Los traumatismos del hombro son frecuentes en la práctica deportiva y en la vida cotidiana. Las lesiones que provocan dependen del mecanismo del traumatismo y de la edad del paciente. A continuación se describen las luxaciones de la articulación glenohumeral y de las articulaciones acromioclavicular y esternoclavicular, así como las fracturas de clavícula, de omóplato y del extremo superior del húmero.

Los traumatismos del tobillo y del mediopié representan entre un tercio y la mitad de los traumatismos del miembro inferior en los servicios de urgencias. La patología más frecuente es el esguince. La función del médico es poder diferenciar clínicamente un simple esguince de tobillo de una fractura o de una luxación del cuello del pie.

Purpose of the study Operative treatment of cervical myelopathy has focused on decompression of the spinal cord to avoid neurological deterioration. Anterior or posterior operative techniques have been used to decompress the canal with variable success. The purpose of this study was to compare surgical results after subtotal corporectomy or discectomy with an anterior approach and laminectomy or laminoplasty with a posterior approach. Material and methods We reviewed 30 patients with cervical spondylolitic myelopathy who had undergone surgery between 1989 and 1998. Mean age was 55.8 years (range 28 to 82). There were 23 men and 7 women. An anterior approach was used for 14 patients to achieve subtotal corporectomy or anterior discectomy with strut grafting. A posterior approach was used in another 14 patients to achieve laminectomy or laminoplasty. Both anterior and posterior approaches Were used for two patients. The severity of the pre- and postoperative neurological deficits was assessed with the Nurick scale. Results Average follow-up was 35.7 months (range 8 to 120). Neurological status improved in 83% of the patients. Improvement was better for those operated with the anterior approach for pain or brachialgia. The duration of the posterior procedures was, however, shorter with less blood loss. There was no statistical difference between the anterior or posterior approaches for motor function, sensory function, gait anomalies, or complications. Conclusion Surgical treatment is effective in cervical spondylolitic myelopathy. The anterior approach is preferred in case of pain or brachialgia; the posterior approach is indicated in case of poor health status or for bedridden patients.

Una buena presunción diagnóstica depende, con frecuencia, de la calidad de la exploración inicial de la rodilla traumatizada. Esta presunción permite a su vez seleccionar las exploraciones complementarias, tanto para confirmar el diagnóstico como para descartar otros.

Purpose of the study We analyzed calcaneum burst fractures in multiple trauma patients and propose a management scheme. Material and methods In a retrospective study, we isolated 23 patients with 31 calcaneum burst fractures. All were stage V in the Duparc classification. We call them "pied de mine" fractures as they resembled those described in military reports. Half of them (16 cases; 54%) were open fractures, All patients suffered multiple injuries and 12 had a psychiatric history. These fractures were associated with spinal fracture in 17 cases (73%) and half had neurologic deficit, limb fracture in 16 (73%), and pelvic fracture in 12 (52%). The most frequent associated foot injuries were a talus fracture in 9 cases (29%) and Chopart displacement in 16 cases (32%). Clinical evaluation used the Maryland foot score, foot print and radiologic evaluation with lateral retrotibial view. Results Mean follow-up was 35 months. Mean Maryland foot score was 62.7 and 13 cases were pain free. Pain was due to conflict with the lateral malleolus, bony plantar thorns, medial malleolus and subtalar osteoarthritis. Orthopedic shoes were used 11 times, The other patients used sports shoes. Subtalar mobility was most frequently absent (23/29 cases, 2 amputations). Fool print showed 13/16 flat feet; 6 thorns were indirectly visible. Two patients had retraction toes and were initially treated by external fixation. Radiologic evaluation showed 23/29 complete subtalar arthrodeses, 23/29 migration of the great tuberosity, often (17/23 cases) associated with varus angulation. Eleven patients needed subsequent surgery: 5 for arthrodeses and 6 for resection of bony thorns. Rate of complication was high, especially for open fractures: 2 infections for 15 closed fractures, and 8 infections (50%) for 16 open fractures with 2 cases of chronic osteitis. Secondary amputation was required in 2/31 cases due to sepsis. Treatment propositions For closed calcaneum burst fractures, it is better to wait one week before osteosynthesis. This delay is used to decrease edema with limb elevation and compressive bandaging. Skin tension due to trauma is increased by edema and osteosynthesis gives a high risk of wound disunion. We recommend reduction and Y-plate fixation even for burst fracture. Reduction must lower the tuberosity and correct the varus. After surgery, subtalar spontaneous arthrodesis is usually observed in a good position. Any bony plantar thorn must be resected. For open calcaneum burst fracture, the risk of sepsis is high. First treatment is debridement, stabilization and external fixation with antibiotic therapy. Stabilization should improve vascularization and facilitate internal fixation. The external fixation can be placed on the medial side to free the lateral approach to the calcaneum. Flap repair can be performed after one week when skin tension has subsided and areas of necrosis controlled.

Purpose of study Ten cases of ipsilateral hip and femoral shaft fractures were reviewed. Material and methods All patients were treated operatively for both fractures between 1988 and 1997 in Pitie Hospital. Five were treated with antegrade reamed intramedullary nails and cancellous screw fixation of the femoral neck, and 5 by long Gamma nail. The shaft fractures were fixed prior to definitive neck stabilization. Results Ipsilateral hip and femoral shaft fractures accounts for 5,6 p. 100 of the whole femoral shaft fractures registered in the same period. All cases occurred in young adults and resulted from high-energy impaction injuries. There were numerous associated injuries and all patients were polytrauma. The hip fracture was initially overlooked in 1 case without subsequent nonunion or avascular necrosis. At a mean follow-up examination of 22 months, two-thirds had a good result and one-third a fair or a poor result. Nonunion of the femoral neck occurred in one patient as a result of initial displacement and subsequent malreduction, while all shaft fractures united. Discussion X-ray films of the hip should be done in all cases of femoral shaft fracture in order to decrease the high incidence of missed femoral neck fractures in ipsilateral injuries of the femur. The results indicate that patients with ipsilateral fractures of the femoral neck and shaft can obtain good results when rigid anatomic stabilization of the femoral neck is performed. The femoral shaft fracture is given first priority and is reduced and immobilized with antegrade closed intramedullary nailing. The femoral neck fracture is then treated with cancellous screw fixation or compression screw with long Gamma nail. Conclusion The authors recommend the use of a long Gamma nail to fix this dual fracture whenever possible.

PURPOSE OF STUDY:Ten cases of ipsilateral hip and femoral shaft fractures were reviewed.MATERIAL AND METHODS:All patients were treated operatively for both fractures between 1988 and 1997 in Pitié Hospital. Five were treated with antegrade reamed intramedullary nails and cancellous screw fixation of the femoral neck, and 5 by long Gamma nail. The shaft fractures were fixed prior to definitive neck stabilization.RESULTS:Ipsilateral hip and femoral shaft fractures accounts for 5.6 p. 100 of the whole femoral shaft fractures registered in the same period. All cases occurred in young adults and resulted from high-energy impaction injuries. There were numerous associated injuries and all patients were polytrauma. The hip fracture was initially overlooked in 1 case without subsequent nonunion or avascular necrosis. At a mean follow-up examination of 22 months, two-thirds had a good result and one-third a fair or a poor result. Nonunion of the femoral neck occurred in one patient as a result of initial displacement and subsequent malreduction, while all shaft fractures united.DISCUSSION:X-ray films of the hip should be done in all cases of femoral shaft fracture in order to decrease the high incidence of missed femoral neck fractures in ipsilateral injuries of the femur. The results indicate that patients with ipsilateral fractures of the femoral neck and shaft can obtain good results when rigid anatomic stabilization of the femoral neck is performed. The femoral shaft fracture is given first priority and is reduced and immobilized with antegrade closed intramedullary nailing. The femoral neck fracture is then treated with cancellous screw fixation or compression screw with long Gamma nail.CONCLUSION:The authors recommend the use of a long Gamma nail to fix this dual fracture whenever possible.

PURPOSE OF THE STUDY:The cost effectiveness of wrist fractures in 1996 at Pitié-Salpétrière Hospital in Paris has been thoroughly analysed. The purpose of this retrospective study was to identify the factors responsible for the variation in the treatment cost of those fractures.MATERIAL AND METHODS:Cost, hospital stay, functional status, ASA score and surgical treatment were analysed in 53 patients with a median age of 57 years.RESULTS:The mean cost per patient was 6,120 FF divided as follows: 26.1% for pre-operative care, 36.4% for surgical procedures, 37.5% for post-operative care. The mean hospital stay was 4.3 days. The cost of personnel (43%) and medical investigations (35%) were the two main sources of hospital expenses beside medical materials (12.5%), hostelry (5.5%), and drugs (4%).DISCUSSION:The duration of hospital stay, the age and the type of the fracture were the only factors that affected statistically the mean cost per patient. Furthermore, factors related to the patient as sex, place of residence prior to admission, functional status, ASA score, had no influence on cost variation.CONCLUSION:Therefore, the best way to reduce the cost of wrist fractures management is to minimize the hospital stay before and after surgical procedure to avoid a lengthy and costly hospital stay and to minimize the abuse utilisation of systematic medical investigations.

Purpose of the study The cost effectiveness of wrist fractures in 1996 at Pitie-Salpetriere Hospital in Paris has been thoroughly analysed. The purpose of this retrospective study was to identify the factors responsable for the variation in the treatement cost of those fractures. Material and methods Cost, hospital stay, functional status, ASA score and surgical treatment were analysed in 53 patients with a median age of 57 years. Results The mean cost per patient was 6 120 FF divided as follows: 26,1 % for pre-operative care, 36,4 % for surgical procedures, 37,5 % for post-operative care. The mean hospital stay was 4,3 days. The cost of hospital personel (43 %) and medical investigations (35 %) were the two main sources of hospital expenses beside medical materials (12,5 %), hostelry (5,5 %), and drugs (4 %). Discussion The duration of hospital stay, the age and the type of the fracture were the only factors that affected statistically the mean cost per patient. Furthermore, factors related to the patient as sex, place of residence prior to admission, functionnal status, ASA score, had no influence on cost variation. Conclusion Therefore, the best way to reduce the cost of wrist fractures management is to minimize the hospital stay before and after surgical procedure to avoid a lengthy and costly hospital stay and to minimize the abuse ut utilisation of systematic medical investigations.

Endoscopic surgery was first carried out in 1807 by Bozzini, who developed the first endoscopic instruments. European surgeons continued to develop this technique, especially Dubois in France, who performed the first laparoscopic cholecystectomy in 1987.1 Bruhat and Mouret first used laparoscopic techniques in gynaecological surgery. This decade has seen endoscopic techniques used for thoracic surgery, particularly video-assisted thoracic surgery (VATS). This technique was developed by Regan 2'3 and Mack 4 in the USA and by RosenthaP in Germany. However, it was not until the beginning of this century that thoracoscopy was first used diagnostically by Jacobaeus 6 in the treatment of tuberculosis.

Corrective surgery for kyphotic deformities of the spine in ankylosing spondylitis is a major surgery. for rare indications. The authors report 31 lumbar osteotomies. The goal is to correct the deformity through a posterior limited approach and to minimise the neurological risks. The modifications developed by the authors for monosegmental closing wedge osteotomies are explained. The posterior resection is rhomboid shaped with a bilateral lamina removal. An osteotomy is performed in a forwards direction on the lateral aspects of the vertebral body without bone resection. This osteoclasty allows progressive vertebral body compression. Pediclectomy is associated if the corresponding foramen at the osteotomy level becomes too narrow in the process of redressing the spine. The resection level is adjusted so that superior and inferior posterior arches come into contact with a good compression. The authors point out the risk of lateral translation. Before the osteotomy, the two adjacent vertebrae are implanted with 5-mm cylindrical pedicular screws, so that posterior fixation can be carried out at any time. Posterior monobloc fixation allows for very great compression of the osteoclasty. The authors compare the results of their experiences in opening and closing osteotomy. They progressively changed their technique for closing osteotomies, because of published vascular complications and mechanical risks (instability and pseudarthrosis in opening osteotomies). Closing osteotomy also minimises the risk of stenosis with radicular compression or traction if an important correction is performed. The level of the osteotomy varied in this series, which had a correction rate of up to 75°. The choice of level depends on secondary effects on pelvic position and projection of the centre of gravity. The preferred procedure remains a monosegmental correction because it is faster and easier, with minimum bleeding. Short monobloc posterior fixation is sufficient to maintain reduction and to obtain stability from posterior compression.