Floating thumb metacarpal in a motorcyclist: A case report

We present a case of simultaneous dislocation of the carpometacarpal and the metacarpophalangeal joints of the thumb (floating thumb metacarpal) in a 47-year-old motorcyclist. The treatment consisted of closed reduction of both joints with cast immobilization. After 24 months, the functional result was excellent. The mechanism of this rare injury and its therapeutic management are discussed.

Dislocation of the elbow with ipsilateral forearm fracture. Six particular cases

Elbow dislocation associated with ipsilateral radial shaft fracture is an infrequent injury (nine cases reported in the literature). We present six new cases observed between 2006 and 2012, with an average age of 31 years and a mean follow-up of 18 months. The forearm fracture and ipsilateral dislocation of the elbow were probably caused by forearm hypersupination with extension of the elbow. The dislocation was reduced by manipulation before open reduction and osteosynthesis of the forearm fracture. Four elbows were stable after reduction; two markedly unstable elbows necessitated temporary humero-ulnar external fixation; one case needed a ligamentoplasty several months later. Despite the complexity of the traumatic lesion, the clinical and radiological outcomes were acceptable.

[Myxoid neurofibroma of the thumb]

Myxoid neurofibroma (MN) is a benign tumor of poorly identified perineural cell origin. We report a case of NM of left thumb and discuss the main differential diagnosis.

CASE REPORT

A 34-year-old woman presented with a painless, slowly progressive tumor of the left thumb of 6 months duration. This tumor had recurred after resection done 26 years before. Clinical examination revealed a tumor on the anterior surface of the left thumb, painless, firm, 4×3cm, ulcerated and covered with thin telangiectasia. The X-ray of the phalanx showed no alteration to the underlying bone. The histopathological study of a skin biopsy reported a myxoid neurofibroma. Excision of the lesion was performed with preservation of the nail. Neither the patient nor her family members had neurofibromatosis. The outcome was favorable and no recurrence was noted after 18 months of follow-up.

COMMENTS

The usual sites of the MN are the face, shoulders, arms, and periungual regions. It is usually a solitary lesion; however, lesions may be multiple or recur after initial incomplete excision as in our patient. It must be considered in the differential diagnosis of tumors of the extremities. We report this case because of the rarity of both the tumor and its site.

[Facial wounds: an epidemiological review of 850 cases]

BACKGROUND

Facial wound are among the most frequent emergencies. They often affect a young population. We studied the epidemiological profile of facial wounds admitted in our hospital.

PATIENTS AND METHODS

This prospective study was carried out in the Emergency Unit from June 2008 to June 2009. It included all patients having presented with at least one facial wound. The analysed parameters were patient, trauma, and wound characteristics.

RESULTS

Eight hundred and fifty patients were included, 20% of whom were female patients. The most frequent etiologies were traffic accidents for men, assault for women, and domestic accidents for children. Alcohol abuse was involved in 12.4% of the cases. The most frequent wound localization was frontal (35.4%). A craniofacial organ (eye, brain…) was affected in 6.1% of the cases; the wound was associated to a craniofacial fracture in 9.6% of the cases, and to an extrafacial lesion in 22% of the cases.

DISCUSSION

Facial wounds are a frequent emergency. They are predominant in young male patients. The high frequency of traffic accident and alcohol abuse requires an adequate prevention policy.

[How to avoid operative injury to Martin-Grüber communicating branch in the transmuscular medial approach of the elbow?]

The incidence of Martin-Grüber medio-ulnar communicating branch (MUCB), from median nerve to ulnar nerve, is about 20%. To avoid operative injury to MUCB, the authors suggest some modifications to the medial approach of the elbow. They suggest medial aponeurotomy of the anterior compartment of the forearm, disinsertion of the medial epicondylar muscles with dissection between the flexor carpi ulnaris (FCU) and the other medial epicondylar muscles, not exceeding 3 cm distally. This allows a valuable exposure of the elbow joint through a medial approach, with FCU disinsertion and ulnar nerve transposition preserving the ulnar nerve vascularization, without injury to the MUCB.

[The digital external fixator, new equipment (24 cases report)]

Phalangeal fractures and osteoarticular infections can be challenging injuries to manage, and their treatment is frequently complicated by deformity and stiffness. External fixation techniques have a well-established role in the treatment of these injuries. The mini-Hoffman external fixator is a particularly simple apparatus in design and in application. We report a technique of digital external fixator with a new original material developed in the service. It is an inexpensive and simple technique with good stability. The technical procedure is simple, consisting of two joints, Kirchner pins, 4mm diameter screwdrivers and a motor. Between 2001 and 2006, we used this method to treat 24 patients in a prospective study. The mean age was 35 years (range 16 to 68 years) with a male predominance, left hand predominance (14 cases), and carpenter's hand was the most frequent indication (11 cases). Mean duration of follow-up was two years (6 months to 5 years). Functional results were excellent in 12 cases and bad in six cases. Complications included a case of ischemic necrosis of the finger, two cases of secondary displacement, three cases of sepsis, two cases of algodystrophy and a case of pseudoarthrosis.

[Medial cleft lip: one diagnosis masking another]

Median cleft lip and palate are one of the facial manifestations of holoprosencephaly, a brain malformation resulting from a defect in the development of the prosencephalon, the embryonic precursor of the forebrain. It can occur in isolation or as part of a broader pattern of malformation in many different syndromes. The diagnosis of holoprosencephaly requires a complete malformative assessment.

CASE REPORT

FIRST CASE

a newborn baby seen at birth for a median cleft lip associated with a complex craniofacial malformation. The search for malformations revealed the absence of the median cerebral structure and trisomy 13. The baby died at 48 h.

SECOND CASE

A 28-day-old newborn baby consulting for a median cleft lip and palate. The brain ultrasounds showed no anomalies of the median cerebral structure. The malformative assessment revealed no other malformation.

DISCUSSION

Holoprosencephaly is a complex developmental brain malformation. From the advances in neuroimaging and genetics, our understanding of the etiology and pathogenesis of this condition has advanced dramatically. This advance should lead to improved management of common medical complications and more optimal family counseling. Surgical treatment is the preferred therapy for viable malformations.

[Rare localization of an aggressive epithelioid sarcoma in an adolescent]

Epithelioid sarcoma is a rare soft-tissue sarcoma affecting mostly young adult males. It is exceptional under the age of 20. Diagnosis is by histiochemistry. Treatment is mainly wide surgical excision. The normal evolution is local spread followed by generalized metastasis. We report a case of epithelioid sarcoma of the left arm in a 16-year old adolescent of 8 months duration.

Ostéome ostéoïde du lunatum: à propos d'un cas

The Osteoid Ostéome is a benign tumour which affects the young subjects and is electively located on the level of the long bones. We report a hyperalgic form of the lunatum in a young student with which surgical excision with bone-graft allowed the cure.

[Bipolar dislocation of the forearm]

The authors report the case of a 23 year old patient, who presented the following combination of injuries after a fall, namely a divergent dislocation of the elbow, a fracture of the radial head, a fracture of the ulna and a perilunate dislocation with scaphoid fracture. The entire injury thus represented a bipolar dislocation of the forearm. The emergency management consisted of a closed reduction of the elbow together with osteosynthesis of the ulna, internal fixation of the scaphoid with a compression screw, and scaphocapitate K wiring. After 26 months, the function of the elbow was satisfactory, and the range of motion of the wrist was from 50 degrees of flexion to 40 degrees of extension. Satisfactory healing of the scaphoid was observed. This combination of injuries has only rarely been reported in the literature.

[Ewing's sarcoma of the hand: a case report]

Ewing's sarcoma of the hand is rare. This tumor was first described in 1921, since then, only a few cases with hand involvement have been reported. We report a case of Ewing's sarcoma of the left hand, presenting as a swelling of the hand gradually enlarging over six months. Plain radiographs showed marked osteolysis of the second, third and fourth metacarpals. Histological confirmation was made following biopsy. Despite amputation and post-operative chemotherapy, death occurred two months later due marrow aplasia.

[Aseptic osteonecrosis of the femoral head in thalassemia minor: a case report]

We report a case of aseptic necrosis of the femoral head in a 14-year-old black adolescent with thalassemia minor disclosed by physical examination and blood tests. No other anomaly could be identified. Despite the very probably secondary nature of the aseptic osteonecrosis of the femoral head and the absence of any other etiology, it is highly difficult to demonstrate the causal effect of thalassemia minor. We reviewed the literature and discuss the pathogenesis of this association.

La luxation carpométacarpienne antérieure complète des doigts. À propos d'un cas

Anterior carpometacarpal dislocation are rare injuries. The anterior type is exceptional. Mr A.T 18 years old, male, student, right-handed, without pathological medical history. He was admitted in emergency after a fall of a motorbike (unknown mechanism) for a closed left hand injury; examination revealed a total impaired mobility and an important swelling of the hand without vasculonervous disorders. X-ray revealed a pure anterior dislocation of the five carpometacarpal joints. The patient was operated on in emergency using both anterior and posterior approach, which allowed to reduce the dislocation. It was maintained by K-wires. An antebrachiopalmar cast was applied for six weeks. One year later, the result obtained was considered excellent.

[Cubital tunnel syndrome and heterotopic ossification. Eight case reports]

INTRODUCTION

The occurrence of cubital tunnel syndrome during heterotopic ossification is infrequent. Entrapment of the nerve requires early decompression whereas definitive elbow release is often delayed to reduce the risk of recurrence of periarticular ossification. The pathophysiology and treatment of these two conditions are discussed.

METHOD

The authors report a retrospective study of eight men (average age 37 years), all with previous head injury. The nerve entrapment was severe in two cases, moderate in four and mild in two. The elbow was ankylosed with a mean flexion deformity of 96 degrees (77 degrees-123 degrees). Management consisted of early decompression and neurolysis with anterior transposition of the ulnar nerve. In four cases elbow release was postponed until maturation of the ossification.

RESULTS

The neurolysis results were assessed according to the score of KLEIMAN modified by TEOH. They were excellent in two cases, good in five and bad in one.

DISCUSSION

Entrapment of the ulnar nerve in the context of heterotopic ossification seems related to compression and tension on the ulnar nerve. The compression may be due to prolonged pressure of the medial edge of the elbow on the bed of the nerve, or to a periarticular bony bridge and the initial inflammatory reaction of the heterotopic ossification. Ulnar nerve tension seems to be due to prolonged flexion of the elbow joint and to movements of the shoulder and the wrist, on either side of the ankyrozed elbow. Treatment should be by early decompression of the nerve and we recommend, in addition, anterior transposition to reduce the tension on the nerve. The elbow release can be combined with the neurolysis or delayed according to the state of activity of the heterotopic ossification.

[Hand trauma from table saw: best prevention]

OBJECTIVE

Trauma to the hand from a circular saw table is a common occurrence in developing countries. It tends to occur in young people, leading to psychologic- and socio-economic disability and loss.

METHOD AND RESULTS

In this series of 834 patients. The mean age was 25 years. The left hand was involved in 88%. The authors report on the epidemiologic features of these lesions. These accidents are correlated with postprandial somnolence. The most frequent causes are absence of security systems and heterogeneity of the wood.

DISCUSSION

The authors emphasize the importance of information for workers, using consciousness raising campaigns. They also stress the necessity of improvement of the conditions of work. Professional formation must be mandatory for young woodworkers and the laws concerning utilization of dangerous machines must be rigorously enforced, in order to lower the incidence of these accidents.

[Lateral dislocation of the elbow: pathophysiological and therapeutic analysis]

Lateral dislocation of the elbow is exceptional, and its pure form even more so. We report a case of lateral dislocation of the elbow observed in a 65-year-old woman following a fall on the medial aspect of the elbow in the flexion position. Reduction could not be achieved because of the anconeus muscle interposition. Analysis of the mechanism involved and the displacements observed enabled to propose a reduction manoeuvre using gentle traction on the elbow with extension and progressive supination of the forearm, pushing the olecranon backward then pulling it medialy. This enabled avoiding incarceration of the nerve bundle or capsulo-ligamentary structures.

[Ossifying parosteal lipoma of the rib: a case report]

Ossifying parosteal lipoma is an uncommon form of parosteal lipoma. We report an exceptional rib localization where hyperosteosis probably arose from contact between the lipoma and the periosteum. Foci of metaplastic cartilage undergoing chondral ossification within the adipose tissue suggest a possible mixed origin.

[Chondrosarcoma of the hand. Diagnostic and therapeutic discussion (three case reports)]

Chondrosarcoma of the hand is very rare. We report three observations which enable us to make a review of its pathology. There were two men and one woman aged 72, 38 and 63 years respectively. Localisation was phalangeal in two cases and metacarpal in one case. Two cases were central and one peripheral. Radiographs were characterised by the presence of lytic areas with intralesional calcifications and soft tissue extension. Histological diagnosis was made by biopsy in two cases and after amputation of the finger for lesional spread in one case. Treatment consisted of amputation of the finger in two cases. In the case of metacarpal localisation, wide resection of two rays was followed by recurrence after ten months which required amputation of the hand. We agree with other authors who believe that chondrosarcoma in the hand is due to malignant change in a pre-existing chondroma. Conservative treatment is difficult due to the small size of the hand which allows easy spread of the tumour from compartment to compartment.

[Metaphysis fracture of the distal radius: Kapandji's or Py's pinning?]

The authors report a prospective and randomized study comparing two pinning techniques for fractures of the distal radius. The series compared 42 patients treated by Kapandji's intrafocal pinning (Group I) and 46 patients treated by Py's isoelastic pinning (Group II). Secondary displacement was observed in 7 patients in group I and in 2 patients in Group II. Secondary displacement of K-wire was observed in 6 patients in group I and in no patient in group II. Functional results were analysed according to jakim's criteria. A significant difference was observed between the two groups, for global scores, objectives scores and radiological scores, with better results for Py's pinning. No significant difference was observed for subjective scores advantages of Py's pinning were: stability of isoelastic wires preventing posterior comminution and no need for radioscopic control. Kapandji's pinning is proposed in cases of lower and unstable fractures in teenagers without focal comminution and in T fractures. In the other cases of metaphyseal fractures with posterior displacement, Py's pinning could be proposed.

[Solitary osteochondroma of the limbs. Clinical review of 76 cases and pathogenic hypothesis]

The authors report a retrospective study of 76 solitary osteochondromas of the appendicular skeleton treated between 1981 and 1995. The ages of the patients ranged from 13 to 55 years with a mean of 21 years. The male/female-ratio was 1.37. Tumefaction with or without associated pain was the reason for consultation in 68 cases (89%). In 62 cases the osteochondroma was localized in the distal part of the femur or the proximal part of the tibia. All lesions were surgically resected; the resection was complete in all cases. Six patients were lost to follow-up; the other 70 were seen on a regular basis over a time period ranging from 1 to 12 years. The result from surgical treatment was assessed based on pain, joint motion, cosmetic consequences, nerve compression and recurrence of osteochondroma. The results were good in 68 cases and fair in two cases. Based on a review of previous experimental studies, the authors suggest a hypothesis to explain the rotation of a fragment of the growth plate which is needed for the development of osteochondroma. This rotation occurs as a result of the mechanical action from the periosteum under tension.

[Local digital anesthesia using lidocaine with or without bicarbonate. A comparative randomized study]

PURPOSE OF THE STUDY

Local anesthesia with lidocaine is widely used in surgery of the extremities, particularly for fingers. Injection causes pain. In order to minimize this discomfort, addition of bicarbonate has been used by many authors. Results were however contradictory in relation with the difference of approaches. Our study is based on a randomized comparative series with and without lidocaine alcalinization.

MATERIAL AND METHODS

Sixty patients presenting multidigital trauma concerning at least two fingers. For each patient, one finger was anesthetized by lidocaine 2 per cent alone and one by lidocaine 2 per cent plus bicarbonate 8.4 per cent respectively in proportion of 4/5 and 1/5. We compared the intensity of pain during injection by a scale ranging from 0 to 10.

RESULTS

Significant difference was found between both groups (p < 0.001), alcalinization appearing to decrease discomfort during injection.

DISCUSSION

Mechanism of pain decrease by alcalinization is unclear. It appears that intracellular passage of non ionic form of lidocaine is facilitated by alcalinization. This allows the decrease of latence of lidocaine and relieve pain more rapidly by pain receptors blockade.

CONCLUSION

Diminution of pain during anesthetic injection has major advantage in out-patient surgery of extremities, in ligamentar testing of digital articulations and in steroid injection.

[Subungual exostoses. A retrospective study of a series of 28 cases]

Subungual exostosis represents an uncommon osteocartilaginous benign proliferation with a trend towards recurrence. The authors report on a retrospective series of 28 cases of subungual exostosis of the first toe with histologic confirmation. There were 20 male and 8 female patients, with a mean age of 18 years. A history of trauma or repetitive microtrauma was noted in 21 cases. Surgical treatment was performed using the most direct approach. The tumor was widely excised and the ungual apparatus was reconstructed under optic magnification. All patients were reviewed after 14 to 96 months. Tumor recurrence was observed in 4 cases, treated secondarily with success. No malignant transformation was seen.

[Primary muscular echinococcosis. Apropos of 2 cases]

We report 2 cases of primary muscular hydatosis of the thigh in a 30-year-woman and a 75-year-man. The clinical picture was a benign soft tissue tumor. The ultrasound and C.T. scan exams confirmed the diagnosis and showed precisely the intimacy of the lesion with the femoral vascular axe. Preoperative diagnosis of this affection is mandatory in order to prevent any rupture of the cyst so as to avoid anaphylactic shock and local recurrence. Percystectomy is the treatment of choice for this lesion.

Osteoid osteoma after a fracture of the distal radius

We report a case of osteoid osteoma occurring at the site of a previous fracture of the radius treated by internal fixation with insertion of a rod. The fracture may have acted as a trigger for the formation of an osteoid osteoma.

Tuberculous osteitis in limbs. Twenty five case-reports

Tuberculous osteitis is a rare condition that can be difficult to differentiate from bone tumor on X-ray films. The purpose of this retrospective study was to analyse the epidemiologic, diagnostic and therapeutic aspects of this disorder. Data from 25 patients (13 men; 12 women; mean age = 37) were collected between 1984 and 1993. The source of contagion was traced in 32% of the cases and 24% of patients were known as tuberculous. Patients searched medical attention because of pain in 84% of cases. The greater trochanter was involved in more than 50% of cases. The definite diagnosis was obtained by examination of a surgical biopsy and the anti-bacillary treatment led to recovery in all cases. This study highlights that tuberculosis must be considered when investigating a bone lacuna, all the more so when the greater trochanter is involved, in a country where tuberculosis is endemic.

[Association of monomelic melorheostosis and synovial chondromatosis of the knee]

Melorheostosis is a rare affection, of obscure etiopathogenesis, corresponding to osteosclerosis with running hyperostosis. We report the observation of melorheostosis of a lower limb occurring to an 18-year old patient who consulted for tumefaction of the lower limb with an aching and stiffened knee. The radiography allowed the diagnosis by showing an aspect characterized by a running like of a candle accompanied by osteochondromatosis of the knee and the calcification of soft tissues. The synovectomy of the knee brought about indolence and the lesions seem to stabilise after a 3 years follow-up. The synovial osteochondromatosis seems to be an integral part of the disease. The characteristics of melorheostosis are studied according to the data of the literature.

[Triquetro-lunar instability. The role of the radio-styloidian index]

Based on a series of 13 isolated triquetro-lunar instabilities, the authors underline the excess of the radio styloidian index measured radiologically. They found a significant difference (p < 0.001) when comparing this series with a group of 100 normal wrists. A similar comparative study of 13 triquetro-lunar instabilities secondary to perilunar dislocations and of a series of 16 hyperlax wrists did not reveal any significant difference. The same applies to a similar parallel study of the ulnar variance index measurements when comparing the various groups with the control group. After reviewing the mechanism of lesions, and disorders of the wrist's axial forces, caused by changes in the ulnar lengths, ulnar styloid overshooting is designated as a risk factor for isolated triquetro-lunar instabilities. Finally, the authors insist on the necessity of proper reduction of radial low end fractures and detachments, and on the shortening of the long ulna, as a "complementary" procedure when treating isolated triquetro-lunar instabilities.