Blast injury of the hand related to warfare explosive devices: experience from the French Military Health Service.

INTRODUCTION: The objective was to report on the experience of the French Army Health Service in the management of blast injury of the hands related to warfare explosive devices. METHODS: A retrospective study was conducted in the Percy Military Hospital (role 4 medical treatment facility) among French soldiers who presented with a combat-related blast injury of the hand between 2002 and 2018. The functional result was assessed by the disabilities of the arm, shoulder and hand (DASH) and the Orthotics and Prosthetics User Survey (OPUS, upper extremity functional status) scores. Proximal amputations (PAs) and distal amputations (DAs) were distinguished for the analysis. RESULTS: Fifteen patients with a mean age of 31±8 years were included. They totalised 20 blasted hands. There were 16 traumatic amputations: 8 in each of the PA and DA groups. Twelve patients had additional injuries, four of which were polytraumatic. Skin closure time and flap use were higher in the DA group. Only one thumb reconstruction was performed. At a mean follow-up of 6.5±4 years, the number of amputees wearing a prosthesis was higher in the PA group. The mean DASH and OPUS scores were 35.5%±24.0% and 64.0%±19.0%, respectively, with no difference between the two groups. CONCLUSION: The severity of hand blasts related to warfare explosive devices requires the systematic application of damage control surgery. PAs are frequent and secondary reconstruction options are limited. The functional result is poor and similar between proximal and distal amputees.

Microprocessor prosthetic ankles: comparative biomechanical evaluation of people with transtibial traumatic amputation during standing on level ground and slope.

BACKGROUND: The compensations occurrence due to the alteration of the posture and the gait of persons with lower limb amputation is still an issue in prosthetic fitting. Recently, prosthetic feet designed to reproduce the physiological behaviour of the ankle using a microprocessor control have been commercialized to address this issue. OBJECTIVES: Investigate the relevance of these microprocessor prosthetic ankles (MPAs) in the ability of standing on both level and inclined surfaces. METHODS: Six persons with transtibial amputation usually fitted with energy storing and returning (ESR) foot tested three MPAs: Elan® Endolite (MPA1), Meridium® Ottobock (MPA2), ProprioFoot® Ossur (MPA3). Each MPA data acquisition was preceded of a 2 weeks adaptation period at home and followed by a 3-weeks wash-out period with their ESR. Lower limb angular position and moment, Centre of Pressure (CoP) position, Ground Reaction Forces (GRF) and functional scores were collected in static, on level ground and 12% inclined slope. RESULTS: MPAs allowed a better posture and a reduction of residual knee moment on positive and/or negative slope compared to ESR. Results also reflect that the MPA2 allows the best control of the CoP in all situations. CONCLUSIONS: An increased ankle mobility is associated with a better posture and balance on slope. Gait analysis would complete these outcomes. CLINICAL RELEVANCE: This study compares three MPAs to ESR analysing static posture. Static analysis on level ground and slope represents the challenging conditions people with amputation have to cope with in their daily life, especially outdoors. Having a better understanding of the three MPAs behaviour could help to adequately fit the prosthesis to each patient. Implications for rehabilitation This is a study comparing three MPAs. The static analysis in standard and constraining conditions (slope) reflects the balance of people with amputation in their daily life, especially outdoors. Having a better understanding of the behaviour of each foot could help to adequately fit the prosthesis to each patient.

[Autonomic nervous system alteration in multiple sclerosis patients with urinary symptoms. Clinical, urodynamic and cardiovascular study]. / Dysautonomie et troubles urinaires au cours de la sclérose en plaques. Étude clinique, urodynamique et cardiovasculaire.

OBJECTIVE: To assess symptoms related to autonomic nervous system alteration in a population of patients suffering from multiple sclerosis (MS) and presenting with urinary symptoms. PATIENTS AND METHODS: We investigated 65 patients (mean age 47.5 years) suffering from MS, and presenting with urological dysfunction by means of symptom scores, urodynamic investigation, cardiovascular autonomic function tests (orthostatic hypotension testing, Valsalva test, deep breath test, cold pressor test) and sympathetic skin responses. RESULTS: Forty-five (69%) patients suffered from overactive bladder, 48 (73%) from voiding dysfunction, 14 (21%) from urinary retention and 13 (20%) from fecal incontinence. Urodynamic investigation demonstrated overactive detrusor in 46 (70%) cases, and underactive detrusor in four (6%) cases. Twenty-five (38%) patients had dysautonomia without correlation neither with clinical or urodynamic data, nor gravity of multiple sclerosis (EDSS). CONCLUSION: In this series, the prevalence of dysautonomia was high in patients suffering from MS and presenting with urinary disorders.

[Amputation in low-income countries: particularities in epidmiological features and management practices]. / Les amputations dans les pays à faibles revenus: particularités de l'épidémiologie, de l'appareillage et de la rééducation.

The epidemiological features and management practices associated with amputation in low-income countries, generally synonymous with the tropics, are different from those observed in Western countries. Unlike developed countries, amputation most frequently involves traumatic injury in young active people. However, Westernization of the lifestyle is leading to an increasing number of cases involving diabetes and atherosclerotic disease. In the developing world, leprosy and Buruli ulcer are still significant etiologic factors for amputation. In war-torn countries, use of antipersonnel landmines is another major cause of amputation with characteristic features. Management of amputees in the developing world is hindered by the lack of facilities for rehabilitation and prosthetic fitting. Many international organizations are supporting national programs to develop such facilities. In addition to being affordable, prosthetics and orthotics must be adapted to the living conditions of a mostly rural amputee population, i.e., heat, humidity, and farm work. The rehabilitation process must be part of a global handicap policy aimed at changing attitudes about disability and reintegrating amputees both socially and professionally.

A rare case of paraplegia complicating a lumbar epidural infiltration.

OBJECTIVE: We report the case of a patient who developed paraplegia following a low lumbar epidural steroid injection. Alternative approaches to (or alternative means of) performing transforaminal injections should be considered, in order to avoid devastating neurological complications. CASE REPORT: A 54-year-old man (who had undergone surgery 14 years earlier to cure an L5-S1 slipped disc with right S1 radiculopathy) presented with low back pain (which had begun 6 weeks previously) and left S1 radiculopathy. During a second infiltration of prednisolone acetate, the patient reported feeling a heat sensation in his legs and concomitantly developed facial flushing. Immediately after the injection, the patient developed complete, flaccid T7 ASIA A motor and sensory paraplegia. Three days later, T2 magnetic resonance imaging (MRI) of the spine revealed a spontaneous hypersignal in the conus medullaris and from T6 to T9, suggesting medullary ischemia. Recovery has been slow; after 4 months of treatment in a physical and rehabilitation medicine department, urinary and sensory disorders are still present (T7 ASIA D paraplegia). The patient can walk 200 m unaided. Three months later, the MRI data had not changed. DISCUSSION: This is a rare case report of paraplegia following low lumbar epidural infiltration via an interlaminar route. The mechanism is not clear. Most of authors suggest that the pathophysiological basis of this type of complication is ischemia caused by accidental interruption of the medullary blood supply. Direct damage to a medullary artery, arterial spasm or corticosteroid-induced occlusion due to undetected intra-arterial injection could result in medullary infarction. This serious incident should prompt us to consider how to avoid further problems in the future. It also raises the issue of providing patients with information on the risks inherent in this type of procedure. CONCLUSION: Despite the rarity of this complication, patients should be made aware of its potential occurrence. In the case reported here, the functional prognosis is uncertain.

Comparison of the repercussions of cLBP in four French-speaking countries.

INTRODUCTION: Sociocultural factors may influence the impact of chronic low back pain (cLBP) on patients. The goal of this study was to compare pain and disability levels, and psychobehavioural parameters in four French-speaking countries in patients with cLBP. METHODS: Two hundred and seventy-eight patients were included: 83 in France, 36 in Morocco, 75 in the Ivory Coast and 84 in Tunisia. Demographic data were collected; pain was assessed using a visual analogue scale (VAS), disability with the Quebec scale, psychobehavioural factors by the hospital anxiety depression scale (HAD), the fear and avoidance beliefs questionnaire (FABQ) and the coping strategy questionnaire (CSQ). A Student t-test was used to compare means. Anova (covariance) was used to test for a "Country Effect", i.e. the incidence of country on outcomes. OUTCOMES: There was no difference in disability levels between countries. A "country effect" was found (p<0.001) for pain (F=2.707), anxiety (F=3.467), depression (F=5.137), fear and avoidance beliefs regarding professional activity (F=1.974) and physical activity (F=5.076), strategy of distraction, dramatization, efforts to ignore pain, prayer, seeking social support and reinterpretation (p<0.01). Pain level was higher in Morocco (p<0.05); anxiety, depression, fear and avoidance beliefs about physical activities were higher in Tunisia (p<0.05) and fear and avoidance beliefs about professional activities were higher in the Ivory Coast (p<0.01). Among the coping strategies used, distraction, dramatization, prayer and search for social support were used more in the Ivory Coast; reinterpretation in Tunisia; seeking social support was less common in France. CONCLUSION: In this population of patients with cLBP, despite similar disability levels across the four French-speaking countries, there were considerable variations in pain level and psychobehavioural repercussions.

Change of impairment, disability and patient satisfaction after total knee arthroplasty in secondary care practice.

OBJECTIVES: To assess the evolution of impairment and disability after total knee arthroplasty (TKA) for osteoarthritis and to seek an association with patient satisfaction with surgery. METHOD: Consecutives patients (n=45, 18 women) with osteoarthritis undergoing primary TKA in two secondary care inpatient clinics were prospectively assessed before one month and six months after surgery. Disability was assessed by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; range 0-900) and the Lequesne Index (range 1-24). Patients' perceived handicap was assessed on a visual analog scale (VAS, range 1-100). At one month and six months postoperatively, kinetic strength of quadriceps and hamstrings was obtained by isokinetics measures and patient satisfaction on a VAS (range 1-100). RESULTS: Mean age was 71.7+/-7.0 years; mean duration of symptoms was 38.3+/-33.4 months. Patient satisfaction was 83.9+/-17.7 and 83.1+/-22.4 at one month and six months after TKA, respectively. At one month, significant improvements were observed over baseline for pain (-30.73+/-32.2; p<0.01), physical function (Lequesne Index -2.28+/-3.6, p<0.01; and WOMAC score, -82.60+/-148.5, p<0.01), and patient perceived handicap (-21.84+/-29.6, p<0.01). A significant decrease in global knee range of motion was also observed. At six months, significant improvement was observed for pain (-47.96+/-26.8; p<0.01), physical function (Lequesne Index, -5.08+/-3.66, p<0.01; and WOMAC score, -157.04+/-153.2, p<0.01) and patient perceived handicap (-39.60+/-24.1; p<0.01). All isokinetics measures for quadriceps and hamstring were significantly improved between one month and six months after surgery. At one month and six months, the correlation between patient satisfaction and change in impairment, disability and patient perceived handicap was weak. DISCUSSION AND CONCLUSION: Impairment, disability and patient perceived handicap improved significantly after TKA for osteoarthritis. However, these improvements were poorly correlated with patient overall satisfaction with surgery.

What is the place of electroneuromyographic studies in the diagnosis and management of pudendal neuralgia related to entrapment syndrome?

Entrapment of the pudendal nerve may be at the origin of chronic perineal pain. This syndrome must be diagnosed because this can result in the indication of surgical decompression of the entrapped nerve for pain relief. Electroneuromyographic (ENMG) investigation is often performed in this context, based on needle electromyography and the study of sacral reflex and pudendal nerve motor latencies. The limits of ENMG investigation, owing to various pathophysiological and technical considerations, should be known. The employed techniques do not assess directly the pathophysiological mechanisms of pain but rather correlate to structural alterations of the pudendal nerve (demyelination or axonal loss). In addition, only direct or reflex motor innervation is investigated, whereas sensory nerve conduction studies should be more sensitive to detect nerve compression. Finally, ENMG cannot differentiate entrapment from other causes of pudendal nerve lesion (stretch induced by surgical procedures, obstetrical damage, chronic constipation...). Thus, perineal ENMG has a limited sensitivity and specificity in the diagnosis of pudendal nerve entrapment syndrome and does not give direct information about pain mechanisms. Pudendal neuralgia related to nerve entrapment is mainly suspected on specific clinical features and perineal ENMG examination provides additional, but no definitive clues, for the diagnosis or the localization of the site of compression. In fact, the main value of ENMG is to assess objectively pudendal motor innervation when a surgical decompression is considered. Perineal ENMG might predict the outcome of surgery but is of no value for intraoperative monitoring.

[Psychobehavioural assessment for chronic low back pain]. / Evaluation psychocomportementale dans la lombalgie chronique.

INTRODUCTION: Psychobehavioural assessment may be a complementary approach to assess response to treatment for pain and disability in patients with low back pain. OBJECTIVES: To assess the correlation between psychobehavioural factors and pain and disability in patients with chronic low back pain in France. METHODS: We asked 83 patients with chronic low back pain to complete questionnaires during a primary care consultation by a general practitioner. Pain was measured by a visual analog scale (VAS), disability by the Quebec Back Pain Disability Scale and psychobehavioural factors by the Fear-Avoidance Beliefs Questionnaire (FABQ) and the Coping Strategy Questionnaire (CSQ). RESULTS: Pain was poorly correlated with anxiety (R = 0.36) and scores on the FABQ 1 (R = 0.46) and FABQ 2 (R = 0.30) and not correlated with depression (R = 0.22), duration of pain evolution (R = 0,10) and body mass index (R = 0.12). The duration of stopping work was poorly correlated with disability (R = 0.35) and FABQ 1 score (R = 0.43) and not correlated with pain (R = 0.11), anxiety (R = 0.11), depression (R = 0.26) and FABQ 2 score (R = 0.23). Disability was poorly correlated with scores on the FABQ 1 (R = 0.45) and FABQ 2 (R = 0.3), anxiety (R = 0.39) and depression (R = 0.47) and not correlated with pain (R = 0.25). Dramatization is the only way to cope with pain and was correlated with pain (R = 0.34), scores on the FABQ 1 (R = 0.47) and FABQ 2 (R = 0.43), disability (R = 0.38), anxiety (R = 0.44) and depression (R = 0.46). The use of prayer was poorly correlated with FABQ 1 score (R = 0.37) and anxiety (R = 0.30). Distraction was poorly correlated with scores on the FABQ 1 (R = 0.40) and FABQ 2 (R = 0.30). No strategy was correlated with duration of pain and stopping work. DISCUSSION-CONCLUSION: All the correlation assessments with psychobehaviour factors are weak. So evaluating each of these parameters will be interesting. Duration of pain was not correlated with increasing pain or change in behavioural strategy. Psychobehavioural factors are more invalidating than pain. More study is needed to assess psychobehavioural therapies in patients with low back pain.

Perineal neuromuscular fatigue.

AIM: The physiology of urinary continence during stress is complex and the role of passive and active mechanisms remains unclear. Coughing leads to a contraction of urethral rhabdomyosphincter and pelvic floor muscles leading to a positive urethro-vesical gradient and continence. Neuromuscular fatigue can involve all striated muscles, including rhabdomyosphincter, peri-urethral and pelvic floor muscles. This article reviews results of studies assessing perineal muscular fatigue in urinary incontinence. MATERIALS AND METHODS: A systematic review of the literature (Medline, Pascal and Embase) with use of the MESH keywords fatigue, stress, urinary incontinence, pelvic floor, urethra, urethral pressure, and muscle. RESULTS: Animal models have shown that the pelvic muscles (iliococcygeus and pubococcygeous) exhibit more neuromuscular fatigue than classical skeletal striated muscles (i.e. soleus muscle). Although the human external urethral sphincter is considered to be a highly fatigue-resistant muscle with its high proportion of slow muscle fibers, repeated coughing seems to lead to decreased urethral pressure in numerous women affected with stress urinary incontinence. In this case, "urethral fatigue" might be a possibility. CONCLUSIONS: Although few studies have focused on perineal muscular fatigue, such increased fatigue in pelvic floor muscles may play a role in the pathophysiologic features of stress urinary incontinence in women.

[Constituted adult equine from the ankle: surgical treatment by Ilizarov external fixator]. / Pieds équins constitués de l'adulte: correction par fixateur externe d'Ilizarov.

INTRODUCTION: Ilizarov's external fixator indications are classically used in children to lengthen the lower limbs. This technique is used for adults to gradually correct articular limitations, especially in the knee, ankle and foot. METHOD AND RESULTS: We report a case of a 53-year-old patient with distal microangiopathy of the lower limbs leading to amputation of the toes and a bilateral, direct, irreducible, isolated equine feature? from the back foot to 0/50/60 degrees? on retraction of the Achilles tendon. The aim of patient management was to regain walking ability. Because of vascular and cutaneous fragility, the classical surgical treatment was contra-indicated. Progressive reduction by Ilizarov's external fixator was tried. Dorsal inflection was obtained by twice-daily screwing until a radiological angle of 90 degrees was obtained between the tibia and talus. At ten weeks post-surgery, the dorsal voluntary inflection ankle amplitude was symmetrical to 0/10/60 degrees. The patient walked with orthopaedic shoes compensating for the few degrees of residual equine. DISCUSSION: Correction of adult equine without osseous deformation by Ilizarov's external fixator should be considered when conventional surgery is contra-indicated.

[Clinical evaluation of female urinary incontinence]. / Evaluation clinique de l'incontinence urinaire de la femme.

EXAMINATION: Clinical evaluation of stress and urge incontinence is always necessary before therapeutic decisions. Full bladder examination may reveal stress incontinence during cough when cervico-urethral hypermobility is suspected, and leak during Vasalva manoeuvre when incontinence is due to intrinsic sphincter deficiency. OBJECTIVE SCORES: Pad test objectives the quantitative importance of incontinence. Symptom scores allow intra and inter individual comparisons. Psychosocial implications are studied with specific quality of life scales. They allow better therapeutic strategies in the management of urge and stress urinary incontinence. Objective evaluation of the different treatments and medico-economic approach of incontinence are thus possible.

Cystic rheumatoid arthritis with Felty's syndrome and ankylosing spondylitis.

A 63-year-old man with strictly axial ankylosing spondylitis since the age of 28 years had a seven-year history of cystic seronegative rheumatoid arthritis with Felty's syndrome. Cysts were present in the hands, feet, wrists, shoulders, hips, one elbow, and one knee. There was no evidence of juxtaarticular demineralization, joint space loss, erosions, or joint destruction. Rheumatoid pannus was demonstrated within the cysts, particularly at the hip, ruling out cystic hip disease due to ankylosing spondylitis. HLA typing demonstrated the B27 and DR4 haplotypes. HLA B27 may be associated with a worse prognosis of rheumatoid hip involvement.

Nursing students' learning styles: a comparison of degree and non-degree student approaches to studying.

This research utilised the Lancaster inventory to investigate the approaches to studying of a group of nurse learners (n = 32) from a college of nursing and midwifery and a group of nursing undergraduates (n = 23) from an institution of higher education. It was hoped that the research would cast some light on whether the two groups approach their studying in similar or different ways, since these approaches may dictate success in educational ventures. The results indicated no statistically significant differences between the two learner groups' approaches to studying.