Treatment of an acute deep hand burn in a lowincome country with no available microsurgery: a case report.

Deep hand burns usually lead to joint and tendon exposure. A simple skin graft is insufficient to achieve healing. Soft tissue reconstruction represents a surgical challenge that ranges from the simplest to the most complex flaps. In some areas, microsurgery is not technically possible. Choice is then limited to pedicled distant flaps such as the abdominal wall flap-graft. We report a case of an acute burned hand with exposure of metacarpophalangeal joints from the second to the fourth radius as well as proximal inter phalangeal joints from the second to the fifth radius and extensor tendons, treated in the burns and wound care unit of the Sylvanus Olympio Teaching Hospital in Lomé. The dorsum hand and fingers were covered with a pedicled abdominal flap-graft that was severed in two stages at 22 and 29 days. We achieved good results (sensitivity S3+, useful aesthetic hand) at two-year follow up.

Les brûlures profondes de la main conduisent habituellement à une exposition articulaire et tendineuse. La reconstruction des parties molles représente un challenge chirurgical qui va de la technique la plus simple au lambeau le plus complexe. Dans certaines contrées, la microchirurgie n'est pas techniquement possible et le choix se limite à l'utilisation de lambeau pédiculé à distance, comme le lambeau-greffe abdominal; nous rapportons un cas de brûlure récente de la main avec exposition des articulations métacarpo phalangiennes du second au quatrième rayon avec de plus une atteinte des articulations inter phalangiennes proximales du second jusqu'au cinquième rayon et exposition des tendons extenseurs. Ce patient a été pris en charge dans l'Unité des brûlés et des Plaies et Cicatrisation du Centre Hospitalier Universitaire Sylvanus Olympio de Lomé. La face dorsale de la main et des doigts a été couverte par un lambeau-greffe pédiculé abdominal, qui fut sevré en 2 étapes (22ème et 29ème jour). Nous avons obtenu de bons résultats sur le plan de la sensibilité ainsi que sur l'aspect esthétique chez ce patient après deux ans de suivi.

Clinical profile of subdural hematomas: dangerousness of subdural subacute hematoma.

Subacute subdural hematomas are a poorly individualized nosological entity, often equated clinically to chronic subdural hematomas. Yet, their neurological deterioration which is usually rapid seems to distinguish them from chronic subdural hematomas. We wanted to show this dangerousness by establishing the clinically evolving profile of the three types of subdural hematomas. This was a prospective and retrospective study of 63 subdural hematoma (18 acute, 13 subacute, and 32 chronic) patients admitted between 2012 and 2014 in the neurosurgery unit of Lomé University Hospital. Hematomas were classified according to the elapsed time after head injury and blood density on CT. The main parameter studied was the evolution of the Glasgow Coma Score (GCS) in the 3 months following the trauma, enabling to establish an evolving profile of each type of hematoma. The average age of patients was 58.1 years for chronic subdural hematomas and 47.6 years for subacute subdural hematomas. Disease duration before admission was 13.1 days for chronic against 36.6 h for subacute hematoma. The clinical profile shows acute worsening within hours during the second week for patients with subacute hematoma, while it is progressive for patients with chronic hematoma. We noted two deaths, all victims of a subacute hematoma (one operated, one patient waiting for surgery). Iso-density hematoma on CT, especially in a young person, must be considered as a predictive factor of rapid neurological aggravation suggesting an urgent care or increased monitoring by paramedics.

Hand trauma epidemiology in a hospital setting in Togo

Purpose: Hand trauma epidemiological characteristics are lacking in low and middle-income countries. The aim of the study was to determine hand trauma characteristics to be use as a framework for planning hand surgical care in our country. Material et methods: Registers in Surgical Emergency Department from 1st June 2009 to 31st May 2014 were reviewed retrospectively to determine frequency, socio-demographic of patients and clinical characteristics of hands injuries. Results: Frequency of hand trauma was 0.7% of all admissions in the Surgical emergency department. The male to female ratio was 3.4:1. Mean age was 28 years. Manual work was the most representative occupation (33.2%). Road traffic accidents were the main circumstances of hand injuries (38%). Open injuries represented 68%. Fractures, dislocation and sprains were seen respectively in 41%, 31%, and 8% of cases. Simple wounds were seen in 38 % of all patients. Conclusion: Hand trauma seemed to be of low frequency in hospital in our setting. Main injuries encountered are fractures, dislocation, and sprains

[Results of transosseous reattachment for distal rupture of the biceps tendon. Evaluation of results]. / Réinsertion transosseuse par voie antérieure des ruptures du tendon distal du biceps brachial (biceps brachii [bb]) : évaluation des résultats.

Avulsion of the distal biceps brachii tendon is an uncommon injury. This is a retrospective review of cases operated in our department by transosseous suture fixation on the radial tuberosity, using the single anterior incision. Between 2000 and 2007, a total of 10 patients with distal biceps tendon injury were included. All were men, with an average age of 39 years. The most common mechanism was passive extension against active flexion. The dominant limb was affected in all patients. Clinical diagnosis was the rule. Surgical reattachment to the radial tuberosity through the anterior approach to the elbow was performed. The preoperative period was one week in three cases, between one and three weeks in five cases, and superior to three weeks in two cases. Clinical and instrumental evaluation of the results was done. Average follow-up was 48 months. Subjective results were good in seven cases, acceptable in two cases and poor in one case. Nine patients return to their previous level activity with no limitations. The average range of motion was 0° of extension to 135° of flexion. Strength testing of the injured limbs, compared to the contralateral, using the criteria described by Baker and Bierwagen, revealed a loss of 22% of supination strength and 32% of supination endurance. There was a loss of 14% of flexion strength and 27% of flexion endurance. There were two cases of superficial surgical site infection. There were no cases of nerve damage or heterotopic bone formation. Two main factors were found to explain the poor outcomes: experience of the surgeon and a long preoperative delay. Despite the limitations of this study, we found that transosseous reattachment of the biceps' distal tendon to the radial tuberosity can restore supination. Strength and endurance for supination can be better restored by early intervention. Complications are easily avoided if surgery is performed early and by experts.

[Bilateral anterior dislocation of the shoulders]. / Luxation antérieure bilatérale des épaules : à propos d'un cas.

Bilateral anterior shoulder dislocation is a very rare clinical entity. We report another case of traumatic bilateral anterior dislocation of shoulders. We discuss the mechanism of the dislocation which is unusual and the treatment.

Dynamic hip screw and compression plate fixation of ipsilateral femoral neck and shaft fractures.

PURPOSE: To evaluate surgical outcomes of ipsilateral femoral neck and shaft fractures. METHODS: Between April 1997 and September 2004, 29 men and 8 women (mean age, 37 years) underwent fixation of femoral neck and shaft fractures using a dynamic compression plate plus a dynamic hip screw or screws. There were 30 femoral neck and 7 pertrochanteric fractures. Functional results were assessed according to the Friedman and Wyman classification. RESULTS: The mean follow-up period was 49 months. Of the femoral neck fractures, 34 united in a mean of 4 months; 33 of them healed anatomically and one with a 6-degree varus angulation. No osteonecrosis of the femoral head was noted. Of the femoral shaft fractures, 32 united in a mean of 6 months, 5 were non-unions (2 persisted even after revision surgery). Seven patients developed infections (5 superficial and 2 deep), which resolved with debridement and antibiotic treatment. Functional results were good in 29 patients, fair in 5, and poor in 3. CONCLUSION: The use of dynamic hip screws and compression plates for ipsilateral femoral neck and shaft fractures is reliable in achieving bone union with few complications.

[Bristow-Latarjet repairs for anterior instability of the shoulder: clinical and radiographic results at mean 8.2 years follow-up]. / Traitement des instabilités antérieures de l'épaule par la technique de Bristow-Latarjet: résultats cliniques et radiologiques au recul moyen de 8,2 ans.

PURPOSE OF THE STUDY: We reviewed, at a mean follow-up of 8.2 years, clinical and radiographic results after 93 Bristow-Latarjet procedures for anterior instability of the shoulder. MATERIAL AND METHODS: There were 84 men and nine female. The average age was 23 years at the time of operative intervention. Forty-four shoulders were on the dominant side. Eighty patients practiced sports activities, with 74 patients a risk sport. Seventy-seven patients have had five or more recurrent of dislocation of the shoulder. The operations were performed by a senior surgeon. Evaluation was done by a clinician, who did not perform the operation. Clinical outcome was assessed with the Duplay score, and the satisfaction of the patients. Radiographic evaluation was done using the standard radiography of the shoulder. RESULTS: According to the Duplay scoring system, we have had 30.1% of excellent results, 43% of good results, 16.1% of fair results, and 10.8% of poor results. The mean Duplay score was 84.7 points with 19 points for the return in sports, 23 points for the stability, 21 points for the pain, and 22 points for the movement. The loss of rotation was less than 13 degrees (mean). Among the patients, 57.4% returned to their former sports activities at the same level, with 59.8% a risk sports. Five patients reported redislocation and eleven patients reported apprehension. The patients were painless in 75.8%. Forty-four patients were very satisfied or satisfied at follow-up. At review, there were radiological degenerative changes in nine shoulders: six in Samilson grade I, one grade II, and two grade III. There was no radiological evidence of loosing, migration or fracture of the coracoid screws, and no nonunion. We have had six cases of resorption of the coracoid tip. DISCUSSION: We are aware of the limitation of the study. It is a retrospective study and there is no control group. However, we believe that, in regard of our result, the Bristow-Latarjet procedure for anterior glenohumeral instability is safe and effective with good objective and subjective result, and a high degree of patient satisfaction. Radiological findings do not always correlate with the functional outcome and patient satisfaction. CONCLUSION: Although it is a non-anatomical repair, the Bristow-Latarjet procedure provides desirable functional results.

Avulsion fractures of the tibial tubercle.

PURPOSE: To retrospectively study the epidemiology and treatment of acute avulsion fractures of the tibial tubercle in 12 patients. METHODS: Records of 12 patients aged 11 to 17 (mean, 14) years with avulsion fractures of the tibial tubercle presenting to our hospital from April 1998 to September 2004 were studied. Patient age, gender, involved side, injury mechanism, clinical and radiographic records, treatment, complications, and outcomes were reviewed. RESULTS: Eight patients injured the right side, 3 the left side, and one both sides. They all engaged in sports or active play during the injury. Two fractures were type IA, one type IB, 2 type IIB, 5 type IIIA, 2 type IIIB, and one type IV. Three patients with type-I fractures and one with a type-IIB fracture were treated with closed reduction and cast immobilisation for 3 to 4 (mean, 3.8) weeks. The remaining 9 fractures were treated with open reduction and internal fixation. The mean follow-up period was 39 (range, 23-59) months. No complications were noted. Ten patients had excellent results and 2 had fair results. CONCLUSION: Closed reduction and cast immobilisation for minimally displaced fractures, and open reduction and internal fixation for displaced fractures resulted in favourable outcomes.

Intramedullary fixation using multiple Kirschner wires for forearm fractures: a developing country perspective.

PURPOSE: To evaluate treatment results of intramedullary fixation using multiple Kirschner wires for diaphyseal forearm fractures. METHODS: Between January 2001 and January 2004, 184 patients (122 men and 62 women) with 288 displaced diaphyseal forearm fractures underwent intramedullary fixation using multiple Kirschner wires. The wires were inserted by opening the fracture site because radiographic facility for closed pinning was unavailable. The time to union, functional recovery, and the complication rates were assessed. RESULTS: 11 patients were lost to follow-up, leaving 173 whose data was analysed. In 167 (97%) of the patients the fractures united, and in 14 (8%) of them union was delayed. The mean time to union for closed fractures was 13 (range, 7-16) weeks and for open fractures it was 15 (range, 12-22) weeks. The mean time in cast was 6 (range, 3-14) weeks. In all, 34/173 (20%) had complications: superficial infection (n=13), deep infection (n=4), cross-union between bones (n=4), open fracture 'needing' a skin graft (n=2), radial nerve palsy (n=3), paraesthesia (n=1), and non-union (n=7). Among the 173 analysed patients, the infection rate was 10% and the non-union rate was 4%. 130 (75%) of the patients had the wires removed; no re-fracture occurred after wire removal. Based on the Anderson criteria, 47 (27%) of the patients attained excellent, 78 (45%) satisfactory, and 39 (23%) unsatisfactory results. In 9 (5%) of the patients, union failed (7 plain non-union and 2 due to chronic osteomyelitis). CONCLUSION: Kirschner wires are much cheaper than plates and screws, and require minimal expertise for insertion and removal. They remain acceptable for stabilising displaced diaphyseal forearm fractures in developing countries.

[Multiple bone lesions of a type of disseminated African histoplasmosis in a Togolese immunocompetent child]. / Atteinte multi-osseuse au cours d'une forme disséminée d'histoplasmose africaine chez un enfant togolais immuno-compétent.

The authors report one case of disseminated African's histoplasmosis with numerous bones in Togolese immunocompetent child. The left tibia and fibula, the collarbones and the acromion were the bones mostly affected. The chronic fistulate lesion of the left leg associated with skin lesion allowed to evoke the diagnosis, this being confirmed by histological examination. The authors review the different diagnosis which will be discussed considering the radiographic appearance of african's histoplasmosis.