Intramuscular Hemangioma: A Rare Cause of Omalgia / Hemangioma intramuscular: Uma causa rara de Omalgia

Abstract Intramuscular hemangiomas (IHs) are benign soft-tissue tumors that represent less than 1% of all hemangiomas. This clinical entity is rarely considered as a differential diagnosis in cases of musculoskeletal pain. A healthy 38-year-old woman presented to our office with complaint of left omalgia, with 8 months of evolution, limiting her daily activities. She reported the appearance of tumefaction in the previous 4 months. She was medicated with analgesic and antiinflammatory drugs with no clinical improvement. The objective examination showed limitation of left shoulder abduction (0-90°). The patient underwent a magnetic resonance imaging (MRI), in which a well-circumscribed nodular formation was detected in the deltoid muscle. Then, she underwent a biopsy, which confirmed the diagnosis of hemangioma. The patient was referred for sclerotherapy. Intramuscular hemangiomas are usually observed in young patients. The gold-standard examination for diagnosis is MRI, which often forestalls the need for a biopsy. In many cases, IHs are asymptomatic and tend to involute over time. Despite the low frequency of this clinical entity, it is important to place it as a diagnostic hypothesis in cases of chronic pain of the limbs in young patients with poor therapeutic response to antiinflammatory drugs and analgesia.

Resumo Os hemangiomas intramusculares (HIs) são tumores benignos de tecidos moles que representam menos de 1% de todos os hemangiomas. Esta entidade clínica raramente é considerada como diagnóstico diferencial nos casos de dor musculoesquelética. Uma paciente do sexo feminino, de 38 anos de idade, saudável, se apresentou ao nosso consultório com queixa de omalgia esquerda, com 8 meses de evolução, que limitava suas atividades diárias. Ela relatou o aparecimento de tumefação 4 meses antes da consulta. A paciente estava medicada com analgésico e antiinflamatório sem melhoria clínica. Ao exame objetivo, ela apresentava limitação da abdução do ombro esquerdo (0-90°). A paciente foi submetida a uma ressonância nuclear magnética (RNM) na qual foi detectada uma formação nodular bem circunscrita no músculo deltoide,. Em seguida, foi realizada uma biópsia que confirmou o diagnóstico de hemangioma. A paciente foi então encaminhada para a realização de escleroterapia. Os HIs normalmente são observados em pacientes jovens. O exame padrão-ouro para o diagnóstico é a RNM, que muitas vezes torna a realização de biópsia desnecessária. Em muitos casos, os HIs são assintomáticos e tendem a involuir com o tempo. Apesar da baixa frequência desta entidade clínica, é importante colocá-la como hipótese de diagnóstico em casos de dor crônica dos membros em pacientes jovens com má resposta terapêutica a antiinflamatórios e analgesia.

Tuberculosis en húmero proximal. Un diagnóstico infrecuente en infecciones articulares / Tuberculosis in the proximal humerus. A rare diagnosis in joint infections

Resumen La incidencia de Tb osteoarticular es mucho menor que la pulmonar, representando 1-2% de los casos de Tuberculosis (Tb) y el 10% de los casos de Tb extrapulmonar, por lo que usualmente no es considerada para el diagnóstico diferencial de pacientes con enfermedad articular. Su diagnóstico es difícil y se basa en hallazgos clínicos, radiológicos, bacteriológicos e histológicos. Las lesiones extrapulmonares son paucibacilares y las muestras, en la mayoría de los casos, difíciles de obtener, por lo que el diagnóstico a menudo es simplemente presuntivo. La tuberculosis articular en etapas tempranas, presenta manifestaciones clínicas e imagenológicas inespecíficas. Esto puede facilitar la progresión de la enfermedad local, generando lesiones osteoarticulares graves y, finalmente, la destrucción articular. Se presenta el caso de una paciente de 60 años, intervenida quirúrgicamente por presentar manifestaciones clínicas e imagenológicas compatibles con una ruptura del manguito rotador, y cuya evolución tórpida posoperatoria, llevó al diagnóstico bacteriológico de tuberculosis de húmero proximal.

Abstract The incidence of osteoarticular TB is much lower than that of the lung, representing 1-2% of TB cases and 10% of extrapulmonary TB cases, so it is often not considered for the differential diagnosis of patients with joint disease. Its diagnosis is difficult and is based on clinical, radiological, bacteriological and histological findings. Extrapulmonary lesions are paucibacillary and specimens, in most cases, difficult to obtain, so the diagnosis is often simply presumptive. Joint tuberculosis in early stages presents nonspecific clinical and imaging manifestations. This can lead to the progression of the local disease, generating severe osteoarticular lesions and, finally, joint destruction. We present the case of a 60-year-old patient who underwent surgery due to clinical and imaging manifestations compatible with a rotator cuff tear, and whose torpid postoperative evolution led to the bacteriological diagnosis of proximal humerus tuberculosis.

Lipoma arborescente bilateral de hombro: manejo de un caso en consulta de rehabilitación y revisión de la literatura / Bilateral lipoma arborescens of the shoulder: rehabilitation management inoutpatient clinic and literature review

La lipomatosis arborescente, también conocida como 'proliferación de vellosidades de la membrana sinovial', es una entidad que se caracteriza por la proliferación difusa de vellosidades con reemplazo del tejido sinovial por adipocitos maduros. La presentación típica es una enfermedad monoarticular que afecta a la rodilla, con predilección por la bolsa suprapatelar, aunque también se describe afectación mono o biarticular de articulaciones grandes como las caderas, los tobillos, los codos y los hombros. La resonancia magnética nuclear (RMN) es el método de imagen de elección para hacer el diagnóstico. El tratamiento consiste en practicar sinovectomía, ya sea abierta o artroscópica. En este estudio se presenta un caso de lipoma arborescente con afectación simultánea de la bursa subacromial-subdeltoidea, vaina del tendón de la porción larga del bíceps y articulación glenohumeral, que se asoció a lesión del manguito de los rotadores valorado en la Unidad de Alta Resolución de Hombro de nuestro servicio de rehabilitación

Arborescent lipomatosis, also known as 'synovial membrane villous proliferation', is an entity characterized by diffuse proliferation of villi with replacement of synovial tissue by mature adipocytes. The typical presentation is a monoarticular disease affecting the knee, with a predilection for the suprapatellar bursa, although mono- or biarticular involvement of large joints such as the hips, ankles, elbows and shoulders is also described. Magnetic resonance imaging (MRI) is the imaging method of choice for diagnosis. Treatment consists of synovectomy, either open or arthroscopic. This study presents a case of arborescent lipoma with simultaneous involvement of the subacromial-subdeltoid bursa, tendon sheath of the long portion of the biceps and glenohumeral joint, which was associated with rotator cuff lesion assessed in the High Resolution Shoulder Unit of our rehabilitation service.

La presión del CO2 intraoperatorio y su relación con la omalgia; estudio prospectivo aleatorio / Intraoperative CO2 pressure and its relationship with omalgia (randomized prospective trial)

Introduccón: La colecistectomía laparoscópica es considerada desde principios de los años noventa como el tratamiento de referencia de la litiasis vesicular. Uno de sus beneficios demostrados en comparación con el abordaje convencional es la mejoría significativa del bienestar postoperatorio. Creemos que la presión de insuflado abdominal puede influir en la incidencia de dolor postoperatorio, por lo que el objetivo de este estudio fue investigar la influencia de la presión del neumoperitoneo en la aparición de omalgia. Material y Metodos: Se realizó estudio prospectivo, con asignación aleatoria, a dos grupos: A n= 60 pacientes insuflados a una presión 12 mmHg y un grupo B n=40 pacientes insuflados a una presión de 10 mmHg; entre julio de 2010 a julio de 2011. Criterios de inclusión: pacientes adultos con indicación de colecistectomía. Criterios de exclusión; menores de 18 años, embarazadas, pacientes con enfermedades crónicas que requieren de administración de analgésicos (artritis reumatoidea, enfermedades oncológicas, etc), tratamiento quirúrgico previo, quienes se rechacen participar del estudio. Se utilizó el mismo insuflador con flujo constante (máx. 20 l/m.), y el mismo equipo laparoscópico. El neumoperitoneo se realizo con aguja de Veress en todos los casos. Colocación de trocares con técnica americana. La omalgia fue evaluada a las 12 hs de finalizada la cirugía. Resultados: Se incluyeron 120 pacientes, sometidos a colecistectomías laparoscópicas programadas. Ningún paciente requirió de conversiones. Con una edad media de 51 años, con un rango entre 16 y 82 años, La incidencia de omalgia fue del 40% para el grupo con presiones de insuflado de 10 vs 60% para el grupo con presiones de insuflado de 12 mmHg, P =0,006. La incidencia de omalgia no fue diferente según sexo, 20% de las mujeres vs el 25 % de los hombres (p=0,657), ni para edad, comorbilidad, hábito físico y/o cirujano...

Introduction: Since early 1990s, laparoscopic cholecystectomy is considered as the standard of care for gallstones. One of its demonstrated benefits in comparison with the conventional approach is the significant improvement of post-surgery well-being. We believe that abdominal insufflation pressure may affect the incidence of postoperative pain, and thus, the objective of this trial was to investigate the influence of pneumoperitoneum pressure in the incidence of shoulder pain. Material and Methods: A prospective trial was performed between July 2010 and July 2011, with random allocation into two groups: A n=60 patients with insufflation pressure of 12 mmHg, and B n=40 patients with insufflation pressure of 10 mmHg. Inclusion criteria: adult patients with indication for cholecystectomy. Exclusion criteria: patients under the age of 18 years old, pregnant women, patients with chronic diseases which require pain relievers (rheumatoid arthritis, oncologic diseases, etc.), previous surgery and patients who refuse to participate in the trial. The same insufflator was used with constant flow (20 l/m max) and the same laparoscopic device. Veress needle was used for pneumoperitoneum in all cases. Trocars were positioned using the American technique. Omalgia was assessed 12hs. after surgery. Results: The trial included 120 patients, who had undergone scheduled laparoscopic cholecystectomies. None of the patients required conversion to conventional surgery. With a mean age of 51 years old, ranging from 16 and 82 years of age, the incidence of omalgia was 40% for the group with 10 of insufflation pressure vs. 60% for the group with 12 mmHg of insufflation pressure, P=0.006. The incidence of shoulder pain was not different according to sex –20% women vs. 25% men (p=0.657)– nor for age, co-morbidity, fitness and/or surgeon...