[Management of Lagrange and Rigault stage IV extension type supracondylar fracture of the humerus in children]. / Prise en charge des fractures supracondyliennes en extension stade IV de Lagrange et Rigault.

PURPOSE OF THE STUDY: Lagrange and Rigault stage IV extension type supracondylar fracture of the humerus (Gartland and Wilkins type III) involves major displacement, making treatment difficult. Several therapeutic methods have been described but indications vary considerably between teams. We conducted a retrospective analysis in order to evaluate the results of different methods, identify the most adapted technique, and detail the conditions necessary for good results with the collar and cuff immobilization method described by Blount. MATERIAL AND METHODS: Forty-four children (30 boys and 14 girls), mean age seven years six months, were treated between January 1990 and December 2001. The collar and cuff immobilization technique was used for sixteen children (including four who underwent open revision for early secondary displacement), percutaneous pinning for two, and open crossed pinning for thirty (including four who developed secondary displacement after collar and cuff immobilization). One out of two collar and cuff treatments was instituted within six hours of injury. The four secondary displacements after collar and cuff immobilization treatment occurred after fracture reduction more than six hours after injury. The proportion of open reductions increased with longer delay to reduction after injury. Mean immobilization was three and a half weeks. The Flynn criteria were used to assess outcome at mean seven years eight months follow-up. RESULTS: Outcome was satisfactory in all children treated with definitive collar and cuff immobilization and by percutaneous pinning; the rate was 97% after open procedures (persistent sequelae of radial palsy in one child). DISCUSSION: Early treatment before six hours increased the chances of success with the collar and cuff method which remains the technique of choice for Lagrange and Rigault stage IV extension type supracondylar fractures. In the event of failure or complications, other classical methods should be discussed, including percutaneous pinning or direct access for open osteosynthesis.

[Percutaneous rotational osteoclasis in management of congenital radio-ulnar synostosis]. / Ostéotomies percutanées de dérotation de l'avant-bras dans les synostoses radio-ulnaires congénitales de l'enfant.

PURPOSE OF THE STUDY: Congenital radio-ulnar synostosis blocks the wrist in a position of more or less pronounced pronation. The degree of pronation and possible bilateral involvement can compromise upper limb function. We propose percutaneous osteoclasis of the antebrachial skeleton to remedy this situation PATIENTS AND METHODS: We performed 12 percutaneous rotation osteoclasis procedures. The objective was to weaken the metaphysodiaphyseal cortical periosteum of one or both of the forearm bones by intermittent perforations. This enabled derotation of the wrist which was maintained for six to eight weeks in a brachiopalmar cast. RESULTS: Mean correction of pronation was 51 degrees. There were no cases of vascular or nervous complications and healing was uneventful. The esthetic outcome was very satisfactory. DISCUSSION: Surgery is not indicated for all cases of synostosis. We retain for surgery patients presenting pronation at 60 degrees or more. At this degree of pronation, function is greatly compromised in adolescence, particularly if there is a bilateral involvement. Compared with other techniques, percutaneous osteoclasis is a simple safe and reliable technique. Reoperation is not required to remove material. The procedure is easier in young children, preferably at the age of 3 to 7 years, before the development of a functional handicap.

[Capsular shift for voluntary dislocation of the shoulder: results in children]. / Capsulorraphie dans les instabilités volontaires de l'épaule: résultats chez l'enfant et l'adolescent.

PURPOSE OF THE STUDY: Chronic shoulder instability is uncommon in patients with an immature skeleton. Some of these pediatric patients can produce their dislocation voluntarily raising the question of the traumatic or constitutional nature of the condition as well as its direction and tolerance. We report our experience with 29 patients. MATERIAL AND METHOD: Over a period of 28 years, 29 children aged 5 to 15 years were treated for voluntary shoulder dislocation. The dislocation was painful and poorly tolerated in 19, affecting daily life and sports activities. Posterior dislocation was observed in 15 patients and anterior dislocation in 4, but the direction was not always easy to establish, particularly in children with ligament laxity; multiple directions were not uncommon. Rehabilitation for at least eight months did not relieve pain in 11 patients who had a sensation of a blocked, unreliable shoulder which could not be controlled voluntarily. Posterior capsulorrhaphy was performed in 8 patients and anterior capsulorrhaphy in 3. RESULTS: Mean follow-up was 8 years. At last follow-up, all shoulders were stable and shoulder motion was normal with no loss of function. More than half of the children had resumed sports activities. Capsulorrhaphy was proposed when the pre-operative explorations did not reveal any bone or rim anomaly. The only preoperative finding in the operated patients was increased capsule volume, particularly in the inferior portion. Intraoperatively, ulceration of the humeral cartilage was found in two patients. Anatomic reconstruction of the capsuloligamentary structures enabled recovery of passive stability and active stability of the scapulohumeral joint, preventing further voluntary dislocation.