Recurrent carpal tunnel syndrome: Outcomes after neurolysis and synovial flap

OBJECTIVES

If symptoms recur after primary neurolysis of the median nerve, surgical revision is required. Soltani et al. (2013) demonstrated that surgical revision with vascularized flap coverage had a higher success rate (86%) than surgical revision without a flap (75%). The aim of this retrospective study was to present clinical outcomes in 36 cases of secondary open neurolysis of the median nerve, with synovial flap in case of recurrent carpal tunnel syndrome.

METHOD

Thirty-three patients (36 hands) who had undergone secondary neurolysis of the median nerve combined with synovial flap coverage between 2012 and 2019 were selected for this study. We included only recurrent carpal tunnel syndrome cases presenting with scarring of the transverse carpal ligament or epineural fibrosis of the median nerve and with a symptom-free period of at least 3 months. The results were ranked on a 4-point scale as excellent, good, null or poor, depending on progression at last follow-up.

RESULTS

Descriptive analysis showed that 80% of patients had a positive outcome (excellent 33%, good 47%), 6% null outcome and 14% poor outcome.

CONCLUSION

This is an interesting, relatively non-invasive surgical option, and should be part of the therapeutic armamentarium for recurrent carpal tunnel syndrome in case of adherence of the nerve to the transverse carpal ligament.

Midsectional Magnetic Resonance Imaging Analysis of the Sigmoid Notch of the Distal Radioulnar Joint

Purpose  This study describes the anatomy and analyzes the variations of the midsectional morphology of the sigmoid notch. Methods  The wrists of 50 patients with suspected scaphoid fracture were evaluated by magnetic resonance imaging (MRI). Sigmoid notch length, volar and dorsal rim heights, insertion length of the volar radioulnar ligament, and Tolat morphology classification were measured on T1-weighted axial plane MRI. Ulnar variance and distal radioulnar joint (DRUJ) inclination were assessed on anteroposterior radiographs. Results  The most common sigmoid notch shapes were types C (C-shaped, 60%) and B (ski-slope, 30%), followed by types D (S-shaped, 6%) and A (flat, 4%). Types A and B had a flat dorsal rim (mean 0.77 ± 1.09 mm, range 0.0-1.54 mm, and mean 0.22 ± 0.3 mm, range 0.0-0.76 mm, respectively). Types C and D had more prominent dorsal rims (means 1.47 ± 0.59 mm, range 0.66-2.57 mm, and mean 1.6 ± 0.97 mm, range 0.8-2.68 mm, respectively). The average volar lip length was 1.60 ± 1.11 mm (range, 0.0-4.10). The dorsovolar length of the radius was 18.4 ± 2.01 mm; the length of the sigmoid notch was 14.3 ± 1.73 mm. The type of sigmoid notch according to Tolat was significantly associated with volar lip length ( p  = 0.005). The type of sigmoid notch was not associated with ulnar variance or DRUJ inclination. The length of the sigmoid notch was significantly associated with the type of sigmoid notch ( p  = 0.005). The analysis demonstrated a negative association between the sigmoid notch length and the volar insertion of the radioulnar ligament ( p  = 0.019). Conclusions  The transversal morphology of the sigmoid notch was either flat with the least congruence (similar to type A of Tolat), with volar congruence only (similar to type B), or with volar and dorsal congruence (similar to types C and D). A shorter sigmoid notch may be compensated by a broader insertion of the volar radioulnar ligament. Clinical Relevance  The measurements and correlations demonstrated in this study can be a guide when considering reconstructive procedures or dealing with the instability of the DRUJ.

The influence of sagittal deformity of the distal radius on pronosupination: a cadaver study

We performed a cadaver study using seven fresh-frozen adult upper limbs to assess the impact of increasingly larger distal radial deformity in the sagittal plane on the range of motion in pronation/supination. Three palmar (20°, 30° and 40° angulations) and three dorsal (10°, 20° and 30° angulations) tilt deformities, without any radial shortening, were simulated by performing a radial osteotomy and using custom-made three-dimensional-printed anterior plates. We measured the maximum unconstrained pronation and supination before the osteotomy and after each induced deformation. There was a decrease in the median pronation and supination values for all palmar and dorsal tilt deformities. The pronation range was more impaired than the supination range, and dorsal tilt deformities caused the greatest loss in forearm rotation. Our results suggest that forearm rotation in both pronation and supination is reduced as soon as 10° to 20° distal radial deformity occurs in the palmar or dorsal direction.

Perioperative Morbidities in Distal Radius Fractures Treated Using Locking Plates in the Super-Elderly Population: A Retrospective Study

Purpose

Currently, there is no consensus on the treatment of distal radius fractures in the super-elderly population. The aim of this study was to evaluate the perioperative morbidities and the need for rehabilitation care after a distal radius fracture treated with locking plates among patients aged 85 years or older.

Methods

A retrospective study was conducted in all patients aged 85 years or older who underwent open surgical treatment using a locking plate for an isolated distal radius fracture from January 2013 to December 2018 at a level 1 trauma center. The occurrence of minor complications (tendinopathy, neuropathy, carpal tunnel syndrome, and infection), major complications (complex regional pain syndrome, nonunion, loss of reduction, intra-articular screw, and hardware failure), and the need for revision surgery were recorded. The need and timing of rehabilitation were also documented. A nested case-control study was performed to evaluate predictive factors associated with the need for inpatient rehabilitation.

Results

The majority of fractures were AO type A, numbering 88 (55.7%), followed by 64 type C (40.5%), and then 6 type B (3.8%). The overall complication rate among the 158 included patients was 17% (n = 26), with 12 (7.6%) having minor complications and 14 (8.9%) having major complications. Inpatient rehabilitation was required for one-third of the patients (n = 59), and 11 (7%) were definitively discharged to a nursing home. The place of residence before the fracture, American Society of Anesthesiologist score, and the type of anesthesia were associated with a need for inpatient rehabilitation.

Conclusions

Overall, this study suggests that perioperative morbidity of distal radius fractures treated using a locking plate is acceptable even in the super-elderly population. Nevertheless, given the frequent requirement for rehabilitation, the impact of age cannot be ignored.

Type of Study/level of evidence

Therapeutic IV.

Ulna hook plate osteosynthesis for ulna head fracture associated with distal radius fracture

Background

Distal ulna head or neck fracture is commonly associated with distal radius fracture. Treatment of these fractures remains controversial. Plate osteosynthesis is commonly performed. The purpose of this study was to observe clinical and radiological outcomes in ulna hook plate osteosynthesis for distal ulna fracture associated with distal radius fracture.

Materials and methods

This retrospective study between 2010 and 2018 included patients presenting combined displaced distal ulna fracture and distal radius fracture who were treated with ulna hook plate osteosynthesis. Patient evaluation included pain measurement with the visual analog scale, wrist range of motion, grip and pinch strengths, Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score, and Mayo wrist score. Preoperative radiographs were reviewed to classify the distal ulna fracture according to Biyani. Bone union was evaluated on postoperative X-rays. At final follow-up, the usual radiographic parameters were measured and distal radioulnar joint (DRUJ) osteoarthritis was assessed.

Results

A total of 48 patients were included. Mean age was 63 years old and mean follow-up was 28 months. According to the Biyani classification, there were 12 type I, 4 type II, 8 type III, and 24 type IV distal ulna fractures. Wrist flexion was 60°, extension 57°, pronation 85°, and supination 80°. Grip strength was 21 kg (86% of the uninjured opposite side). Pinch strength was 6.6 kg (92% of the uninjured opposite side). Clinical scores were very good to excellent, with a mean Q-DASH of 12 and a Mayo wrist score of 90. Discomfort or pain due to the implant that required implant removal was reported in 29%, and was higher in younger patients. Nonunion was observed in two cases and secondary implant displacement in one case. These three cases required secondary intervention with ulna head resection, which was higher in Biyani type IV. DRUJ osteoarthritis was observed in 12 patients (31%) and was higher in older patients.

Conclusions

Ulna hook plate fixation gives good clinical results and a high rate of fracture union, but complications are common. Implant irritation is a frequent complication, especially in young patients, and often requires implant removal.

Level of evidence: IV

Mid-term Outcomes of Treatment of Fracture Dislocation of the Proximal Interphalangeal Joint with Gexfinger®-A New Dynamic External Fixator

Background: Fracture dislocations of the proximal interphalangeal joint (PIPJ) are challenging injuries and a dynamic external fixator frame is often used. We devised a dynamic external fixator device called the Gexfinger^® that allows greater control of the degree of traction. The aim of this study is to report the mid-term outcomes of this device. Methods: This is a retrospective study of patients with fracture dislocation of the PIPJ who were treated with the Gexfinger^® over a 3-year period. Clinical data with regard to the patient, the injury, treatment and period of follow-up were recorded. The outcome measures included time to return to work, arc of motion at the interphalangeal joints, grip strength, visual analogue score (VAS) for pain, patient satisfaction and complications. Results: We studied 26 patients (17 men and 9 women) with an average age of 38 years. The average articular surface involvement was 56%. The mean period between injury and surgery was 6 days and the frames were maintained for 5.5 weeks on average. The mean follow-up period was 8.5 weeks. All patients returned to work at an average of 7 weeks. The mean arc of motion at the PIPJ and distal interphalangeal joint (DIPJ) were 82° and 65°, respectively and the mean grip strength was 83% of the contralateral side. 22 patients reported no pain at the final follow-up. Fifteen patients were very satisfied, 8 satisfied and 3 unsatisfied. Two patients had stiffness of the PIPJ. Conclusions: The mid-term outcomes of the Gexfinger^® are similar to other methods of dynamic traction described in literature. It is modular, easy to assemble and allows a greater control of the degree of traction. In combination with additional screws and/or K-wires, it has allowed us to treat a wide spectrum of PIPJ fracture dislocations with good outcomes. Level of Evidence: Level IV (Therapeutic).

Comparison of simulated key pinch after three surgical procedures for trapeziometacarpal osteoarthritis: a cadaver study

We performed a cadaver study using 18 fresh-frozen adult forearms and hands to compare the tendon loads required to generate progressively greater key pinch (0.5 kg to 2 kg) after three different surgical procedures to treat trapeziometacarpal osteoarthritis: isolated trapeziectomy, trapeziectomy followed by ligament reconstruction with tendon interposition and total joint arthroplasty using a Touch® implant. Thumb pinch was simulated by loading the main actuator tendons involved in the key pinch. Six specimens were randomly assigned to each of the three surgical procedure groups. Measurements were made before and after the joint surgery. Specimens that underwent trapeziectomy with or without ligament reconstruction with tendon interposition required significantly higher tendon loads than those with the implant to achieve the same pinch force. There was no significant difference between the isolated trapeziectomy and ligament reconstruction groups. Using the implant resulted in similar median tendon loads compared with those of the intact sample. Total joint arthroplasty with a Touch® prosthesis may yield a superior biomechanical profile in which the tendon loads needed to achieve a certain key pinch force are lower and better distributed between the actuator muscles compared with trapeziectomy with or without ligament reconstruction.

[Long fingers proximal interphalangeal joint trauma]

Sprains and dislocations of the proximal interphalangeal joint (PIP) are very common but are, nevertheless, often missed. They require an appropriate treatment to prevent stiffness and deformities. Initial assessment should include anteroposterior and true lateral radiographs. Intra-articular fractures are referred to the specialist. Clinical examination to detect laxity is essential and will guide the treatment. The treatment is based on the restoration of joint congruency and achieving early mobilization. Surgical indication is rare. The evolution is slow, pain and joint swelling can persist up to one year and definitive complications are not excluded.

[Sport wrist ligament injuries]

The wrist is a joint structure particularly exposed during sports practice to trauma or overuse. Ligament trauma is particularly common as well as tendinopathies. A rigorous clinical examination is the key to the management of the sports patient. The additional examinations will confirm the diagnosis and help guide the management. The purpose of the treatment in the athlete will depend on his sports activity, his age, the sport, the time between the accident and the sports season.

[Diagnosis of athlete's elbow injuries]

The elbow joint is highly congruent and subject to less stress than other joints. This contributes to a rather low incidence of pathologies in the general population. However, in athletes who perform repeated movements with supraphysiological forces, diverse pathologies may appear. The objective of this article is to develop an anatomopathological approach to elbow pain in order to identify its origin. A rapid and precise diagnosis allows initiating an adequate treatment and minimizing time of sporting activity arrest.

[Radiology of the hand and wrist for the general practicioner]

The management of many traumatic conditions of the hand and wrist can be done or at least initiated by the primary care physician, often the first actor of the scenario. To do so, he must first have performed a correct reading of X-rays made with specific incidences to the suspected pathology. This article reviews the radiological diagnosis of the most common pathologies in hand and wrist traumatology to facilitate interpretation by general practitioners.

Ultrasound of the ulnar-palmar region of the wrist: normal anatomy and anatomic variations

Ultrasound (US) assessment of the wrist is frequently used for the evaluation of carpal tunnel due to high frequency of local compression of the median nerve (MN), but the ulnar-palmar wrist region (UPWR) has received limited attention in the medical literature. The possibilities of US in the assessment of UPWR are therefore likely underestimated by sonologists. This review article is focused on the US assessment of the normal anatomy and anatomic variations of the UPWR. The anatomy of this region of the wrist is complex and less studied than the radial side. In an effort to simplify it and to present it didactically, we have divided this region in three parts on the basis of osseous landmarks. Our review indicates sonography is effective in identifying the UPWR and related disorders, and is thus a valuable tool for ensuring appropriate management of a variety of disorders.

Carpal Collapse After Scaphoid Nonunion: A Novel Combined Approach to the 1,2 Intercompartmental Supraretinacular Artery Radial Flap

Purpose

Scaphoid nonunion remains a major problem in hand surgery. The 1,2 intercompartmental supraretinacular artery flap (1,2 ICSRA), as first described by Zaidemberg et al, is widely used with reported union rates of approximately 80%. However, its use is limited in the case of associated carpal collapse as in dorsal intercalated segmental instability (DISI) and humpback deformity. In this study, we present a novel approach to this flap enabling the correction of associated carpal collapse.

Methods

Between 2006 and 2015, 9 patients with scaphoid nonunion or delayed union with carpal collapse were treated with a vascularized bone flap based on the 1,2 ICSRA using a combined volar and dorsal approach. Immobilization in a short-arm cast was applied for 8 weeks. Union rates, correction of DISI and humpback deformity, as well as clinical end points were noted. In addition, scapholunate (SL) angles were measured using 2 accepted radiological techniques, employing either the scaphoid midline axis or its proximal radiological landmarks as a reference.

Results

All cases united and a median time to bone consolidation of 4 months (range, 2–5 months) was observed. Preoperative DISI deformities (n = 4) were corrected in all patients. Humpback deformities (n = 5) were also corrected. Two patients had repeat surgery: one for K-wire removal after bony consolidation and the other for neuropathic pain.

Conclusions

The 1,2 ICSRA bone flap is a reliable treatment for scaphoid nonunion associated with carpal collapse. This combined volar and dorsal approach permits the correction of DISI and humpback deformity without compromising the scaphoid vascular supply, which eliminates the need to use free bone flaps from other sites. In this series, we observed a 100% union rate. Two patients required reoperation for symptomatic hardware and dorsal wrist pain linked to superficial neuritis.

Type of study/level of evidence

Therapeutic IV.

Ultrasound of local complications in hand surgery: a pictorial essay

Early detection of local complications (venipuncture complications, nerve lesions, infections, arthritis, and tenosynovitis, tendon adhesions and re-tears, complications related to orthopaedic hardware) after hand surgery is required for prompt treatment. Ultrasound has proven to be a valuable imaging modality for detecting and assessing a variety of disorders of the wrist and hand. The purpose of this pictorial essay is to present a wide range of complications after wrist and hand surgery assessed by ultrasound.

Two weeks versus four weeks of antibiotic therapy after surgical drainage for native joint bacterial arthritis: a prospective, randomised, non-inferiority trial

Objective

The optimal duration of postsurgical antibiotic therapy for adult native joint bacterial arthritis remains unknown.

Methods

We conducted a prospective, unblinded, randomised, non-inferiority study comparing either 2 or 4 weeks of antibiotic therapy after surgical drainage of native joint bacterial arthritis in adults. Excluded were implant-related infections, episodes without surgical lavage and episodes with a follow-up of less than 2 months.

Results

We enrolled 154 cases: 77 in the 4-week arm and 77 in the 2-week arm. Median length of intravenous antibiotic treatment was 1 and 2 days, respectively. The median number of surgical lavages was 1 in both arms. Recurrence of infection was noted in three patients (2%): 1 in the 2-week arm (99% cure rate) and 2 in the 4-week arm (97% cure rate). There was no difference in the number of adverse events or sequelae between the study arms. Of the overall 154 arthritis cases, 99 concerned the hand and wrist, for which an additional subgroup analysis was performed. In this per-protocol subanalysis, we noted three recurrences: one in the 2-week arm (97 % cure); two in the 4-week arm (96 % cure) and witnessed sequelae in 50% in the 2-week arm versus 55% in the 4-week arm, of which five (13%) and six (13%) needed further interventions.

Conclusions

After initial surgical lavage for septic arthritis, 2 weeks of targeted antibiotic therapy is not inferior to 4 weeks regarding cure rate, adverse events or sequelae and leads to a significantly shorter hospital stay, at least for hand and wrist arthritis.

Trial registration number

NCT03615781.

Heartbeat-enhanced immersive virtual reality to treat complex regional pain syndrome

Objectives

To develop and test a new immersive digital technology for complex regional pain syndrome (CRPS) that combines principles from mirror therapy and immersive virtual reality and the latest research from multisensory body processing.

Methods

In this crossover double-blind study, 24 patients with CRPS and 24 age- and sex-matched healthy controls were immersed in a virtual environment and shown a virtual depiction of their affected limb that was flashing in synchrony (or in asynchrony in the control condition) with their own online detected heartbeat (heartbeat-enhanced virtual reality [HEVR]). The primary outcome measures for pain reduction were subjective pain ratings, force strength, and heart rate variability (HRV).

Results

HEVR reduced pain ratings, improved motor limb function, and modulated a physiologic pain marker (HRV). These significant improvements were reliable and highly selective, absent in control HEVR conditions, not observed in healthy controls, and obtained without the application of tactile stimulation (or movement) of the painful limb, using a readily available biological signal (the heartbeat) that is most often not consciously perceived (thus preventing placebo effects).

Conclusions

Next to these specific and well-controlled analgesic effects, immersive HEVR allows the application of prolonged and repeated doses of digital therapy, enables the automatized integration with existing pain treatments, and avoids application of painful bodily cues while minimizing the active involvement of the patient and therapist.

Classification of evidence

This study provides Class III evidence that HEVR reduces pain and increases force strength in patients with CRPS.

Morphological Associations between the Distal Radioulnar Joint and the Lunate

Background  Variations in morphology of the carpal bones have been described. Their implication in wrist disease and specific kinematic features has been recognized, and a better knowledge of these variations is essential. Questions/Purpose  To radiographically determine any association between the morphological variations of the distal radioulnar joint (DRUJ) and the lunate bone. Materials and Methods  Radiographs of 100 wrists of patients presenting to the emergency department with wrist pain and referred to our outpatient clinic were retrospectively reviewed for DRUJ inclination, ulnar variance, and radiocarpal and midcarpal morphology of the lunate. Results  There were 51 females and 49 males, mean age 51.2 years (range: 21-94). There was a statistically significant association between the DRUJ inclination and the morphology of the radiocarpal side of the lunate ( p  < 0.001). The mean values of ulnar variance changed according to DRUJ inclination and the radiocarpal side of the lunate ( p  < 0.001) but not according to the midcarpal side of the lunate. There was no significant association between the morphology of the DRUJ and the midcarpal side of the lunate or between the midcarpal and the radiocarpal morphology of the lunate. Conclusion  This study demonstrated a statistically significant association at the radiocarpal level between the DRUJ inclination, ulnar variance, and the morphology of the lunate. No association was found with the morphology of the midcarpal side of the lunate. Accordingly, a classification of these carpal associations is proposed, highlighting seven main wrist configurations. Clinical Relevance  These associations can guide future studies of wrist kinematics.

Unacceptable failure of the PI2® implant

The PI2® spacer is designed for treatment of trapeziometacarpal (TM) osteoarthritis. However, the shape of this implant has raised concerns about its stability. We retrospectively investigated 45 implants in 41 patients treated for trapeziometacarpal osteoarthritis in our hospital between 2004 and 2009 who underwent trapeziectomy and insertion of a PI2® spacer. Outcome parameters included revision rates and clinical outcomes correlated with implant position and scaphometacarpal distance, assessed using standard radiographs. A total of 12 implants (27%) were removed at a median time of 10 months (interquartile range (IQR), 7-22 months). These included five dislocations and one early infection. Additionally, a further six patients underwent revision due to persistent pain. Three of these had scapho-trapezoid osteoarthritis, two had developed subluxation of the implant, and one did not show any radiographic abnormalities. A review of patient records revealed that 33 implants remained in place at a median time of 29 months (IQR, 20-57). However, of those, only 21 implants (64%) in 17 patients were available for clinical evaluation at a median follow-up of 29 months (IQR, 19-62 months). No significant differences in clinical outcomes including functional results were observed between in-place ( n = 8) and subluxated ( n = 13) implants. Due to the high revision rate (12/45), consistent with other reports in the literature, we have abandoned the use of the PI2® spacer. We recommend the establishment of a registry for evaluation of future implants.

TYPE OF STUDY/LEVEL OF EVIDENCE

Case-series study/level IV.

Giant Cell Tumor of Bone With Pseudosarcomatous Changes Leading to Premature Denosumab Therapy Interruption

Denosumab has shown promising results in the management of giant cell tumor of bone, a primary bone tumor with locally aggressive behaviour. We report a case of premature denosumab interruption due to radiological and clinical tumor expansion of a giant cell tumor of the distal ulna. Although denosumab is known to induce tumor regression, with progressive ossification and loss of the characteristic morphology of giant cell tumor of bone, the ulnar tumor specimen showed a moderately to highly cellular proliferation of short spindle-shaped cells, and no osteoclast-like giant cells. There were no abnormal mitotic figures. We considered the surgical specimen as a giant cell tumor of bone with partial regression after prematurely interrupted denosumab treatment. This case illustrates the diagnostic issues of an initially unfavourable evolution raising concern for malignancy, and the difficulties in histological assessment of a partially treated giant cell tumor of bone, that may mimic osteosarcoma.

Fifth metacarpal neck fractures treated with soft wrap/buddy taping compared to reduction and casting: results of a prospective, multicenter, randomized trial

INTRODUCTION

The majority of fifth metacarpal neck fractures (boxers fracture) are treated conservatively without surgery. The purpose of this prospective, randomized, multicenter trial was to determine if the outcomes of soft wrap and buddy taping (SW) was noninferior to reduction and cast (RC) in boxer's fracture with palmar angulation ≤70° and no rotational deformity.

MATERIALS AND METHODS

Sixty-eight patients with similar characteristics were prospectively enrolled and randomized at four institutions. Our primary outcome was measured by the shortened Disabilities of the Arm, Shoulder and Hand (quickDASH) questionnaire at 4 months. Noninferiority was claimed if there was no more than +10 points difference in the quickDASH. Other secondary radiographic and clinical outcomes were measured.

RESULTS

At 4 months, mean difference in the quickDASH between the two groups was -10.4 (95 % confidence interval, -27.0; +6.2) which was under the pre-specified margin. There was no significant difference between both groups' secondary outcomes of pain, satisfaction with the esthetic appearance, mobility of the metacarpophalangeal-joint at flexion and extension, or power grip. Increased fracture angulation, as measured on follow-up radiographs, was not significantly different between both groups. The degree of palmar fracture angulation was not related to work leave or profession. Duration of time off from work was 11 days shorter in SW compared to RC (P = 0.03).

CONCLUSION

This study supports the use of soft wrap and buddy taping for treatment of boxer's fracture with palmar angulation ≤70° and no rotational deformity. Although there was no statistical difference in satisfaction with the esthetic appearance, the patient must be willing to accept the loss of the "knuckle" with this treatment method.

Third degree formic acid chemical burn in the treatment of a hand wart: a case report and review of the literature

Objective

Cutaneous warts are very common and a large variety of topical treatments and drugs can be employed to cure these skin injuries that can arise on any part of the body. But are these products really safe?

Method

We performed a case description and PubMed literature review using key words “wart,” “chemical burn,” and “formic acid.” All articles in English and French were selected.

Results

This is the first report of a chemical burn by formic acid in the treatment of warts. Numerous topical treatments for cutaneous warts are available with many new drugs appearing every year. However, only a few treatments have proven their effectiveness, such as salicylic acid or cryotherapy with liquid nitrogen that are commonly used. Moreover, most cutaneous warts will resolve spontaneously without any treatment and several products, including topical acids and cryotherapy devices, presented adverse effects such as chemical burns or frostbites so demonstrating that even frequently used treatments can be harmful.

Conclusion

Topical treatments used for wart removal are not without risk even if some products are sold without prescription. For self-treatment products, we recommend enhanced warning by the pharmacist about the risks involved.

Review of the principal extra spinal pathologies causing sciatica and new MRI approaches

In this paper we illustrate the principal extraspinal pathologies causing sciatica and new approaches for the study of structures such as the lumbosacral plexus (LSP). Visualisation of the LSP in its entirety is difficult with conventional two-dimensional MRI sequences owing to its oblique orientation. In our institution, we have found that the utilisation of three-dimensional short tau inversion-recovery sampling perfection with application-optimised contrasts using different flip angle evolutions sequence is helpful, allowing multiplanar and maximum intensity projection reconstructions in the coronal oblique plane and curvilinear reformats through the plexus. Diffusion tensor imaging enables the observation of microstructural changes and can be useful in surgical planning. The normal anatomy of the LSP, its different extraspinal pathologies and differential diagnoses are thoroughly presented.

Occult fractures of the scaphoid: the role of ultrasonography in the emergency department

OBJECTIVE

To evaluate ultrasonography (US) performed by an emergency radiologist in patients with clinical suspicion of scaphoid fracture and normal radiographs.

MATERIALS AND METHODS

Sixty-two consecutive adult patients admitted to our emergency department with clinical suspicion of scaphoid fracture and normal radiographs underwent US examination of the scaphoid prior to wrist computed tomography (CT), within 3 days following wrist trauma. US examination was performed by a board-certified emergency radiologist, non-specialized in musculoskeletal imaging, using the linear probe (5-13 MHz) of the standard sonographic equipment of the emergency department. The radiologist evaluate for the presence of a cortical interruption of the scaphoid along with a radio-carpal or scapho-trapezium-trapezoid effusion. A CT of the wrist (reference standard) was performed in every patient, immediately after ultrasonography. Fractures were classified into two groups according to their potential for complication: group 1 (high potential, proximal or waist), group 2 (low-potential, distal or tubercle).

RESULTS

A scaphoid fracture was demonstrated by CT in 13 (21%) patients: eight (62%) of them belonged to group 1 (three in the proximal pole, five in the waist), five (38%) to group 2 (three in the distal part, two in the tubercle). US was 92% sensitive (12/13) in demonstrating a scaphoid fracture. It was 100% sensitive (8/8) in demonstrating a fracture with a high potential of complication (group 1).

CONCLUSIONS

Our data show that, in emergency settings, US can be used for the triage to CT in patients with clinical suspicion of scaphoid fracture and normal radiographs.

Investigation of radialization and rerouting of the extensor digiti minimi (EDM) in the abduction deformity of the little finger: a cadaver study

BACKGROUND

One of several operations to correct abduction deformity of the little finger, (Wartenberg's sign) in ulnar nerve palsy, is a combined procedure that radializes the extensor digiti minimi (EDM) at the level of the fifth metacarpophalangeal (MCP) joint and reroutes it from the fifth to fourth extensor compartment. This cadaveric study was designed to investigate the impact of both elements on adduction.

MATERIALS AND METHODS

Anatomy of the little finger extensor apparatus was studied in 16 freshly frozen cadaver hands sectioned at mid forearm. We observed little finger motion after different modifications of the EDM. We tested the effect of a rerouting maneuver by pulling on the EDM, as well as radialization of the EDM alone and in combination with rerouting.

RESULTS

The EDM was present in all cases. Little finger extensor digitorum communis (EDC(V)) was missing in two cadavers. In no case was adduction created by rerouting the EDM to the fourth compartment. Radialization of the EDM corrected the abduction deformity beyond the axis of abduction/adduction of the fifth MCP joint in 13 cases and only up to it in three cases. In one of the three with limited correction, a rerouting maneuver allowed for further adduction.

CONCLUSION

The key to correct abduction deformity of the little finger is radialization of the EDM, which can be done through a solitary incision at the level of the MCP joint. Rerouting alone does not correct the abduction deformity, and in combination with radialization it does not predictably enhance the correction.

Cerebral plasticity in crossed C7 grafts of the brachial plexus: an fMRI study

In order to rescue elbow flexion after complete accidental avulsion of one brachial plexus, seven patients underwent a neurotization of the biceps with fibers from the contralateral C7 root. The C7 fibers used for the graft belonged to the pyramidal pathway, which descends from the cerebral hemisphere ipsilateral to the damaged plexus, and which controls extension and abduction of the contralateral arm. After several months of reeducation, a functional magentic resonance imaging study was performed with a 1.5 tesla clinical magnetic resonance scan system, in order to investigate the central neural networks involved in the recovery of elbow flexion. Functional brain images were acquired under four conditions: flexion of each of the two elbows, and imagined flexion of each elbow. Results show that flexion of the neurotized arm is associated with a bilateral network activity. The contralateral cortex originally involved in control of the rescued arm still participates in the elaboration and control of the task through the bilateral premotor and primary motor cortex. The location of the ipsilateral clusters in the primary motor, premotor, supplementary motor area, and posterior parietal areas is similar among patients. The location of contralateral activations within the same areas differs across patients.

Preliminary Results of Double Nerve Transfer to Restore Elbow Flexion in Upper Type Brachial Plexus Palsies

BACKGROUND

Restoration of elbow flexion is the main objective in the treatment of brachial plexus palsies affecting the upper roots. Transfer of the ulnar nerve to the nerve of the biceps has given satisfactory results, but the restored biceps is often weak in cases with avulsions of the C5-C6-C7 roots, in elderly patients, and after long preoperative delays. The authors decided to investigate a double nerve transfer: one or more fascicles of the ulnar nerve to the nerve to the biceps and a fascicle of the median nerve to the motor branch to the brachialis muscle.

METHODS

The authors operated on 15 patients using this technique. The authors have follow-up of more than 6 months in 10 of them. Six had C5-C6 injuries, three had C5-C6-C7 palsies, and one had sustained an infraclavicular injury. The average age was 27.2 years. The average delay before surgery was 6.6 months. The average follow-up was 12.1 months.

RESULTS

Grade 4 elbow flexion was restored in each of the 10 patients. In 10 cases, the patients were able to lift 1 to 5 kg. There was no secondary deficit in grip strength or sensation.

CONCLUSIONS

The results of this technique compare favorably with those of other methods. The percentage of success and the strength of elbow flexion restored were increased without any morbidity. This technique will probably reduce the need for secondary procedures to augment elbow flexion. The authors propose double nerve transfer as a standard procedure in C5-C6 and C5-C6-C7 injuries.