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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.

This study reports on complications following extended tourniquet application in patients with combat extremity injuries treated by the French Military Health Service in the Sahelian strip. A retrospective review was performed in a French forward medical treatment facility deployed in Gao, Mali, between 2015 and 2020. All patients treated for an extremity injury with the application of at least one tourniquet for a minimum of 3 h were included. Prehospital data were injury pattern, associated shock, tourniquet location, and duration. Subsequent complications and surgical procedures performed were analyzed. Eleven patients with a mean age of 27.4 years (range 21–35 years) were included. They represented 39% of all patients in whom a tourniquet was applied. They had gunshot wounds (n = 7) or multiple blast injuries (n = 4) and totaled 14 extremity injuries requiring tourniquet application. The median ISS was 13 (interquartile range: 13). Tourniquets were mostly applied proximally on the limb for a mean duration of 268 min (range 180–360 min). Rhabdomyolysis was present in all cases. The damage control surgeries included debridement, external fixation, vascular repair, and primary amputation. Ten injuries were complicated by compartment syndrome requiring leg or thigh fasciotomy in the field or after repatriation. Two severely injured patients died of their wounds, but the others had a favorable outcome even though secondary amputation was sometimes required. Extended and proximal tourniquet applications led to significant morbidity related to compartment syndrome and rhabdomyolysis. Hemorrhagic shock, mass casualty incident, and tactical constraints often precluded revising the temporary tourniquet applied under fire.

To evaluate functional results after treatment of large defects of the sciatic nerve and its divisions by direct nerve suturing in high knee flexion.A retrospective review was conducted in patients treated for lower extremity nerve defects between 2011 and 2019. Inclusion criteria were a defect 2 cm with a minimal follow-up period of 2 years for the sciatic nerve and 1 year for its divisions. Nerve defects were bridged by an end-to-end suture with the knee flexed at 90° for 6 weeks. Functional results were assessed based on the Medical Research Council's grading system.Seventeen patients with a mean age of 27.6 years were included. They presented with seven sciatic nerve defects and ten division defects, including eight missile injuries. The mean time to surgery was 12.3 weeks and the mean nerve defect length was 5 cm. Overall, 21 nerve sutures were performed, with eight in the tibial distribution and 13 in the fibular distribution. Post-operatively, there was no significant knee stiffness related to the immobilization. The mean follow-up time was 24.5 months. Meaningful motor and sensory recovery were observed after 7 of 8 sutures in the tibial distribution and 11 of 13 sutures in the fibular distribution. A functional sural triceps muscle with protective sensibility of the sole was restored in all patients. There were no differences according to the injury mechanisms.Temporary knee flexion at 90° allows for direct coaptation of sciatic nerve defects up to 8 cm, with promising results no matter the level or mechanism of injury.

Radial club hand deformities are commonly treated with arthrolysis to allow centralization of the ulna. In this retrospective cohort study of 31 hands in 28 patients, we aimed to assess the outcomes of correction using progressive distraction and subsequent percutaneous pinning of the wrist with a corrective ulnar osteotomy. Mean follow-up time was 7 years (range 2 to 20). The angulation of the hand–forearm complex was decreased after each step of the procedure. Mean correction of the angulation was 64°, and the residual total forearm–hand angulation was 12° after completion of the surgery. At the time of bony maturity (four patients), all wrists had fused. Fifty-eight reoperations were required in 31 wrists because of pin migration or breakage, and in addition 18 secondary osteotomies of the ulna were performed. From this study we conclude that distraction and pinning provide satisfactory and stable realignment of the wrist to correct the deformity, but this treatment has drawbacks regarding the high number of reoperations and the loss of wrist mobility. Level of evidence: IV

IntroductionThe objective was to report on the experience of the French Army Health Service in the management of blast injury of the hands related to warfare explosive devices.MethodsA retrospective study was conducted in the Percy Military Hospital (role 4 medical treatment facility) among French soldiers who presented with a combat-related blast injury of the hand between 2002 and 2018. The functional result was assessed by the disabilities of the arm, shoulder and hand (DASH) and the Orthotics and Prosthetics User Survey (OPUS, upper extremity functional status) scores. Proximal amputations (PAs) and distal amputations (DAs) were distinguished for the analysis.ResultsFifteen patients with a mean age of 31±8 years were included. They totalised 20 blasted hands. There were 16 traumatic amputations: 8 in each of the PA and DA groups. Twelve patients had additional injuries, four of which were polytraumatic. Skin closure time and flap use were higher in the DA group. Only one thumb reconstruction was performed. At a mean follow-up of 6.5±4 years, the number of amputees wearing a prosthesis was higher in the PA group. The mean DASH and OPUS scores were 35.5%±24.0% and 64.0%±19.0%, respectively, with no difference between the two groups.ConclusionThe severity of hand blasts related to warfare explosive devices requires the systematic application of damage control surgery. PAs are frequent and secondary reconstruction options are limited. The functional result is poor and similar between proximal and distal amputees.

Anterior glenoid rim fracture is a consequence of the humeral head impacting the glenoid fossa. The management of large glenoid fractures involving more than 20% of the articulating glenoid requires surgical treatment. The 2 main techniques are open reduction internal fixation (ORIF) by screws and arthroscopic treatment using suture anchors or transcutaneous screws. Next to the technical equipment, a surgeon requires extensive experience to achieve good results with the arthroscopic technique. The main disadvantage using the ORIF technique is the detachment of the subscapularis muscle, which is often criticized for causing functional deficits of the subscapularis. Our study demonstrates the feasibility of the ORIF technique through a deltopectoral approach and splitting of the subscapularis. To our knowledge, subscapularis splitting has never been described to treat glenoid fractures.

Ballistic injuries to peripheral nerves are devastating injuries frequently encountered in modern conflicts and civilian trauma centers. Such injuries often produce lifelong morbidity, mainly in the form of function loss and chronic pain. However, their surgical management still poses significant challenges concerning indication, timing, and type of repair, particularly when they are part of high-energy multi-tissue injuries. To help trauma surgeons, this article first presents basic ballistic concepts explaining different types of missile nerve lesions, described using the Sunderland classification, as well as their usual associated injuries. Current controversies regarding their surgical management are then described, including nerve exploration timing and neurolysis's relevance as a treatment option. Finally, based on anecdotal evidence and a literature review, a standardized management strategy for ballistic nerve injuries is proposed. This article emphasizes the importance of early nerve exploration and provides a detailed method for making a diagnosis in both acute and sub-acute periods. Direct suturing with joint flexion is strongly recommended for sciatic nerve defects and any nerve defect of limited size. Conversely, large defects require conventional nerve grafting, and proximal injuries may require nerve transfers, especially at the brachial plexus level. Additionally, combined or early secondary tendon transfers are helpful in certain injuries. Finally, ideal timing for nerve repair is proposed, based on the defect length, associated injuries, and risk of infection, which correlate intimately to the projectile velocity.

Gunshot wounds to the hand often produce complex injuries and large segmental bone defects. Bone reconstruction remains a challenge in this context. The induced membrane technique is a simple and effective procedure for reconstruction of segmental bone defects. The technique is straightforward but must be performed rigorously. Usually polymethylmethacrylate (PMMA) cement is required for the first stage of the surgery. We describe four cases of metacarpal bone reconstruction after gunshot wounds in a limited-resource setting. Two patients were treated using the induced membrane technique with a polypropylene syringe body instead of PMMA cement, which was unavailable in this situation. A thick membrane was observed 6 weeks after spacer implantation. Bone union was achieved in all cases.

IntroductionMicrosurgical training is an asset for military orthopedic surgeons who frequently treat hand or nerve injuries in external operations. The objective of this study was to evaluate a microvascular surgery simulation model intended to prepare residents prior to their enrolment in conventional degree training.Materials and MethodsAn experimental study was conducted to evaluate technical progress and satisfaction of military surgical residents using a model based on Japanese noodles with four tests of increasing difficulty. Objective endpoints included: instrument handling, distribution and quality of stitches, duration of anastomoses and responses to the Structured Assesment of MicrosurgerySkill (SAMS) self-assessment questionnaire were also analyzed.ResultsNine residents from different specialties participated in the study. The quality of their anastomoses and their average satisfaction were significantly increased between the first and the last session: respectively 7.2 / 15 versus 10.7 / 15 (p

Objective We sought to elucidate the conditions of direct suturing of sciatic nerve defects in high-degree knee flexion. We aimed to establish a correlation among the defect length, defect location, degree of knee flexion, and eventual need for hip immobilization in extension. Methods We performed an experimental study by completing bilateral dissection of the sciatic nerve in 6 cadavers. Three groups of lesions were identified: at the buttock (BG), in the thigh (TG), and in the popliteal fossa (PG). For each defect, a direct, tensionless suture was performed with minimal knee flexion. Next, the hip was progressively flexed until rupture. The nerve defect length correlated with the degree of knee flexion and hip extension required to perform and protect the installed sutures. Results A 30° knee flexion allowed for direct suturing of defects >2 cm in the 3 groups. The largest suturable nerve defects measured 7 cm in the TG and PG and 6 cm in the BG. When considering the same-size defects, the required knee flexion tended to be significantly greater in the BG. A bowstringing effect was noted at the buttock and popliteal levels. Hip flexion placed tension on the nerve suture at all locations. Conclusions The middle third of the thigh was the most compliant level, because the largest defects will be suturable without a visible bowstringing effect. Hip immobilization should be considered as soon as the defect has exceeded 2 cm, regardless of the location.

Missile injuries of the sciatic nerve are frequently encountered in modern violent conflicts. Gunshot and fragment wounds may cause large nerve defects, for which management is challenging. The great size of the sciatic nerve, in both diameter and length, explains the poor results of nerve repair using autografts or allografts. To address this issue, we used a simple technique consisting of a direct suture of the sciatic nerve combined with knee flexion for 6 weeks. Despite a published series showing that this procedure gives better results than sciatic nerve grafting, it remains unknown or underutilized. The purpose of this cases study is to highlight the efficiency of direct sciatic nerve coaptation with knee flexed through three cases with missile injuries at various levels. At the follow-up of two years, all patients were pain free with a protective sensory in the sole and M3+ or M4 gastrocnemius muscles, regardless of the injury level. Recovery was also satisfying in the fibular portion, except for the very proximal lesion. No significant knee stiffness was noticed, including in a case suffering from an associated distal femur fracture. Key points to enhance functional recovery are early nerve repair (as soon as definitive bone fixation and stable soft-tissue coverage are achieved) and careful patient selection.

Treatment of war wounds is based on a sequential surgical strategy, which frequently faces therapeutic failures, which then burden the final functional result. The aim of this study was to identify risk factors of failure of the different treatments to prevent the therapeutic failure. A monocentric case–control study was done on French war-wounded soldiers treated for an open fracture caused by an invasive war weapon. The primary end point was the treatment failure three months after the injury. The risk factors of failure studied were the traumatic mechanism, the general and local lesional assessment, and the surgery performed. Between January 1, 2004 and December 31, 2016, 57 soldiers were included, with an average follow-up of 3.42 years. On 81 limb segments studied, the most injured segment was the leg (37.0%). A vital or urgent surgery requirement (OR = 1.56; p = 0.02) and bone loss substance (OR = 5.45; CI95% = 1.54–20.09) were risk factors of failure for limb salvage treatment. Improvised explosive device traumatic mechanism (OR = 1.56; p = 0.02) and the persistence of surgical site contamination after two debridement procedures (OR = 1.20; p = 0.04) were risk factors of failure for amputation procedures. Two main risk factors of treatment failure are highlighted: those in relation to traumatic mechanisms and general lesional assessment and those in relation to surgical site conditions. There is no over risk of failure in relation to surgical procedure and treatment.

Les sections partielles de nerf sont frequentes dans les plaies balistiques. Des lesions nerveuses par etirement ont ete decrites lors des plaies balistiques au sein de la cavitation temporaire. Le but de cette etude est de rechercher les lesions histologiques de la portion en continuite d’une section partielle de nerf par projectile chez le porc. Six cuisses de porc euthanasies 24 heures auparavant ont subi des tirs de projectile pour obtenir des sections partielles de nerfs sciatiques. Les cuisses ont ete preleves par desarticulation coxofemorale au bistouri. Elles ont ete conservees dans une chambre froide a 4 degres pendant 24 heures. Les nerfs ont ete repartis en 3 groupes de 2 nerfs pour subir des tirs de projectile de 3 calibres differents — basse velocite, haute velocite et fusil a grenaille. Les nerfs ont ensuite ete preleves puis analyses en laboratoire d’anatomopathologie et les lesions ont ete classees selon la classification de Sunderland. Aucune lesion de grade II, III ou IV n’a ete vu sur la partie en continuite des nerfs sectionnes quel que soit le projectile utilise. Lors de l’exploration primaire d’un nerf partiellement sectionne par un projectile, qu’il soit a haute ou basse velocite, la portion du nerf semblant macroscopiquement saine presente au maximum des lesions de type I de Sunderland qui vont recuperer spontanement. A la phase initiale, il convient donc de prendre beaucoup de precautions avec la partie du nerf restant en continuite. Lorsqu’il existe une perte de substance dans la portion sectionnee, la reparation se fera donc par une greffe fasciculaire respectant la portion continue. Pour nous cette greffe doit etre effectuee de facon secondaire precoce, aux alentours de 3 a 6 semaines en raison des difficultes de dissection lors du 2e temps. Cette etude n’a pas mis en evidence de lesion histologique significative sur la portion continue de nerfs sciatiques de porcs partiellement sectionnes par des projectiles de haute ou basse velocite. Bien que l’existence d’une atteinte de la gaine de myeline n’ait pas pu etre etudiee, il semble que des lesions de types II et III de Sunderland puissent etre eliminees. Un aspect macroscopiquement intact de la partie non sectionnee du nerf a donc toutes les chances de recuperer spontanement dans les semaines suivant le traumatisme.

Qu’elles soient totales ou partielles, les amputations digitales survenant dans un contexte de guerre relevent habituellement d’un traitement radical compte tenu du mecanisme lesionnel, des lesions associees ou de l’absence de moyens microchirurgicaux. Malgre cela, des revascularisations ou replantations digitales ont ete effectuees de facon exceptionnelle sur les theâtres d’operations exterieures. Une etude observationnelle retrospective a ete effectuee au sein des formations chirurgicales de l’avant francaises entre 2010 et 2015. Ont ete inclus les patients ayant beneficie d’une revascularisation ou d’une replantation digitale. Les dossiers cliniques ont ete colliges et analyses afin de determiner le resultat vasculaire et le resultat fonctionnel. Six patients d’âge moyen 37 ans ont ete inclus. Il s’agissait d’un accident du travail dans 4 cas et d’un traumatisme balistique dans 2 cas. Un seul doigt etait en ischemie — le pouce dans 3 cas, l’index, le majeur ou l’annulaire dans les 3 autres cas. Une replantation a ete effectuee pour deux amputations distales et un ring finger. Une revascularisation a ete effectuee pour trois lesions complexes en ischemie. Les reparations arterielles ont ete effectuees sous loupes grossissantes dans la majorite des cas. Il n’a pas ete effectue de reparation veineuse. Un militaire etranger a ete rapidement perdu de vu apres evacuation. Parmi les 5 autres patients, le resultat vasculaire a ete favorable dans 3 cas et defavorable dans 2 cas de replantation. Le resultat fonctionnel a toujours ete satisfaisant, y compris dans les 2 cas ayant necessite une regularisation secondaire. Bien que limitee en effectif, cette serie n’en reste pas moins inedite. Elle montre qu’en depits d’un contexte sanitaire degrade, des revascularisations ou replantations digitales peuvent etre effectuees dans les formations chirurgicales de l’avant, lorsqu’il s’agit d’une lesion isolee et que le contexte operationnel s’y prete. Les auteurs proposent un algorithme de prise en charge fonction du type et du niveau d’amputation. Tout chirurgien militaire forme a la microchirurgie doit etre capable de tenter une revascularisation digitale en situation sanitaire precaire, a l’aide de loupes grossissantes et d’un materiel microchirurgical minimaliste.

Des revascularisations digitales ont ete effectuees en situation sanitaire degradee sans microscope. L’objectif de cette etude experimentale etait d’evaluer les possibilites et la qualite de reparations microvasculaires effectuees sous loupes grossissantes ou smartphone sur des arteres de rat ayant un diametre comparable a celui des arteres digitales humaines. Apres avoir recu l’approbation du comite d’ethique local sur l’experimentation animale, 30 rats ont ete repartis en trois groupes de 10 individus selon le moyen grossissant utilise : microscope (groupe controle M), loupes (groupe L) et smartphone (groupe S). L’aorte abdominale sous-renale a ete dissequee sous microscope, puis anastomosee par des points separes de nylon 9/0 selon la technique de la bi-angulation symetrique en utilisant l’instrument grossissant specifique a chaque groupe. Toutes les procedures ont ete effectuees par le meme operateur ayant une pratique reguliere de la microchirurgie. Les principaux criteres d’analyse etaient : le diametre des vaisseaux, la duree de l’anastomose, la permeabilite immediate (T1) et apres une heure (T2), ainsi que la qualite de l’anastomose. La duree de l’anastomose etait comparable entre les groupes M et L, mais elle etait doublee dans le groupe S (p La realisation d’anastomoses d’arteres digitales sous loupes grossissantes est possible mais avec une qualite inferieure a celle du microscope, et donc avec un risque de thrombose secondaire plus eleve. En revanche, a l’heure actuelle, l’utilisation de smartphones ne permet pas la realisation de reparations microvasculaires chez le modele vivant. Les loupes grossissantes sont alternative valable au microscope en contexte sanitaire degrade. Le smartphone n’est qu’un outil de simulation interessant au debut de l’apprentissage de la microchirurgie.

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.

Les blasts de la main de guerre se distinguent des blasts de pratique civile par la severite des lesions et les conditions de prise en charge des patients. Une etude retrospective observationnelle a ete conduite parmi les militaires francais ayant presente un blast de la main occasionne par un agent vulnerant de guerre entre 2002 et 2018. Les donnees peri-operatoires ont ete recueillies dans le dossier medical informatise des patients. L’evaluation du resultat fonctionnel au dernier recul s’est faite par un entretien telephonique associe aux questionnaires DASH et OPUS. Quinze patients d’âge moyen 31 ans [extremes 20 a 48 ans] ont presente 19 mains de blast. Il s’agissait de 16 amputations traumatiques (5 amputations trans-radiales, 3 radio-carpiennes et 8 trans-metacarpiennes) et 3 fracas ouverts. Douze patients avaient des lesions associees, dont quatre etaient en etat de choc hemorragique lors de la prise en charge initiale. Aucune revascularisation n’a ete possible. La couverture a ete effectuee apres un delai moyen de neuf jours [extremes 2 a 22 jours]. Une seule reconstruction du pouce a ete effectuee. Neuf membres amputes ont ete appareilles. Au recul moyen de 7,4 ans [6 mois a 14 ans], les moyennes des scores DASH et OPUS etait respectivement de 35 % [extremes 3 a 84 %] et 58,6 % [extremes : 48 a 74 %]. A notre connaissance cette etude est la premiere a decrire un suivi sur le long terme de patients militaires victimes d’un blast de la main par des agents vulnerants de guerre. La haute intensite de l’explosion explique que les amputations traumatiques, les atteintes bilaterales et les lesions associees sont bien plus frequentes qu’en pratique civile. Par consequence, les resultats fonctionnels sont moins bons que dans les series civiles. Une prise en charge sequentielle, basee sur les principes du damage control, s’impose en raison du contexte de soin initial et des traumatismes associes, mais aussi du fait du haut degre de contamination et de la severite des lesions tissulaires.

Les mains botes radiales acquises sont des formes cliniques rares, principalement rencontrees dans les pays en developpement et secondaires a une destruction du radius par un traumatisme ou une osteomyelite. Un patient droitier de 17 ans, refugie malien, etait adresse pour une deformation de la main gauche apparue dans les suites d’un traumatisme dans l’enfance. Il presentait un avant-bras court (19 versus 33 cm) avec une main ballante deviee de 90° sur le bord radial. La main etait indemne de malformation, sensible et mobile, malgre un deficit d’extension des doigts. Les radiographies montraient une destruction de la quasi-totalite du radius, dont il ne persistait que l’epiphyse distale fusionnee avec le bloc scapho-lunaire. La croissance etant terminee, il a ete decide de realiser une centralisation du radius distal et une arthrodese radio-carpienne, apres un premier temps de distraction et correction axiale afin d’eviter d’encore raccourcir l’avant-bras. Un fixateur externe dedie a ete implante sur l’ulna et le 5e metacarpien, et une osteotomie realisee au col de l’ulna. La distraction et la correction axiale se sont faites simultanement. L’epiphyse radiale a ete centralisee sous l’ulna distal en 45 jours environ. Le fixateur a ensuite ete retire et remplace par une manchette en resine le temps d’obtenir la cicatrisation des orifices de fiches. Une arthrodese ulno-radio-carpienne en one bone forearm a enfin ete effectuee par une plaque dorsale avec greffe iliaque. La fusion a ete acquise en 2 mois. L’aspect esthetique et fonctionnel de la main etait tres satisfaisant, et les extenseurs avaient gagne en force. Les series rapportant le traitement de mains botes radiales post-osteomyelite sont rares, et comportent de faibles effectifs d’enfants ou adolescents. L’originalite de ce cas tient dans la prise en charge tardive d’un adulte jeune, en situation sociale precaire, ayant besoin d’un traitement fiable et rapide pour s’integrer au plus vite dans la societe. L’autre particularite etait la survenue d’une fusion radio-scapho-lunaire spontanee, egalement sequellaire de l’osteomyelite. La distraction axiale suivie d’une procedure de one bone forearm apportent une solution simple et perenne a ce probleme complique.