Acute pain after digital crushing and nicotine intoxication. Cigarettes are always a false friend. A prospective study

BACKGROUND

Nicotine addiction is a public health problem. Our hypothesis was that the degree of nicotine dependence is positively correlated with the perceived intensity of acute pain.

MATERIALS AND METHODS

A single-center prospective comparative observational study was conducted from 2019 to 2021. Patients included presented distal phalanx extra-articular trauma of less than 24hours' progression. We compared a group of smokers with a group of non-smokers. A Digital Pain Scale (DPS) was assessed at time of trauma, at first consultation, and once a day until the fifth day post-trauma. A Fagerström test was performed. The primary endpoints were the correlation between dependence and DPS and the correlation between the amount of tobacco consumed and DPS. The secondary endpoints were analgesic consumption according to Fagerström, DPS and tobacco consumption.

RESULTS

Sixty-seven patients were included: 26 smokers, 41 non-smokers. No significant correlation was found between dependence level or amount of tobacco used and DPS. Consumption of level II analgesics was significantly 2-fold higher in the smoking group on the second, third and fifth day: respectively, 2.15 tablets versus 1.22 (p=0.02), 1.27 versus 0.49 (p=0.01), and 0.69 versus 0.20 (p=0.04).

CONCLUSION

Patients who smoke are exposed to more frequent and more intense pain and consume more palliative painkillers.

LEVEL OF EVIDENCE

IIB; exposed vs. non-exposed cohort.

Comparison of results of arthroscopic arthrolysis between traumatic and degenerative elbow stiffness

INTRODUCTION

Elbow stiffness significantly affects the patient's quality of life. This joint must have at least 30°/130° extension/flexion and 50°/50° pronation/supination to function normally according to Morrey.

HYPOTHESIS

The objective of this study was to evaluate functional outcome of arthroscopic arthrolysis by comparing stiffness of post-traumatic and degenerative origin. The hypothesis was that this surgical technique allows functional improvement in any indication but with a faster result in degenerative pathology.

MATERIAL AND METHODS

This was a retrospective study including all patients who underwent elbow arthrolysis under arthroscopy, operated on by a single operator, between 2013 and 2020. Thirty-four patients were included, with a mean age of 45years (range, 18-78years). Patients were divided into two groups according to etiology. Group A (post-traumatic) consisted of 18 patients with a mean age of 33years (range, 18-64years) and group B (degenerative) of 16 patients with a mean age of 59years (range, 42-78years). All patients were clinically assessed at a mean 27months. Range of motion, level of satisfaction and Mayo Elbow Performance Score (MEPS) were collected.

RESULTS

In the overall series, preoperative range of motion was 81° and significantly improved postoperatively to 122° (p<0.001). The preoperative data of the 2 groups were comparable except for age (p<0.001) and MEPS (p=0.044). Postoperatively, range of motion improved significantly in both groups but with greater gain in group A (p=0.003). MEPS improved significantly in both groups, but the postoperative score was poorer in group B (p=0.001). Recovery of range of motion was faster in group B (2.4months) than in group A (3.7months) (p=0.021). There were 5 complications: 4 secondary decompensations of ulnar tunnel syndrome, and 1 postoperative radial nerve paresis. 94% of patients were satisfied or very satisfied with the result of surgery.

CONCLUSION

Arthroscopic arthrolysis is an effective option for post-traumatic and non-traumatic elbow stiffness. Improvement was significant in terms of both function and range of motion, with, however, better results in the post-traumatic group but results achieved more rapidly in the degenerative pathology group.

LEVEL OF EVIDENCE

IV, retrospective study.

Modeling and concepts of the Malingue plasty compared to Z-plasty

Malingue's diamond-shaped skin plasty is a random skin plasty derived from the Z-plasty. Not widely known, this technique is an alternative to fasciectomy in Dupuytren's disease. The main objective of the present study was to analyze the topographical and anatomical differences between Z-plasty and Malingue plasty in cadaveric and experimental models and the geometrical and mathematical differences in modeling, in order to determine the respective gains in length. The study was carried out in two steps. An anatomical step on a cadaveric model studied vascularization. The second step was based on inert models (latex gloves) and cadaveric models, to study the mechanical behavior of the flaps. Differences in gains in length were analyzed by Euclidean and non-Euclidean geometry. The Malingue plasty flaps showed greater vascular richness than in Z-plasty. The experimental cadaver and inert material models showed 50% length gain with a single Malingue plasty, versus 33.3% with Z-plasty. The gain decreased in multiple plasties: respectively, 25% and 17.5% with double plasty and 20% and 16.7% with triple plasty. The analysis of Euclidean plane geometry did not explain these results, whereas 3D analysis on non-Euclidean geometry can explain a superior elongation effect in the Malingue plasty. The Malingue plasty could be an interesting option when significant lengthening is required, especially when Z-plasty would be insufficient.

Septic arthritis of the fingers: is short-term oral antibiotic therapy appropriate?

The management of septic arthritis of the hand is poorly described and there is no consensus. It is based on how septic arthritis of the large joints is managed, despite certain specificities related to the hand, typically involving inpatient management and intravenous antibiotic therapy. The primary objective of this work was to evaluate our postoperative protocol for the management of septic arthritis of the hand with short-term antibiotic therapy. The secondary objective was to determine the risk factors for treatment failure. We conducted a retrospective, descriptive, single-center study and analyzed the medical records of patients managed for septic arthritis of the fingers over a 1-year period from January 2018 to December 2018. We collected patient demographics and all pre-, intra-, and postoperative data. A total of 128 patients were included. The median age was 52.4 years (41-66). An exogenous source of contamination was reported in 98% of cases (animal bite, plant thorn, wound, cyst trituration, etc.). The most frequently isolated microorganism was Staphylococcus aureus (45%), followed by Streptococcus spp. (22%) and Pasteurella spp. (18%). The vast majority of patients (79%) were treated with oral amoxicillin/clavulanic acid. This treatment was continued in 91% of patients after microbiological results were obtained for a median treatment duration of 8 days (7-15). Nine percent of patients failed treatment. The risk factors identified were crush wounds (p = 0.04), initial radiological abnormalities (chondrolysis and/or osteolysis) (p = 0.016) and infection with Pasteurella spp. (p = 0.015). Our study suggests that simplified antibiotic therapy is feasible for the management of septic arthritis of the hand with short duration, broad spectrum oral antibiotics in the absence of identified risk factors.

Preiser's disease or avascular osteonecrosis of the scaphoid: An updated literature review

Avascular necrosis of the scaphoid, often referred to as Preiser's disease, is little known despite the scaphoid being the second most frequently involved location in avascular pathology of the carpal bones after the lunate (Kienböck's disease). Nonetheless, very few cases have been reported in the medical literature over the last century. Its pathophysiology is not completely elucidated although the unique vascularization of the scaphoid and several risk factors seem to be recurrently incriminated. Two new classifications based on modern imaging have appeared in the last decade and are now considered essential supplements to Herbert and Lanzetta's original radiographic classification. Because of the lack of formal treatment guidelines, a wide range of different treatments have been explored over time, contributing to the confusion around this pathology. Adding to this confusion, are the numerous terms used to designate the condition and lack of knowledge concerning its pathophysiology, risk factors, clinical and radiographic presentation. The aim of this review is therefore to explore and clarify Preiser's disease in terms of history, terminology, pathophysiology, clinical considerations and imaging and to propose a simple updated treatment algorithm based on the results provided by a thorough review of literature (53 publications, 170 patients) since Georg Preiser's original and controversial description in 1910.

Revision of Arpe® trapeziometacarpal prosthesis by isolated head and linear exchange in five patients

With the increase in the number of trapeziometacarpal arthroplasties being done, the indications for revision due to implant wear will also increase significantly in the coming years. Isolated linear exchange in the context of polyethylene wear without osteolysis or loosening of the implants is already well known in the case of hip arthroplasty. This revision option offers the advantages of less morbidity, faster recovery, and bone preservation. We retrospectively reviewed five patients who underwent trapeziometacarpal revision with isolated polyethylene liner exchange. Revision surgery was performed an average of 17.6 years (10.7-21.3 years) after the primary arthroplasty procedure. The indication for revision was dislocation in four cases and prophylactic revision for wear and limited osteolysis of the cavity in the other case. Mean follow-up was 48.7 months (36-60). One patient had a recurrent dislocation 4 years after revision and required another revision where only the cup was changed. The other patients had no instability, and no complications were reported. The mean QuickDASH score was 11.9 (4.5-15.9). Pinch strength was 102% (90-120) and grip strength was 92% (70-110) relative to the opposite side. Radiological evaluation showed no abnormalities at the last follow-up. Trapeziectomy is often the solution of choice in the surgical revision of arthroplasties. Unipolar revision of the cup has the risk of trapezium fracture, especially when the cup is well integrated. The technique we report here preserves bone and simplifies the surgical procedure with outcomes corresponding to those of primary arthroplasty. Isolated exchange of the polyethylene liner is a relevant option in the revision of trapeziometacarpal arthroplasty with good short-term results.

Benefits of a collagen membrane for recurrent ulnar nerve entrapment at the elbow: A series of 40 cases

The rate of failure or recurrence after ulnar nerve release at the elbow is up to 25%. Various biomaterials have been developed to protect nerves from postoperative adhesions. The aim of this study was to review a case series of 40 surgical revision procedures of the ulnar nerve at the elbow, protected by a collagen membrane (Cova™ ORTHO). Forty patients who had this revision surgery between January 2013 and December 2017 were reviewed: 34 were evaluated in person, 6 were evaluated over the phone. The operation consisted in release of the ulnar nerve, anterior subcutaneous transposition and nerve protection using a collagen membrane. We assessed the following parameters with an average follow-up of 4 years and 3 months: paresthesia, night awakening, quality of life (QuickDASH score) and neuropathic pain (DN4 questionnaire). The outcome was determined with the Gabel & Amadio score. The patients' satisfaction was evaluated. A significant decrease in paresthesia and night awakening was found (p < 0.05). The average Gabel & Amadio score improved from 4.4 to 6.7 with 5 excellent, 19 good, 9 fair, and 1 poor result. The average DN4 was 5/10 and the QuickDASH score was 40.1. Eighty percent of patients were satisfied or very satisfied with the outcome. Surgical revision of the ulnar nerve at the elbow remains a delicate operation without a gold standard. This case series found good or excellent results in 70% of patients. Surgical revision of the ulnar nerve with a collagen membrane is a reliable alternative among other possibilities for ulnar nerve release at the elbow.

Arpe total joint arthroplasty for trapeziometacarpal osteoarthritis: 80 thumbs in 63 patients with a minimum of 10 years follow-up

In this retrospective study, we report a series of 80 Arpe prostheses for trapeziometacarpal osteoarthritis in 63 patients. Twenty-seven prostheses (20 patients) were lost to follow-up. Twenty-one were revised, eight of them during the first year after operation. The calculated cumulated implant survival rate was 85% at 10 years but could be lower due to the lack of information on the patients lost to follow-up. The number of complications due to technical errors was high; but after we had done 30 cases, the number of early revisions decreased markedly. At follow-up, 23 of 32 thumbs were totally free of pain, and the patients were satisfied with 31 thumbs. We conclude that the implant survival declines progressively in the long run, with a survival rate of 80% after 15 years of follow-up and a further decline thereafter. We also found that this surgery was difficult to master. We advise selecting this implant for thumb trapeziometacarpal osteoarthritis with caution. Level of evidence: IV.

Middle phalangectomy with shortening fusion of the fifth finger in Dupuytren's digital hooks

Severe contracture of the little finger due to Dupuytren's disease continues to be a therapeutic problem. Fifth finger amputation, which is sometimes the only solution, has a major negative impact on function and appearance, and exposes the patient to adjacent digital hook aggravation. Middle phalangectomy with finger shortening fusion is an alternative surgical solution. The aim of this study was to report on a continuous series of 36 cases treated with this approach. This was a retrospective series of 33 patients (26 males and 7 females) operated from 1994 to 2015. All patients had severe contracture of their little finger and 30 had prior surgery. The combined extension lag was 143° (75-270), with considerable functional deficit and poor appearance. The surgical technique consisted of a dorsal approach, a more or less extensive excision of the middle phalanx, and arthrodesis with alignment of the remaining bone segments, while preserving the fingertip/nail complex. The following outcomes were determined when the patients were reviewed: functional discomfort and use, appearance, residual pain, pulp sensitivity, recurrence of contracture and overall satisfaction. Six patients were dead and two were lost to follow-up. Twenty-five patients (27 cases) were reviewed at a mean follow-up of 64 months (12-280). There were no post-operative complications. Twenty-two patients (24 cases) were satisfied or very satisfied. The resulting appearance was graded at 7.13/10 (1-10). Pain on a 10-point Visual Analog Scale was 0.46 (0-5). Cold intolerance was found in 9 cases (33.3%) and decreased fingertip sensitivity in 3 cases (11.1%). The hand could be flattened in 21 cases; in the other cases, it could not be flattened due to contracture in another finger. Wearing gloves was again possible in 26 cases. Fusion was achieved in 18 of the 21 cases evaluated with X-rays at the last follow-up (85.7%). All the other cases had a non-union with no clinical repercussions. There were 5 local recurrences at the level of the little finger. Finger shortening through a dorsal approach seems to provide satisfactory outcomes in patients with Dupuytren's disease who have severe contracture of the little finger. This technique results in an acceptable looking functional finger, which has sensation and no significant morbidity.

Vein conduit with microsurgical suture repair of superficial branch of the radial nerve injuries at the wrist

The superficial branch of the radial nerve (SBRN) at the wrist is susceptible to trauma and lacerations. These lesions can develop into painful neuromas with debilitating consequences. The aim of our study was to demonstrate the effectiveness of systematic use of vein conduits associated with microsurgical suture repair in SBRN injuries to prevent the occurrence of these neuromas. Our study was retrospective and performed at a single site. An independent examiner performed the clinical assessment. The study included 33 patients and the mean follow-up was 63 months. We looked for a so-called "trigger point". None of the patients developed a painful neuroma or experienced any pain. All the patients were either satisfied or very satisfied with their treatment. Systematic use of vein conduit in SBRN injuries at the wrist helps prevent the occurrence of painful neuroma and the disorder's inherent consequences, which can be severe not only clinically, but also socially and professionally.

Acute finger-tip infection: Management and treatment. A 103-case series

INTRODUCTION

Acute fingertip infections (AFTI) are common. Surgical treatment is the norm in case of effusion. There is, however, no consensus on treatment modalities, or on adjuvant antibiotic therapy (AT). We present the results of a consecutive cohort of 103 AFTIs treated in emergency consultation.

MATERIALS AND METHOD

One hundred and one patients were treated by excision and extensive lavage under digital anesthesia, with systematic bacteriological sampling. Patient history, treatment history, location, type of bacteria, complications or recurrences and AT prescription were recorded and analyzed. All patients were reviewed at first dressing (5-7 days) and recontacted at 1 month, to record any pain, stiffness or recurrence. Three groups were distinguished: A: without preoperative AT (n=71); B: under AT before surgery (n=14); C: with postoperative AT (for severe comorbidity) (n=16).

RESULTS

Mean age was 39.7 years (range: 14-84 years). The three main types of bacteria were: Staphylococcus aureus (58.3%), polymicrobial flora (16.5%), and Streptococcus (12.6%). Mean time to first dressing was 5.7 days. There were no recurrences, whatever the bacterial type or patient group. In 5 patients in group A (8.2%), AT was later prescribed at day 5 (3 for hypercicatrization and 2 for maceration). In groups B and C, progression was unproblematic. At 1 month, all patients considered themselves cured; finger-tip sensitivity was conserved in 10, and 16 were awaiting complete nail regrowth.

DISCUSSION

Hospital admission, operative treatment under general anesthesia, and AT are factors exacerbating cost and increase the management burden of AFTI. Treatment in emergency consultation seems perfectly feasible. AT does not seem useful in the absence of severe comorbidities if resection is complete. Analysis of bacterial susceptibility and renewal of the initial dressing at 1 week enable progression to be monitored and treatment changed as necessary.

Interest of the "compress test" in diagnosis of nerve injury in hand wounds

INTRODUCTION

Hand wounds are a common cause of emergency department admission. Digital nerve lesions are found in 5% of palm wounds. Early diagnosis reduces the risk of morbidity, sequelae and litigation. Screening for digital nerve injury by the usual tests is difficult in an emergency context. We assessed the diagnostic value of the simple "compress test" to screen for pulp sensibility disorder and the factors that may influence the value of this examination, with a view to validating routine use.

MATERIAL AND METHOD

A retrospective study included 821 palm wounds treated between January 2014 and May 2016. There were 605 male and 216 patients; mean age, 42.8 years (range: 18-90 years). The dominant hand was involved in 307 cases (37.4%). Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of the compress test were calculated. Diagnostic value was also calculated according to age, gender, affected digit, dominant side and examiner's experience.

RESULTS

Clinical deficit was found in 412 cases (50.2%). A digital nerve lesion was found intraoperatively in 277 cases (33.6%). Test sensitivity was 87.3%, specificity 68.6%, positive predictive value 58.5%, negative predictive value 91.4%, positive likelihood ratio 2.78 and negative likelihood ratio 0.18. The test was more effective for thumb wounds and for examination by a junior surgeon. There were no differences according to injured side, innervation territory or gender.

CONCLUSION

This clinical test is reliable, with very good negative predictive value and good sensitivity, allowing its use in routine clinical practice. Nevertheless, surgical exploration of deep palm injuries should remain the rule.

Occupational prognosis factors for ulnar nerve entrapment at the elbow: A systematic review

Although ulnar nerve entrapment is the second most common entrapment neuropathy, there is a dearth of studies identifying occupational prognosis factors. We carried out a systematic review of the occupational prognosis factors for ulnar nerve entrapment in order to identify professions at risks and allow better follow-up for their workers. Using the key words, "ulnar OR cubital", "neuropathy OR tunnel", and "work OR occupational" without limitations, original prospective studies were selected from four databases (PubMed, Embase, Web of Science, Cochrane Library) after two rounds (valid design, valid prognosis outcome reported, valid work exposure). Associations between prognosis for ulnar neuropathy and occupational factors were extracted and analyzed qualitatively. Dating from 1981 to 2013, three prospective studies were included; 1420 cases of ulnar nerve entrapment were followed for an average of 4 years and occupational exposure was retrieved. The only high-quality study (related to this question) found a significant relationship between occupational exposure and prognosis with an odds ratio for ulnar nerve entrapment of 1.78 (1.10-2.88). The two other studies were less focused on the occupational prognosis factors; one found that work activity requiring effort had worse prognosis after surgery, while the other found no significant relationship between occupational hand exposure and prognosis. Occupations requiring high effort may be associated with more severe ulnar neuropathies, but further studies (exposure as well as associated disorders) are mandatory for clinicians to provide work task information to their patients.

Cross-finger flap for reconstruction of fingertip amputations: Long-term results

Fingertip amputations are severe hand injuries. Their treatment must restore the sensation and metabolic activity needed for pain-free finger function. The cross-finger flap (CFF) can be used for this purpose. The goal of this study was to assess the long-term clinical outcome following use of this flap.

METHODS

This was a retrospective analysis of 28 patients operated because of fingertip amputation: 16 type 3, 8 type 2 and 4 type 4. The CFF was harvested from an adjacent finger on the dorsal side of the middle phalanx down to the epitenon. A dorsopalmar hinge was preserved to ensure vascularisation. The CFF was divided an average of 18.7 days later. The following parameters were evaluated: pulp volume (injured compared to contralateral finger), presence of neuroma, occurrence of complications (necrosis, infection, and donor site morbidity), cold discomfort, static and tactile discrimination, and patient satisfaction (0 to 10 on VAS).

RESULTS

The average follow-up was 19.7 years; 22 patients (78.6%) were re-examined in person or contacted by telephone. The average healthy pulp to reconstructed pulp ratio was 1.03. No postoperative complications such as neuroma were found. Cold sensitivity was present in 7 patients. The flap was re-sensitised in all the patients. There was no donor site morbidity. The average patient satisfaction score was 9 (range 8-10).

CONCLUSIONS

Over the long-term, use of the CFF results in nearly normal fingertip metabolism, no complications and good distal sensitivity without pain or neuromas. This is a simple, reliable, long-lasting reconstruction technique.

LEVEL OF EVIDENCE

IV.

Intermediate term evaluation of the Eclypse distal radio-ulnar prosthesis for rheumatoid arthritis. A report of five cases

HYPOTHESIS

Early medical management of rheumatoid arthritis with biotherapy has changed the traditional musculoskeletal damage from this disease. When the distal radio-ulnar joint (DRUJ) is involved, classic procedures may be inappropriate. We chose a hemi-arthroplasty of the DRUJ joint (Eclypse™) in patients with persistent synovitis and chondrolysis with a stable joint. The aim of this study was to assess the intermediate term results of this approach in these specific cases.

MATERIALS AND METHODS

We report a retrospective study of 5 Eclypse arthropasties implanted between March 2005 and March 2011. There were 4 women and 1 man, mean age: 58.4years old (54-62) with RA that had been present for 21.6years (15-33). This hemi-arthroplasty replaced the ulnar head with a pyrocarbon component. Patients were evaluated by an independent observer for pain by VAS, range of motion, grip strength in the neutral position by Jamar dynamometer, pronation and supination strengths with a pronosupinator, DASH score and wrist X-rays.

RESULTS

One patient was lost to follow-up and the 4 others underwent a follow-up evaluation at 64 months (43-90). There were no intra-operative or postoperative complications. The pain score at the final follow-up was 1.5/10 (0-4), pronation was 70° (60-80) and supination was 80° (80-80). Grip strength was 148% compared to the contralateral side (73-200%). Pronation and supination strengths were 1.7kg (1.5-2) and 2.1kg (2-2.5) respectively. The DASH score was 55.9 points (42.6 to 79.3). X-rays did not show any changes in the ulnar notch.

CONCLUSION

This distal radio-ulnar arthroplasty is less invasive and preserves the bone and ligaments. Clinical results are rapid, remain stable over time and are well tolerated. This arthroplasty, which was initially developed for osteoarthritis and traumatic lesions of the DRUJ, is promising for specific cases of rheumatoid arthritis.

"Butterfly flap": The retinaculum to the rescue of the extensors

Extensor digitorum tendon (EDT) tear in the wrist is frequently associated with inflammation (rheumatoid arthritis, chondrocalcinosis) or distal radio-ulnar osteoarthritis. EDT protection and repair is often hampered by poor tissue trophicity and associated procedures. We describe an extensor retinaculum (ER) plasty, protecting and recentering the EDTs. The procedure consists in raising the ER on either side of Lister's tubercle so as to create a strap protecting and recentering the 4th, 5th and 6th compartment EDTs; the 2nd and 3rd compartment EDTs are left free on the lateral side of Lister's tubercle. This "butterfly plasty" provides solid and effective protection of the EDTs in an often fragile pathologic context. It creates a glide space, stabilizing EDTs and wrist.

LEVEL IV

Retrospective series.

Focal periosteal chondroma of the hand: a review of 24 cases

INTRODUCTION

Periosteal chondroma is a benign cartilaginous tumour that is less common than enchondroma and rarely arises at the hand.

PATIENTS AND METHOD

We report a retrospective review of 24 patients with focal periosteal chondroma of the hand and a mean follow-up of seven years and four months. The 13 females and 11 males had a mean age of 41 years and three months.

RESULTS

Radiographs performed to investigate a hard lump on a finger established the diagnosis in 23 (95.8%) patients, and histological documentation was obtained consistently. The proximal and distal phalanges were the most common sites of involvement. The tumour recurred in a single patient, a 10-year-old child, 10 months after surgery.

CONCLUSION

No other complications were recorded. Tumour excision and curettage of the lesion are the suggested treatments for periosteal chondroma. Most recurrences occur early after initial surgery.

LEVEL OF EVIDENCE

Level IV.

Neuroma-in-continuity of the median nerve managed by nerve expansion and direct suture with vein conduit

Autologous nerve grafting is the current standard for bridging large gaps in major sensory and motor nerves. It allows both function and pain improvement with predictable results. Clinical observations of nerve elongation caused by tumours have prompted experimental animal studies of induced gradual elongation of the nerve stump proximal to the gap. This technique allows direct suturing of the two nerve ends to bridge the gap. Here, we describe a case of neuroma-in-continuity of the median nerve managed by resection and direct suture after nerve elongation with a tissue expander. We are not aware of similar reported cases. Secondary repair 3 years after the initial injury improved the pain and hypersensitivity and restored a modest degree of protective sensory function (grade S1).

Reverse wedge osteotomy of the distal radius in Madelung's deformity

Madelung's deformity results from a growth defect in the palmar and ulnar region of the distal radius. It presents as an excessively inclined radial joint surface, inducing "spontaneous progressive palmar subluxation of the wrist". The principle of reverse wedge osteotomy (RWO) consists in the reorientation of the radial joint surface by taking a circumferential bone wedge, the base of which is harvested from the excess of the radial and dorsal cortical bone of the distal radius, then turning it over and putting back this reverse wedge into the osteotomy so as to obtain closure on the excess and opening on the deficient cortical bone. RWO corrects the palmar subluxation of the carpus and improves distal radio-ulnar alignment. All five bilaterally operated patients were satisfied, esthetically and functionally. Its corrective power gives RWO a place apart among the surgical techniques currently available in Madelung's deformity.

[Cartoons, local anesthesia and nitrous oxide: a solution for the treatment of child's hands wounds]

Wounds and injuries of child's hands are common and create anxiety. The context of stress makes difficult therapeutic cares, anesthesia and surgery, and prevents child's cooperation. We propose a technique combining a local anesthesia performed during inhalation of oxygen and nitrous oxide, and child distraction by watching a cartoon. In a prospective series of 39 children, we evaluated the feasibility of such care and its impact on the child's anxiety by a visual analog scale (VAS) at three moments of care sequence: arrival of the child (EVA1), at the end of the cartoon (EVA2), and at the postoperative visit (EVA3). Thirty-seven children were included (94.9%). Mean anxiety decreased throughout the therapeutic course: EVA1 (5.6), EVA2 (2.97), EVA3 (1.4). Children were less and less anxious along the procedure (100%, 46%, 10.8%, respectively). All children could be treated as outpatients. This procedure allows a rapid and adapted treatment for children's hand injuries. It reduces impact of children's anxiety.

Simplified scaphoid reconstruction technique with Zaidemberg's vascularized radial graft

For more than 10 years, we have been using a simplified reconstruction technique for scaphoid non-unions that involves the use of a graft first described by Zaidemberg et al. [1]. This approach requires that an island bone graft harvested from the radial styloid and pedicled on the 1,2-intercompartmental supraretinacular artery be embedded into the site of the non-union. The objective of our technical modifications was to simplify the harvesting and handling of the graft and the internal fixation. This technique is only used for cases of scaphoid non-union with avascular changes in the proximal fragment, repeated non-union after bone grafting and internal fixation, chronic non-union with osteophyte formation in the dorso-radial aspect and fracture secondary to Preiser disease.

Factors affecting return to work after carpal tunnel syndrome surgery in a large French cohort

OBJECTIVE

To evaluate occupational outcomes after surgical release of the median nerve in carpal tunnel syndrome (CTS).

DESIGN

Retrospective study 12 to 24 months after surgery.

SETTING

Hand centers (N=3) in 2 different areas.

PARTICIPANTS

Patients who had undergone surgical release of the median nerve in 2002 to 2003.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Duration of sick leave after surgery and associated factors were analyzed by using bivariate (log rank) and multivariate analyses of survival (Cox model).

RESULTS

Questionnaires mailed in 2004 regarding medical condition (history and surgery), employment (occupational category codes in 1 digit), and compensation were returned (N=1248; 62%), with 253 men and 682 women stating they were employed at the time of surgery (N=935). Most were working at the time of the study (n=851; 91.0%). Median duration of sick leave before returning to work was 60 days. The main factors associated with adverse occupational outcome (long duration of sick leave) were simultaneous intervention for another upper-extremity musculoskeletal disorder, belief (by the patient) in an occupational cause, and "blue-collar worker" occupational category (the strongest determinant).

CONCLUSION

This study emphasizes the multifactorial nature of the occupational outcome of CTS after surgery, including occupational category. The probability of return to work for each risk factor provides a fair description of prognosis for physicians and patients.

Vein conduit associated with microsurgical suture for complete collateral digital nerve severance

The aim of this study is to present the long term results of a series of 53 vein conduit grafts as first line therapy to repair complete severance of one or more collateral digital nerves. The surgical technique included an epi-perineural suture of the nerve under minimal tension, associated with a vein graft harvested from the back of the hand to cover the nerve. None of the patients presented with a neuroma, spontaneous pain or had stopped using the injured finger. Sensibility results were good or very good in 67% of cases. The scar at the donor site was very light or invisible. A total of 96% of patients were satisfied or very satisfied. This simple technique, by protecting the injured nerve, results in a rate of sensory nerve recovery that is comparable or better than that of other series in the literature, without neuroma and with minimal scarring at the donor site.

Lateral epicondylitis treatment by extensor carpi radialis fasciotomy and radial nerve decompression: is outcome influenced by the occupational disease compensation aspect?

INTRODUCTION

The etiology, treatment, and patient management in cases of chronic epicondylitis, within the legislation on occupational disease, remain highly controversial.

HYPOTHESIS

Recognition as an occupational disease has a negative influence on the functional result of epicondylitis treated with aponeurotomy and neurolysis of the motor branch of the radial nerve.

PATIENTS AND METHODS

Twenty-eight patients (30 cases of epicondylitis) were operated between January 2007 and January 2008. There were nine men and 19 women whose mean age was 46.1 years. A preoperative EMG found anomalies in the deep posterior interosseous nerve in all cases. Patients were divided into two groups: one group of patients recognized as having an occupational disease and a group of patients whose disease was not considered occupation-related.

RESULTS

The patients were seen at follow-up at a mean 21.8 months. In the group of patients with occupational disease, there were six excellent, nine good, and five acceptable results; in the second group, there were six excellent, two good, and two acceptable results.

CONCLUSION

Recognition of epicondylitis as an occupational disease has a significant influence only on the time to pain relief and the result on strength.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

[Glomus tumors in the extremities of children--a rare cause of chronic pain. Two clinical cases]

Glomus tumor (GT) of limb extremities (finger, toe) is a rare tumor, especially in children. It is formed by hyperplasia of the neuro-myoarterial elements. Chronic pain is often associated. The diagnosis is made by the history and several clinical tests (Hildreth's and Love's tests). This diagnosis must be suspected in a child with chronic extremity pain. Magnetic resonance imaging (MRI) is the most sensitive imaging test. Complete surgical excision of the lesion is curative. We report two clinical cases of glomus tumor of limb extremities (finger and toe) in two children - aged 7 and 12 - causing severe chronic pain; the diagnosis of this condition remains a challenge.

Attributable risk of carpal tunnel syndrome according to industry and occupation in a general population

OBJECTIVE

An epidemiologic surveillance network for carpal tunnel syndrome (CTS) was set up in the general population of a French region to assess the proportion of CTS cases attributable to work in high-risk industries and occupations.

METHODS

Cases of CTS occurring among patients ages 20-59 years living in the Maine and Loire region were included prospectively from 2002 to 2004. Medical and occupation history was gathered by mailed questionnaire for 815 women and 320 men. Age-adjusted relative risks of CTS and the attributable risk fractions of CTS among exposed persons (AFEs) were computed in relation to industry sectors and occupation categories.

RESULTS

Twenty-one industry sectors and 8 occupational categories for women and 10 sectors and 6 occupational categories for men were characterized by a significant excess risk of CTS. High AFE values were observed in the manufacturing (42-93% for both sexes), construction (66% for men), and personal service industries (66% for women) and in the trade and commerce sectors (49% for women). High AFE values were observed in lower-grade white-collar occupations for women (43-67%) and blue-collar occupations for men (60-74%) and women (48-88%).

CONCLUSION

The attributable proportions of CTS cases among workers employed in industry sectors and occupation categories identified at high risk of CTS varied between 36% and 93%.

[Acute closed injuries of the digital proximal interphalangeal joints]

Acute closed injuries of the digital proximal interphalangeal (PIP) joints are frequent and can leave sequelae because of imprecise diagnosis of the lesions, poorly adapted treatment, or insufficient follow-up. The therapeutic options proposed in this presentation are advocated by all of the participants and are based on their personal experience and evidence reported in the literature. After a brief anatomic review necessary for the understanding of PIP joint pathophysiology we have presented the longterm outcomes of PIP joint injuries, which are central to the therapeutic decision-making process in terms of risk benefit ratio. To facilitate the presentation, we have separated lesions "with" and "without" fracture. A specific chapter is devoted to surgical approaches essential for successful management of these injuries and another to particular problems related to the seldom reviewed topic of traumatic injury of the PIP joint during bone growth.

Facteurs de risque professionnels du syndrome du tunnel radial chez les salariés de l’industrie de production de masse

STUDY

The purpose of the study was to evaluate the professional and extraprofessional risk factors for radial tunnel syndrome (RTS) in employees of three large companies.

METHOD

Twenty-one cases of RTS were compared to 21 controls, matched for age, sex, and activity. In nine cases, RTS was associated with carpal tunnel syndrome. The analysis considered medical history, extraprofessional activity, and the ergonomic and organisational aspects of work.

RESULTS

The study demonstrated three risk factors of RTS related to work conditions. The regular use of a force of at least 1 kg (OR = 9.1 (1.4-56.9)) more than 10 times per hour is the main biomechanical risk factor. Static work (OR = 5.9 (1.2-29.9)) as well as work with the elbow constantly extended 0 degree to 45 degrees, is strongly associated with an increased risk of RTS (OR = 4.9 (1.0-25.0)). Complete extension of the elbow associated with pronation and supination of the forearm may cause trauma to the radial nerve in the radial tunnel. On the other hand, we found no personal factors and no extraprofessional activities which were associated with an increased risk of RTS.

CONCLUSIONS

This study shows that motions of the forearm requiring intense effort and performed with the elbow in extension and the forearm in pronation and supination increase the risk of RTS.

Coûts des urgences mains

In France at the present time, there is no comprehensive registry of hand injuries. Three types of occurrences; motor vehicle accidents, work accidents, and accidents incident to activities of daily living, are covered by different types of insurance. It is the individual insurance companies, payers of the indemnification, who maintain registries of these accidents. Statistics on work accidents are very detailed and consistent, but they are oriented toward risk management. The aggregate cost of traumatic injuries to the hand is not known. Only large financial institutions are equipped to determine appropriate preventive measures and to establish premium rates based on loss experience. In 2001, hand injuries accounted for 27% of work accidents causing loss of work of at least 1 day. About 29.8% of these work accidents caused permanent partial impairment. About 17.7% of total days lost and 18.2% of the total costs of permanent impairment were due to hand injuries. In the system of compensation for work accidents, there is a major difference in the cost according to the severity of the impairment. If the permanent impairment is equal to or less than 9%, a lump sum payment is made, but if the permanent impairment is over 9%, the worker receives regular payments for the rest of his life. In 2000, the average cost of a work injury with partial permanent impairment of over 9% was [symbol: see text] 85,405, while the average cost of a lump sum settlement was only [symbol: see text] 1479, a ratio of 57 to 1. The compensation costs represent 80% of the cost of work accidents, while the cost of treatment, including all providers and institutions, makes up only 20% of the cost. Compensation for sequelae of accidents in the course of daily life is new for the insurance companies, although these accidents are frequent and often cause significant repercussions in the professional lives of victims because of the loss of hand function. Provision of optimal treatment for these traumatic injuries from the very first moment is the best strategy for the third party payers. Better results of treatment not only reduce the costs of compensation for permanent partial impairment, but also greatly diminish the psychological impact on the injured worker. In the future, the management of the costs of these work injuries will become a priority. Pressure from consumers, which is growing, will favor this trend through the intermediary of private insurance companies.

[Gouty arthritis of the wrist. Five case reports]

Gout is rarely localized to the wrist. Based on five new cases of this condition and literature review, the authors outline the clinical and radiographic signs which differentiate gout from other causes of isolated unilateral chronic synovitis of the wrist. On the clinical basis, this localization was the first appearance of the disease in three of the five cases. On the X-rays, large defects and joint destructions were present. A scapholunate dissociation was evident in 4/5 cases with sometimes bone condensation. Other diagnoses should be eliminated as chondrocalcinosis, rheumatoid arthritis or wrist infections in subacute forms. Final diagnosis is provided by histological examination, demonstrating specific microcrystals.

Occupational risk factors for radial tunnel syndrome in industrial workers

OBJECTIVES

The aim of the study was to evaluate both nonoccupational and occupational factors associated with radial tunnel syndrome (RTS) among industrial workers in 3 large plants.

METHODS

Twenty-one cases of RTS were compared with 21 referents matched for gender, age, and plant. RTS was associated with carpal tunnel syndrome (CTS) in 9 cases. Past medical history, household activities, and ergonomic and organizational characteristics of the job were analyzed.

RESULTS

The study found 3 occupational risk factors for RTS. Exertion of force of over 1 kg [odds ratio (OR) 9.1, 95% confidence interval (95% CI) 1.4-56.9] more than 10 times per hour was the main biomechanical risk factor. Prolonged static load applied to the hand during work was strongly associated with RTS (OR 5.9, 95% CI 1.2-29.9). Work posture with the elbow fully extended (0-45 degrees) was associated with RTS (OR 4.9, 95% CI 1.0-25.0). Full extension of the elbow, associated with a twisted posture of the forearm, stressed the radial nerve at the elbow. However, personal activities, household chores, and sport and leisure activities were not associated with RTS.

CONCLUSIONS

The study confirms that RTS occurs in workers performing hard manual labor that requires forceful and repetitive movements involving elbow extension and forearm prosupination.

[Rupture of extensor tendons due to an isolated lesion in the distal ulnar extremity]

Rupture of the extensor tendons is a well known complication of rheumatoid arthritis involving the wrist or any form of diffuse arthrosis. It is much less common in the context of isolated arthrosis of the distal radioulnar joint. The authors report ten cases of this disease in patients without rheumatoid arthritis. All patients in this series were over sixty years of age and reported insidious development of an extension deficit of the little finger, followed by the ring finger. The typical radiographic image of erosion into the sigmoid notch of the radius should be noted and should lead to arthrography in order to determine the status of the joint capsule. Surgical intervention should be performed before major tendon rupture occurs. The results presented here were adversely affected by the delay in surgical treatment. Once rupture of the extensor digiti minimi has occurred, the articular and tendinous pathology must be both be treated, including tendon repair and plasty of the dorsal retinaculum.

[Late flexor synovitis induced by the use of a fabric lace]

A thirty year old woman underwent trigger finger release of her left middle finger after two injections failed to give relief. Several months later, she developed an area of nodular tenosynovitis localized to the operative site. Her finger had recovered full function, her general health was good, and routine lab work was normal. Because of the persistent mass, flexor tenosynovectomy was performed. Histologic examination revealed synovial hyperplasia associated with a filamentous birefringent foreign material. The bluish color of the foreign material indicated that it came from a fabric retraction loop used during the original operation. She made an uneventful recovery, and three years later her hand remained normal. As a result of this unusual complication, we recommended the use of retraction loops made of plastic rather than fabric. Whenever a micro-foreign body remains in the flexor tendon shealth, there is risk of aseptic tenosynovitis.

Analysis of twenty-eight recurrent pseudarthroses of the carpal navicular after the Matti-Russe operation

The authors present a review of 28 cases of failure of consolidation of the carpal navicular after the Matti-Russe operation (multicentric study of 106 cases). The causes of the failures are analysed. Among the non significant factors, we find the delay, the radiographic character of the pseudarthrosis, the donor site of the graft, the time of immobilization and the site of the fracture. The superior polar fractures do not have a bad prognosis in this series. Five causes seem to be in direct relation with the failure of consolidation: the age, the failure of an initial surgery procedure, the presence of radiologic "necrosis", the quality of the technical performance of the Matti-Russe operation, and finally dorsal carpal instability that seems to be a fundamental cause in the failure of bony union. The future of these pseudarthroses is analysed concerning: the functional results (64% of poor results); the evolution towards the pseudarthrosis (30%); the surgical reoperations (12 cases out of 28) with eight repeat Matti-Russe operations that finished in five consolidations.