Tratamiento de las fracturas por herida de arma de fuego: revisión bibliográfica sistematizada / Treatment of gunshot wound fractures: systematic review of the literature / Tratamento de fraturas por arma de fogo: revisão bibliográfica sistematizada

Introducción: Las fracturas por heridas de arma de fuego son un motivo de consulta habitual en nuestro país. Existe gran variabilidad de conductas respecto a su tratamiento. El objetivo principal de este trabajo es analizar los distintos tratamientos y sus indicaciones. Materiales: Se realizó una revisión sistematizada de la literatura en las bases de datos Pubmed y Scielo. Se incluyeron artículos con fracturas por herida de arma de fuego en miembros superiores e inferiores, excluyendo la mano. Se analizó: tratamiento (ortopédico o quirúrgico), debridamiento, antibioticoterapia y complicaciones. Resultados: Se obtuvieron 19 artículos que cumplían los criterios de inclusión y exclusión. Los artículos tuvieron un Nivel de Evidencia tipo 2b, 3 y 4. Conclusiones: Los artículos analizados tienen un bajo nivel de evidencia. La fijación quirúrgica es variable y depende de la topografía ósea, la lesión de partes blandas y las lesiones asociadas. El debridamiento profundo está relacionado con mayores índices de infección. Las fracturas estables de tratamiento ortopédico no deberían debridarse ya que aumenta los índices de infección. Debería realizarse antibioticoterapia intravenosa inicial en todos los pacientes, la terapia posterior es discutida.

Introduction: Fractures due to gunshot wounds are a common reason for consultation in our country. There is great variability of conduct regarding its treatment. The main objective of this work is to analyze the different treatments and their indications. Materials: A systematic review of the literature was carried out in the Pubmed and Scielo databases. Articles with fractures due to gunshot wounds in the upper and lower limbs (excluding the hand) were included. We analyzed: treatment (orthopedic or surgical), debridement, antibiotic therapy and complications. Results: 19 articles were obtained that met the inclusion and exclusion criteria. The articles had a Level of Evidence type 2b, 3 and 4. Conclusions: The articles analyzed have a low level of evidence. Surgical fixation is variable and depends on bone topography, soft tissue injury, and associated injuries. Deep debridement is associated with higher rates of infection. Stable orthopedically treated fractures should not be debrided as this increases infection rates. Initial intravenous antibiotic therapy should be performed in all patients, subsequent therapy is discussed.

Introdução: As fraturas por ferimentos por arma de fogo são motivo comum de consulta em nosso país. Há grande variabilidade de conduta quanto ao seu tratamento. O objetivo principal deste trabalho é analisar os diferentes tratamentos e suas indicações. Materiais: Foi realizada revisão sistemática da literatura nas bases de dados Pubmed e Scielo. Foram incluídos artigos com fraturas por arma de fogo em membros superiores e inferiores, excluindo a mão. Foram analisados: tratamento (ortopédico ou cirúrgico), desbridamento, antibioticoterapia e complicações. Resultados: foram obtidos 19 artigos que atenderam aos critérios de inclusão e exclusão. Os artigos tinham Nível de Evidência tipo 2b, 3 e 4. Conclusões: Os artigos analisados ​​apresentam baixo nível de evidência. A fixação cirúrgica é variável e depende da topografia óssea, lesão de tecidos moles e lesões associadas. O desbridamento profundo está associado a maiores taxas de infecção. Fraturas estáveis ​​tratadas ortopedicamente não devem ser desbridadas, pois isso aumenta as taxas de infecção. A antibioticoterapia intravenosa inicial deve ser realizada em todos os pacientes, a terapia subsequente é discutida.

Anatomia óssea e muscular do antebraço e mão de Chrysocyon brachyurus (carnivora, canidae) / Bone and muscular anatomy of the antibone and hand of Chrysocyon brachyurus (carnivora, canidae)

O lobo-guará Chrysocyon brachyurus Illiger, 1815, é o maior canídeo da América do Sul, pesa cerca de 25 kg quando adulto e está ameaçado de extinção. Descrições anatômicas contribuem para a complementação das informações sobre espécies silvestres e para implicações conservacionistas, clínicas e cirúrgicas. Objetivou-se descrever os ossos e os músculos do antebraço e mão do lobo-guará. A preparação das peças foi feita a partir dos métodos usuais de dissecação, em animais preservados em solução de formol a 10%. Os espécimes pertencem ao acervo didático do Laboratório de Ensino e Pesquisa em Animais Silvestres da UFU e são provenientes de indivíduos atropelados. Os ossos descritos foram: rádio, ulna, ossos cárpico acessório, cárpico ulnar e cárpico intermédio; ossos cárpicos I, II, III e IV; ossos metacárpicos I, II, III, IV, V; falanges proximais, falanges médias e falanges distais do primeiro ao quinto dedo. Os músculos observados foram: extensor radial do carpo; pronador redondo; braquiorradial; extensor comum dos dedos; extensor ulnar do carpo; extensor lateral dos dedos;supinador; abdutor longo do dedo I; flexor radial do carpo; flexor profundo dos dedos; flexor superficial dos dedos; flexor ulnar do carpo; pronador quadrado; interflexor; lumbricais; abdutor curto dos dedos I e II e flexor curto do dedo I.

The maned wolf Chrysocyon brachyurus (Illiger, 1815) is the largest canid in South America, weighs about 25 kg as an adult and is threatened of extinction. Anatomical descriptions contribute to the complementation of information on wild species and for conservation, clinical and surgical implications. The purpose of this study was to describe the bones and muscles of the forearm and hand of the maned wolf. The methodology was through the usual dissecting methods in animals preserved in 10% formalin solution. The animals belong to the didactic collection of the Laboratory of Teaching and Research in Wild Animals of the UFU and come from run over. The bones evaluated were: radius, ulna, carpal accessory, carpi ulnar and carpi intermedium; carpal bones I, II, III and IV; metacarpal bones I, II, III, IV, V; proximal phalanges, middle phalanges and distal phalanges from first to fifth finger. The muscles observed were: radial extensor carpal; pronator round; brachioradial; common extensor of fingers; ulnar carpal extensor; lateral extensor of the fingers; supinator; abductor long finger I; flexor carpi radialis; flexor deep fingers; superficial flexor of the fingers; ulnar flexor of the carpus; square pronator; interflexor; lumbrils; short abductor of fingers I and II and short flexor of finger I.

Embrochage centromédullaire des fractures diaphysaires des os de l'avant bras chez l'adulte

Introduction - Les méthodes thérapeutiques des fractures diaphysaires déplacées de l'avant bras chez l'adulte sont variées. Le but de cette étude était d'évaluer les résultats de l'embrochage centromédullaire. Patients et méthodes - Cette étude rétrospective a concerné 45 patients opérés pour une fracture diaphysaire d'un ou des deux os de l'avant bras chez l'adulte. Les fractures étaient fermées (n=25), ou ouvertes (n=20 ). Le siège de la fracture était le 1/3 supérieur (n=5), le 1/3 moyen (n=35), et le 1/3 inférieur (n=5 ). L'ostéosynthèse a été réalisée à foyer ouvert avec des broches de Kirschner de 2,5 mm de diamètre (n=37) ou de 2 mm ( n= 8 ). Un plâtre de 8 semaines était posé après l'intervention. Nous avons étudié la réduction de la fracture, la cicatrisation cutanée, la consolidation, la fonction selon les critères d'Anderson, et les complications. Résultats - La réduction postopératoire était satisfaisante chez 43 patients. La cicatrisation a été obtenue chez tous les patients dans un délai moyen de deux semaines. La consolidation osseuse a été obtenue chez 43 (95%) patients dans un délai moyen de 90 jours. Au recul moyen de 24 mois, 32 patients ont été revus. Les résultats finaux étaient excellents (n=18) bons (n=5), moyens (n=5), et mauvais (n= 3). Un seul cas d'infection (2%) a été noté. Conclusion - Cette méthode donne de bons résultats. Elle est simple, rapide, et peu onéreuse. Cette étude suggère que l'embrochage centromédullaire peut constituer une alternative dans le traitement des fractures diaphysaires des os de l'avant bras chez l'adulte

Manual reduction of children's Monteggia fractures associated with anterior interosseous nerve injury / 中国骨伤

<p><b>OBJECTIVE</b>To study clinical results of the manual reduction in treatment.</p><p><b>METHODS</b>From October 2010 to April 2013,39 children with Monteggia fracture associated with anterior interosseous nerve injury were treated by manual reduction and fixation on buckling rotation backward,including 17 females and 22 males with an average age of 6.3 years old ranging from 3.2 to 11 years old. Among them, 15 cases were on the right side and 24 cases on the left. The course of disease was 40 minutes to 8 days (averaged 1.5 days). There were 7 cases with skateboard injured, 13 cases with stumble injured, 11 cases with falling injured,8 cases with air bed injured. According to Bado classification, 13 cases were type II, 22 cases were type III, 4 cases were type IV.</p><p><b>RESULTS</b>The distal forefinger showed exercise normally in 34 cases at 3 weeks after treatment, and the patients restored normal activities at 6 weeks after treatment. All patients were follow-up from 54 days to 6 months (averaged 67 days. According to Mayo elbow functional evaluation standard,the scoring result was 19.62±1.35 in activity, 45.00 ± 0.00 in pain, 9.87 ± 0.80 in stability, 25.00±0.00 in strength, 99.49 ±1.92 in total. The outcome of all patients was excellent and good evaluation results.</p><p><b>CONCLUSION</b>If the anterior interosseous nerve injury could be identified early and treated timely, patients could gradually restore reasonable function and recover with satisfactory results. Raising understanding of anterior interosseous nerve injury can effectively reduce misdiagnosis.</p>

Tenotomia com ou sem tenodese da cabeça longa do bíceps no reparo artroscópico do manguito rotador / Tenotomy with or without tenodesis of the long head of the biceps for arthroscopic repair of the rotator cuff

OBJETIVO: Comparação dos resultados funcionais nos pacientes submetidos à tenotomia com ou sem tenodese da CLB associada ao reparo da lesão do manguito rotador por visão artroscópica, com seguimento superior a dois anos. MÉTODO: Estudo retrospectivo não randomizado, com nível de evidência III, em que foram revisados os prontuários e realizada reavaliação clínica de 77 pacientes com lesão da cabeça longa do bíceps, sendo que 55 foram submetidos à tenotomia sem tenodese e 22 à tenotomia com a tenodese, com seguimento ambulatorial maior que dois anos. Foram avaliados idade, dominância, lado operado, tamanho das lesões classificadas por Gartsman, arco do movimento pré e pós-operatório, presença ou ausência do sinal do Popeye, dor na corredeira bicipital, avaliação segundo a escala University of California at Los Angeles e Elbow Strength Index. RESULTADOS: O UCLA médio total da amostra foi de 16,92 (8 a 25) para 31,45 (13 a 35) (p < 0,001). Comparando a variação do UCLA pré com o pós-operatório entre os dois grupos, nos pacientes submetidos à tenotomia com a tenodese esta variação foi de 15,95 e nos pacientes submetidos somente à tenotomia a variação foi de 14,62 (p = 0,023). No entanto, não houve significância estatística na comparação entre os grupos quanto à dor na corredeira bicipital, sinal do Popeye e Elbow Strength Index. CONCLUSÃO: O estudo apresentou diferença estatística na variação do UCLA. O grupo em que foi realizada a tenotomia com a tenodese da CLB apresentou melhores resultados funcionais.

OBJECTIVE: To compare the functional results among patients un dergoing tenotomy with or without tenodesis of the long head of the biceps associated with arthroscopic repair of rotator cuff in juries, with a minimum two-year follow-up. METHOD: This was a retrospective non-randomized trial with evidence level III, in which the medical files of 77 patients with lesions of the long head of the biceps were reviewed and clinically reassessed. Among these, 55 patients underwent tenotomy without tenodesis and 22 underwent tenotomy with tenodesis, with outpatient follow-up for at least two years. The age, dominant side, operated side, lesion size using the Gartsman classification, pre and postoperative range of mo tion, presence or absence of the Popeye sign, pain in the bicipital groove and assessments using the University of California at Los Angeles (UCLA) score and the elbow strength index. RESULTS: The mean UCLA score of the sample went from 16.92 (range: 8 to 25) to 31.45 (range: 13 to 35) (p < 0.001). Comparison of the pre and postoperative UCLA scores in the two groups showed that the dif ference in the group with tenotomy and tenodesis was 15.95 and in the group with tenotomy alone, 14.62 (p = 0.023). However, there was no statistical significance in comparing the groups regarding pain in the bicipital groove, Popeye sign or elbow strength index. CONCLUSION: This study showed that the difference in UCLA scores was statistically significant. The group with tenotomy and tenodesis of the long head of the biceps presented better functional results.

Stature estimation of teenagers by limb long bones with computerized radiography / 法医学杂志

OBJECTIVE@#Relative parameters of upper limb bones, tibia and fibula were measured with computed radiography and used to establish the mathematical models for stature estimation of teenagers (from 14 to 18 years old) of Han population in Sichuan Province.@*METHODS@#The upper limb bones, tibia and fibula of 194 subjects were taken computerized radiography on normal position and were measured the lengths between relative landmarks. The body height of each subject was recorded. Linear regression equations for stature estimation between body height and the lengths of upper limb bones, tibia and fibula were established.@*RESULTS@#Forty-two single linear regression equations and 4 multiple regression equations were obtained. The coefficients of correlation(r) were 0.689-0.917 and the standard errors of estimate(SE) were between 3.075 and 5.485 cm. All of the equations were statistically tested and diagnosed with good applicability.@*CONCLUSION@#These equations could be used to estimate the body height of Sichuan Han population aged from 14 to 18. The lengths of the upper limb bones, tibia and fibula measured on the CR films could be useful to stature estimation of the adolescence and the forensic personal identification.

A model for the estimation of personal stature from the length of forearm / Un modelo para la estimación de la estatura personal desde la longitud del antebrazo

Prediction of stature from incomplete and decomposing skeletal remains is vital in establishing the identity of an unknown individual. It has been stated that a variety of factors such as race, gender and nutrition play an important role in determining the height of an individual. Estimation of stature from measurements of various long bones has been achieved with varying degree of accuracy. Those studies resulted in establishing different formulae for the estimation of stature for the respective populations. However, evidence shows that there is a great void in such norms for Sri Lankans. Hence, this study was designed to investigate the relationship and to propose a gender and age specific linear regression models between the ulna length and height of an individual. A total of 258 subjects with an age span of 20-23 years were included in the study. The ulna length was measured using a digital sliding caliper capable of measuring to the nearest 0.01 mm. The height of the individual was measured standing erect, in anatomical position using a standing height measuring instrument. The findings of the study indicated significant differences of the ulna length between the genders. A positive correlation between height and ulna length was observed in both sexes and it was statistically significant. Regression equations for stature estimation were formulated using the ulna lengths for both males and females. The ulna length provides an accurate and reliable means in estimating the height of an individual. The regression formulae proposed in this study will be useful for clinicians, anatomists, archeologists, anthropologists and forensic scientists when such evidence provides the investigator the only opportunity to gauge that aspect of an individual's physical description.

La predicción de la estatura a través de restos de esqueletos incompletos o en descomposición es de vital importancia para determinar la identidad de un individuo desconocido. Se ha dicho que la variedad de factores como raza, sexo y la nutrición juegan un papel importante en la determinación de la altura de un individuo. La estimación de la estatura a partir de mediciones de varios huesos largos se ha logrado con diversos grados de precisión. Los estudios han resultado en el establecimiento de fórmulas diferentes para la estimación de la estatura de las poblaciones específicas. Sin embargo, la evidencia muestra que existe un gran vacío en las normas para ciudadanos de Sri Lanka. Por lo tanto, este estudio fue diseñado para investigar la relación y proponer modelos de regresión lineal específicos en relación al sexo y la edad, entre la longitud de la ulna y la altura de un individuo. Un total de 258 sujetos con un rango de edad de 20-23 años se incluyeron en el estudio. La longitud ulnar se midió con un caliper digital deslizante, precisión de 0,01 mm. La altura del individuo se midió de pie, en posición anatómica con un instrumento de medición. Los resultados del estudio indicaron diferencias significativas de la longitud de la ulna entre los géneros. Se observó una correlación positiva entre la altura y la longitud ulnar en ambos sexos, siendo estadísticamente significativa. Las ecuaciones de regresión para la estimación de la estatura se calcularon usando las longitudes de la ulna tanto en hombres como en mujeres. La longitud de la ulna es un medio preciso y fiable en la estimación de la altura de un individuo. Las fórmulas de regresión propuestas en este estudio serán útil para los médicos, anatomistas, arqueólogos, antropólogos y científicos forenses cuando la evidencia de ese tipo permita al investigador evaluar este aspecto de la descripción física de un individuo.

Ultrasound Diagnosis of Either an Occult or Missed Fracture of an Extremity in Pediatric-Aged Children

OBJECTIVE: To report and assess the usefulness of ultrasound (US) findings for occult fractures of growing bones. MATERIALS AND METHODS: For six years, US scans were performed in children younger than 15 years who were referred with trauma-related local pain and swelling of the extremities. As a routine US examination, the soft tissue, bones, and adjacent joints were examined in the area of discomfort, in addition to the asymptomatic contralateral extremity for comparison. Twenty-five occult fractures in 25 children (age range, five months-15 years; average age, 7.7 years) were confirmed by initial and follow-up radiograms, additional imaging studies, and clinical observation longer than three weeks. RESULTS: The most common site of occult fractures was the elbow (n = 9, 36%), followed by the knee (n = 7, 28%), ischium (n = 4, 16%), distal fibula (n = 3, 12%), proximal femur (n = 1, 4%), and humeral shaft (n = 1, 4%). On the retrograde review of the routine radiographs, 13 out of the 25 cases showed no bone abnormalities except for various soft tissue swelling. For the US findings, cortical discontinuity (direct sign of a fracture) was clearly visualized in 23 cases (92%) and was questionable in two (8%). As auxiliary US findings (indirect signs of a fracture), step-off deformities, tiny avulsed bone fragments, double-line appearance of cortical margins, and diffuse irregularity of the bone surfaces were identified. CONCLUSION: Performing US for soft tissue and bone surfaces with pain and swelling, with or without trauma history in the extremities, is important for diagnosing occult or missed fractures of immature bones in pediatric-aged children.

Extremity fractures in children: a hospital based study in Tehran / 中华创伤杂志(英文版)

<p><b>OBJECTIVE</b>Although long bone fracture in children is not life-threatening, it may cause major disability, loss of working days and severe psychological distress. We conducted this study to determine the pattern of extremity fracture due to trauma in children.</p><p><b>METHODS</b>During one year in six general hospitals in Tehran, trauma patients who were hospitalized for more than 24 hours and sustained injuries within seven days before admission were included in the study. The records of children (< or = 16 years old) hospitalized in six general hospitals in Tehran due to trauma were reviewed prospectively.</p><p><b>RESULTS</b>During the study period, 1 274 children had sustained extremity fractures. Male to female ratio was 3.6/1, with the mean age of (10.3+/-4.2) years. Falls and traffic crashes were the main causes of injuries, with the percentages of 57.3% and 37.1%, respectively. Simple fall (falling on the ground) consisted 60% of patients that sustained fall-related injuries. Pedestrians and bicycle riders comprised most of the cases that were injured due to traffic crashes. Of our cases, 56.8% sustained fractures in the upper extremities and 43.2% in the lower extremities. Forearm was the most common fracture site (34.1%). Comparing our results in preschool and school-age children, falls were the main cause of injuries in both groups, but fractures of lower extremities were significantly more common in preschool children.</p><p><b>CONCLUSIONS</b>Improvement of physical condition of sidewalks and crossings in roads will be necessary for prevention of injuries. More attention to safety of home environment should be paid for control of preschools'injury at home. Education of children and adults is necessary to reduce injuries resulting from road traffic crashes.</p>

Condrodiastasis y transporte óseo simultáneos para formación de hueso único como alternativa de reconstrucción por trauma severo de antebrazo en niños: reporte de un caso / Chondrodiatasis and bone simultaneous transport for formation of one-bone as reconstruction alternative for severe trauma of forearm in children: report of a case

Los defectos post traumáticos severos de miembros superiores en niños son infrecuentes y cuando ocurren involucran mecanismos de alta energía. Se realiza estudio descriptivo, sobre preescolar masculino, 7 años, indígena, quien presentó trauma severo en antebrazo derecho con fractura abierta III b y pérdida de 2/3 distales del cúbito y 2/3 proximales del radio con preservación de placa de crecimiento de éste último. Planteamos como objetivo preservar el miembro, mantener longitud axial y su máxima función realizando la reconstrucción de antebrazo por condrodiastasis del radio y transporte óseo del cúbito simultáneamente utilizando fijador externo llizarov. Logramos alargamiento de 2,5 cms. en radio y 3 cms. en cubito con la consolidación de ambos para la formación de un hueso único radio-cubito, conservando los movimientos intrínsecos de la mano, el crecimiento epifisiario, la flexo-extensión de codo y muñeca con abolición de pronosupinación. Concluimos que la cirugía reconstructiva con formación de hueso único mediante técnicas combinadas de alargamiento óseo es una opción terapéutica eficaz para el manejo del trauma complejo del antebrazo con pérdida de hueso en niños.

Severe post-traumatic defects in the upper limbs of children are rather rare and when they happen they involve mechanisms of high energy. Material and methods descriptive and prospective study about indigenous masculine, 7 years, who present severe trauma in right forearm with open fracture III b and loss of 2/3 distal of the ulna and 2/3 proximal of the radio with preservation of plate of growth. We outline as objective to preserve the limb, to maintain axial longitude and their maximun function carrying out the forearm reconstruction simultaneously for chondrodiatasis of the radio and bone transport of the ulna using external fixation llizarov. We achieved lengthening of 2,5 cm. in radio and 3 cm. in ulna with thinks about the consolidation of both for the formation of a one-bone radio-ulna, conserving the intrinsic movements of the hand, the epiphyseal growth, the elbow flexo-extension and wrist with pronosupination abolition. WE concluded that the reconstructive surgery with formation of one-bone mediating combined techniques of bone lengthening is a therapeutic effective option for the hadling of the complex trauma of the forearm with bone loss in children.

Influência das propriedades antiinflamatórias do ultra-som terapêutico no tratamento de lesões musculares / Influence of anti-inflammatory properties of ultrasound therapy in muscle injuries treatment

Este estudo investigou possíveis efeitos da aplicação da técnica do Spiral Taping na força dos dedos das mãos de 15 homens e 11 mulheres. Foram feitos três testes em estudo duplo-cego, em ambos os antebraços: com tira de esparadrapo afixado no antebraço aplicado no sentido anti-horário, no sentido horário e sem esparadrapo. Os sujeitos prensavam uma célula de carga com os dedos polegar e indicador, e o valor da força era registrado em um computador. Em seguida, realizou-se o O’RING test (OT) para detectar o sentido da espiral dominante do indivíduo, se direito (OD) ou esquerdo (OE). Os valores de força foram comparados, considerando os testes e os resultados do OT, através de ANOVA. Comparando os testes, não houve diferença significativa entre as forças para o membro direito (p = 0,174), nem para o esquerdo (p = 0,556). Quando comparadas às forças dos grupos OD e OE, não foi observada diferença significativa para o antebraço direito (p = 0,09). Quanto ao esquerdo, indivíduos com OE apresentaram maior força do que os OD (p = 0,04). Não houve alteração significativa de força entre as aplicações com e sem esparadrapo. Entretanto, sugere-se que através de um mecanismo desconhecido, existam variações na força máxima produzida por pessoas de OD e OE.

This study investigated the possible effects of Spiral Taping technique on hand fingers strength of 15 men and 11 women. Three double-blind tests were performed on both forearms: with tape attached to the forearm in the clockwise, and counterclockwise direction, and with no tape applied. The subjects pressed a load cell with the index and the thumb fingers, and the force was registered in a computer. The o´ring test (OT) was then performed to detect the orientation of the dominant spiral in the individual, right (RT) or left (LT) hand. The strength was measured and thus compared, considering the tests and the OT results, through ANOVA. When comparing the tests, no statistical difference was detected in the strength of right (p = 0.174) or left (p = 0.556) limb. The comparison between the strength of groups RO and LO showed no statistical difference for the right forearm (p = 0.09). Regarding the left one, individuals with LO showed higher strength than those with OD (p = 0.04). No statistical difference was found in strength when comparing the tests with and without tape. However, it suggested that through an unknown mechanism, there are variations on maximal strength produced by individuals with RO and LO.