Purpose of the study: Lengthening can be proposed for children with congenital or acquired short fingers in order to overcome the length defect and improve function, the aesthetic aspect, or enable installation of a hand prosthesis. Three techniques have been proposed. The purpose of this study was to compare the three techniques in terms of lengthening, achieved, cure index, and complication rate.

Material and method: The was a series of 13 lengthening procedures for metacarpals in children with congenital or post-trauma sequelae.

Results: The callotasis method was used for seven children. Slow distraction using a mini-external fixator was applied for progressive lengthening without bone graft. Mean lengthening was 13 mm (range 8–21) for mean a mean cure index of 81 d/cm (range 41.7 to 140.9). There was one major complication: fracture with angulation. The two-phase progressive distraction method with graft was used in four children. The distraction using a mini-external fixator was rapid, followed by second phase bone graft. Mean lengthening was 22 mm (range 13–32) with a cur index of 40.8 d/cm (range 32.8 to 46). There was one fracture of a grafted zone. Single-phase extemporaneous lengthening with immediate graft was used for two children. The intraoperative distraction of the osteotomy was followed immediately by insertion of the graft. Mean lengthening was 9 mm for a cure index of 50 d/cm. One patient required tenolysis of the extensor at six months because of adherences at the graft site.

Discussion: Our results suggest that the two- phase distraction-graft method enables greater lengthening than the callatasis technique for shorter treatment periods but a the cost of a second operation and donor site morbidity. The extemporaneous lengthening method is less ambitious, achieving lengthening to the order of 10 mm, but with a less aggressive procedure.

Purpose of the study: We reviewed traumatic distal leg amputations managed in our unit between 1990 and 1993. Reimplantation or unilateral emergency revascularization were undertaken in five cases.

Material and methods: The initial loss of length was considerable (range 8.5–12 cm) allowing direct internal fixation, protected with an external fixator bridging the ankle, and direct vasculonervous suture. Secondary lengthening was undertaken early in the proximal metaphyseal zone before sensorial recovery was complete.

Results: Healing was achieved within a normal delay in all cases. Nerve regeneration was monitored from the site of the microsuture by following the progression of the Tinel sign along the repaired nerve trunks; this defined the rate of regeneration. Our observations showed that nerve lengthening above the site of the microsurgical suture did not hinder nerve regeneration and even appear to stimulate it.

Conclusion: This strategy of extensive initial debridement compensated for by significant but well-tolerated secondary lengthening enabled us to broaden indications for unilateral leg reimplantations. The quality of the functional results at follow-up extending up to 15 years is probably one of the reasons justifying this strategy.

Purpose of the study: Even more so than adults, children are exposed to serious foot trauma caused by lawn mowers, bicycle spokes, or car wheels. These different mechanisms produce specific lesions to the rear foot or the toes and the dorsal aspect of the foot. Each type of lesion raises specific problems concerning emergency cover. Sequelae evolve with growth. We present a series of thirteen children given emergency treatment then long-term care over periods of six months to twenty years.

Material and results: The heel was amputated in four children (lawn mower or bicycle spoke accidents). Cover was obtained with a sural (three first-intention) neurovascular island flap with a distal pedicle. The long-term assessment evaluated function as well as residual growth of the calcaneum. Four lawn mower accidents produced lesions involving the toes and the mediotarsal area which did not require emergency flap cover. Dorsal retractions occurred in all four cases and progressed secondarily, later requiring a good quality skin flap and dorsal release. In five children lesions of the toes, forefoot, or the entire foot occurred in five children whose foot was crushed under car (or truck) wheels or was injured during fall from a wall. In these children, the urgent or secondary skin problems predominated in the dorsal area and required a variety of flaps.

Discussion: «Dorsal trauma» appears to have a predominant effect in children because the toe alignment during growth is directly dependent on the flexibility of the dorsal tissues. Several flaps can be used for this indication but are often difficult to achieve for the more distal areas (commissures and toes). Heel reconstruction is also a difficult challenge with the problem of sensitivity and tissue quality. It does not resolve the problem raised by amputation of the posterior calcaneal growth nucleus.

Purpose: We reviewed a series of pollicizations in children with congenital thumb malformations. The purpose of this study was to assess the influence of anatomic or technical factors on functional and cosmetic outcome.

Material: The series included 33 operations in 26 children. The Blauth classification was: grade IIIA (n=1), grade IIIB (n=8), grade IV (n=8), grade V (n=13), mirror hand (n=8). We noted the type of skin incision, technique used to fix the metacarpal head on the carpus, and tendon shortenings. Results were assessed at mean 4 years follow-up on the basis of the cosmetic aspect (parent satisfaction) and functional outcome measured with the Kapandji index and flexion-extension of inter-phalangeal joint, thumb finger opposition, and sensitivity.

Results: Mean age at surgery was 32 months. Fixation was achieved with sutures in 24 cases and pinning in nine. Tendon shortening was performed in 16 cases on the extensor system and in one case on the deep flexor system. Mean follow-up was four years. There was no significant difference between groups A and B for cosmetic outcome. The main factor influencing objective functional outcome was the association of a grade III or IV radial club hand. In these patients, the final outcome was compromised by the stiffness or deformation of the radiocarpal joint and the stiffness of the preoperative Kapandji index which was 7 (mean) in group A and 4.75 in group B.

Discussion and conclusion: The following technical aspects did not have a significant effect on the final functional result in our series: type of skin incision, type of carpal fixation, shortening the extensor or flexor system. Technical aspects which must be performed with particular care include reconstruction of the thenar muscles using interosseous muscles, curettage of the growth cartilage of the head of the second metacarpus, and hyper-extension of the head of the second metacarpus during fixation onto the carpus. Careful technique avoids future complications such as excessive growth of the neometa-carpus or Z-thumb.