Incidence and preventability of adverse events in the emergency room of an orthopaedic traumatologic surgery unit.

This paper reviews the nature and the frequency of adverse events in the everyday functioning of a French trauma emergency unit, and evaluates the feasibility of their detection by the means of a daily record review. A senior surgeon identified the adverse events by reviewing the complete record with a minimal 6-months follow-up for every patient attending the emergency unit during a 10-week period. To test the reliability of this review, a blind re-review of all records corresponding to the detected adverse events, mixed with an equal number of controls, was carried out by two independent experts. The review of the 2604 records identified 210 medical adverse events, most of them occurring early in the care process. Sixty-seven per cent of the adverse events involved prevention failure, mainly for tetanus but also for thrombosis and rabies. For the other 33% it was possible to determine two situations with a high risk of adverse event: body contusions following a traffic accident and metacarpo-phalangeal thumb sprains. The re-review evaluated the positive predictive value of the initial review to be 97.5% and its negative predictive value to be 96%. It is concluded that the review of the initial record by a single senior is effective in detecting the adverse events. Prevention of two-thirds of them could be possible by the implementation and monitoring of protocols.

[Traumatic isolated palmar dislocation of the distal radio-ulnar joint. Apropos of a case]. / Luxation traumatique palmaire isolée de l'articulation radio-cubitale inférieure. A propos d'un cas.

PURPOSE OF THE STUDY: The authors report a rare case of an isolated palmar dislocation of the distal radio-ulnar joint (DRU). Diagnosis was easily established in emergency even though this lesion is usually unknown in 50 per cent of cases, according to literature. CASE REPORT: A surgical approach was necessary because of irreducibility of the lesion: ulna and radius were hitched with no other anatomical interposition. Treatment succeeded and the functional result was good with only 25 degrees of loss of pronation. This suggests a commentary on DRU joint physiology, on the mechanism of dislocation, and on the methods of treatment.

[Gustilo type IIIb open fractures of the leg - Emergency treatment by internal fixation and simultaneous skin cover]. / Fractures ouvertes de jambe stade IIIb de Gustilo - Traitement en urgence par stabilisation interne et couverture dans le même temps.

Sixteen patients were studied between 1986 and 1992. Fourteen patients were reviewed. One had died and one was lost to follow-up. The average was 35 years. There were 15 men and one woman. In 10 cases the fracture was isolated and in 6 there were multiple injuries. Two pre-operative arterial grafts were done. Four fractures were comminuted and in 3 there was a segmental loss of bone. Antibiotics were given for an average of 8 days using Penicillin and Metronidazole. Surgical treatment involved emergency debridement and fixation of the fracture by intramedullary nailing in 15 cases and by external fixation in one case. In 12 cases skin cover was done by local flaps (particularly gastrocnemius and soleus) and in 4 cases by free flaps (2 gracilis, 2 latissimus dorsi). There were no cases of amputation. There were no failures of the free flaps. Healing occurred by primary intention in 10 out of 16 cases (62.5%) at an average of 7.3 months with an average of 2.2 operations and an average hospitalisation of 36.8 days. Two local flap failures led to complications. There were 2 deep vein thromboses and one flap haematoma which required revision. There were 3 infections. Two early infections and one late infection with atrophic non-union were treated by removal of the nail and application of Ilizarov fixator which led to healing. Three non-infected non-unions required intertibial fibial grafting and exchange nailing. One delayed union healed after exchange nailing. The average time to secondary healing was an average of 16.5 months with an average of 5.6 operations and length of hospitalisation of 58.6 days. There were two cases of local flap necrosis, 2 cases of inadequate or absent locking and one case of lack of graft for a bony defect. In the late sequellae there were 5 rotatory or angulatory malunions and 4 shortenings from 1 to 3.5 cm. The inadequate locking and septic complications are the subject of litigation. From a functional viewpoint there was no loss of knee movement. In 9 out of 14 cases there was loss of ankle movement. In 9 out of 14 cases there was loss of ankle movement. Four cases had toe clawing and 3 cases of pes cavus. Eleven cases were able to work. Thirteen out of 14 complained of pain while one patient had a persistent limp and one required a walking stick.In conclusion, emergency stabilisation and skin cover are the imperatives. The results of nailing are encouraging in spite of a significant level of complications. The functional sequellae affected particularly the ankle and foot.

Reconstruction of a complex defect of the dorsum of the hand.

A 37-year-old right-handed male truck driver was admitted with a severe injury of the dorsum of his right hand following a traffic accident. He had a large combined defect involving skin, tendons and bone. A complex reconstruction was performed using a large iliac crest allograft, a tendon graft and a free serratus anterior flap in one stage, 8 hours after the injury. A skin graft was performed later. 2 years later the functional and aesthetic result are good.

[Emergency cover of open fractures of the leg. Apropos of a series of 24 clinical cases]. / Couverture en urgence des fractures ouvertes de jambe. A propos d'une série de 24 cas cliniques.

The authors present 24 emergency covering procedures for 24 open leg fractures: 6 free flaps and 18 pedicled flaps. The procedure was selected according to the site dimensions and topography of the defect. Topographically, the division of the leg into 3 zones: middle, upper and lower seems to be some what artificial because in practice the junction between the middle and lower segments is still a source of error in the choice of the local flap which can be used. It is preferable to use pedicled flaps in the proximal half of the tibia and free flaps in the distal half. Many failures were observed with the use of fascio-cutaneous flaps. 18 of 24 fractures were internally fixed, which allowed emergency covering. In fact, although bony covering can wait 48 hours, the presence of osteosynthesis material means that covering must be performed at the same time. This makes the plastic and microsurgical procedures easier and ensures greater patient comfort during the consolidation period and rehabilitation. The authors present their results according to the method of soft tissue coverage, their reliability, the type of osteosynthesis, the complications, number of operations and time to bony consolidation. Encouraged by their results, the authors continue with this approach.

[Results of the primary repair of the collateral palmar digital nerves]. / Résultats de la réparation primaire des nerfs collatéraux digitaux palmaires.

The aim of this study was to analyse the results of primary collateral digital nerve repair as a function of several factors: age, surgeon's experience, type of lesion and associated lesions, etc. The conclusions are based on a homogeneous series of 64 patients with 83 nerve lesions treated by primary microsurgical nerve repair with a follow-up of at least one year.

[Treatment of extensive traumatic loss of substance of the foot and ankle by free flaps. Apropos of 7 clinical cases]. / Traitement des pertes de substance traumatiques étendues du pied et de la cheville par transferts libres. A propos de sept cas cliniques.

The authors report 7 cases of extensive skin defects of the foot and/or the ankle treated by using a free flap. All cases presented with major trauma of the lower limb with obvious exposure of bone and joint tissues. The skin defect was covered: as an emergency in 4 cases; within the 48 hours following the trauma in 3 cases; on the 7th day after the injury in 1 case. The free flap used was: the latissimus dorsi muscle, 2 cases; the gracilis muscle, 1 case; the serratus anterior muscle, 1 case; the greater omentum, 2 cases. Arterial microanastomoses were performed onto the anterior tibial or pedal arteries, in 4 cases, and onto the posterior tibial artery in 4 cases. Except for 1 failure on the 8th day after the operation due to thrombosis of the venous anastomosis, requiring arthrodesis of the ankle, the outcome was favorable in all other cases, free of osteitis or arthritis. The authors emphasize the importance of covering defects the lower limb as quickly as possible, ideally as an emergency, when a free flap is required.

[Place of microvascularized tissue transplants in emergency treatment of multiple trauma of the limbs. Excluding reimplantation]. / Place des transferts tissulaires microvascularisés en urgence dans le traitement des traumatismes complexes des membres. En dehors des réimplantations.

When we evoked the indications of microsurgery in Traumatology, at first, we think reimplantations performed in emergency and also secondary management of soft tissues or complex defects. In fact, we resort to microsurgery in many other circumstances. Early microsurgical reconstruction of complex trauma of the extremities yield better results than delayed free flaps. In 7 cases, free flaps were performed on the lower extremities, in 2 cases on the upper extremities. Many advantages are credited with this offensive attitude which requires an appropriate organisation of the Departments of Traumatology, the intimate collaboration of surgeons called orthopedic or plastic surgeons, improperly divided by too administrative compartmentalization of the surgical specialties.

[Procedures for repairing skin losses of the knee with joint exposure]. / Procédés de réparation des pertes de substance tégumentaires du genou exposant l'articulation.

The authors analyse the various procedures for covering skin defects at the knee region exposing either the bones or the joint. Actually, various local flaps allowed in most cases coverage in this area using either a pedicular muscle flap or fasciocutaneous, or even an island flap. For every local flap, its vascularisation, its technique of elevation and its arc of rotation are described. Occasionally, free flaps or cross leg flaps have been used. Indications depended on the patient age, topographic size of the defect, time of covering in emergency or secondarily, trophicity of the surrounding soft-tissues and also the eventual associated vascular injuries.

[Reflections on 4 cases of ante-lunar carpal luxations]. / Réflexions à propos de quatre observations de luxations antélunaires du carpe.

Over the past 20 years, 4 cases of ante-lunate carpal dislocation have been treated in the Traumatology and Orthopaedics Department of Besançon. During this same period, 61 cases of retro-lunate dislocation have also been treated. Ante-lunate dislocations are very rare lesions as confirmed by a review of the literature. Our cases do not illustrate the mechanisms of such injuries since 3 cases involved patients with multiple injuries Clinical symptoms may be very minor in children in whom such injuries may easily be overlooked. A thorough interpretation of X-rays is necessary for diagnosis in adults. All 4 cases showed a fracture of the lunate in a frontal plane (factor of instability). Such an instable lesion justifies either internal osteosynthesis or percutaneous trans-articular pinning when rigid internal fixation is impossible. However, in all cases in which the lesion was treated surgically, the capsular plane was not disrupted. Retrospectively, such a finding contraindicates an open surgical approach. Relationships between such dislocations and isolated fractures of the lunate are discussed. The prognosis is mainly determined by early diagnosis and management rather than the type of treatment itself.

[Role of a "watch and wait" policy in the treatment of blunt traumatic lesions of the spleen in adults]. / Place de l' "abstention armée" dans le traitement des lésions traumatiques fermées de la rate chez l'adulte.

Modern imaging has considerably modified our therapeutic indications, as it allows appreciating the nature of traumatic lesion s of the spleen. We now know that part of the damage sustained by this organ does not evolve towards major internal hemorrhages. In addition, it is advisable to avoid splenectomy, which entails its own complications. It is therefore justified, not only to preserve the spleen, but also to perform no laparotomy whenever this is possible. A series of 22 injured patients, following several isolate cases of "watch and wait policy", confirms the validity of our attitude.

[Carpal tunnel syndrome before 20 years of age. A report of 7 cases]. / Syndrome du canal carpien avant 20 ans. A propos de sept observations.

Seven cases of carpal tunnel syndrome before 20 years old are described: 4 were associated with an increase in the patient's athletic activities. In five cases, no etiology was found, marked median nerve stenosis was observed in three cases and hypertrophy of the median nerve was observed in two cases. Flexor retinaculum was thickened in four cases.

[Free-flap transfer of the omentum to the lower leg]. / Transfert libre hétérojambier de l'épiploon.

The authors describe an unusual procedure for closure of a large skin defect of the lower limb exposing the tibia. Due to the severity of the vascular and cutaneous lesions, a greater omentum free flap was used with micro-anastomosis onto the contra-lateral leg: heeling was satisfactory after release of the flap.

[Pedal cutaneous island flap. Apropos of 6 case reports]. / Le lambeau cutané pédieux en îlot. A propos de 6 observations.

The authors report their experience using the dorsalis pedis island flap, described by MacCraw, for coverage of soft tissue defects of the heel, and both lateral and medial areas of ankle. The operative technique is recalled and six cases are presented. The authors analyse the several indications of the island flap. Its disadvantages are emphasized.

[Open fracture of the leg with major cutaneous lesions. Imperative character of immediate closure and following possibilities of internal stabilization of the skeleton. Apropos of a continuous series of 20 cases]. / Les fractures ouvertes de jambe avec lésions cutanées majeures. Le caractère impératif de la couverture immédiate et les possibilités consécutives de stabilisation interne du squelette. A propos d'une série continue de 20 observations.

The advantages of immediate wound closure in case of open leg wounds, as opposed to delayed repair or the use of greasy dressings, need no longer be proven. Indeed, modern plastic surgery technics have become quite ingenuous, reliable and applicable to most severe skin, lesions (type III as per Cauchoix-Duparc and so--called potential type III). These facts have been confirmed by a study of 20 cases including both types. Moreover, more and more often, immediate wound repair allows for external fixation replacement, typically by osteosynthesis, which is more advantageous from the viewpoint of fracture consolidation. Complications (namely infection rates) have not increased, which is an encouragement for the continued application of this method, which constitutes a departure from usual indications.

[Entrapment of the median nerve after dislocation of the elbow]. / Incarcération du nerf médian après luxation du coude.

Entrapment of the median nerve as a complication of a dislocation of the elbow has rarely been reported. The prognosis is worse in case of delayed diagnosis. Exploration surgery is indicated when neurological signs remain following reduction of a dislocation of the elbow.

[Chronic instability of the metacarpophalangeal joint of the thumb without arthrosis. Apropos of 16 cases]. / Instabilité chronique de l'articulation métacarpo-phalangienne du pouce sans arthrose. A propos de seize observations.

A series of 16 cases of chronic instability of the metacarpo-phalangeal joint of the thumb is presented. The authors begin by summarising the two main surgical procedures used in such cases: ligamentous reconstruction and arthrodesis. In our series, a ligamentous reconstruction with Smith's procedure was performed in 13 patients, a primary arthrodesis in 2 patients and a secondary suture in one patient. The results are analysed in 15 patients (7 women, 8 men) with a minimum followup time of two years. Failure was noted in 4 cases treated by ligamentous reconstruction (3 men and 1 woman). An arthrodesis was subsequently performed in all these patients. There were therefore a total of 6 arthrodesis and 8 ligamentous reconstruction to review. Ligamentous reconstruction gave better functional results than arthrodesis in particular as regards mobility, opposition of the thumb and strength of pinch grip (decreased by 50% with arthrodesis). In manual workers the use of ligamentous reconstruction in these cases was shown in our series to give inconstant results.