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Resume Objectifs La geometrie variable du carpe dans le plan frontal est connue depuis longtemps. Pourtant, la modelisation dynamique du carpe en rangees ou en colonnes est encore discutee, ainsi que le role du scaphoide. Cette etude tente de mieux comprendre l’organisation fonctionnelle du carpe. Methodes Nous avons mesure dans le plan frontal les deplacements angulaires des os du carpe, excepte ceux du pisiforme. Nous avons radiographie 40 poignets droits, sains, de face en inclinaison radiale et ulnaire. Nous avons mesure le mouvement angulaire decrit par chaque os par rapport a un axe vertical passant par le centre geometrique du carpe. Cet axe vertical etait une parallele a l’axe du radius, defini comme etant une droite joignant deux points a mi-largeur du radius a 2 et 5 cm de la glene radiale. Nous avons etudie et compare le mouvement entre les rangees, puis entre les colonnes carpiennes. Resultats Les mouvements angulaires mesures, arrondis au degre pres, sont les suivants : scaphoide 26°, lunatum 28°, triquetrum 29°, trapeze 44°, trapezoide 50°, capitatum 50°, hamatum 56°. La moyenne d’arc de mouvement pour la premiere rangee est de 27° et pour la deuxieme rangee de 50°. La moyenne d’arc de mouvement pour la colonne radiale est de 38°, pour la colonne moyenne de 39°, pour la colonne ulnaire de 42°. Conclusions Les mouvements des os sont proches entre les os d’une meme rangee et eloignes entre les os d’une meme colonne. Les deux rangees ont une amplitude de mouvement bien differenciee l’une de l’autre. Les trois colonnes entre elles ont des mouvements d’amplitude proche. Les mouvements efficaces du poignet, mobilisant la main, se mesurent entre les rangees carpiennes et non entre les colonnes. Les mouvements mesures entre les colonnes sont des mouvements de torsion intrarangees, permettant aux deux rangees carpiennes de rester congruentes entre elles et avec la glene radiale. Le scaphoide decrit un mouvement proche des mouvements du lunatum et du triquetrum, les mouvements sont unifies au sein de chaque rangee carpienne et le scaphoide s’inscrit totalement dans la cinematique de la premiere rangee. Le mouvement de bascule de la premiere rangee carpienne sous le radius et de bascule de la deuxieme rangee carpienne sous la premiere, les deux bascules ayant des amplitudes voisines, constitue pour nous le modele d’une double cupule carpienne.

A case of ulnar artery aneurysm following repeated hand injury in a mountain biker, is reported. The patient underwent surgical aneurysm resection with venous graft end-to-end anastomosis. Complete relief of symptoms is observed at 3 years follow-up. A literature review is presented.

The case of a patient 41 years old is reported. He sustained a posterior open carpal fracture dislocation transcapho-trans-capitate with radius styloid process fracture. The original aspect of this observation is that the lunatum was enucleated. The treatment was not usual. Capitatum bone was first fixed and associated with an external fixation. Proximal row carpectomy was performed in a second procedure when removing internal and external fixation, capitatum being healed. Follow up is now at four years with a very good radiological and clinical result. The patient is working with an intermittent mild pain. Radiographic examination demonstrated a very good vascularisation of the capitate head.

Resume Nous avons observe une tumeur a cellules geantes et trois osteosarcomes de l'extremite inferieure du radius. Le recul moyen de cette etude prospective etait de dix ans avec des extremes de quatre et 13 ans. Nous avons realise dans tous les cas une resection tumorale suivie d'une reconstruction par un greffon fibulaire non vascularise. Le but de notre etude etait d'apprecier les resultats carcinologique, fonctionnel et radiologique de cette technique a un recul moyen de dix ans. Le type histologique etait trois fois un osteosarcome de haut grade et une fois une tumeur a cellules geantes de grade I. En moyenne, la flexion du poignet etait de 45° et l'extension etait de 20°, la pronation de 30° et la supination de 50°. L'inclinaison radiale etait en moyenne de 10° et l'inclinaison ulnaire de 15°. Toutes les patientes etaient satisfaites de la fonction du poignet opere et menaient une vie familiale et professionnelle normales. La force de prehension etait trois fois, subjectivement correcte et une fois diminuee. Le delai de consolidation greffonradius restant etait en moyenne de six mois avec des extremes de quatre et neuf mois.

Resume Introduction La rhizarthrose primitive est une pathologie commune affectant essentiellement la femme en periode post-menopausique. Pour la traiter, plusieurs voies sont possibles : la trapezectomie, l’arthrodese, l’arthroplastie prothetique avec ou sans ciment. On peut aujourd’hui se demander si les traitements non prothetiques ont encore une raison d’etre. Pour tenter de repondre a cette question, les auteurs ont revu une serie de patients operes par trapezectomie-interposition-ligamentoplastie. Methode L’intervention associait une trapezectomie, une ligamentoplastie tendineuse de la base du premier metacarpien et une interposition par anchois fibreux. La serie portait sur 47 interventions au recul de 5 ans. Les patients ont ete evalues premierement avec un score fonctionnel incluant le resultat sur la douleur, la fonction au travail et dans les loisirs. Deuxiemement, avec l’opposition du pouce, la mobilite radiographique scapho-metacarpienne et la force de serrage. Resultats Les resultats fonctionnels etaient excellents ou bons dans 42 cas. L’opposition etait satisfaisante dans 46 cas. L’arc de mobilite scapho-metacarpien etait de 16 °. La pince etait a 4,2 kg et la prise a 23 kg. Nous n’avons pas releve de complications. La perte de force de la pince est de 1 a 2 kg par rapport a un groupe temoin. L’âge et le cote opere sont sans incidence sur les resultats. Le benefice de l’intervention persiste avec le temps. Le stade d’atteinte semble correle avec la qualite des resultats. L’aspect de collapsus de la premiere colonne n’est pas un facteur pejoratif. Nous n’avons eu aucune des complications decrites dans les autres techniques : synovite, ossifications, descellement, algodystrophie. Discussion Comparee aux autres techniques, la trapezectomie-interposition-ligamentoplastie donne des resultats de bonne qualite, durables et avec un minimum de complications. Pour toutes ces raisons, cette intervention garde notre preference.

The authors report a case of acrometastasis in a patient with breast carcinoma who, after nine years of remission, developed multiple osseous metastases including one in the distal phalanx of her right little finger. The patient who was aged 48, presented with a painful swelling of the distal end of the right little finger. Three weeks previously, she had been diagnosed with multiple osseous metastases. A distal interphalangeal disarticulation was advised and was performed without complications. Histological examination confirmed the diagnosis of metastasis of adenocarcinoma. The clinical picture of acrometastasis is generally dominated by pain, but a presentation similar to a whitlow is also possible. When the lesion is distal, amputation is preferred except possibly in the case of the thumb. Clubbing must be differentiated from pseudoclubbing. Clubbing is a nail deformation affecting all digital rays of one or both hands. It belongs to the syndrome of hypertrophic osteoarthropathy whose systemic etiologies are numerous. Pseudoclubbing is an atypical deformation, concerning one or more rays, and is asymmetrical; its causes are different and can be local. The normal angle of Lovibond is approximately 160 degrees, it is greater than 180 degrees in clubbing and less than 180 degrees in pseudoclubbing. Clinical examination makes it possible to differentiate these two signs and must be supplemented by radiographic examination.

The authors report a case of acrometastasis in a patient with breast carcinoma who, after nine years of remission, developed multiple osseous metastases including one in the distal phalanx of her right little finger. The patient who was aged 48, presented with a painful swelling of the distal end of the right little finger. Three weeks previously, she had been diagnosed with multiple osseous metastases. A distal interphalangeal disarticulation was advised and was performed without complications. Histological examination confirmed the diagnosis of metastasis of adenocarcinoma. The clinical picture of acrometastasis is generally dominated by pain, but a presentation similar to a whitlow is also possible. When the lesion is distal, amputation is preferred except possibly in the case of the thumb. Clubbing must be differentiated from pseudoclubbing. Clubbing is a nail deformation affecting all digital rays of one or both hands. It belongs to the syndrome of hypertrophic osteoarthropathy whose systemic etiologies are numerous. Pseudoclubbing is an atypical deformation, concerning one or more rays, and is asymmetrical; its causes are different and can be local. The normal angle of Lovibond is approximately 160 degrees, it is greater than 180 degrees in clubbing and less than 180 degrees in pseudoclubbing. Clinical examination makes it possible to differentiate these two signs and must be supplemented by radiographic examination.

To prevent the mechanical consequences of trapeziectomy, interposition devices are promoted, such a Dacron spacer. We report three cases of osteolysis and synovitis related to the use of such a device. This phenomenon occurred 4 months after insertion and required revision surgery after 9 months of follow-up because of pain and extensive osteolysis of the carpal bones. Revision consisted of an extended synovectomy, removal of the broken Dacron followed by a ligamentoplasty using the Flexor Carpi Radialis. Two years after revision surgery the result was satisfactory, with no recurrence of pain or osteolysis. The Dacron device did not demonstrate improvement in clinical results after short-term follow-up when compared to conventional ligamentoplasty. We recommend cautious use of the Dacron device at trapeziectomy and attention must be paid to follow up of the patient.

Surgery of the wrist relies on the known notions of biomechanics of the wrist. But these notions are incomplete. For a better understanding of the movements of the wrist, we studied five wrists of healthy volunteers with CT scanning. Each wrist was studied in neutral position, and in the four extreme positions: flexion, extension, radial and ulnar deviations. Using oblique reformatted CT sections, we measured the angular displacements in frontal and sagittal views of every carpal bone in the different positions of the wrist. This allowed us to construct a table of intracarpal mobility. By comparing the angle values and the three-dimensional pictures of these wrists, we illustrate some fundamental points regarding intracarpal movement. The dynamics of the wrist are like those of two super-imposed mobile cups with different movements. The proximal row is malleable with flattening and torsion according to the transverse axis and its behavior is like that of an articular meniscus. The distal row, more rigid but deformable, behaves like a T-handle giving attachment to the hand and articulating under the proximal row around the head of the capitate and the proximal pole of the hamate. During radial and ulnar deviations of the wrist, the movement between the two rows is like an inverse pronation-supination shearing. During flexion-extension, the distortion of the two rows allows maximal congruence to be maintained between the different carpal bones.

A case of ulnar artery aneurysm following repeated hand injury in a mountain biker, is reported. The patient underwent surgical aneurysm resection with venous graft end-to-end anastomosis. Complete relief of symptoms is observed at 3 years follow-up. A literature review is presented.

We examined clinical and radiological outcome in fifteen patients who underwent shoulder fusion after brachial plexus palsy.This retrospective analysis included 15 patients who underwent shoulder fusion between 1981 and 1997 for the treatment of sequelae secondary to brachial plexus palsy. There were 13 men and two women, mean age 24.6 years (range 18-33 years). The right shoulder was fused in nine cases and the dominant shoulder in ten. There was one obstetric paralysis and one paralysis secondary to a cervical neurinoma. Eleven patients were motorcycle accident victims and two were automobile accident victims. The patients were installed in the lateral supine position with 30 degrees antepulsion and 60 degrees abduction, measured from the axillary axis of the scapula, and internal rotation. All patients had internal fixation by plate through a posterior approach. The same observer examined all the patients at last follow-up. Clinical and radiological findings were recorded and the position of the arthodesis was analyzed.There was one case of delaved fusion and one case of late humeral fracture. The arthrodesis position was abduction 52 degrees, internal rotation 20 degrees, flexion 20 degrees (means). Hand-mouth and hand-pocket movements were possible for all patients. Seven had no pain. Active motion was: 48 degrees abduction, 46 degrees antepulsion, 40 degrees internal rotation, 4.6 degrees external rotation, 23 degrees retropulsion. For 13 patients, mean lifting force was 5.2 kg.

The case of a patient 41 years old is reported. He sustained a posterior open carpal fracture dislocation transcapho-trans-capitate with radius styloid process fracture. The original aspect of this observation is that the lunatum was enucleated. The treatment was not usual. Capitatum bone was first fixed and associated with an external fixation. Proximal row carpectomy was performed in a second procedure when removing internal and external fixation, capitatum being healed. Follow up is now at four years with a very good radiological and clinical result. The patient is working with an intermittent mild pain. Radiographic examination demonstrated a very good vascularisation of the capitate head.

We report four cases of primary bone tumour of the distal radius. Follow-up averaged ten years with a range of four to 13. Each case underwent excision of the tumour followed by reconstruction with a non-vascularised fibular graft. The aim of our study was to investigate the carcinologic, functional and radiological results at an average of ten years after the initial surgery. There were three high grade osteosarcomas and one giant cell tumour of bone. The mean postoperative wrist flexion was 45 degrees, extension was 20 degrees, pronation 30 degrees and supination 50 degrees. Radial tilt was a mean 10 degrees and ulnar tilt 15 degrees. All the patients had satisfactory function so as to be able to perform activities of daily living and to work. Grip strength was normal in three cases and reduced in one. Bone graft healing occurred at a mean of six months with a range of from four to nine months. Resection followed by a non-vascularised fibular graft is an effective way to managing these patients.

Osteoarthritis of the carpometacarpal joint of the thumb is a common pathology. Several surgical methods exist, including trapeziectomy, arthrodesis, cemented or cementless prosthesis. Therefore, one must question the legitimacy of non prosthetic surgery. The authors have tried to answer this question.Surgery consisted in trapeziectomy and ligament reconstruction with tendon interposition arthroplasty (LRTI). Authors reviewed 47 cases with five years follow-up. Patients were evaluated using a functional score, including pain, professional and domestic activities, and leisure involving the hand. Objective data were also assessed: thumb opposition, radiographic scaphometacarpal mobility, key and tip pinch, grasp strength.Functional results ranged from good to excellent in 42 cases. Opposition was satisfactory in 46 cases. Scapho-metacarpal range of motion was 16 degrees. Pinch strength was 4.2 kg and grasp strength was 23 kg. There were no complications. Loss of pinch strength was 1 to 2 kg as compared to our reference group. Such a loss does not impair patients' daily life. Age and operated side do not influence results. Scores do not decrease with time. Radiographic staging seems to be linked with scoring. Reducing the trapezial space does not influence results. We had none of the complications described in other techniques: synovitis, ossifications, loosening and reflex sympathetic dystrophy.This study, as well as literature, confirms that trapeziectomy and ligament reconstruction with tendon interposition arthroplasty gives satisfactory functional results which are stable with time and without complication. For all these reasons, the authors prefer this technique in degenerative osteoarthritis.

Porous beta-tricalcium phosphate (betaTCP) has osteoconductive properties. The adsorption of human recombinant bone morphogenetic protein-2 (rhBMP-2) onto TCP could realize an osteoinductive bone substitute. We evaluated it on an animal model using dual-energy X-ray absorptiometry (DEXA) and solid-state 31P nuclear magnetic resonance (NMR) spectroscopy. BetaTCP cylinders loaded with rhBMP-2 were implanted into rabbits' femoral condyle bone defects, and betaTCP alone as control into the contralateral femur. We studied two different doses of rhBMP-2 (10 and 40 microg) on two groups of four animals. Evaluation consisted in radiography, histology, and histomorphometry, DEXA, and NMR spectroscopy using an original method of quantification. With both doses of rhBMP-2, we observed on radiographs an increase of trabecular bone around implants. Histology showed resorption of the ceramic, trabecular bone with osteoblasts and osteoid substance around the implants, and colonization inside the porous betaTCP by new bone formed. Histomorphometry showed that the osteoid surface (OS/BS) was greatest with the high dose of rhBMP-2. The difference was slight between the low dose of rhBMP-2 and control. DEXA showed a dose-dependent increase of bone mineral density of rhBMP-2-loaded betaTCP vs. control. NMR spectroscopy confirmed that the amount of new bone formed in betaTCP was greater when betaTCP carried rhBMP-2, and increased with the dose of rhBMP-2 used. We showed that betaTCP was a good matrix for rhBMP-2, which gave it osteoinductive properties in an orthotopic site, in a dose-dependent manner. Thus, such composite biomaterial seems to be of great interest in reconstructive bone surgery. Further studies are needed in clinical practice to determine optimal doses.