Les disjonctions sterno-claviculaires

Résumé Quarante-neuf disjonctions sterno-claviculaires dont deux décollements épiphysaires sont étudiées. 55% des patients ont été réévalués avec un recul moyen de 6,7 ans, 15 entre 2 et 6 ans et 12 entre 6 et 16 ans après la lésion. La disjonction n'était isolée que dans 41% des cas. Cette série comporte 40 disjonctions antérieures, 8 disjonctions rétrosternales et 1 instabilité multi-directionnelle. Dissept ont été opérées, 17 négligées et 15 fois un traitement orthopédique par plâtre ou écharpe a été appliqué. Le résultat est acquis en moyenne en trois mois et ne se modifie plus à long terme. Dans un quart des cas persistent des séquelles diverses. 42% des patients ont un excellent résultat, 58% sont satisfaits mais 25% déçus du traitement. Le traitement chirurgical donne le plus grand nombre d'excellents résultats (66%) et l'immobilisation, surtout lorsque la lésion n'est pas réduite, le plus grand nombre de mauvais résultats (19%). L'association à d'autres lésions de la ceinture scapulaire (55%) ou du thorax (37%) est caractéristique de ces disjonctions dont le pronostic est fonction du sens du déplacement et de la qualité de la réduction. Le traitement orthopédique s'impose toujours initialement, mais l'échec de la réduction doit conduire à l'intervention. Les lésions invétérées mal tolérées bénéficient d'une stabilisation par myoplastie, ou d'une résection du quart interne de la clavicule si les surfaces articulaires sont pathologiques.

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Dislocation of the sternoclavicular jointA review of 49 cases

Summary Over a period of 19 years, 49 dislocations of the sternoclavicular joint were treated. Two were epiphyseal separations. The dislocation was an isolated injury in only 41% of the patients. There were associated injuries to the scapula in 55% and to the thorax in 37%. Forty dislocations were anterior, 8 retrosternal and one merely unstable. Seventeen were treated by operation, 15 by closed reduction and 17 were left untreated. We have been able to review 55% of these patients with an average follow up of 6.7 years; 15 were between 2 and 6 years after injury, and 12 between 6 and 16 years. The end result was achieved by 3 months; 42% of patients had an excellent result, 58% were satisfied and 25% disappointed with the final outcome. Operative treatment gave 66% of excellent results, whereas immobilisation, particularly with unreduced dislocations, accounted for most of those judged unsatisfactory.Closed treatment should be undertaken initially, but if reduction is not achieved an operation should be carried out. If old unreduced dislocations are unsatisfactory they should be stabilised by myoplasty, or by excision of the inner end of the clavicle if the articular surface is damaged.

     

A method for locating the external ramus of the accessory nerve in the posterior cervical triangle

Injury to the external ramus of the accessory nerve during surgery in the posterior triangle of the neck results in a disfiguring and incapacitating paralysis of the trapezius. In order to avoid this, a simple method for locating the ramus was devised. In 17 cadavers the anterior border of the trapezius was palpated and the skin marked at a point 5 cm above its clavicular attachment. A second point, situated over the posterior border of the sternocleidomastoid 6.5 cm below the tip of the mastoid process was similarly marked. A line joining these two points overlies the course of the ramus. As the ramus may lie superficially in this region, the skin incision along this line was followed by blunt dissection of the underlying fascia. The ramus was thus identified at the anterior border of the trapezius 5 cm above its clavicular attachment. This method was successful in all 17 cadavers (34 exposures), even though 3 of these were very obese with short necks. Using this surface marking, injury to the external ramus of the accessory nerve in the posterior triangle can be avoided.     

Frequent computer-related activities increase the risk of neck-shoulder and low back pain in adolescents

BACKGROUND: Neck-shoulder pain (NSP) and low back pain (LBP) increased among adolescents in the 1990s and the beginning of 2000. A potential risk factor for this increase is the use of information and communication technology. We studied how the use of computers, the Internet, and mobile phones, playing digital games and viewing television are related to NSP and LBP in adolescents. METHODS: Mailed survey with nationally representative samples of 14-, 16-, and 18-year-old Finns in 2003 (n = 6003, response rate 68%). The outcome variables were weekly NSP and LBP. RESULTS: NSP was perceived by 26% and LBP by 12%. When compared with non-users, the risk of NSP was 1.3 (adjusted odds ratios) when using computers > 2-3 h/day, and 1.8 when using 4-5 h/day; 2.5 when using computers > or = 42 h/week, and 1.7 when using the Internet > or = 42 h/week. Compared with non-users, the risk of LBP was 2.0 when using computers > 5 h/day, 1.7 when using > or = 42 h/week, 1.8 when using the Internet > or = 42 h/week, and 2.0 when playing digital games > 5 h/day. Times spent on digital gaming, viewing television, and using mobile phones were not associated with NSP, nor were use of mobile phones and viewing television with LBP after adjusting for confounding factors. CONCLUSIONS: Frequent computer-related activities are an independent risk factor for NSP and LBP. Daily use of computers exceeding 2-3 h seems to be a threshold for NSP and exceeding 5 h for LBP. Computer-related activities may explain the increase of NSP and LBP in the 1990s and the beginning of 2000.     

Avascular necrosis of the femoral head due to malposition in untreated congenital dislocation of the hip

Summary Avascular necrosis of the femoral head is reported as a complication due to malposition in 12 cases of untreated congenital dislocation of the hip (CDH). It occurs after walking has commenced, both in cases of subluxation and in cases of complete dislocation. Two mechanisms are considered responsible. In subluxation or high dislocation, a reduced area of contact between the femoral head and the acetabulum or false acetabulum causes very high loading pressures on weight bearing, leading to pressure necrosis. In unstable dislocation, stretching of the nutrient vessels occurs on weight bearing, leading to vascular obstruction and necrosis of the ossific centre.Concentric reduction of the femoral head eliminates both causes of necrosis. Treatment should be meticulously planned and performed to reduce the risk of yet another, unfortunately common, cause of avascular necrosis associated with CDH, i. e., the iatrogenic one.

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Résumé Une nécrose ischémique de la tête fémorale a été découverte dans 12 cas de luxation congénitale de la hanche avant tout traitement. Elle est apparue à l'âge de la marche, aussi bien dans des luxations vraies que dans des subluxations. Deux mécanismes distincts peuvent être incriminés. Dans les subluxations ou dans les luxations appuyées, la réduction de la surface de contact entre la tête et le cotyle (ou le néo-cotyle) entraîne au cours de la marche une augmentation considérable de la pression unitaire et, de ce fait, la nécrose. Dans les luxations hautes non appuyées, la marche provoque un étirement des vaisseaux nourriciers, aboutissant à leur obstruction et à la nécrose par ischémie.La réduction de la luxation élimine ces deux causes de nécrose. Mais le traitement doit être parfaitement conduit afin de réduire le risque d'une autre cause, malheureusement encore fréquente, la nécrose iatrogène.

     

Traumatic atlantoaxial dislocation

In our series of traumatic atlantoaxial injuries we found a 21% incidence of dislocation without an associated fracture of the odontoid process (7 of 33 cases). Clinically these patients initially exhibited associated cranial trauma (5 cases), cervical pain and headache (5 cases), subjective neurological complaints (5 cases), and objective neurological abnormalities (4 cases); in 4 patients, diagnosis was delayed because diastasis of the atlantoaxial joint was not recognized on lateral cervical radiograms. The wide spectrum of clinical presentations is partially accounted for by the varying degrees of injury to the transverse atlantal ligament and other associated ligamentous injuries. The findings in this series emphasize the need for awareness of this disorder, which may represent a significant number of the injuries to the region.     

Surgical Treatment of Acromioclavicular Dislocation

The results of surgical treatment of 17 patients with complete acromioclavicular dislocation are presented. The operative procedure described is technically easy, gives good results, has few complications, and is not associated with the complications which often follow operations using metallic fixation devices. a second operation to remove fixation devices is avoided.     

The CE Angle of Normal Hips

The Center-Edge angle (CE angle) of Wiberg was measured in normal hips in patients between 8 and 75 years of age. Males and females were recorded separately. Means and standard deviations are presented here. The angle increased with growth up to adult age, and then only slowly. in children only values below 15° can be classified as abnormal.     

Posttraumatic anterior-inferior instability of the shoulder: arthroscopic findings and clinical correlations

Introduction: The main purpose of our study was to evaluate intra-articular lesions in glenohumeral-instability with arthroscopy and correlate them with clinical findings as well as history of instability. Material and methods: In this prospective multi-centre study, we evaluated arthroscopic findings in 303 patients with posttraumatic anterior-inferior instability of the shoulder. The study cohort was divided into 2 groups: patients with a history of one dislocation (Group 1, n=61, 20.1%) and patients with a history of more than one dislocation (Group 2, n=242, 79.9%). Results: In Group 1, 37 patients had an IGHL-lesion, 31 a MGHL-lesion and 41 a Hill-Sachs lesion. In Group 2, 182 patients had an IGHL-lesion, 172 a MGHL-lesion and 203 a Hill-Sachs lesion. The percentage of lesions in Group 2 (IGHL-75.2%, MGHL-71.1%, Hill-Sachs-83.9%) was significantly higher than in Group 1 (IGHL-60.7%, MGHL-50.8%, Hill-Sachs-67.2%, P=0.0233, P=0.0026, and P=0.0033, respectively). Within Group 2 we found significantly more Hill-Sachs-lesions with a history of an increasing number of recurrences (P=0.0436). We also found an increase of IGHL- and MGHL-lesions with an increasing number of recurrences, but this difference was not significant. The distribution of lesion types of the anterior labrum-ligament complex showed no significant difference between the two groups, apart from a higher incidence of ALPSA-lesions within Group 2 (34.7% versus 18.0% in Group 1). The results of this study show that recurrences after primary posttraumatic anterior-inferior shoulder dislocation cause increasing ligamental damage as well as increasing Hill-Sachs lesions within the gleno-humeral joint. Conclusion: Thus we conclude that early surgical stabilization after posttraumatic anterior-inferior shoulder dislocation is necessary to prevent increasing damage within the shoulder joint.     

Acute dislocation of the elbow caused by a solitary osteochondroma of the proximal radius

A young man presented with acute dislocation of the left elbow at the radio-capitellar articulation caused by trapping of the biceps tendon at the stalk of a solitary osteochondroma. There was no deformity of the ulna and radius shaft suggestive of a developmental growth disturbance of the forearm bones. Good reduction could be achieved by simple relocation of the biceps tendon. The osteochondroma was excised.     

Fractures of the coronoid process of the ulna

The coronoid process is critical to elbow stability and is vulnerable during injury. Traumatic elbow injures are relatively uncommon, so it is important for surgeons to be mindful of the importance of specialized treatment of the coronoid for optimal elbow function. Optimal coronoid fracture fixation is determined by fracture morphology, which can usually be predicted based on the overall pattern of injury. There is evidence that improved understanding of coronoid fractures and their management is improving the results of treatment.