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Anatomical variations in the distal insertion of the abductor pollicis longus (APL) muscle onto the 1st metacarpal bone and around the 1st carpometacarpal joint led Eduardo Zancolli to introduce a surgical yet conservative partial APL tenotomy targeting its accessory or supernumerary distal bundles. Following an anatomical and pathophysiological review, we will describe the surgical technique for this minimally invasive extra-capsular procedure. Results and operative indications of this very simple technique are reported as well, which can be performed in Dell stage I or II of trapeziometacarpal osteoarthritis when well-conducted conservative medical treatment has failed to achieve pain relief.

Il trattamento delle perdite di sostanza cutanee della mano fa appello a tecniche varie, dalla cicatrizzazione guidata ai lembi liberi passando per gli innesti cutanei, lembi locali, lembi regionali e lembi a distanza. Le tecniche presentate sono sperimentate. Le indicazioni sono discusse in funzione della localizzazione e dell’importanza della perdita di sostanza da trattare. Lo principio informatore e di ottenere una ricostruzione funzionale ed estetica nei migliori termini, consentendo una mobilizzazione precoce, garanzia di un buon risultato funzionale. La scelta del metodo piu efficace e piu semplice non esclude la sofisticazione allo scopo di raggiungere lo scopo fissato.

En el tratamiento de la perdida de sustancia cutanea de la mano se utilizan tecnicas diversas, desde la cicatrizacion dirigida a los colgajos libres, pasando por los injertos cutaneos y por los colgajos locales, regionales y a distancia. Las tecnicas que se presentan en este articulo han demostrado ser eficaces. Se plantearan sus indicaciones en funcion de la localizacion y de la extension de la perdida de sustancia que se va a tratar. La finalidad consiste en obtener una reconstruccion funcional y estetica lo mas precoz posible, que permita a la vez una movilizacion temprana y un buen resultado funcional. La eleccion del metodo mas eficaz y mas sencillo no excluye la sofisticacion para alcanzar el objetivo fijado.

Las sinovectomias de los tendones, se realicen sobre flexores o extensores, se necesitan frecuentemente en la mano y la muneca; por ello merecen un buen conocimiento, no solamente de las indicaciones quirurgicas, sino igualmente de sus tecnicas de realizacion. Dichas sinovectomias pueden ser aisladas, en cuyo caso se realizan sobre un tendon o un grupo de tendones afectados por un trastorno mecanico o inflamatorio puntual. El tratamiento generalmente permite resolver definitivamente el problema, aunque para ello a veces se requiere la asociacion de alguna maniobra quirurgica con el fin de suprimir la causa de la irritacion tenosinovial. En el resto de los casos las sinovectomias de los tendones extensores y flexores entran en el cuadro de patologias inflamatorias mas generalizadas, como la poliartritis reumatoide, que asocia a la afectacion tenosinovial una afectacion osteoarticular, o lesiones tendinosas a veces complejas, y por lo tanto mas extensas. La sinovectomia se incluye asi en una estrategia quirurgica mas amplia que tiene como objetivo resolver en un mismo tiempo quirurgico, por un abordaje dorsal o palmar, todos los problemas provocados por la patologia original, lo que implica un buen conocimiento, no solamente de las tecnicas de sinovectomia, sino tambien de las maniobras asociadas, oseas o de reparacion tendinosa.

We report our experience with patients who underwent surgery for entrapment neuropathies involving the ulnar nerve at the wrist and into the hand and the peroneal nerve. For the ulnar nerve, the cause of the lesion was identified in all patients, generally a cyst which had developed in the Guyon canal. The patients usually recovered completely. For the peroneal nerve, there was a wide variety of causes, with mucoid cysts frequently involved. Recovery was often incomplete, because of the very marked initial axonal damage. We emphasized the need for rapid diagnosis and surgical treatment.

Resume Objectif Le lymphœdeme secondaire du membre superieur est une complication survenant chez 15 a 20 % des femmes traitees pour un cancer du sein. Des pathologies necessitant un acte chirurgical peuvent survenir sur le membre ayant un lymphœdeme. Le but de l’etude etait d’analyser l’influence d’un acte chirurgical sur le volume d’un lymphœdeme du membre superieur. Methodes Neuf femmes droitieres ayant un lymphœdeme secondaire du membre superieur apres traitement d’un cancer du sein ont ete incluses dans l’etude. L’âge moyen lors du cancer du sein etait de 45,6 ± 8 ans. Le cancer etait localise a droite dans 6 cas et avait ete traite par tumorectomie (n = 5) ou mammectomie (n = 4), radiotherapie externe (n = 8), chimiotherapie (n = 4) et hormonotherapie (n = 5). Le lymphœdeme du membre superieur etait present en moyenne depuis 10 ans avant la chirurgie du membre superieur et s’etait complique d’au moins un erysipele chez 6 des 9 femmes. Les indications chirurgicales du membre superieur etaient un syndrome du canal carpien (n = 6), une fracture des os de l’avant-bras (n = 2) ou une fracture de l’humerus (n = 1) traitees par osteosynthese. Le volume du lymphœdeme, calcule par la difference entre le volume du membre atteint et celui du membre sain, a ete compare avant et a distance de l’acte chirurgical du membre superieur. Resultats Six patientes ont ete operees d’un syndrome du canal carpien sous anesthesie locoregionale et garrot pneumatique de courte duree. Le traitement a consiste en une liberation du nerf median par voie palmaire. Les deux patientes avec une fracture des os de l’avant-bras ont eu une osteosynthese puis une immobilisation plâtree. La fracture de l’humerus a ete traitee par enclouage. En preoperatoire, le volume du lymphœdeme etait de 747 ± 315 ml. Le traitement du lymphœdeme, avant et apres la chirurgie, etait inchange et comportait des bandages peu elastiques (n = 9), le port de compression elastique de classe 3 (n = 9) et des drainages lymphatiques manuels (n = 8). Avec un recul median de 8 mois apres la chirurgie, le volume du lymphœdeme avait augmente a 858 ± 293 ml (p = 0,012) soit une augmentation absolue moyenne de 111 ml (IC 95 % : 32 a 109 ml) representant 15 % du volume avant chirurgie. Conclusion La chirurgie du canal carpien ou les osteosyntheses pour fracture entraine une augmentation de volume sur un membre atteint de lymphœdeme secondaire apres traitement d’un cancer du sein malgre la poursuite du traitement par contention/compression. (J Mal Vasc 2006 ; 31 : 202-205).

Resume Alors que le traitement orthopedique par immobilisation stricte du doigt en maillet recent est largement admis, le traitement des lesions inveterees reste discute. Depuis 1989, nous utilisons dans les lesions anciennes la technique d’accourcissement-suture du cal tendineux. Parmi les 77 operes sur 10 ans, 66 ont pu etre revus avec un recul moyen de 21 mois. Le deficit postoperatoire d’extension active de l’interphalangienne distale etait alors de 4,5° en moyenne avec 52% de doigts ayant recupere une extension complete, soit un gain moyen de 41°. La flexion moyenne etait de 50°. Cela represente 77% de resultats favorables selon des criteres classiques modifies. A l'exception de 2 echecs ayant du etre reoperes, nous ne deplorons aucune complication grave : 2 cicatrices douloureuses et 20 % de sensibilite au froid, non specifique. Nous proposons donc ce procede de reconstruction anatomique, simple et benin, de premiere intention pour les doigts en maillet non traites des le 2 e mois, sans le substituer avant ce delai au traitement orthopedique. De meme, cette intervention peut etre proposee en cas d’echec de ce dernier des le 3 e mois si l’articulation est souple et le deficit d’extension active superieur a 30°. Les deformations en col de cygne sont facilement ameliorees par une tenotomie associee selon Fowler. En cas d’echec un accourcissement iteratif ou une arthrodese peut etre discute.

Traumatic dislocation of the pisiform bone is uncommon. The authors report a case treated by primary excision with a good result. The literature is reviewed and treatment choices are discussed.

Resume Nous rapportons le cas d’un homme de 49 ans presentant une fracture pathologique inaugurale du deuxieme metacarpien. Celle-ci conduit dans un premier temps a un curetage-comblement iliaque sans diagnostic histologique prealable, associe a un brochage transfixiant la carpometacarpienne. Ce geste insuffisant ne parvient ni a consolider la fracture, ni a enrayer l’evolution de la lesion initiale, dont l’histologie exacte apres biopsie n’est precisee que quatre mois plus tard en faveur d’un osteosarcome. Apres chimiotherapie neo-adjuvante, une resection en bloc du deuxieme rayon emportant egalement le trapezoide est realisee. Dix-huit mois plus tard, considere comme gueri au niveau de la main avec un resultat fonctionnel satisfaisant, la decouverte d’une localisation sarcomateuse volumineuse au niveau de la zone de prelevement iliaque oblige a pratiquer une resection de l’hemibassin. Cette intervention de sauvetage n’empechera pas la survenue ulterieure de metastases pulmonaires et vertebrales, puis le deces du patient. A la lumiere de cette observation exemplaire, les regles elementaires concernant le traitement des tumeurs malignes sont rappelees. Elles auraient permis d’eviter la complication decrite au pronostic catastrophique.

Resume Syndrome canalaire le plus frequemment rencontre, le syndrome du canal carpien correspond par definition a la compression du nerf median dans sa traversee du canal carpien a la face anterieure du poignet et du carpe. Apres un court rappel anatomique et physiopathologique, la presentation clinique habituelle, de meme que les formes atypiques ou rares, sont decrites. Si le syndrome du canal carpien reste idiopathique dans plus de la moitie des cas, ses autres causes sont neanmoins nombreuses et ainsi detaillees. Son traitement doit etre d’abord medical (infiltrations et attelle de posture nocturne) dans les formes moderees et non deficitaires. La chirurgie, de toute facon precedee d’un electroneuromyogramme systematique, est particulierement efficace qu’elle soit pratiquee a ciel ouvert ou sous controle endoscopique, technique plus « moderne » mais non denuee de risques.

Resume Les auteurs rapportent une serie de 76 patients presentant 95 doigts avec section d'un ou des deux tendons flechisseurs siegeant, dans 66,6% des cas, en zone II. La technique operatoire utilise le point de Tsuge associe a un surjet epitendineux et, tous resultats confondus, a donne 60% de tres bons resultats, 22% de resultats moyens et 18% de mauvais resultats. Ces pourcentages ne sont pas differents de ceux des autres series publiees utilisant d'autres types de suture tendineuse. Les facteurs influencant les resultats sont la gravite des lesions associees, en particulier celles des deux pedicules vasculaires, et la localisation a la zone II. Les complications mecaniques sont representees par 5% de rupture et 22% d'adherence tendineuse. Les auteurs recommandent le point de Tsuge parce qu'il est plus simple et de realisation plus rapide avec des resultats semblables a ceux des autres techniques.

Resume Les tumeurs glomiques des extremites digitales sont des tumeurs benignes, rares et de petite taille, dont le diagnostic est clinique, mais leur localisation precise est difficile par les examens classiques d'exploration. L'IRM, realisee en haute resolution et a l'aide d'injection IV de contraste, paraissait une methode prometteuse pour la detection mais surtout pour le bilan topographique et morphologique de la lesion et a ete ainsi evaluee chez 20 patients, cliniquement suspectes de cette pathologie. Sur 18 lesions glomiques, prouvees chirurgicalement et histologiquement, l'IRM a permis de retrouver 16 lesions. Dans 2 cas, l'IRM s'est averee negative et l'exploration chirurgicale egalement. Une excellente correlation anatomo-chirurgicale a ete obtenue pour la taille (7 lesions de 2 mm d'epaisseur), la localisation et le retentissement osseux. L'association de sequences ponderees en T2 et en T1 apres IV a permis d'ameliorer encore les performances de cette methode. Les informations fournies sur la localisation et la taille de la tumeur ont ainsi optimise le diagnostic et la technique chirurgicale.

Maxime, 18 ans, rugbyman, presente lors d’un plaquage une douleur tracante de l’annulaire remontant a l’avant-bras pour laquelle il ne s’inquiete pas immediatement. Le lendemain, la pulpe de son doigt est devenue ecchymotique (fig. 1) et il constate l’absence de flexion de son extremite distale (fig. 2) s’accompagnant d’un defaut d’enroulement complet du doigt pour lequel il consulte en urgence.

Resume La luxation, d'origine traumatique, de l'appareil extenseur au dos de l'articulation metacarpo-phalangienne de l'auriculaire est une lesion rare et meconnue puisque nos six patients n'ont ete operes que secondairement, a distance du traumatisme. Le diagnostic est clinique : la flexion est possible tandis que l'extension est impossible a partir de la position de flexion. L'extension peut etre maintenue contre resistance si la luxation tendineuse est reduite par remise en extension de l'articulation. La radiographie, necessaire, permet d'eliminer toute atteinte osseuse ou articulaire. Nous avons regroupe six cas qui repondent a deux situations differentes : soit les deux tendons (extenseur propre et extenseur commun) sont luxes simultanement en parallele sur le bord cubital de l'articulation, soit les deux tendons sont disjoints et luxes de part et autre de cette articulation. Dans le premier cas, la lesion survient chez les trois patients les plus âges de notre serie, victimes d'un traumatisme en varus force avec dechirure de la bandelette sagittale radiale et de la partie proximale de la dossiere externe. Cette luxation fut reduite et stabilisee par une plastie selon la technique de Michon. Dans le deuxieme cas, la lesion survient chez les trois patients les plus jeunes de notre serie, victimes d'un traumatisme axial direct. Cette disjonction fut reduite par readossement et suture des tendons entre eux au dos de l'articulation apres liberation de la dossiere interne et scarification de la dossiere externe retractee. Les suites operatoires ont ete assurees, dans tous les cas, par une attelle palmaire maintenant l'articulation metacarpo-phalangienne en extension et autorisant une reeducation immediate en syndactylie des deux derniers doigts. Cette attitude therapeutique nous a permis d'obtenir de bons resultats, puisque avec un recul moyen de six ans, aucune raideur ou recidive n'est a deplorer.

We report our experience with patients who underwent surgery for entrapment neuropathies involving the ulnar nerve at the wrist and into the hand and the peroneal nerve. For the ulnar nerve, the cause of the lesion was identified in all patients, generally a cyst which had developed in the Guyon canal. The patients usually recovered completely. For the peroneal nerve, there was a wide variety of causes, with mucoid cysts frequently involved. Recovery was often incomplete, because of the very marked initial axonal damage. We emphasized the need for rapid diagnosis and surgical treatment.

Secondary upper lymphedema occurs in 15 to 20% of patients after breast cancer treatment. Surgery may be required on lymphedematous limb. The aim of our study was to analyze the effects of surgery on lymphedema volume.Nine women with upper limb lymphedema after breast cancer treatment were recruited. Mean age at time of breast cancer was 45.6 +/- 8 years. Breast cancer was localized at right side and was treated with mammectomy (n=4), radiotherapy (n=8), chemotherapy (n=4) and antiestrogen (n=5). Mean duration of lymphedema before upper limb surgery was 10 years. Six patients reported one or more previous cellulitis. Surgery was indicated for carpal tunnel syndrome (n=6), forearm (n=2) or humeral (n=1) fracture. Lymphedema volume, calculated by the difference of volume between the lymphedematous and the contralateral arm, was compared before and after surgery.Six patients had carpal tunnel release by transecting the transverse carpal ligament under local anesthesia with short total time tourniquet. Humeral and forearm fractures were treated with osteosynthesis. Before surgery, lymphedema volume of upper limb was 747 +/- 315 ml. Lymphedema management included low stretch bandages, elastic sleeve, manual lymph drainage. After 8 months follow up, lymphedema volume was significantly higher, 858 +/- 293 ml (p=0.012). Mean absolute variation of lymphedema volume was 111 ml (CI 95%: 32 to 109 ml), i.e. 15% of pre surgery lymphedema volume.Surgery of carpal tunnel syndrome or osteosynthesis for fractures may lead to increased lymphedema volume in patients previously treated for breast cancer despite compressive therapy.

Acute mallet fingers are commonly treated by splinting. Treatment of chronic injuries is more debated. Since 1989, a "shortening and suture" technique have been used for such chronic injuries on the elongated tendon scar. Sixty six of 77 patients treated on a 10 years period were reviewed with a mean follow-up of 21 months. The mean active extension lag at the distal interphalangeal (DIP) joint was 4.5 degrees (41 degrees of improvement) with 52% of fingers which recovered a full extension, representing 77% of good and excellent results according to Abouna's and Brown's modified criteria. There were two failures which lead to reoperation, and no complication (2 painful scars and 20% of cold intolerance). We propose this safe and simple technique for chronic mallet fingers if deformity exceeds 30 degrees, for patients untreated (after the second month), or when splinting has failed. "Swan-neck" deformities were improved by an associated Fowler procedure. In case of failure, a new "shortening and suture" or a DIP arthrodesis can be discussed.

Traumatic dislocation of the pisiform bone is uncommon. The authors report a case treated by primary excision with a good result. The literature is reviewed and treatment choices are discussed.

In this study, the case has been examined of a 49-year old male who initially presented with a pathological fracture of the second metacarpal. This was first treated by curettage, iliac bone graft and internal fixation, without any complementary investigation being carried out, i.e., no preliminary biopsy and histological diagnosis were made. The results of this inadequate approach were poor: neither satisfactory fixation of the fracture nor control of the primary lesion were obtained. Moreover, the definitive diagnosis was only made four months later, when biopsy findings confirmed the presence of an osteosarcoma. After neoadjuvant chemotherapy, an en-bloc resection of the second metatarsal and the trapezoid bone was carried out. At ten months post-surgery, one and a half years after the original fracture, the hand was found to be disease-free and functioning satisfactory. However, nearly a year later the discovery of a large tumor mass at the site where the iliac bone graft was originally taken necessitated resection of the hemi-pelvis, with chemotherapy prior to resection and radiotherapy following surgery. Unfortunately, this salvage procedure did not limit the spread of the disease, and subsequent pulmonary and vertebral metastases were found, leading to the death of the patient three years after the initial fracture. This particular case underlines the fact that the basic rules for the management of malignant tumors should be taken into consideration from the onset, so that a catastrophic prognosis such as that described can be avoided.

After revealing tendon healing and the international classification adopted in 1980 for flexor tendon lesions, the author reviews the primary tendon repair procedures and the various postoperative mobilization protocols. The current tendency is towards early active mobilization with a protection orthosis. The various secondary surgical procedures are then critically discussed: secondary suture, tendon release, one-stage or two-stage tendon graft, total anterior tenoarthrolysis, tendon transfer, vascularized tendon graft, active tendon implants.

The authors review a series of 76 patients with 95 fingers involved, 66.6% of them occurring in zone II. The core stitch was performed according to the Tsuge technique (type II) combined with a peritendinous running suture. Results based on TAM were excellent or good in 60%, fair in 22%, and poor in 18%. Influencing factors were associated lesions, mainly vascular and lesions in zone II. Rupture occurred in 5% and adhesion in 22% of cases. Providing similar results to those of other techniques published in the current literature, the Tsuge techniques is preferred because it is simpler and faster to perform.

Despite the high incidence of wrist trauma, severe sprains with disruption of the ligaments are actually rare, apart from lesions of the scapholunate joint line. However, the diagnosis of severity should now be established, if not as an emergency, at least soon after the trauma, as deterioration of carpal instability always leads top osteoarthritis after a variable interval of time. When a ligament lesion is suspected, initial pain-free immobilisation, plain and dynamic x-rays followed by at least arthrography of CT arthrography, should be performed. After describing scapholunate sprain, the commonest form, the other varieties are reviewed: pyramidolunate, midcarpal, scaphotrapezoid, radiocarpal and finally inferior radioulnar sprains.

High pressure injection injuries of the hand are rare, but very severe. The material injected acts in two ways: chemical irritation as a result of its toxicity, and physical distension of tissues of the finger, which are not normally distensible, as a result of the pressure of injection of the liquid which may reach 700 kg/cm2. The main complications were necrosis and infection ending in amputation in thirty percent of the cases. Often the conserved fingers suffered cold intolerance. Therefore, the gravity of this accident has led us to believe that it is the "most urgent of hand emergencies".

The glomus tumors of the finger tip are benign. Their diagnosis is clinic but their precise localization is quite difficult by classic imaging. MRI with gadolinium injection seemed a good method to check exactly this lesion and have been tested on 20 patients suspected suffering of glomus tumor. On 18 glomus tumors surgically and histologically confirmed MRI examination have been positive for 16. In two cases MRI and surgery were negative. A good correlation seems observed with surgery for the size (7 tumor of 2 mm) the localization and osseus extension. Addition of T2 and T1 before and after injection weighted acquisitions improved the results. Precise informations on topography and size seems improved the surgical approach.

Dislocation of the extensor tendon over the MP joint as a result of trauma is a rare and unrecognized injury as our six patients were only operated subsequently. The diagnosis is simple: flexion is possible, while extension is not. The patient is able to hold the extension despie resistance if the dislocation is reduced by artificial extension. X-rays eliminate any possible fracture. Six cases have revealed two different assumptions: either the two tendons (extensor digitorum communis and extensor digiti quinti proprius) are simultaneously dislocated together on the ulnar side, or they are dislocated on either sides of the joint. In the first assumption, the injury occurred ulnar-wise tearing the sagittal band. This case concerns the three older patients. The dislocation was reduced and stabilized by the Michon surgery method. The second assumption concerns the three youngest patients who suffered from a direct axial shock. This separation was reduced by suture of the two tendons on the dorsal base of the joint. The postoperative care was ensured in all cases by a splint attached to the palm, keeping the MP joint in extension and enabling immediate web-fingered reeducation. This therapeutic technique has given satisfactory results as over an average period of six years no recurrence of stiffness has been observed.

We report our experience of the use of a scalar type incision associated with a total skin graft in the treatment of recurrences of Dupuytren's contracture. This is not an original technique, but one described by Hueston in 1984, which consists of a "Fire Break" skin graft after a simple transverse incision of recurrent Dupuytren's contracture. We attribute the absence of recurrence with this graft to the impossibility of the disease to affect the thin tissue between the skin graft and the underlying tendons. Our series is composed of 25 patients, all male. The majority of these patients had undergone surgery on a single occasion before treatment of recurrences with an average time interval of seven years. In a great majority of cases the little finger was deformed and generally severely (stage III or IV). All of our patients were reviewed with a mean follow-up of 28 months after surgery, and we did not observe any recurrences under the graft. In this series, which remains too small and too recent, 67% of cases presented an acceptable result with nearly complete extension and satisfactory grasp. We do not apply this technique to the treatment of all cases of recurrent Dupuytren's contracture, but we reserve it preferentially for elderly patients, operated on several occasions for ulnar fingers especially the little finger, in digital or digito-palmar forms in which the deformity predominates on the proximal interphalangeal joint with marked digital infiltration.

Nous rapportons une serie de 24 cas de luxation de l’appareil extenseur au dos de la metacarpophalangienne des doigts longs, pathologie rare, toujours chirurgicale, mais de diagnostic souvent meconnu donc tardif. L’etiologie traumatique domine (14 cas) en regle en rapport avec un traumatisme ferme du sujet jeune (11 cas) et la pratique sportive. A l’oppose, 10 cas correspondent a des sujets âges ou la rupture peut etre consideree comme « degenerative », pouvant s’accompagner de defaut d’extension pluridigitale des deux doigts (2 cas), voire des trois doigts cubitaux (2 cas). Le medius est de loin le plus souvent atteint, representant plus de la moitie des cas (13 cas). Pour l’auriculaire (6 cas), il faut distinguer les lesions habituelles de la bandelette sagittale radiale et la dissociation longitudinale traumatique des deux tendons extenseurs propre et commun (2 cas). Si le diagnostic de luxation traumatique de l’appareil extenseur reste clinique, le traitement en est resolument chirurgical permettant une reparation directe de la bandelette sagittale le plus souvent radiale, voire de la dossiere. Pour les lesions anciennes, il faut individualiser les luxations traumatiques ou la sangle peut etre encore reparee apres liberation controlaterale, des cas degenerants ou la realisation d’une plastie de neodossiere peut etre necessaire. Les elements du diagnostic ainsi que les differents procedes chirurgicaux sont passes en revue, detaillant de plus un cas exceptionnel d’instabilite traumatique complete de l’appareil extenseur du medius, dissocie du plan reste intact des sangles laterales et des dossieres, luxable de part et d’autre de la tete metacarpienne et ayant necessite de ce fait une double stabilisation cubitale et radiale au dos de celle-ci, avec un resultat clinique normal a 3 mois postoperatoires.

Resume L'etude d'une serie homogene de vingt-huit plaies isolees du nerf median au poignet, suturees en urgence, nous a permis de determiner l'evolution et les sequelles d'une telle lesion nerveuse sans atteinte tendineuse associee. La reparation a associe une suture epiperineurale sous grossissement optique, une immobilisation en legere flexion du poignet pendant trois semaines et une reeducation de la sensibilite. 60,7 % des malades ont un bon ou tres bon resultat avec une meilleure recuperation motrice que sensitive. La contusion du nerf, la perte de substance nerveuse avec suture sous tension, et les accidents de travail sont des facteurs de mauvais pronostic.

Synovectomy of twenty-three elbows was done in eighteen patients, eight to twenty-five years old, who had severe hemophilia and were followed for eighteen to seventy months. Episodes of bleeding recurred in four elbows, and moderate pain persisted in three. A significant improvement in mobility was observed for pronation-supination in nine elbows and for flexion-extension in fourteen. No radiographic evidence of arthritis was seen. Synovectomy of the elbow, performed through a single lateral incision, appears to be a valuable surgical procedure in hemophiliacs in whom non-operative treatment has failed, and resection of the radial head should be done in adults when there is moderate or severe damage to the cartilage of the radial head.

Seemingly spontaneous subcutaneous ruptures of the flexor tendons of the hand are not frequently encountered. The case studied is that of a young man whose deep flexor tendon of the third finger snapped during a slight effort. The histological and immunohistochemical analysis led to the conclusion that there was localization of an intra-tendinous neurofibroma, which would seem to be a so-far undescribed phenomenon. The patient presented neurofibromas elsewhere and had pigmented spots on the body, which enabled Von Recklinghausen's disease to be diagnosed.

Two cases were seen in elderly patients in which a carpal tunnel syndrome was present in association with an ununited scaphoid fracture. The carpus had remodelled and the lunate was dorsi-flexed. Its upper end bulged into the tunnel and was the cause of the nerve compression. It was aggravated by associated osteoarthrosis. The two cases were treated surgically by neurolysis and division of the carpal ligament and partial resection of the lunate to restore the normal concavity of the carpus.