INTRODUCTION:Articular screw protrusion remains frequent after percutaneous fixation of acute scaphoid fractures and may be influenced by screw length and positioning. This study evaluated the influence of screw length, diameter, direction, and postoperative immobilization on fracture union and CT-detected articular protrusion. HYPOTHESIS:Shorter screws are associated with a lower rate of CT-detected articular protrusion without an observed reduction in fracture union. METHODS:This retrospective single-center study included 249 adults treated with percutaneous screw fixation for acute scaphoid fractures between 2017 and 2026. Fracture union and CT-detected articular protrusion on postoperative CT were the primary outcomes. Protrusion was defined as ≥1 mm beyond the osseous articular boundary. Screw length was primarily analyzed as a continuous variable, with an additional comparison between screws ≤20 mm and ≥22 mm. A screw-to-scaphoid length ratio was also calculated. Multivariable logistic regression was performed to identify factors associated with CT-detected articular protrusion. RESULTS:Overall union was achieved in 232 cases (93.2%), whereas CT-detected articular protrusion was observed in 130 cases (52.2%). Protrusion was significantly less frequent with screws ≤20 mm than with screws ≥22 mm (25.9% vs 60.2%; p < 0.001), while union rates were similar (93.1% vs 93.2%; p = 1.000). Each 1-mm increase in screw length was independently associated with higher odds of CT-detected articular protrusion (OR 1.32; 95% CI 1.16-1.50; p < 0.001). Similarly, a higher screw-to-scaphoid length ratio was independently associated with protrusion (OR 1.73 per 0.10 increase; 95% CI 1.26-2.37; p < 0.001). Screw diameter, fixation direction, and postoperative immobilization duration were not significantly associated with union. CONCLUSION:In this retrospective cohort, shorter screws were associated with a substantially lower rate of CT-detected articular protrusion, while no lower union rate was observed. The association persisted after normalization of screw length to individual scaphoid length. These findings support considering shorter screw fixation when anatomy and fracture configuration allow, although prospective studies incorporating clinical outcomes are required to determine the clinical significance of CT-detected protrusion and the optimal screw length. LEVEL OF EVIDENCE:III.
Purpose Fingertip injuries are very common and can lead to significant functional impairment or even loss of finger function. Techniques for pulp reconstruction often involve the use of flaps. The Joshi and Pho flap is a single-pedicle island flap. Our purpose was to evaluate the long-term functional and aesthetic outcomes of the Joshi and Pho flap in digital pulp reconstruction from 2010 to 2022 in a University Hospital. Methods An observational retrospective single-center study included 14 patients who underwent Joshi and Pho flap reconstruction for subtotal pulp defects between 2010 and 2022, with a minimum follow-up of 12 months. The primary outcome was functional recovery assessed by the DASH score. Secondary outcomes included pain (VAS, DN4), joint mobility, sensibility (two-point discrimination, Semmes-Weinstein monofilament test), scar quality (POSAS scale, donor site morbidity), flap survival and complications. Results The mean follow up duration was 78 month (min-max : 12-183). The mean DASH score was 22.16/100 (min-max: 5-45; SD: 11.9). Pain scores were low (VAS: 0.64 SD; DN4: 0.5 SD). DIP flexion was statistically reduced on the injured side (58 ° vs 63 °, p < 0.01), but the clinical relevance of this reduction was limited. Two-point discrimination averaged 5.4 mm and the mean Semmes-Weinstein monofilament test was 3,5 mm with 6 patients (43%) grade 6. POSAS scale were 13.9/60 (patient) and 17.7./50 (observer). No flap necrosis was observed. One infection led to secondary amputation. Donor-site morbidity was minimal with no case of hook deformation ou ungual dystrophy. Conclusion The Joshi and Pho flap provides a durable and sensible coverage for subtotal digital pulp defects with satisfactory long-term function and aesthetic outcomes. It remains a valuable reconstructive option in hand surgery. Level of evidence Level IV.
PURPOSE:To investigate the in vivo effects of forearm rotation and selective isometric wrist muscle activation on the dorsal scapholunate (SL) interval using dynamic ultrasonography, and to determine whether previously described cadaveric biomechanical mechanisms are reproducible in healthy subjects. METHODS:Twenty-four asymptomatic adults underwent ultrasonographic assessment of the dorsal SL interval under six experimental conditions combining forearm position (maximal pronation or maximal supination) and contraction state (rest, resisted isometric radial deviation, resisted isometric ulnar deviation). Measurements were obtained using a standardized dynamic ultrasound protocol. Intra-rater reliability was assessed using ICC(3,1). A 2 × 3 repeated-measures ANOVA with Bonferroni-adjusted planned contrasts was performed. RESULTS:Ultrasound measurements demonstrated good-to-excellent reliability (ICC = 0.82-0.99). Significant main effects were identified for both forearm position (F(1,23) = 20.15, p < 0.001, η2p = 0.467) and contraction condition (F(1.32,30.37) = 140.40, p < 0.001, η2p = 0.86) on the dorsal SL interval. Resisted isometric radial deviation significantly decreased the SL interval compared with rest (p < 0.0001), whereas resisted isometric ulnar deviation significantly increased it (p < 0.0001). Maximal forearm supination resulted in significantly greater SL widening than maximal pronation (p = 0.0002). No significant interaction effect was observed between forearm position and contraction condition. CONCLUSION:Selective wrist muscle activation and forearm rotation significantly influence the dorsal SL interval in vivo. Radial deviation appears to exert a protective stabilizing effect on the SL complex, whereas ulnar deviation increases SL separation, likely through ECU-mediated intracarpal pronation. These findings support rehabilitation strategies emphasizing activation of intracarpal supinator muscles while minimizing ECU recruitment during conservative or postoperative management of SL instability. LEVEL OF EVIDENCE:III.
Background Task-specific three-dimensional data describing thumb carpometacarpal (CMC)-related kinematics during activities of daily living remain limited. Purpose To describe thumb CMC-related kinematics during standardized functional tasks in healthy young adults using high-frequency magnetic tracking. Study Design Cross-sectional descriptive study. Methods In 11 healthy young adults, thumb CMC-related motion was recorded during 11 standardized tasks corresponding to the hand-function domain of the Thumb Disability Exam. Radial-ulnar motion, palmar-dorsal motion, and opposition-related axial rotation were summarized within each participant for each task and axis, and task-specific descriptive values were calculated across participant-level summaries. Results The functional tasks demonstrated distinct kinematic profiles. Tasks involving manipulation, rotation, or bimanual object handling, including using a knife, opening a jar, buttoning a shirt/blouse, tying shoelaces, and wringing a dishcloth/washcloth, showed larger angular excursions than tasks involving more static holding or precision positioning. Descriptive heat maps showed commonly observed angular regions within the processed dataset, but these patterns were interpreted descriptively because the time-series samples were not independent participant-level observations. Conclusions This study provides preliminary descriptive data on three-dimensional thumb CMC-related kinematics during standardized activities of daily living in healthy young adults. The findings suggest that thumb motion requirements differ across functional tasks. Further validation in larger, older, and clinical populations is required before these data can be applied to orthotic design, surgical planning, or rehabilitation goal setting. Clinical relevance These preliminary findings describe task-specific thumb CMC-related motion during activities of daily living and may contribute to future research on thumb biomechanics, functional assessment, and clinical intervention planning after further validation. Level of evidence Diagnostic Level III.
Optimal intraprosthetic tension is critical for function and longevity of dual‑mobility thumb carpometacarpal (CMC1) arthroplasty.The objective of this work is to describe and formalize the use of the tenodesis effect as a reliable, reproducible intraoperative test to optimize tensioning of dual‑mobility CMC1 prostheses and reduce complications related to over tensioning.The tenodesis‑based assessment performed after trial implantation is detailed: with the prosthesis in place, passive wrist flexion/extension is used to observe thumb interphalangeal (IP) joint movement. Excessive resistance to IP passive flexion during wrist flexion or to IP extension during wrist extension indicates over tensioning; corrective options include selecting a shorter neck or advancing the metacarpal stem.Using the tenodesis effect yields a dynamic, stable assessment that reflects postoperative biomechanics better than the piston test, improving restoration of natural thumb motion and reducing risks of polyethylene wear, cup migration, and early failure.The tenodesis effect is a simple, reproducible intraoperative tool to optimize tension in dual‑mobility CMC1 arthroplasty, enhancing functional outcomes and prosthesis durability.
Following brain injury, neuromotor disorders of the upper limb are a major cause of functional disability and poor quality of life. In association with paresis and muscle changes, spasticity leads to motor imbalances responsible for joint deformities in general and in the shoulder in particular. In this expert narrative review, we address the assessment and management of spastic shoulder in patients with brain injury, including analysis of the discomfort and the clinical examination. Motor blocks and electromyography are essential, complementary tools. The definition of personalized SMART objectives (specific, measurable, achievable, realistic, and timely) is a crucial step in treatment planning. Depending on the type of impairment, the severity and the objectives, the treatment will combine conservative approaches (rehabilitation, splints, botulinum toxin injections, and stretching) and targeted surgical procedures (tenotomies, muscle and tendon lengthening, and neurectomies).
BACKGROUND:The posterior interosseous nerve (PIN) is a motor branch of the radial nerve. It is particularly vulnerable to compression as it passes through the supinator muscle, especially at the arcade of Frohse. Most anatomical studies describe its course using fixed distances from deep landmarks, such as the radial head, which limits clinical applicability due to interindividual variation in limb dimensions. Therefore, a surface-landmark-based, ratio-driven approach may provide a practical and reproducible method for localising the PIN in surgical settings. METHODS:In this study, upper limbs from 15 adult cadavers were dissected. With the forearm in pronation, the lateral epicondyle to radial styloid line (LR line; distance a) and the lateral epicondyle to a point 1 cm radial to ulnar styloid (LU line; distance b) were marked as surface reference lines. The PIN was identified between the brachioradialis and extensor carpi radialis longus muscles, and distances from the lateral epicondyle to its entry (c) and exit (d) points from the supinator were measured, along with the intramuscular travel length (Tr). Ratios a/c and b/d were calculated. RESULTS:Mean distances were:a 24.54 cm, b 22.82 cm, c 4.26 cm, d 8.54 cm, and Tr 5.83 cm. The mean a/c and b/d ratios were 5.76 and 2.67, respectively. PIN entry and exit points are consistently projected near the LR and LU lines. CONCLUSION:Ratio-based surface mapping is a practical technique for estimating PIN location in forearm peripheral nerve surgeries. However, additional validation in actual patients is needed. LEVEL OF EVIDENCE:V (Cadaveric anatomical study).
OBJECTIVE:The aim of this study was to determine the anterior or posterior predominance of the methylene-blue-stained perineural vascular network surrounding the deep branch of the radial nerve (DBRN). METHODS:An anatomical study was conducted on ten elbows from five fresh-frozen donor bodies following low-flow methylene blue injection into the brachial artery. The methylene-blue-stained perineural vascular network surrounding the DBRN within the supinator muscle was observed and classified into three groups: posterior to the nerve, mixed, or anterior. The distribution of the stained network along the nerve was analyzed, as well as the morphology of the tendinous arch of the supinator muscle and the superficial layer of the supinator muscle. RESULTS:Ten elbows were dissected. Fifty percent showed a posterior staining pattern (Group 1), 20% a mixed pattern (Group 2), and 30% an anterior pattern (Group 3). The stained network was concentrated proximally in 40% of cases, extended along the entire intramuscular course of the nerve within the supinator muscle in 40%, and was limited to the distal portion in 20%. The tendinous arch of the supinator muscle was tendinous in 40%, musculotendinous in 40%, and purely muscular in 20% of cases. The superficial layer of the supinator was musculotendinous in 60% and purely muscular in 40%. CONCLUSIONS:This descriptive anatomical study showed that the DBRN is surrounded by a methylene-blue-stained perineural vascular network with substantial interindividual variability. Given the limitations inherent to the injection technique, these findings should be interpreted as preliminary observations rather than a definitive characterization of the vascularization of the DBRN. Their clinical implications will need to be confirmed by further studies. LEVEL OF EVIDENCE:V Cadaveric Anatomical Study.
Les para-ostéo-arthropathies neurogènes (P.O.A.N.) ou ostéomes sont une complication fréquente rencontrée principalement chez les personnes cérébrolésées et les blessés médullaires. Ces ossifications ectopiques juxta-articulaires ou para-osseuse sont moins fréquents aux membres supérieurs qu’aux membres inférieurs. Elles sont à l’origine d’ankyloses articulaires qui limitent les capacités fonctionnelles. Aucun traitement pharmacologique n’a fait la preuve de son efficacité en préventif ou curatif. Les traitements physiques ne permettent pas d’éviter leur apparition mais permettent au mieux de limiter la gêne fonctionnelle en conservant un minimum de mobilité ou en guidant l’ankylose afin qu’elle se fasse dans une position "utile". Seule la chirurgie, associée à une prise en charge post-opératoire rigoureuse, permet un traitement de ces ossifications. Notre expérience repose sur le traitement chirurgical de 609 ostéomes (de 1990 à 2016) pris en charge conjointement par le service de chirurgie orthopédique de Garches et le service de médecine physique et réadaptation dans une approche pluridisciplinaire médico-chirurgicale.
In the context of fixed upper-limb deformities, percutaneous tendon lengthening procedures are particularly relevant when the limb is non-functional. The therapeutic goals will be to relieve pain and improve passive mobility, thereby facilitating nursing care. While these procedures can easily be performed using simple anatomical landmarks on superficial tendons, ultrasound guidance is necessary for deeper muscles. Among the various muscles targeted, we detail the ultrasound-guided technique for sectioning the subscapularis and brachialis tendons. Deep tenotomies are performed in the operating room under general or regional anesthesia, whereas simple tenotomies can be performed using the WALANT (Wide Awake Local Anesthesia No Tourniquet) technique in a dedicated suite, predominantly on an outpatient basis. They have the advantage of simplifying the management of postoperative care for patients-often in institutional settings-who have cognitive impairments.
Central paralyses are not limited to a simple motor deficit; they are associated with spasticity and—over time—contractures, as well as major disturbances in motor patterns. Significant clinical variability complicates both their assessment and the formulation of a therapeutic strategy. For these reasons, indications for tendon transfers in this patient population are more limited than in cases of peripheral paralysis; such procedures are generally incorporated into a complex surgical program that variously combines tendon lengthening, selective denervation, and joint stabilization.Faced with clinical presentations involving widely differing objectives—ranging from functional restoration to mere comfort—it is difficult at first glance to devise a standardized surgical program.In this article, we therefore propose an evaluation method using a score (INOM) based on functional prognostic factors and parameters requiring surgical correction to improve grasp.Three key areas guide this program: a prognostic factor, proximal motor control of the shoulder and elbow, and the correction of abnormal postures alongside the restoration of active extension of the elbow, wrist, and fingers. The INOM score highlights treatment priorities, enabling the formulation of a surgical strategy.Spasticity often obscures the motor assessment of these patients; anesthetic blocks and botulinum toxin injections are essential tools for this analysis. They make it possible to distinguish between spasticity and contracture, as well as to unmask certain antagonist muscles.In this population, a tendon transfer will be just as effective through the function it restores as through the elimination of its detrimental effect on the development of a deformity.We thus report, for each joint segment, the indications for tendon transfers and their relative roles among the techniques with which they must be combined.
Les complications neuro-orthopédiques du membre supérieur touchent tous les segments et entraînent une multitude de tableaux cliniques. L’évaluation clinique, qui sera au mieux pluridisciplinaire, devra répondre à des questions essentielles pour définir un objectif précis et une stratégie chirurgicale adaptée. Quelle est la plainte du patient et de son entourage? Quelle est l’utilité éventuelle des déformations? Quel est le type des déformations? Sont-elles réductibles? L’évaluation des possibilités thérapeutiques au niveau de la main nécessite une analyse fonctionnelle de tout le membre supérieur. De nombreux patients ont des déformations multiples, ce qui impose une hiérarchie des corrections en fonction des objectifs.Ceux-ci vont se répartir entre deux extrêmes : permettre de simples soins d’hygiène et de nursing dans des mains non fonctionnelles jusqu’à une amélioration ciblée chez des patients peu handicapés.Le bilan clinique doit évaluer les douleurs, les amplitudes passives, les capacités motrices volontaires et le rôle des différents muscles, agonistes et antagonistes, dans la déformation du poignet et des doigts.La réponse à ces différentes questions permet de définir un objectif clair qui sera contractualisé avec le patient et de définir la stratégie chirurgicale. La chirurgie repose sur un principe simple : détendre les muscles déformants, soit par neurectomie sélective s’il existe une simple hypertonie, soit par un geste tendineux si le muscle est rétracté ; compenser les antagonistes s’ils sont déficitaires, stabiliser éventuellement l’articulation. Les gestes plutôt conservateurs sont privilégiés pour garder les potentialités éventuelles.Les solutions médico-chirurgicales sont multiples et permettent une personnalisation de la prise en charge. Au niveau du membre supérieur, les résultats sont meilleurs dans les contrats hygiéniques, de nursing et antalgique. Ils restent plus difficiles à obtenir dans les contrats fonctionnels, en raison de la complexité biomécanique de la fonction de préhension.
