Correlations between physical and ultrasound findings in congenital clubfoot at birth.

BACKGROUND: At birth, clinical classifications are the only available tools for evaluating the severity of congenital clubfoot. Ultrasound provides an assessment of the anatomical abnormalities. The objective of this study was to assess correlations between physical and ultrasound findings at birth. HYPOTHESIS: Physical and ultrasonography provide different findings in congenital clubfoot and should therefore be used in conjunction. MATERIAL AND METHOD: One hundred and forty-five clubfeet in 108 patients born between 2006 and 2010 were included in a retrospective study. Clubfoot severity was classified using two methods, the modified Dimeglio classification based on physical findings and an ultrasound score based on the talo-navicular angle (TNA) and metaphyso-talo-calcaneal angle (MTCA). Each of these two methods distinguished three severity grades. Agreement between the two methods was assessed by computing the coefficient. RESULTS: The results confirmed the hypothesis by showing low agreement between the clinical and ultrasound classifications. The severity grades were identical with the two methods for only 83/145 (57%) feet. The coefficient was 0.086. DISCUSSION: The two ultrasound views used to measure the TNA and MTCA, respectively, added an assessment of the three main deformities that characterise congenital clubfoot (equinus, adduction of the forefoot, and adduction of the calcaneo-pedal unit). Ultrasonography complements the physical examination at birth. In the future, using both physical examination and ultrasound scanning to monitor babies with clubfoot may allow early treatment adjustments aimed at optimising the outcome. LEVEL OF EVIDENCE: IV, retrospective observational study.

Whole-body post-mortem computed tomography compared with autopsy in the investigation of unexpected death in infants and children.

OBJECTIVES: To investigate the contribution of whole-body post-mortem computed tomography (PMCT) in sudden unexpected death in infants and children. METHODS: Forty-seven cases of sudden unexpected death in children investigated with radiographic skeletal survey, whole-body PMCT and autopsy were enrolled. For imaging interpretation, non-specific post-mortem modifications and abnormal findings related to the presumed cause of death were considered separately. All findings were correlated with autopsy findings. RESULTS: There were 31 boys and 16 girls. Of these, 44 children (93.6 %) were younger than 2 years. The cause of death was found at autopsy in 18 cases (38.3 %), with 4 confirmed as child abuse, 12 as infectious diseases, 1 as metabolic disease and 1 as bowel volvulus. PMCT results were in accordance with autopsy in all but three of these 18 cases. Death remains unexplained in 29 cases (61.7 %) and was correlated with no abnormal findings on PMCT in 27 cases. Major discrepancies between PMCT and autopsy findings concerned pulmonary analysis. CONCLUSIONS: Whole-body PMCT may detect relevant findings that can help to explain sudden unexpected death and is essential for detecting non-accidental injuries. We found broad concordance between autopsy and PMCT, except in a few cases of pneumonia. It is a non-invasive technique acceptable to relatives. KEY POINTS: • Whole-body post-mortem computed tomography (PMCT) is an effective non-invasive method. • Whole-body PMCT is essential for detecting child abuse in unexpected death. • There is concordance on cause of death between PMCT and autopsy. • Whole-body PMCT could improve autopsy through dissection and sampling guidance. • PMCT shows findings that may be relevant when parents reject autopsy.

Preserving the superficial branch of the radial nerve during carpometacarpal and metacarpophalangeal joint arthroscopy: an anatomical study.

BACKGROUND: The superficial branch of the radial nerve (SBRN) is potentially at risk during thumb carpometacarpal (TCM) or thumb metacarpophalangeal (TMP) joint arthroscopy. The aim of this anatomical study was to describe the different branching patterns of the SBRN and to optimize positioning of portals during TCM and TMP arthroscopy. METHODS: The SBRN was dissected in 30 forearms. Three branches of the nerve (SR1, SR2, and SR3) were recorded and distances between SBRN branches and portals used for carpometacarpal (TCM) and metacarpophalangeal (TMP) joints of the thumb arthroscopy were measured. Three main portals were used for TCM joint arthroscopy. These portals were an ulnar portal (1-U), a radial portal (1-R), and an accessory portal (D-2). A radial metacarpophalangeal (MCP-rad) and an ulnar metacarpophalangeal (MCP-uln) portal were used for TMP joint arthroscopy. RESULTS: In 24 cases (80%), the 1-R portal was inserted radially (volar) to SR3 at a mean distance of 4.8 mm (0-8). In the remaining six cases (20%) when 1-R portal was inserted ulnar (dorsal) to SR3, the distance was less than 2 mm in all cases. SR3 was always far from the 1-U portal at a mean 13 mm (7-22). The D-2 portal was always close to SR2-D1 at a mean distance of 1.7 mm (0-6). The distance from SR2-D2 and D-2 portal was also inferior by 5 mm. At the level of the metacarphalangeal joint of the thumb, the MCP-rad portal was always situated dorsally and very close to SR3, at a mean distance of 1 mm (0-5). The MCP-uln portal was also situated dorsal to SR2-D1 at a mean distance of 3.7 mm (1.5-6.5). CONCLUSION: The results of this anatomical study confirm actual reported findings about the SR2 and SR3 branches. These two branches of the SBRN are the most at risk of injury during TCM and TMP joint arthroscopy. According to our measurements, the 1-U portal is a safer portal than 1-R and D-2 portal for TCM arthroscopy and should be preferred for surgery necessitating only one portal. Concerning TMP arthroscopy, the SBRN appears less at risk of injury when using a MCP-uln portal and safer than MCP-rad which is at risk at less than 5 mm from the extensor pollicis longus tendon.

The subthalamic nucleus is a key-structure of limbic basal ganglia functions.

Among the basal ganglia nuclei, the subthalamic nucleus has a major function in the motor cortico-basal ganglia-thalamo-cortical circuit and is a target site for neurosurgical treatment such as parkinsonian patients with long-term motor fluctuations and dyskinesia. According to animal and human studies, the motor functions of the subthalamic nucleus have been well documented whereas its implication on limbic functions is still less well understood and is only partially explained by anatomical and functional theories of basal ganglia organisation. After chronic subthalamic nucleus stimulation in patients with Parkinson's disease, many studies showed executive impairments, apathy, depression, hypomania, and impairment of recognition of negative facial emotions. The medial tip of the subthalamic nucleus represents its limbic part. This part receives inputs from the anterior cingulate cortex, the medial prefrontal cortex, the limbic part of the striatum (nucleus accumbens), the ventral tegmental area and the limbic ventral pallidum. The medial tip of the subthalamic nucleus projects to the limbic part of the substantia nigra and the ventral tegmental area. We propose a new function scheme of the limbic system, establishing connections between limbic cortical structures (medial prefrontal cortex, amygdala and hippocampus) and the limbic part of the basal ganglia. This new circuit could be composed of a minor part based on the model of cortico-basal ganglia-thalamo-cortical loop, and of a major part linking the subthalamic nucleus with the mesolimbic dopaminergic pathway via the ventral tegmental area and the nucleus accumbens, and with limbic cortical structures. This scheme could explain limbic impairments after subthalamic nucleus stimulation by disruption of limbic information inside the subthalamic nucleus and the ventral tegmental area.

Anatomical study of the lateral femoral cutaneous nerve with special reference to minimally invasive anterior approach for total hip replacement.

BACKGROUND: Lesion of the lateral femoral cutaneous nerve (LFCN) represents the main complication during minimally invasive anterior approach dissection to the hip joint. The aim of this anatomical study was to describe the different presentation features of the LFCN at the thigh and particularly to determine the potential location of damage during minimally invasive anterior approach for total hip replacement. METHODS: The LFCN was dissected bilaterally at the thigh under the inguinal ligament in 17 formalin-preserved cadavers. Branching patterns of the nerve were recorded and distances from the LFCN to the anterior superior iliac spine (ASIS) and the anterior margin of the tensor fascia lata (TFL) were measured to clarify skin incision positioning during minimally invasive anterior approach for total hip replacement. RESULTS: The LFCN divided proximal to the inguinal ligament in 13 cases and distal to it in 21 cases. In the distal group the mean distance from the ASIS to the nerve division was 34.5 mm (10-72 mm). The gluteal branch crossed the anterior margin of the TFL 44.5 mm (24-92 mm) distally to the ASIS. In 18 cases the femoral branch did not cross the TFL and was located in the intermuscular space between TFL and sartorius. In the remaining 16 cases, this branch crossed the anterior margin of the TFL 46 mm (27-92 mm) distally to the ASIS. During minimally invasive anterior approach along the anterior border of the TFL, the LFCN was found to be potentially at risk between 27 and 92 mm below the ASIS. We used those informations to describe a map of "danger zones" for the LFCN or its two main branches. CONCLUSION: According to this study, numerous anatomical variations of the LFCN at the thigh should be considered when performing anterior approach to the hip joint. Different mechanisms of injury during surgery should be considered especially during minimally invasive total hip replacement, such as section of the gluteal or the femoral branch where it crosses the anterior margin of the TFL or stretching of the femoral branch due to retractors positioned into the intermuscular space between sartorius and TFL. According to the map of "danger zones" reported, the author policy consists of positioning the skin incision as lateral and distal to the ASIS as possible.

Ultrasound: a helpful technique in the analysis of congenital vertical talus. A case report.

Congenital vertical talus is a rare condition. In newborns, the diagnosis is evident in severe forms, but it can be difficult to confirm in mild ones. Non-ossified tarsal navicular cannot be visualized on standard roentgenograms until it is ossified. This work demonstrates that ultrasound is helpful in the early diagnosis of congenital vertical talus and in the evaluation of the therapeutic concept and effects.