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Resume Introduction Mieux connaitre la proprioception de l‘epaule saine permettrait d’ameliorer la prise en charge therapeutique et reeducative de l’epaule pathologique. Plusieurs methodes visent a evaluer la sensibilite de position articulaire (SPA), mais elles sont souvent couteuses et complexes. Balke et al. ont propose un test simple. En utilisant cette methode de mesure, l’objectif primaire etait d’isoler les facteurs pouvant influencer l’evaluation de la SPA au niveau de la ceinture scapulaire chez des sujets sains. L’objectif secondaire etait de proposer un systeme de valeurs de references a partir de l’ensemble des mesures en prenant en compte ces eventuels facteur de variabilite. Patients et methode Une evaluation prospective monocentrique continue a ete menee de septembre 2012 a janvier 2013. La capacite a reproduire une position donnee a ete evaluee sur chacune des deux epaules saines de sujets volontaires selon le protocole de Balke. Le sujet etant debout sur une ligne au sol distante de 1 m d’une cible murale sur laquelle etait reperee 3 angles (55°, 90° et 125°), il devait memoriser et reproduire en abduction, puis en flexion, les 3 positions (55°, 90° et 125°) a 3 reprises. L’ecart entre l’angle vise et l’angle effectivement realise etait mesure en valeur absolu de degres et designe sous le terme de « deviation ». L’âge, le sexe et le membre dominant etaient colliges. Resultats Quatre-vingt-huit epaules chez 44 patients ont pu etre analysees. Il n’y avait pas de difference significative entre les sexes (p > 0,05). Seule la flexion a 55° etait significativement mieux reproduite par le membre dominant (p = 0,03). En analyse univariee, seul l’âge etait significativement associe a la presence d’une erreur de position (p = 0,003), mais le membre dominant et le sexe ne l’etaient pas (respectivement p = 0,29 et p = 0,59). En flexion, la deviation augmentait avec l’amplitude de facon significative. Les differentes mesures realisees ont permis d’etablir un tableau des valeurs de deviation attendues dans une population saine en prenant en compte l’âge, le type de mouvement et son amplitude. Discussion Le test de Balke est simple et utilisable en pratique courante. L’influence de l’âge, du caractere dominant et du secteur de mobilite est a prendre en compte lors de l’evaluation d’une epaule pathologique. D’autres etudes sont necessaires avec un plus grand nombre de patients afin de mieux connaitre les valeurs normales de deviation attendues en fonction de ces facteurs. Niveau de preuve IV.

Background Improved knowledge of normal shoulder girdle proprioception should benefit the treatment and rehabilitation of shoulder disorders. Whereas many of the available methods for assessing joint position sense (JPS) are costly and complex, Balke et al. have described a simple test. The primary objective of this study was to use this test to identify factors that influence shoulder-girdle JPS evaluation in healthy individuals. The secondary objective was to determine reference values based on the values obtained and on the factors associated with their variability. Hypothesis Age and dominant limb influence the results of shoulder girdle JPS evaluation, creating a need for reference values that take these factors in account. Patients and methods A single-centre prospective study of healthy volunteers was performed between September 2012 and January 2013. In each volunteer, shoulder repositioning accuracy was assessed bilaterally as described by Balke et al. A line was drawn on the floor parallel to and 1 metre away from a wall. A target on the wall showed marks corresponding to three angles of arm elevation: 55°, 90°, and 125°. The volunteer was asked to raise the arm to the three positions, in abduction and in flexion, while memorising the joint positions, then to replicate the same positions with the eyes closed. The absolute differences between the replicated positions and the reference positions, designated angle deviations, were measured in degrees. Age, sex, and dominant upper limb were recorded. Results The 88 shoulders of 44 healthy volunteers were studied. No significant difference was found between males and females (p > 0.05). The only significant difference between sides was better replication by the dominant arm of flexion at 55° (p = 0.03). By univariate analysis, age was the only factor significantly associated with repositioning errors (p = 0.003); neither dominant limb nor sex were significant (p = 0.29 and p = 0.59, respectively). In flexion, the angle deviation increased significantly with movement amplitude. The measurements were used to create a chart of expected angle deviations in healthy individuals according to age and to plane and amplitude of movement. Discussion The test described by Balke et al. is simple and feasible in everyday practice. Age, dominance, and plane of movement should be considered when evaluating abnormal shoulders. Further studies in larger numbers of individuals are needed to better define normal angle deviations related to these factors. Level of evidence IV.

None of the classification systems for distal radius fractures is ideal. However a validated system to analyze these fractures is available that is based on the "metaphysis, epiphysis, ulna" (MEU) classification and the "patient, accident, fracture" (PAF) system. It makes it possible to understand the injury and select the best treatment.

Metacarpal diaphyseal fractures are classically treated using a non-removable glove for 4 to 6 weeks. Here, we report the results of treatment by immediate active protected mobilization (buddy taping for four weeks) of minimally displaced M2 to M5 fractures. Fifty-four fractures (15 transverse or short oblique and 39 spiral or long oblique) in 51 patients were included during a one-year period; the average age of patients was 31 years. Clinical and radiographic assessments were carried out at day 15 and then months 1, 2 and 6 post-fracture. Thirty-one cases were reviewed at day 15, 27 at 1 month, and 22 at 2 months. The initial volar tilt was 26° on average for the short oblique or transverse fractures, and 11.5° for the long oblique or spiral fractures. Six fractures (11%) experienced 16.6° of secondary displacement on average. The fracture was healed in 37% of cases at 1 month, and in 100% of cases at 2 months in the patients who were reviewed clinically. Reduction in the QuickDASH and VAS for pain was evidence of fast functional recovery. The range of motion was comparable to that of the contralateral side in 90% cases after 2 months. Grip and pinch strength was 33% less than the contralateral side at 2 months. Although secondary displacement occurs in some cases, the functional results of this simple and practical treatment method are good after 2 months, as there is little pain, stiffness, strength loss and no cases of nonunion.

Resume Introduction Le taux de recidive apres un premier episode de luxation gleno-humerale chez le sujet jeune, a haute demande fonctionnelle, est proche de 75 %. L’objectif de notre travail etait d’evaluer l’interet d’une stabilisation arthroscopique en urgence dans cette population specifique. Materiel et methodes Dans une etude prospective non randomisee, nous avons inclus 31 patients sportifs Resultats Le recul moyen etait de 19 mois pour les « stabilise en urgence » et 25 mois pour les « traitement orthopedique ». Le taux d’echec etait nul pour le groupe « stabilise en urgence » contre 77 % pour le groupe « traitement orthopedique », survenue en moyenne a 7,5 mois avec 2,6 recidives en moyenne. Sept patients (54 %) en echec de traitement orthopedique ont du etre stabilises secondairement. Le niveau de reprise sportive etait au moins identique au niveau precedant la luxation pour 93 % des patients « stabilises en urgence », 44 % des patients du groupe « immobilise » et 71 % des patients du groupe « stabilise secondairement ». Dans le groupe « stabilise en urgence », le QuickDASH moyen etait de 1,46 ; contre 5,3 pour les « immobilises » (p Discussion La stabilisation arthroscopique en urgence diminue le taux de recidive (Kirkley et al.) avec de meilleurs resultats fonctionnels que lorsque la stabilisation est effectuee secondairement, la « fraicheur lesionnelle » etant a priori un environnement plus propice a la cicatrisation labro-ligamentaire. L’attente d’un recul plus important est necessaire afin de confirmer ces resultats encourageants.

Few surgical approaches have been described that spare the pronator quadratus (PQ) during the treatment of distal radius fractures. The PQ supplies blood to the distal radial epiphysis, helps stabilize the distal radio-ulnar joint, and contributes 21% of pronation strength. Sparing the PQ should result in faster bone union and shorter recovery time. To achieve these goals, we currently use a minimally-invasive volar procedure using a specially-designed short plate (APTUS Wrist 2.5 XS, Medartis © ). A 20 mm incision is made over the fracture line as described by Henry. The PQ is dissected and then detached from the volar side of the radius. Forceps are used to slide the plate under the muscle. The screws are locked after carefully elevating the distal edge of the PQ. A preliminary study of distal radius fracture fixation by this technique was performed in 31 patients. The scar was 26 mm in length and the duration of surgery was 34 minutes on average. Patients wore a removable brace for 15 days, and passive wrist motion without loading was allowed during the first week. Functional recovery was faster than seen in previously published series. An average Quick DASH score of 10 was achieved by the 10th post-operative week. Although there are no contraindications to this technique, the quality of the reduction is more important than the scar size and desire to spare the PQ. Never hesitate to convert the incision to a classical Henry approach if technical difficulties arise. Our technique seems best suited to patients with high functional demands. It is currently being evaluated in a prospective series.

We searched the existence of a link between the strength of pronation and supination of the dominant forearm and those of the non-dominant one. Ninety-seven volunteers were tested in pronation and supination with an analog dynamometer. Gender, age, dominance, height and weight were recorded. The measurement position was: 90° of elbow flexion, 0° of shoulder abduction, wrist slightly extended and neutral pronation-supination. We took four measurements per patient: strength in pronation and supination, in both the dominant and non-dominant sides. Fifteen subjects were evaluated twice. The left-handed (4) were removed from the statistical analysis. There were 38 men (37 years, 18-66) and 55 women (45 years, 21-71). Torques were higher (P 0.6). Relating to the 15 subjects evaluated twice, the value of the forces varied during the day, but the ratio "non-dominant/dominant" was constant. The left-handed people were excluded, their values may be different from those of right-handers, as has been shown for grip strength. There was a strength variation during the day, but the ratio "non-dominant/dominant" was constant, making it more relevant intra-individual comparison (non-dominant side versus dominant side) rather inter-individual (based on charts of gender, age, weight and height). In the right-handed, the ratio "strength non-dominant side/dominant" is constant, defining easily in consultation the expected value of recovery of an injured forearm.

SummaryIn patients for whom function is a priority, anatomic reduction and stable fixation are prerequisites for good outcomes. Several therapeutic options exist, including orthopedic treatment and internal fixation with pins (intra- and extrafocal), external fixation which may or may not bridge the wrist, and different internal fixation techniques with dorsal or palmar plates using or not, locking screws. Arthroscopy may be necessary in case of articular fracture. In the presence of significant metaphyseal bone defects, filling of the comminution with phosphocalcic cements provides better graft stability. The level of evidence is too low to allow recommending one type of fixation for one type of fracture; and different fixation options to achieve stable reduction exist, each with its own specific complications. With the new generations of palmar plate, secondary displacement is becoming a thing of the past.

Resume La reduction anatomique et une fixation stable permettent d’obtenir un bon resultat chez des patients a haute demande fonctionnelle. En termes de traitement, plusieurs options existent, allant du traitement orthopedique a l’osteosynthese par broches (intra- et extrafocales) au fixateur externe pontant ou non le poignet aux differentes techniques d’osteosynthese par plaque dorsale et palmaire avec ou sans vis verrouillees. L’utilisation de l’arthroscopie peut etre necessaire en cas de fracture articulaire. En cas de grand vide metaphysaire, le comblement de la comminution par les ciments phosphocalciques permet une meilleure stabilite que la greffe. Le niveau de preuve est bas pour recommander un type de fixation pour un type de fracture et differentes techniques de fixation sont possibles, permettant de maintenir une reduction perenne avec des complications specifiques de chaque technique. Avec les nouvelles generations de plaque palmaire, le deplacement secondaire est en train de disparaitre.

Distal radius fractures remain the most frequent fractures in the adult. Associated osteoporosis increases morbidity risk (secondary displacement is the most frequent) and mortality risk (in women older than 60). Severity of the fracture and functional results are related to the bone mineral density. Anatomy has been recently revisited with better description of palmar and dorsal aspects in order to avoid material-related complications. Standard postero-anterior, lateral and oblique radiographs of the wrist show the fracture and the displacement. CT scan is warranted if conventional X-rays are insufficient to show the articular surface. The involvement of the metaphysis (comminution), the epiphysis (articular fracture) and the ulna is different in each case and each fracture is an association of these three components. The MEU classification describes the fracture with sufficient inter-observer reliability and intra-observer reproducibility to be a useful tool for treatment and prognosis. The PAF system is used to propose the most appropriate treatment for each patient. Anatomical reduction and stable fixation are associated with good functional results but in high demanding patients.

The authors present the case of a patient with a rare combination of open volar radiocarpal dislocation and complete destruction of the dorsal capsule-ligament complex and tendons. The treatment consisted of open reduction and arthrorisis (temporary arthrodesis during 45 days) with four K-wires (radiocarpal and radioulnar). The capsule-ligament complex was fixed with anchors and the extensor tendons were repaired by suturing. A long-arm cast was applied for six weeks. After an 18-month follow-up, the Cooney-modified Green and O'Brien score was 70 and the wrist range of motion was 85°. Dynamic intraoperative X-rays are needed to look for bone or ligament (intracarpal or radioulnocarpal) injuries. Arthrography, arthroscopy or MRI may provide additional information. In cases of stable lesions without intracarpal ligament injuries, conservative treatment may be sufficient. Otherwise, surgical treatment is required, using temporary external fixation or arthrorisis (temporary arthrodesis) associated with anatomic repair of capsular ligaments. The average duration of postoperative immobilization is 6.6 weeks. An external fixator seems to be useful for reduction and for placing optimal tension on repaired ligament repair. Twenty-three cases of volar radiocarpal dislocation are described in published studies. None of them was associated with bone, tendon, skin or capsule-ligament complex injuries. Few studies describe the long-term functional and radiological outcomes of these injuries.

The aim of this study was to describe the nature and incidence of hand injuries caused by snowblowers, as well as the accident conditions and accident prevention. We conducted a retrospective evaluation over ten consecutive winters. Nine patients were included. All were men with an average age of 49.7 years (17-71). The accidents occurred at home in seven out of nine patients. The machine was running in 50% of the injury events. In most cases, the injuries occurred when the patient tried to unclog snow from the lateral discharge chute. Only four out of the nine patients had read the instructions or received instructions from the salesperson. The dominant hand was injured in 7 out of 9 patients. An average of 2.7 fingers were injured. The longest fingers were most commonly injured: 8 middle fingers, 7 ring fingers, 4 little fingers, 2 indexes and 1 thumb. All the fractures were open. Three patients were operated on several times. In 7 out of 9 cases, the patients had sequelae such as amputation. The mean time off work was 11.4 weeks (3-24). All the patients were experienced snowblower users (9 years and 57th use on average). Snowblower accidents are very mutilating. Prevention must include protected access to blades and better verbal and written safety warnings.

Introduction L’angle gleno-metaphysaire decrit par Favard est correle a la diminution des encoches. Nous avons evalues 76 protheses inversees avec correlation des resultats avec la valeur de l’angle gleno-metaphysaire. Materiel et methodes Quatre-vingt-dix patients ont ete operes (67 omarthroses excentrees, 5 omarthroses centrees, 7 ruptures massives de coiffe, 11 autres), par 8 operateurs (3 centres), principalement par voie delto-pectorale (71 %), et evalues de facon retrospective. Trois types de protheses ont ete utilisees – les protheses inversee 1re generation (Aequalis-Reversed, Torniery - angle cervico-diaphysaire a 155°), les BioRSA (angle a 155°, mais lateralisation du centre de rotation, Torniery), et les protheses avec verticalisation a 145° de la pente humerale (Humelock-Reversed, FX-Solutionsy) – L’evaluation realisee au plus grand recul par un chirurgien non operateur a consiste dans le recueil des scores de QuickDash, de Constant brut et pondere, et des complications cliniques et radiologiques. Resultats Soixante-seize des 90 patients ont pu etre evalues (15,6 % de perdus de vue) avec un recul moyen de 18,44 mois. Lorsque l’angle gleno-metaphysaire etait compris entre 35 et 45°, le QuickDash, le constant brut et pondere etaient meilleurs et atteignait 25,6+ 59 et 85,2 %. Le taux d’encoche etait, significativement moins important lorsque l’angle etait compris entre 35 et 45° (p = 0,039), et lors de l’utilisation des protheses a angle cervico-diaphysaire a 145° (p = 0,024). Dans la serie globale, il existait 59,2 % de complications radiologiques (dont 35,5 % d’encoche), et 14,5 % de complications cliniques. Il a ete demontre que la valeur de l’angle gleno-metaphysaire etait significativement correlee (p = 0,007) a la presence d’encoche. Lorsque l’angle gleno-metaphysaire etait entre 35 et 45°, les complications cliniques n’atteignaient que 6,25 %. Discussion L’analyse de la litterature des 15 dernieres annees (32 series publiees de protheses inversees en pathologie non traumatique – 2200 patients), permet de retrouver un gain de 60° d’abduction et d’ante-elevation et de 38,58 points au Constant brut. Le taux de complications clinique moyen est de 20 % (luxation puis infection). Celui des complications radiologiques est de 50 % (80 % d’encoche). Il s’agit du 2e travail concernant l’angle gleno-metaphysaire. Comme Falaise et Favard, nous retrouvons que plus l’angle gleno-metaphysaire est faible, plus le risque d’apparition d’encoche est faible. Conclusion Pour diminuer la valeur de l’angle gleno-metaphysaire, l’operateur peut agir sur l’inclinaison de la glenosphere et sur le versant humeral (implant humeral plus vertical qui n’augmente pas le risque de luxation).

Avec l’apparition d’implants dedies a l’anatomie du radius distal, l’idee d’une osteosynthese par abord mini-invasif s’est imposee. Cependant, il n’existe aucune evaluation du benefice a court terme pour le patient. Nous avons developpe une methode d’evaluation de la recuperation de la force de pronation-supination avec un dynamometre commercialise, puis une technique operatoire mini-invasive permettant de conserver le pronator quadratus avec un implant dedie (plaque APTUS XS–Medartis–Basel–Suisse). Cinquante-cinq patients traites par voie mini-invasive pour une fracture du radius distal, et evalues selon la methode decrite ont ete suivis de maniere prospective d’avril 2012 a novembre 2013. Nous avons etudie la dose d’irradiation necessaire a l’intervention, la duree operatoire, la taille de la cicatrice, l’evolution des criteres radiographiques de reduction, la recuperation de la force de pronation ainsi que des amplitudes articulaires. Le produit dose.surface etait de 60,8 mGy cm2. La duree operatoire etait de 34 minutes, avec une cicatrice de 26 mm en moyenne. Les criteres radiographiques de reduction de la fracture au recul etaient de −0,3 mm pour la variance ulnaire, 18° pour l’inclinaison de l’epiphyse radiale dans le plan frontal avec 3° d’anteversion. La recuperation de la force de pronation-supination se faisait au 3e mois lorsque le cote non dominant etait atteint et au 6e mois lorsqu’il s’agissait du cote dominant. Les amplitudes articulaires etaient compatibles avec les gestes de la vie courantes en 6 semaines. L’irradiation etait la meme que dans les techniques de brochage du poignet (59,6 mGy cm2 d’apres Roux). Une voie de Henry classique necessite un abord de 60 mm contre 26 mm dans notre serie. Les criteres radiologiques retrouvaient un deficit d’anteversion de la glene radiale, lie a la courbure de l’implant. Dans les series evaluant la recuperation de la force de pronation apres osteosynthese du radius distal, le delai moyen est de 12 a 14 mois (avec une methode d’evaluation differente de la notre) contre 3 a 6 mois dans notre serie. La recuperation des amplitudes articulaires n’etait pas amelioree par rapport aux techniques classiques. Ce travail a permis de valider une methode d’evaluation de la recuperation de la force de pronation-supination ainsi qu’une technique operatoire fiable et reproductible. Le principal avantage reside dans la rapidite de recuperation de la force de pronation (par la conservation du pronator quadratus), et accessoirement dans le benefice esthetique lie a la petite taille de l’incision permise par l’implant. Il s’agit d’une technique a proposer essentiellement aux patients a haute demande fonctionnelle.

IntroductionThe recurrence rate after primary shoulder dislocation in young subjects with high functional demand is close to 75%. The present study assessed the interest of emergency arthroscopic stabilization in this specific population.Material and methodsA non-randomized prospective study included 31 athletes under 30years of age with primary anterior shoulder dislocation. Fifteen were offered emergency stabilization; after informed consent, 14 were enrolled in the “emergency stabilization” group. This was compared to a group matched for age, sport and lesion, managed 1year previously by “non-operative” treatment (n=17), divided into 2 subgroups: “immobilization” and “secondary stabilization”. Continuous prospective assessment of recurrence, return to sport and function (QuickDASH, QDsport, Duplay and Rowe scores) enabled comparison between the 3 groups.ResultsMean follow-up was 19months for the “emergency stabilization” group and 25months for the “non-operative” group. There were no failures in the “emergency stabilization” group, compared to a 77% rate in the “non-operative” group with onset at a mean 7.5months and a mean 2.6episodes of recurrence. Seven (54%) of the failures of non-operative treatment required secondary stabilization. Ninety-three percent of the “emergency stabilization” group, 44% of the “immobilization” group and 71% of the “secondary stabilization” group resumed sport at least at their pre-dislocation level. Mean Quick DASH was 1.46 in the “emergency stabilization” group, versus 15.28 the “immobilization” group (P