Purpose of the study: We report our experience with 59 cases of secondary nailing after external fixation of tibial fractures.

Material and methods: Between 1988 and 2002, 59 tibial fractures (58 patients) were treated initially by external fixation then by secondary nailing. The AO classification was: A (n=28), B (n=20), C (n=11). The Gustilo classification was: closed (n=28), grade 1 (n=18), grade 2 (n=10), grade 3A (n=1), grade 3C (n=2). Tibiotibial or tibio-calcaneal external fixation was used initially for these lower diaphysometaphyseal fractures. The reason for using external fixation was: soft tissue damage (n=38), complex fracture (n=14), associated injuries (n=7). Associated plastic surgery procedures were: medial gastrocnemius flap (n=1), skin graft (n=3). Secondary nailing was undertaken early in 41 cases at about the sixth week because of improvement in the local or general status. For seven cases, the secondary nailing was performed at about four weeks after the multiple-fragment fracture had partially consolidated. There were three infectious complications after nailing (abscess on screw, fistula, pandiaphysistis) in patients whose initial samples of the reaming material were bacteriologically negative. Bone healing was achieved after nailing in 56 cases. Dynamizing the nail was sufficient to achieve healing in one case. Two cases of septic non-union were nailed again and finally healed. The case of pandiaphysitis was treated by removing the nail then a new external fixation which was successful in achieving bone healing.

Results: The results of the secondary centromedullary nailing were satisfactory. Several operations were necessary however (removal of the fixator, nailing, dynaiztion, material removal) with considerable risk of infection. This two-stge method enables treatment of difficult situations rapidly (external fixation) and early (four weeks) revision to allow «programmed» treatment in safer conditions. This secondary nailing can also be used as a treatment in the event of late healing after initial external fixation. Contraindications are pin tract osteitis and serious local infection during the external fixation phase.

Purpose: The purpose of this study was to establish the map of the motor branches of the median and ulnar nerves of the forearm and to count the Martin-Gruber anastomoses. Knowledge of anatomic variability would be useful for hyponeurotisation surgery of the spastic hand. Variations in the antebrachial emergence of the six motor branches of the medial nerve and the three motor branches of the ulnar nerve were studied.

Material and methods: This study was conducted on twenty anatomic specimens obtained from five men and five women. We measured the length of the forearm and identified the origin of each motor branch of the medial and ulnar nerves using a horizontal line between the meidal and lateral epicondyles as the reference line.

Results: Mean length of the forearm was 26.93±2.6 cm. Unlike the origin of the superior and inferior pronator teres nerves, and the palmaris longus, flexor carpi radialis, and flexor digitorum superficialis nerves which were very variable (coefficient of variation 49%–113%), the origin of the anterior interosseous nerve of the forearm (CV=39%) and its branches, and the flexor pollicis longus nerve and the flexor digitorum profondus nerves (CV =23% and 29% respectively) were much more regular. The superior and inferior origins of the flexor carpi ulnaris nerve were variable (CV = 157 and 22%) while the origin of the nerves for the deep flexor of the IV and V fingers showed a better coefficient of variation (13%). We observed four Martin-Gruber anastomoses (20%).

Conclusion: This study demonstrated the wide anatomic variability of the medial and ulnar nerves both interin-dividually and intraindividually. Emergence of certain nerve branches appeared to be more regular, particularly the lower group of the median nerve and the anterior interosseous nerve of the forearm. It was however impossible to identify two groups exhibiting a statistically significantly greater frequency for the median nerve. The anatomic variations of the ulnar nerve were less pronounced. The inconsistency of the inferior flexor carpi ulnaris is noteworthy.