Obstetrical brachial plexus palsy.

Obstetrical brachial plexus palsy is considered to be the result of a trauma during the delivery, even if there remains some controversy surrounding the causes. Although most babies recover spontaneously in the first 3 months of life, a small number remains with poor recovery which requires surgical brachial plexus exploration. Surgical indications depend on the type of lesion (producing total or partial palsy) and particularly the nonrecovery of biceps function by the age of 3 months. In a global palsy, microsurgery will be mandatory and the strategy for restoration will focus first on hand reinnervation and secondarily on providing elbow flexion and shoulder stability. Further procedures may be necessary during growth in order to avoid fixed contractured deformities or to give or increase strength of important muscle functions like elbow flexion or wrist extension. The author reviews the history of obstetrical brachial plexus injury, epidemiology, and the specifics of descriptive and functional anatomy in babies and children. Clinical manifestations at birth are directly correlated with the anatomical lesion. Finally, operative procedures are considered, including strategies of reconstruction with nerve grafting in infants and secondary surgery to increase functional capacity at later ages. However, normal function is usually not recovered, particularly in total brachial plexus palsy.

[Efficacy and tolerance of Algosteril (calcium alginate) versus Jelonet (paraffin gauze) in the treatment of scalp graft donor sites in children. Results of a randomized study]. / Evaluation de l'efficacité et de la tolérance d'Algostéril (compresse d'alginate de calcium) versus Jelonet (gaze paraffinée) dans le traitement du site donneur de greffe dermo-épidermique du cuir chevelu. Résultats d'un essai pédiatrique.

Split skin graft is frequently needed in the treatment of burned patients. Scalp is often free of burns. Due to its good skin quality and important surface, scalp is a very interesting skin donor site, specially in case of children. A controlled, randomised clinical trial was carried out in 10 French Plastic Surgery or Burns Units. It assessed the efficacy and the acceptability of calcium alginate dressing (Algosteril) versus paraffin gauze dressing (Jelonet) in the treatment of scalp donor sites in children. 67 children (mean age 54 months) entered the study, 34 in the alginate group and 33 in the control group. Follow-up visits were on day 2/d3, d5/d6, Day complete healing, d30 and d60 after surgery. The two groups were comparable on inclusion (demographic characteristics, burn nature and surface, donor site surface and thickness of split skin graft). The mean healing time was 10 and 11 days for Algosteril and Jelonet group respectively (ns). The quality of the newly formed tissue was estimated to permit a sooner skin reharvesting in the Algosteril group than in the control group (p = 0.003). Bleeding through dressing was significantly less important in the Algosteril group (p = 0.02). Changes were considered by investigators less painful with Algosteril on day complete healing (p = 0.0096). Hair growth is homogenous in both groups on day 30 and day 60 (ns). These results showed that scalp is a very interesting skin donor site and that Algosteril is of a real interest in donor site treatment.

Coverage of large skin defects of the pediatric upper extremity.

Reconstructive surgery of the locomotion apparatus in children has been built from several surgical advances. It is a specific activity that cannot be detached from all other orthopedic pediatric surgery. The care of problems in a child must be provided with a holistic point of view: It cannot be the addition of different techniques done by different surgeons. Bone morphology has a close relationship with the soft tissues; an injury of the envelope has consequences for growth harmony.

Management of purpura fulminans at the upper extremity.

A multidisciplinary approach often is needed, especially at the acute phase. Indeed, resuscitative treatment is first indicated. [figure: see text] Optimal time for surgery depends on the patient's status. Surgical management should be more aggressive than previously thought. Debridement of necrotic tissue must be performed when the eschar has demarcated to avoid infection. Escharectomy can improve the vitality of the distal segments by releasing the compressive mechanical effect. In the same vein, early amputations are likely to reduce the need for secondary revisional surgery. Necrotic tissue over a joint should be excised early and procedures to provide coverage by flaps should be undertaken to avoid osteoarthritis. Late sequelae are dominated by skeletal growth disturbances and require specific procedures.

Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg.

An anatomic study performed on 64 fresh injected legs has shown the role of the vascular axis that follows the superficial sensitive nerves in supplying the skin. Three nerves were studied: the saphenous nerve, the superficial peroneal nerve, and the sural nerve. Conclusions are the same for the three nerves: The vascular axis, which can be either a true artery or an interlacing network, ensures the vascularization of the nerves, gives off several cutaneous branches in the suprafascial course of the nerve, and anastomoses with the septocutaneous arteries issuing from a deep main vessel. The superficial nerves that course the leg can therefore be considered as vascular relays owing to their neurocutaneous arteries. The concept of a neuroskin island flap has been developed and applied to six clinical cases for coverage of some specific areas of the knee and of the lower part of the limb.

[Soft tissue preservation and reconstruction in non-supporting foot parts]. / Weichteilerhaltung und Rekonstruktionen an unbelasteten Fussanteilen.

The foot has two skin surfaces which differ on a morphological and functional basis. The plantar skin is a highly specialized organ which has a dash-pot-like effect in weight bearing. The skin which does not participate in weight bearing covers tendons and a very rich syndesmotic complex. The internal soft tissue is segmented in tiny compartments and therefore ist not extensible. The skin and the rather thin subcutaneous layer are not extensible either because of the proximity and the rigidity of the underlying structures. In consequence, trauma to the soft tissue of the foot may cause compartment syndromes and skin defects, or secondary unstable scars which impede function. Compartment syndromes must be recognized early and treated by immediate release. Fresh skin defects need early coverage when tendons and joints are exposed. There is a variety of local flaps which are evenly good for replacement of retracting scars.

The medialis pedis flap: a new fasciocutaneous flap.

An anatomic study (30 fresh specimens dissected) and clinical experience (5 patients) have shown the reliability of a fasciocutaneous flap raised from the medial side of the foot. The artery that supplies the flap is issued from the medial plantar artery. The arch of rotation allows one to cover some specific areas, such as the medial malleolus, posterior aspect of the heel, and distal insertion of Achilles tendon.

Vascularized periosteum associated with cancellous bone graft: an experimental study.

The association of a vascularized periosteal flap with a cancellous bone graft was studied on a group of 20 Wistar rats. Ten rats were sacrificed at 6 weeks and seven at 12 weeks (three died prematurely). The behavior of the cancellous bone graft buried in striated muscle and the osteogenic capacity of a simple vascularized periosteal flap also were observed on the same animals. Results of the study are as follows: In 14 of 17 animals, a vascularized periosteal flap wrapped around a cancellous bone graft resulted in new cortical bone formation with little resorption of the initial cancellous graft. A vascularized musculoperiosteal flap has produced a small amount of new compact bone only in 4 of 17 animals. A cancellous bone graft buried into well-vascularized muscle tissue was resorbed (15 cases) or necrotic (2 cases) at 12 weeks. In conclusion, the association of a vascularized periosteal flap and cancellous bone is a better means to produce compact bone than a vascularized periosteal flap alone or an isolated cancellous bone graft.

Periosteal flaps: anatomical bases of sites of elevation.

An anatomical study made in 25 injected fresh subjects made it possible to map out the periosteal flaps capable of being raised on the limbs. The preferred donor sites are the distal third of the humerus, the iliac fossa and the distal third of the femur. At the last 2 sites composite osteo-periosteal or musculo-osteo-periosteal flaps can be raised. These technical possibilities illustrate the importance of experimental studies which have shown the osteogenic capacity of grafts of vascularized periosteum.

Bourgery's artery: anatomic basis for a new cutaneous skin flap (21.06.88).

Bourgery's artery, the first branch of the popliteal a., delivers further branches to the vastus lateralis and biceps femoris m., by its terminal cutaneous branch, supplies a large territory of the external surface of the thigh. This area can be mobilized as a skin flap pedicle to cover tissue losses in the knee area.

[External supramalleolar flap in the reconstructive surgery of the foot]. / Le lambeau supramalléolaire externe dans la chirurgie réparatrice du pied.

The external supramalleolar flap is a mixed cutaneoaponeurotic flap removed from the external surface of lower part of leg and with, as its principal vascular pedicle, the anterior perforating branch of the peroneal artery. The flap can be used in two ways: as a rotation flap with distal cutaneous hinge allowing lover third of internal surface of leg and instep to be covered, or as a retrograde flux island flap by anastomosis of perforating artery to arteries of foot. The latter procedure is of interest in that it permits covering of loss of distal substance of foot in the dorsal or plantar region. Results of use of this method in 35 patients situate the place of the external supramalleolar flap in the techniques available for lower limb repair.

[Vascularization of the skin of the limbs and surgical applications]. / Vascularisation tégumentaire des membres et applications chirurgicales.

Skin flaps for coverage of skin defects in orthopaedic surgery have been more and more used in recent years. However all the authors are not in agreement concerning the pattern of vascularization of these flaps. Two problems should be studied separately: the vascularization of the skin in situ which is already rather well known and the vascularization and the pattern of vascularization of the flaps after transfer. Several models of flaps, that is axial, septal or musculo-cutaneous, are based on the origin of skin vascularization, that is by long running arteries, septal arterioles or indirectly by arteries coming from muscles. Therefore a flap must be determined by its type of vascularization, its shape and its composition. Surgical rules concerning skin incisions and deep structures approaches are recalled.

Anatomic basis of a fascio-cutaneous flap supplied by the perforating branch of the peroneal artery.

The length, caliber and course of the perforating branch of the peroneal artery are described following examination of both feet of 20 cadavers. This terminal branch of the peroneal artery has a constant, predictable course and may normally be sacrificed without any vascular compromise in the foot. It has great surgical potential at it is strategically situated so that it can act as a vascular pedicle for a large cutaneous flap situated on the lower lateral leg, with an axis of rotation centered at the midtarsal joint. This has been used by the senior author (AC Masquelet) as a pedicle flap and as an island flap for reconstruction of the foot and ankle with satisfying results.