Bloqueo interescalénico guiado por ecografía en un paciente con alteraciones anatómicas de la región supraclavicular secundarias a radioterapia y cirugía / Ultrasound-guided interscalene block in a patient with supraclavicular anatomical abnormalities due to radiotherapy and surgery

Los bloqueos anestésicos regionales para anestesia quirúrgica pueden resultar difíciles en pacientes con determinadas alteraciones de la anatomía de superficie. Los ultrasonidos para anestesia regional pueden permitir el acceso en estos casos. Presentamos un paciente que sufrió una fractura de húmero derecho al que se realizó un bloqueo del plexo braquial interescalénico guiado por ultrasonidos. El paciente presentaba alteraciones secundarias a radioterapia en la zona cervicofacial derecha que alteraban las referencias externas. Se describe la técnica de abordaje para insertar un catéter, y las características de la exploración ecográfica. No emplear neuroestimulación evitó contracciones dolorosas. La analgesia intra y postoperatoria durante 24 horas fueron óptimas(AU)

Regional blocks can be difficult in surgical patients with certain superficial anatomical abnormalities. Such blocks may be possible, however, under ultrasound guidance. We report a case in which a man with a fractured right humerus required an ultrasound-guided interscalene brachial plexus block. Secondary to radiotherapy, the patient had right cervical and facial abnormalities that had altered the location of external anatomical landmarks. We describe the approach used to insert the catheter and the exploration of the region by ultrasound. Nerve stimulation was not used to avoid painful contractions. Analgesia was excellent during surgery and over the following 24 hours(AU)

Anatomical variations associated with the carotid arterial system in the neck

During routine dissection of the neck regionof a middle aged female cadaver, the brachiocephalictrunk was found to arise from thearch of the aorta along the left margin of thetrachea. The right common carotid arose anteriorto the upper trachea and crossed it. Thecrossing of the upper part of the trachea by theright common carotid artery is a rare occurrence.A more distal branching of the aorticsac during fetal life could explain the anomalousorigin of the brachiocephalic trunk. Thismay lead to an unusual origin and course ofthe right common carotid artery. Knowledgeof this rare variation is clinically important formaking midline neck incisions, as well as forrevealing the diagnoses of pulsatile neckswellings. The other variations of the carotidarterial system described in this case includebilateral tortuosity of the common carotidarteries and external carotid arteries; ananterolateral relationship of the right externalcarotid artery to the right internal carotidartery at their origins; high bifurcation of theleft common carotid artery, and a bilateral originof the superior thyroid arteries from thecommon carotid artery. These more commonvariations need to be kept in mind when makingclinical diagnoses, conducting neck surgeriesand carrying out carotid angiography.The isthmus of the thyroid gland was found tobe absent. This finding is important because itmay be associated with other thyroid abnormalities (AU)

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Entrapment of plantaris tendon between the tibial nerve and its branch: a case report

The plantaris muscle arises from the lateralsupra condylar line and the long slender tendonof the muscle descends between the gastrocnemiusand the soleus muscles. The tibialnerve, a branch of the sciatic nerve, is thenerve of the posterior compartment of the leg.The tibial nerve is related superficially to theplantaris tendon, but in the present case wereport an anomalous plantaris tendon that passed between the tibial nerve and its branch to the soleus muscle. Such an entrapment of the plantaris tendon between the tibial nerve and its branch to the soleus is an extremelyrare finding, which is neither reported in standardtextbooks of anatomy nor in any other research report. The pull of the plantaris tendon may press upon the nerve to the soleus,thereby causing compression neuropathy. Also, surgical exploration of the thin plantaris tendon must be carefully performed, especiallywhen it is trapped between the two nerves. Knowledge and awareness of such anomalies may be important for academic, clinical and surgical purposes (AU)

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Origen aórtico de arteria pulmonar izquierda en neonato con tetralogía de Fallot / Aortic origin of the left pulmonary artery in an infant with Fallot's tetralogy

Presentamos el caso de un neonato con diagnóstico prenatal de tetralogía de Fallot. Durante la segunda semana de vida presentó dificultad respiratoria; en la radiografía de tórax se observó un aumento del ventrículo derecho con edema pulmonar. La ecocardiografía mostró los hallazgos de la tetralogía de Fallot. En el cateterismo cardíaco se encontró además un origen anómalo de la arteria pulmonar izquierda desde la aorta ascendente. A los 23 días se realizó cirugía correctora con anastomosis directa sin utilizar interposición de conducto. Fue dado de alta hospitalaria 10 días después. Revisamos la literatura médica de esta rara entidad, en sus hallazgos epidemiológicos, fisiopatológicos, clínicos, diagnósticos y quirúrgicos (AU)

We report the case of a male neonate who had a prenatal diagnosis of Fallot's tetralogy. He presented with respiratory distress during the second week of life. Chest x-ray showed an enlarged right ventricle and pulmonary edema. Echocardiography demonstrated characteristic features of Fallot's tetralogy. However, cardiac catheterization disclosed that, in this case of Fallot's tetralogy, the left pulmonary artery had an anomalous origin in the ascending aorta. At 23 days of age, the patient underwent total surgical correction of the defects, during which a direct anastomosis was employed without conduit placement. 10 days later, he was discharged. We present the results of a literature review of the epidemiological, physiopathological, clinical, diagnostic, and surgical characteristics of this rare condition (AU)

Hemorragia intestinal severa en una niña con duplicación ileal y breve reseña de la entidad / Severe hemorrhage intestinal in a child with ileal duplication and brief entity review

Las duplicaciones intestinales son malformaciones congénitas poco comunes localizadas en el borde mesentérico del intestino delgado, particularmente en el íleon. Más del 60% de los casos son sintomáticas durante el primer año de vida y el resto en escolares y adultos. El amplio espectro de síntomas y signos inespecíficos que presentan, frecuentemente simulan otras enfermedades. Entre las complicaciones destaca la hemorragia gastrointestinal que llega, ocasionar anemia severa y shock, como el caso que describimos de una niña de 11 años de edad, que presentó durante 15 meses severas evacuaciones sanguinolentas intermitentemente acompañadas de dolor abdominal intenso y anemia. Los niveles de hemoglobina llegaron hasta 6 g/dL requiriendo en varias ocasiones hemotransfusión. Múltiples diagnósticos y exámenes fueron realizados y finalmente la gammagrafía con Tc99m mostró mucosa gástrica ectópica; mediante laparotomía se encontró una duplicación intestinal en el íleon terminal. Se analiza esta entidad y su importancia de considerarla en el diagnóstico diferencial en cualquier tipo de sangrado del tubo digestivo (AU)

Intestinal duplications are very uncommon congenital malformations located in the mesenteric edge of the small bowel, particularly in the ileum. Over 60% of the patients become symptomatic during the first year of life whereas the remainder demonstrates symptoms at school age or adulthood. The wide spectrum of symptoms and unspecific signs frequently simulate other diseases. Gastrointestinal hemorrhage is the most noteworthy complication, which can cause severe anemia and shock. In the case we describe an 11-year-old girl experienced massive intermittent intestinal hemorrhage, anemic syndrome and intense abdominal pain over 15 months. In this patient, hemoglobin levels rose up to 6 g/dL necessitating several hemotransfusion. Multiple diagnosis and examinations were carried out until finally the gammagram with Tc99m disclosed an ectopic gastric mucosa. Using a laparotomy an intestinal duplication was found in the terminal ileum. In this paper the intestinal duplication is analyzed and the importance of considering it as a differential diagnosis in any kind of bleeding of the digestive tube is discussedIntestinal duplications are very uncommon congenital malformations located in the mesenteric edge of the small bowel, particularlyin the ileum. Over 60% of the patients become symptomatic during the first year of life whereas the remainder demonstrates symptoms at school age or adult hood. The wide spectrum of symptoms andunspecific signs frequently simulate other diseases. Gastrointestinal hemorrhage is the most note worthy complication, which can cause severe anemia and shock. In the case we describe an 11-year-old girl experienced massive intermittent intestinal hemorrhage, anemic syndromeand intense abdominal pain over 15 months. In this patient,hemoglobin levels rose up to 6 g/dL necessitating several hemotransfusion. Multiple diagnosis and examinations were carried out until finally the gammagram with Tc99m disclosed an ectopic gastric mucosa. Usinga laparotomy an intestinal duplication was found in the terminal ileum. In this paper the intestinal duplication is analyzed and the importance of considering it as a differential diagnosis in any kind of bleeding ofthe digestive tube is discussed (AU)

Determinación de función renal y cambios compensadores en niños con riñón único / Study of renal function and compensatory changes in children with single kidney

Introducción. Se ha considerado siempre que la reducción de la masa renal durante la infancia, causa una serie de cambios funcionales que eventualmente pueden conducir a un daño irreversible en el riñón remanente con el paso de los años. Objetivos. La evidencia de estas lesiones en múltiples publicaciones nos movió a revisar a un grupo de 38 pacientes monorrenos en la edad infantil y a intentar determinar el riesgo de aparición de las mismas a través de parámetros como la función renal, la tensión arterial, la presencia de proteinuria y el volumen renal. Material y métodos. Se estudiaron 38 pacientes, 23 de ellos varones y 15 mujeres, de edades entre 1 y 13 años, que habían sufrido pérdida de masa renal por causas congénitas o adquiridas. Se separaron en dos grupos de enfermos: Grupo I: Ausencia congénita unilateral de riñón funcionante (25 casos). Grupo II: Nefrectomizados por pérdida de un riñón(con función previa normal) después del segundo año de vida (13 casos). Se midió la somatometría, la tensión arterial (TA), el filtrado glomerular (FG), la proteinuria, el volumen renal (VR) y se consideró la presencia de anomalías contralaterales (AC). Resultados. El peso y la talla se encontró en percentiles normales. La TA se encontró elevada en 5 pacientes. La creatinina sérica sólo estaba elevada en 1 paciente con severa afectación del riñón remanente, el aclaramiento de creatinina (Ccr) resultó elevado de forma generalizada y se observó microalbuminuria en 2 pacientes. El volumen renal fue similar en ambos grupos. El estudio isotópico evidenció ectasia sin obstrucción en el 80% de todos los casos y el FG según el método de Inoue (corregido para niños) resultó en ambos grupos dentro de valores normales. Conclusiones. No encontramos diferencias significativas en la función renal entre los dos grupos de pacientes ni tampoco indicios de nefropatía por hiperfiltración. El Ccr evidenció una situación de hiperfiltrado en todos los casos. El filtrado glomerular calculado por estudio isotópico no confirmó estasituación. El volumen renal no se observó relacionado con la edad a la que se produjo la pérdida renal, y sí con el tiempo transcurrido postpérdida. La existencia de anomalías en el riñón contralateral influye en el grado de hipertrofia que desarrolla (AU)

Introduction. It has always been thought that a reduction of renal tissue in childhood sometimes causes some irreversible injury in the remnant kidney as the years go by. The aim of this paper is to look over the presence of these changes and identify the risk of nephropaty throughout several parameters. Material and methods. We reviewed 38 children, 23 males and 15 females, aged between 1 and 15 years, who had lost unilateral renal mass because of congenital or adquired diseases. We made two groups of patients on the basis of having born without any unilateral renal function –group I– or having lost unilateral renal function after the second year of life. We measured: Somatometry, arterial pressure, glomerular filtration, microalbuminuria, renal volume and gammagraphic studies were also made. We also considered the presence of contralateral anomalies. Results. Body weight and height were within normal percentiles. Arterial pressure increased in 5 patients. Seric creatinine was normal, creatinine clearance (Ccr) was higher than normal in all patients of both groups, and urinary excretion of protein was normal. Renal volume of remnant kidney was similar in both groups, and no relation with renal function level was found, but it increased through the years. Isotopic studies showed ectatic drainage in all urinary systems. Contralateral anomalies were seen in 7 patients, and they consisted in hydronephrosis and vesico-ureteral reflux. Conclusions. Hypertension was not related to the cause of renal absence nor the pathology of remnant kidney. Ccr was higher than normal, showing an hyperfiltration status, not confirmed by the values of isotopic filtrate. Renal volume reached by the single kidney was affected by the time after the renal loss, and apparently has been slowed down in cases with contralateral anomalies Introduction. It has always been thought that a reduction of renal tissue in childhood sometimes causes some irreversible injury in the remnant kidney as the years go by. The aim of this paper is to look over the presence of these changes and identify the risk of nephropaty throughout several parameters. Material and methods. We reviewed 38 children, 23 males and 15 females, aged between 1 and 15 years, who had lost unilateral renal mass because of congenital or adquired diseases. We made two groups of patients on the basis of having born without any unilateral renal function –group I– or having lost unilateral renal function after the second year of life. We measured: Somatometry, arterial pressure, glomerular filtration, microalbuminuria, renal volume and gammagraphic studies were also made. We also considered the presence of contralateral anomalies. Results. Body weight and height were within normal percentiles. Arterial pressure increased in 5 patients. Seric creatinine was normal, creatinine clearance (Ccr) was higher than normal in all patients of both groups, and urinary excretion of protein was normal. Renal volume of remnant kidney was similar in both groups, and no relation with renal function level was found, but it increased through the years. Isotopic studies showed ectatic drainage in all urinary systems. Contralateral anomalies were seen in 7 patients, and they consisted in hydronephrosis and vesico-ureteral reflux. Conclusions. Hypertension was not related to the cause of renal absence nor the pathology of remnant kidney. Ccr was higher than normal, showing an hyperfiltration status, not confirmed by the values of isotopic filtrate. Renal volume reached by the single kidney was affected by the time after the renal loss, and apparently has been slowed down in cases with contralateral anomalies (AU)

Transcaval ureter: case report and a review of the literature

The authors describe a case of post-mortem transcavalureter. This is a rare congenital anomaly,where the inferior vena cava (IVC) forms a circleover the right ureter, in a vascular ring. In thebibliographic survey carried out through MEDLINEit was found that only 8 cases have beendescribed in the worldwide literature as of December2004 (AU)

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Clinical anatomy of the superficial peroneal nerve in the distal leg / Anatomía clínica del nervio peroneo superficial en la parte distal de la pierna

Applied anatomy of the superficial peroneal nerve in real clinical situations requires a good knowledge of the anatomical relationships and their common variations. Here we present an anatomoclinical description not only of the normal superficial peroneal nerve but also of its different variations with surgical implications based on twelve lower limbs. In order to gain some landmarks, the followings measurements were taken: a) distance from the upper end of the fibular head to the lower eminence of the lateral malleolus; b) number of branches from the nerve when it emerges through the superficial sural fascia; c) distance from the nerve emergence point to the lateral malleolus; d) distance from the nerve division to the lateral malleolus. We also recorded the site were the nerve pierces the sural fascia from the anterior or lateral muscular compartment. The data obtained seem to be sufficiently reliable for usual clinical practice, but it must be taken into account that frequent and important variations may occur (AU)

La anatomía aplicada del nervio peroneo superficial en situaciones clínicas reales requiere un buen conocimiento de las relaciones anatómicas y sus variaciones comunes. Presentamos aquí una descripción anatomoclínica no sólo del nervio peroneo superficial sino también de sus diferentes variaciones con implicaciones quirúrgicas, basadas en el estudio de 12 miembros inferiores. Con el fin de obtener algunos parámetros de referencia, se determinaron las siguientes mediciones: a) distancia desde el extremo superior de la cabeza del peroné hasta la eminencia inferior del maleolo lateral; b) número de ramas del nervio cuando emerge a través de la fascia sural superficial; c) distancia desde el punto de emergencia del nervio hasta el maleolo lateral; d) distancia desde la división del nervio hasta el maleolo lateral. También registramos los lugares donde el nervio atraviesa la fascia sural desde el compartimiento muscular anterior o lateral. Los datos obtenidos parecen ser suficientemente fiables para la práctica clínica habitual, pero debe tenerse en cuenta que pueden existir variaciones frecuentes e importantes (AU)

Arterial patterns of the human upper limb: update of anatomical variations and embryological development / Patrones arteriales de la extremidad superior humana: actualización de variaciones anatómicas y desarrollo embriológico

The arterial pattern of the upper limb is one of the systems that shows a large number of variations in the adult human body. However, embryological explanations for these variations have been subject to much debate. Recent studies have provided a new classification of the arterial variations in the upper limb, as well as a new model of arterial development based on the study of large anatomical and embryological samples. In the present article, we offer a review of the embryological and morphological data obtained in adults, contrasting them with those found in a new sample of adult material (AU)

El patrón arterial de la extremidad superior es uno de los sistemas que presentan mayor número de variaciones dentro del cuerpo humano adulto. Sin embargo, la justificación embriológica de estas variaciones había sido un tema de controversia hasta la actualidad. Estudios recientes han aportado una nueva clasificación de las variaciones arteriales de la extremidad superior, así como un nuevo modelo sobre el desarrollo embriológico basado en el estudio de grandes muestras de material embrionario y adulto. En el presente artículo presentamos una revisión conjunta de los datos embriológicos y morfológicos en adultos y los contrastamos con una nueva muestra de material adulto (AU)