Duration of sick leave after surgical repair of the ulnar collateral ligament of the thumb metacarpophalangeal joint with K-wire immobilization: Prospective case series of 21 patients.

Surgical repair of the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal (MCP) joint after complete rupture is usually protected by cast immobilization, which hinders return to work. The goal of this study was to determine the duration of sick leave for patients who had 6 weeks of K-wire immobilization instead of cast immobilization after surgical repair of the UCL. This prospective, observational, non-comparative study included patients who had surgical repair of the UCL of the thumb MCP joint followed by K-wire immobilization. Manual laborers were excluded. The main outcome measure was the duration of sick leave. The other outcomes were the need to adapt to the work duties and the patient's subjective assessment of the result. The data were collected by telephone interview. Twenty-one patients were included, 13 (62%) of whom returned to work within 7 days. The average sick leave duration was 3 weeks and 2 days; 10% of patients required adaptation of the work duties. The average satisfaction score was 4.4 out of 5. The average follow-up was 3 years and 5 months. There were no complications. In conclusion, K-wire immobilization after surgical repair of the UCL of the thumb MCP joint, along with precautionary measures is an option that allows early return to work, except for manual labourers.

Application of WHO recommendations in outcome assessment of clinical series published in hand surgery journals with five years interval.

Outcome measurement is becoming increasingly important in hand surgery. The International classification of functioning, disability and health (ICF), is a WHO multi-dimensional approach to health condition including three domains: body "functions and structures", activities and participation. The aim of this study was to measure how often these three ICF domains were included in outcome measurements of the clinical series published in the American, European and French hand surgery journals. Our study included clinical series published in 2007 and 2012 in the American Journal Of Hand Surgery, European Journal Of Hand Surgery and Chirurgie de la Main. Analysis of each of these publications was done in two steps. First, we checked the presence or absence of the three domains of ICF in outcome measurement without considering the way it was measured. Then, we reported the use of evaluation instruments and/or quantitative measurement for each domain. We included 54 series in 2007 and 119 in 2012. The number of series reporting on the three domains and using at least one quantitative measurement for each domain represents 6% of articles in 2007 and 10% in 2012. This study shows that the quality of outcome measurement has improved over these 5 years, but remains poor according to the ICF recommendation.

Outcome measurements in hand and upper limb surgery.

Of marginal importance only 20 years ago, outcome measurement has become one of the most widely published topics in medical literature. The concept of global health is described by the International Classification of Function, Disability and Health. Today, the surgeon's perspective is no longer sufficient to evaluate global health condition of a patient. The patient cannot be reduced to an organ. Outcome measurement must take into consideration body structures and function (symptoms, organ function) as reviewed by a professional, the individual's functional health status in terms of activity and evaluated by the patient himself, and his participation in his social environment. These principles are now being applied to our specialty and it is essential to know them to be able to collect, analyze and publish valid results. This review article defines the rules for using clinical outcome tools, provides the most widely used clinical and self-evaluation forms for our specialty as well as instructions for their use. Global outcome is usually obtained by arithmetic addition of scores; which is a simple but questionable method. The sieving and radar charts can be used for a more comprehensible representation showing areas of relative strength and relative weakness on a graph, as well as depicting general overall performance. The reliability of data is also affected by declaration of conflicts of interest, negligence or fraud. The level of evidence is questionable as long as a data verification system is not implemented.

The French initiated FESUM - historical development, experience and perspectives.

FESUM is an association dedicated to management, research and education of hand trauma. Created by surgeons in 1979, it is now accepted by the national and regional health administrations. The first goal of FESUM is to apply strict guidelines for specialized hand trauma centers. These guidelines are verified on site by 2 FESUM surgeons, and re-checked every 3 years. Patients are selected to be directed to the FESUM cen-ters following very simple recommendations: every severe trauma must be addressed to and accepted by FESUM centers, 24/7. Seemingly less severe lesions such as deep palmar lacerations must also be systematically explored in FESUM centers to ensure patients have the best opportunity for treatment. Prevention is also a very important part of FESUM activities. The FESUM prevention campaigns are currently focused more specifically on daily life trauma, that represents 2/3 of the total injuries and is very poorly managed by authorities.

[Scaphotriquetral capsulodesis for scapholunate instability]. / Traitement de l'instabilité scapholunaire par capsulodèse au ligament scaphotriquétral selon Berger.

OBJECTIVES: Scapholunate ligament injuries may lead to scapholunate instability and wrist osteoarthritis. Many surgical techniques have been described to repair these injuries. The goal of our study is to assess the clinical results after capsulodesis with the scaphotriquetral ligament for scapholunate instabilities. METHODS: Twenty-eight patients, 22 men and six women, were operated for scapholunate instability between January 2006 and December 2008. The average age was 37.8 years, and the average time between trauma and surgery was 9.9 months. The scaphoid shift test was present in 26 patients. All patients underwent static and dynamic X-rays of the wrist and scan. A capsulodesis with scaphotriquetral ligament was performed in all patients. RESULTS: At 24 months follow-up, a 13° significant decreased of wrist range-of-motion was noted. The strength was significantly improved after surgery. The wrist stability was improved in 26 patients. Concerning pain, a significant reduction was noted with Analogical Visual Scale after surgery (p<0.005). Twenty-one patients returned to their previous work. Complications were reflex dystrophy in one patient and wrist infection in one patient. CONCLUSION: Many techniques were described for treatment of scapholunate injuries, from the simple scapholunate ligament suture to partial wrist arthrodesis. Capsulodesis with scaphotriquetral ligament improves grip strength, decreases wrist instability and pain with a slight lost of range-of-motion.

[Results of primary repair of injuries to the median and ulnar nerves at the wrist]. / Résultats de la réparation primaire des plaies du nerf médian et du nerf ulnaire au poignet.

INTRODUCTION: Wounds on the palmar side of the wrist affecting the median or ulnar nerves are responsible for motor and sensory sequelae, severe pain and cold intolerance. MATERIALS AND METHODS: Thirty-nine patients with 40 nerve sections were retrospectively reviewed with a mean follow up of 23 months. The median nerve alone was affected 20 times, the ulnar nerve seven times and both nerves simultaneously 13 times. In 75% of the cases, there was an associated vascular injury (radial artery and/or ulnar artery). The average number of tendons cut was 4.25. RESULTS: After repair of the median nerve, 71% of patients recovered antepulsion and opposition that was normal or possible against resistance. The strength was approximately 70% of the opposite side. The sensitive recovery was good (S3 in>or=50% of cases) but it was accompanied by cold intolerance one out of two patients. After repair of the ulnar nerve, 29% of the cases had an ulnar claw hand, 71% of patients recovered sensitivity greater or equal to S3 but with cold intolerance in 42% of the cases. The combined median and ulnar sections had a poorer sensory-motor prognosis. Revision surgery was necessary in 12 of these cases. CONCLUSION: Sensory recovery after an isolated ulnar nerve lesion at the wrist is better than after an isolated median nerve lesion but there is no difference in the motor recovery. Combined median and ulnar lesions have an especially bad prognosis and may require secondary palliative surgery. The existence of nerve contusion and a high number of tendon injuries were factors associated with a poorer prognosis.

[Schwannomas of the peripheral nerve in the hand and the upper limb: Analysis of 14 cases]. / Schwannomes des nerfs périphériques de la main et du membre supérieur: analyse de 14 cas.

The Schwannomas are usually considered as enucleable lesions of which the excision under microscope doesn't entail a post-operative deficit. Having frequently observed the inclusion of fascicle in the tumor, we wanted to verify the absence of deficit in a retrospective survey. Our survey is composed of 14 patients operated of schwannoma of the superior member and whose mean age is 53 years old. All patients presented an average of nine months old palpable mass; the pain was present in four cases; paresthesiae in seven cases; irritatif syndrome in ten cases. A preoperative sensory deficit was present in two patients but without any case of preoperative motor deficit. The schwannoma was localized in eight cases in the hand, one case in the forearm, two cases in the elbow, two cases in the arm and one case in the armpit. The affected nerves were the digital ones in six cases, the main trunk of the median nerve in four cases, the trunk of the ulnaire nerve in three cases and the sensory branch of the radial nerve in one case. All tumors have been operated under a microscope. The enucleation was possible without fascicle lesion in six cases. In the eight other cases we have proceeded to a resection of indissociable fascicles. The diagnosis is confirmed by the histologycal examination in all cases. In postoperative, the two patients that presented a preoperative sensory deficit no longer presented it. On the contrary, three patients that didn't have any preoperative deficit presented each a post-operative sensory deficit with in addition a motor trouble in one of cases. We conclude from this survey that there is a risk of peroperative fascicle lesion even when using the microscope. This information is important to consider in the setting of deciding how to proceed before the excision of this benign lesion.

Long-term review of five leg replantations: emergency strategy and examples of lengthening of the leg on nerve regeneration.

The success rate for leg replantation has improved with the development of shortening-lengthening protocols. We checked whether this success was maintained long term in five cases of emergency reimplantation. The significant initial shortening of 93 mm, on average, enabled direct internal osteosynthesis, secondary lengthening was initiated swiftly, in the proximal metaphyseal area, and average lengthening was 85 mm. Consolidation was achieved in all cases within normal time periods, with an average inequality in residual length of 8mm. The speed of nerve regeneration was on average 1.926 mm/day, twice faster than usual after simple nerve suturing. At average follow-up of more than 11 years, all patients were walking. We conclude that nerve lengthening stimulates nerve regeneration, and that the results of this protocol, involving extensive initial debridement compensated by secondary lengthening, have enabled the limitations on unilateral leg replantation to be reduced.

Extensor tendon impingement in a gymnast.

Wrist injuries in the gymnast are due to the transformation of the upper extremity into a weight bearing entity. Gymnast wrist pain presents a difficult diagnostic and therapeutic challenge. Here, we present a new case of extensor tendon impingement in an elite gymnast. To our knowledge, there is no similar report in the literature.

[Patient information in carpal tunnel release]. / Syndrome du canal carpien: information et consentement eclairé.

Patients must be informed of the benefits and risks before any surgical procedure. This information must be clear, honest, specific and complete in order that the patient can give his or her informed consent. This information has to be given face to face, however paper may be used to emphasize certain points and aid retention of information. We studied information sheets for carpal tunnel release given out in ten different hand surgery centres. Different points were identified to analyse each form. From this analysis, a literature review and recent law texts, we propose a new information sheet for carpal tunnel release.

[Skin graft and cross finger flap for salvage reconstruction of ring finger avulsion]. / Reconstruction d'une forme particulière d'arrachement digital par bague par greffe de peau totale et lambeau "cross finger".

An exceptional case of complete cutaneous ring finger avulsion is reported. The distal fragment was not replantable because of lack of vessels. The reconstruction restored a functional finger.

[A new cause for iatrogenic lesion of the ulnar nerve at the arm: contraceptive hormonal implant. Report of two cases]. / Une nouvelle cause iatrogène d'atteinte du nerf ulnaire au bras: l'implant hormonal contraceptif. A propos de deux cas.

The authors describe two cases of iatrogenic lesions of the ulnar nerve at the arm level after insertion of contraceptive hormonal implants. The presence of only a thin subcutaneous fat layer on the medial side of the arm in slim women, exposes the ulnar nerve to danger during the insertion or withdrawal of the implant. We therefore advise the insertion of such implants on the medial side of the thigh in slim women. We equally recommend that withdrawal of non-tangible devices implanted on the medial side of the arm or in case of neurologic symptoms, even transitory, be done by a trained microsurgeon.

The safest location for steroid injection in the treatment of carpal tunnel syndrome.

Steroid injections are routinely performed for carpal tunnel syndrome. Direct needle injury of the median nerve is the major complication of these injections. The safest location of the injection remains controversial. The purpose of this study is to define safe guidelines to avoid nerve injury. The distances between the Median nerve, Palmaris Longus, Flexor Carpi Ulnaris and Flexor Carpi Radialis tendons were measured pre-operatively, 1cm proximal to the distal wrist crease in 93 endoscopic carpal tunnel releases. We found that the median nerve extended ulnarly beyond the Palmaris Longus tendon in 82 hands (88%). It is concluded that the median nerve is at risk if the injection is performed within 1cm on either the ulnar or radial side of the Palmaris Longus tendon. More ulnarly, there is risk to the ulnar pedicle. The safest location is to inject through the FCR tendon.

[Acute PIP joint fractures]. / Fractures récentes des articulations IPP.

Recent PIP fractures are challenging trauma in terms of diagnosis as well as treatment. It must be remembered that the final outcome will have a considerable impact on the global finger and hand function. Immediate mobilization and rehabilitation are mandatory, and may justify a surgical approach and fixation in selected cases. A good understanding of the fracture type is essential and relies in good part on precise, focused and standardized radiographs. Non-displaced fractures are generally treated conservatively. In the proximal phalanx, the orientation of the fracture line dictates the stability of the fracture. Thus non-displaced fractures can occasionally be preventively stabilized, in order to allow early mobilization. Displaced fractures should always be anatomically reduced and surgically fixed. A temporary joint stabilization is optional. In the middle phalanx, one must consider palmar and dorsal fractures differently. Palmar fractures include a distal palmar plate avulsion. The degree of impaction will dictate the stability of the joint towards dorsal subluxation. Dorsal fractures include central slip avulsion of the extensor tendon. An antomical reduction and surgical fixation is mandatory to avoid a progressive boutonniere deformity. Prognosis of all the middle fractures is closely dependent on the degree of impaction. When direct osteosynthesis is not possible, distraction devices, bone graft or palmar plate reconstruction may be useful alternatives. In complex fractures, bone fixation and joint stabilization must be combined in order to prevent secondary displacement and joint instability.

[Sifting through the results, a proposal for a new concept of outcome measurement. In connection with a series of 72 carpal tunnel endoscopic releases]. / Le tamisage des résultats, proposition d'un nouveau principe d'evaluation en chirurgie de la main. A propos d'une série de 72 libérations du canal carpien.

We present a new concept in outcome measurement namely "sifting", which we demonstrate in a series of endoscopic carpal tunnel releases on 72 patients. Each patient is evaluated by considering three groups of criteria. The criteria in the first group are evaluated by the patients themselves (self-evaluation), those in the second group are evaluated by a medical observer (clinical examination) and those in the third group are evaluated by the community (socio-professional aspects). We consider that the global outcome result is good only if it is good at the same time from the point of view of the patient himself, from the point of view of the medical observer and from the point of view of the community. The originality of this "sifting" concept consists in sorting the global outcomes according to a principle of elimination. When the global outcome of each patient is passed through the sieve, this total result is considered as "poor" if only one of the three groups is noted as having a bad result. By applying this original principle to our series, we obtained 11 bad self-evaluated results (reduction in the preoperative DASH lower than 10), 6 bad clinical results (persistence of awkward paraesthesiae) and 1 bad socio-professional result (absence of return to work). After sifting all the patients the poor results represented 14 patients (19 %). It seems to us that this sifting principle represents an advance compared to existing evaluation forms, which do not independently consider these three points of view, and which provide a total score by means of arithmetic operations with arbitrary coefficients.

[Eight days of hand emergencies. Report of the audit carried out at the FESUM centers from June 3 to June 9, 2002]. / Huit jours d'urgences mains. Rapport de l'audit réalisé dans les centres FESUM du 3 au 9 juin 2002.

All the FESUM centers in France, Belgium and Switzerland were invited to participate in this prospective audit, during 1 week in June 2002. In these FESUM centers, the patients are operated by senior hand surgeons or trainees graduated with a microsurgical and a hand surgery University degrees. All acute hand disorders, requiring surgery or not, were to be included. For every case, a standardized form was to be filled. This form included 22 fields concerning the specificities of the patient, the circumstances of the accident, the lesions and initial treatment up to exit of the patient out of the Hand Center. Out of the 43 French centers, 38 (90%) participated in this study, but only 30% in the other French speaking countries. A total of 2360 forms were completed and analyzed, representing a mean of 8 forms per day center (6-147). The population was predominantly active men with a mean age of 31. Manual workers represented 41%, scholars 33%. Most of them came to the Hand Center with a non-specilized vehicle (86%). Emergency medical transportation was required in 130 cases (5.8%). A majority of the patients were treated on an outdoor basis. A 1-day admission concerned 29% of the patients, and 4.6% have been admitted on an indoor basis during several days. Work accident represented 28% of all the cases, while the majority was daily living (62%) or sport (15%) accidents. Closed trauma represented 50% of the cases. Amongst open trauma (974 cases), 862 were simple skin lacerations, 156 skin loss, 140 extensor tendon lacerations, 70 flexor tendon lacerations. A preliminary wound exploration had been performed in a non-specialized center in 124 cases (12%). Complete amputation of some part was observed in 33 cases. In 32%, the initial severity of the lesion led to expect some degree of definitive consequences. Some kind of anesthesia was required in 43% of the cases (local in 41%, troncular in 19%, plexical in 28% and general in 9%). A surgical procedure was performed in 45% of the patients. Microsurgery was necessary in 15%, six of which were replantations. The period between presentation to the Hand Center and treatment was less than 1 day in 95% of the cases. Time of treatment was considered to be delayed in 113 cases (5%). Following this audit, it is considered that the FESUM centers make provision for the care of 120,000 cases per year, 54,000 of which needing a surgical procedure. This may be a small part of the total load of emergency hand surgery throughout the country (generally estimated over 1.4 million), but compares quite favorably with other European studies. We believe that improvement relies essentially on a better orientation of the patients whether they need a simple skill or specialist skill treatment. An information leaflet about orientation of hand trauma has been distributed to non-specialized emergency centers. Hand surgery training must be reevaluated inside the universitary system to avoid a dramatic lack of hand surgeons within a few years. A new audit will be presented next year.

[Patient-rated wrist questionnaire: preliminary report on a proposed French version of a North American questionnaire designed to assess wrist pain and function]. / Auto-évaluation de la douleur et de la fonction du poignet. Proposition d'une version française d'un questionnaire nord-américain et essai préliminaire.

We present a French translation of a North American self-assessment questionnaire (Patient Rated Wrist Questionnaire or PRWE). This questionnaire was developed by Joy MacDermid and members of the IWI (International Wrist Investigators). Three years were needed to establish the specific items and questions to get a valid and reliable questionnaire. It includes 5 questions on pain and 10 questions on function. All the questions were rated on a 0-10 scale. The questionnaire provides several scoring options with a total of 100. MacDermid assessed the responsiveness of three questionnaires (DASH, SF-36 and PRWE) in 59 patients after distal radius fractures. Standardised response means (SRM) were calculated to indicate responsiveness. The PRWE was the most responsive. The French version was evaluated on 20 patients. All the questions were understood. The mean writing time was 5 minutes (3 min - 7 min).