Purpose of the study: Neurolysis is required for the treatment of non-regressive posttraumatic or spontaneous palsy of the anterior interosseous nerve. This technique is difficult because of the anatomic variability of the nerve and the neighbouring structures. The purpose of this study was to determine the imperative elements for neurolysis by analysing the anatomic relations of the anterior interosseous nerve and identifying the potentially compressive musculo-aponeurotic and vascular structures.

Material and methods: Twelve fresh anatomic specimens were dissected unilateral; the subjects (six male, six female) were aged 82.6 years on average at death. Emergences of the anterior interosseous nerve and its division branches were studied. The relations with the following structures and their anatomic variations were analysed: the lacertus fibrosus, the fibrous arcades of the pronator teres, and the flexor digitorum superficialis, the accessory head (if present) of the flexor pollicis longus (Gantzer muscle) and the vascular structures in close contact with the nerve. The topographic landmarks were noted in relation to the bi-epicondylar line.

Results: Emergence of the anterior interosseous nerve was situated, on average 54.5 mm below the bi-epicondylar line, on the posterior (n=9) or ulnar (n=3) aspect of the median nerve. The relative situations of its division branches were variable. A fibrous arcade was found between the lacertus fibrosus and the pronator teres in two specimens. Nine specimens had two arcades at the pronator teres and the flexor digitalis superficialis, but three specimens only had one. The presence of an accessory head within the flexor digitalis superficialis was a configuration with risk of nerve compression. The Gantzer muscle was present in six specimens and crossed the nerve superficially. Two types of potentially compressive vascular arcades were found in eight specimens.

Discussion: Sites of compression of the anterior interosseous nerve were found a various positions and in variable numbers in the different anatomic specimens. The presence of several sites of compression in the same individual could explain why the electromyogram fails to identify the level of the nerve compression in certain cases, leading to the standardised neurolysis technique recalled here.

Conclusion: This study demonstrates that several sites of potential compression of the anterior interosseous nerve can coexist in the same patient. The surgeon should be perfectly aware of these “at risk” sites when performing neurolysis.

Purpose of the study: Surgical management of neurological injury encountered in patients with a ruptured pelvic girdle remains exceptional. In this work, we present our experience and compare our results with data in the literature.

Material and methods: This retrospective analysis concerned four clinical css. Mean patient age was 20.2 years for two men and two women. All patients were victims of high-energy trauma and presented type C (Tile) pelvic girdle injury. All presented a paralysis of the lumbosacral plexus. One patient presented bilateral paralysis of the pudendal plexus. The work-up included: saccora-diculography, myeloscan, lumbar magnetic resonance imaging. One patient presented a pseudomeingocele.

Results: Surgical exploration was performed within a mean delay of 3.75 months. Two types of exploration were used: for two patients the transperitoneal approach was used because of a suspected lesion of the lumbosacral trunk and for two others, the trans-sacral approach because of suspected intra-spinal rupture. Neurolysis was performed for three patients and an caudia equina nerve graft for one. Nervous injuries involved section or rupture of the roots. There were no cases of medullary avulsion. All patients presented signs of nerve regeneration at last follow-up (mean 5.5 years).

Discussion: Even though injury to the lumbosacral plexus is exceptional, advances in surgical techniques offer therapeutic options adapted to each type of injury and nerve territory. One or more motor functions can be restored. Microsurgical nervous repair of the lumbo-sacral plexus is possible irrespective of the level of the injury. Nerve repair by grafting or neurotization can be achieved via a combination of trans-sacral and anterior retroperitoneal approaches or even a transabdominal approach.

Purpose of the study: Balistic nerve injury is not common in civil medicine. We analyzed a series of 30 patients who underwent surgery for this type of injury suffered in the Gaza strip between 2002 and 2004. All patients presented paralysis of the sciatic nerve or one of its major branches. All injuries were caused by war weapons.

Material and methods: The series included 28 men and two women, mean age 22 years (range 2.5–65). The injury had occurred more than one year earlier for 33% of patients. The injury was situated at the knee level in twelve patients and in the thigh in ten. Complete nerve section was observed in 12 patients and partial section in two. Loss of nervous tissue was significantly greater for lesions around the knee. Nineteen patients underwent surgery for: neurolysis (n=3), direct nerve suture (n=8) and nerve grafts (n=8). Eleven patients were reviewed at mean 13.7 months (range 3–30 months). There were no failures. Results of reinnervation of the tibial nerve territory were better than for the fibular nerve. Sixteen patients underwent palliative transfer for a hanging foot for more than six months: 15 transfers of the posterior tibial muscle through the interosseous membrane and hemitransfer of the Achilles tendon. Seven patients underwent Achilles tendon lengthening at the same time and five had a reinnervation procedure on the common fibular nerve.

Results: Seven patients were reviewed with a mean follow-up of 1.8 years (range 4–30 months. None of the patients used an anti-equin orthesis. There were three cases of forefoot malposition. The overall Stanmore score was good at 75.4/100 (range 59–100).

Discussion: High-energy ballistic trauma creates a specific type of injury. Nervous surgery can be indication early to favor spontaneous recovery. Palliative surgery for fibular lesions provides regularly good results.

Conclusion: Nerve injuries due to ballistic trauma should be explored surgically because of the possibility of direct nerve repair. In addition, depending on the type of paralysis, reliable palliative surgery can be proposed.

Purpose of the study: Proximal replantation is a technically feasible but life-threatening procedure. Indications must be restricted to patients in good condition with a good functional prognosis. The goal of replantation must be focused not only on reimplanting the amputated limb but also on achieving a good functional outcome. For the lower limb, simple terminalization remains the best choice in many cases. When a proximal amputation is not suitable for replantation, the main aim of the surgical procedure must be to reconstruct a stump long enough to permit fitting a prosthesis preserving the function of the adjacent joint. If the proximal stump beyond the last joint is very short, it may be possible to restore some length by partial replantation of spared tissues from the amputated part. We present here the results we obtained following this policy.

Materials and methods: This series included 16 cases of partial replantations, 14 involving the lower limb and 2 the upper limb. All were osteocutaneous microsurgical transfers. For the lower limb, all transfers recovered protective sensitivity following tibial nerve repair. The functional calcaeoplantar unit was used in 13 cases. The transfer of this specialized weight bearing tissue provided a stable distal surface making higher support unnecessary. In one case, we raised a 13-cm vascularized tibial segment covered with foot skin for additional length. For the upper limb, the osteocutaneous transfer, based on the radial artery, was not reinnervated, but this lack of sensitivity did not impair prosthesis fitting.

Results: One vascular failure was finally amputated. This was the only unsuccessful result. For all other patients, the surgical procedure facilitated prosthesis fitting and preserved the proximal joint function despite an initially very proximal amputation.

Discussion: The advantages of partial replantation are obvious compared with simple terminalization or secondary reconstruction. There is no secondary donor site and, because there is no major muscle mass in the distal fragment, the overall risk is very low compared with the risk of total proximal leg replantation.

The palmar ligaments of the wrist were dissected in 15 adult cadaver wrists and demonstrated by MRI in three. Ten fetal wrists (10 to 19 weeks' gestation) were studied in histological sections. The palmar scaphotriquetral ligament was found in them all. Its attachment to the triquetrum is substantial but that to the scaphoid is thin and fan-shaped, its fibres interdigitating with those of the radioscaphocapitate ligament. The contribution of the ligament to carpal stability has yet to be studied, but it may help to support the head of the capitate when the wrist is dorsiflexed.