Management of C5 Palsy After Anterior Cervical Decompression Using Oberlin Nerve Transfer: A Case Report.

C5 palsy is a potential complication of cervical decompression surgery from which many patients do not recover or partially recover function. We present the case of a 48-year-old patient who developed elbow flexion paralysis after anterior decompression surgery with fusion of the C5-C7 levels. Muscle function was not spontaneously restored until eight months after surgery. In this case, we performed an Oberlin procedure to restore the function of the arm. Muscle strength (5/5) and volume were obtained 13 months after surgery. A reasonable waiting period is required after C5 palsy in case spontaneous recovery occurs. Treatment decision should be based on the patient's symptoms. Nerve transfers have been shown to be effective when performed after six months, especially in Oberlin transfer.

Neurotization of femoral nerve using the anterior branch of the obturator nerve

Nerve transfer is nowadays a standard procedure for motor reinnervation. There is a vast number of articles in the literature which describe different techniques of neurotization performed after brachial plexus injuries. Although lower limb nerve transfers have also been studied, the number of articles are much limited. The sacrifice of a donor nerve to reinnervate a disrupted one causes morbidity of whichever structures that healthy nerve innervated before the transfer. New studies are focused on isolating branches or fascicles of the main donor trunk that can also be useful for rein-nervation in order to limit donor site motor dysfuntion. Femoral nerve injury due to trauma or surgery cause loss of function of the iliopsoas and quadriceps muscles, which impairs normal gait. In this article we present two clinical cases of femoral nerve injury that were successfully treated with the anterior branch of the obturator nerve

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Pseudotumor cerebri in kaposiform lymphangiomatosis: a case report and pathogenetic hypothesis.

CASE REPORT: A 4-year-old boy with kaposiform lymphangiomatosis (KLA) developed progressive headaches and papilloedema and was diagnosed with pseudotumor cerebri initially treated with acetazolamide. Clinical deterioration prompted placement of a ventriculoperitoneal shunt. After the surgery, the child's condition has markedly improved. DISCUSSION AND CONCLUSIONS: A network of intracranial lymphatics is presently being investigated. Neuroimaging excluded KLA infiltration of the skull and/or meninges, leaving as the most plausible explanation for the child's pseudotumor cerebri the existence of an increase in intracranial venous pressure by venous compression at the thorax. To our knowledge, our case constitutes the first report of pseudotumor cerebri occurring in the context of KLA.

Oblique triangular neurovascular osteocutaneous flap for hook nail deformity correction.

Hook nail deformity results in aesthetic and functional problems after fingertip amputations. Previously described techniques do not correct the osseous defect, which may be the principle cause of the problem. We present a surgical technique based on a compound homodigital advancement flap combining bone of the distal phalanx, finger pulp, and skin. We describe this technique, report a case, and discuss the advantages over former techniques.

Nerve transfers from branches to the flexor carpi radialis and pronator teres to reconstruct the radial nerve.

PURPOSE: To present our method and results for transferring branches of the median nerve for radial nerve palsy or posterior cord lesions. METHODS: We transferred 1 branch to the pronator teres to the branch to the extensor carpi radialis longus muscle and transferred the branch to the flexor carpi radialis to the posterior interosseous nerve. We carried out these transfers in 6 patients with radial nerve palsy or posterior cord lesions. We reviewed functional outcomes, Disabilities of the Arm, Shoulder and Hand scores, and Patient Evaluation Measure scores. RESULTS: After 20 months of follow-up evaluation, all patients had recovered extensor carpi radialis longus activity of M4. Activity of the extensor carpi ulnaris was M3 in 2 patients and M4 in 4 patients. Extensor pollicis longus activity was M4 in all 6 cases. Metacarpophalangeal extension was M4 in 4 cases and M3 in 2 cases. The mean Disabilities of the Arm, Shoulder, and Hand score was 26 (range, 7-43), and the mean Patient Evaluation Measure score was 34 (range, 24-53). CONCLUSIONS: Selective independent synergistic transfer of median nerve fascicles to the radial nerve branches has shown excellent results in the treatment of severe lesions of the radial nerve. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Transfer of brachioradialis motor branch to the anterior interosseous nerve in C8-T1 brachial plexus palsy. An anatomic study.

We present an anatomical and histomorphometric study of the transfer of the motor branch to the brachioradialis muscle to the anterior interosseous nerve in recent brachial plexus lesions, involving C8 and T1 roots. The aim of this study was to demonstrate the anatomic constancy of the nerves involved in the transfer, feasibility, and reproducibility of the transfer. We performed a study of 14 elbows in fresh cadavers. Transfer of the motor branch of the brachioradialis muscle to the anterior interosseous nerve was possible in all specimens; there was constancy in the origin and entry into the muscle of the donor nerve, and it was always possible to dissect the recipient nerve at the level of the donor nerve, thereby allowing for direct coaptation of the nerves. The mean diameter of the anterior interosseous nerve was 2.9 ± 0.5 mm and the mean diameter of the brachioradialis muscle branch was 2 ± 0.4 mm. The branch to the brachioradialis muscle contains an average of 550 ± 64 myelinated axons and the anterior interosseous nerve has an average of 2266 ± 274 myelinated axons. The anatomic study in cadavers showed that the technique is justified and anatomically reproducible.

Transfer of median and ulnar nerve fascicles for lesions of the posterior cord in infraclavicular brachial plexus injury: report of 2 cases.

In infraclavicular lesions of brachial plexus, severe lesions of the posterior cord often occur when medial and lateral cord function is preserved to a greater or lesser extent. In these cases, shoulder function may be preserved by activity of the muscles innervated by the suprascapular nerve, but complete paralysis exists in the deltoid, triceps, and brachioradialis, and all wrist and finger extensors. Classical reconstruction procedures consist of nerve grafts, but their results in adults are disappointing. We report an approach transferring: (1) an ulnar nerve fascicle to the motor branch of the long portion of the triceps brachii muscle, (2) a median nerve branch from the pronator teres to the motor branch of the extensor carpi radialis longus, and (3) a median nerve branch from the flexor carpi radialis to the posterior interosseous nerve. We describe the procedure and report 2 clinical cases showing the effectiveness of this technique for restoring extension of the elbow, wrist, and fingers in the common infraclavicular lesions of the brachial plexus affecting the posterior cord.

Anterior release of elbow flexion contractures in children with obstetrical brachial plexus lesions.

PURPOSE: A flexion contracture of the elbow is common in upper obstetric brachial plexus palsy. One less than 30° involves no major aesthetic or functional abnormalities, whereas for one greater than 30°, conservative treatment with serial splints produces variable results. We evaluated anterior release of the elbow with partial tenotomy of the anterior brachialis muscle and of the biceps, for their effect on elbow flexion contractures. METHODS: We performed 10 anterior releases of the elbow with lengthening of the distal tendons of the biceps and the anterior brachialis muscle. All patients had upper obstetric brachial plexus palsies (C5-C6) and elbow flexion contractures of 35° or greater (range, 35° to 60°). The flexion strength of the elbow was 4 or higher on the British Medical Research Council scale, and the patients had no bone abnormalities in the elbow region. RESULTS: After a mean follow-up period of 3 years, the mean gain in extension was 28° (range, 20° to 35°). All patients maintained flexion strength. Elbow extension was 2° less than obtained at surgery and was maintained during follow-up. All patients were satisfied or very satisfied, and none presented major complications, except hypertrophic scarring to a greater or lesser extent at the incision site. CONCLUSIONS: Anterior release of the elbow is a useful method for treating elbow flexion contractures of more than 35° and can reduce the deformity to bring it within functional range without compromising flexion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Transmanubrial transclavicular approach in tumors of the brachial plexus.

The standard transclavicular approach allows only limited and narrow exposure if the cervical thoracic region for the resection of tumors of the brachial plexus is involved. We report 2 cases of retroclavicular tumors of the brachial plexus. We performed a complete resection in both cases using the transmanubrial transclavicular approach. This approach consists of retracting an osteomuscular flap that involves the medial portion of the clavicle, part of the sternal manubrium, the sternoclavicular joint, and the sternocleidomastoid muscle. We describe and discuss this approach, which provides access to the entire brachial plexus and the major vessels, thereby affording excellent control of the vessels; it is the approach of choice for tumors in this location.

Transfer of the nerve to the brachioradialis muscle to the anterior interosseous nerve for treatment for lower brachial plexus lesions: case report.

In lower lesions of the brachial plexus (C8-T1) there is good function of the shoulder, elbow, and wrist, although that of the hand is impaired. Reconstruction of finger flexion is generally obtained by tendon transfer. We present a case report involving transfer of the motor nerve branch of the brachioradialis muscle to the anterior interosseous nerve to restore finger flexion in acute lower brachial plexus lesion.

Anciano Frágil y Calidad de Vida / Frail elderly people and Quality of life

Objetivo. Conocer el grado subjetivo de deterioro de la calidad de vida en ancianos con criterios defragilidad.Diseño. Estudio observacional, descriptivo, transversal.Emplazamiento. Atención Primaria, Zona de Salud.Participantes. Ancianos con criterios de fragilidad. Criterio de exclusión: ancianos frágiles con deteriorofísico/psíquico que impidiera cumplimentar los cuestionarios o negativa a participar (total8,5%).Mediciones principales. Cuestionario de calidad de vida Nottingham Health Profi le (NHP) para lavariable principal. Otras variables recogidas: sociodemografi cas (edad, sexo y convivencia), númerode enfermedades crónicas y de fármacos consumidos y el cuestionario de capacidad funcional de Barthel.Resultados. Edad media de 81,4 años, 67,5% mujeres, 33,7% vivían solos, número medio de 3,2patologías crónicas y de 4,7 fármacos consumidos. El porcentaje de deterioro global en el NHP fuede 25,6 (IC95% 22,8-28,3), siendo dicho deterioro variable en cada una de las dimensiones: energía(26,1; 21,2-31,0), dolor (20,5; 16,8-24,3), movilidad (32,5; 28,6-36,5), reacción emocional (23,7;20,4-27,1), sueño (33,8; 29,0-38,5) y aislamiento social (17,2; 14,3-20,1). El grado de deterioro globalse asoció, de forma estadísticamente signifi cativa, con mayor edad, convivencia fuera del núcleofamiliar, mayor número de patologías crónicas, mayor consumo de fármacos y menor capacidadfuncional.Conclusiones. Existe un grado de deterioro subjetivo importante en la calidad de vida del ancianofrágil. Parece justifi cada la inclusión de la valoración de la calidad de vida subjetiva en la valoración integral de este tipo de pacientes

Objective. To determine the subjective deterioration in quality of life in elderly people who met frailty criteria.Design. Cross-sectional, descriptive, observational study.Setting. Primary Care, Health AreaParticipants. Elderly people with signs of frailty. Exclusion criteria: frail elderly people who, due to their physical or mental impairment, were unable to complete the questionnaires or did not want to take part(total 8.5 %).Main measurements. Primary variable: Nottingham Health Profi le (NHP) quality of life questionnaire. Othervariables were: socio-demographic data (age, gender and co-residence), number of chronic diseases, numberof drugs being taken, and Barthel’s index for functional capacity.Results. The mean age of the participants was 81.4 years, 67.5% were women and 33.7% lived alone.The mean number of chronic diseases was 3.2 and the mean number of drugs being taken was 4.7. Thepercentage of overall deterioration on the NHP was 25.6 (95% CI 22.8-28.3), This percentage deteriorationvaried among the dimensions: energy (26.1; 21.2-31), pain (20.5; 16.8-24.3), physical mobility (32.5; 28.6-36.5), emotional reactions (23.7; 20.4-27.1), sleep (33.8; 29-38.5) and social isolation (17.2; 14.3-20.1). The degree of overall deterioration was associated, in a statistically signifi cant manner, with older age, co-residence outside the family, higher number of chronic diseases, higher number of drugs being taken and lowerfunctional capacity.Conclusions. There is a signifi cant level of subjective deterioration in the quality of life in frail elderly people. Including the subjective evaluation of quality of life in the overall assessment of this type of patient would seem justified (AU)

Closed degloving of the thumb.

We present a work-related injury where the drums of a printing machine caused a closed degloving of the distal phalanx of the thumb, which represents detachment of the soft tissue from the bone.

Reconstruction of bone defects with impacted allograft in femoral stem revision surgery.

A retrospective clinical review was done on 54 revision hip patients. Radiological analysis examined the Gross and AAOS classifications, stem position, cement mantles, allograft and evolution (subsidence, resorption and remodelling). The Harris Hip score was used for clinical assessment. We used bone bank allograft and a polished non-collared stem LD. The follow-up period was 60.5 months (19.4-152.4), and the average age 68.5 (range: 22-85). There were 21 females and 33 males. The surgical approach was: lateral (5.56%) posterior (91.4%); trochanteric osteotomy: 25.9%; associated acetabular revision: 59.3%; previous operations: 1.9. The preoperative Harris score was 35 (28-40) and rose to 81 (50-99) postoperatively. The stem alignment was neutral (44.44%), varus (38.89%) and valgus (16.67%). The femur/stem diameter relationship was 1.8 (1.2-2.7). There were no changes in stem alignment in 94.4%. An adequate cement mantle was: proximal zone (61.1%), medium zone (27.8%) and distal zone (16.7%). The rate of any subsidence was 38.9% (progressive: 12.96%). The rate of complications was 40.7% and included periprosthetic fracture: 14.8%; superficial infection: 1.9%; deep late infection: 1.9%; dislocation: 3.7%; heterotopic ossification: 13%. The rate of new stem revision was 16.6%. The clinical and radiological success rate was 77.78%. A greater incidence of revisions has been found in stem malalignment, progressive subsidence, a Harris increase of <20 points, allograft resorption, small diameter stems and inadequate cement mantle. We recommend hard impaction and a cement mantle of at least 2 mm. Non-progressive subsidence does not increase stem loosening. The technique has been useful in recovering bone stock in a severely defective femur and achieves a stable reconstruction. The level of evidence was therapeutic study level III-2 (retrospective cohort study; see the instructions to the authors for a complete description of the levels of evidence).

¿Por qué acuden nuestros pacientes directamente a las urgencias hospitalarias? / Why our patients goes directly to emergency department in hospital?

Objetivo. Conocer los motivos por los que los pacientes acuden a urgencias hospitalarias sin pasar por urgencias de Atención Primaria (AP).Diseño. Estudio descriptivo transversal.Emplazamiento. Urgencias hospitalarias.Participantes. Pacientes atendidos en urgencias entre junio 2004 y febrero 2005 seleccionados aleatoriamente.Mediciones principales. Cuestionario anónimo preguntando: edad, sexo, tipo de derivación, distanciaal hospital, confi anza en urgencias hospitalarias, urgencias AP y médico AP, motivo de utilizacióndel servicio, duración del proceso e ingresos.Resultados. Se realizaron 508 entrevistas, el 48,2 % hombres, con edad media 38,97 (DE 24,21). Acudieron no derivados el 66,7 % (IC 95 %: 62,42 – 70,79), sin diferencias estadísticamente signifi cativaspor sexo o edad respecto al tipo de derivación. El tiempo medio en llegar al hospital los no derivadosfue 23,25 minutos (DE 15,17) frente a 28,03 (DE 16,12) en los derivados (t = -3,07; p< 0,01). Confianza en urgencias AP alta/muy alta en el 37,7 % de los no derivados frente al 60,2 % de los derivados(χ2 :18,07; p< 0,01). Motivos de no acudir a urgencias AP: pruebas complementarias (21,2%), especialista (18%) y desconfi anza en urgencias AP (16,8%). Ingresó el 5,3% de no derivados frente al 19,3% de derivados (χ2:95,79; p< 0,01). En análisis multivariante infl uye, en acudir directamente al hospital, la desconfi anza en urgencias AP (OR: 2,61; IC 95 %: 1,64-4,15) y la cercanía al hospital (OR: 1,02; IC 95%: 1-1,03).Conclusiones. Dos tercios de los pacientes acuden directamente al hospital, siendo la cercanía y ladesconfi anza en urgencias AP las principales causas

Objective. To know why patients goes directly to emergency department in hospital avoiding emergencyin primary care level.Design. Descriptive and transversal study.Setting. Emergency department in hospitalSubjects. Patients who went hospital emergency department between June’04 and February’05 withrandom selectionPrincipal measurements. Anonymous questionnaire with questions following: age, sex, sending origin,distance from home to hospital, confi dence in emergency hospital department, emergency serviceat primary care level and doctor, reason why went to emergency department, duration of process andadmission in hospital fl at.Results. Have been done 508 interviews, 48,2% male, average age 38.97 (SD 24,21). 66,7% (IC 95%: 62,42 – 70,79) went without document from primary care level, without differences with statisticalsignifi cance by sex, age or origin. The average arriving time was 23,25 minutes (SD 15,17) in thecase of not previous stop at primary care level vs. 28,03 (SD 16,12) with previous stop (t = - 3,07; p<0,01). The confi dence related about emergency at primary care level was high/very high in 37,7% inthe case of not previous stop in primary care vs. 60,2% with previous stop (X2: 18,07; p<0,01). Thereasons for not visit primary care level are: demand of complementary trials (21,2%), specialized consultancy(18%) and poor confi dence in emergency care at primary level (16,8 %). Was admitted in fl at 5,3% in the case of not previous stop vs. 19,3% in the case of patients with previous stop (X2: 95,79; p<0,01). The multivariant research show that have infl uenced to visit directly hospital, poor confi dence in emergency service at primary care level (OR: 2,61; IC 95 %:1,64 – 4,15) and the close distance to hospital (OR: 1,02; IC 95 %: 1-1,03).Conclusions. 66,66 of patients went directly to hospital, been the more important reasons the closedistance to hospital and the poor confi dence in emergency service at primary care level

Incontinencia anal / Anal incontinence

La continencia anal se produce como consecuencia de la compleja asociación de diversos procesos anatómicos y fisiológicos. De ello se deduce que la incontinencia, es decir, la incapacidad de controlar voluntariamente la emisión de heces, líquidos o gases es, así mismo, debida a una amplia variedad de situaciones.La incontinencia anal se reconoce hoy como un trastorno más frecuente de lo que antes se pensaba, se inicia por lo general después del parto y aumenta conforme avanza la edad. Es más común en multíparas y la incidencia más alta es en las mayores de 65 años.El conocimiento por parte del médico de la prevalencia, incidencia, fisiopatología y factores que favorecen la incontinencia anal; el diagnóstico acertado y la correcta utilización de las ayudas diagnósticas le darán las pautas para un tratamiento eficaz que beneficie efectivamente al paciente.

Avascular necrosis of trapezium bone: a case report.

A 26-year-old woman presented with radiologic signs of avascular necrosis of the trapezium bone. Treatment by bone excision and suspension arthroplasty gave an excellent clinical result. Pathology studies confirmed the diagnosis of avascular necrosis of the trapezium.

Incontinencia urinaria / Urinary incontinence

Poco se sabe de la evolución natural de la incontinencia urinaria, como la edad de inicio, las tasas de incidencia, el avance y la remisión espontánea. A la fecha, casi todos los estudios se han hecho en individuos de raza blanca y se requieren datos de grupos étnicos diferentes. Aunque la incontinencia urinaria es un síntoma de muchos trastornos, definir los factores de riesgo es útil para identificar personas de alto riesgo lo mismo que para un esfuerzo concertado de tipo preventivo. Así mismo, el conocimiento de los factores que favorecen la incontinencia urinaria es importante para identificar cual es el tipo de componente de la incontinencia que afecta a la paciente, entre los cuales están la incontinencia de esfuerzo y la de urgencia. Los signos de la incontinencia urinaria son parámetros objetivos de la pérdida de orina o las crisis de incontinencia y pueden incluir un diario de frecuencia, una prueba de esfuerzo con tos, una prueba de toalla sanitaria, el uso de un colorante para teñir la orina y confirmar la pérdida, o pruebas urodinámicas formales. Antes de proceder con tratamientos invasores como la cirugía, es aconsejable confirmar la presencia o intensidad de la incontinencia urinaria por uno o más métodos.

Prolapso de órganos pélvicos / Genitalia prolaps

El prolapso de órganos pélvicos se constituye en una de las indicaciones más frecuentes de cirugía ginecológica y se calcula que se han realizado más de 0.5 millones de procedimientos al año en Estados Unidos. El prolapso de órganos pélvicos a menudo no se hace sintomático hasta que el segmento descendido atraviesa el introito, y en otras ocasiones no se reconoce hasta que está en etapa terminal. Existen múltiples factores que favorecen el prolapso entre los que se encuentran el parto, los trastornos del tejido conectivo, neuropatías, factores congénitos y todos aquellos que conduzcan a un aumento de la presión intraabdominal como la obesidad, tos, ejercicio, etc. Cada uno de los componentes del prolapso de órganos pélvicos, bien sea del compartimiento anterior, medio o posterior, se clasifica por etapas o grados y la sintomatología de cada uno de ellos está directamente relacionada con la epata, siendo más sintomáticos aquellos con un grado más avanzado. La historia clínica, el examen ginecológico y las diversas ayudas diagnósticas se constituyen en la base primordial que darán las pautas para identificar el problema, seleccionar el tratamiento adecuado para cada paciente y lograr el éxito deseado por el médico y esperado por la paciente.