[Aseptic non-union of humeral shaft fractures treated by plating and bone grafting]. / Pseudarthroses et retards de consolidation aseptiques de la diaphyse humérale: à propos de 30 cas traités par plaque et autogreffe osseuse.

PURPOSE OF THE STUDY: Although aseptic non-union of humeral shaft fractures is generally considered to be an exceptional complication, rates in the literature have varied from 1 to 10%. Factors favoring non-union are often related to technical error or inappropriate therapeutic indication. Several types of treatment (orthopedic, locked centromedullary nailing, ascending pinning, plating, external fixation) can be proposed for humeral shaft fractures. In all cases, a precise technique and proper indication are essential for success. We reviewed the cases of 30 patients who underwent surgery for aseptic non-union of humeral shaft fractures between 1995 and 2000. MATERIAL AND METHODS: Mean patient age was 43 years. Oblique and transverse fractures of the middle third of the shaft predominated. All types of treatment had been used but most of the patients had had ascending pinning. All patients were treated with plate fixatin and a cancellous bone graft after identifying the radial nerve. RESULTS: Bone healing was achieved in all patients. Mean delay to healing was 16 weeks with good motion of the shoulder (mean elevation 136 degrees ) and elbow (mean motion 10-130 degrees ). Transient radial paresia recovered spontaneously in two patients. There was one infection. Only two patients complained of a painful arm that was not bothersome for daily activities and did not require long-term analgesia. There were no cases of radial nerve injury. Elbow function improved in 16 patients, was unchanged in 11, and showed limited extension in 3. Shoulder function improved in 15 patients and was unchanged in 15. DISCUSSION: Plate fixation is widely described in the literature for the treatment of humeral non-union. The main complications of this treatment are radial palsy and infection, reported in 5% of the series. Several recent reports have therefore advocated locked nailing or external fixation with an Ilizarov device but these techniques are difficult to use and have their own risks of complications. It is difficult to block rotation and the nail may injure the rotator cuff. Pin tract infection, nerve injury, and prolonged external fixation are other disadvantages. We therefore recommend screw plate fixation with a cancellous bone graft. Our good results combined with the very low rate of complications argue in favor of this therapeutic option.

[Isolated traumatic serratus anterior muscle palsy]. / Paralysie isolée du muscle serratus antérieur d'origine traumatique.

PURPOSE OF THE STUDY: The serratus anterior, innervated by the long thoracic nerve, participates in shoulder abduction and elevation, stabilizing the scapula on the rib cage. Paralysis of the serratus anterior prohibits shoulder abduction and elevation beyond 90 degrees and elevation of the spinal border of the scapula. We report our experience with traumatic serratus anterior palsy. MATERIAL AND METHODS: Our series included 16 patients with traumatic unique injury to the long thoracic nerve. Mean age of the patients at the time of the accident was 27.6 years. Seven patients were not operated on due to total or partial spontaneous recovery. Scapulothoracic arthrodesis or scapulopexy was performed in nine patients. RESULTS: For the non-operated patients, mean elevation was 125 degrees at diagnosis and 145 degrees at five years follow-up with a Constant score of 85 and muscle force reaching 83% (12 kg shoulder abduction) of the healthy side. Outcome was rated very good in 4 patients, and good, fair and poor in one each. For the operated patients, elevation was 95 degrees preoperatively and 104 degrees at last follow-up. At four years follow-up mean values were: elevation 104 degrees, Constant score 75, muscle force 72% (9 kg shoulder abduction) of the healthy side. An infection required a revision procedure in one patient who recovered successfully. Outcome was rated very good in six patients and good in three. DISCUSSION: Several types of treatment have been proposed for serratus anterior palsy: non-operative care, muscle transfers mainly with pectoralis major flaps, and scapulothoracic arthrodesis. Most of the series on scapulothoracic arthrodesis have concerned fascioscapulohumeral dystrophy and cannot be compared with our patients. Data in the literature on muscle transfers, which could be considered as comparable with our trauma injuries, have demonstrated good results for shoulder motion but a limited effect on overall muscle force. In our series, scapulothoracic arthrodesis provided good results for muscle force, pain relief, and overall shoulder function, with shoulder motion being limited by the position of the arthrodesed scapula. We propose this type of treatment for serratus anterior palsy mainly for manual laborers.

[Chondroma of the soft tissues of the hand. Report of a recurrent case]. / Chondromes des parties molles de la main. A propos d'un cas récidivé.

A twenty six-year-old man presented a mass of the fifth left finger. X Ray and pathological examination after surgical treatment showed an extraskeletal chondroma. One month later, this tumor recurred, leading to a second surgical procedure. At one year follow up there was no evidence of new recurrence. A review of the literature shows that recurrence of this type of tumor is extremely rare. Also, it stresses the importance of a proper diagnosis which allows an appropriate treatment initially and after a recurrence.

[Treatment of metaphyseal fractures of the tibia by the Ilizarov external fixator]. / Traitement des fractures métaphysaires proximales du tibia par fixateur externe d'Ilizarov.

PURPOSE: This external fixation was used for 46 of 60 cases of proximal tibial metaphyseal fractures, over a 10 years period. The choice of an external fixation was determined by the poor reputation of internal fixation for even complex closed fractures. The reasons for the choice of the Ilizarov device were: the possibility of fitting the fixation pins close to the knee joint if necessary, the circular nature of the system, and finally the possibility of adding an intrafocal mounting (I.F.M.) which can bring the displaced bone fragments together using shaped blockstops pins. The program theoretically foresaw an initial sequence using external fixation until bone continuity was achieved, followed by a complementary plaster for one or two months. MATERIALS: 7 of the 46 fractures were lost for follow-up. Of the remaining 39 cases, there were 5 early complications: one knee septic arthritis which led to stop the method before the second month. Each of these 5 failures were due to improper use of the method. 34 cases have been followed for more than two years. RESULTS: 29 cases of consolidation of which 3 initial displacements were wrongly considered as acceptable. There was no case of displacement while the fixation was in place. There were 5 nonunions: 2 at the diaphyseal level in long metaphyso-diaphyseal fractures, 2 were comminutive metaphyseal fractures in which the fixation had been removed by error before the third month. With this fixation, neither the traumatic opening, nor the presence of a fibular fracture significantly affected consolidation. The healing period was however longer when the fracture was more extensive and comminutive. The bone gaps were treated by interfocal mounting (I.F.M.) but loss of bone stock persisted; they affected the occurrence of nonunion. CONCLUSION: Each failure of the method is explained by its improper use. The Ilizarov fixation is an excellent mechanical response to these fractures: on condition that the technical rules are respected, that an intrafocal mounting is used to remove interfragmentary gaps, and that the fixator is kept in place long enough, according to the size and comminutive nature of the fracture. This fixation is reliable in these conditions but does not compensate intrafocal bone loss exceeding 40 per cent of the metaphyseal bone mass.