Necrotizing fasciitis of the upper extremity: a retrospective analysis of 19 cases.

Necrotizing fasciitis (NF) is both a limb-and life-threatening disease that affects skin, hypodermis as well as superficial fascia and deep fascia by rapidly progressive necrosis. Although this serious infection frequently occurs in the extremities, upper limb NF is a rare clinical presentation. The present study attempted to evaluate the clinical profiles, paraclinical findings, treatment modalities, outcomes and predictors of morbidity and mortality in patients with NF of the upper extremity. The validity of the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) scoring system was also assessed. Nineteen patients who were treated between January 2010 and December 2019 for NF of the upper extremity were eligible for this study. Data including demographics, clinical signs, paraclinical findings, treatment and outcomes were collected retrospectively from our medical records. Fisher's exact test was used to analyze predictive factors for mortality and morbidity. The mean age was 62 years, with a male predominance. The most common comorbidity was diabetes mellitus (42%). Main clinical manifestations were pain (79%), tense edema (79%) and a large infiltrated swollen erythematous plaque (58%). Severe sepsis and septic shock were identified in 32% and 21% of patients, respectively. Thirteen of our 19 patients (68%) were identified as having a high or intermediate likelihood of NF based of the LRINEC scoring system, while the other 6 (32%) were classified as having low likelihood. All patients received systemic broad spectrum antibiotic therapy in addition to surgical debridement. Two patients (10%) died and one (5%) required amputation. Mortality was associated with septic shock (p = 0.006), delay in surgery >24 h (p = 0.018), creatininemia >141 mmol/l (p = 0.018) and LRINEC score ≥ 8 (p = 0.035). Otherwise, anemia (p = 0.021), hypercreatininemia (p = 0.001) and delayed surgical debridement (p = 0.001) were risk factors for morbidity and mortality. The surviving patients underwent reconstructive surgery (skin grafting after wound preparation by using vacuum therapy) with positive outcome. Early diagnosis coupled with emergent surgical debridement and broad-spectrum empiric antibiotic therapy are the keystones of a successful outcome. The LRINEC score was not strongly correlated to the true diagnosis of NF and was a prognostic tool rather than a diagnostic one.

Floating thumb metacarpal in a motorcyclist: A case report.

We present a case of simultaneous dislocation of the carpometacarpal and the metacarpophalangeal joints of the thumb (floating thumb metacarpal) in a 47-year-old motorcyclist. The treatment consisted of closed reduction of both joints with cast immobilization. After 24 months, the functional result was excellent. The mechanism of this rare injury and its therapeutic management are discussed.

[How to avoid operative injury to Martin-Grüber communicating branch in the transmuscular medial approach of the elbow?]. / Comment éviter les lésions iatrogènes du rameau communicant médio-ulnaire de Martin-Grüber dans la voie d'abord transmusculaire médiale du coude ?

The incidence of Martin-Grüber medio-ulnar communicating branch (MUCB), from median nerve to ulnar nerve, is about 20%. To avoid operative injury to MUCB, the authors suggest some modifications to the medial approach of the elbow. They suggest medial aponeurotomy of the anterior compartment of the forearm, disinsertion of the medial epicondylar muscles with dissection between the flexor carpi ulnaris (FCU) and the other medial epicondylar muscles, not exceeding 3 cm distally. This allows a valuable exposure of the elbow joint through a medial approach, with FCU disinsertion and ulnar nerve transposition preserving the ulnar nerve vascularization, without injury to the MUCB.

[The digital external fixator, new equipment (24 cases report)]. / Le fixateur externe digital, nouveau matériel (à propos de 24 cas).

Phalangeal fractures and osteoarticular infections can be challenging injuries to manage, and their treatment is frequently complicated by deformity and stiffness. External fixation techniques have a well-established role in the treatment of these injuries. The mini-Hoffman external fixator is a particularly simple apparatus in design and in application. We report a technique of digital external fixator with a new original material developed in the service. It is an inexpensive and simple technique with good stability. The technical procedure is simple, consisting of two joints, Kirchner pins, 4mm diameter screwdrivers and a motor. Between 2001 and 2006, we used this method to treat 24 patients in a prospective study. The mean age was 35 years (range 16 to 68 years) with a male predominance, left hand predominance (14 cases), and carpenter's hand was the most frequent indication (11 cases). Mean duration of follow-up was two years (6 months to 5 years). Functional results were excellent in 12 cases and bad in six cases. Complications included a case of ischemic necrosis of the finger, two cases of secondary displacement, three cases of sepsis, two cases of algodystrophy and a case of pseudoarthrosis.

[Ewing's sarcoma of the hand: a case report]. / Sarcome d'Ewing de la main: a propos d'un cas.

Ewing's sarcoma of the hand is rare. This tumor was first described in 1921, since then, only a few cases with hand involvement have been reported. We report a case of Ewing's sarcoma of the left hand, presenting as a swelling of the hand gradually enlarging over six months. Plain radiographs showed marked osteolysis of the second, third and fourth metacarpals. Histological confirmation was made following biopsy. Despite amputation and post-operative chemotherapy, death occurred two months later due marrow aplasia.

[Total carpometacarpal dislocation. Case report]. / La luxation carpométacarpienne antérieure complète des doigts. A propos d'un cas.

Anterior carpometacarpal dislocation are rare injuries. The anterior type is exceptional. Mr A.T 18 years old, male, student, right-handed, without pathological medical history. He was admitted in emergency after a fall of a motorbike (unknown mechanism) for a closed left hand injury; examination revealed a total impaired mobility and an important swelling of the hand without vasculonervous disorders. X-ray revealed a pure anterior dislocation of the five carpometacarpal joints. The patient was operated on in emergency using both anterior and posterior approach, which allowed to reduce the dislocation. It was maintained by K-wires. An antebrachiopalmar cast was applied for six weeks. One year later, the result obtained was considered excellent.