Fracturas complejas del tercio lateral de la clavícula / Complex fractures of the clavicle's lateral third

Resumen: Antecedentes: Las fracturas del tercio lateral de la clavícula representan 18% de todas las fracturas de clavícula. A pesar de que las fracturas no desplazadas pueden manejarse conservadoramente, las desplazadas tienen un porcentaje de no unión de 30%. Múltiples manejos han sido propuestos para las fracturas desplazadas. El objetivo de este estudio fue registrar la prevalencia de fracturas del tercio lateral de la clavícula con afectación de la articulación acromioclavicular, así como hacer una revisión breve del tratamiento realizado en nuestro centro y compararlo con la literatura actual. Material y métodos: Estudio retrospectivo, transversal, descriptivo y observacional, que consistió en una revisión de los expedientes de los pacientes con diagnóstico de fractura del tercio lateral de la clavícula con lesión de la articulación acromioclavicular. Resultados: Las fracturas del tercio lateral representaron 24% de todas las fracturas de clavícula. Distribución por sexos: 10:2, hombres:mujeres. Predominio: hombro izquierdo, 8:4. Los manejos predominantes fueron placa anatómica para tercio lateral de la clavícula (50% de los casos), técnica de cerclaje coracoclavicular más resección del tercio lateral de la clavícula (25%), placa gancho (8.3%), Mumford combinado con Waever/Dunn (8.3%), ancla más varillas Kirschner (8.3%). Discusión: La elección del tratamiento adecuado dependerá del tipo de fractura y las características específicas de cada paciente. Sugerimos el uso de la técnica de cerclaje coracoclavicular en los casos en que el fragmento lateral sea multifragmentado, irreductible o de tamaño menor al que permitiría su osteosíntesis, realizando plastía de ligamentos acromioclaviculares y coracoclaviculares.

Abstract: Background: Fractures of the lateral third of the clavicle represent 18% of all clavicle fractures. Even though non-displaced fractures can be managed conservatively, displaced fractures have a non-union percentage of 30%. Multiple approaches have been proposed to manage the displaced fractures. The objective of this study was to record the prevalence of fractures of the lateral third of the clavicle with involvement of the clavicular-acromial joint, as well as to briefly review the treatment performed in our center and compare it with the current literature. Material and methods: Retrospective, cross-sectional, descriptive and observational study, which consisted in a review of the records of patients with a diagnosis of fracture of the lateral third of the clavicle with an injury to the clavicular-acromial joint. Results: Lateral third fractures accounted for 24% of all clavicle fractures. Distribution by sex: 10: 2, men: women. Left shoulder predominance, 8:4. The predominant maneuvers were anatomical plate for the lateral third of the clavicle (50% of the cases), coracoclavicular cerclage technique plus resection of the lateral third of the clavicle (25%), plate hook (8.3%), Mumford combined with Waever/Dunn (8.3%), anchor plus Kirschner rods (8.3%). Discussion: The choice of the appropriate treatment will depend on the type of fracture and specific characteristics of each patient. We suggest the use of the coracoclavicular cerclage technique in cases in which the lateral fragment is multifragmented, irreducible or smaller in size than its osteosynthesis would allow, performing plasty of clavicular and coracoclavicular ligaments.

Tratamiento quirúrgico o conservador para fracturas de cóndilo mandibular / Surgical or conservative treatment for mandibular condyle fractures

INTRODUCCIÓN: Las fracturas maxilofaciales se asocian a importante morbilidad, pérdida de función y secuelas estéticas, entre otros. Dentro de las fracturas mandibulares, las fracturas de cóndilo mandibular son las más frecuentes. Estas pueden ser tratadas mediante un tratamiento quirúrgico (reducción abierta más estabilización con miniplacas de titanio) o un tratamiento conservador (ortopédico). MÉTODOS: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos ocho revisiones sistemáticas que en conjunto incluyen 66 estudios primarios, de los cuales, seis corresponden a ensayos aleatorizados. Concluimos que, en comparación con el tratamiento conservador, el tratamiento quirúrgico en fracturas de cóndilo mandibular probablemente se asocia a menor dolor articular, menor maloclusión y menor desviación lateral en apertura bucal.

INTRODUCTION: Maxillofacial fractures are associated with significant morbidity, loss of function and aesthetic sequelae, among others. Within mandibular fractures, mandibular condylar fractures are the most frequent. These can be treated by surgical treatment or conservative treatment (orthopedic). METHODS: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified eight systematic reviews including 66 primary studies overall, of which six were randomized trials. We concluded surgical treatment of mandibular condyle fractures, compared to conservative treatment, is probably associated with less joint pain, less malocclusion and less lateral deviation in buccal opening.

Tratamiento quirúrgico de la luxación acromioclavicular aguda: Reporte preliminar / Surgical treatment of acute acromioclavicular dislocation: Preliminary report

Introducción: El manejo ideal de las lesiones tipo III en agudo es controversial, dentro del manejo quirúrgico de estas lesiones es fundamental la reconstrucción de los ligamentos coracoclaviculares. Material y métodos: Se revisaron los expedientes de los pacientes con luxación acromioclavicular aguda, tratadas mediante reducción abierta y fijación con suturas de alta resistencia evaluando los resultados de manera preliminar a tres meses de evolución. Resultados: Fueron 12 pacientes; todos del sexo masculino, con una edad media de 28 años; tres de grado III, uno grado IV y ocho grado V de la clasificación de Rockwood. El tiempo promedio entre la lesión y la intervención quirúrgica fue de nueve días. En la escala de Constant 11 pacientes presentaron resultados excelentes y 1 bueno. Sólo un paciente desarrolló un seroma. La reducción radiográfica se mantuvo en todos los pacientes. Conclusiones: La reconstrucción anatómica de los ligamentos coracoclaviculares disminuye notablemente las complicaciones, más aún cuando dicha reconstrucción es provista por materiales que tengan una fuerza tensil semejante a los ligamentos nativos.

Introduction: Determining what is the ideal acute management of type III lesions is controversial. The reconstruction of coracoclavicular ligaments is a fundamental part of the surgical management of these lesions. Material and methods: The records of patients with acute acromioclavicular dislocation treated with open reduction and fixation with highly resistant sutures were reviewed. The preliminary results were assessed at the 3-month follow-up. Results: Twelve patients were included, all of them males; mean age was 28 years. Three were Rockwood grade III, one grade IV, and 8 grade V. The mean time elapsed between the injury and the surgery was 9 days. According to the Constant scale 11 patients had excellent results and one had good results. Only one patient developed a seroma. Radiographic reduction was maintained in all patients. Conclusions: The anatomical reconstruction of coracoclavicular ligaments reduces complications considerably, especially when such reconstruction is made using materials with a grip strength similar to the one offered by native ligaments.

Rupture of the uterus

Despite advances in the science and refinements in the art and practice of obstetrics, the incidence of rupture of the pregnant uterus in Manila and its suburbs seems to be increasingThis increase is apparently due to the fact that more sections are now being done. If ruptures from the cesarean scar are excluded, the incidence is apparently going downToo many classical operations are still being done despite the fact that the tendency to rupture is about 15 times more in the classical than in the low. In the present study, the ratio is 1:12Grand multiparity seems to be the sole cause in 5 spontaneous non-cesarean ruptures in this series. After the 4th delivery the danger of rupture should be born in mind in using oxytocics or intervening per vaginam. In the non-cesarean group, there was not a single case of spontaneous rupture observed below para VA successful vaginal delivery following a section is no guarantee against rupture. Ruptures have taken place following several successful vaginal deliveries in a previously sectioned uterus, particularly if the section is classicalTime does not seem to strengthen the cesarean scar and therefore it is doubtful whether wide spacing of pregnancies in sectioned patients is really necessary. Some people believe that the union is as strong as it can ever be after one yearIn the presence of an impending or suspected rupture of the uterus, destructive operations such as craniotomy or decapitation should be considered as formidable procedures, particularly if the presenting part is still high. Preference should be given to extraperitoneal or Porro section.(Summary and Conclusions)

Stillbirths and neonatal deaths in the Philippine General Hospital after liberation (April 5, 1945 to April 4, 1946)

1. The stillbirth rate for 895 full-term babies born at the Philippine General Hospital during the first year after liberation is 3.12 per cent. The full-term neonatal deaths is 1 per cent. The gross full-term fetal mortality is 4.12 per cent2. Prematurity from seven to eight months has a gross fetal mortality rate of 53.57 per cent. This includes the stillbirths and neonatal deaths3. Cephalopelvic disproportion malformations are the outstanding causes of full-term stillbirths4. Placenta previa, chronic nephritis, syphilis, and eclampsia are the most frequent causes of premature stillbirths5. Syphilis and chronic nephritis are the most frequent causes of premature macerated stillbirths. Syphilis as a cause of stillbirth was a rare phenomenon before, but it has become prominent after the liberation. (Summary)

Cesarean section in the Philippine General Hospital

An analysis of the cesarean sections and hysterectomies in the obstetrical department of the Philippine General Hospital during the two years following liberation is presented.The incidence of cesarean section among 3,749 viable births is 123 cases or 3.28 per cent.The complication that caused the greatest number of cesarean sections is placenta previa. None of the mothers died; but, out of 48 infants, 18 or 37.5 per cent either were stillborn (9) or died after birth. Sixteen infants or 88.88 per cent were premature.Dystocia, because of disproportion or malpresentation, was the next outstanding indication for cesarean section. There was no maternal mortality; but 3 out of 36 infants died, and 2 were stillborn. Two of the infant deaths were caused by hydrocephalus which were not diagnosed before the operation. One infant died of bronchopneumonia. Of the two stillbirths, one was a case of anencephalus with a large body, and the other was a severed after-coming head which could not be extracted below. The corrected fetal mortality of this complication is 1 death or 2.76 per cent.Cesarean section was performed in 7 cases of severe preeclampsia that failed to improve with conservative treatment, and in 91 cases of severe eclampsia where the fetus was alive and the cervix was either closed or dilated 1-2 cm. The maternal mortality of preeclampsia was 14.28 per cent, and that of eclampsia 22.22 per cent. We agree with those who believe that the best treatment for eclampsia, next to prevention, is the conservative treatment.Traumatic rupture of the uterus was caused by neglected transverse presentation in 41.5 per cent, and by pituitrin and salag or by pituitrin alone in 33.33 per cent. The high incidence of these causes calls for greater attention to, and proper management of, malpresentations and fetopelvic disproportion; and for more efficient instruction to those dealing in midwifery on the danger, limitation, and contraindications of pituitrin and salag.Rupture of the uterus through the cesarean section scar has been found in 4 cases (2.5 per cent), all of which were of the classical type. Because of the fibrotic condition of the scar and its lessened blood supply, the morbidity of such a type of rupture is relatively lower than when the rupture occurs in a noncesareanized uterus. Though all the babies were stillborn, all the mothers recovered; whereas from the traumatic rupture the maternal mortality was 41.66 per cent.The relative morbidity of the mothers exposed to infection operated on by extraperitoneal cesarean section and those operated on by laparotrachelotomy in conjunction with penicillin and the sulfa drugs is discussed.From 15 to 30 years dystocia was the most frequent indication for cesarean section, its incidence being 30%. But, after 31 years, placenta previa was the most frequent complication, its incidence being 46.87 per cent.Beginning from Para II to Para V, placenta previa was the highest indication for cesarean section, its incidence being 36.8 per cent. But from Para VI onwards, the incidence of placenta previa as indication for cesarean section is as high as 66.66 per cent. (Summary and Conclusion)

The occiput-posterior positions and dystocia

1. Although occiput-posterior position may not be a cause of dystocia, it appears that it is of not associated with something (may be abnormal shape of the pelvis) that causes more prolonged labor, with a higher incidence of interventions and a heavier infant mortality2. Anterior rotation, spontaneous or with the aid of the forceps, is the rule in occipitoposterior positions except in cases of gross pelvic deformities, such as marked contraction of the transverse diameter, when anterior rotation would be difficult and dangerous. (Summary)