Two objective "archivable" tests for voluntary muscle testing in ulnar and median nerve paralysis.

Two tests are proposed for assessment of ulnar and median nerve function for use under field conditions: (i) "flap flexion" of fingers for ulnar nerve, and, (ii) tip-to-tip thumb opposition to the fourth finger for median nerve. These tests, which are a part of a series of simple clinical tests proposed for rapid neurological evaluation of the function of the nerves involved in leprosy, are simple, objective and easy to do. Because these tests depend on the strength of muscles tested, they might spare its direct assessment. In fact, it is difficult to assess and grade the strength of the little muscles of the hand and that is very much dependent on the examiner's own experience. Therefore, it is rather subjective. The tests described here may also be used for evaluating the results of corrective surgery of the hand. Whenever possible, making photographic records of these two tests, to be archived in the forms where everyone can see and compare them, seems to be easier and more objective than the subjective transcription of the feelings of an examiner assessing the strength of the small muscles of the hand. These two tests seem to be most objective for a scientific prospective study with a long term follow up. So, they could be used in assessing the results of leprosy neuritis by medical treatment, or, by medical treatment completed (when necessary only and not routinely) by surgical decompression of nerves and also of corrective surgery of claw hand, or, loss of opposition of the thumb.

The metacarpophalangeal stabilization test: its surgical interest.

If the fingers of the claw hand are stabilized in order to prevent over-extension of the metacarpophalangeal joints, the long extensors will fully extend both interphalangeal joints. Based on the proximal interphalangeal stiffness assessed by this test, a simple therapeutic plan is proposed for the choice of the appropriate techniques for palliative claw hand surgery.

[Mycetoma of the hand. Apropos of 10 cases]. / Les mycétomes de la main. A propos de dix observations.

Mycetomas of the hand are a rare site of an uncommon disease, particularly in temperate climates. They are non-purulent inflammatory pseudotumours of mycotic origin. They are generally seen in Tropical Africa with a slow course progressing towards a phase of cutaneous fistula formation producing black, white or red grains depending on the fungus responsible. Ten cases are reported together with a review of the literature. Treatment must often be radical to prevent recurrence in the actinomycotic forms and this raises difficult problems of mutilating surgery of the hand for a benign and painless disease. However, ketoconazole has revolutionised the treatment of fungal varieties by allowing partial resections compatible with preservation of hand function.

[Palliative operations for correction of claw fingers]. / Interventions palliatives pour correction des griffes des doigts.

Palliative treatment of palsy of intrinsic muscles of the four fingers classically aims at suppressing claw. But functional restoration is mainly ensured in setting up again the volar flexion, the stage preparing prehension. Three hundred and thirty seven hands have been operated. Each one of the utilized interventions has advantages and drawbacks that have to be known in order to select the best adapted technics, the more or less important stiffness of fingers being the most important criteria. Finally a simple choice is easy and possible, particularly for inexperienced surgeons in the treatment of those paralysis (that become rarer and rarer in the West on account of the success of nervous sutures facing a large number of leprotic hands to operate in endemic countries); it is the metacarpophalangeal stabilization test: the active interphalangeal extension obtained after passive manual stabilization, of metacarpophalangeal joint indicates the degree of proximal interphalangeal residual stiffness, and the indications come in function of these various types of stiffness. Loose PIP joint: residual flexion from 0 degree to 20 degrees: MP capsular shortening, H shaped, and flexor pulley advancement; "Lasso" operation: a single slip of FDS by finger or one FDS for two fingers; Bunnell-Litter's operation: one FDS for 4 fingers; Giraudeau's operation: FCR + fascia lata; Brand's operation: 1st (ECRL) or 2nd (ECRB) + tendon graft; Palande's operation: ECRB + many tailed fascia lata graft fixed at the muscle tendon junction. Stiff PIP Joint: residual flexions from 20 degrees to 60 degrees: modified Bunnell's operation: one FDS for 2 fingers, the FDS of the third used to restaure the opposition; "lasso" operation: one FDS for each finger, or for two fingers. Very stiff PIP joint: residual flexion superior to 90 degrees: proximal interphalangeal joint arthrodesis.

[The metacarpophalangeal stabilization test and its value in surgery of the leprous hand]. / L'épreuve de stabilisation métacarpo-phalangienne, intérêt en chirurgie de la main lépreuse.

In a claw hand with ulnar-nerve and median-nerve paralysis, if the digits are stabilized to prevent over-extension at the metacarpophalangeal joints, the long extensor alone could fully extend all phalanges. From the proximal interphalangeal stiffness evaluated by this test (on more than 200 claw hands operated on 20 years ago) I propose a simple therapeutic scheme for palliative surgery.

[Volar flexion of the fingers. Its value in diagnosis of leprous paralysis of the intrinsic muscles of the fingers and in the study of the results of palliative interventions]. / La flexion en volet des doigts. Son intérêt dans le diagnostic des paralysies lépreuses des muscles intrinséques des doigts et l'étude des résultats des interventions palliatives.

Active metacarpophalangeal flexion with simultaneous active extension of interphalangeal joints places the fingers in the position in preparation for prehension. This volar flexion of the fingers is due to the action of their intrinsic muscles, and this movement, which is irreplaceable, has been used by the author for the last twenty years as a specific exploratory test of intrinsic finger muscles. It can be investigated as an emergency procedure in cases of ulnar nerve wounds at the elbow or injury to the upper forearm before suture, and clearly demonstrates the presence of an ulnar claw hand. It is a very sensitive test since this position potentiates an ulnar claw hand in its early stage which would have passed unnoticed with fingers extended. This rapid examination is particularly valid during neurologic investigation of the hand in lepers in countries where this disease is endemic, and it forms part of the 10 tests that the author has selected for exploration, within 2 or 3 minutes, in a standing patient, of the facial, ulnar, median, superficial peroneal and posterior tibial nerves. The test is also the most effective evaluation criterion of palliative surgery for claw hand which to be considered as successful must restore volar flexion, as shown by a personal series of over 200 operated hands.

[The reaction to viewing slides on tropical medicine. Evaluation study]. / L'impact d'un mur d'images en santé tropicale. Essai d'évaluation.

A series of slides on health priorities in Africa was shown to an audience of 123 people, of which 19 were not medical specialists. The authors of this experiment wanted to verify that the objectives set by the producers were met. The study, conducted in the form of a questionnaire, asked the people questioned to give their opinion on the objectives, the kind of public aimed at, the standard of the various subjects covered and the usefulness and cost-efficiency ratio of the type of audio-visual equipment used. Although the analysis of collected data reveals certain discrepancies as to the professional status of those questioned, the vast majority of participants considered this documentary support to be extremely worthwhile.

[Teaching at the Institute of Tropical Medicine of the Army Health Service (Le Pharo)]. / L'enseignement a l'Institut de Médecine Tropicale du Service de Santé des armées (Le Pharo).

Specialized education and training in tropical medicine given at I.M.T.S.S.A. aimes at bringing up the medical officers, attached to the Institute for instruction, to the highest possible level of competency to fulfil their duties in tropical zones in general and in particular in their first assignment, sometimes even in rural areas. Therefore, the objectives imparted to the different matters must correspond to the different tasks the newly seconded or posted medical officers will have to perform in tropical zones. In addition, pedagogical evaluation of these objectives and of the guided training, as well as evaluation of the knowledge acquired, are carried out several times during the course of the studies, in order to adapt these three parameters to the means and possibilities available in tropical zones.

[Training in epidemiology at the Institute of Tropical Medicine of the Army Health Service. Experience over 4 years]. / La formation en épidémiologie à l'Institut de Médecine Tropicale du Service de Santé des Armées. Une expérience de 4 ans.

The authors described the training in epidemiology received by 185 Army medical doctors attached for instruction to the I.M.T.S.S.A. since 1981. Statistical methodology, basic epidemiology, and applied epidemiology are taught in such way that Army medical doctors are better capable of rationalizing and strengthening their action of prevention in their posting either in France or seconded to developing countries. Description of pedagogical targets is underlined as well as methodology of control and evaluation of progress towards these targets. The authors are also able to appreciate, in terms of the level of capacity of the personnel trained, the severity of the consequences either of a strengthening of the pedagogical targets or of a reduction. When the reform of medical education and training imposes very often such an alternative, the authors point out how the leading opinion of the ones who utilize the services of the personnel should be taken into full consideration prior to any decision.

The metacarpophalangeal stabilization test beevor or bouvier?

In a claw hand by ulnar and median nerve palsy if the digits are stabilized in order to prevent overextension of the metacarpophalangeal joints, the long extensor alone can fully extend all phalanges. Based on the proximal interphalangeal stiffness evaluated by this test (in more than 200 claw hands I have had the opportunity to operate in over 20 years), I would like to propose a simple therapeutic plan for palliative surgery. Some have recognized Beevor as the author of this test in 1903, but, it seems as though it was Bouvier who first described it in 1851. In any case, rather than using a name, why not just call it "the metacarpophalangeal stabilization test"?