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La rupture spontanée du tendon quadricipital est rare, ainsi qu'une atteinte bilatérale et simultanée. Nous rapportons un patient de 53 ans suivi pour adénome parathyroïdien compliqué d'insuffisance rénale, admis pour rupture bilatérale et spontanée des deux tendons quadricipitaux. Il a bénéficié d'une réparation chirurgicale qui lui a permis une autonomie.

Hand injuries in children are frequent in pediatric emergencies. Epidemiology of hand injuries in children depends on age and social context. The management of these injuries requires experienced pediatrics in order to obtain a functional hand to preserve the potential growth and to reduce the risk of cosmetic sequelae. We will describe the specificities of hand trauma in children and their therapeutic principles.

Nous rapportons le cas d'une rupture post-traumatique du tendon tibial postérieur survenue lors d'une fracture bimalléolaire de la cheville. Le diagnostic a été posé lors de l'intervention chirurgicale. La réparation du tendon, non dégénératif, a été réalisée en même temps que l'ostéosynthèse. Bien que rare, cette possibilité de lésion tendineuse lors des fractures de la cheville ne doit pas êtreoubliée. Des douleurs résiduelles, un déficit de l'inversion active du pied, une modification de l'arche médiane du pied et à terme une évolution vers un pied plat valgus doivent faire évoquer rétrospectivement le diagnostic.

Les ruptures traumatiques du tendon quadricipital sont rares, elles surviennent préférentiellement après 40 ans, suite à un traumatisme indirect chez le sportif (flexion contrariée du genou) ou traumatisme banal chez le sédentaire. La tendinopathie préexistante est fréquente. La rupture est le plus souvent totale et siège au corps du tendon 60% des cas ou décallotement quadricipital au bord supérieur de la rotule (40% des cas). Le diagnostic est essentiellement clinique. Les examens complémentaires (échographie et imagerie par résonance magnétique) sont utiles et appuient le diagnostique, mais sont souvent faussement rassurants hormis la radiographie qui montre une rotule basse. Le traitement essentiellement chirurgical associé à la rééducation fonctionnelle donne des résultats largement meilleurs. Le délai d'intervention est un facteur pronostic très important. Les auteurs rapportent 03cas de rupture de tendon quadricipital. L’âge moyen est de 50ans. Ils ont été traités chirurgicalement et revus régulièrement, avec un recul de 16 mois pour apprécier l’évolution. Les résultats ont été très bons chez 02 cas et bon chez 01 cas. L'amélioration a été très nette selon les critères: marche, douleur et reprise d'activité physique.

In the absence of systemic disease, specific treatment or sport tendonitis, simultaneous bilateral patellar tendon rupture is rare. Often missed on the first glance, it represents a diagnostic difficulty that should not be overlooked at the initial medical visit. The loss of active extension of the lower limb and a radiographic patella alta, even in a bilateral context, should raise suspicion of this diagnosis. It is then necessary to search for predisposing causes and to evoke the differential, or frequently associated, diagnoses. The present report illustrates these diagnostic difficulties and summarizes some clinical considerations that might help to avoid neglecting these different elements at the first medical visit (positive diagnosis, associated lesions, favouring factors).

La rupture du tendon d'Achille est de plus en plus fréquente dans le monde et dans notre pays en raison du développement considérable des activités sportives, de l'accroissement de leur intensité et de l'absence de moyens de prévention. Notre travail porte sur une étude concernant 58 cas de rupture du tendon d'Achille, avec un recul moyen compris entre 5 mois et 80 mois. L’âge moyen était de 36 ans, tous les patients inclus ont tous bénéficier d'un traitement chirurgical. Le but de notre étude étant de souligner la supériorité d'une technique chirurgicale par rapport à une autre dans la prise en charge, ainsi qu'une mise au point sur les différents aspects épidémiologiques, cliniques, thérapeutiques et post-thérapeutiques de cette lésion.

Primary flexor tendon repair is still challenging even in the most experienced hands. With atraumatic surgery, the goal is to suture the tendon in a way that it will be strong enough to allow for tendon gliding without the risk of rupture or adhesions during the 12 weeks needed for the tendon to heal. After reviewing the zone 2 anatomy, the authors describe the state of art for flexor tendon repair along with their personal preferences. Although suture methods and postoperative rehabilitation programs are not universal, most specialized teams now use multistrand suturing techniques with at least 4 stands along with protected and controlled early active mobilization. Although the published rates of failure of the repair or postoperative adhesions with stiffness have decreased, these complications are still a concern. They will continue to pose a challenge for scientists performing research into the mechanics and biology of flexor tendon repairs, especially in zone 2.

Surgical repair of zones 1 and 2 flexor tendon injuries is a technically demanding procedure. Surgical repair of zones 3 to 5 lacerated flexor tendons is less demanding. The associated vascular and neural damage will impact the functional outcome. The surgical techniques used to repair flexor tendons in zones 3, 4 and 5 are described, along with the strategy used to treat any associated lesions.

The repair of the finger flexor tendons can be complicated by the appearance of ruptures and peritendinous adhesions. Ruptures are often treated with tendon grafts. Peritendinous adhesions can require tenolysis. Following these two surgical procedures, there is a risk of new adhesions and rupture. Rehabilitation after this secondary surgery consists of a tailored, closely supervised protocol. Protocols used by the team at the Physical Medicine and Rehabilitation Department of the Regional Rehabilitation Institute and the team at the Plastic and Reconstructive Surgery Department of the Emile-Gallé Surgical Center of Nancy (France) are described. A close collaboration between these teams of surgeons and physical therapists is essential. After tendon grafting, protected early motion helps to move the transplant immediately while still protecting it. After tenolysis, immediate (several times a day) and extended rehabilitation ensures that the mobility obtained intraoperatively is maintained. It is performed in a specialized rehabilitation center during the first three postoperative weeks. The goal is to prevent new adhesions from forming while taking into account tendon's fragility.

Rehabilitation after primary repair of flexor tendons, particularly in the early phase, has changed due to more solid suture repairs. The objectives of this article are to outline the general principles surrounding this rehabilitation, set out the indications for various early mobilization techniques and describe in detail the physiotherapy protocol used by the Physical Medicine and Rehabilitation Department of the Regional Institute of Rehabilitation in collaboration with the Plastic and Reconstructive Surgery Department of the Émile-Gallé Surgical Center in Nancy, France. This protocol is mainly used for adult patients and carried out in four stages over a 12-week period. If there are no contraindications, the patient learns protected early active self-rehabilitation during the first four postoperative weeks. The protocol includes standardized multidisciplinary follow-up until the social and occupational rehabilitation phase to ensure the best chance of functional recovery.

Flexor tendon adhesions in zone II are common. The origin of these adhesions is multifactorial. Flexor tenolysis consists of releasing the adhesions to restore the tendon's normal path and the patient's active range of motion. This surgery is complex and extremely delicate. It must be associated with early active mobilization. Any surgical procedure that would hamper this active mobilization must be completed before the flexor tenolysis. The patient should be informed of the risk of flexor digitorum profundus rupture, which is the main complication of this surgery.

Rehabilitation post surgical repair of the rotator cuff is an important determinant of the quality of the healing process, and of the clinical and functional results. Techniques used have been reported to favor certain of those parameters at the expense of others. Several approaches have been proposed; none has reached a consensus yet. The level of evidence in the literature does not allow for definitive recommendations and elaborating a protocol relies on clinical experience as well as expert opinion, incorporating scientific data. An initial period of rest with limited passive motion emerges though as an approach suited to the treatment of most clinical situations.

Of the 1603 civil liability cases filed between 2002 and 2012 related to upper-limb surgery, we found 20 proceedings (11 in court and 9 in front of the French CCI [commission for medical accidents]) that involved a total of 24 physicians: three proceedings involved multiple parties for a single patient and implicated two physicians in two cases and three physicians in one case. The grounds for liability being invoked varied greatly, but a good many of these cases concerned outcomes that were deemed unsatisfactory or insufficient in light of the initial injury. Information is always difficult to convey in an emergency setting, but is not generally disputed. However, the information process must be completed during the postoperative period and the patient informed of the injury assessment, expected results, potential complications and the possibility of surgical revision in the medium term. An expert found grounds for physician liability and breach of best practices in only three cases. In summary, this study shows that trauma-related flexor tendon injuries are rarely grounds for indictment of physicians before courts of civil jurisdiction (12 per 1000) and findings of liability for breach of best practices are even more rare (2 per 1000).

The improvement of primary flexor tendon repair has limited the indications of secondary repairs to neglected initial wound care and deficiencies in the surgical technique or rehabilitation. The surgical and rehabilitation care is complex and prolonged, requiring full cooperation of the patient. That is why the surgeon must evaluate patient's ability to integrate instructions and to comply with a long and demanding protocol. The functional needs of the patient are important in treatment decisions and the surgeon should not hesitate to use an appropriate surgical alternative (tenodesis, arthrodesis, tendon transfer, etc.). After a brief historical review, the authors discuss the indications, technical procedures and finally the results of one-stage and two-stage flexor tendon graft, which despite mixed results keep a real place in our current armamentarium.

The authors report on 11 cases of ulnar dislocation of the extensor pollicis longus (EPL) due to rupture of the dorsal aponeurosis at the thumb metacarpophalangeal (MCP) joint. This condition is rare. By performing a descriptive study of this injury, we were able to establish a classification system for thumb extensor tendon dislocation. The series included 11 patients with a mean age of 27years. All patients presented with either varus or rotational thumb injury. This resulted in an active extension deficit in the thumb MCP joint with EPL dislocation behind the MCP. Surgery was required in all cases. We defined three different injury presentations: 1) dissociated form with isolated EPL dislocation, but the EPB still in place; 2) complete form with dislocation of both tendons on the ulnar side of the MCP; 3) dissociated or complete form associated with a severe sprain of the lateral collateral ligament of the thumb MCP joint. The surgical treatment was adapted to each case. A classification into three types of dislocation of the extensor tendons at the MCP joint of the thumb was established. This rare condition must be identified at the time of thumb MCP joint injury and also when harvesting the EPB. This new classification system has a diagnostic and therapeutic role as it precisely describes the dislocation type and the resulting damage. Only a surgical treatment can produce good repairs.

The patient with an injury of the hand has unfortunally not choose the type of injury, the time and the medical doctor; this patient is not sick but injuried. Even if this is an open or closed trauma, begnin or not, the patient is going to discover dressing, immobilisation and time to recover function with a "new hand" .... Hand injuries have shown their impact on global function in case of inadequate treatment. After hand trauma, finding the right diagnosis and choosing the right treatment depend on the capacity of avoiding the traps.

This short story of flexor tendon repair aims to illustrate hesitations and wanderings of this surgery. Obviously tendon repair was very early considered, but it developed and diffused rather lately. It became a routine practice only in 20th century. This was due on the one hand, in Occident, to the Galen's dogmatic interdiction, on the other hand, to the repair difficulties of this paradoxical structure. Actually tendon is made of fibroblasts and collagen (sticky substances), and then its only goal is to move. According to this necessity, whatever the used techniques are, gliding is the final purpose. Technical evolutions are illustrated by historical contributions to flexor tendon surgery of several "giants" of hand surgery.

Flexor tendons repair in zone 1 is classically considered providing good results with an overall satisfactory finger function. However, the objective functional results after surgical repair of flexor digitorum profundus are sometimes disappointing. The authors describe the different surgical repair techniques available to the operator from so-called "traditional" sutures to newer methods of internal fixation using miniaturized anchor sutures. The management of postoperative procedures, that of failures and old cases are reported.

La rupture du tendon calcanéen est une des lésions les plus fréquentes en pathologie du sport, les deux options thérapeutiques classiques sont le traitement orthopédique et la chirurgie à ciel ouvert. Dans le but de minimiser ces complications, des techniques mini-invasives de ténorraphie percutanée ont été proposées dont les résultats sont encourageants. Il s'agit d'une étude rétrospective d'une série de cas de rupture sous cutanée du tendon d'Achille s’étalant de Avril 2005 au Juin 2012 concernant 67 patients; 11 femmes et 56 hommes avec un âge moyen de 41 ans. La cause principale était un accident de sport dans 45 cas. Le diagnostic était évident à l'examen chez tous les patients. Dans deux cas il s'agissait d'une rerupture survenant à 1 et 5 ans d'un traitement orthopédique. Dans un cas il s'agissait d'une rerupture survenant après une ténorraphie percutanée. Dans deux cas il s'agissait d'une rupture sur tendinopathie chronique. Tous les patients avaient bénéficié d'une radio de la cheville qui avait montré une horizontalisation du calcanéum chez 5 patients et surtout elle n'avait pas montré de fracture associée, alors que 15 patients avaient bénéficié d'une échographie qui a confirmé le diagnostic. Tous les patients avaient été opérés dans un délai de moins de 48 heures Une ténorraphie percutanée a été pratiqué chez tous les patients. Le recul moyen est de 43 mois, trois patients ont été perdus de vue Nous avons noté une reprise des activités professionnelle effective en moyen 90 jours après l'intervention et celle des activités sportive à 6 mois en moyenne L’état cutané local a été jugée bon dans 63 cas. Par ailleurs les complications ont été marquées par un seul cas d'infection ayant nécessité une reprise chirurgical a été noté mise à plat, trois cas de rerupture repris par suture à ciel ouvert, un cas d'algodystrophie et un cas de tendinopathie Il n'y a eu aucune complication thromboembolique ni neurologique. Il n'existe pas de réel consensus concernant la prise en charge des ruptures du tendon calcanéen. Ainsi, La ténorraphie percutanée du tendon calcanéen est une méthode simple rapide et efficace, elle allie les avantages de la chirurgie à ciel ouvert en termes de pourcentage de rerupture et les avantages du traitement fonctionnel en rapport avec un faible risque infectieux.

Les auteurs rapportent une série de 90 patients, présentant une section tendineuse des fléchisseurs de la main, et suivis avec un recul moyen de 8 mois (min: 2 mois; max: 13 mois). La lésion était localisée dans 12% des cas en zone I, 46% des cas en zone II, 2% en zone III et 25% des cas en zone IV et V. Pour le pouce (13 patients), 10 cas en zone T2 et 3 cas en zone T3. La technique opératoire utilisée était les sutures tendineuses en cadre de Kessler modifié, associée à un surjet épitendineux. Nous avons obtenus 54% de très bons résultats, 34% de résultats moyens et 12% de mauvais résultats. Pour le pouce les résultats semble moins bons avec un taux de résultats médiocre de 48%. Certes les chiffres de cette série sont moins bons que ceux des autres séries publiées dans la littérature. Les facteurs influençant les résultats sont d'abord l'utilisation d'immobilisation postopératoire systématique ainsi que le mécanisme d'agression, et la localisation à la zone II et au pouce. Les complications mécaniques sont représentées par 7% de rupture, toutes au niveau de pouce, et 31% des adhérences tendineuses (soit 30 cas), dont 19 en zone II, l'infections (22%) et 4% des cas d'algodystrophies.

We report a unique and previously unreported case of motor paralysis of the posterior interosseous nerve of rapid onset in a context of hypertrophy of the short supinator muscle, occurring 2 years after a distal rupture of the biceps in a 62 year-old man. The ruptured tendon had received functional treatment due to the patient's age and low functional requirements. Operatively, the deep branch of the radial nerve was released within the arcade of Frohse with complete recovery from symptoms at 5 months. The unrepaired rupture of the distal portion of the biceps could be a risk factor for posterior interosseous nerve compression in active subjects.

Primary or secondary flexor tendon repair after laceration in children do not have any technical specificity in comparison with adults. However, tendon ruptures may occur more frequently in case of light postoperative immobilization, especially in young children as little cooperation can be expected in the postoperative period. A closed above elbow cast should therefore be applied for onemonth. Early mobilization program has no significant effect on the final result in young children. However, these observations must be relativized in teenagers who should be rehabilitated such as adults. For extensor tendon injuries, dynamic splintage was found to be unnecessary in children. In cases with total transection in zones I, II or III, it is necessary, especially in children younger than 5 years, to transfix the IP joint in extension with a smooth Kirschner wire during postoperative immobilization period.

Injuries of the flexor pulleys are common in rock climbers. Ruptures of the flexor profundus tendons are less common and take place almost exclusively in zone I at the level of the distal phalangeal insertion of the tendon. We report the case of a 48 years old rock climber who sustained an uncommon complete rupture of the flexor profundus tendon of the long finger during a monodigital grip. The tear was localized in zone III, immediately distal to the distal edge of the carpal tunnel. Tendon repair by direct suture followed by early active mobilization led to a satisfactory result. To the best of our knowledge, this is the first description of this type of injury in a rock climber.

Spontaneous tendon rupture is rare in the course of systemic lupus erythematosus (SLE). Its incidence rate remains unknown. The pathogenesis of this manifestation is complex and poorly understood. We report a 39-year-old woman who presented with a spontaneous Achilles tendon rupture as the presenting presentation of SLE, before any corticosteroid therapy. All the patients previously published were receiving corticosteroids and reported in some an associated traumatism. Risk factors are prolonged disease duration, chronic therapy with corticosteroids, deforming arthropathy of the hands, and inactive disease.

Knee extensor mechanism is composed of the quadriceps and its tendon, patella and patellar tendon. Rupture of either the quadriceps or patellar tendon, or of the patella itself, lead to a disruption of the knee extensor mechanism. Clinical examination reveals an inability to actively extend the knee. Standard radiographs of the knee show a suprapatellar swelling of the soft tissues in case of quadriceps tendon rupture, or a displaced patellar fracture, or a patella alta in case of patellar tendon rupture. Echography and MRI confirm the diagnosis and may reveal associated injuries. In case of knee extensor mechanism rupture, early surgical reconstruction of quadriceps or patellar tendon, or patella osteosynthesis, are mandatory to achieve early functional recovery.

Tendon injuries are common in hand wounds and their functional consequences are not negligible. In emergency, tendon repairs techniques are well codified to restore function. These tendon repairs can be made in one session, in two sessions, or even use tendon transfers. Tendon transfers are not usual in the emergency but more common in the treatment of sequelae or failure of primary repair. We report one case of transfer to restore thumb flexion in emergency.

Adult patients with chronic ulnar wrist pain often seek medical advice. There are a number of diagnoses for chronic ulnar-sided wrist pain. A sound diagnostic strategy is therefore of paramount importance. Patient's history, clinical examination and high quality standard radiographs are the most important part of this strategy. Sophisticated investigations should only be performed to focus on solid clinical hypotheses. The palmar and dorsal aetiologies of ulnar wrist pain are considered as well as their treatment principles.

The disorders of the Achilles tendon, acute or chronic, are common among the physically active subject. We will treat successively chronic tendinopathies due to overuse, and then acute ruptures. Predisposing intrinsic or extrinsic factors have to be systematically identified if present, because taking them into account for the treatment will be important. The diagnosis of Achilles lesions remains clinical in a first step, either in acute cases or in chronic ones. The therapeutic options will be systematically discussed for the 2 entities, guided on validated evidence-based studies.