Introduction: Surgical treatment of thoracolumbar spine fractures from T11 to L2 with correction of the traumatic kyphosis should be expected to avoid the deceptions observed with former treatments.

Material and methods: Seventy trauma victims (41 men and 29 women) underwent surgery between 1996 and 2003. According to the Denis classification, they presented: 16 compressions, 43 burst fractures, 8 seat belt fractures, and 3 disclocations. The Frankel classification was E:62, A:2, C2, D:2. Mean follow-up was 30.7 months. A pedicle screw protected with sublaminal hooks below and pediculotransverse claws above was used in 50 patients with a hybrid configuration in 20. Reduction was achieved by in situ cerclage. A secondary anterior graft was implanted for 38 patients.

Results: Patients were allowed to rise without contention on day 3. The traumatic angle measured with the sagittal index of Farcy (SIF) (the quality parameter used to study reduction) was 17 preoperatively and 1.6 after surgery. The loss at last follow-up was −2.2° with 81% of patients presenting normal or over correction. The loss was greatest (5.2°) for uniquely posterior approaches. The final Oswestry score was 29.8 (range 6–80) with a better result for the double approaches (20.7 versus 37.4, p< 0.001). Complications were phlebitis (n=1), sutured dural breaches (n=2), disassembly and nonunion (revision with a double approach) (n=1), infection (treated by wash-out and antibiotics) (n=10), retroperitoneal hematoma (treated by embolization) (n=1). Thirty-two patients resumed their work at seven months on average and 13 did not (25 without professional occupation).

Discussion: The overall results are better than those after orthopedic treatment. The rate of resumed work was 71%. This is an excellent result with a less aggressive treatment protocol (no corset) and shorter hospital stay (5–19 days). The protective hooks facilitate in situ cerclage, avoiding catching the screws and the risk of disassembly. The anterior graft is necessary when the reduction is discal and reduces the angle loss leading to less morbidity.

Conclusion: In situ cerclage enables constant sustained reduction of thoracolumbar fractures. Indication for surgery is often retained because of major deformation. Spinal fractures should be examined with the same assessment criteria as used for fractures of long bones and weight bearing should begin early to avoid the risks associated with prolonged bed rest.

Purpose of the study: We report our experience with the LCP DRP 2.4 plate with a locking screw for the treatment of distal factures of the radius.

Material and methods: Between 2003 and June 2004, 67 displaced fractures of the distal radius were treated with a LCP DRP 2.4 system. Patients were subsequently immobilized in a removable anatomic orthesis for three weeks. The Fernandez, Castaign and AO classifications were used. Clinical evaluation was based on the DASH test, the Green and O’Brien score and the PWRE.

Results: Clinical assessment was available for 59 patients who also responded to the questionnaires. Mean follow-up was eight months. Healing was achieved in six weeks. There were no cases of secondary displacement nor of lost reduction. The mean Green and O’Brien assessment was 85% good and very good outcome, the mean DASH score was 20.6 and the mean PWRE was 32.8.

Discussion: Appropriate fixation for fractures of the distal radius remains a controversial issue, as illustrated by the variety of treatments used, the different materials proposed for fixation, and the large number of publications. The primary stability achieved with the locking screw in the LCP plate enables early rehabilitation. The absence of secondary displacement, irrespective of the quality of the bone, enables equivalent results in osteoporotic patients as in younger patients. No other material has enabled equivalent results to date. This is a major advance in osteosynthesis.

Purpose of the study: Since 2001, we have used arthroscopy systematically to control the treatment of distal radius fractures. We report our three years experience.

Material and methods: Arthroscopic control was used for all patients aged less than 65 admitted to our unit for treatment of an articular fracture of the distal radius. The same operator performed all procedures. Fixation methods were: K-wire pinning, locked plating (Synthes) or a combination of these two methods. The arthro-scope had a 2.4 mm optic. Bony lesions were noted according to the Cataign, Fernandez and AO classifications. The DASH, Green and O’Brien, and PWRE scores were noted.

Results: Intraoperative arthroscopic control was performed for 61 patients between November 2001 and November 2004. Mean follow-up was 17 months (range 6–36 months). Arthroscopic exploration revealed: scapholunate ligament tears (n=11), lunotriquetral ligament injuries (n=3), pathological perforations of the triangle complex (n=4), damage to the radial cartilage (n=15), and mirror involvement of the carpal cartilage (n=4). An arthroscopic procedure was necessary to treat a bone or ligament lesion in 28 cases. At last follow-up, the DASH score was 19.3 and the PWRE 37.6.

Discussion: Arthroscopic evaluation of articular fractures of the distal radius, a routine practice in English-speaking countries, remains a limited practice in France. There is nevertheless a real advantage of using intraoperative arthroscopy. The particular anatomy of the radial surface makes it impossible to achieve proper assessment on the plain x-ray for a quality reduction of the fracture. Recent ligament injuries are rarely detectable on a wrist x-ray. An intra-articular stair-step or an untreated ligament injury can pave the way to short-term development of osteoarthritic degeneration. Intraoperative arthroscopic control is the only way to diagnosi and treat these osteoligamentary lesions observed in patients with an articular fracture of the distal radius. For us, non use of intraoperative arthroscopy constitutes a lost chance for patients with an articular fracture of the distal radius.

Purpose: We report preliminary results after treatment of humeral fracturs with a Targon centromedullary nail (Aesculap(r)).

Material and methods: Forty-five patients, predominantly women, underwent surgery from June 2001 to June 2002. Mean age was 63.5 years. The right side predominated. The series included 28 proximal fractures (65.9 years): 3-4 fragments (n=14), two fragments (n=8), pathological fracture (n=3),metaphyseo-diaphyseal fracture (n=3); and 17 shaft fractures (59.5 years): pathological fractures (n=4), nonunion (n=3), trauma (n=10). The Beach position, fractured limb free, was used with a superolateral approach. We inserted 28 Targon PH nails, including nine long nails, for proximal fractures and 17 Targon H nails for shaft fractures. Nail diameter was 8 mm. Nails were locked with four self-locking proximal screws (5 mm) and two distal screws (3.5 mm). The patients were immobilised with an arm to body brace. Hanging limb exercises were initiated immediately and active exercises at bone healing. The Constant score and radiographic measures were recorded at last follow-up.

Results: Mean follow-up was 12.2 months. We had six deaths and five patients lost to follow-up. Bone healing was achieved at eight weeks on average. Fracture reduction was acceptable for 37 limbs, including three which required open reduction. There were nine postoperative complications: superficial infection (n=1), distal screw pull out (n= 3), distal screw fracture (n=1), nail fracture (n=1). The mean Constant score was 69 (30–96).

Discussion: Proximal fractures of the humerus are often comminuted displaced fractures requiring cephalic arthroplasty. Total functional recovery is often difficult leading to mid and long-term problems for this young population. Stable quadruple proximal locking, associated with good filling of the canal by the nail enables fracture stablisation and satisfactory maintenance of the tuberosities. This stable assembly allows early rehabilitation. These advantages are particularly important for shaft fractures in young patients. The material does however have certain limitations related to fragility of the distal screws which are situated near the circumflex bundle for the Targon PH nail.

Conclusion: Our early results are encouraging for humeral fractures, both in elderly and young patients. This type of osteosynthesis can be a useful alternative to arthroplasty and allows early rehabilitation necessary for good functional recovery.

Purpose: Necrosis of the navicular bone, described by Müller then Weiss in 1927, is an uncommon finding, unlike talonavicular degeneration which is a rather frequent complication of talipes planovalgus. Between 1985 and 2000, we cared for 25 patients with this condition. The purpose of this retrospective analysis was to describe the clinical and radiological presentation and attempt to reconstruct its natural history with the aim of determining therapeutic indications.

Material and methods: We analysed 25 cases of navicular bone necrosis observed in 14 women and 3 men (eight bilateral cases). Mean age of the patients was 39 years (range 16–59). The diagnosis of necrosis was established on the basis of structural alterations (densification, bone defects) and in the more advanced cases, flattening and “expulsion” of the navicular bone. We looked for clinical signs and described the radiological aspect of the necrotic zone. A computed tomography was available in 14 cases and magnetic resonance imaging in the five most recent cases.

Results: Pain was the major sign in all cases. One-third of the cases occurred in a foot with prior planovalgus. History taking revealed elements suggestive of an aetiology in three cases: probable Köhler-Mouchet disease in a 16-year-old boy, sickle cell disease in a 35-year-old man, and prolonged walking with signs suggesting stress fracture in a 40-year-old woman. In the other 19 cases (11 women and 1 man, 7 bilateral cases), necrosis was considered idiopathic. Radiologically, we used the Ficat classification (described for hips): stage 0 with normal x-ray and strong uptake on scintigram (n=1), stage 1 with a normally shaped navicular bone but condensation or bone defect, stage 2 with modification of the shape of the bone without signs of degeneration, stage 3 where changes in the shape of the bone are associated with narrowing of the talonavicular then cuneonavicular space. Computed tomography included frontal and horizontal slices as well as lateral reconstructions indispensable to assess the posterior part of the interarticular spaces. Treatment was surgical in 12 cases and medical in 13. Well tolerated forms were treated with plantar ortheses with regular surveillance. Surgical procedures included triple arthrodesis (early in our experience), mediotarsal arthrodesis (n=2), talonavicular arthrodesis (n=7) and talocuneate arthrodesis with replacement of the scaphoid by an iliac graft (n=2). The natural course of necrosis was studied in the cases without surgery. The first sign was medial mediotarsal pain. At this stage scin-tigraphy or MRI was required for positive diagnosis. At stage 0 condensation of the navicular bone, confirmed by computed tomography, preceded bone flattening then expulsion upwardly and medially, sometimes with fragmentation and onset of talonavicular degeneration. Cuneonavicular degeneration appeared to occur later (except in one case). Long-term results of surgery were good with pain relief and renewed activity.

Discussion: The clinical presentation initially described as Müller-Weiss disease or scaphoiditis, which concerns a bilateral condition generally occurring after trauma and sometimes with a favouring factor (alcoholism, osteoporosis), appears somewhat different from our description. Mechanical factors predominated in our patients and the aetiologies were quite similar to those observed in Kienböck syndrome. Excessive pressure on the navicular bone, which leads to avascular necrosis, flattening, and expulsion, is undoubtedly the essential cause of this condition. It is well tolerated in some individuals and can lead to spontaneous fusion. In this situation, treatment can be limited to surveillance or orthopaedic care. If the functional impact is important, surgical treatment can be proposed, generally limited to talonavicular arthrodesis. If the navicular bone is sclerosed and flat, the remaining fragment can be replaced by an iliac graft to achieve talocuneate fusion.

Conclusion: Necrosis of the navicular bone appears to be less uncommon than in the classical description, particularly in black women aged 25–50 years. A more precise study of favouring anatomic factors (length of the medial ray, size of the talar neck, depression of the medial arch) could provide further information concerning the aetiology which appears to be similar to that of Kienböck disease.

Purpose: Radial paralysis is a major complication of humeral shaft fractures. In most cases, the paralysis is regressive but in certain patients surgical repair is required to achieve full neurological recovery. We reviewed retrospectively our patients to determine the causes of non-recovery and evaluate the efficacy of different treatments.

Material and methods: Thirty patients were operated between 1990 and 1997 for radial nerve paralysis that was observed immediately after trauma or developed secondarily. Mean follow-up after surgery was 6.3 years. There were 22 men and 8 women, 16 right side and 14 left side. Mean delay from injury to surgery was four months (0–730 days). Elements that could be involved in radial paralysis were noted: type of fracture, level of the fracture, treatment, approach, material used. There were ten cases with non-union. Neurological recovery at three years was assessed with muscle tests and with the Alnot criteria. An electrical recording was also made in certain patients. Surgery involved neurolysis in 23 cases, nerve grafts in five and tendon transfers in two.

Results: Outcome was very good and good in 22 patients, good in one and could not be evaluated in one (tendon transfer). There were three failures (two neurolysis and one graft) and two patients were lost to follow-up. After neurolysis, mean delay to recovery was seven months; it was 15 months after nerve grafts. Recovery always occurred proximally to distally.

Discussion: Radial paralysis after femoral shaft fracture regresses spontaneously in 76% to 89% of the cases, depending on the series. There is a predominance in the 20 to 30 year age range. Several factors could be involved in radial paralysis (fracture of the distal third of the humerus, spiral fracture, plate fixation, nonunion). The anterolateral approach allows a better exposure of the nerve. Unlike other authors, we do no advocate exploration of the injured nerve during surgical treatment of the fracture because it is most difficult to determine the potential for recovery of a continuous nerve.

Conclusion: The risk of radial nerve paralysis is greatest for spiral fracture of the distal third of the humerus. In such cases, it may be useful to explore the nerve during the primary procedure and insert a plate. For other cases, we prefer to wait for spontaneous nerve recovery. If reinnervation is not observed at 100 days, we undertake exploration.