Morphometric evaluation of second to fifth metacarpals for retrograde intramedullary headless screw fixation / Evaluación morfométrica del segundo al quinto metacarpianos para la fijación retrógrada con tornillos intramedulares sin cabeza

SUMMARY: Intramedullary headless screw fixation has come to the fore in the treatment of metacarpal fractures in recent years with its advantages. Our aim was to evaluate the metacarpal morphometry for retrograde intramedullary entrance and to determine the optimal entry point. Computed tomography images of 105 patients including 64 men and 41 women, were examined. Distal and proximal metacarpal widths, medullary cavity width, cortex thickness and the measurements of the optimal entry site in volar-dorsal and radio-ulnar directions were measured in both coronal and sagittal planes. In the sagittal plane, the second metacarpal had the widest proximal width (16.29 mm), distal width was greatest in the third metacarpal (14.34 mm) which was significantly different between the sexes (p<0.001). Third metacarpal had the widest medullary cavity width in the sagittal plane (4.12 mm). In the coronal plane, it was the second metarcarpal with the widest proximal (16.14 mm) and distal width (13.92 mm) and was also the longest (66.32 mm). Unlike the sagittal plane, the medullary cavity width in the coronal plane was at the widest (4.06 mm) in fifth metacarpal. The points determined for optimal entry were respectively (4.60 mm; 4.97 mm; 4.55 mm; 4.36 mm) in the dorsal-volar plane, close to the dorsal side. There was no significant difference between the sexes for optimal insertion point in the sagittal planes in all the measured metacarpals. Considering its three dimensional structure, metacarpal bones have irregular morphometric properties and these features differ in sagittal and coronal planes. The optimal entry site is located in the midline in the coronal plane, while it is located in the sagittal plane close to the dorsal part. Knowing these properties can reduce the complication rate by reducing entry attempts and help select the correct material.

RESUMEN: En los últimos años, debido a sus ventajas la fijación intramedular con tornillos sin cabeza ha pasado a primer plano en el tratamiento de las fracturas de los huesos metacarpianos. Nuestro objetivo fue evaluar la morfometría del hueso metacarpiano para la entrada intramedular retrógrada y determinar el punto de entrada óptimo. Se examinaron imágenes de tomografía computarizada de 105 pacientes, incluidos 64 hombres y 41 mujeres. Los anchos de los huesos metacarpianos distal y proximal, el ancho de la cavidad medular, el grosor de la cortical y las medidas del sitio de entrada óptimo en las direcciones palmar-dorsal y radioulnar se midieron en los planos coronal y sagital. En el plano sagital, el segundo hueso metacarpiano presentó el mayor ancho proximal (16,29 mm), el ancho distal fue mayor en el tercer hueso metacarpiano (14,34 mm), lo que fue significativamente diferente entre individuos de ambos sexos (p<0,001). El tercer metacarpiano tenía la cavidad medular más ancha en el plano sagital (4,12 mm). En el plano coronal, era el segundo hueso metarcarpiano con mayor ancho proximal (16,14 mm) y distal (13,92 mm) y también era el más largo (66,32 mm). A diferencia del plano sagital, el ancho de la cavidad medular en el plano coronal era más ancho (4,06 mm) en el quinto hueso metacarpiano. Los puntos determinados para la entrada óptima fueron respectivamente (4,60 mm; 4,97 mm; 4,55 mm; 4,36 mm) en el plano dorsal-volar, próximo del lado dorsal. No hubo diferencia significativa entre ambos sexos para el punto de inserción óptimo en los planos sagitales en todos los huesos metacarpianos medidos. Teniendo en consideración su estructura tridimensional, los huesos metacarpianos tienen propiedades morfométricas irregulares, y estas características difieren en los planos sagital y coronal. El sitio de entrada óptimo se encuentra en la línea mediana en el plano coronal, mientras que se ubica en el plano sagital cerca de la parte dorsal. Conocer estas propiedades puede reducir la tasa de complicaciones al disminuir los intentos de entrada y ayudar a seleccionar el material correcto.

Enfermedad de Dieterich: reporte de un caso de una enfermedad muy poco frecuente / Dieterich's disease: a case report of a very rare disease

RESUMEN La enfermedad de Dieterich o necrosis avascular de la cabeza de los metacarpianos es una enfermedad muy poco frecuente, con poco más de 50 casos reportados en la literatura. De etiología desconocida, clínicamente se puede manifestar de forma variable, desde asintomática hasta con evidente inflamación y limitación funcional dolorosa de la articulación metacarpofalángica afectada. Presentamos el caso de un paciente de 82 anos que presentaba dolor a nivel de la articulación metacarpofalángica del tercer dedo de la mano derecha, de un año de evolución, sin causa aparente. La exploración física no evidenciaba limitación funcional, ni dolor; tampoco se objetivó eritema, tumefacción o efecto masa. Se realizó un estudio radiológico con diagnóstico de enfermedad de Dieterich avanzada, estableciendo tratamiento conservador con antiinflamatorios no esteroideos con mejoría clínica significativa.

ABSTRACT Dieterich's disease, or avascular necrosis of the metacarpal head, is a very rare disease, with just over 50 cases reported in the literature. Of unknown aetiology, it can manifest clinically in a variable way, from asymptomatic to obvious inflammation and painful functional limitation of the affected metacarpophalangeal joint. The case is presented of an 82-yearold patient who presented with pain at the level of the metacarpophalangeal joint of the third finger of the right hand of 1 year of duration without apparent cause. The physical examination showed no functional limitation or pain. Furthermore, no erythema, swelling, or mass effect was observed. A radiological study was carried out, leading to a diagnosis of advanced Dieterich's disease. Conservative treatment was started with nonsteroidal anti-inflammatory drugs, with a significant clinical improvement.

Osteosíntesis mínimamente invasiva con tornillos centromedulares canulados para fracturas de metacarpianos / Minimal invasive osteosynthesis with cannulated screws in metacarpal fractures

Resumen: Antecedentes: Las fracturas de los metacarpianos comprenden de 18 a 44% de las fracturas de la mano. La mayoría de las fracturas simples de cuello y transversales diafisiarias de metacarpianos pueden ser tratadas de manera conservadora con buenos resultados. Sin embargo, en el caso de fracturas inestables no existe un estándar de oro para la osteosíntesis y ningún método ha mostrado hasta la fecha superioridad sobre los demás. Recientemente ha habido publicaciones sobre osteosíntesis con tornillos canulados centromedulares sin cabeza retrógrados con buenos resultados funcionales en fracturas de cuello y transversales diafisiarias de metacarpianos. Material y métodos: Series de casos con seguimiento a corto plazo tratados con osteosíntesis retrógrada con tornillos canulados sin cabeza en nueve fracturas de cuello de quinto metacarpiano, una de cuello de cuarto metacarpiano y una transversal diafisiaria de quinto metacarpiano. Resultados: Todos los pacientes lograron consolidación radiográfica y al mes de seguimiento tenían arcos de movimiento completos y realizaban actividades habituales. Una paciente con mano traumática y fractura de quinto metacarpiano presentó limitación de arcos de movimiento. En un caso con hueso osteoporótico y conminución de cortical volar no logramos evitar la pérdida de altura con tornillos, por lo que utilizamos clavillos Kirschner. Conclusión: La osteosíntesis mínimamente invasiva con tornillos canulados retrógrados sin cabeza es una buena opción para el tratamiento de fracturas transversales de diáfisis y de cuello de metacarpianos inestables porque es mínimamente invasiva y permite movilización y regreso temprano a actividades habituales.

Abstract: Metacarpal fractures comprise 18 to 44% of hand fractures. Fractures from the second to the fifth metacarpals are 88% of the metacarpal fractures and fractures of the fifth metacarpals are the most common. Fractures of the neck of the fifth metacarpal are about 20% of all the hand fractures. Most of these fractures can be treated conservatively with good functional results. However, for those neck and shaft unstable fractures that need surgical treatment, there is no gold standard for osteosynthesis. Recently, there have been reports of minimally invasive osteosynthesis using headless retrograde intramedullary cannulated screws with good functional results. Material and methods: We report our short term experience treating nine fifth metacarpal neck fractures, one fourth metacarpal neck fracture and a transverse fifth metacarpal shaft fracture that did not fulfill criteria for conservative treatment. We treated them with minimally invasive osteosynthesis using retrograde intramedullary headless cannulated screws. Results: All patients showed radiographic healing and had full range of motion of the metacarpophalangeal joint at one month follow up except for one patient who suffered a dorsal mutilating hand injury along with a fifth metacarpal neck fracture. One patient had osteoporotic bone and we could not control height loss with screws, so we had to use k-wires. Conclusion: Minimally invasive osteosynthesis with cannulated headless retrograde screws is a good option to treat neck and transverse diaphyseal fractures of the metacarpals. It confers a stable construct that allows early range of motion and return to activities.

Propiedades morfológicas en la parte media de la díafisis del hueso metacarpiano III de equino mestizo criollo / Morphological properties in the mid part of the metacarpal III bone diaphysis of equine criollo crossbreed

El desarrollo del esqueleto es de máxima importancia en caballos de trabajo y alta competencia. Los miembros torácicos sostienen el 60% del peso corporal y están sometidos a esfuerzos biomecánicos que los predisponen a lesiones, estando obligados a especializarse en el apoyo. El metacarpiano III soporta la mayor carga entre los huesos del cuerpo y la sustancia compacta tiene gran espesor dorsal y medial. Es un material complejo que posee plasticidad y fuerza considerable, con capacidad para soportar la deformación y recuperar su forma. El objetivo de este estudio es aportar conocimientos morfológicos, aplicables a la clínica animal, del hueso metacarpiano III de equino mestizo criollo. Se estudiaron los huesos metacarpiano III de 30 equinos hembras y machos, entre 18 meses y 5 años de edad, divididos en dos grupos etarios, provenientes del frigorífico General Pico, Las Higueras. Se determinó: peso y longitud total; diámetro latero-medial y dorso-palmar en la parte media de la diáfisis. Al metacarpiano III izquierdo se le practicó una osteotomía transversal en la parte media de la diáfisis para determinar: espesor de la cortical, área cortical, área medular y área total. Los datos fueron analizados mediante técnicas de correlación y regresión lineal simple, análisis de la varianza y comparaciones múltiples de Tukey usando el paquete estadístico InfoStat, con un nivel de significación de 0,05. Los resultados muestran que existe asociación entre el peso versus área cortical (r= 0,76, p= 0,0001) y longitud del hueso versus área cortical (r= 0,74 p= 0,0001), el área depende linealmente del peso y longitud del hueso (R2= 0,97, p<0,0001 y R2= 0,96, p<0,0001 respectivamente). Se comprobó que existen diferencias significativas entre los diámetros de las áreas y espesor de los cuadrantes (p<0,0001), al contrastar los cuadrantes entre sí se observaron diferencias a excepción del cuadrante dorsal y lateral. Existe diferencias entre las áreas de los distintos grupos etários (p= 0,0034). La morfología tiene influencia sobre las propiedades biomecánicas del hueso.

The development of high skeleton is important in working horses and associated high competition. Thoracic members hold 60% of body weight and are subjected to biomechanical efforts that predispose the animal to injury, being forced to rely on the support. The large metacarpal III supports load between bones of the body and the compact substance is large dorsal and medial thickness. It is composed of complex material and possesses plasticity and considerable force, with the ability to sustain deformation and subsequently recover its form. The objective of this study is to provide morphometric knowledge applied to animal clinic of the metacarpal III bone of equine criollo crossbreed. Thirty (30) metacarpal III bones of male and female horses, between 18 months and 5 years old, divided into two age groups, from the Frigorifico General Pico, Las Higueras groups were studied. We determined: weight, total length, diameter latero-medial and dorsal-palmar in the middle of the diaphysis. A transverse osteotomy was performed left to metacarpal III in the middle diaphysis to determine: cortical thickness, cortical area, medullary area and total area. The data was analyzed by correlation and simple linear regression techniques, analysis of variance and Tukey multiple comparisons using the statistical InfoStat (2009) package, with a significance level of 0.05. The results showed an association between weight vs. cortical area (r= 0.76, p= 0.0001) and bone length vs. cortical area (r= 0.74, p= 0.0001), the area depends linearly on the weight and length bone (R2= 0.97, p<0.0001 and R2= 0.96, p<0.0001 respectively). It was found that there are significant differences between the diameters of the area and thickness of the quadrants (p<0.0001), contrasting quadrants were observed in the dorsal and lateral exception quadrant. There are differences between areas of different age groups (p= 0.0034). The morphology influences the biomechanical properties of the bone.

Avaliação da composição macroelementar do osso terceiro metacarpiano de equinos / Evaluation of the macro elemental composition of the equine third metacarpal bone

O terceiro osso metacarpiano equino é uma região de particular interesse devido ao grande número de lesões a que está sujeito. Assim, justifica-se o estudo detalhado da sua estrutura anatômica, dimensões e composição elementar para o aprimoramento de técnicas de diagnóstico, tratamento e prevenção de lesões. Neste trabalho,foi estudada a composição macroelementar óssea de 30 pares de osso terceiro metacarpiano equino e sua relação com a idade, sexo, peso, raça, alimentação e atividade dos animais. As concentrações médias de cálcio e fósforo das amostras foram 205 ± 62 mg/g e 97 ± 32 mg/g, respectivamente. A relação [Ca]/[P] encontrada foi de 2,12 ± 0,13, indicando que a proporção entre o cálcio e fósforo no tecido ósseo é constante e aproximadamente igual à razão 2:1. A análise estatística dos dados mostrou normalidade para todo o conjunto de medidas. A avaliação entre os animais com atividade física intensa e os animais com atividade física leve, em que a quantidade de material mineralizado para o primeiro e segundo conjuntos são, respectivamente, [Ca] = 222 ± 57 mg/g e [Ca] = 179 ± 47 mg/g, evidenciou a existência de correlação estatística entre o depósito de material mineral e a função exercida pelos animais. Para as demais características, não foram verificadas evidências estatísticas de inter-relações. Tais achados serão subsídios para estudos posteriores acerca de possíveis correlações com enfermidades de origem fisiológica ou nutricional frente à casuística de fraturas e outras afecções comuns ao aparelho locomotor equino.

The equine third metacarpal bone has been seen as a region of particular interest due to the large number of injuries to which it is subject. Thus, the detailed study of its anatomical structure, size and elemental composition is justified for the improvement of diagnostic techniques, treatment and prevention of injuries. In this work it has been studied the macro elemental composition of 30 pairs of equine third metacarpal bone and its relation with age, sex, weight, breed, nutrition and activity of animals. The average concentrations of calcium and phosphorus of the samples were 205 ± 62 mg/g and 97 ± 32 mg/g, respectively. The ratio [Ca] / [P] was found to be 2.12 ± 0.13, indicating that the ratio of calcium and phosphorus in bone tissue is constant and approximately equal to the ratio 2:1. The statistical analysis showed normal values for the entire set of measurements. In the evaluation of the animals with intense physical activity, and animals with light physical activity, it was found that the amount of mineralized material for the first and second sets respectively ([Ca] = 222 ± 57 mg/g [Ca] = 179 ± 47 mg/g), showing the existence of statistical correlation between the deposit of mineral material and the function performed by the animals. For the other characteristics were not found statistical evidence of correlations. These findings will be input for further studies of possible correlations with diseases of nutritional origin or physiological outside the series of fractures and other disease common to the equine locomotor system.

Determinação da densidade mineral e da elasticidade óssea após a aplicação de ondas de choque extracorpóreas no terceiro metacarpiano de equinos atletas / Mineral density and bone elasticity determination after extracorporeal shock waves application in third metacarpus of athlete equines

Objetivou-se neste estudo avaliar os efeitos da aplicação de ondas de choque extracorpóreas (ESWT) no terceiro metacarpiano de equinos hígidos através da determinação da elasticidade óssea. Foram utilizados 20 equinos Puro Sangue Inglês, machos e fêmeas, com dois anos de idade, em início de treinamento e selecionados quanto ao estado de higidez. No início do experimento (D0), todos os animais foram submetidos à avaliação da elasticidade óssea do terceiro metacarpiano. Os animais foram divididos em dois grupos (Grupo Controle - GC e Grupo Experimental - GE). A aplicação das ESWT foi realizada no membro torácico direito dos animais do GE, na região coincidente à da avaliação da elasticidade óssea. Foi utilizado aparelho para terapia de ondas extracorpóreas com densidade de fluxo de energia de 0,15mJ/mm2 e 2000 pulsos com probe E6R20, com característica do foco da onda de choque de 20 mm. A ESWT foi repetida a cada 21 dias totalizando três sessões (D0, D21 e D42). A análise da determinação da elasticidade óssea foi realizada no D0, D21, D42 e D72. A média da velocidade ultrassonográfica diferiu entre os grupos no D21, D42 e D72, sendo que os animais do GE apresentaram menor densidade mineral óssea após as aplicações das ESWT. Houve igualmente, diferença na massa óssea entre os grupos no D21 e D42, parâmetro onde os animais do GE apresentaram diminuição significativa da massa óssea. O risco de fratura apresentou-se maior nos animais do GE no D21. Concluiuse que, a ESWT é capaz de promover alteração da densidade mineral óssea.

The porpoise of this study was to evaluate the effects of extracorporeal shock waves in third metacarpus bone from healthy horses by determination of bone elasticity. It were used 20 Thoroughbred horses, male and female, with two years old, on top of training and selected as the state healthy. At the beginning of the experiment (D0), all animals were submitted for evaluation of bone elasticity held in the third metacarpus bone. The animals were divided into two groups (Control Group - CG and Experimental Group - EG). The application of extracorporeal shock wave therapy (ESWT) was performed on the right forelimb of the animals in the experimental group in the same place evaluated for bone elasticity and was used apparatus for extracorporeal therapy of waves with 0.15 mJ/mm2 energy flux density and 2000 pulses with E6R20 probe, with focus feature of the shock wave of 20 mm. The ESWT were repeated every 21 days, a total of three sessions (D0, D21 and D42). The analysis of bone elasticity determination was realized at D21, D42 and D72. The average of speed ultrasound differed between groups at D21, D42 and D72, and the animals from EG had lower bone mineral density after applications of ESWT. There was also difference in the analysis of bone mass (Z-Score) between the groups at D21 and D42, which animals from EG showed a significant decrease in bone mass. The risk of fracture was higher in animals from experimental group at D21. It was concluded that ESWT is able to promote change in bone mineral density.

The first metacarpal is the thumb first phalange: EvoDevo implications / El primer metacarpiano es la primera falange del pulgar: implicaciones en EvoDevo

We examined the status of the first metacarpal bone whose shape, fetal and post-natal development correspond to those of the thumb proximal phalanx. Galen already described this, circa 170 CE. Our radiographic data confirm that the pre-axial (radial or anterior) side of the hand matures, later than the post-axial (ulnar or posterior) side, both, pre- and post-natally. A new perspective on thumb primate and human ontogeny is discussed and comparative observations on the Evolutionary Development (EvoDevo) of the thumb and the first toe are proposed along with a nomenclature honoring Galen's original roposition.

Se analiza el estado del primer metacarpiano cuya forma y desarrollo embrionario, fetal y postnatal corresponde a los de la primera falange del pulgar. Galeno notó que éste era la primera falange del pulgar cerca de 170 DC. Esto no es un simple cambio de nomenclatura, ya que da una nueva luz a los problemas evolutivos de ontogenia (EvoDevo). Nuestros datos radiográficos confirman que el lado radial (anterior o pre-axial) de la mano madura, pre y post-natalmente, mas tardíamente que el lado cubital (posterior o post-axial). Se discuten nuevas perspectivas sobre la ontogenia y filogenia humana y de primates, y se proponen estudios comparativos del desarrollo del pulgar y del ortejo mayor.