Foot drop - an uncommon presentation of FOLFOX toxicity

A quimioterapia com FOLFOX (oxaliplatina, leucovorina e 5-fluorouracilo) é frequentemente utilizada em doentes com cancro colorretal. Os sais de platina são conhecidos por serem uma classe de quimioterápicos que comumente induzem neurotoxicidade periférica. Na toxicidade induzida pela oxaliplatina, os sintomas sensitivos são os mais frequentes. Neste artigo, apresentamos dois casos clínicos de pacientes com adenocarcinoma de cólon, ambos submetidos à quimioterapia com FOLFOX4, e que desenvolveram neurotoxicidade incomum, apresentando pé pendente após o terceiro ciclo de tratamento. Esta manifestação clínica pode ser explicada por dano axonal nos neurônios motores periféricos do nervo peroneal comum (fibular), que fornece inervação motora aos músculos do pé. A paralisia do nervo fibular causa fraqueza súbita nos músculos do pé, que parece ser temporária. Ambos os doentes recuperaram completamente do evento sem necessidade de ajustes no tratamento, nem introdução de medicamentos diferentes. A apresentação de pé pendente como toxicidade da quimioterapia ainda é pouco compreendida. Os casos relatados mostram o pé pendente como uma manifestação grave e incomum de neuropatia induzida por FOLFOX, que pode ser transitória, e não requer necessariamente intervenção específica.

Chemotherapy based on FOLFOX (oxaliplatin, leucovorin, and 5-fluorouracil) regimen is frequently used in colorectal cancer patients. Oxaliplatin and other platinum agents are known to be a class of chemotherapy drugs that commonly induce peripheral neurotoxicity. The most frequent oxaliplatin related neurotoxicity is sensitive symptoms. Here, we present two cases of patients with colon adenocarcinoma, both undergoing chemotherapy with FOLFOX4, who developed uncommon neurotoxicity, presenting with foot drop after the third treatment cycle. Foot drop may be explained by axonal damage of peripheral motor neurons of the common peroneal (fibular) nerve, which provides motor innervation to the foot muscles. Peroneal nerve palsy causes sudden weakness in the muscles of the foot that seems to be temporary. Both patients completely recovered from the event. There was no need for treatment adjustments, neither introduction of different drugs. Foot drop as chemotherapy toxicity is still poorly understood. The reported cases show foot drop as a severe and uncommon manifestation of FOLFOX-induced neuropathy, that might be transitory, and does not necessarily requires specific intervention.

Características morfológicas y morfométricas del músculo aductor del hállux y sus ramos motores / Morphological and morphometric characteristics of the hallux adductor muscle and its motor branches

El hállux se encuentra en aducción en relación al eje del pie y para mantener esta posición requiere de una adecuada alineación ósea, la que está determinada principalmente por la actividad muscular. Una de las estructuras involucradas en esta función es el músculo aductor del hállux, el cual puede producir hállux valgus o hállux rígido cuando ocurre un desbalance en su actividad normal. A pesar de la importancia de este músculo, existen pocos estudios de su complejo neuromuscular. El objetivo de esta investigación fue describir las características morfológicas y morfométricas del músculo aductor del hállux y sus ramos motores en 30 miembros inferiores. Se disecó la planta del pie hasta alcanzar el plano del músculo aductor del hállux y sus ramos motores. La longitud media de la cabeza oblicua del músculo aductor del hállux fue de 78,16 mm (±13,35) con un ancho máximo promedio de 20,55 mm (±2,59) y un tendón de 25,87 mm (±7,97) de longitud. Respecto a las mismas medidas en la cabeza transversa, estas fueron 39,55 (±8,26), 15,04 (±3,52) y 18,51 (±10,04), respectivamente. La inervación de ambas cabezas del músculo aductor del hállux provenía del ramo profundo del nervio plantar lateral. En la mayoría de las muestras dicho nervio emitió un ramo para la cabeza oblicua y uno para la cabeza transversa. La cabeza oblicua presentaba uno o dos puntos motores, localizados generalmente en su tercio medio. La cabeza transversa presentaba sólo un punto motor localizado frecuentemente en su tercio lateral. El conocimiento de las características morfológicas y morfométricas del músculo aductor del hállux y de sus ramos motores son clínicamente significativos, puesto que permiten realizar una aproximación de la localización del punto motor en los procedimientos electromiográficos.

The hallux is adducted in relation to the axis of the foot and to maintain this position requires adequate bone alignment, which is determined mainly by muscle activity. One of the structures that is involved in this function is the adductor muscle of the hallux, which can produce hallux valgus or rigid hallux when an imbalance occurs in its normal activity. Despite the importance of this muscle, there are few studies of its neuromuscular complex. The objective of this study was to describe the morphological and morphometric characteristics of the adductor muscle of the hallux and its motor branches in 30 lower limbs. The sole of the foot was dissected until it reached the plane of the muscle and its motor branches. The average length of the oblique head of the adductor muscle of the hallux was 78.16 mm (± 13.35), with an average maximum width of 20.55 mm (± 2.59) and a tendon of 25.87 mm (± 7, 97) in length. Regarding the same measurements of the transverse head were 39.55 (± 8.26), 15.04 (± 3.52) and 18.51 (± 10.04), respectively. The innervation of both heads came from the deep branch of the lateral plantar nerve. In most of the samples, said nerve emitted a bouquet for the oblique head and one for the transverse head. The oblique head had one or two motor points, generally located in its middle third. The transverse head had only one motor point that was usually in its lateral third. The knowledge of the morphological and morphometric characteristics of the adductor muscle of the hallux and its motor branches are clinically significant, since they allow an approximation of the location of the motor point in electromyographic procedures.

Tarsal tunnel syndrome: a still challenge condition / Síndrome do túnel do tarso: uma condição ainda desafiadora

Tarsal tunnel syndrome is a rare, under diagnosed and often confused neuropathy with other clinical entities. There is a lack of population studies on this disease. Herein, we performed a non-systematic review of articles between January 1992 and February 2018. Although with a less complex anatomy comparing to the carpal tunnel, the tarsal tunnel is source of pain and some other conditions. Treatment involves conservative measures such as analgesics and physical therapy rehabilitation or surgical procedures in case of conservative treatment failure. Randomized control studies are lack and mandatory for uncover the best modality of treatment for this condition.

A Síndrome do túnel do tarso é uma rara e subdiagnosticada neuropatia geralmente confundida com outras entidades clínicas. Há falta de estudos populacionais sobre a doença. Assim sendo, realizamos uma revisão da literatura de artigos entre Janeiro de 1992 e fevereiro de 2018. Apesar de possuir uma anatomia de menor complexidade comparada ao túnel do carpo, o túnel do tarso é origem de dor e algumas outras condições. O tratamento envolve medidas conservadoras como analgésicos e terapia de reabilitação ou procedimentos cirúrgicos, em caso de falha do tratamento conservador. Estudos randomizados são escassos e necessários para descoberta da melhor modalidade de tratamento desta condição.

Primeros ramos del nervio plantar lateral: revisión anátomo - clínica / First branches of the lateral plantar nerve: anatomo- clinical review

El nervio plantar lateral es un ramo terminal del nervio tibial, inerva la mayor parte de la musculatura del pie, y otorga inervación sensitiva a parte de la planta del pie. En esta revisión abordamos diversos aspectos del nervio plantar lateral desde su origen hasta su división, dando énfasis a aquellos ramos que por su disposición anatómica han sido señalados como causantes de síndrome de compresión, y a variaciones anatómicas importantes que deben ser conocidas cuando se aborda la región plantar. Numerosos estudios se han realizado para describir el trayecto y relaciones de los primeros ramos del nervio plantar lateral. Los ramos emitidos directamente por el nervio plantar lateral están destinados a los músculos abductor del dedo mínimo y cuadrado plantar, además de un ramo cutáneo lateral y ramos vasculares para los vasos plantares laterales y para el ligamento plantar largo. Como variación anatómica es posible encontrar ramos calcáneos mediales, tronco común de ramos calcáneo medial y para el músculo abductor del dedo mínimo, 2 ó 3 ramos para el músculo cuadrado plantar, tronco común para los músculos abductor del dedo mínimo y cuadrado plantar, ramo para el músculo flexor corto del dedo mínimo y ramo "anastomótico" para el nervio plantar medial. Cada vez más, es más necesario tener conocimientos acabados de la anatomía del pie, particularmente en aquellos procedimientos quirúrgicos que requieren precisión, con abordajes menos radicales y buenos resultados.

The lateral plantar nerve is a terminal branch of the tibial nerve, which innervates most of the foot's musculature, and also provides sensory innervation to the sole of the foot. In this present review we address various aspects of the lateral plantar nerve from its origin to its division, emphasizing those branches that, as a result of their anatomical disposition have been identified as causing compression syndrome. Furthermore, thorough knowledge and experience of anatomical variations are essential in procedures of the plantar region. Numerous studies have been carried out to accurately describe the path and relationship of the first branches of the lateral plantar nerve. Branches originating directly from the lateral plantar nerve are for the abductor digiti minimi and quadratus plantae muscles, in addition to a lateral cutaneous branch.Among these anatomical variations it is possible to find medial calcaneal branches, common trunk for medial calcaneal branches and abductor digiti minimi muscle, vascular branches for the plantar vessels, 2 or 3 branches for the quadrate plantae muscle, common trunk for the abductor digiti minimi muscle an quadratus plantae muscle,branch for the flexor digiti minimi brevis muscle, "anastomotic" branch for the medial plantar nerve and branch for long plantar ligament. Updated and absolute knowledge of the anatomy of the foot are necessary, particularly during those surgical procedures that require precision, with fewer invasive approaches and positive results.

Sensory disturbance and polyneuropathy in rheumatoid arthritis patients with foot deformity / Perturbações sensitivas e polineuropatia em pacientes com artrite reumatoide com deformidade do pé

Abstract Introduction Our aim in this study was to present the results of sensory evaluation tests and electrophysiological evaluations in rheumatoid arthritis (RA) patients with foot deformity and to determine their relation with general health status and lower extremity functionality. Materials and methods Fifty-one patients with RA diagnosis and foot deformity were included in the study. Demographic and disease characteristics of the patients were recorded, and a detailed neurological examination was performed. Superficial sensation, pain, heat, vibration, and two-point discrimination sensation were evaluated in each foot, and their sum was used to determine the sensory deficits index (SDI) of 0–10. The presence of polyneuropathy was evaluated with electrophysiological methods. The Health Assessment Questionnaire and mobility and walking subscales of the Arthritis Impact Measurement Scales-2 were used to assess general health status and lower extremity functionality, respectively. According to the sensory examination and electromyography results, patients were compared in terms of their general health status and lower extremity functional status. Results Sensory disturbance was detected in 39 patients (74%) during the examination; however, 27 patients (52.9%) had polyneuropathy determined electrophysiologically. In patients with sensory deficits, statistically significant deterioration was detected in general health and foot functionality, including mobility and walking, when compared to patients with a normal sensory evaluation. Conclusions Even in the presence of normal electrophysiological tests, sensory dysfunction alone seems to be associated with severe disability in general health status and foot functionality when compared to patients with a normal sensory examination.

Resumo Introdução O objetivo deste estudo foi apresentar os resultados dos testes de avaliação sensitiva e do exame eletrofisiológico em pacientes com artrite reumatoide (AR) com deformidade do pé e determinar a sua relação com o estado geral de saúde e o aspecto funcional dos membros inferiores. Materiais e métodos Foram incluídos no estudo 51 pacientes com diagnóstico de AR e deformidade do pé. Foram registradas as características demográficas e da doença de cada indivíduo e foi feito um exame neurológico detalhado. Foi avaliada a sensibilidade superficial, dolorosa, térmica e vibratória e aplicado o teste de discriminação de dois pontos em cada um dos pés. A soma dos escores foi usada para determinar o índice de déficits sensitivos (IDS) de 0‐10. A presença de polineuropatia foi avaliada com métodos eletrofisiológicos. Foram usados o Health Assessment Questionnaire e as subescalas mobilidade e deambulação da Arthritis Impact Measurement Scales‐2 para avaliar o estado geral de saúde e o aspecto funcional de membros inferiores, respectivamente. De acordo com os resultados dos exames de eletromiografia e de sensibilidade, os pacientes foram comparados em relação ao seu estado geral de saúde e estado funcional de membros inferiores. Resultados Foram detectados distúrbios sensitivos em 39 pacientes (74%) durante o exame; contudo, 27 (52,9%) tinham polineuropatia determinada eletrofisiologicamente. Em pacientes com déficits sensitivos, foi detectada deterioração estatisticamente significativa no estado geral de saúde e no aspecto funcional do pé, inclusive na mobilidade e deambulação, quando comparados com os pacientes com uma avaliação sensitiva normal. Conclusão Mesmo na presença de testes eletrofisiológicos normais, a disfunção sensitiva isolada parece estar associada a incapacidade grave no estado geral de saúde e ao aspecto funcional do pé em comparação com pacientes com um exame sensitivo normal.

Características planimétricas y estereológicas de los nervios palmar lateral y medial en manos de equinos con y sin síndrome navicular / Planimetric and stereological characteristics of lateral and medial palmar nerves in hands of equine with and without navicular syndrome

El Síndrome Navicular (SN) es una de las patologías claudicógenas mas frecuentes en la práctica clínica equina. Se ha descrito, cierta susceptibilidad individual respecto a ésta presentación clínica, es decir, algunos equinos con SN claudican y otros, con similares hallazgos radiográficos en mano no lo hacen sugiriendo que existen diferencias cuantitativas, entre equinos con y sin SN, en las características de las fibras nerviosas de los nervios periféricos que inervan la mano. El objetivo del estudio fue describir las características morfológicas cuantitativas de los nervios palmar lateral y medial en equinos con SN. Se obtuvo manos mediante un muestreo dirigido y diagnosticadas por inspección visual y evaluación radiográfica. Se conformó dos grupos: "No afectadas" (n= 6) y "Síndrome Navicular" (n= 8). Para determinar diferencias cuantitativos entre ambos grupos se realizó: i) Estudio 1, evaluó las características morfológicas, planimétricas y estereológicas de los nervios palmar lateral y medial, ii) Estudio 2: evaluó la cantidad de axones mielinizados y no mielinizados. En ambos estudios, el análisis de los datos morfológicos, estereológicos y planimétricos, en general, no detectó diferencias significativas entre grupos. En conclusión, los resultados obtenidos en el estudio no entregan evidencia morfológica respecto a diferencias entre nervios palmares entre equinos con y sin SN.

Navicular Syndrome (NS) is one of the most frequent claudicogen pathologies in the equine clinical practice. Certain individual susceptibility has been described in this clinical presentation, that is, some horses with SN halt, while others with similar radiographic findings in hand do not, suggesting that there are quantitative differences, between horses with and without clinical presentation of SN, on the characteristics of the nerve fibers of the peripheral nerves of the hand. The aim of this study was to describe the morphologic quantitative characteristics of the lateral and medial palmar in horses with SN nerves. Hands were obtained by sampling directed and diagnosed by visual inspection and radiographic evaluation. Two groups were formed: "Not affected" (n= 6) and "Navicular Syndrome" (n = 8). To determine quantitative differences between two groups we performed: i) Study 1: evaluated the morphological, planimetric and stereological lateral and medial palmar nerves, ii) Study 2: evaluated the number of unmyelinated and myelinated axons. In both studies, analysis of stereological, morphological and planimetric data generally detected no significant differences between groups. In conclusion, the results of the study do not provide morphological evidence for differences between palmar nerves between horses with and without SN.

Nervios digitales palmares comunes del ramo superficial del nervio ulnar y nervios digitales plantares comunes del ramo superficial del nervio plantar lateral: un error anatómico en terminologia anatomica / Common palmar digital nerves from the superficial branch of the ulnar nerve and common plantar digital nerves from superficial branch of the lateral nerve: an anatomical error in terminologia anatomica

Terminologia Anatomica contempla la existencia de nervios digitales palmares comunes del ramo superficial del nervio ulnar y nervios digitales plantares comunes del ramo superficial del nervio plantar lateral. De acuerdo a la mayoría de los textos clásicos y estudios anatómicos de las regiones de la palma de la mano y de la planta del pie, solo existiría un nervio digital palmar común (IV) originado del ramo superficial del nervio ulnar y un nervio digital plantar común (IV) con origen en el ramo superficial del nervio plantar lateral. Realizamos una revisión anatómica de la inervación cutánea de la palma de la mano observando el comportamiento de los nervios mediano y ulnar y de la planta del pie a través de los nervios plantares medial y lateral, comentamos la literatura relacionada y concluimos que debe corregirse la Terminologia Anatomica, en el término A14.2.03.046(Nn. digitales palmares comunes) y en el término A14.2.07.071(Nn. digitales plantares comunes), los cuales deberían denominarse N. digital palmar común y N. digital plantar común, ambos corresponderían al IV nervio digital palmar común y IV nervio digital plantar común, respectivamente.

Terminologia Anatomica contemplates the existence of common palmar digital nerves from the superficial branch of the ulnar nerve and common plantar digital nerves from the superficial branch of the lateral plantar nerve. According to most classical texts and anatomical studies of the regions palmar and plantar, there would only be common palmar digital nerve (IV) originated from the superficial branch of the ulnar nerve and common plantar digital nerve (IV) arising from the superficial branch of lateral plantar nerve. We conducted an anatomical review of the cutaneous innervation of the palm observing the behavior of the median and ulnar nerves, and the foot through the medial and lateral plantar nerves. In this study we discuss the related literature and conclude that Terminologia Anatomica must be corrected in the A14.2.03.046 term (Nn. common palmar digital) and in A14.2.07.071 term (Nn. common plantar digital ), which should be called: common palmar digital nerve and common plantar digital nerve, corresponding to both the IV common palmar digital nerve and IV common plantar digital nerve, respectively.

Reprodutibilidade intra-avaliador do teste de discriminação de dois pontos na sola dos pés em idosos e jovens assintomáticos / Intra-observer reproducibility of the feet soles two-point discrimination test in asymptomatic elderly and young individuals

CONTEXTUALIZAÇÃO: Os primeiros sinais de comprometimento sensorial plantar decorrente do envelhecimento e de neuropatias periféricas são manifestados na sola dos pés e podem resultar em déficits no controle postural e no equilíbrio. Os testes de sensibilidade cutânea visam a avaliar a densidade da inervação sensorial na pele e têm sido utilizados para avaliação de segmentos distais. Alguns estudos têm aplicado o teste de discriminação de dois pontos (DDP) na sola dos pés e diferenciado idosos com e sem históricos de quedas, porém sua reprodutibilidade ainda precisa ser determinada. OBJETIVO: Verificar a reprodutibilidade intra-avaliador do teste de DDP na sola dos pés em idosos e jovens assintomáticos. MÉTODO: Participaram do estudo 21 idosos ativos (67±5 anos; 1,56±0,08 m; 65,3±13,7 kg) e 21 jovens ativos (24±3 anos; 1,69±0,09 m; 54,5±9,5 kg). Os participantes realizaram duas sessões de testes com procedimentos experimentais idênticos, com intervalo de 48 horas. Foi avaliada a sensibilidade cutânea da sola do pé direito por meio do teste de DDP. Para avaliar a reprodutibilidade intra-avaliador, foi aplicado o teste de Bland-Altman. RESULTADOS: Idosos e jovens apresentaram variações de 0,71% e 1,53%, respectivamente. CONCLUSÕES: Esses valores não excedem dois desvios-padrão, e o teste de DDP foi considerado como uma medida reprodutível para a avaliação da sensibilidade cutânea da sola dos pés de jovens e idosos fisicamente ativos.

BACKGROUND: The first sign of plantar sensory impairment due to aging and peripheral neuropathies are manifested on the soles of the feet and can result in postural control and balance deficits. The aim of cutaneous sensitivity tests is to assess the skin sensory innervation density such as those of the distal segments. In some studies the two-point discrimination test (TPD) have been applied on the soles of the feet and have proven to accurately distinguish elderly with and without falls events. However, the reproducibility of the test still needs to be determined. OBJECTIVES: The aim of the present study was to verify the intra-observer reproducibility of the TPD test on the soles of feet in asymptomatic elderly and young individuals. METHOD: The sample was composed of 21 physically active elderly participants (67±5 years; 1:56±0.08 m, 65.3±13.7 kg) and 21 physically active young adults (24±3 years, 1.69±0.09 m, 54.5±9.5 kg). The participants attended two sessions with identical experimental procedures, with an interval of 48 hours between them. The skin sensitivity of the right foot sole was assessed using the TPD test. Intra-observer reproducibility was assessed using Bland-Altman plots. RESULTS: Elderly and young participants showed sensitivity variations of 0.71% and 1.53%, respectively. CONCLUSIONS: These values did not exceed two standard deviations and the TPD test was considered as a reproducible measure for the assessment of feet cutaneous sensitivity in asymptomatic and physically active young and elderly participants.

División Alta del Nervio Fibular Superficial: Origen Precoz de los Nervios Cutáneos Dorsales del Pie / High Division of Superficial Fibular Nerve: Early Origin of the Dorsal Cutaneous Nerves of the Foot

Los nervios cutáneos dorsales del pie se originan a partir del nervio fibular superficial (NFS), después que éste pasa desde el compartimiento lateral de la pierna a través de la fascia profunda, para luego distribuirse superficialmente en el dorso del pie. A veces, el nervio fibular superficial se divide precozmente, por lo que estos nervios se originan profundamente y con una disposición diferente. Con el propósito de dar a conocer en estos casos, los niveles de origen de los nervios cutáneos dorsales del pie y el punto de penetración en la fascia profunda de la pierna, se estudiaron 16 muestras de individuos, chilenos, adultos, fijadas en formaldehido al 10 por ciento. En 2 de ellas, su origen se observó a un nivel alto, cerca de la parte proximal de la fíbula. En el primer caso, el nervio cutáneo dorsal intermedio se originó directamente de la división posterior del NFS; la división anterior del NFS se subdividió en dos ramos, los que después de un corto trayecto se unieron y formaron el nervio cutáneo dorsal medial. En el segundo caso, los nervios cutáneos dorsales intermedio y medial se originaron directamente del NFS, que después de un corto trayecto se dividió en estos dos nervios. El origen de los nervios cutáneos dorsales del pie se registró en relación al epicóndilo lateral del fémur y el paso de éstos a través de la fascia profunda de la pierna hacia su distribución cutánea fue relacionado al maléolo lateral. Aunque el origen de los nervios cutáneos dorsales del pie ocurra a un nivel próximo a la cabeza de la fíbula, perforan la fascia mencionada, en su tercio distal. Un conocimiento detallado del NFS y de sus ramos y variaciones anatómicas puede reducir lesiones iatrogénicas en éstos durante los procedimientos quirúrgicos realizados en el compartimiento lateral de la pierna.

The dorsal cutaneous nerves of the foot originate from the superficial fibular nerve (SFN), then pass from the lateral compartment of the leg piercing the deep fascia, thus distributed superficially in the dorsum of the foot. Sometimes SFN splits early, so these nerves originate deeply and with a different arrangement. The objective of this research was to study in these cases, the origin of the dorsal cutaneous nerves of the foot and pierce point level in the deep fascia of the leg. We studied 16 formolized samples of Chilean adult individuals. In two of them its origin was observed at a high level, near the proximal epiphysis of the fibula. In the first case the intermediate dorsal cutaneous nerve arose directly from the posterior division of SFN, of short course; the anterior division of SFN was subdivided into two branches, which after a short course, both branches joined to form the medial dorsal cutaneous nerve. In the second case the medial and intermediate dorsal cutaneous nerves originated directly from the SFN, which after a short course, it divided in these two nerves. The origin level was recorded in relation to the lateral epicondyle of the femur and the passage of these nerves through the deep fascia of the leg for its skin distribution was located in relation to the lateral malleolus. Although the origin of the dorsal cutaneous nerves of the foot occur very close to the proximal epiphysis of the fibula, passing through the mentioned fascia in its distal third. A detailed knowledge of the branches of the SFN and variations can reduce injuries in these nerves during surgical procedures in the lateral compartment of the leg.

Morfometría de los ramos nerviosos para los músculos interóseos plantares del pie en el hombre / Morphometry of nerve branches for plantar interossei muscles in the foot of man

La inervación del pie ha requerido especial atención por su utilidad en el abordaje clínico y quirúrgico de patologías y síndromes dolorosos como talalgias, fascitis plantar y fibromatosis plantar, entre otras. Estudios realizados, han permitido conocer la importancia funcional de los músculos interóseos plantares. Sin embargo, no se conoce mayores detalles de su inervación. Realizamos un estudio morfométrico en 5 muestras de ramos nerviosos para el primer, segundo y tercer músculo interóseo en cadáveres de individuos adultos, masculinos. Se obtuvieron secciones transversales de cada uno de los nervios después de su origen, a nivel del plano profundo de la región plantar del pie. Realizamos cortes de 4 um de grosor los cuales fueron teñidos con Hematoxilina-Eosina (H.E.). El promedio de fascículos en el ramo para el primer músculo interóseo (R1 IOP) fue 1 (D.E. 0,00); para el segundo músculo interóseo (R2 IOP) fue 2 (D.E. 0,45) y para el tercer músculo interóseo (R3 IOP) fue 2 (D.E. 1,00). El promedio de fibras para el R1 IOP, R2 IOP Y R3 IOP fue: 547 (D.E. 153), 644 (D.E. 258) y 1.161 (D.E. 465) respectivamente. El área promedio del R1 IOP, R2 IOP Y R3 IOP fue: 0,06 mm2 (D. E. 0,02), 0,08 mm2 (D. E. 0,03), 0,14 mm2 (D. E. 0,06), respectivamente. El estudio morfométrico y estereológico de estos ramos nerviosos espera aportar al conocimiento de los profesionales que deben intervenir clínica y quirúrgicamente en la región plantar del pie.

Innervation of the foot has required special attention in view of its use in clinical and surgical treatment of painful diseases and syndromes such as talalgia, plantar fasciitis and plantar fibromatosis are among those mentioned. Studies realized have made possible the functional significance of plantar interossei muscles. However, there is no information regarding greater detail of their innervation. A morphometric study was carried out in 5 nerve branches for the first, second and third plantar interossei muscles in cadavers of adult male individuals. Cross sections were obtained of each one of the nerves after their origin, at the deep level of the plantar region of the foot. Cuts of 4 um thick were realized which were stained with Hematoxylin-Eosin (H.E.). Average fascicles in the branch for the first interosseous muscle(R1 IOP) was 1 (D.E. 0,00); for the second interosseous muscle(R2 IOP) was 2 (D.E. 0.45); and for the third interosseous muscle(R3 IOP) was 2 (D.E. 1.00). The average of fibers for thel R1 IOP, R2 IOP was:547 (D.E. 153), 644 (D.E. 258) and 1.161 (D.E. 465) respectively. The average area ofR1 IOP, R2 IOP Y R3 IOP was: 0.06 mm2 (D. E. 0.02), 0.08 mm2 (D. E. 0.03), 0.14 mm2 (D. E. 0.06), respectively. The morphometric and stereological study of these nerve branches is expected to contribute to the information available to professionals who must clinically and surgically treat the plantar region of the foot.

Inervación de los músculos interóseos plantares del pie humano / Innervation of the plantar interossei muscles of the human foot

Los músculos interóseos plantares son tres y están situados en el plano profundo de la región plantar del pie. Se originan en la base de los metatarsianos y ligamentos cercanos, para insertarse en la base de la tercera, cuarta y quinta falanges y aponeurosis extensora de los dedos del pie. La literatura no entrega detalles de la inervación de los músculos interóseos plantares, por tanto realizamos un estudio anatómico del tema. Se disecaron 21 pies, 6 derechos y 15 izquierdos, de cadáveres formolizados al 10 por ciento, de individuos adultos, de ambos sexos y diferentes grupos étnicos, pertenecientes a las Unidades de Anatomía Humana de las Facultades de Medicina de la Universidad de La Frontera y Universidad Mayor, sede Temuco. La división del nervio plantar lateral en ramos superficial y profundo se produce a nivel del margen lateral del músculo cuadrado plantar. Los músculos interóseos plantares reciben su inervación del ramo profundo, los cuales se originan en el tercio medio de la región plantar, cruzan inferiormente a la arteria plantar lateral y se dirigen anterolateralmente hacia estos músculos. La longitud de los ramos nerviosos para el tercer y segundo músculos interóseos son similares (X=12,19 mm y X=11,62 mm, respectivamente) y diferente para el primer músculo interóseo (X=21,95 mm). Estos resultados, permiten padronizar la distribución y longitud de los ramos nerviosos para los músculos interóseos plantares, contribuyendo al conocimiento anatómico de la región plantar.

There are three plantar interossei muscles located in the deep plane of the plantar region of the foot. These originate in the base of the metatarsals and adjacent ligaments insert in the base of the third, fourth and fifth phalanges and extensor aponeurosis of the toes. The literature does not include details of the innervation of the plantar interossei muscles. Therefore we carried out an anatomical study of the subject matter. Twentyone feet, six right feet and fifteen left feet of adult individuals of both sexes and different ethnic groups, belonging to the Human Anatomy Units of the Faculty of Medicine of the Universidad de La Frontera and Universidad Mayor Temuco campus, were dissected in cadavers formolized at 10 percent. The division of the lateral plantar nerve in superficial and deep branches occurs at the level of the lateral margin of the plantar muscle. The plantar interossei muscles receive their innervation from the deep branch, which originate in the middle tertium of the plantar region, crossing inferior to the lateral plantar artery and are anterolaterally aimed toward these muscles. The longitude of the nerve branches for the third and second interossei muscle are similar (X=12.19mm and X= 11.62 mm, respectivelly) and differ from the first interossei muscle (=21.95 mm). These results allow standardization of the distribution and longitude of the nerve branches for the plantar interossei muscles, contributing to anatomical information of the plantar region.

Morfometría de los nervios sensitivos del dorso del pie en el hombre / Morphometry of the sensitive nerves of the dorsum of the foot in man

La inervación cutánea del dorso del pie, está dada por los nervios fibular superficial (NFS), ramo del nervio fibular común; sus ramos, cutáneo dorsal medial (NCDM) y cutáneo dorsal intermedio (NCDI), así como también por el cutáneo dorsal lateral (NCDL), ramo del nervio sural y el ramo cutáneo del nervio fibular profundo (RCNFP). Estos, pueden ser lesionados en su proximidad con estructuras óseas en su ubicación más superficial, en intervenciones quirúrgicas, por compresión, tracción o fricción crónica. Realizamos un estudio morfométrico y estereológico en 5 muestras de NFS, NCDM, NCDI, NCDL y RCNFP en cadáveres de individuos adultos, masculinos. Se obtuvieron secciones transversales de cada uno de los nervios después de su origen, a nivel del tercio distal de la pierna y del dorso del pie. Realizamos cortes de 4 um de grosor, teñidos con H.E. El promedio de fascículos fue: NFS 12 (D.E. 2,39); NCDM 8 (D.E. 4,82); NCDI 5 (D.E. 1,67); NCDL 7 (D.E. 3,27) y RCNFP 4 (D.E. 1,30). El promedio de fibras para el NFS, NCDM, NCDI, NCDL y RCNFP fue: 14.080, 7.636, 4.602, 3.732 y 2.941, respectivamente. El área promedio del NFS, NCDM, NCDI, NCDL y RCNFP fue: 1,54 mm2 (D. E. 0,22), 0,82 mm2 (D. E. 0,31), 0,54 mm2 (D. E. 0,23), 0,42 mm2 (D.E. 0,19) y 0,32 mm2 (D.E. 0,13) respectivamente. Con este estudio, se espera contribuir al conocimiento morfológico respecto a los factores que podrían influir en el grado de recuperación de lesiones nerviosas, importantes en la clínica y en las técnicas de microcirugía.

The cutaneous innervation on the dorsum of the foot, is given by the superficial fibular nerves (SFN) a branch of the common fibular nerve: its branches, and cutaneous medial dorsal (MDCn) and cutaneous intermediate dorsal (IDCn). Also, the cutaneous lateral dorsal (LDCn) branch of the sural nerve and cutaneous branch of the deep fibular nerve (DFCBn). These can be injured in their proximity with osseous structures in their most superficial location, in surgical procedures, by compression, traction or chronic friction. We carried out a morphometric and stereological study in 5 samples of SFN, MDCn, IDCn, LDCn and DFCBn in cadavers of adult male individuals. Transverse sections of each of the nerves were obtained following its origin, at the level of the distal third of the leg and dorsum of the foot. We realized slices of 4 um thick, stained with H.E. The average of the fascicles was: SFN 12 (D. E. 2.39); MDCn 8 (D. E. 4.82); IDCn 5 (D. E. 1.67); LDCn 7 (D. E. 3.27) and DFCBn 4 (D. E. 1.30). The average of fibers for SFN, MDCn, IDCn, LDCn, and DFCBn was: 14.080, 7.636, 4.602, 3.732 y 2.941 respectively. Average area of SFN, MDCn, IDCn, LDCn, and DFCBn was 1.54 mm2 (D. E. 0.22), 0.82 mm2 (D. E. 0.31), 0.54 mm2 (D. E. 0.23), 0.42 mm2 (D. E. 0.19) y 0.32 mm2 (D. E. 0.13) respectively. With this study we hope to contribute to morphological information in reference to factors that could influence in the degree of recovery of nerve lesions, important in clinic as well as microsurgery techniques.

Distribución de los nervios cutáneo dorsal medial y cutáneo dorsal intermedio en el hombre / Distribution of the medial dorsal cutaneous and intermediate dorsal cutaneous nerves in man

Gran parte de la inervación sensitiva del dorso del pie está dada por los ramos cutáneos del nervio fibular superficial, los nervios cutáneo dorsal medial (NCDM) y cutáneo dorsal intermedio (NCDI). El objetivo de esta investigación fue estudiar las divisiones de los NCDM y NCDI a nivel del tercio distal de la pierna y el dorso del pie, para contribuir con conocimientos específicos al abordaje quirúrgico de la región. Disecamos 19 piernas y pies en cadáveres de individuos adultos, masculinos, correspondientes al Departamento de Morfología de la Universidad de La Frontera de Temuco. Se dividió el dorso del pie, en tercios anterior, medio, posterior y luego, las divisiones observadas se padronizaron. La división de los NCDM y NCDI, en ramos medial y lateral, se observó en el tercio distal de la pierna, en un 47,4 por ciento y 52,6 por ciento respectivamente. La división del ramo medial de los NCDM y NCDI en ramos terminales, se observó en el tercio posterior del dorso del pie (42,2 por ciento) y en el tercio distal de la pierna (21,1 por ciento), respectivamente. La división del ramo lateral de los NCDM y NCDI en ramos terminales, se observó en el tercio posterior del dorso del pie (21,1 por ciento) y en el tercio anterior del dorso del pie (15,8 por ciento) respectivamente. La división de los ramos terminales del ramo medial de los NCDM y NCDI en nervios digitales dorsales, se observó en el tercio medio del dorso del pie en un 21,1 por ciento y 15,6 por ciento respectivamente. La división de los ramos terminales del ramo lateral de los NCDM y NCDI en nervios digitales dorsales, se observó en el tercio anterior del dorso del pie en un 15,8 por ciento, para ambos. Estos datos, pueden servir de referencia durante los procedimientos quirúrgicos realizados en la región, evitando lesiones iatrogénicas del área.

The sensory innervation of the dorsum of the foot is given by the cutaneous branches of the superficial fibular nerve, the medial dorsal cutaneous (MDCn) and intermediate dorsal cutaneous (IDCn) nerves. The aim of this research was to study the divisions of the MDCn and IDCn at the distal third of the leg and dorsum of the foot, to contribute expertise for the surgical approach in the región. Nineteen legs and feet of adult male cadavers, of the Department of Morphology, Universidad de La Frontera in Temuco, were dissected. We divided the dorsum of the foot in anterior, middle and posterior third, then the divisions were observed and patterned. The division of the MDCn and IDCn in medial and lateral branches was observed in the distal third of the leg, 47.4 percent and 52.6 percent respectively. The division of the medial branch of the MDCn and IDCn in terminal branches, was observed in the posterior third of the dorsum of the foot (42.2 percent) and in the distal third of the leg (21.1 percent), respectively. The division of the lateral branch of the MDCn and IDCn in terminal branches, was observed in the posterior third of the dorsum of the foot (21.1 percent) and in the anterior third of the dorsum of the foot (15.8 percent) respectively. The division of the terminal branches of the medial branch of the MDCn and IDCn in dorsal digital nerves was observed in the middle third of the dorsum of the foot at 21.1 percent and 15.6 percent respectively. The division of the terminal branches of the lateral branch of the MDCn and IDCn in dorsal digital nerves was observed in the anterior third of the dorsum of the foot at 15.8 percent for both. These data may serve as a reference during surgical procedures performed in the region, avoiding iatrogenic injuries of the area.

Avaliação funcional do equilíbrio e da sensibilidade cutânea plantar de idosos moradores na comunidade / Balance and plantar cutaneous sensitivity functional assessment in community-dwelling elderly

Desequilíbrio é um dos muitos fatores de risco que aumenta a susceptibilidade de um idoso a quedas. O equilíbrio pode ser avaliado mediante testes posturais e de sensibilidade plantar. OBJETIVO: Avaliar a ocorrência de desequilíbrio e perda de sensibilidade cutânea plantar em idosos da comunidade e verificar a existência de associação entre ambas as alterações. CASUÍSTICA E MÉTODOS: Estudo transversal descritivo envolvendo 45 idosos submetidos à escala de equilíbrio de Berg (EEB) e ao teste de sensibilidade plantar com monofilamento de nylon. Foram utilizados os testes qui-quadrado e exato de Fisher e elaboradas curvas ROC para estudo da sensibilidade e especificidade da EEB. RESULTADOS: Idosos com alteração do equilíbrio e da sensibilidade cutânea foram em número de 2 e 4, respectivamente. Houve associação significativa entre queixa de desequilíbrio e perda da sensibilidade (p = 0,047) e ocorreu concordância razoável (Kappa: 0,6457) entre a EEB e o teste da sensibilidade. Verificou-se também associação significativa entre 6 dos 14 tarefas da EEB e o teste sensorial. CONCLUSÃO: Idosos vivendo com independência na comunidade, em sua maioria, apresentam equilíbrio e sensibilidade cutânea plantar normais. Quando alteradas estas funções mostram-se associadas de forma que, se os testes forem realizados conjuntamente, a precisão da avaliação do equilíbrio idoso aumenta.

Impaired balance is one of several factors that increase an elderly's susceptibility to falls. Balance assessment can be performed using postural tests and plantar cutaneous sensitivity tests. AIM: To assess balance disorders and loss of plantar cutaneous sensitivity in the elderly and look for association between these alterations. MATERIALS AND METHODS: A descriptive cross-sectional study involving 45 elderly submitted to the Berg Balance Scale (BBS) and the plantar sensitivity test with nylon monofilament. We used chi-square and Fisher's exact tests, and ROC curves were created in order to study the sensitivity and specificity of BBS. RESULTS: Two and 4 individuals showed balance and cutaneous sensation disorders, respectively. There was a significant association between the complaint of impaired balance and loss of skin sensitivity (p = 0.047), and there was a reasonable agreement (Kappa: 0.6457) between the BBS and the sensorial test. A significant association was also found among 6 of the 14 BBS tasks and the sensitivity test. CONCLUSION: Most of the elderly living independently in the community showed normal balance and plantar cutaneous sensation. When impaired, these functions appeared associated in a way that if the tests are performed together, the accuracy of the evaluation of the balance increases.

Limiar de sensibilidade cutânea dos pés em pacientes diabéticos através do pressure specified sensory device: uma avaliação da neuropatia / Cutaneous sensibility threshold in the feet of diabetic patients with pressure specified sensory device: an assessment of the neuropathy

OBJETIVO: A neuropatia diabética leva à diminuição ou perda da sensibilidade protetora do pé, tornando o diabético mais vulnerável ao trauma mecânico, consequentemente, levando-o à formação de feridas e eventualmente, perda segmentar nos membros inferiores. A profilaxia das complicações neuropáticas deve ser iniciada pela identificação do grau de neuropatia e, portanto, do comprometimento neurológico. O Pressure Specified Sensory DeviceTM foi desenvolvido para quantificar o limiar de pressão aplicada sobre a pele, necessário para que o paciente sinta o estímulo de um ponto estático, um ponto em movimento, dois pontos estáticos e dois pontos em movimento. É um meio direto para se avaliar os sistemas de fibras de adaptação lenta e rápida e seus respectivos receptores periféricos. MÉTODOS: Trinta e três pacientes diabéticos do tipo II, sem história prévia de feridas e/ou amputações nos pés foram avaliados neste estudo de corte transversal. A sensibilidade nos territórios cutâneos dos nervos plantar medial, calcâneo e o ramo profundo do nervo fibular foi avaliada usando os testes de um ponto estático (1PE), um ponto dinâmico (1PD), dois pontos estáticos (2PE) e dois dinâmicos (2PD). RESULTADOS: Nos três territórios nervosos examinados encontramos valores alterados para as modalidades estática e dinâmica em relação ao padrão de normalidade. As diferenças foram estatisticamente significantes com p < 0,05. CONCLUSÃO: A quantificação numérica do limiar de pressão cutânea nos permite tanto a avaliação do conjunto fibra/receptor, quanto à determinação do déficit funcional da fibra nervosa imposto pela neuropatia diabética.

OBJECTIVES: Neuropathy is a severe progressive loss of protective sensation in the feet, increasing patient vulnerability to mechanical trauma and consequently more prone to development of chronic wounds, major distortion of the foot bone architecture and to eventual limb amputation. Prophylaxis should be enforced to avoid foot ulceration and for this purpose, evaluation of the degree of loss of sensation on the skin is essential. The PSSD (Pressure Specified Sensory DeviceTM) was developed to quantify the threshold of pressure applied to the skin that the patient might recognize as positive. Pressure of one or two points is tested both statically and with movement, thus assessing the function of fast and slow response nerve fibers. METHODS: 33 diabetic patients, type II, with no previous history of wounds on the lower extremity were studied. The tests used were, one point static, one point moving and two points, static and moving on the cutaneous territory of the fibular nerve and posterior tibial nerve (two territories - medial plantar and calcaneous nerves). RESULTS: Altered values were observed for the static and dynamic tests over the three nerve territories studied. Differences were statically significant (p < 0.05). This numeric quantification of the threshold of pressure supports the evaluation of the status of the fiber/receptor structures as well as the functional deficit subsequent to diabetic neuropathy.

Abnormal dip phenomenon: a characteristic electrophysiological marker in interdigital neuropathy of the foot

OBJECTIVE: The nerve conduction findings in interdigital neuropathy of the foot (IDN; Morton's neuroma) have rarely been reported. We analyzed the nerve conduction data in 23 patients with suspected IDN studied between 1982 and 2002. METHOD: Diagnosis of IDN was made on the basis of clinical features. All patients underwent routine nerve conduction studies and a near-nerve needle sensory nerve conduction study of the interdigital nerves by Oh's method in the symptomatic foot. RESULTS:Of the 23 patients, the diagnosis of definite IDN was made in 13 cases and of possible NDN in the others cases. Nineteen were females. Twenty two patients had only one nerve affected. One patient had two nerves affected. The III-IV interdigital nerve was affected in 17 cases and the II-III interdigital nerve in 7 cases. The near-nerve needle nerve conduction showed abnormality in the affected interdigital nerves in all definite IDN cases and confirmed the diagnosis of IDN in 10 cases by the abnormal dip phenomenon (a selective decrease of 50 percent or more in the sensory CNAP amplitude of the affected nerve compared with that of the preceding interdigital nerve). In 11 possible IDN cases, IDN was identified by the abnormal dip phenomenon. CONCLUSION: The near-nerve needle sensory nerve conduction of the interdigital nerves is a highly sensitive diagnostic test, and abnormal dip phenomenon is the most characteristic electrophysiological marker for the diagnosis of IDN.

OBJETIVO: Os achados da condução nervosa na neuropatia interdigital do pé (NIP) têm sido raramente descritos. Nós analisamos os dados da condução nervosa de 23 pacientes com suspeita de NIP entre 1982 e 2002. MÉTODO: O diagnóstico de NIP foi clínico. Todos os pacientes foram submetidos a estudos de condução nervosa de rotina e ao estudo de condução sensitiva dos nervos interdigitais com agulha justa-neural pelo método de Oh. RESULTADOS: Dos 23 pacientes, o diagnóstico de NIP foi definitivo em 13 casos é possível nos demais. Dezenove pacientes eram mulheres e 22 tinham somente um nervo afetado. Apenas um paciente teve dois nervos comprometidos. O nervo interdigital III-IV foi afetado em 17 casos e o nervo interdigital II-III em 7 casos. A condução nervosa justa-neural foi anormal nos nervos interdigitais acometidos em todos os casos definitivos e confirmou o diagnóstico de neuropatia interdigital em 10 casos pelo fenômeno da diminuição de amplitude anormal (uma diminuição seletiva de 50 por cento ou mais da amplitude do PANS do nervo afetado quando comparado com o nervo anterior. Em 11 casos possíveis, a neuropatia interdigital foi identificada pelo fenômeno da diminuição de amplitude anormal. CONCLUSÃO: A condução nervosa sensitiva justa-neural dos nervos interdigitais do pé é um teste diagnóstico altamente sensível e o fenômeno da diminuição da amplitude anormal é o marcador eletrofisiológico mais característico para o diagnóstico de neuroma de Morton.

Morfometría de los ramos del nervio plantar lateral antes de su división en ramos superficial y profundo / Morphometry of the branches of the lateral plantar nerve before to its division in superficial and deep branches

RESUMEN: Los músculos del pie son frecuentemente afectados por accidentes que pueden comprometer su inervación. Así, el conocimiento anatómico de los nervios plantares y de sus ramos musculares adquiere importancia en los aspectos morfológico y quirúrgico. Se ha efectuado esta investigación debido a la poca información morfométrica existente respecto a los nervios de la musculatura inervada por el nervio plantar lateral, antes de su división en ramos superficial y profundo. En 5 pies de cadáveres adultos, se disecó el nervio plantar lateral desde su origen hasta su división en ramos superficial y profundo identificándose los ramos originados en esta parte. A través de cortes histológicos transversales de los nerviosse obtuvo información cuantitativa sobre el número de fascículos, área de los fascículos y número de fibras por nervio. El número promedio de fascículos de los nervios para los músculos abductor del dedo mínimo y cuadrado plantar, fue de 3. El área promedio de los fascículos para los músculos abductor del dedo mínimo, cuadrado plantar y ramo cutáneo lateral, fue 0,165 mm2 (DE 0,119), 0,070 mm2 (DE 0,042) y 0,041m2 (DE 0,005), respectivamente. El número de fibras en los nervios para losmúsculos abuctor del dedo mínimo y cuadrado plantar y ramo cutáneo lateral, fue de 1.161 (DE 111), 419 (DE 136) y 445 (DE 97), respectivamente. Con este trabajo se espera contribuir al conocimiento morfométrico de los nervios del pie sirviendo, además, como un apoyo anatómico a la microcirugía reparadora que se realiza en esa región.