Of marginal importance only 20 years ago, outcome measurement has become one of the most widely published topics in medical literature. The concept of global health is described by the International Classification of Function, Disability and Health. Today, the surgeon's perspective is no longer sufficient to evaluate global health condition of a patient. The patient cannot be reduced to an organ. Outcome measurement must take into consideration body structures and function (symptoms, organ function) as reviewed by a professional, the individual's functional health status in terms of activity and evaluated by the patient himself, and his participation in his social environment. These principles are now being applied to our specialty and it is essential to know them to be able to collect, analyze and publish valid results. This review article defines the rules for using clinical outcome tools, provides the most widely used clinical and self-evaluation forms for our specialty as well as instructions for their use. Global outcome is usually obtained by arithmetic addition of scores; which is a simple but questionable method. The sieving and radar charts can be used for a more comprehensible representation showing areas of relative strength and relative weakness on a graph, as well as depicting general overall performance. The reliability of data is also affected by declaration of conflicts of interest, negligence or fraud. The level of evidence is questionable as long as a data verification system is not implemented.

Objectives. - Scapholunate ligament injuries may lead to scapholunate instability and wrist osteoarthritis. Many surgical techniques have been described to repair these injuries. The goal of our study is to assess the clinical results after capsulodesis with the scaphotriquetral ligament for scapholunate instabilities.Methods. - Twenty-eight patients, 22 men and six women, were operated for scapholunate instability between January 2006 and December 2008. The average age was 37, 8 years, and the average time between trauma and surgery was 9,9 months. The scaphoid shift test was present in 26 patients. All patients underwent static and dynamic X-rays of the wrist and scan. A capsulodesis with scaphotriquetral ligament was performed in all patients.Results. - At 24 months follow-up, a 13 significant decreased of wrist range-of-motion was noted. The strength was significantly improved after surgery. The wrist stability was improved in 26 patients. Concerning pain, a significant reduction was noted with Analogical Visual Scale after surgery (p < 0.005). Twenty-one patients returned to their previous work. Complications were reflex dystrophy in one patient and wrist infection in one patient.Conclusion. - Many techniques were described for treatment of scapholunate injuries, from the simple scapholunate ligament suture to partial wrist arthrodesis. Capsulodesis with scaphotriquetral ligament improves grip strength, decreases wrist instability and pain with a slight lost of range-of-motion. (C) 2011 Elsevier Masson SAS. All rights reserved.

Several types of cryostimulation have been recently proposed to rapidly lower skin temperature therefore gaining a possible neuro/muscular recovery after strenuous exercise or, more generally, in sports. Local cryostimulation may be a viable and relatively portable tool to obtain physiological benefits in previously-efforted muscular districts. However, cohesive and standardized cryo-exposure protocols are lacking as well as the righteous procedure to efficaciously combine duration, treatments and temperature in relation to desirable effects on muscular strength. In this randomized-controlled study, fifty young women were tested for maximum isometric handgrip strength, before and after exhausting contractions.Following the fatiguing protocol, the intervention group (cryo, n = 25, 24.7 ± 2.5 years, BMI 21.7 ± 1.8 kg/m2) underwent a 6-min local cryostimulation (−160 °C) on the extensor-flexor muscles of the dominant arm, while control-matched peers sat rested in a thermo-neutral room (22 ± 0.5 °C). Handgrip tests were repeated at baseline (T0), after cryostimulation (T1), and 15 min after T1 (T2). Throughout the protocol, the AUC of the strength performance was significantly higher in the cryo- compared to control group (P = 0.006). In particular, following fatigue and cryostimulation, the cryo group preserved higher strength at T1 with respect to controls (26.8 ± 2.8 vs 23.9 ± 2.8 kg, Bonferroni's post-hoc, P < 0.01). Likewise, ventral and dorsal temperature, recorded with a thermal camera, were lower in cryo- than control group (P < 0.0001).In conclusion, a brief session of local cryostimulation may acutely preserve maximal isometric force in young women following a fatiguing protocol. These findings may have implications in orchestrating strategies of district muscular recovery.

Introduction. - Wounds on the palmar side of the wrist affecting the median or ulnar nerves are responsible for motor and sensory sequelae, severe pain and cold intolerance.Materials and methods. - Thirty-nine patients with 40 nerve sections were retrospectively reviewed with a mean follow up of 23 months. The median nerve alone was affected 20 time,, the ulnar nerve seven times and both nerves simultaneously 13 times. In 75% of the cases, there was an associated vascular injury (radial artery and/or ulnar artery). The average number of tendons cut was 4.25.Results. - After repair of the median nerve, 71% of patients recovered antepulsion and opposition that was normal or possible against resistance. The strength was approximately 70% of the opposite side. The sensitive recovery was good (S3 in >= 50% of cases) but it was accompanied by cold intolerance one out of two patients. After repair Of the ulnar nerve, 29% of the cases had an ulnar claw hand, 71% of patients recovered sensitivity greater or equal to S3 but with cold intolerance in 42% of the cases. The combined median and ulnar sections had a poorer sensory-motor prognosis. Revision Surgery was necessary in 12 of these cases.Conclusion. - Sensory recovery after an isolated ulnar nerve lesion at the wrist is better than after an isolated median nerve lesion but there is no difference in the motor recovery. Combined median and ulnar lesions have an especially bad prognosis and may require secondary palliative surgery. The existence of nerve contusion and a high number of tendon injuries were factors associated with a poorer prognosis. (C) 2009 Elsevier Masson SAS. All rights reserved.

The success rate for leg replantation has improved with the development of shortening-lengthening protocols. We checked whether this success was maintained long term in five cases of emergency reimplantation. The significant initial shortening of 93 mm, on average, enabled direct internal osteosynthesis, secondary lengthening was initiated swiftly, in the proximal metaphyseal area, and average lengthening was 85 mm. Consolidation was achieved in all cases within normal time periods, with an average inequality in residual length of 8mm. The speed of nerve regeneration was on average 1.926 mm/day, twice faster than usual after simple nerve suturing. At average follow-up of more than 11 years, all patients were walking. We conclude that nerve lengthening stimulates nerve regeneration, and that the results of this protocol, involving extensive initial debridement compensated by secondary lengthening, have enabled the limitations on unilateral leg replantation to be reduced.

Il trattamento delle lesioni dei tendini flessori è ancora molto problematico, soprattutto in zona 2. Negli ultimi 30 anni le modalità di trattamento di queste lesioni si sono notevolmente evolute. Tali progressi sono stati possibili innanzitutto grazie a una migliore conoscenza della fisiologia della cicatrizzazione. Attualmente tutti gli Autori concordano sul fatto che la riparazione dei flessori deve essere effettuata in urgenza mediante sutura diretta primaria, seguita da mobilizzazione precoce.

Patients must be informed of the benefits and risks before any surgical procedure. This information must be clear, honest, specific and complete in order that the patient can give his or her informed consent. This information has to be given face to face, however paper may be used to emphasize certain points and aid retention of information. We studied information sheets for carpal tunnel release given out in ten different hand surgery centres. Different points were identified to analyse each form. From this analysis, a literature review and recent law texts, we propose a new information sheet for carpal tunnel release.

Les schwannomes sont habituellement considérés comme des lésions énucléables dont l'excision sous microscope n'entraîne pas de déficit postopératoire. Ayant observé fréquemment l'inclusion de fascicule indissociable de la tumeur, nous avons voulu vérifier l'absence de déficit postopératoire dans une série rétrospective. Notre série comporte 14 patients d'âge moyen de 53 ans opérés de schwannomes du membre supérieur. Tous les patients présentaient une masse palpable depuis neuf mois en moyenne ; la douleur était présente dans quatre cas ; les paresthésies dans sept cas, le syndrome irritatif dans dix cas. Un déficit sensitif préopératoire était présent chez deux patients mais sans aucun cas de déficit moteur préopératoire. Le schwannome était localisé dans huit cas à la main, dans un cas à l'avant-bras, dans deux cas au coude, dans deux cas au bras et dans un cas au creux axillaire. Les nerfs atteints étaient les nerfs digitaux dans six cas, le tronc principal du nerf médian dans quatre cas, le tronc du nerf ulnaire dans trois cas et la branche sensitive du nerf radial dans un cas. Toutes les tumeurs ont été opérées sous microscope. L'énucléation a été possible sans lésion fasciculaire dans six cas. Dans les huit autres cas il a été procédé à une résection de fascicule indissociable de la tumeur. L'examen anatomopathologique a confirmé le diagnostic de schwannome pour tous les cas. En postopératoire, le déficit sensitif constaté en préopératoire chez deux patients a complètement disparu. Au contraire, trois patients qui n'avaient aucun déficit préopératoire ont présenté chacun un déficit sensitif postopératoire avec en plus un trouble moteur dans un des cas. Nous concluons de cette étude qu'il existe un risque de lésion fasciculaire peropératoire même sous microscope. Cette information est importante à considérer dans le cadre du consentement éclairé avant excision de cette lésion bénigne.

L'information du patient est indispensable avant une intervention chirurgicale. Cette information « loyale claire et appropriée » doit être la plus complète possible afin que le consentement du patient soit « éclairé ». Cette information doit obligatoirement être orale. Néanmoins, elle peut s'appuyer sur un support écrit. Nous avons étudié dix fiches, d'information et de consentement sur la libération du nerf médian dans le cas d'un syndrome du canal carpien, données dans des centres de chirurgie de la main. Plusieurs critères ont été analysés afin de structurer la critique de chaque fiche. À partir de ces critères, des textes de loi récents et de la littérature, une fiche d'information et de consentement éclairé est proposée.

The Schwannomas are usually considered as enucleable lesions of which the excision under microscope doesn't entail a post-operative deficit. Having frequently observed the inclusion of fascicle in the tumor, we wanted to verify the absence of deficit in a retrospective survey. Our survey is composed of 14 patients operated of schwannoma of the superior member and whose mean age is 53 years old. All patients presented an average of nine months old palpable mass; the pain was present in four cases; paresthesiae in seven cases; irritatif syndrome in ten cases. A preoperative sensory deficit was present in two patients but without any case of preoperative motor deficit. The schwannoma was localized in eight cases in the hand, one case in the forearm, two cases in the elbow, two cases in the arm and one case in the armpit. The affected nerves were the digital ones in six cases, the main trunk of the median nerve in four cases, the trunk of the ulnaire nerve in three cases and the sensory branch of the radial nerve in one case. All tumors have been operated under a microscope. The enucleation was possible without fascicle lesion in six cases. In the eight other cases we have proceeded to a resection of indissociable fascicles. The diagnosis is confirmed by the histologycal examination in all cases. In postoperative, the two patients that presented a preoperative sensory deficit no longer presented it. On the contrary, three patients that didn't have any preoperative deficit presented each a post-operative sensory deficit with in addition a motor trouble in one of cases. We conclude from this survey that there is a risk of peroperative fascicle lesion even when using the microscope. This information is important to consider in the setting of deciding how to proceed before the excision of this benign lesion.

Recent PIP fractures are challenging trauma in terms of diagnosis as well as treatment. It must be remembered that the final outcome will have a considerable impact on the global finger and hand function. Immediate mobilization and rehabilitation are mandatory, and may justify a surgical approach and fixation in selected cases. A good understanding of the fracture type is essential and relies in good part on precise, focused and standardized radiographs. Non-displaced fractures are generally treated conservatively. In the proximal phalanx, the orientation of the fracture line dictates the stability of the fracture. Thus non-displaced fractures can occasionally be preventively stabilized, in order to allow early mobilization. Displaced fractures should always be anatomically reduced and surgically fixed. A temporary joint stabilization is optional. In the middle phalanx, one must consider palmar and dorsal fractures differently. Palmar fractures include a distal palmar plate avulsion. The degree of impaction will dictate the stability of the joint towards dorsal subluxation. Dorsal fractures include central slip avulsion of the extensor tendon. An antomical reduction and surgical fixation is mandatory to avoid a progressive boutonniere deformity. Prognosis of all the middle fractures is closely dependent on the degree of impaction. When direct osteosynthesis is not possible, distraction devices, bone graft or palmar plate reconstruction may be useful alternatives. In complex fractures, bone fixation and joint stabilization must be combined in order to prevent secondary displacement and joint instability.

Nous présentons un nouveau principe de mesure des résultats par tamisage à propos d'une série prospective de libérations du canal carpien par voie endoscopique chez 72 patients. Chaque patient est évalué en prenant en compte trois groupes de critères. Les critères du premier groupe sont évalués par les patients eux-mêmes (autoévaluation), ceux du deuxième groupe sont évalués par un observateur médical (examen clinique) et ceux du troisième groupe sont évalués par la collectivité (aptitudes socioprofessionnelles). Nous considérons que le résultat global n'est bon que s'il l'est à la fois du propre point de vue du patient, du point de vue de l'examinateur et du point de vue de la collectivité. L'originalité du principe de tamisage consiste à trier les résultats globaux suivant un principe d'élimination. Lorsque le résultat global de chaque patient est passé à travers le tamis, ce résultat global reste bloqué si un seul des trois groupes est noté comme mauvais résultat. En appliquant ce principe original à notre série, nous avons obtenu 11 mauvais résultats autoévalués (diminution du DASH préopératoire inférieure à dix), six mauvais résultats cliniques (persistance de paresthésies gênantes) et un mauvais cas socioprofessionnel (absence de reprise du travail). Après tamisage, l'ensemble des résultats insuffisants a représenté 14 patients (19 %). Il nous semble que ce principe est un progrès par rapport à l'utilisation des fiches d'évaluation existantes qui ne prennent pas toujours en compte ces trois points de vue, et qui fabriquent un score global avec des moyennes arithmétiques à coefficients arbitraires.

An exceptional case of complete cutaneous ring finger avulsion is reported. The distal fragment was not replantable because of lack of vessels. The reconstruction restored a functional finger.