[Intrathoracic dislocation fracture of the head of the humerus]. / Fracture-luxation intrathoracique de la tête humérale.

We present a rare case of fracture-dislocation of shoulder with intrathoracic displacement of the humeral head. This case is well documented by CT. The mechanism and treatment modalities are discussed, and pertinent literature is reviewed.

Interleukin (IL)-6 and its soluble receptor induce TIMP-1 expression in synoviocytes and chondrocytes, and block IL-1-induced collagenolytic activity.

To define the potential role of interleukin-6 (IL-6) and its soluble receptor alpha in cartilage metabolism, we analyzed their effects on tissue inhibitor of metalloproteases (TIMP) synthesis by synoviocytes and chondrocytes. TIMP-1 production by isolated human articular synovial fibroblasts and chondrocytes, stimulated by IL-6 and/or its soluble receptor, was first assayed by specific enzyme-linked immunosorbent assay; the slight stimulatory effect of IL-6 on TIMP-1 production by both types of cells was markedly amplified by the addition of soluble receptor, the maximal secretion being observed only at 96 h. TIMP-1 mRNA expression, determined by ribonuclease protection assay, was induced by IL-6 together with its soluble receptor, but TIMP-2 and -3 mRNAs were not affected by these factors. A specific neutralizing antibody abolished the effects of the soluble receptor. Finally, supernatant from synoviocytes stimulated by IL-6 plus its soluble receptor blocked almost completely the collagenolytic activity of supernatant from IL-1-induced synoviocytes. These observations indicate that IL-6 and its soluble receptor have a protective role in the metabolism of cartilage. Given the high levels of soluble receptor in synovial fluid and the marked induction of IL-6 by IL-1 or TNF-alpha, it is likely that IL-6 and its soluble receptor are critical in controlling the catabolic effects of pro-inflammatory cytokines.

[Distal humeral fracture in adults: functional evaluation and measurement of isometric strength]. / Fractures de la palette humérale chez l'adulte: évaluation fonctionnelle et mesures de forces isométriques.

PURPOSE: The purpose of the study was to determine prognostic parameters in adult distal humeral fracture. MATERIAL: Thirty patients were reviewed retrospectively at a mean follow-up of 5 years. According to the AO classification there were 5 type A, 5 type B and 20 type C fractures, of which 7 were open. An internal fixation was performed in 27 patients while 3 cases were treated conservatively. An olecranon osteotomy was performed in 8 patients. A bilaterotricipital approach according to Alonso-Llames was performed in 8 cases while 6 times a V-shaped section of the triceps and 3 times a transtricipital approach were performed. A lateral approach and a combined medial and lateral approach were performed one time each. Active-assisted motion begun in 19 patients before the fifth post-op day. Three secondary displacements required reoperation. METHOD: The assessment included a questionnaire, a physical as well as radiological examination and measurements of isometric flexion and extension strength of both elbows. Statistical correlations were performed using non parametric tests at a P < 0.05 level. RESULTS: Average flexion was 127 degrees, while there was an average lack of extension of 29 degrees. Pronation and supination were respectively 68 degrees and 85 degrees. Twenty-two patients were subjectively satisfied with their elbow. The measurements of isometric strength of the fractured elbow showed that the right side which was dominant in the whole population was statistically weaker at follow-up than the left side. This difference was significant for flexion strength (Wilcoxon test P = 0.028) and highly significant for extension strength (Wilcoxon test P = 0.0002). The surgical approaches also influenced strengths. The Alonso-Llames approach was thought to give a better result than the other approaches. Patients mobilized before the fifth post-op day showed a statistically better flexion than patients mobilized later on (exact Fisher test P = 0.013). The difference was not statistically significant for the extension. DISCUSSION AND CONCLUSION: The distal humeral fracture produces a decrease of the elbow strength which is more severe for the dominant side. The reason is unknown. The Alonso-Llames approach seems to be the most favorable approach while the V-shaped section of the triceps shows a deleterious effect on strength. Early post-op exercises seem to have a positive effect on the long term ROM. Neither the fracture type (classification) nor the ROM, nor the strength are correlated with the subjective feeling of the patient. On the other hand statistical correlations show that unsatisfied patients are heavy workers (exact Fisher test P = 0.033) and patients younger than 60 years old (exact Fisher test P = 0.029).

Restoration of metacarpophalangeal extension of the thumb in inflammatory arthritis.

Nine patients (11 cases) with inflammatory arthritis who had an early boutonnière deformity of the thumb treated by rerouting of the extensor pollicis longus tendon were reviewed. Preoperatively, all patients complained of pain, disability in activities of daily living and extensor lag of the MP joint ranging from 10 to 60 degrees. At a mean follow-up of 38 months, nine thumbs had equal active and passive MP joint extension. Two thumbs had a moderate extensor lag. Functional strength assessment demonstrated no deleterious effect of the procedure in the operated compared to the non-operated thumb. Subjectively, all patients but one were satisfied. This procedure appeared to correct or to limit the progression of the deformity. A deficit of interphalangeal extension in five patients may require a modification of the procedure to tighten the extensor pollicis longus distal to the MP joint.

Fasciculated intramedullary pinning of metacarpal fractures.

We reviewed 20 patients with 23 displaced extraarticular fractures of the distal end of the long metacarpals, treated by fasciculated pinning. At a mean follow-up of 5 years, all the patients were subjectively satisfied with the result. All the patients but one, who fractured four metacarpals, had a normal range of motion. The average grip strength was 43.4 kg for the operated side compared to 43.4 kg for the uninjured hand. Radiologically, the fractured fifth metacarpal had a shortening of 2.2 mm compared to a control group, whereas the volar angulation was 16.6 degrees (13.2 degrees for the control group). The technique of intramedullary fasciculated pinning is a reliable alternative when conservative treatment of fractures of the metacarpal neck has failed or is inappropriate. The procedure provides sufficient stability to allow early mobilization and a good functional result.

[Progressive fragmentation of a bipartite patella: apropos of a case]. / Fragmentation progressive d'une patella bipartita. A propos d'un cas.

PURPOSE OF THE STUDY: Progressive dissolution of the supero-lateral fragment of a bipartite patella is reported. MATERIAL AND METHODS: The patient, a 44 year old professor of gymnastics, was examined for long standing anterior knee pain. For many years, his daily activities included forceful knee flexion exercises. Serial radiographs, between 1986 and 1990, revealed a progressive fragmentation of the accessory ossification center and accompanying calcific deposits in the lateral patellar retinaculum. RESULTS: Surgical excision of the calcific mass and accessory ossification center relieved the painful symptomatology completely, allowing the patient full normal function at one year's follow-up. DISCUSSION: The pathological findings were compatible with a dystrophic calcinosis associated with detritic synovitis. A pathogenic mechanism is hypothesized for this unusual and progressive course of a common condition: Repetitive trauma, in this case forceful knee flexion exercises, shear microscopic bony fragments of the poorly vascularized accessory ossification center. These microscopic fragments act as deposits of an apatite crystal which go on to induce the secondary soft tissue calcifications seen in our patient.

Infective iliopsoas bursitis. A case report.

We report a case of infective iliopsoas bursitis, and to our knowledge a similar case has not been described. The anatomical relation between the bursa and the hip, and related pathological conditions are reviewed. The contribution of CT-guided catheterisation is emphasised as it allows aspiration of fluid, injection of radio-opaque material and lavage.