[Palsy of the upper limb: Obstetrical brachial plexus palsy, arthrogryposis, cerebral palsy]. / Les paralysies du membre supérieur : plexus brachial obstétrical, arthrogrypose, paralysie cérébrale.

"Palsy of the upper limb" in children includes various diseases which leads to hypomobility of the member: cerebral palsy, arthrogryposis and obstetrical brachial plexus palsy. These pathologies which differ on brain damage or not, have the same consequences due to the early achievement: negligence, stiffness and deformities. Regular entire clinical examination of the member, an assessment of needs in daily life, knowledge of the social and family environment, are key points for management. In these pathologies, the rehabilitation is an emergency, which began at birth and intensively. Splints and physiotherapy are part of the treatment. Surgery may have a functional goal, hygienic or aesthetic in different situations. The main goals of surgery are to treat: joints stiffness, bones deformities, muscles contractures and spasticity, paresis, ligamentous laxity.

[Congenital malformations of the forefoot]. / Les malformations congénitales de l'avant-pied.

Malformations and deformations of the forefoot are a frequent reason for consultation. The most frequent malformations viewed at birth are syndactylies (second web space), clinodactylies (quintus varus, halllux), polydactylies (hallux, fifth toe). The macrodactylies, hypoplasia, amniotic bands are rare. The management of these defects requires knowledge of surgery adult foot, plastic surgery and especially collaboration with physiotherapists, podiatrists and orthotists. The fast growth of the foot the first year and the development of walking at one year require to start early the treatment of deformations and to anticipate the evolution of malformations.

[Management of upper obstetrical brachial plexus palsy. Long-term results of non-operative treatment in 22 children]. / Traitement conservateur des paralysies obstétricales hautes du plexus brachial. Résultats à long terme chez 22 enfants.

INTRODUCTION: Treatment of obstetrical brachial plexus palsy (OBPP) is always debated, especially for upper plexus palsy. Some authors perform early surgical treatment in case of absence of biceps contraction at the age of 3 months. Others prefer to wait until the age of 6 months before considering a surgical procedure when no suspicion of root avulsion is found. We think that a conservative approach with intensive rehabilitation program can obtain good functional outcome for patients who will recover biceps function spontaneously between 3 and 6 months, and that it is not necessary to perform surgery at 3 months. To argue our choice, we have compared the long-term outcome of two groups of children with upper OBPP conservatively treated regarding the age of biceps recovery (before or after 3 months). PATIENTS AND METHODS: Twenty-two patients with non operated upper roots birth palsy, followed in Timone's Hospital of Marseille by a multidisciplinary team, have recovered a biceps contraction between 1 and 8 months and were retrospectively included in this study. All children underwent an intensive rehabilitation program since birth, performed by a specialized physiotherapist. Patients were reviewed, and their shoulder function was assessed using Mallet score. The score was analysed regarding the age of biceps recovery. RESULTS: The mean follow up was 8.2 years. Nine children recovered a biceps contraction at 3 months of age or before; the mean global Mallet score was 4.11. Thirteen children recovered a biceps contraction after 3 months of age (between 3 and 8 months); the mean global Mallet score was 3.92. The difference was not statistically significant. CONCLUSION: This study shows that global shoulder function is comparable for two groups. The children who did not recover a biceps contraction at 3 months of age had a global shoulder function as good as the one who recovered biceps function earlier. We think our intensive rehabilitation program allowed us to avoid a useless early surgery. Surgical plexus treatment was indicated for children who did not have biceps contraction after 6 months of age.

[The paediatric plastic surgery]. / La chirurgie plastique de l'enfant.

Paediatric plastic surgery is a complex surgery. The management of traumatized or malformed children needs a lot of contributors: the paediatric plastic surgeon is often the "conductor" of a large team. Paediatric plastic surgery is a very nice but fragile speciality. This surgery needs a long experience, a large recruitment and a rigorous training. Good university education is necessary to know techniques and children's pathologies. An international recruitment is necessary for these rare pathologies. Surgical training is also important with a good training in microsurgery and minimally invasive surgery. The management of children needs to know physiologic particularities, specific pathologies, cicatrisation particularities and especially the outcome of growth and psychomotor development. Some French surgeons are references in the world for surgery of hand abnormalities, ear reconstruction or skin expansion. They changed techniques and indications to improve each day the live of children with abnormalities. Interviews of these surgeons are very useful to understand and improve the French creativity.

Congenital ptosis: Long-term outcome of frontalis suspension using autogenous temporal fascia or fascia lata in children.

Children with severe congenital blepharoptosis are at risk of developing amblyopia. For this reason, ptosis repair is indicated as soon as the diagnosis is made. Frontalis suspension of the upper lid is an effective and simple method of treatment. This study reports on the long-term outcome of frontalis suspension surgery for congenital ptosis using autogenous sling material. Twelve children with severe congenital ptosis underwent frontalis suspension surgery using autologous fascia lata or temporal fascia. The results were assessed with a mean follow-up period of 8 years. Eleven children had good or excellent functional and aesthetic results. There were no cases of recurrence or overcorrection. Frontalis suspension using autologous material is a harmless procedure, which does not alter the upper eyelid structures. It is an effective procedure in the long term. In our opinion, it is the technique of choice to treat young children with severe congenital ptosis.

Two rare cases of association of thumb hypoplasia and polydactyly of the homolateral foot.

This paper presents two cases of radial deficiency and thumb aplasia associated with polydactyly of the homolateral foot and a supernumerary toe resembling a thumb. To our knowledge, this association of malformations has not been described previously.

Malignant melanoma on congenital naevus: a case of degeneration in a 6-month-old child with severe histological criteria.

Malignant melanoma in children is a rare and poorly understood pathology. We report a case of nodular melanoma that developed on congenital naevus in a 6-month-old infant. The histological results revealed a nodular melanoma on a congenital naevus measuring 6.625 mm in tumour thickness according to Breslow. The infant was treated by broad resection without adjuvant treatment. Follow up is 43 months without metastasis. Malignant melanoma is a rare pathology: 1-4% of all melanomas occur before the age of 20 and 0.3-0.4% of those are before puberty. The risk of degeneration of a congenital naevus into a melanoma is approximately 0.7%. Surgical exeresis must be broad. Up to now, no complementary treatment has proven to be effective. Pre-operative examination for sentinel lymph nodes by lymphography can be of interest although such an examination is difficult in children. The prognosis would appear to be similar to that of malignant melanoma in adults with a high mortality. This is therefore an argument in favour of early treatment and prolonged follow up of children with malignant melanoma.

[The upper limb of children with cerebral palsy: surgical aspects]. / Le membre supérieur de l'enfant infirme moteur cérébral: aspects chirurgicaux.

Cerebral palsy has a complex and multifactorial etiology. The management of the upper limb aims to improve function, hygiene and cosmesis in many patients. Surgical treatment need a good and repeated clinical examination before. The functional surgery has a lot of procedures on the elbow, the wrist, the fingers and the thumb. These procedures include the release or lengthening of spastic muscles, tendon transfers and joint stabilizations. The surgeon must know the indications and contraindications of functional surgery.

[Children's tumors of the hand]. / Tumeurs de la main chez l'enfant.

Soft-tissue and osseous tumors of the hand in children differ considerably from those of adults, not only in frequency but also in terms of anatomic distribution, histologic type and prognosis. Malignant tumors are rare in children, the most common being rhabdomyosarcoma for soft-tissue tumors, and osteosarcoma and Ewing sarcoma for osseous tumors. Hemangioma is the most common soft-tissue tumor in infancy and childhood. Other vascular abnormalities are capillary malformation, venous malformation. Many other benign soft-tissue and cutaneous tumors can be seen (ganglion cyst, naevus, fibroma...). The surgeon must know the signs, evolution and the treatment of these tumors.

[The Apert's syndrome hand: therapeutic management]. / La main du syndrome d'Apert: stratégie thérapeutique.

Apert's syndrome is the most common among acrocephalosyndactylies with complex malformations of the hands. Treatment of the Apert hand is complex and numerous procedures are required. The aim of this study is to propose a strategy for hand management. Sixteen Apert syndrome hands were submitted to early surgery which included opening of the first web, separation of the fingers, realignment of the thumb and correction of the clinodactylies. We performed an average of six operations per child. Treatment of the first web depended on the classification of Upton: for the severe stages, we used a dorsal hand flap. Radical clinodactyly was treated by osteotomy of the delta phalanx and Z-plasty. We treated nine hands with four fingers and seven hands with five fingers. There was always bilateral opposition and symphalangism, excluding the fifth finger. All of the children have a rudimentary but functional pinch grip. Revision of the webs was necessary in 16% of the cases. The Apert hand requires early and specialised treatment that aims to provide a functional hand before two or three years, with the least surgical complications. The functional prognosis is darkened by symphalangism.

[Vascular anomalies of the children's hand]. / Les anomalies vasculaires de la main de l'enfant.

Vascular anomalies are common on the hand of children. There are two types of vascular anomalies: the vascular tumours and the vascular malformations. The most frequent vascular tumour is infantile haemangioma. The vascular malformations could be predominantly venous, lymphatic, capillary or arteriovenous. Combined vascular malformations, often syndromic, must be searched for. Diagnosis is sometimes difficult. It is based on clinical history, aspect, evolution and radiological examinations (color-Doppler ultrasound and MRI). Treatment is often a combination of medical and surgical approaches performed by a multidisciplinary team.

[Macrodactylies of the hand and foot]. / Les macrodactylies de la main et du pied.

Macrodactyly is a rare congenital anomaly defined by an enlargement of all the structures of fingers or toes. Two forms of macrodactyly have been described. One form is static with an enlargement present at birth and growing proportionately to the other digits. The other is progressive with an enlargement beginning in early childhood and growing faster than that of the normal digits. Macrodactyly is responsible of a functional handicap and an aesthetic prejudice. Treatment may be indicated for this reason. Treatment must be individualised and depends on the proportionate size of the enlarged finger, growth rate and the patient's age when first seen. The parents and the child should be advised that multiple procedures may be required and that the result will be somewhat unsatisfactory. Surgical approaches include either reconstructive surgery or amputation. Amputation is indicated at any age for a large, unsightly and stiff digit that interferes with function of the rest of the hand. In feet with involvement of the lesser toes, proximal amputation has the best cosmetic and functional outcome. Epiphyseal arrest, bulk reduction procedures, finger shortening, lateral closing-wedge osteotomies or stripping of the nerves can be performed in the other cases.

[Camptodactyly]. / Les camptodactylies.

Camptodactyly is a permanent, nontraumatic flexion of the proximal interphalangeal joint. The prevalence is around 1% and the little finger is most commonly affected. Two groups may be identified, depending on the age of onset: camptodactyly severe within 2-3 years or beginning in the early teens. Many anatomical abnormalities have been incriminated as the cause of camptodactyly: anomalous lumbrical muscle, short flexor digitorum superficialis, retractile subcutaneous tissue, anomalous extensor muscle. Splinting is always required, with dynamic and/or static splinting of the proximal interphalangeal joint. If improvement is not obtained with splinting, surgery can be proposed. Surgical treatment must correct the soft tissue contracture (flap and skin graft), the tendinous anatomical abnormalities and the joint contracture. Splinting and physiotherapy is necessary after surgery.

[Syndactyly]. / Syndactylies.

Syndactyly is one of the most common congenital anomalies of the hand. It can be isolated or associated with systemic syndromes. Surgical treatment is performed between the ages of six and 18 months depending on the type and extent of the malformation. Commissure construction is achieved using local flaps. Direct closure of the lateral sides of the digits is possible in many cases. In complex cases, and/or when adjacent web spaces are involved, full-thickness skin grafts remain useful. Functional and cosmetic results are usually excellent in simple cases. In complex cases, postoperative prognosis depends on the severity of bone, joint and tendons abnormalities.

[Management of a perineal arteriovenous malformation in a 5-year-old child]. / Prise en charge d'une malformation artérioveineuse périnéale chez un enfant de 5 ans.

Arteriovenous malformations are seldom in children but raise important therapeutic problems. Apart from intracranial arteriovenous malformations, few observations have been described in the literature. We report the case of a superficial perineal arteriovenous malformation in a 5-year-old child. Tailored embolization followed shortly by thorough surgery is the best attitude. Surgery must totally eradicate the lesion to allow hope for a cure. Surgery should be reserved for forms that are extensive or a source of complications. Even total resection does not ensure non-recurrence.

[A new technique of intrafocal pinning for phalangeal neck fractures in children]. / Une nouvelle technique d'embrochage intrafocal des fractures de cols de phalanges chez l'enfant.

INTRODUCTION: Phalangeal neck fractures are unusual, occurring mainly in children. This study aims at assessing the results of treatment of this type of fracture and presents a new technique for displaced fractures namely intrafocal pinning. PATIENTS AND METHODS: From January 2001 to January 2007, we treated 49 children (32 boys and 17 girls) with 52 phalangeal neck fractures. The patients were aged between three months and 14 years (average seven years). Five fractures were open but without nerve, artery or tendon damage. The 32 undisplaced or minimally displaced fractures were treated by closed methods. Thirteen displaced fractures (of which three were secondary displacements) were treated with an intrafocal pinning technique inspired by the Kapandji technique for distal radius fractures. Seven fractures (five open and two closed but displaced) were treated using standard osteosynthesis techniques (temporary arthrodesis, crossed K wires or cerclage). RESULTS: We reviewed the patients an average of 18 months later. We classified the results according to Barton's classification: excellent, good, fair and bad. Among the 13 fractures treated with an intrafocal pinning technique, 11 gave excellent results and two gave good results. We did not find any infection, tendon rupture, phalangeal head osteonecrosis or nonunion. We had to reoperate on one proximal phalanx thumb fracture because of delayed consolidation. DISCUSSION: Percutaneous reduction of the displacement and pinning seems to give the best results for the treatment of displaced fractures. The surgeon aims at getting the best anatomical result whilst limiting soft tissue damage. The proposed technique seems to give good results as it allows a percutaneous reduction of the displacement and an effective means of holding the reduction. Open fractures have a poorer prognosis.

Vacuum-assisted closure in the treatment of poststernotomy mediastinitis in the paediatric patient.

INTRODUCTION: Delayed sternal closure after paediatric open heart procedure is often necessary. The risk of delayed sternal closure is infection: superficial wound or sternal and mediastinal infection. The incidence of sternal wound infection reported in the literature varies from 0.5 to 10%. The mortality for poststernotomy deep sternal infection continues to be high--from 14 to 47%. Established treatment includes surgical debridement, drainage and irrigation, antibiotics, frequent change of wound dressing and direct or secondary closure with omentum or pectoral muscle flap. PATIENTS AND METHODS: Between October 2003 and August 2005, three children, aged from 9 days to 2 years and who had developed severe mediastinitis after cardiac surgery were treated with the vacuum-assisted closure (VAC) system. RESULTS: The duration of VAC treatment ranged from 12 to 21 days. The response to VAC was rapid with local purulence and C-reactive protein (CRP) both decreasing within 72 h in all cases. After good granulation was obtained, two patients required a thin skin graft. DISCUSSION: All three children had peritoneal dialysis which did not permit omental use. The use of pectoralis major is a difficult technique in neonates and the haemodynamic conditions were poor in our cases. The VAC technique is a good indication in post-cardiotomy mediastinitis in children: it plays a role in the reduction of infection and provides good healing.

[Ulnar dimelia: Management of a rare malformation]. / La Main en miroir : prise en charge d'une malformation rare.

Mirror hand is a rare congenital deformity of the upper limb which is characterized by duplication of the ulna (ulnar dimelia), absence of the radius and polydactyly. The authors report a case of ulnar dimelia with treatment of the of the elbow stiffness by surgery and splinting, and the flexed radial club hand deformity of the wrist solely by early splinting. This treatment was performed both before and after pollicization which was performed at 12 months. The stiffness of the elbow and wrist is very difficult to treat and remains a major problem whereas pollicization is now an established and successful means of treating the hand deformity.

[Velopharyngeal sequels in labial-alveolar-velopalatine clefts. Pharyngoplasty by pharynx Lipostructure]. / Les séquelles vélopharyngées dans les fentes labioalvéolopalatovélaires. Pharyngoplastie par Lipostructure du pharynx.

Advancing the posterior pharyngeal wall is a classic technique to treat velopharyngeal insufficiency. Injection of autologous fat behind the posterior pharyngeal mucosa according to the Coleman Lipostructure technique is a recent development. The authors report their experience in six cases using this modification. The preoperative work-up was performed by a speech therapist with a physical examination and measurement of the nasal air loss was performed using an aerophonometer. Fat was harvested either on the abdominal wall or on a buttock and then centrifuged. Fat injection was performed using a curved blunt cannula under the mucosa of the lateral and posterior pharyngeal walls. Injecting fat is an autologous graft of fat tissue: after a postoperative period of three months, the volume of fat becomes permanently stable. In five out of the six patients who presented moderate velopharyngeal insufficiency, speech improvement was significant. The single failure was a patient with bilateral cleft lip and palate sequels after previous pharyngoplasty using the Orticochea procedure. Treatment of moderate velopharyngeal insufficiency using fat injection is an efficient method. The advantages are its innocuousness and that scaring of the pharynx is avoided.