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To evaluate functional outcomes after direct suturing of upper extremity nerve defects in high elbow or wrist flexion.A retrospective review was conducted in patients treated for median, ulnar, or radial nerve defects between 2011 and 2019. Inclusion criteria were a defect 1 cm and a minimal follow-up period of 1 year. Nerve defects were bridged by an end-to-end suture in 90° elbow flexion or 70° wrist flexion for 6 weeks.Nine patients with a mean age of 30.2 years were included. The patients presented with two ulnar nerve defects, four median nerve defects, and three radial nerve defects at various levels. The mean time to surgery was 13.5 weeks for recent injuries. The mean defect length was 2.9 cm, and the mean follow-up time was 22.4 months. Two patients had joint stiffness that was more likely related to the associated injuries than the 6-week immobilization. Successful outcomes were achieved in eight of the nine patients. Meaningful motor recovery was observed in seven patients, and all recovered meaningful sensation. Excellent nerve recovery was noted in pediatric patients and in those with distal nerve defects.Temporary high joint flexion allows for direct coaptation of upper extremity nerve defects up to 4 cm located near the elbow or wrist. In this small and heterogenous cohort, functional outcomes seemed to be comparable to those obtained with short autografting.

This study aimed to analyze upper-extremity combat-related injuries (CRIs) and non-combat-related injuries (NCRIs) treated in the French Forward Surgical Team currently deployed in Gao, Mali. A retrospective study was conducted using the French Military Health Service OpEX surgical database from February 2013 to March 2020. All patients operated on for upper-extremity injury were included: 224 patients, with a mean age of 28.15 years, for 249 upper-extremity injuries. Seventy-six (33.9%) sustained CRIs and 148 (66.1%) NCRIs. Multiple upper-extremity injuries and associated injuries were significantly more common in the CRI group. The majority of NCRIs involved the hand. Debridement and wound care was the most common procedure in both groups. External fixation and fasciotomy were significantly more frequent in the CRI group, and internal fracture fixation in the NCRI group. The overall number of procedures was significantly higher in the CRI group. Due to the high frequency of upper-extremity injury in current theaters of operations, deployed orthopedic surgeons should be trained in basic hand surgery so as to optimally manage both CRIs and NCRIs.

Introduction Ultrasound is now recognized as a key tool in the practice of medicine in isolated situations. This study aims to evaluate the impact of transthoracic echocardiography (TTE) in a military mission when performed by a trained military practitioner (MP). Materials and Methods We conducted a 2-month retrospective observational study on the use of TTE in a French medical complex in Mali with a mission that included providing a medical aid to the population. All patients were included. Every ultrasound performed by the MP was listed, and the epidemiologic data, indication for the exam and results were collected for each TTE. Results A total of 349 patients were included, 16 were war-wounded patients and 333 came for a general medical consultation. In all, 153 ultrasounds were performed, including 48 TTEs. Sixteen TTEs were performed to evaluate injuries in war-wounded patients. During the 333 medical consultations, 32 TTEs were realized. The indications were dyspnoea (10), heart murmur (7), acute chest pain (5) and assessment of heart disease (10). TTE permitted a direct positive diagnosis for 18 patients: 7 with acute heart failure and 11 with morphologic problems. The normality of the exam was a supplementary argument to exclude a cardiac implication for eight patients. Conclusions TTE can provide important information with a direct impact on the management of patients. Faced with cardiac emergencies, an adapted training can be proposed for the MP. Thereby, the transfer of conventional cardiac views could facilitate the advice of a cardiologist.

The chosen treatment and long-term evaluation of hindfoot blast injuries are not well-represented in the literature. The first objective of this retrospective study was to evaluate functional outcomes in French service personnel who had sustained such injuries caused by improvised explosive devices. The second objective was to compare the results for patients who had amputations with those who did not. The hypothesis was that amputee recovered better function. Long-term functional evaluations were carried out using the American Orthopaedic Foot and Ankle Society scale (AOFAS), the Foot and Ankle Ability Measure (FAAM), and the Short Form 12 health survey (SF-12). Eight servicemen with ten hindfoot blast injuries were reviewed at a mean follow-up time of seven years. Primary management was always conservative although half of the patients required late amputation for chronic pain. The patients who underwent amputation reported significantly lower levels of pain than those who did not have an amputation, with higher FAAM and SF-12 scores. In this series, long-term functional results appear better in the amputated group.

Le soutien sanitaire en operations exterieures est dedie a sauver la vie et les membres des blesses en appliquant les principes du damage control chirurgical : il n’est donc pas adapte a la pratique de la microchirurgie. Ainsi, les publications rapportant la realisation de lambeaux libres ou de reparations nerveuses sur les theâtres d’operations sont tres rares. Notre objectif etait d’analyser la pratique de la microchirurgie dans les formations chirurgicales de l’avant francaises deployees dans le monde depuis les annees 2000. Une etude retrospective a ete realisee a l’aide du logiciel OPEX (SSA) chez les patients operes dans les antennes chirurgicales ou hopitaux militaires de campagne entre 2003 et 2015. Ont ete inclus les patients ayant beneficie d’une intervention microchirurgicale realisee sur le theâtre d’operations pour traiter des lesions nerveuses, des lesions vasculaires ou reconstruire des pertes de substances. Les parametres etudies etaient le mecanisme traumatique, le type lesionnel, le geste microchirurgical effectue, l’experience du chirurgien en microchirurgie et le moyen grossissant utilise. En raison de l’evacuation precoce des patients, seuls les resultats vasculaires ont ete evalues. Parmi les 2589 patients operes pour un traumatisme des membres, 56 (2,1) ont ete inclus dans l’etude. Les traumatismes balistiques representaient 43 % des cas et les lesions de main 56 % des cas. Il y avait 29 lesions nerveuses isolees, 28 lesions nerveuses et arterielles combinees et 2 lesions arterielles isolees. Les gestes nerveux etaient essentiellement des sutures directes (n = 38) mais des autogreffes et des transferts nerveux ont aussi ete effectues. Treize reparations microvasculaires ont ete effectuees dont 9 revascularisations proximales ou digitales. Six des neuf revascularisations ont ete reussies. Ces gestes ont ete realises par un chirurgien de la main dans 34 cas et par un chirurgien orthopediste non specialise dans 22 cas. Des loupes grossissantes ont ete utilisees 38 fois et un microscope 18 fois. Il s’agit de la premiere etude evaluant l’exercice de la microchirurgie sur les theâtres d’operations exterieures. La pratique courante des reparations nerveuses a l’avant est une specificite francaise rendant particulierement service aux populations locales. De meme la realisation de revascularisations digitales dans ce contexte n’avait jamais ete rapportee auparavant. Cette etude plaide pour une formation obligatoire a la microchirurgie pour les chirurgiens orthopedistes militaires projetables.

Hand ballistics traumas often produce complex limb injuries and large segmental bone defects. The induced membrane (IM) technique is a simple and effective procedure for reconstruction of segmental bone defects. Usually polymethylmethacrylate (PMMA) cement is required for the first stage of the surgery. We describe four metacarpal bone reconstructions with the IM technique but without PMMA cement after ballistic trauma in a low-resources setting. Two patients were treated in a forward surgical unit for gunshot wounds of the hand. A 33 years old man presented a 4th and 5th metarcarpal bone fracture with critical bone defect and a 25 years old man presented a 2nd and 3rd metacarpal bone and soft tissue defect. In addition to the surgical initial management, we performed the IM technique with a syringe's body in polypropylene (PP) instead of PMMA cement that was not available in this situation. A thick membrane was observable six weeks after the spacer implantation. We performed the bone graft in one case with an iliac crest and in the other with a tibial cortical and cancelous graft. Bone union was achieved in the two cases for the four metacarpal bones. We report cases treated in an austere environment where PMMA cement was not available. This PP induced membrane technique as first been described in a public communication at the SICOT congress by Mozumder et al. It involved critical bone defects from the lower limb. The IM technique has proven its efficiency in hand and wrist bone defect reconstruction but its success is based on strict compliance with technical execution. Our plastic spacers met the requirements of surgical technique. After six weeks, an IM membrane macroscopically similar to cement's IM was found in all cases. The PP spacer shows interesting characteristics: it does not contain antibiotics, it does not heat the surrounding tissues and it is not expensive and easily available. The use of a PP spacer allowed us to achieve bone union in four critical metacarpal bone defects related to ballistic trauma. This procedure respects the technical execution of the IM technique. It is achievable in very low-resources settings. Further biomolecular studies are necessary to assess the PP IM biological properties.

Introduction Le traitement inadapte d’un syndrome compartimental a l’avant-bras peut conduire a des situations critiques devant lesquelles un geste d’amputation peut etre envisage en situation precaire. Les auteurs rapportent leur experience du traitement conservateur de ces lesions septiques graves. Patients et methode Il s’agit d’une etude retrospective observationnelle menee lors de missions en ne et Afghanistan. Quatre patients masculins ont ete inclus- 2 enfants de 5 et 9 ans, et 2 adultes de 28 et 45 ans. La lesion initiale etait une fracture fermee de la palette humerale dans 2 cas et du segment antebrachial dans 2 cas. Les enfants traites initialement par un tradipraticien ont ete pris en charge apres un delai de 4 et 5 mois. Ils presentaient un tableau d’osteomyelite chronique avec des abces musculaires et une necrose du bord ulnaire de l’avant-bras dans un cas. Les adultes avaient ete traites par des dermo-fasciotomies tardives ayant evolue vers une fonte purulente des loges musculaires. L’un a ete adresse 3 semaines apres dans un tableau septique grave, l’autre plus d’un an apres l’accident pour une exposition chronique des 2 os avec osteomyelite. Resultats Tous ont beneficie d’un traitement conservateur avec une moyenne de 6,2 interventions par patient. Il s’agissait de parages iteratifs des parties molles (2,7 en moyenne), de therapie a pression negative dans tous les cas, de couverture par lambeau inguinal dans 2 cas, greffe de peau mince ou cicatrisation dirigee. Des resections osseuses ont ete effectuees dans 3 cas avec reconstruction par technique de la membrane induite chez les enfants et par ulnius (one bone forearm) chez un adulte. Une antibiotherapie ciblee prolongee a ete associee dans les cas d’osteomyelite. Au dernier recul moyen de 75 jours, la couverture cutanee etait acquise et l’infection controlee a l’exception d’une recidive de fistule chez un adulte. Discussion Des procedures de parages iteratifs et de reconstruction des parties molles simples permettent d’etre conservateur, y compris en situation precaire. La limite reste le traitement de l’infection osseuse sous-jacente, particulierement difficile dans ce contexte mais justifiant rarement une amputation. Conclusion En depits de leur aspect dramatique, ces complications septiques graves peuvent faire l’objet d’un traitement conservateur en situation precaire.