[Severe and complex traumatic hand]

SEVERE AND COMPLEX TRAUMATIC HAND . Serious and complex traumatic injuries of the hand are multiple tissue injuries (skin, vascular, bone and nerves), requiring urgent surgical management. They are responsible for significant functional and aesthetic sequelae. Their incidence is clearly decreasing thanks to information, prevention and security measures. The absolute emergencies are injections under pressure, amputations-devascularizations, and serious mutilations. The objective of the management is to make a functional and aesthetic hand: restoration of the opposition of the thumb with a key-pinch, a sufficient length thumb, and restoration of the sensitivity of the reconstructed hand. This calls for numerous surgical and microsurgical techniques and must be undertaken by trained teams in specialized centers.

[Hand infections]

HAND INFECTIONS. Hand and finger infections are very common. They result from the inoculation of a germ through the skin barrier. They can range from simple paronychia to extremely serious necrotizing fasciitis. Certain infections, such as those resulting from bites, have their own specific characteristics, which will determine how they are managed. While management can be medical in the early stages, it is important not to ignore the need for surgical treatment, otherwise serious complications may arise, leading to functional and aesthetic sequelae. Delays in treatment cannot be made up. Any infectious lesion can be potentially serious and must be treated in an appropriate department if there is the slightest doubt.

Comparison of clinical outcomes of three-corner arthrodesis and bicolumnar arthrodesis for advanced wrist osteoarthritis

We retrospectively compared results of 27 wrists with bicolumnar arthrodesis with mean follow-up of 67 months to 28 wrists with three-corner arthrodesis adding triquetral excision with mean follow-up of 74 months in 54 patients (55 wrists). Minimal follow-up was 2 years for all patients. Capitolunate nonunion occurred in three wrists with bicolumnar arthrodesis and six wrists with three-corner arthrodesis, and radiolunate arthritis developed in four wrists with three-corner arthrodesis. Among patients with bicolumnar arthrodesis, hamatolunate arthritis occurred in seven wrists, all with a Viegas type II lunate; and pisotriquetral arthritis occurred in three wrists. At mean 5 years after surgery, 45 wrists had not needed revision surgery, and both groups had similar revision rates. The wrists with three-corner arthrodesis and bicolumnar arthrodesis had similar functional outcomes, and range of wrist motion was not significantly different between the two groups. We concluded that bicolumnar arthrodesis results in greater longevity than three-corner arthrodesis for a type I lunate. We do not recommend bicolumnar arthrodesis for type II lunate. We also concluded that three-corner arthrodesis has a greater incidence of radiolunate arthritis and capitolunate nonunion.Level of evidence: III.

Arthrodesis Versus Carpometacarpal Preservation in Key-Grip Procedures in Tetraplegic Patients: A Comparative Study of 40 Cases

PURPOSE

Constructing a lateral key pinch (KP) is a universal aim of any functional upper limb surgery program for tetraplegia. Three stages are required: (1) activating the pinch mechanism by flexor pollicis longus tenodesis to the radius or by tendon transfer to the flexor pollicis longus, (2) simplifying the polyarticular chain, and (3) positioning the thumb column. We compared 2 techniques for accomplishing the latter stage, 1 utilizing arthrodesis of the carpometacarpal joint (CMC) and 1 that did not require arthrodesis of the CMC.

MATERIALS AND METHODS

We reviewed 40 cases of KP reconstruction at a mean follow-up of 7.4 years: 17 who had undergone CMC arthrodesis and 23 without CMC arthrodesis. In this group, an abductor pollicis longus tenodesis was necessary to properly position the thumb column in 17 patients.

RESULTS

Active KP cases with CMC arthrodesis were significantly stronger than those without an arthrodesis. For passive KP cases, the difference between those cases with CMC arthrodesis and those without was not significant. Regarding opening, for active KP cases with CMC preservation alone, the mean distance between the thumb pulp and the index finger was 4.0 cm at rest and 5.8 cm when passively grasping large objects; for active KP cases without arthrodesis, these values were 3.4 and 6.8 cm, respectively, with the wrist in flexion. For passive KP cases, these values were 2.2 and 3.5 cm with CMC arthrodesis compared with 2.4 and 6.9 cm without arthrodesis. Overall, 23.5% of patients with CMC arthrodesis could not maintain contact between the thumb and the index finger compared with 30.4% without arthrodesis.

CONCLUSIONS

Active KP is stronger with than without CMC arthrodesis; however, the KP reconstruction does not open as far when grasping large objects. For passive KP, CMC arthrodesis significantly limits passive opening, with no gain in strength. Neither technique is superior in terms of KP stability.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Nerve stress during reverse total shoulder arthroplasty: a cadaveric study

BACKGROUND

Neurologic lesions are relatively common after total shoulder arthroplasty. These injuries are mostly due to traction. We aimed to identify the arm manipulations and steps during reverse total shoulder arthroplasty (RTSA) that affect nerve stress.

METHODS

Stress was measured in 10 shoulders of 5 cadavers by use of a tensiometer on each nerve from the brachial plexus, with shoulders in different arm positions and during different surgical steps of RTSA.

RESULTS

When we studied shoulder position without prostheses, relative to the neutral position, internal rotation increased stress on the radial and axillary nerves and external rotation increased stress on the musculocutaneous, median, and ulnar nerves. Extension was correlated with increase in stress on all nerves. Abduction was correlated with increase in stress for the radial nerve. We identified 2 high-risk steps during RTSA: humeral exposition, particularly when the shoulder was in a position of more extension, and glenoid exposition. The thickness of polyethylene humeral cups used was associated with increased nerve stress in all but the ulnar nerve.

CONCLUSION

During humeral preparation, the surgeon must be careful to limit shoulder extension. Care must be taken during exposure of the glenoid. Extreme rotation and oversized implants should be avoided to minimize stretch-induced neuropathies.

[Extra-articular distal radius fractures in young adults]

Extra-articular distal radius fractures in young active patients are typically the result of sport injuries or traffic accidents. Displaced fractures are less well tolerated in young patients than in older people, especially in terms of dorsal tilt and radial shortening. Non-surgical treatment is only indicated when the fracture is minimally or not displaced. No fracture fixation method is superior to another, however, the treatment goal is a rapid return to previous activities.

The effect of the anatomy of the distal humerus and proximal ulna on the positioning of the components in total elbow arthroplasty

Determining and accurately restoring the flexion-extension axis of the elbow is essential for functional recovery after total elbow arthroplasty (TEA). We evaluated the effect of morphological features of the elbow on variations of alignment of the components at TEA. Morphological and positioning variables were compared by systematic CT scans of 22 elbows in 21 patients after TEA. There were five men and 16 women, and the mean age was 63 years (38 to 80). The mean follow-up was 22 months (11 to 44). The anterior offset and version of the humeral components were significantly affected by the anterior angulation of the humerus (p = 0.052 and p = 0.004, respectively). The anterior offset and version of the ulnar components were strongly significantly affected by the anterior angulation of the ulna (p < 0.001 and p < 0.001). The closer the anterior angulation of the ulna was to the joint, the lower the ulnar anterior offset (p = 0.030) and version of the ulnar component (p = 0.010). The distance from the joint to the varus angulation also affected the lateral offset of the ulnar component (p = 0.046). Anatomical variations at the distal humerus and proximal ulna affect the alignment of the components at TEA. This is explained by abutment of the stems of the components and is particularly severe when there are substantial deformities or the deformities are close to the joint.

Radial nerve palsy in surgical revision of total elbow arthroplasties: A study of 4 cases and anatomical study, possible aetiologies and prevention

BACKGROUND

Damage to the radial nerve in the arm during revision of total elbow arthroplasty is a serious complication; which is still not well documented. The aim of this study was to define a way on how to avoid this complication and to prevent it.

PATIENTS AND METHODS

Four patients underwent radial palsy after revision of total elbow arthroplasty. An anatomical study on 20 upper limbs was performed to define landmarks for the radial nerve in the arm and elbow.

RESULTS

Radial nerve damage occurred near the proximal tip of the stem in all four patients, due to cement seepage caused by cortical effraction in two patients, and to damage caused by the retractors in the two other patients. The anatomical study made it possible to specify landmarks for the radial nerve in relation to the humerus. A high-risk area located 14cm away from the tip of the olecranon fossa, and 15.5cm from the medial epicondyle, was identified.

CONCLUSION

A high-risk area for the radial nerve was defined and suggested targeted landmarks with a posterior proximal counter-incision situated at about 14cm above the olecranon fossa.

LEVEL OF EVIDENCE

IV.

Combined Treatment of Wrist and Trapeziometacarpal Joint Arthritis

Background Combined thumb basal and wrist joint arthritis (excluding scaphotrapeziotrapezoid arthritis) is rare considering the frequency of arthritis of either joint alone. Combined surgical treatment has never been described in the literature. Furthermore, the scaphoidectomy common to all interventions for Watson stage 2 or 3 wrist arthritis theoretically makes it impossible to perform a trapeziectomy for thumb basal joint arthritis. Question/Purpose The aim of this study was to present and analyze the results of two types of surgical treatment when both wrist and thumb arthritis was present. Materials and Methods Our retrospective series included 11 patients suffering from Eaton Stage III thumb basal joint arthritis and scapholunate advanced collapse (SLAC) II and III-type wrist arthritis. Five patients (group A) underwent trapeziectomy and palliative surgery for their wrist with conservation of the distal pole of the scaphoid (one proximal row carpectomy [PRC] and four four-corner fusions), and six (group B) patients had a trapeziometacarpal arthroplasty either with PRC (two cases) or four-corner arthrodesis (four cases) including total scaphoidectomy. Results The mean follow-up was 57 months. The overall visual analog scale (VAS) score for pain was 1.5 at rest, with no difference between the trapeziectomy and arthroplasty groups. The average Kapandji score was 9.3 (9 in group A and 9.5 in group B). The flexion/extension range of motion for the wrist was 64° following four-corner arthrodesis and 75° following PRC. Only one case of algodystrophy was observed. The radiological analysis revealed no complications. Discussion This study shows that thumb basal joint arthritis and SLAC type wrist arthritis may be treated by combined treatment during the same intervention without any complications. The results of palliative surgery for the wrist, either with trapeziectomy or with a trapeziometacarpal arthroplasty, are comparable. With a trapeziectomy, the distal pole of the scaphoid must be fused to the capitate to help stabilize the thumb column. Level of Evidence Level IV.

Total elbow arthroplasty: Influence of implant positioning on functional outcomes

BACKGROUND

Restoring the axis of rotation is often considered crucial to achieving good functional outcomes of total elbow arthroplasty. The objective of this work was to evaluate whether variations in implant positioning correlated with clinical outcomes.

HYPOTHESIS

Clinical outcomes are dictated by the quality of implant positioning.

MATERIAL AND METHODS

A retrospective review was conducted of data from 25 patients (26 elbows). Function was assessed using a pain score, the Disabilities of the Arm, Shoulder, and Hand (DASH) Score, and the Mayo Elbow Performance Score (MEPS). The patients also underwent a clinical evaluation for measurements of motion range and flexion/extension strength. Position of the humeral and ulnar implants was assessed by computed tomography with reconstruction using OsiriX software. Indices reflecting anterior offset, lateral offset, valgus, height, and rotation were computed by subtracting the ulnar value of each of these variables from the corresponding humeral value. These indices provided a quantitative assessment of whether position errors for the two components had additive effects or, on the contrary, counterbalanced each other. Elbows with prosthetic loosening or extensive epiphyseal destruction were excluded.

RESULTS

Of the 26 elbows, 5 were excluded. In the remaining 21 elbows, the discrepancy between the humeral and ulnar lateral offsets was significantly associated with pain intensity (P ≤ 0.05) and the MEPS (P ≤ 0.05). Anterior position of the ulna relative to the humerus was associated with decreased extension strength (P ≤ 0.05) and worse results for all functional parameters (P ≤ 0.05).

DISCUSSION

In the absence of loosening, positioning errors seem to adversely affect functional outcomes, probably by placing inappropriate stress on the soft tissues.

LEVEL OF EVIDENCE

III.

Radiocapitate congruency as a predictive factor for the results of proximal row carpectomy

PURPOSE

To evaluate whether the congruency between the joint surfaces of the lunate fossa of the distal radius and the proximal capitate might be a prognostic factor for functional, clinical, or radiographic results after proximal row carpectomy (PRC).

METHODS

After reconstructing the computed tomographic arthrogram of patients with PRC, we evaluated the shape of the proximal capitate by measuring the radius of curvature of the tip of the capitate. The congruency of the future radiocapitate joint was then evaluated by the radiocapitate index in the frontal and sagittal planes. This was calculated by dividing the radius of curvature of the tip of the capitate by the mean radius of curvature of the lunate fossa. We determined the relationship between these morphological results and the functional (Disabilities of the Arm, Shoulder, and Hand [DASH] score, Mayo Wrist score, and pain relief), clinical (mobility and strength) and x-ray results (radiocapitate arthrosis).

RESULTS

A total of 27 patients were reviewed at a mean follow-up of 59 months. The shape of the proximal capitate did not affect outcomes. In the frontal plane, a better radiocapitate congruency was significantly associated with an increase in wrist flexion and better functional results for the DASH. There was a non-significant relationship between congruency and improvement of Mayo Wrist score and pain relief. In the sagittal plane, the DASH score tended to improve when congruency was better.

CONCLUSIONS

The shape of the capitate was not a prognostic factor for functional outcome after PRC. The radiocapitate index seems more relevant in predicting results at last follow-up.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

[Dislocation of the thumb extensor tendons: an anatomical, clinical study and new classification]

The authors report on 11 cases of ulnar dislocation of the extensor pollicis longus (EPL) due to rupture of the dorsal aponeurosis at the thumb metacarpophalangeal (MCP) joint. This condition is rare. By performing a descriptive study of this injury, we were able to establish a classification system for thumb extensor tendon dislocation. The series included 11 patients with a mean age of 27years. All patients presented with either varus or rotational thumb injury. This resulted in an active extension deficit in the thumb MCP joint with EPL dislocation behind the MCP. Surgery was required in all cases. We defined three different injury presentations: 1) dissociated form with isolated EPL dislocation, but the EPB still in place; 2) complete form with dislocation of both tendons on the ulnar side of the MCP; 3) dissociated or complete form associated with a severe sprain of the lateral collateral ligament of the thumb MCP joint. The surgical treatment was adapted to each case. A classification into three types of dislocation of the extensor tendons at the MCP joint of the thumb was established. This rare condition must be identified at the time of thumb MCP joint injury and also when harvesting the EPB. This new classification system has a diagnostic and therapeutic role as it precisely describes the dislocation type and the resulting damage. Only a surgical treatment can produce good repairs.