Ultrasound (US) measurement of the distance between the Achilles tendon and the posterior tibial neurovascular bundle in equinus infantile deformity.

OBJECTIVE: To study the distance between the Achilles tendon and the posterior tibial neurovascular bundle via ultrasound (US) - Doppler, with the goal of preventing neurovascular bundle injuries. METHODS: We studied 36 feet with equinus deformity (18 cases on the right and left side) in children with a mean age of 20.9 months. The distance between the Achilles tendon and the posterior tibial artery was intraoperatively measured using linear US at 10 MHz with Doppler. The measurement was made 1 cm proximal to the calcaneus insertion of the Achilles, where we planned to perform the tenotomy. The patient's weight and height were also recorded. Kolmogorov-Smirnov, t test, and Pearson correlation analyses were applied. Statistical significance was defined as p < 0.05. RESULTS: Mean distance between Achilles tendon and posterior neurovascular tibial bundle was 7.3 mm, and no differences between sexes or sides were observed. The distance was significantly correlated with weight (r = 0.54, p = 0.01) but not height or age. CONCLUSIONS: The distance between the Achilles tendon and the tibialis posterior neurovascular bundle is small, and there is a risk of surgical injury during tenotomy of the Achilles tendon.

Aplicabilidad de análogos de la prostaglandina I2 en el tratamiento del síndrome de edema de médula ósea de la cabeza femoral. Caso clínico / Applicability of prostaglandin I2 analogs in the treatment of bone marrow edema syndrome of the femoral head. Clinical case

Objetivo: Mostrar nuestra experiencia con el uso de la prostaciclina en el tratamiento del síndrome de edema de médula ósea de la cabeza femoral. Material y método: Se evalúa retrospectivamente la efectividad de la infusión intravenosa de prostaciclina en un caso clínico de una mujer de 40 años de edad con síndrome de edema de médula ósea de cabeza femoral, con pruebas de imagen (radiografía y resonancia magnética) y escalas analógicas (EVA) y funcionales (Harris). Resultados: Se objetivó la prácticamente plena resolución del edema óseo en resonancia magnética a las seis semanas de la infusión, con mejoría significativa tanto de la escala analógica como de la funcional. En el control clínico y radiográfico a los cuatro meses la paciente estaba asintomática, sin evidencia de osteonecrosis. Conclusión: Los análogos de la prostaglandina I2 podrían tener beneficio terapéutico en los síndromes de malperfusión ósea, si bien son necesarios más estudios para determinar su efectividad real (AU)

Objective: To show our experience with the use of prostacyclin in the treatment of bone marrow edema syndrome of the femoral head. Material and method: We retrospectively evaluated the effectiveness of intravenous infusion of prostacyclin in a case of a 40 year old woman with bone marrow edema syndrome of the femoral head, with imaging techniques (x-ray and MRI), pain scale (VAS) and functional scale (Harris). Results: We achieved nearly complete resolution of bone edema on MRI at seis weeks after infusion, with significant improvement of both the pain and the functional scale. At the clinical and radiographic control after four months the patient is asymptomatic, without evidence of osteonecrosis. Conclusion: Prostaglandin I2 analogues may have therapeutic benefit in bone malperfusion syndromes, although more research is necessary to determine its real effectiveness (AU)

Fractura incarcerada de epitróclea con lesión del nervio cubital / Incarcerated epitrochlear fracture with a cubital nerve injury

Las epifisiólisis de la epitróclea son lesiones relativamente frecuentes, que afectan fundamentalmente a niños entre los 7 y los 15 a˜nos. Las características anatómicas de esta apófisis puede dificultar el diagnóstico en las fracturas mínimamente desplazadas. En un peque˜no porcentaje de casos el fragmento fracturario puede ocupar el surco retroepitroclear. La presencia de disestesias en el territorio del nervio cubital obliga a la reducción abierta urgente del fragmento incarcerado. Se presenta el caso de un paciente varón de 7 a˜nos de edad, que precisó de una revisión quirúrgica por una fractura desplazada de epitróclea asociada a lesión del nervio cubital. Se realiza una revisión de la literatura médica respecto a esta enfermedad (AU)

Injuries of the medial epicondyle are relatively common, mostly affecting children between 7 and 15 years. The anatomical characteristics of this apophysis can make diagnosis difficult in minimally displaced fractures. In a small percentage of cases, the fractured fragment may occupy the retroepitrochlear groove. The presence of dysesthesias in the territory of the ulnar nerve requires urgent open reduction of the incarcerated fragment. A case of a sevenyear- old male patient is presented, who required surgical revision due to a displaced medial epicondyle fracture associated with ulnar nerve injury. A review of the literature is also made (AU)

[Incarcerated epitrochlear fracture with a cubital nerve injury]. / Fractura incarcerada de epitróclea con lesión del nervio cubital.

Injuries of the medial epicondyle are relatively common, mostly affecting children between 7 and 15 years. The anatomical characteristics of this apophysis can make diagnosis difficult in minimally displaced fractures. In a small percentage of cases, the fractured fragment may occupy the retroepitrochlear groove. The presence of dysesthesias in the territory of the ulnar nerve requires urgent open reduction of the incarcerated fragment. A case of a seven-year-old male patient is presented, who required surgical revision due to a displaced medial epicondyle fracture associated with ulnar nerve injury. A review of the literature is also made.

[Palliative surgical treatment of spastic paralysis in the lower extremity]. / Cirugía paliativa de la parálisis espástica en las extremidades inferiores.

AIMS: The purpose of this paper is to describe our experience with and to review the best results in the surgical treatment of patients suffering from spastic paralysis of the lower limbs. DEVELOPMENT: To enable a correct indication of the techniques to be employed the authors recommend a thorough examination of the types of deformity (fixed, dynamic or mixed) and the use of specific tests for exploring the different deformities. These are necessary steps to be able to interpret the different disorders in a global manner and thus reach diagnostics that provide us with a proper surgical therapeutic orientation about the spastic hip, knee, ankle and foot. Due to the importance of the overall problem, it is becoming increasingly more frequent to advise multidisciplinary work involving the collaboration of different specialists (neurologists, rehabilitators, physiotherapists, psychologists, paediatricians, neurophysiologists and orthopaedic surgeons). Spasticity is as heterogeneous as the results of the different treatment projects. The techniques used must allow the rehabilitation therapy to be continued. Surgical intervention is recommended when the damage to the CNS has stabilised and the patient is over 4 years old. The psychic state of the patient and the family must also be evaluated. CONCLUSIONS: The objective of the treatment in patients who can walk is to improve motor functioning, the type of gait and to prevent fixed deformities from developing. In patients who do not walk, the aim is to improve their hygiene and their capacity to sit and to walk. These indications are indispensable to be able to successfully perform a little-known area of orthopaedic surgery which does not respond to the techniques used in flaccid paralysis surgery.

[Palliative surgical treatment of spastic paralysis in the upper extremity]. / Cirugía paliativa de la parálisis espástica en las extremidades superiores.

AIMS: In this paper we review the main studies conducted on therapy applied to the bony and soft parts in spastic paralysis of the upper extremity. DEVELOPMENT: Spasticity presents muscular hypertonia and hyperexcitability of the stretch reflex, which are typical of upper motoneuron syndrome. Physiopathologically, spasticity is due to the medullar and supramedullar alteration of the afferent and efferent pathways. Treatment is multidisciplinary and involves the collaboration of rehabilitators, neurophysiologists, neurologists, paediatricians, orthopaedic surgeons and psychologists, who all contribute with their different therapeutic aspects and characteristics (which can be pharmacological, peripheral neurological blockages, surgical, etc.). The characteristic posture of the upper extremities in spastic cerebral palsy is the inward rotation of the shoulder, flexion of the elbow and pronated forearm, and the deformity of the fingers (swan-neck and thumbs-in-palm). The primary objectives in these patients will be to improve communication with their surroundings, perform activities of daily living, increase mobility and walking. CONCLUSIONS: The surgical treatment applied by orthopaedic surgeons in the upper extremities are aimed at achieving an enhanced adaptive functionality rather than morphological normality. Factors to be taken into account include age, voluntary control over muscles and joints, level of severity of the spasticity (Ashworth scale) and stereognostic sensitivity. In general, on soft parts we will use procedures such as dehiscence or lengthening of the flexor muscles of the shoulder and elbow or of the adductor of the thumb; transfer of the pronators in order to adopt the supinating function or of the flexors so as to reinforce the extensors of the forearm, and capsulodesis or tenodesis in the hand. The bony procedures will consist in derotational osteotomies of the humerus and radius and arthrodesis in the wrist or in the metacarpophalangeal joints of the thumb, depending on whether there is greater rigidity or age in the former cases or instability in the latter.

Cirugía paliativa de la parálisis espástica en las extremidades superiores / Palliative surgical treatment of spastic paralysis inthe upper extremity

Objetivo. En el presente trabajo se revisan los principales estudios de las aplicaciones terapéuticas sobre las partes óseas y las partes blandas en la parálisis espástica de las extremidades superiores. Desarrollo. La espasticidad se presenta con hipertonía muscular e hiperexcitabilidad del reflejo de estiramiento, típicos del síndrome de la motoneurona superior. Fisiopatológicamente, la espasticidad se debe a la alteración de las vías aferentes y eferentes medular y supramedularmente. Su tratamiento es multidisciplinar: intervienen, fundamentalmente, rehabilitadores, neurofisiólogos, neurólogos, pediatras, cirujanos ortopédicos y psicólogos, que aportan sus distintos enfoques y sus características terapéuticas (tratamiento farmacológico, bloqueos neurológicos periféricos y quirúrgico, etc.). La postura característica de las extremidades superiores en la parálisis cerebral espástica es la rotación interna del hombro, la flexión del codo y la pronación del antebrazo, y la deformidad de los dedos (cuello de cisne y pulgares en palma). Los objetivos prioritarios en estos pacientes serán mejorar su comunicación con el entorno, que realicen actividades de la vida diaria e incrementar su movilidad y deambulación. Conclusiones. Los tratamientos quirúrgicos que aplican los cirujanos ortopédicos en las extremidades superiores pretenden, más que la normalidad morfológica, una mejor funcionalidad adaptativa. Son factores a considerar la edad, el control voluntario muscular y de las articulaciones, la gravedad de la espasticidad (escala de Ashworth) y la sensibilidad estereognósica. En general, utilizaremos procedimientos sobre las partes blandas, como la desinserción o el alargamiento de los músculos flexores del hombro y el codo o del aductor del pulgar; transferencia de los pronadores para adoptar función supinadora, o de los flexores para potenciar los extensores en el antebrazo, y capsulodesis o tenodesis en la mano. Los procedimientos óseos consistirán en osteotomías desrotadoras del húmero y el radio y artrodesis en la muñeca o en la articulación metacarpofalángica del pulgar, según existan mayor rigidez o más edad en los primeros casos o inestabilidad en el último (AU)

Aims. In this paper we review the main studies conducted on therapy applied to the bony and soft parts in spastic paralysis of the upper extremity. Development. Spasticity presents muscular hypertonia and hyperexcitability of the stretch reflex, which are typical of upper motoneuron syndrome. Physiopathologically, spasticity is due to the medullar and supramedullar alteration of the afferent and efferent pathways. Treatment is multidisciplinary and involves the collaboration of rehabilitators, neurophysiologists, neurologists, paediatricians, orthopaedic surgeons and psychologists, who all contribute with their different therapeutic aspects and characteristics (which can be pharmacological, peripheral neurological blockages, surgical, etc.). The characteristic posture of the upper extremities in spastic cerebral palsy is the inward rotation of the shoulder, flexion of the elbow and pronated forearm, and the deformity of the fingers (swan-neck and thumbs-in-palm). The primary objectives in these patients will be to improve communication with their surroundings, perform activities of daily living, increase mobility and walking. Conclusions. The surgical treatment applied by orthopaedic surgeons in the upper extremities are aimed at achieving an enhanced adaptive functionality rather than morphological normality. Factors to be taken into account include age, voluntary control over muscles and joints, level of severity of the spasticity (Ashworth scale) and stereognostic sensitivity. In general, on soft parts we will use procedures such as dehiscence or lengthening of the flexor muscles of the shoulder and elbow or of the adductor of the thumb; transfer of the pronators in order to adopt the supinating function or of the flexors so as to reinforce the extensors of the forearm, and capsulodesis or tenodesis in the hand. The bony procedures will consist in derotational osteotomies of the humerus and radius and arthrodesis in the wrist or in the metacarpophalangeal joints of the thumb, depending on whether there is greater rigidity or age in the former cases or instability in the latter (AU)

Cirugía paliativa de la parálisis espástica en las extremidades inferiores / Palliative surgical treatment of spastic paralysis in the lower extremity

Objetivo. En el presente trabajo se expone nuestra experiencia y la revisión de los mejores resultados en el tratamiento quirúrgico de los enfermos afectados de parálisis espástica de los miembros inferiores. Desarrollo. Para la correcta indicación de las técnicas a emplear, los autores recomiendan el examen exhaustivo de los tipos de deformidades (fija, dinámica o mixta) y el empleo de los test de exploración específicos de las distintas deformidades, pasos necesarios para poder interpretar las distintas alteraciones de una forma global, y llegar así a unos diagnósticos que nos permitan una adecuada orientación terapéutica quirúrgica sobre la cadera, la rodilla, el tobillo y el pie espásticos. Debido a la importancia que tiene el problema global, cada vez más frecuente, se aconseja el trabajo multidisciplinar con la colaboración de distintos especialistas (neurólogo, rehabilitador, fisioterapeuta, psicólogo, pediatra, neurofisiólogo y cirujano ortopédico). La espasticidad es tan heterogénea como los resultados de los diversos proyectos de tratamiento. Las técnicas utilizadas deben permitir la continuación del tratamiento rehabilitador. Se aconseja la intervención quirúrgica cuando se ha estabilizado el daño del SNC y el paciente tiene más de 4 años. Ha de valorarse el psiquismo del paciente y de la familia. Conclusiones. El objetivo del tratamiento en los pacientes que deambulan es mejorar la función motora y el tipo de marcha, y prevenir el desarrollo de deformidades fijas, mientras que en los pacientes que no deambulan se pretende mejorar la higiene y la capacidad de sentarse y deambular. Estas indicaciones son imprescindibles para llegar a realizar con éxito una parcela de la cirugía ortopédica poco conocida y que no responde a las técnicas empleadas en la cirugía de las parálisis flácidas (AU)

Aims. The purpose of this paper is to describe our experience with and to review the best results in the surgical treatment of patients suffering from spastic paralysis of the lower limbs. Development. To enable a correct indication of the techniques to be employed the authors recommend a thorough examination of the types of deformity (fixed, dynamic or mixed) and the use of specific tests for exploring the different deformities. These are necessary steps to be able to interpret the different disorders in a global manner and thus reach diagnostics that provide us with a proper surgical therapeutic orientation about the spastic hip, knee, ankle and foot. Due to the importance of the overall problem, it is becoming increasingly more frequent to advise multidisciplinary work involving the collaboration of different specialists (neurologists, rehabilitators, physiotherapists, psychologists, paediatricians, neurophysiologists and orthopaedic surgeons). Spasticity is as heterogeneous as the results of the different treatment projects. The techniques used must allow the rehabilitation therapy to be continued. Surgical intervention is recommended when the damage to the CNS has stabilised and the patient is over 4 years old. The psychic state of the patient and the family must also be evaluated. Conclusions. The objective of the treatment in patients who can walk is to improve motor functioning, the type of gait and to prevent fixed deformities from developing. In patients who do not walk, the aim is to improve their hygiene and their capacity to sit and to walk. These indications are indispensable to be able to successfully perform a little-known area of orthopaedic surgery which does not respond to the techniques used in flaccid paralysis surgery (AU)

Cálculo vectorial in vitro de las fuerzas de cizallamiento y compresión en la cadera del niño / Vectorial calculations in vitro of shears and compression forces in teh infantile HIP

Objetivo: Estudiar in vitro las magnitudes vectoriales de las fuerzas de cizallamiento y compresión en el acetábulo y el fémur proximal en la cadera infantil. Diseño experimental: Se efectuaron cálculos con ecuaciones trigonométricas con las variables: índice acetabular, ángulo fisario de Alsberg y peso corporal medio a los 7 y 12 meses de edad, tanto en a) bipedestación estática como en b) apoyo monopodal. Todo ello con 3 coeficientes de fricción: 0; 0,3 y 0,6. Resultados: En el acetábulo, las fuerzas de cizallamiento, aumentaron un 41 por ciento entre los 0° y los 40° en bipedestación estática y 40 por ciento y 69 por ciento entre 20° a 25° y 35° a 40°, respectivamente, durante el apoyo monopodal. Las de compresión disminuyeron un 4 por ciento entre 0° y 40°, 1 por ciento de 0° a 15° y 2 por ciento de 15° a 40° con la bipedestación, doblando casi su magnitud en el apoyo monopodal. Las fuerzas de cizallamiento fueron la cuarta parte de las de compresión en bipedestación y apoyo monopodal. En el fémur proximal, las fuerzas de cizallamiento aumentaron 24 por ciento entre 90° y 0°, (60 por ciento entre 70°-65°) en bipedestación y 11,5 por ciento, entre 75° y 70° del ángulo fisario, todo ello con apoyo monopodal. Las de compresión aumentaron un 12 por ciento globalmente, pero sólo el 2 por ciento entre 75° y 90° en bipedestación, incrementándose un 6,4 por ciento en apoyo monopodal, pero con descenso de su magnitud entre 75° y 90°. El cizallamiento dobló en el fémur proximal a la compresión, especialmente en bipedestación, pero sólo fue un 4 por ciento mayor en 60° del ángulo fisario en apoyo monopodal. Conclusión: La morfología normal del acetábulo y el fémur proximal, parecen ajustarse a evitar grandes magnitudes vectoriales de cizallamiento y compresión. (AU)

Epidemiology of trochanteric fractures of the femur in Alicante, Spain, 1974-1982.

From 1974 until 1982, the cases of 1287 patients with trochanteric fractures of the femur were examined. The incidence of this injury (16.6 per 100,000 persons per year) was lower than in other countries and increased over time. The predominance of the injury in women was 2:1 and the average age was 76.6 years. Women had a higher average age, but there was a progressive increase in age among men. There were no seasonal differences in the frequency of the injury. Seventy-seven percent of the cases were due to moderate trauma; most injuries occurred in the home. Sixty-four percent of the patients had associated diseases. Radiologic morphometry, using the Singh index and a modified method of the cortical-shaft index, was used in 246 patients older than 60 years of age; 84% of these patients had poor bone quality. There was no correlation between the degree of osteopenia and sex, although there was a correlation between osteopenia and fracture type.