Luxación congénita de cabeza radial: reporte de dos casos / Congenital radial Head dislocation: report of two cases

Resumen: Introducción: La luxación congénita de cabeza radial es un padecimiento que se ha descrito en contados casos en la literatura internacional, siendo la luxación anterior y lateral las formas de presentación menos frecuentes con 15% de los casos cada una y la luxación posterior la más frecuente con 70% del total de los casos reportados. Sin embargo, esta patología es considerada la patología congénita más frecuente del codo en el niño. Se presenta el caso de un paciente con luxación congénita de codo variedad anterior y otro caso con luxación variedad lateral, ambos diagnosticados a temprana edad, en los que se decidió realizar un manejo conservador y un seguimiento anual. Asimismo, se hizo una revisión bibliográfica del tema. Discusión: La luxación congénita de codo tiene por lo general una evolución benigna, siendo indolora y poco limitante para el paciente, por lo que puede ser manejada de manera conservadora. El dolor y la limitación de movimientos son indicativos de un tratamiento quirúrgico; sin embargo, no son ampliamente aceptados debido a las complicaciones y resultados deficientes que presentan.

Abstract: Introduction: Congenital dislocation of the Radial head is a condition that has been described in a few cases in the international literature, the anterior and lateral dislocation were the less frequent forms of presentation with 15% of cases, each, and the posterior dislocation the most frequent with 70% of the total cases reported. However, this pathology is considered the most frequent congenital pathology of the elbow in children. The present study describes the case of a patient with congenital dislocation of elbow anterior variety and another case with dislocation lateral variety, both diagnosed at an early age, in which it has been decided for conservative management and an annual follow-up. A bibliographic review of the subject is also carried out. Discussion: The congenital elbow dislocation usually has a benign evolution, being painless and not very limiting for the patient, so it can be managed conservatively. Pain and limited movement are indicative of surgical treatment. There are multiple surgical treatments for this entity, however they are not widely accepted due to the complications and poor results presented by them.

Síndrome del tunel radial. Hallazgos y tratamiento en 17 pacientes / Radial tunnel syndrome. Findings and treatment in 17 patients

Introducción: El síndrome del túnel radial es un cuadro que se debe al atrapamiento intermitente del nervio interóseo posterior entre la masa superficial y profunda del músculo supinador corto y estructuras adyacentes, como vasos y fascias. El propósito de este trabajo fue identificar las estructuras anatómicas que producían la eventual compresión, establecer y comunicar las diferencias en cuanto a la percepción subjetiva del dolor antes de la liberación del nervio interóseo posterior en el túnel radial y después de ella. Materiales y Métodos: Entre 2009 y 2014, 17 pacientes fueron sometidos a cirugía mediante liberación del nervio interóseo posterior. Se utilizó la vía de abordaje entre el primer radial externo y el supinador largo. Se evaluó a los pacientes mediante la escala analógica visual para intensidad del dolor antes de la cirugía y a las 6 semanas, y según los criterios funcionales de Roles y Maudsley. Resultados: Las causas de compresión del nervio interóseo posterior fueron: banda fibrosa (arcada de Frõhse) (7 casos), vasos recurrentes (4 casos), compresión por la masa del fascículo superficial del supinador corto (2 casos) y compresión por tendón del segundo radial externo (4 casos). Los resultados fueron excelentes (4 pacientes), buenos (10 pacientes) y regulares (3 pacientes). Los pacientes atendidos a través de la Aseguradora de Riesgos de Trabajo obtuvieron peores resultados que aquellos fuera de este sistema. Conclusiones: El síndrome del túnel radial es una patología que debe ser tenida en cuenta ante un cuadro de epicondilalgia lateral resistente al tratamiento; tiene una incidencia marcada en pacientes con conflicto laboral, lo que puede sesgar el resultado terapéutico final. Nivel de evidencia: IV.

Introduction: Radial tunnel syndrome is a condition secondary to the intermittent entrapment of the posterior interosseous nerve between superficial and deep mass of short supinator adjacent structures, such as vessels and fascias. The purpose of this study was to identify the anatomical structures that produce the eventual compression, to establish and communicate the differences in the subjective pain perception before and after the release of the posterior interosseous nerve in the radial tunnel. Methods: Between 2009 and 2014, 17 patients underwent surgical treatment by posterior interosseous nerve release. We used the approach between the first external radial and brachioradialis. Patients were assessed by visual analogue scale for pain intensity before surgery and at week 6, and according to the Roles and Maudsley functional criteria. Results: The causes of posterior interosseous nerve compression were fibrous band of short supinator (arcade of Frohse) (7 cases), recurrent vessels (4 cases), compression by the mass of the superficial portion of the short supinator muscle (2 cases) and secondary compression by extensor carpi radialis brevis tendon (4 cases). Results were excellent (4 patients), good (10 patients) and fair (3 patients). Patients treated through the Labor Risk Insurance had worse outcomes than those who were not covered by this system. Conclusions: Radial tunnel syndrome is a condition that must be taken into account when there is refractory lateral epicondylalgia. This disease has a marked effect in patients with labor conflict, which may bias the outcome of treatment. Level of evidence: IV.

Impacto do internamento em unidade de cuidados intensivos na amplitude de movimento de pacientes graves: estudo piloto / Impact of hospitalization in an intensive care unit on range of motion of critically ill patients: a pilot study

Objetivo: Aferir a amplitude de movimento articular de pacientes graves durante o internamento numa unidade de cuidados intensivos. Métodos: Estudo prospectivo e longitudinal, realizado em uma unidade de cuidados intensivos de um hospital público da cidade de Salvador (BA), no período de setembro a novembro de 2010. A principal variável avaliada foi a amplitude de movimento articular passiva, por meio da goniometria dos cotovelos, joelhos e tornozelos, no momento da admissão e na alta. Todos os pacientes internados no período foram incluídos, sendo excluídos aqueles com tempo de internamento <72 horas e com reduções da amplitude de movimento articular na admissão. Resultados: A amostra foi composta por 22 indivíduos, com idade média de 53,5±17,6 anos, tempo de internamento na unidade de cuidados intensivos de 13,0±6,0 e de ventilação mecânica de 12,0±6,3 dias. O APACHE II foi 28,5±7,3, sendo que a maioria dos pacientes era independente funcional previamente ao internamento, com índice de Barthel prévio de 88,8±19. As perdas de amplitude de movimento articular foram 11,1±2,1°; 11,0±2,2°; 8,4±1,7°; 9,2±1,6°; 5,8±0,9° e 5,1±1,0°; para cotovelos, joelhos e tornozelos, respectivamente do lado direito e esquerdo (p<0,001). Conclusão: Houve uma tendência de decréscimo nas amplitudes de movimento de grandes articulações, como tornozelo, joelho e cotovelo, durante o internamento em unidade de cuidados intensivos. .

Objective: To evaluate the joint range of motion of critically ill patients during hospitalization in the intensive care unit. Methods: This work was a prospective longitudinal study conducted in a critical care unit of a public hospital in the city of Salvador (BA) from September to November 2010. The main variable evaluated was the passive joint range of motion. A goniometer was used to measure the elbows, knees and ankles at the time of admission and at discharge. All patients admitted in the period were included other than patients with length of stay <72 hours and patients with reduced joint range of motion on admission. Results: The sample consisted of 22 subjects with a mean age of 53.5±17.6 years, duration of stay in the intensive care unit of 13.0±6.0 days and time on mechanical ventilation of 12.0±6.3 days. The APACHE II score was 28.5±7.3, and the majority of patients had functional independence at admission with a prior Barthel index of 88.8±19. The losses of joint range of motion were 11.1±2.1°, 11.0±2.2°, 8.4±1.7°, 9.2±1.6°, 5.8±0.9° and 5.1±1.0°, for the right and left elbows, knees and ankles, respectively (p<0.001). Conclusion: There was a tendency towards decreased range of motion of large joints such as the ankle, knee and elbow during hospitalization in the intensive care unit. .

Treatment of Medial Epicondyle Fracture without Associated Elbow Dislocation in Older Children and Adolescents

PURPOSE: Displaced medial humeral epicondyle fractures with or without elbow dislocation have been treated with open reduction and fixation using K-wires or screws. The purpose of this study is to evaluate the clinical and radiological outcomes of surgical treatments of medial humeral epicondyle fracture without elbow dislocation according to the fixation methods. MATERIALS AND METHODS: Thirty-one patients who had undergone open reduction and fixation of the displaced medial humeral epicondyle fracture without elbow dislocation were included. Group I consisted of 21 patients who underwent fixation with K-wires, and Group II comprised 10 patients who underwent fixation with cannulated screws. Immediate postoperative, final follow-up and normal anteroposterior radiographs were compared and the clinical outcome was assessed using the final Japanese Orthopaedic Association (JOA) elbow assessment score. RESULTS: On the immediate postoperative radiographs, the distal humeral width in Group II was larger than that in Group I. On the final follow-up radiographs, the epicondylar position in Group I was lower than that in Group II. There was no significant difference in the distal humeral width, epicondylar position and joint space tilt between the immediate postoperative, final follow-up radiographs and the normal side within each group. There was no significant difference in the final JOA score between groups. CONCLUSION: Open reduction followed by K-wire fixation or screw fixation of the displaced medial humeral epicondyle fracture without elbow dislocation in older children and adolescents resulted in improved radiologic outcome and good elbow function in spite of diverse radiologic deformities.

Consideraciones anátomo-clínicas sobre el nervio radial en el codo / Anatomical and clinical considerations about the radial nerve in the elbow

El recorrido del nervio radial a través del codo constituye, para este elemento nervioso, un camino con riesgo de lesiones intrínsecas o extrínsecas. Cambios de la morfología de las estructuras osteomusculares que constituyen el desfiladero del nervio radial, tanto patológicos como traumáticos, pueden determinar el atrapamiento y compresión del mismo, determinando el daño del nervio y/o la inflamación localizada a nivel de las estructuras circundantes. Mediante la disección de 30 preparados, formolizados al 10 por ciento, y el análisis subsecuente de la disposición de las estructuras musculares e inserción de las mismas, se determinaron los posibles puntos de riesgo anatómico que pudiesen alterar al nervio radial o a sus ramos en la canal bicipital lateral o en su ingreso y distribución en el parte proximal del antebrazo (relación con el músculo supinador y los músculos extensores radial largo y corto). Definimos 4 zonas de posible atrapamiento y compresión del nervio radial y sus ramos: 1. Septo intermuscular lateral. 2. Músculo extensor radial corto. 3. Músculo supinator, a nivel de la Arcada de Frohse. 4. Músculo supinator, a la salida de la masa muscular, en el dorso del antebrazo. La compresión del nervio radial a nivel del codo es una de las neuropatías del miembro superior, más frecuentes. El objetivo de este trabajo fue analizar las implicancias anatómicas del recorrido del nervio radial en su pasaje desde el brazo al antebrazo, especialmente las relaciones con las estructuras osteomusculares, cuyas alteraciones pueden ser las responsables de patologías compresivas del nervio radial que puedan llevar a dolor, parestesias, con o sin pérdida sensorial y/o impotencia funcional.

The radial nerve route through elbow constitutes, for this nervous element, a way with risk of intrinsic or extrinsic injuries. Morphologic changes of the structures that constitute the denle of the radial nerve, pathological as much traumatic, can determine it atrapment and compression, determining the damage of the nerve and/or the inflammation located at level of the surrounding structures. 30 forearm-elbow, preserved with formol to 10 percent, were dissected, and the subsequent analysis of the disposition of the muscular structures and insertion of the same ones, will determine the possible points of anatomical risk that they will affect the radial nerve or its branches in the brachial track or in the proximal forearm (relation with the supinator muscle and extensor carpi radialis longus and brevis muscles).We defined 4 zones of atrapment and compression of the radial nerve and its branches: 1. External intermuscular setum; 2. Extensor carpi radialis brevis muscle; 3. Supinator muscle , atlevelof theFrohse's Arch;4. Supinator muscle, when coming out of the muscular mass, in the back of the forearm. The compression of the radial nerve at level of the elbow is one of the frequent neuropathies of the superior member. It is for that reason that the objective of this work consists of analyzing the anatomical aspects of the route of the radial nerve in its passage from the arm to the forearm, specially relations with morphological structures, whose alterations determines pathologies of the radial nerve which can take to pain, parestesies, with lost sensorial and functional impotence.

Doença de depósito de hidroxiapatita: aspectos por imagem e comportamento biológico / Hydroxyapatite crystal deposition disease: imaging aspects and biological behavior

OBJETIVO: Demonstrar, através dos métodos de imagem (raios-X, tomografia computadorizada (TC), ressonância magnética (RM) e ultra-sonografia (US)), as fases da doença de depósito de cristais de hidroxiapatita nas articulações, principalmente no ombro, apresentando da fase silenciosa até a migração intra-óssea das calcificações e o controle radiológico com remissão completa após tratamento fisioterápico. MATERIAL E MÉTODO: Foram avaliadas 27 articulações (25 ombros, um quadril e um cotovelo) de pacientes seguidos com controle radiográfico, sendo os extremamente sintomáticos e os refratários ao tratamento encaminhados a RM ou US. RESULTADOS: Com o tratamento houve remissão completa das calcificações em 15 articulações - 14 no ombro e uma no cotovelo. Em duas articulações houve migração da calcificação para o interior do osso, em uma para a bursa subdeltóidea, em uma para a bainha do cabo longo do bíceps, em uma para o recesso subcoracóide e em uma para o interior do músculo infraespinal. Em dois casos a RM e a TC demonstraram o alto grau de processo inflamatório desencadeado pela doença. CONCLUSAO: A doença de depósito de cristais de hidroxiapatita acomete várias articulações, podendo ser assintomática até extremamente sintomática. Os métodos de imagem demonstram todas as fases, inclusive a fase migratória. Geralmente, a radiografia é suficiente para o diagnóstico e seguimento. A RM e a TC possibilitam o diagnóstico mais acurado da fase ativa da doença. Nosso trabalho demonstrou remissão em 55 por cento dos casos com tratamento fisioterápico - iontoforese.

Ipsilateral dislocation of the shoulder and elbow

Ipsilateral dislocation of shoulder and elbow joints is a rare injury. Only 2 such cases have been reported in the English literature. We report a case of a 35-year-old man involved in a road traffic accident under the influence of alcohol. He sustained posterior left elbow and anterior left shoulder dislocation with minimally displaced greater tuberosity fracture. He also had partial median nerve palsy. Under intramuscular pethidine and intravenous diazepam, close reduction of elbow followed by shoulder was carried out. At 2 months, median nerve function returned to normal. At 3 months, almost full elbow and shoulder joint movement returned. Although rare and complex, this ipsilateral injury can be treated conservatively

Tumoral calcinosis

Two cases of Tumoral Calcinosis are reported. It is a rare condition, hence the key to diagnosis lies in increased awareness of such lesions amongst orthopaedic surgeons and pathologists. Precise histopathological diagnosis is crucial, as the management of such a tumor is successful if appropriately treated. Advances in radiology and histology have helped immensely in the diagnosis of this condition. Complete excision of the mass has conferred very good results and is recommended

Evidence for a new ad sysdrome: report of a large iranin sibship with severe multiple synostosis

An investigation was carried out on a young unrelated couple, both 29 years old, with two boys and three girls, 3 months to 8 years old. One boy and the mother were healthy, the other four children and the father were affected. The family, originally from the district of Nour, in northern Iran, near the Caspian Sea, was first counseled at the Genetic Clinic in Tehran in 1984. Several trips were made to the location in a period of five years, to examine this large family. The major anomalies in this family were brachyphalangia, elbow joint aplasia [humero - radial synostosis, 110 to 140°C], carpal/tarsal synostosis and talus/calcaneus fusion. All affected individuals present a fixation of the feet in supination position and because of partial synostosis [physis] of calcaneus and talus, walked on lateral side with the external cant of the foot. All deformities were studied by clinical examinations and radiological confirmations, on each affected individual

Artrogripose múltipla congênita: revisäo de 56 pacientes / Arthrogryposis multiplex congenita: a review of 56 patients

Foram revistos 56 pacientes portadores de artrogripose múltipla congênita em tratamento no Grupo de Doenças Neuromusculares do Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de Sao Paulo - Pavilhao "Fernandinho Simonsen"- no período de 1983 a 1994. Os autores mostram as deformidades presentes nesses pacientes e o tratamento instituído nessas condiçoes.

Artoplastia del codo / Elbow artroplasty

Fueron revisados 12 casos con artroplastia de codo, durante los años 1977 y 1989 ambos inclusive, en el Hospital San Juan de Dios, Caracas. Después de una descripción anatómica de la articulación del codo y de la etiología, estudiamos los diferentes métodos empleados para la artroplastia. Presentamos 7 pacientes con fracturas de codo (58%), 4 con A.R.J. (38%), y 1 caso con Osteomielitis (8%). Se obtuvieron excelentes resultados en dos casos y buenos resultados en tres y regulares en cuatro. En los nueve se utilizó Fascia Lata

Reseccion artroplastia de codo / Elbow resection arthroplasty

Las rigideces del codo, con la consiguiente limitacion para la flexoextension, producen una incapacidad funcional a menudo importante. Las secuelas de traumatismos, de infecciones y procesos inflamatorios, figuran dentro de las causas mas frecuentes de rigidez. Entre los procedimientos operatorios utilizados, las artroplastias en sus distintas variedades pueden estar indicadas. La reseccion artroplastia de codo o artroplastia sin interposicion, ha sido el procedimiento de nuestra eleccion en las situaciones antes mencionadas (resumen truncado)