Prognostic factors in the treatment of carpal scaphoid non-unions.

In this literature review, the authors analyse the prognostic factors in the curative treatment of scaphoid non-unions. The main negative prognostic factors are smoking, the time elapsed since the fracture, and avascular necrosis of the proximal fragment. If the latter is present, the revascularization by a pedicle or microsurgical bone autograft is probably the treatment of choice. In non-unions without evidence of osteonecrosis, vascularized bone grafts are probably not superior to conventional bone grafts, which can presently be performed under arthroscopic control, with minimal morbidity.

Flexor digitorum profundus tendon infiltration by post-traumatic hemangioma. A pediatric case.

Pediatric cases of post-traumatic hemangioma of the palm are rare. Clinical evaluation and imaging are sometimes ambiguous and surgical exploration may show more conclusive results. This case report discusses the diagnosis and treatment of a teenager with post-traumatic hemangioma infiltrating the flexor digitorum profundus tendon of the index finger. Pathologic examination revealed a lobular capillary hemangioma known as pyogenic granuloma.

[Nerve transfers]. / Les transferts nerveux.

Nerve transfers are recent surgical techniques where an unaffected nerve or part of its fascicules is transferred onto another nerve and co-apted end-to-end, or sometimes end-to-side, in order to "reanimate", sensitive or motor deficits. The technique is indicated when the proximal nerve stump has been destroyed or is of bad histological quality (brachial plexus root avulsion, or stump hidden in an extended scar), far from the target (important loss of substance), or difficult to access. Nerve transfers may be indicated for the microsurgical repair of brachial or lumbo-sacral plexus lesions, and in specific upper and lower limb peripheral nerve injuries : rupture of the axillary nerve in the quadrilateral space, irreversible lesion of the upper trunk of the brachial plexus, and in facial nerve surgery.

[Original developments of navigation techniques in traumatology]. / Développements originaux des techniques de navigation en traumatologie.

This article presents an original method for long objects modeling and two navigation applications in trauma surgery. Both concern long bone fracture treatment. Our modeling method requires only two x-ray views. The projection cones of the object are determined and their intersection is computed, providing an approached 30 model, which can be improved by adding a priori knowledge or other information. The first application concerns the control of diaphyseal fracture reduction treated by external fixation. Reference frames are fixed to the bone fragments and tracked by a 3D optical localizer, allowing the computation of their relative position. Approached 3D models of the fragments are displayed in real time according to the manipulation effected by the surgeon. The principal axes of the fragments, very useful for the fracture reduction, are also displayed. The alignment of the bone fragments is quantified by parameters provided in real time during the reduction. The second application concerns the distal locking of intra-medullary nails. A 3D model of the nail and its locking holes is built from two calibrated fluoroscopic views. The nail and the surgical tool are tracked thanks to reference frames fixed to each of them. A 3D view of these two elements is displayed in real time, guiding the surgeon in the difficult task of distal targeting. Experiments and results are presented for both applications. These techniques provide real 3D models to the surgeon during the operation, allowing precise guidance of the surgical gesture and considerable reduction of the irradiation to the patient and the surgical team.

[External fixation at the wrist and hand]. / Fixation externe au poignet et à la main.

Distraction radio-metacarpal external fixation is an excellent technique for the osteosynthesis of distal radius fractures, in particular of comminuted articular fractures. The alternative is the locked palmar plate, a more demanding technique. The published literature does not allow concluding if one method is better than the other. The other main possible indications of external fixation at the wrist are comminuted fractures of the base of the thumb metacarpal, distal radius osteotomies, and wrist arthrodeses. At the hand, external minifixation is an excellent technique of osteosynthesis. Stable bone fixation is obtained, allowing early active mobilization of the fingers. The technique is especially indicated to treat open lesions or to perform lengthening, but we use also external minifixation to treat closed fractures, to perform arthrodesis or to cure non-unions, and to maintain the length of the thumb after trapeziectomy for osteoarthrosis.

Direct Nerve Sutures in (Extended) Upper Obstetric Brachial Plexus Repair.

Background In rare, selected cases of severe (extended) upper obstetric brachial plexus palsy (OBPP), after supraclavicular exposure and distal mobilization of the traumatized trunks and careful neuroma excision, we decided to perform direct nerve coaptation with tolerable tension and immobilized the affected arm positioned in adduction and 90-degree elbow flexion for three weeks. Objectives We present our surgical technique and preliminary results in a prospective open patient series, including 22 patients (14 right and 8 left side affected) between 2009 and 2016, operated at a mean age of 8.4 months. Methods Analysis of functional results after a minimum of 18 months was conducted using the British Medical Research Council (BMRC) scale. Results All children reached 60-90° of elbow flexion and 75° of shoulder abduction at already six months after surgery. For those patients having already passed one year post surgery, the mean active shoulder abduction reached 92°, and for those who past the 18 months 124°. We discuss the actual knowledge about nerve coaptation under "reasonable" tension including its advantages and drawbacks. Conclusion This technique may be indicated in preoperatively selected cases of (extended) upper OBPP and may give good functional results.

Extensor pollicis longus entrapment in a paediatric distal radius fracture.

This paper reports the rare phenomenon of entrapment of the Extensor Pollicis Longus (EPL) tendon in a wrist fracture and reviews the literature on this injury.

Trapeziometacarpal osteoarthrosis: clinical results and sonographic evaluation of the interposed tissue after trapeziectomy and first metacarpal suspension by external minifixation at a minimal two-year follow-up.

Among the surgical options to treat trapeziometacarpal osteoarthrosis, trapeziectomy has been criticized as unable to prevent postoperative collapse of the thumb, causing painful scapho-metacarpal impingement. The implantation of an external minifixator between the first and the second metacarpals for sufficient time has been proposed to maintain the postoperative space created by the bone resection to allow the development of a resistant interposed fibrous tissue. Nineteen patients (16 women, 3 men, mean age 64.5 years) were evaluated at 3.3 years of follow-up after an unilateral trapeziectomy and first metacarpal suspension by external minifixation. Eighty-four percent of the patients were very satisfied with the operation. The mean DASH score was 27.7%, the pain 1.7/10 (Visual Analogue Scale), the opening angle of the first web 58.3° and the Kapandji opposition score 9.5/10. Sonography demonstrated the existence of a strong fibrotic interposed tissue, preventing scapho-metacarpal impingement. The mean height of the trapeziectomy space (8.4mm) was maintained upon active pinch and maximal traction on the thumb. A significant atrophy of thenar muscles was also demonstrated, except for the Abductor pollicis brevis. In conclusion, total trapeziectomy with external minifixation provides acceptable clinical results, stabilizes the base of the thumb and prevents scapho-metacarpal impingement. The study brings also important new information about the nature of the interposed tissue in the trapezial space and about the state of the thenar muscles after trapeziectomy.

Arthrodesis of the wrist with bone autograft and Hoffmann external fixation.

We report a series of 29 cases of wrist arthrodesis using a radiometacarpal half-frame or triangular Hoffmann configuration, bone autograft, and relocation of a retinacular rectangular flap under the extensor tendons to prevent adhesions. No splint or plaster cast has been used. Early active motion of the fingers was encouraged. The average duration of follow-up was 4 years. Bone healing was obtained in 27 patients after 104 days on average. All patients regained full finger movements and rotation of the forearm. Nine patients were reassessed on average 7.2 years after the arthrodesis: the VAS for pain at rest was 2.4/10, the DASH score 33/100, the grip strength 75% of the contralateral side on average.

Value of Gilliatt's pneumatic tourniquet test for diagnosis of carpal tunnel syndrome.

OBJECTIVES: In 1953, Gilliatt and Wilson described the pneumatic-tourniquet test to diagnose the carpal tunnel syndrome (CTS). It was originally carried out by inflating a brachial cuff at suprasystolic pressure, looking for the appearance of dysesthesiae; several authors later proposed to perform it at infrasystolic pressure, arguing that it would better reflect the elevated venous pressure supposed to be present in CTS. The purpose of this study was to compare both methods. METHODS: This prospective randomized controlled study included 49 patients and compared both methods to perform Gilliatt's test with more commonly used provocative tests (Tinel, Phalen, Durkan, and Weber). The following end-points were considered: typical clinical presentation, altered neurophysiological tests, abnormal ultrasound findings and early resolution of symptoms after surgical decompression. RESULTS: For all these end-points, no significant difference was observed in sensibility nor specificity, whether Gilliatt's test was performed supra- or infra-systolic. In addition, Gilliatt's test proved to have less diagnostic value than Phalen and Durkan tests for sensibility. CONCLUSION: This study did not permit to distinguish the two versions of Gilliatt's test but to open a discussion about the utility of such a test to diagnose the CTS.

Conception of a navigation system controlling diaphyseal fracture reduction treated with external fixation.

BACKGROUND: The reduction of long bone fractures treated with external fixation is usually performed with fluoroscopic images, which include several disadvantages: 2D information, distortions, and irradiation to the patient and the surgical team. This article presents a new navigation technique to control the reduction of such fractures while minimizing the irradiation. METHODS: Optically tracked markers are fixed to pins inserted into the bone fragments. These last are modelled using two initial calibrated radiographs. The models can be improved with several types of anatomical data and are displayed in real time. RESULTS: This navigation system was tested on dry bones and an anatomical specimen leg. CONCLUSIONS: This new technique allows the visualization of the fracture in real time and from any viewpoint during the reduction. Irradiation is minimized using only two X-ray images.