Validation of the spontaneous lateral laxity sign for radial collateral ligament sprain of the metacarpophalangeal joint of the fingers: Anatomical study.

Severe collateral ligament sprain of the metacarpophalangeal joint (MCP) of the fingers is rare. Clinical examination is mandatory to diagnose severity. The purpose of our study was to validate a clinical sign for MCP joint laxity: the spontaneous lateral laxity sign (SLLS), recently described by Meyer et al. to diagnose severe MCP radial collateral ligament (RCL) sprain, with a comparison with the already validated rotational laxity test (RLT). SLLS and RLT were assessed before RCL transection, after RCL transection and after RCL repair on 40 long fingers in 10 fresh thawed cadavers. SLLS was performed with the elbow on the table, wrist in 70° flexion, in neutral pronation-supination, hands drooping passively with the dorsal side toward the examiner and the ulnar side toward the table. The MCP joints were at rest, in passive slight extension. Positive results were defined as an overlap of the damaged finger on the next, or as an increased abduction of the little finger. Correlation between the two tests was calculated. SLLS was positive in 0% of cases before RCL transection, 100% after transection and 0% after repair. Mean arcs of pronation and supination on RLT were 16 and 19.5 mm before section, 24 and 33 mm after section (52% and 69% increase compared to preoperative data), and 17 and 21 mm after repair (7% and 8% increase). Correlation between the two tests was 100%. The spontaneous lateral laxity sign is a simple and reliable clinical sign for diagnosing complete long-finger MCP RCL tears requiring surgery. LEVEL OF EVIDENCE: : III, case-control study.

Hand involvement in gout.

Damage to the hand in patients suffering from gout is rare and is often detected at an advanced stage. The main clinical manifestations are the appearance of subcutaneous tophi at the finger joints. Other clinical manifestations of osteoarticular, tendinous or neurological lesions have been described in the hand and are often difficult to diagnose. In the majority of cases, surgery and adequate medical care with a suitable anti-gout treatment will allow the patient to recover normal hand function. However, surgical treatment is rare and is only performed after several months of carefully adapted medical treatment. The purpose of this article is to present the various clinical forms of gout in the hand and their surgical management.

Intramuscular hemangioma of the hypothenar eminence. A case report.

Intramuscular hemangiomas are benign vascular tumors. They develop in striated muscles. Various sites have been reported in the literature but only rarely in the hand. We report on a case of an intramuscular hemangioma located within the hypothenar eminence, diagnosed by a biopsy. Treatment options are limited in the hand as embolization may lead to a risk of digital ischemia and sclerotherapy may lead to recurrence. This type of infiltrating tumor is poorly structured within the muscle, thus simple removal is not an option. Surgical excision of the entire affected muscle, in our case the abductor digiti minimi, was performed without any consequences on the hand's function and no signs of recurrence at the latest follow-up of 6months.

Subcutaneous rupture of the superficial branch of the radial nerve at the wrist. A case report and review of literature.

Isolated neuropathy of the superficial branch of the radial nerve (SBRN) is a rarely recognized pathology. It was initially described by Wartenberg in 1932. Various causes have been published. We report a case of an unusual injury of the SBRN at the wrist, never been previously reported in the literature. A 40-year-old woman presented with pain and paresthesia over the area of the lateral aspect of the wrist, thumb and first web two months after a blunt trauma of the left forearm. After failure of conservative treatment, surgical exploration found a neuroma of one branch of the SBRN. No distal nerve stump was found. Neuroma resection was performed and the nerve was transposed and embedded into the flexor pollicis longus muscle. With a six months follow-up, the result was satisfactory.

[Flexor tendons involvement in gout. A case report and review of literature]. / L'atteinte des tendons fléchisseurs dans la maladie goutteuse. A propos d'un cas et revue de la littérature.

We present a case of synovial and flexor tendons gouty involvement associated to the flexion contracture of a single digit. The case was treated surgically by tenosynovectomy and resection of the flexor superficialis tendon followed by arthrolysis of the proximal interphalangeal joint. This rare etiology of flexion contracture must be taken into account in every patient with a history of gout and tendon pathology.

[Knee arthroscopy in children]. / Arthroscopie du genou de l'enfant.

PURPOSE OF THE STUDY: Between 1990 and 1998, 110 knee arthroscopies were performed in children. We analyzed the epidemiology and diagnostic data and studied the correlation between clinical and radiographic findings and the final diagnosis after arthroscopy in order to establish a consensus on use of knee arthroscopy in children. MATERIAL AND METHODS: We made a retrospective analysis of 110 knee arthroscopies performed in children, classing the patients in three age groups: 0-5 years, 5-10 years, 10-17 years. Clinical and radiological findings were compared with the arthroscopy findings. RESULTS: One or more arthroscopies were performed in 56 boys and 48 girls. Mean age at the time of the procedure was 12 years 4 months. There were 11 children aged 0-5 years, 14 aged 5-10 years and 85 aged 10-17 years. The main pathology was arthritis in the 0-5 year and 5-10 year age groups. Trauma was more frequent in the older children. Knee arthroscopy was found to be normal in 19 cases. DISCUSSION: For most surgery teams, arthroscopy is indicated for arthritis of the knee. Arthroscopy may also be needed for hemarthrosis. In these contexts, arthroscopy is both a diagnostic and therapeutic procedure. Our analysis demonstrates that emergency arthroscopy is only warranted for free floating osteochondral fractures and fractures of the tibial articular surfaces, with the exception of the tibial spines. Arthroscopy may be performed later in other cases after careful physical examination and radiographic series. We had 19 normal arthroscopies and 10 that showed femoropatellar chondropathies and plicas that could explain knee pain. We recommend arthrography before arthroscopy to avoid unnecessary procedures. CONCLUSION: Arthritis of the knee is an excellent indication for arthroscopy. Painful and acute hemarthrosis requires attentive physical exams and x-rays before making the decision for surgery.

Radiocarpal dislocations: classification and proposal for treatment. A review of twenty-seven cases.

BACKGROUND: The radiographic characteristics and treatment of radiocarpal dislocation are not well defined. There have been only two reported series of more than eight patients. Thus, there are many questions concerning treatment and functional results. METHODS: Two groups of patients were defined. Group 1 included all patients with pure radiocarpal dislocation and patients with only a fracture of the tip of the radial styloid process. Group 2 included patients with radiocarpal dislocation and an associated fracture of the radial styloid process that involved more than one-third of the width of the scaphoid fossa. A retrospective review and a clinical evaluation were performed. RESULTS: From 1975 to 1998, we observed twenty-seven cases of radiocarpal dislocation. Four were displaced volarly, and twenty-three were displaced dorsally. Fourteen patients presented with associated lesions. Four patients were treated with closed reduction and immobilization in a plaster cast; five, with percutaneous Kirschner wire fixation and cast immobilization; and two, with an external fixator. Eleven patients had open reduction with Kirschner wire fixation and cast immobilization. The seven patients in Group 1 had a highly unstable injury, and four of the seven patients presented with ulnar translation of the carpus. At the time of follow-up, at an average of 26.8 months, pronation averaged 76 degrees; supination, 66 degrees; wrist flexion, 54 degrees; wrist extension, 54 degrees; radial inclination, 15 degrees; and ulnar inclination, 18 degrees. The average grip strength was 27 kg. Group 2 included twenty patients. Only thirteen, with dorsal dislocation, were evaluated at the time of follow-up, which averaged fifty-one months. At that time, six reported no pain; four, slight pain; and two, moderate pain. Pronation averaged 63 degrees; supination, 76 degrees; wrist flexion, 51 degrees; wrist extension, 56 degrees; radial inclination, 21 degrees; and ulnar inclination, 39 degrees. Grip strength averaged 38 kg. Seven patients had complications. CONCLUSIONS: On the basis of our experience and a review of the literature, we believe that patients with pure radiocarpal dislocation or with radiocarpal dislocation with a fracture of the tip of the radial styloid process should be treated with reattachment of the ligaments through a volar approach. In patients with radiocarpal dislocation and a fracture of the radial styloid process that involves more than one-third of the width of the scaphoid fossa, the ligaments are still attached to the radial fragment. We believe that in this group of patients, exact articular reduction should be performed through a dorsal approach. Additional studies are needed to support these hypotheses.

Congenital pseudarthrosis of both forearm bones: long-term results of two cases managed by free vascularized fibular graft.

We analyzed the clinical and radiographic outcome of 2 cases of congenital pseudarthrosis of both forearm bones managed by free vascularized fibular grafts. The follow-up periods were 17 and 13 years, respectively. The first patient, a 4-year-old girl, had reconstruction of both the radius and ulna by a vascularized fibular graft, restoring pronation/supination to 110 degrees. The second patient, a 17-year-old boy, underwent a 1-bone forearm procedure using a vascularized fibular graft. After surgery, he had a stable forearm that was shortened by approximately 15 cm. In these 2 cases of congenital pseudarthrosis of both forearm bones, bone union was obtained by means of vascularized fibular graft.

[Finger replantation after 60 years of age. Apropos of 7 cases]. / Replantation digitale après 60 ans. A propos de sept cas.

The authors analysed retrospectively 7 cases of digital replantation in 7 men aged from 60 to 71 years, performed between 1985 and 1996. There were 2 amputations of the thumb, 1 of the index, 2 of the middle finger, 1 of the fourth and 1 of the fifth finger. 4 failures of replantation were noted. These 4 failures always concerned amputations of long digits by a circular saw with associated complex multidigital injuries of bad prognosis and in combination with a poor vascular status. We had 3 successful results: the 2 amputations of the thumb and the ring finger of the auricular. All these 3 patients recovered a good hand function. We found some common characteristics in this group of patients: excellent general condition, non smoker, good motivation and cooperation, injury of one digit, clear amputation (except the ring finger), correct conservation of the amputated part. The advanced patient's age does not represent a contraindication for digital replantation. The injury mechanism and the general condition of the patient represent major criteria of prognosis. In favourable circumstances, a good functional result can be expected.

Long-term results of unconstrained Roper-Tuke total elbow arthroplasty in patients with rheumatoid arthritis.

We evaluated the long-term results of 12 unconstrained Roper-Tuke total elbow replacements that were performed in 12 patients with rheumatoid arthritis from 1983 to 1989. The mean follow-up period was 9.5 years (range 8 to 13 years). We used the Ewald elbow-scoring system to chart results. This showed that the scores for the 12 elbows had improved from an average preoperative score of 39 points (range 17 to 72 points) to an average postoperative score of 80 points (range 45 to 97 points). The greatest improvements were in terms of pain relief, function, and range of motion. Eight elbows were free of pain by the end of follow-up. Average elbow flexion increased from 115 degrees before operation to 140 degrees after operation, and pronation and supination increased from 52 degrees to 61 degrees and 42 degrees to 71 degrees, respectively. Radiographs of the 12 elbows showed constant wear of the ulnar polyethylene with loosening of 2 ulnar components. Revision of the prosthesis was necessary in 2 elbows because of aseptic loosening. Complications included 1 subluxation, 1 supracondylar fracture, and 2 ulnar neuropathies. Despite some excellent clinical results with a follow-up of over 10 years, the authors no longer recommend the use of this kind of elbow prosthesis in patients with rheumatoid arthritis because of the high complication rate and the impossibility of adapting this implant in the event of bone loss. The authors propose a new classification of humeral bone loss that will allow for better planning of primary and revision total elbow arthroplasties.

Chronic recurrent multifocal osteomyelitis (C.R.M.O.). A case report and review of literature.

The case of an 8-year-old boy presenting two episodes of osteomyelitis of the left and right tibial diaphysis is reported. The recurrent course, the negative cultures and the symmetrical aspect of the lesions suggest the diagnosis of recurrent multifocal osteomyelitis. The location of the lesions at the middle of the diaphysis and the histological finding of predominant bone necrosis are unusual.

[Arthrodesis of the shoulder for post-traumatic palsy of the brachial plexus. Analysis of a series of 18 cases]. / L'arthrodèse d'épaule pour paralysie post-traumatique du plexus brachial. Analyse d'une série de 18 cas.

PURPOSE OF THE STUDY: In case of severe traction injuries of the supraclavicular brachial plexus in adult, the functional results of direct shoulder nerve repair are less predictable than those of the elbow. Furthermore, the surgical management of the remaining flail shoulder is still controversial. The post-operative results and the indication for shoulder arthrodesis are evaluated in this study. MATERIAL AND METHODS: Between October 1978 and January 1994, 18 gleno-humeral arthrodesis were performed on 18 patients for paralytic shoulder following brachial plexus injury. The average age at the time of operation was 25 years. A C5C6 lesion was present in 2 patients, a C5C6C7 lesion in 8 patients and a C5 to T1 lesion in the remaining 8 patients. Seven patients had a suprascapular nerve reinnervation failure. All these 18 patients recovered an active elbow flexion spontaneously or following direct nerve repair, tendon or free muscle transfer. The average delay between nerve repair and arthrodesis was 2 years and 4 months. For fixation, we always used internal fixation by screws, combined to an external fixator device in 10 cases. RESULTS: 16 patients were reviewed with an average follow-up of 6 years and 10 months (min. 6 months, max. 15 years and 8 months). Two types of complications occurred: 2 cases of gleno-humeral non-union requiring revision with bone-grafting, and 3 humeral fractures in the first 6 months after arthrodesis. The study of the arthrodesis position showed an average abduction of 25 degrees, an average flexion of 18 degrees, an average internal rotation of 22 degrees. The average motion values are 60 degrees of abduction and flexion, 14 degrees of extension, 0 degree of external rotation and 48 degrees of internal rotation. The range of motion depends closely on scapulo-thoracic muscles strength, especially the serratus anterior muscle. A flail hand primarily influences the subjective result. 14 of the 16 patients could easily reach their mouth. The average muscle shoulder strength, evaluated with the Isobex device, is 11 kg for flexion and abduction, 9 kg for adduction, 8 kg for internal rotation and 4 kg for external rotation. DISCUSSION AND CONCLUSION: Gleno-humeral arthrodesis is a reliable method for restoring shoulder function in case of brachial plexus sequellae lesion, giving more strength, but less external rotation than shoulder nerve repair.

Compression of the ulnar nerve in Guyon's canal by pseudotumoral calcinosis in systemic scleroderma.

We report one case of ulnar nerve compression in Guyon's canal due to calcium deposits in a 50-year-old woman with long standing systemic scleroderma. To our knowledge, this is the second known case. The symptoms consisted of a motor and partial sensory disturbance. Calcification of the piso-triquetral joint was prolonging into Guyon's canal, lifting its contents, and into the subcutaneous tissue of the ulnar border of the wrist. Excision of calcium deposits and of the pisiform in combination with external neurolysis of the ulnar nerve resulted in complete relief of symptoms.