G. Lefort

Prise en charge des fractures supracondyliennes en extension stade IV de Lagrange et Rigault

Resume Le but de cette etude retrospective de 44 fractures supracondyliennes de l’humerus en extension, stade IV de Lagrange et Rigault, a ete d’evaluer les resultats des differentes methodes de traitement de ces fractures, et de determiner ainsi la meilleure conduite a tenir. Trente garcons et quatorze filles ont ete traites entre janvier 1990 et decembre 2001. L’âge moyen etait de 7 ans et 6 mois. La technique de Blount a ete appliquee dans seize cas (dont quatre repris a foyer ouvert pour deplacement secondaire a court terme), le brochage percutane dans deux cas et la reduction a foyer ouvert avec brochage en croix dans trente cas (incluant les quatre deplacements secondaires apres Blount). La duree moyenne d’immobilisation etait de trois semaines et demie. Huit traitements initiaux selon Blount ont ete effectues avant la sixieme heure, et huit apres, parmi lesquels se trouvaient les quatre deplacements secondaires, repris a foyer ouvert. Ainsi, plus le delai entre le traumatisme et la reduction augmentait, plus grand etait le nombre de cas traites a foyer ouvert. Suivant les criteres de Flynn et avec un recul moyen de 7 ans et 8 mois, les resultats ont ete satisfaisants dans tous les cas traites en definitive selon Blount et par brochage percutane, et dans 97 % des cas traites a foyer ouvert. La methode de Blount, appliquee precocement, doit etre la technique prioritaire dans la prise en charge de ces fractures, le brochage percutane reserve aux fractures instables, et l’abord direct aux fractures irreductibles ou compliquees.

Capsulorraphie dans les instabilités volontaires de l’épaule: Résultats chez l’enfant et l’adolescent

PURPOSE OF THE STUDYnChronic shoulder instability is uncommon in patients with an immature skeleton. Some of these pediatric patients can produce their dislocation voluntarily raising the question of the traumatic or constitutional nature of the condition as well as its direction and tolerance. We report our experience with 29 patients.nnnMATERIAL AND METHODnOver a period of 28 years, 29 children aged 5 to 15 years were treated for voluntary shoulder dislocation. The dislocation was painful and poorly tolerated in 19, affecting daily life and sports activities. Posterior dislocation was observed in 15 patients and anterior dislocation in 4, but the direction was not always easy to establish, particularly in children with ligament laxity; multiple directions were not uncommon. Rehabilitation for at least eight months did not relieve pain in 11 patients who had a sensation of a blocked, unreliable shoulder which could not be controlled voluntarily. Posterior capsulorrhaphy was performed in 8 patients and anterior capsulorrhaphy in 3.nnnRESULTSnMean follow-up was 8 years. At last follow-up, all shoulders were stable and shoulder motion was normal with no loss of function. More than half of the children had resumed sports activities. Capsulorrhaphy was proposed when the pre-operative explorations did not reveal any bone or rim anomaly. The only preoperative finding in the operated patients was increased capsule volume, particularly in the inferior portion. Intraoperatively, ulceration of the humeral cartilage was found in two patients. Anatomic reconstruction of the capsuloligamentary structures enabled recovery of passive stability and active stability of the scapulohumeral joint, preventing further voluntary dislocation.Resume L’instabilite chronique de l’epaule est une pathologie peu frequente avant la fermeture de la physe humerale superieure. Ces instabilites sont souvent volontaires, c’est-a-dire reproductibles plus ou moins facilement par l’interesse. L’experience rapportee repose sur l’etude de 29 cas. Deux categories d’instabilites volontaires etaient identifiables. Celles parfaitement asymptomatiques (10 cas), et, celles douloureuses (19 cas), retentissant dans certains actes de la vie courante ou sportive. Ces instabilites etaient le plus souvent posterieures (15 fois) survenant volontiers dans le cadre d’une laxite multidirectionnelle. La reeducation inefficace pour 11 de ces cas a fait proposer une capsulorraphie, devant l’absence constante de lesions osseuses et du bourrelet. Ces interventions avec un recul moyen de 8 ans ont apporte indolence et stabilite a toutes ces epaules.

Résection fémorale supérieure chez l’enfant polyhandicapé grabataire

INTRODUCTIONnHip dislocation in nonambulatory multiply handicapped children (particularly in cerebral palsy [CP]) is a common and severe problem involving painful transportation and uneasy positioning, usually resulting from major anatomical osteoarticular and soft tissue disorders. Therefore, proximal femoral resection is seen as a salvage procedure whose primary purpose is to provide children and their caregivers with better comfort during activities of daily living thus allowing improved sitting tolerance in the wheelchair and painless nursing care.nnnMATERIALS AND METHODSnA series of 21 proximal femoral resections performed on 16 patients with a mean age at surgery of 12 years, and a follow-up period of 21 years (from 1984 to 2005) were retrospectively reviewed. All patients suffered from painful dislocation of the hip. Sixteen of the hips (76%) had been managed previously with bony and soft tissue surgery. Femoral resection was performed in the basicervical region in eight hips and distal to the lesser trochanter in 13 hips.nnnRESULTSnAt a mean follow-up of five years and eight months, 18 of the 21 painful hips reported to be painless (86%). All preoperative stiffness and deformity of the hip joints was corrected, resulting in floppy, mobile hips with an increased range of motion after surgery. Femoral stump, regarding the acetabulum was above in three hips, at the same level in 18 and never below. The proximal end of the femoral shaft could often been palpated but did not reveal any skin irritation. The formation of heterotopic bone was discernible in five hips (24%). However, it did not affect the functional outcomes.nnnDISCUSSIONnSoft-tissue releases combined with femoral and pelvic osteotomies have reported poor results with regard to their long-term inefficacy in children. The outcomes of our series support these findings, since surgical procedures had been performed previously in 76% of the hips. Therefore, we believe that proximal femoral resection is a promising and reliable surgical treatment option to address such failures, in case of severe and painful deformities of the hip. The success of our series corroborates Widemann, Mc Carthy and Abu-Rajab encouraging results on proximal femoral resection. Postoperatively, we advise placement of a hip spica cast immobilization with a soft cotton lining to prevent pressure sores from developing. This surgical procedure seems to be an appropriate management in nonambulatory multiply handicapped children reporting more promising results than other surgical treatment options such as rotational osteotomy, arthrodesis or even arthroplasty.

MémoireRésection fémorale supérieure chez l’enfant polyhandicapé grabataireProximal femoral resection in nonambulatory multiply handicapped child

INTRODUCTIONnHip dislocation in nonambulatory multiply handicapped children (particularly in cerebral palsy [CP]) is a common and severe problem involving painful transportation and uneasy positioning, usually resulting from major anatomical osteoarticular and soft tissue disorders. Therefore, proximal femoral resection is seen as a salvage procedure whose primary purpose is to provide children and their caregivers with better comfort during activities of daily living thus allowing improved sitting tolerance in the wheelchair and painless nursing care.nnnMATERIALS AND METHODSnA series of 21 proximal femoral resections performed on 16 patients with a mean age at surgery of 12 years, and a follow-up period of 21 years (from 1984 to 2005) were retrospectively reviewed. All patients suffered from painful dislocation of the hip. Sixteen of the hips (76%) had been managed previously with bony and soft tissue surgery. Femoral resection was performed in the basicervical region in eight hips and distal to the lesser trochanter in 13 hips.nnnRESULTSnAt a mean follow-up of five years and eight months, 18 of the 21 painful hips reported to be painless (86%). All preoperative stiffness and deformity of the hip joints was corrected, resulting in floppy, mobile hips with an increased range of motion after surgery. Femoral stump, regarding the acetabulum was above in three hips, at the same level in 18 and never below. The proximal end of the femoral shaft could often been palpated but did not reveal any skin irritation. The formation of heterotopic bone was discernible in five hips (24%). However, it did not affect the functional outcomes.nnnDISCUSSIONnSoft-tissue releases combined with femoral and pelvic osteotomies have reported poor results with regard to their long-term inefficacy in children. The outcomes of our series support these findings, since surgical procedures had been performed previously in 76% of the hips. Therefore, we believe that proximal femoral resection is a promising and reliable surgical treatment option to address such failures, in case of severe and painful deformities of the hip. The success of our series corroborates Widemann, Mc Carthy and Abu-Rajab encouraging results on proximal femoral resection. Postoperatively, we advise placement of a hip spica cast immobilization with a soft cotton lining to prevent pressure sores from developing. This surgical procedure seems to be an appropriate management in nonambulatory multiply handicapped children reporting more promising results than other surgical treatment options such as rotational osteotomy, arthrodesis or even arthroplasty.

Ostéotomies percutanées de dérotation de l’avant-bras dans les synostoses radio-ulnaires congénitales de l’enfant

Resume La position en pronation complete du poignet dans les synostoses radio-ulnaires superieures congenitales retentit sur la fonction du membre superieur surtout dans les formes bilaterales. La derotation du squelette anti-brachial est l’intervention habituellement proposee. Les techniques et les sites envisages pour cette chirurgie sont nombreux, et soulignent les difficultes, les risques et les complications possibles. A propos d’une serie de 12 cas, nous proposons de realiser la derotation par une osteoclasie d’un ou des deux os de l’avant-bras effectuee en percutane. La nouvelle position permettant un gain moyen de 51° est assuree par un plâtre brachio-palmaire jusqu’a consolidation. La surveillance post-reductionnelle est necessaire. Nous n’avons cependant pas eu de complication vasculo-nerveuse, probablement par le peu d’hematome ainsi cree. Le prejudice esthetique est quasiment nul et il n’y a pas de re intervention pour ablation de materiel. Sa realisation est d’autant plus facile que l’enfant est jeune, et impose donc une indication operatoire avant l’apparition de la gene fonctionnelle.