two groups were studied: Group A of 14 patients with dorsal tilt of the distal radius and Group B of 7 patients with palmar tilt of the distal radius. Mean follow-up of this series was 69 months ranged from 12 to 109 months. MATERIAL AND METHODS: In Group A, after exposure of the distal radius through a dorsal approach, the site of osteotomy, proximal to the distal radio-ulnar joint, was determined by fluoroscopy. The angular correction was done by progressive opening using a small external fixator. After checking on the correction, the bone graft was harvested 7 times on the radius as described by Watson et Castle, 7 times on the iliac crest. Bone fixation was done by two K-wires and a cast for 8 to 10 weeks. Three Sauvé-Kapandji procedures was done at the same time. In Group B, the approach was palmar, extended distally to open the carpal tunnel. The distraction was done with a distal T-shaped external fixator. The bone graft was always harvested on the iliac crest. Bone fixation was done with a T-shaped palmar plate. Two Sauvé-Kapandji procedures was done at the same time. RESULTS: Group A: Flexion-extension arc was improved of 15.5 p. 100, pronation-supination of 83.7 p. 100 and grip strength of 80 per cent of the pre-operative values. Radiological evaluation showed good correction except one case of undercorrection of the dorsal tilt (-7 degrees) and one case of undercorrection of the radial inclination (+6 degrees). The distal radio-ulnar index was measured at the mean of 0mm postoperatively compared to +5 mm pre-operatively. One patient developed a postoperative radiocarpal arthritis. Group B: Flexion-extension arc was improved of 96.2 p. 100, pronation-supination of 76.9 p. 100 and grip strength of 108.3 p. 100 of the preoperative values. Radiological evaluation showed good correction except one case of overcorrection of the palmar tilt (-10 degrees) and one case of undercorrection of the radial inclination (+7 degrees). The distal radio-ulnar index was measured at the mean of 0mm postoperatively compared to +7 mm pre-operatively. DISCUSSION: The functional consequences of malunions of the distal radius have been stressed by others for more than sixty years. Since, many authors have contributed to refine and improve their surgical correction. Several displacements should be taked into account for the preoperative planning. They are sagittal tilt, frontal horizontalisation, shortening, sagittal and frontal translation, and axial rotation. Many types of osteotomies could be done; closing wedge, opening wedge or reorientation. In some cases, an operative procedure of the distal radio-ulnar joint should be done at the same time. We chose an opening-wedge osteotomy and the use of a temporary external fixator to ensure progressive distraction and good adjustment in the correction of angular deformities. In the dorsal tilt group we were satisfied in using on 7 patients a trapezoidal cortico-cancellous bone graft harvested on the radius. CONCLUSION: The authors would like to stress two points: The technical interest of using a temporary external fixator to adjust the angular correction of the distal radius. The importance of an adequate treatment of distal radius fractures in emergency situation, considering the functional and cosmetic alterations due to malunions and their need for surgical corrections in main instances.

[Humanitarian surgery of the hand. Our experience in Vietnam]. / La chirurgie de la main humanitaire. Notre expérience au Vietnam.

After a general presentation of the geographical and social aspects of Vietnam, the authors describe the conditions of their surgical work during short time humanitarian hand surgery missions. These missions, lasting 7 to 10 days are dedicated to the care of children, and a half-day of teaching for Vietnamese corresponding surgeons. The technical and material limits, the constraints for the patients to travel to the hospital, to pay for care and the difficulties of follow-up, require the selection of patients in whom the disease can be treated in a single stage procedure. Three types of diseases were treated: congenital anomalies, post-burn and post-trauma sequelae. Typical cases of these diseases are described and shown. Due to the absence of hand rehabilitation, reconstructive tendon surgery is inadvisable to avoid disappointing poor results and discredit this part of hand surgery. For reason of complexity and unreliability of electromyographic examination, brachial plexus injuries cannot be treated, except the simplest cases needing one or two tendon transfers. Concerning skin coverage and reconstructive surgery, our experience has shown that pedicled local and locoregional flaps, and even microsurgical transfers are adapted and reliable techniques due to the imperative of single stage procedure. The education and teaching of young surgeons in European teams and regular relation-ships with corresponding surgeons from developing countries are certainly the best way to promote humanitarian hand surgery.

[The use of pedicular flap from the squared pronator muscle in the prevention and treatment of neuritis. Report of 8 cases]. / Utilisation du lambeau pédiculé de muscle carré pronateur dans la prévention et le traitement des névrites. A propos de huit cas cliniques.

The distal third of the forearm is a tendinous area, in which nerves could be irritated by surrounding skin scars or synovitis. In this area, a distally or proximally based pronator quadratus muscle flap could be used to wrap around the median or superficial branch of the radial nerve. Such flaps have been used successfully in eight cases, four cases of chronic neuritis, 2 cases of wrapping a median nerve graft and 2 cases of nerve coverage following trauma. All patients obtained pain relief with no alteration of finger movements.

Vascular supply of the palmar subcutaneous tissue of fingers.

The arterial system of the palmar subcutaneous fatty tissue of fingers was studied by injecting a coloured silicone polymer into the vessels of 12 fresh human cadaver hands. Arterial vascularisation of these tissues is ensured by small palmar branches arising from the main digital arteries: there were an average of 7 branches on each side varying between 4 and 12 in the specimens studied. Three anatomical patterns could be distinguished: an I-shaped configuration in 64% of cases, a narrow V-shape in 23%, and a Y-shape in 13%. An accompanying venous network was always present and drained into either the superficial or deep venous network. These anatomical findings confirm the vascular reliability of the homodigital subcutaneous flap described by the authors.

[Treatment of cutaneous loss of substance of the dorsal surface of the proximal interphalangeal joints of fingers. A general review]. / Traitement des pertes de substance cutanée de la face dorsale des articulations interphalangiennes proximales des doigts longs. Revue générale.

Dorsal skin defects of proximal interphalangeal joint (PIP) of fingers are a common situation in hand surgery. Skin grafting is contraindicated in the absence of extensor peritendon. The choice of flap depends on the site and surface area of the skin defect and the injuries of adjacent digits. Homodigital flaps, such as Smith's sliding flap, advancement-rotation or advancement-recession flaps and dorsal V-Y advancement flap, are the first choices for small defects. In case of larger dorsal skin defects, flaps must be raised on the dorsal aspect of the hand, such as reverse dorsal metacarpal flaps, distally based dorsal hand flaps and dorsocommisural flaps. Cross-finger flaps are only used when the previous options are not feasible. Descriptions of the dorsal vascular network have led to the loss of indications for venous flaps, with the exception of the Tsai's venous free flap. In case of multidigital dorsal skin defect, flaps, such as radial forearm flap, pediculed groin flap or free lateral arm flap, used for temporary syndactylisation of the fingers.

Bioabsorbable rods and pins for fixation of metacarpophalangeal arthrodesis of the thumb.

We report results on the use of bioabsorbable pins and intramedullary rods made of high-molecular-weight polylactic acid in both experimental and clinical conditions. In the experimental study, bioabsorbable rods were implanted in rabbit femora. Histologic assessment on nondecalcified bone showed that resorption of the material began at 4 months after implantation and gradually fragmented over a period of 3 years. In 12 patients 13 metacarpophalangeal joints of the thumb were arthrodesed by using one bioabsorbable intramedullary rod with one or two oblique pins. All joints fused within 6 to 8 weeks. During that period there was no sign of inflammation, and there were no nonunions. Postoperative magnetic resonance imaging assessment was done in all rabbits and eight patients. This modality is a useful tool in postoperative evaluation of the position and shape of the rod but is not sufficiently sensitive to assess the presence of local inflammation and the rate of resorption of the rods.

Wartenberg's sign. A new method of surgical correction.

A method of surgical correction is described for Wartenberg's sign, or persistent abduction of the little finger, using a slip of the extensor digitorum communis of the ring finger. The transferred component can be either the central slip, or the ulnar slip extended by the connexus intertendineus to the little finger. This technique maintains the integrity of the extensor mechanism of the little finger, avoiding loss of active extension, which is frequently observed when extensor digiti minimi is used. The donor site is dependable since the extensor digitorum communis tendon of the ring finger is always composed of several slips. This technique should be considered only in cases of isolated persistent abduction of the little finger, when there is no claw deformity.

[A simple and efficient pin guide]. / Un guide broche simple et efficace.

The authors propose the use of the metallic trocar used for venous catheter introduction as a pin guide and protector. These trocars are available in several internal diameters, allowing the use of 8/10 mm to 15/10 mm Kirschner pins. This technique has the following advantages: easy guiding of the pins and protection of subcutaneous neurovascular structures. The disadvantages are related to overheating and its consequences due to metal-on-metal friction.