Manejo ortoplástico de fractura expuesta de pierna grave: a propósito de un caso / Orthoplastic management of severe open fractures: case report / Tratamento ortoplástico das fraturas expostas grave: relato de caso

Las fracturas expuestas de pierna son lesiones frecuentes, sus principales complicaciones son la infección y la dificultad en la consolidación ósea. El abordaje ortoplástico implica llevar a cabo principios y prácticas de ambas especialidades en forma conjunta, evitando el tratamiento por separado de los problemas que surgen de estas lesiones graves y así intentar disminuir al mínimo las complicaciones. Nuestro objetivo es transmitir la importancia del enfoque ortoplástico en las fracturas expuestas. Se reporta el caso de un paciente adulto, con una fractura de pierna, tibia y peroné expuesta, que requirió múltiples procedimientos quirúrgicos en vistas a preservar el miembro. Fueron necesarias variadas estrategias para controlar la infección ósea y reconstruir las partes blandas y óseas. Con el estímulo de la movilidad del tobillo y pie, se logró comenzar a restituir la función del miembro desde el inicio; permitiendo, a las 6 semanas de evolución, el apoyo del miembro mediante una fijación ósea estable. A los 24 meses de seguimiento clínico y radiográfico evidenciamos paciente y familia satisfechos con un excelente resultado funcional según score ASAMI. Se concluye que en pacientes con fracturas expuestas graves, es clave el abordaje ortoplástico para lograr mejores resultados.

Open leg fractures are frequent injuries; the infection and difficulty in bone healing are their main complications. The orthoplastic approach involves carrying out principles and practices of both specialties together, avoiding separate treatment of the problems that arise from these serious injuries and thus minimizing complications. The objective of the article is to convey the importance of the orthoplastic approach in open fractures. We report the case of an adult patient, with an open fractured leg, to required multiple surgical procedures to preserve the limb. Various strategies were necessary to cure the bone infection and reconstruct the soft tissue and bone. The limb function restore was possible promoting the ankle and foot mobility from the beginning and it allowed weight-bearing on the limb through stable bone fixation, at 6 weeks of evolution. We evidenced a patient and family satisfied with an excellent functional result according to the ASAMI score, at 24 moths of clinical and radiographic follow-up. It is concluding that in patients with severe open fractures, the orthoplastic approach is key to obtain better results.

As fraturas expostas da perna são lesões frequentes, suas principais complicações são infecção e dificuldade de consolidação óssea. A abordagem ortoplástica envolve a realização conjunta de princípios e práticas de ambos ases especialidades, evitando o tratamento separado dos problemas decorrentes dessas lesões graves e minimizando assim as complicações. Nosso objetivo é transmitir a importância da abordagem ortoplástica nas fraturas expostas. É relatado o caso de um paciente adulto, com fratura de perna, tíbia e fíbula expostas, necessitando de múltiplos procedimentos cirúrgicos para preservação do membro. Várias estratégias foram necessárias para curar a infecção óssea e reconstruir os tecidos moles e o osso. Foi possível começar a restaurar a função do membro desde o início, com a estimulação da mobilidade do tornozelo e do pé; com 6 semanas de evolução, concedendo cargas ao membro por meio de fixação óssea estável. Apresentou boa evolução, aos 24 meses de acompanhamento clínico y radiográfico, constatamos a satisfação do paciente e família. com um excelente resultado funcional de acordo a pontuação ASAMI. Conclui-sé que em pacientes com fraturas expostas graves, a abordagem ortoplástica é fundamental para obter melhores resultados.

Experiencia en el manejo del trauma de guerra con un enfoque de control de daños en el hospital para pacientes con fracturas de fémur o tibia / Experience in managing war trauma with a damage control approach in the hospital for patients with femur or tibia fractures

Introducción: El Hospital Militar Central cuenta con un grupo especial para la atención de pacientes con trauma de guerra que incluye una evaluación inicial y manejo urgente de las lesiones que amenacen la vida, mediante un enfoque de control de daños que busca preservar la vida del paciente, salvar la extremidad y conservar su función. Materiales y Métodos: Estudio observacional, descriptivo, transversal de pacientes de las fuerzas militares de Colombia, que sufrieron fracturas de fémur o tibia por trauma de guerra entre 2012 y 2020; y tratados mediante fijación externa en este Hospital. Objetivos: Describir las complicaciones del trauma de guerra tras un año de manejo de pacientes con fracturas de fémur o tibia utilizando un protocolo de control de daños en el Hospital Militar Central, centro de referencia para este tipo de trauma en el país. Resultados: Se realizó una revisión retrospectiva de pacientes con fracturas femorales o tibiales por traumas de guerra entre 2012 y 2020, manejados con un protocolo de control de daños. Se seleccionaron 72 soldados, el 96% de las fracturas eran abiertas, el 91% (66 casos) sufrió alguna complicación, como lesión nerviosa, lesión vascular, defecto de cobertura, infección, falta de consolidación. Conclusiones: El trauma de guerra continúa representando una de las etiologías de politraumatismo en pacientes jóvenes de nuestro país que, a su vez, sigue teniendo grandes implicaciones clínicas y económicas. Las lesiones óseas de las extremidades requieren un manejo por etapas basado en la fijación externa según los principios de control de daños. Nivel de Evidencia: IV

Introduction: The Central Military Hospital of Bogotá, Colombia has a specialized team for treating war trauma patients. They conduct an initial assessment of patients and promptly manage potentially fatal injuries using a damage control approach that aims to save the patient's life, save the limb, and preserve its function. Materials and Methods: An observational, descriptive, cross-sectional study was conducted on patients from the Colombian armed forces who, between 2012 and 2020, had femur or tibia fractures as a result of war trauma; these patients were treated using external fixation by the orthopedics and traumatology service of the Central Military Hospital in Bogotá, Colombia. Objectives: To describe the complications associated with war trauma following a year of treatment for femur and/or tibia fractures under a damage control protocol at the Central Military Hospital, the nation's reference facility for this kind of trauma. Results:A retrospective review of war trauma patients between 2012 and 2020 with femoral or tibial fractures treated with DCO was performed. Fisher's Exact tests were used for comparisons. Seventy-two soldiers were selected, 96% of fractures were open, 91% (66 cases) had some type of complication such as nerve injury, vascular injury, coverage defect, infection, and nonunion. Conclusions: In our country, war trauma persists as one of the causes of polytrauma in young patients, which has significant clinical and financial implications. Bone injuries of severely affected extremities require staged management based on external fixation according to damage control principles. Level of Evidence: IV

Core stability training effects on lower limb rehabilitation of judokas / Efeitos do treino de estabilidade do core na reabilitação em membros inferiores de judocas / Efectos del entrenamiento de la estabilidad del core en la rehabilitación de los miembros inferiores de judokas

ABSTRACT Introduction Judo is a sport that presents a high incidence of sports injuries. Judo athletes want to master their skills to the maximum. Good physical conditioning is necessary to decrease the incidence of surgeries and achieve better results. Core stability exercises can discretely reduce the likelihood of lower limb injuries in judo athletes. Objective This paper examines the rehabilitation of core stability training effects on lower limb injuries in judokas by case studies. Methods A Chinese judo team member with a lower limb injury underwent core stability training. Isokinetic strength tests, body composition tests, and functional checks explored the athlete's physical recovery after training. Results The athletes' lower limbs progressed with good recovery (P<0.05). Additionally, a recovery in fitness level was also noted (P<0.05). Conclusion Core stability training positively affects recovery from lower limb injuries in judokas. Evidence level II; Therapeutic Studies - Investigating the results.

RESUMO Introdução O judô é um esporte com alta incidência de lesões esportivas. Atletas de judô querem dominar o máximo de suas habilidades. Para diminuir a incidência de cirurgias e alcançar melhores resultados é necessário um bom condicionamento físico. Os exercícios de estabilidade do core podem reduzir discretamente a probabilidade de lesões nos membros inferiores em judocas. Objetivo Este artigo analisa o efeito da reabilitação com treino de estabilidade do core em lesões de membros inferiores de judocas por meio de estudos de caso. Métodos Um membro da equipe chinesa de judô com lesão de membro inferior realizou treinamento de estabilidade do core. Foram utilizados testes de força isocinética, testes de composição corporal e verificações funcionais para explorar a recuperação física do atleta após o treino. Resultados Os membros inferiores dos atletas evoluíram com boa recuperação (P<0,05). Adicionalmente, notou-se também uma recuperação no nível de aptidão física (P<0,05). Conclusão O treinamento de estabilidade do core afeta positivamente a recuperação de lesões de membros inferiores em judocas. Nível de evidência II; Estudos terapêuticos - Investigação de resultados.

RESUMEN Introducción El judo es un deporte con alta incidencia de lesiones deportivas. Los atletas de judo quieren dominar el máximo de sus capacidades. Para reducir la incidencia de las cirugías y lograr mejores resultados, es necesario un buen acondicionamiento físico. Los ejercicios de estabilidad del core pueden reducir discretamente la probabilidad de lesiones de las extremidades inferiores en los judokas. Objetivo Este artículo examina el efecto de la rehabilitación con el entrenamiento de la estabilidad del core en las lesiones de las extremidades inferiores en los judokas mediante el estudio de casos. Métodos Un miembro del equipo de judo chino con una lesión en las extremidades inferiores se sometió a un entrenamiento de estabilidad del core. Se utilizaron pruebas de fuerza isocinética, pruebas de composición corporal y controles funcionales para explorar la recuperación física del atleta después del entrenamiento. Resultados Los miembros inferiores de los atletas evolucionaron con una buena recuperación (P<0,05). Además, también se observó una recuperación del nivel de aptitud física (P<0,05). Conclusión El entrenamiento de la estabilidad del core afecta positivamente a la recuperación de las lesiones de las extremidades inferiores en los judokas. Nivel de evidencia II; Estudios terapéuticos - Investigación de resultados.

Enclavado endomedular en fracturas de tibia. ¿Existe una relación entre el punto de entrada para la inserción del clavo y su alineación final? / Intramedullary nailing of tibial fractures. Is there a relationship between the entry point and its final alignment?

Introducción: Las fracturas de tibia representan aproximadamente el 2% de las fracturas del adulto. El enclavado endomedular es hoy el procedimiento de elección para tratar fracturas diafisarias de tibia; sin embargo, esta técnica no está exenta de complicaciones, la desalineación en el plano coronal es una de las más frecuentes y temidas por los cirujanos. El objetivo de este estudio fue investigar la relación entre el punto de entrada del clavo y la desalineación en el plano coronal después de la cirugía. Materiales y Métodos: Se realizó un estudio retrospectivo, descriptivo, observacional, entre enero de 2015 y enero de 2019, de pacientes con fracturas diafisarias de tibia, tratadas con clavo endomedular. Se obtuvieron radiografías en el posquirúrgico inmediato y luego cada dos meses, se tuvo en cuenta la radiografía del octavo mes, en la que se observaban signos francos de consolidación ósea, para valorar la alineación tibial. Resultados:Cuando el punto de entrada del clavo fue central, hubo apenas un 0,021 de posibilidades (o 2,1%) de alguna desalineación significativa en el posquirúrgico inmediato y luego de 8 meses. En cambio, cuando fue medial, las posibilidades de una tendencia al valgo fueron >0,85 (u 85%) ya al tomar la primera imagen, i.e., poscirugía; y cuando fue lateral, esta posibilidad se modifica y profundiza según el tiempo transcurrido hasta la imagen lograda en el paciente. Conclusión: Se observó una relación marcada y continua entre el punto de entrada del clavo endomedular y la alineación de la tibia después de la consolidación ósea. Nivel de Evidencia: IV

Introduction: Tibial fractures represent approximately 2% of adult fractures. Today, intramedullary nailing is the procedure of choice to treat diaphyseal fractures of the tibia; however, this technique is not exempt from complications, misalignment in the coronal plane is one of the most frequent and feared by surgeons. The aim of this study was to investigate the relationship between nail entry point and misalignment in the coronal plane after surgery. Materials and Methods: We carried out a retrospective, descriptive, observational study between January 2015 and January 2019 of patients with diaphyseal fractures of the tibia, treated with intramedullary nailing. Radiographs were obtained in the immediate postoperative period and then every two months. The eighth-month radiograph, in which clear signs of bone consolidation could be observed, was taken into account to assess tibial alignment. Results: When the nail entry point was central, there was only a 0.021 chance (or 2.1%) of any significant misalignment in the immediate postoperative period and after 8 months. In contrast, when it was medial, the chances of a valgus tendency were >0.85 (or 85%) already at the first image, i.e., post-surgery; and when it was lateral, this possibility was modified and deepenedaccording to the time elapsed until the image achieved in the patient. Conclusion: A marked and continuous relationship wasobserved between the entry point of the intramedullary nail and the alignment of the tibia after bone consolidation..Level of Evidence: IV

The Use of Physical Screening Tools to Identify Injury Risk Within Pre-Professional Ballet Dancers: An Integrative Review / El uso de herramientas de cribado física para identificar el riesgo de lesiones en los bailarines de ballet preprofesionales: Una revisión integradora

Objective. To conduct an integrative review of all relevant research investigating the physical risk factors for injury within pre-professional ballet dancers, to provide insight that may benefit practitioners within these institutions and highlight areas for future research within this specialised population.Design. Studies were identified from the following electronic databases: MEDLINE via PubMed, SPORTDiscus via EBSCOhost, and Web of Science Core Collection via Web of Science. 8,415 titles were identified during the electronic search process. Five studies satisfied the inclusion criteria and were included in the review. The mod-ified Agency for Healthcare Research and Quality (AHRQ) scale for observational studies was used to assess study quality.Results. The review identified that the following physical characteristics may influ-ence prospective injury risk in pre-professional ballet dancers: age and maturation status, anthropometrics and body composition, strength and power, joint mobility and range of motion, specific dance function, and cardiorespiratory fitness.Limitations. The research identified lacked methodological quality. This, com-bined with the low number of studies identified, makes the design of screening pro-tocols challenging for practitioners.Originality. Despite the number of pre-professional balletic institutions worldwide, previous reviews have not used a systematic search strategy or investigated both sexes in this cohort. Due to the unique demands of ballet, an understanding of the inter-action between injury and physical characteristics is a critical step in order to reduce injury burden. Conclusions. This review succeeded in determining risk factors for injury within this population, but, due to insufficient evidence, could not provide robust screening recommendations

Objetivo. Llevar a cabo una revisión integradora de toda la investigación relevante sobre los factores de riesgo físico de las lesiones en los bailarines de ballet preprofesionales, para proporcionar una visión que pueda beneficiar a los profesionales de estas instituciones y resaltar las áreas para futuras investigaciones en esta población especializada. Diseño. Los estudios se identificaron en las siguientes bases de datos electrónicas: MEDLINE vía PubMed, SPORTDiscus vía EBSCOhost y Web of Science Core Collection vía Web of Science. Se identificaron 8.415 títulos durante el proceso de búsqueda electrónica. Cinco estudios cumplieron los criterios de inclusión y se incluyeron en la revisión. Para evaluar la calidad de los estudios, se utilizó la escala modificada de la Agency for Healthcare Research and Quality (AHRQ) para estudios observacionales. Resultados. La revisión identificó que las siguientes características físicas pueden influir en el riesgo prospectivo de lesiones en los bailarines de ballet preprofesionales: edad y estado de maduración, antropometría y composición corporal, fuerza y potencia, movilidad articular y amplitud de movimiento, función específica de la danza y aptitud cardiorrespiratoria. Limitaciones. La investigación identificada carecía de calidad metodológica. Esto, combinado con el bajo número de estudios identificados, hace que el diseño de protocolos de detección sea un reto para los profesionales. Originalidad. Las revisiones anteriores no han utilizado una estrategia de búsqueda sistemática ni han investigado ambos sexos en esta cohorte. Debido a las exigencias únicas del ballet, la comprensión de la interacción entre las lesiones y las características físicas es un paso fundamental para reducir la carga de lesiones. Conclusiones. Esta revisión logró determinar los factores de riesgo de lesiones dentro de esta población, pero, debido a la insuficiencia de evidencia, no pudo proporcionar recomendaciones sólidas de cribado.

Puntaje predictivo de resultado en la cirugía reconstructiva de miembros inferiores. Ensayo preliminar / Predictive outcome score in lower limb reconstructive surgery. Preliminary test

Introducción: Las secuelas postraumáticas en los miembros son un cuadro de muy difícil abordaje por la gravedad de las lesiones, la falta de protocolos de tratamiento y especialmente por la elección de la mejor alternativa. El objetivo de este estudio fue analizar el resultado del tratamiento reconstructivo con un puntaje prequirúrgico diseñado para tal fin y evaluar su predictibilidad de resultado. Materiales y métodos: Se realizó un análisis retrospectivo de tipo cohorte de los resultados del tratamiento con fijación externa en 32 pacientes con secuela traumática de la pierna en los últimos siete años que fueron estadificados con un puntaje preoperatorio elaborado para tal fin y comparado con el resultado obtenido con la tabla de resultados de la ASAMI con dos años de seguimiento mínimo. Resultados:Se obtuvo una relación directa entre la estadificación prequirúrgica y el resultado final. Dicha relación se ve reflejada en el alto porcentaje de excelentes resultados en pacientes de bajo riesgo (50%) y una tasa del 60% de malos resultados en pacientes de alto riesgo. Conclusiones: La evidencia actual es contradictoria y se discute cuál es la mejor opción de tratamiento. Los pacientes considerados de alto riesgo tienen un alto porcentaje de malos resultados y tal vez no se beneficien con la cirugía reconstructiva. Nivel de Evidencia: IV

Introduction: Post-traumatic sequelae in the limbs are a very difficult condition to approach due to the severity of the injuries and the lack of treatment protocols, which considerably hinder the choice of the best treatment alternative. The objective of this study was to analyze the outcomes of reconstructive treatment with a pre-surgical score designed ad-hoc and to evaluate its predictability. Materials and methods: A retrospective cohort-type analysis of the outcomes of external fixation treatment was performed in 32 patients with traumatic leg sequelae in the last 7 years who were staged with a pre-operative score designed ad-hoc. This was compared with the results obtained with the ASAMI score with a minimum 2-year follow-up. Results: We obtained a direct relationship between pre-surgical staging and the final outcome. This relationship is reflected by obtaining a high percentage of excellent outcomes in low-risk patients (50%) and 60% of poor outcomes in high-risk patients. Conclusions: The current evidence is contradictory and there is controversy over which is the best treatment option. We found that high-risk patients have a high percentage of poor outcomes and may not benefit from reconstructive surgery. Level of Evidence: IV

Reconstrucción con colgajo peroneo posterior para cobertura de defectos del tercio distal de la pierna y el tercio proximal del pie / Reconstruction with posterior peroneal flap to cover defects in the distal third of the leg and the proximal third of the foot

El colgajo peroneo posterior es un colgajo fasciocutáneo, que está basado en 4 posibles fuentes como son perforantes fasciocutáneas de la arteria peronea, perforantes fasciocutáneas de la arteria tibial posterior, perforantes venocutáneas de la vena safena menor y perforantes neurocutáneas del nervio sural. El objetivo de este trabajo es describir la técnica quirúrgica y demostrar la versatilidad que tiene el colgajo peroneo posterior para la reconstrucción y cobertura de defectos del tercio distal de la pierna y el tercio proximal del pie, proporcionando el potencial para el cierre simple y eficiente de dichos defectos. Este colgajo proporciona grandes ventajas debido a que es reproducible en cualquier centro quirúrgico y no requiere un entrenamiento específico en microcirugía del cirujano y del resto del equipo quirúrgico. Si bien las complicaciones existen, la mayoría no son graves y en general son de resolución simple. En los últimos años, se ha incrementado el empleo del colgajo fasciocutáneo peroneo posterior para lograr la cobertura de los defectos de partes blandas del tercio distal de la pierna y pie. El éxito de estos colgajos está relacionado con el tipo de paciente y de su lesión: el porcentaje es alto en pacientes jóvenes y sanos en quienes el origen del defecto es traumático.

The posterior peroneal flap is a fasciocutaneous flap, which is based on 4 possible sources such as fasciocutaneous perforations of the peroneal artery, fasciocutaneous perforations of the posterior tibial artery, venocutaneous perforations of the saphenous vein, and neurocutaneous perforators of the sural nerve. The objective of this work is to describe the surgical technique and demonstrate the versatility of the posterior peroneal flap for the reconstruction and coverage of defects in the distal third of the leg and the proximal third of the foot, providing the potential for simple and efficient closure of said defects. It provides great advantages because it is reproducible in any surgical center and does not require specific training in microsurgery of the surgeon and the rest of the surgical team. Although complications do exist, most are not serious and are generally of simple resolution. In recent years, the use of the posterior peroneal flap has been increased to achieve coverage of soft tissue defects of the distal third of the leg and foot. The success of these flaps is related to the type of patient and his injury, the success rate is high in young and healthy patients in whom the origin of the defect is traumatic.

Tratamiento con clavo endomedular de las fracturas metafisarias proximales y distales de tibia: Abordaje pararrotuliano medial en posicion de semiextension / Intramedullary nailing treatment of proximal and distal tibia metaphyseal fractures. Medial parapatellar approach in semi-extended position

Objetivo: El enclavado endomedular de las fracturas metafisarias de tibia se asocia con algunas complicaciones relacionadas con la necesidad de flexionar la rodilla durante la introducción del clavo endomedular con la técnica infrarrotuliana clásica. Es por ello, que se han diseñado diferentes abordajes para la colocación del clavo en una posición de semiextensión de rodilla. El objetivo fue evaluar nuestros resultados, de forma retrospectiva, con el abordaje pararrotuliano medial en semiextensión, para el tratamiento de las fracturas metafisarias proximales y distales de tibia con clavo endomedular. Materiales y Métodos: Se incluyó a 23 pacientes con un seguimiento posoperatorio mínimo de un año. Doce eran fracturas distales de tibia; 9, proximales y 2, segmentarias. Se evaluaron el rango de movilidad de la rodilla, el dolor posoperatorio con la escala de Lysholm, el eje posoperatorio y la tasa de consolidación. Resultados: El arco de movilidad de la rodilla fue de 125° (rango 110-140). Al año de la cirugía, 16 de 23 pacientes no tenían dolor, 5 de 23 refirieron un leve dolor durante la actividad física y 2, dolores intensos durante la actividad física. En todos los casos, se consiguió un eje posoperatorio aceptable y la consolidación ósea. Un paciente requirió un aumento con una placa e injerto óseo. Conclusión: La colocación de un clavo de tibia a través de un abordaje pararrotuliano medial con la rodilla en semiextensión es una técnica segura y simple para el tratamiento de las fracturas metafisarias de tibia. Nivel de Evidencia: IV

Objective: To review the results of a series of metaphyseal tibial fractures treated with intramedullary nailing (IMN) in a semiextended position using a medial parapatellar approach. To report reduction quality, bone consolidation, range of motion (ROM) and postoperative knee pain at final follow-up. Materials and Methods: Twenty-three metaphyseal tibia fractures were treated with IMN. Twelve were distal tibial fractures (AO/OTA 43A), nine were proximal tibial fractures (AO/OTA 41A2/3), and two had segmental tibia fractures (AO/OTA 42C2). The minimum follow-up was 1 year. Results: Radiograph angulation at the fracture site was <5 degrees. All patients achieved bone healing. One patient (AO/OTA 42C2) required plate augmentation and bone autografting. Twenty-one out of 23 patients had knee pain scores of >20 according to the Lysholm scale. Conclusion: The parapatellar approach in a semi-extended position is a safe and useful technique for IMN of metaphyseal tibia fracture with no associated increased postoperative knee pain. Level of Evidence: IV

Colgajo de perforante de la arteria tibial posterior: Serie de casos / Posterior tibial artery perforator flap. Case series

Introducción: Los defectos de cobertura en la pierna son un problema difícil de solucionar debido a las características propias de la región anatómica. Por ello, se han desarrollado distintas estrategias de reconstrucción, y los colgajos de perforante fasciocutáneos son los que se utilizan con más frecuencia. Objetivos: Presentar la alternativa terapéutica, describir la técnica quirúrgica, los resultados y las complicaciones del colgajo de perforante de la arteria tibial posterior para el tratamiento de defectos de cobertura en la pierna. Materiales y Métodos: Se realizó una revisión retrospectiva de los pacientes tratados con colgajo fasciocutáneo en la pierna y operados en nuestro Centro. Se analizaron variables demográficas preoperatorias. Se describen la técnica quirúrgica y las indicaciones en cada paciente. Se analizaron variables posoperatorias, como las complicaciones y la supervivencia del colgajo. Resultados: Se incluyeron 12 hombres tratados con colgajo de perforante de la arteria tibial posterior. El promedio de edad en el momento de la cirugía fue de 52 años (rango 29-77). El seguimiento máximo fue de 55 meses y el mínimo, de 5 meses (promedio 18). Hubo dos colgajos con sufrimiento transitorio, una falla parcial y una falla total. Conclusiones: El colgajo de perforante de la arteria tibial posterior ha de ser considerado una opción válida en el tratamiento de heridas de pequeño y mediano tamaño de la pierna. Provee de tejido similar en grosor, textura y color en el sitio receptor con buenos resultados clínicos y estéticos. Nivel de Evidencia: IV

Introduction: Coverage defects in the leg are a challenge due to the particulars of the anatomy in said area, different reconstruction strategies have been developed, being the fasciocutaneous perforator flaps the most frequently used. The aim of this paper is to discuss the therapeutic alternative and to describe the surgical technique, the results and the complications of the posterior tibial artery perforator flap (PTAPF) to treat coverage defects. Materials and Methods: We performed a retrospective review of patients treated with a fasciocutaneous flap. We analyzed preoperative demographic variables. The surgical technique and the indications in each patient are described. Finally, the postoperative variables, such as complications and flap survival, were analyzed. Results: Twelve patients (all male) treated with PTAPF were included. The average age at the time of surgery was 52 years (range: 29-77 years). The maximum follow-up was 55 months, with a minimum of 5 months (average: 18 months). There were two flaps with transient congestion that reverted spontaneously: one partial failure and one total failure. Conclusions: PTAPF should be considered a viable option for the treatment of small- and medium-sized leg wounds, since they provide similar tissue thickness, texture and color on the recipient site, achieving good clinical and cosmetic results. Level of Evidence: IV

Lower Limb Reconstruction - Fasciocutaneous Sural Flap / Reconstrução de membro inferior- retalho fasciocutâneo sural

Abstract Objective The present study aims to evaluate the use of the reverse-flow sural fasciocutaneous flap to cover lesions in the distal third of the lower limb. Methods A total of 24 cases were analyzed, including 20 traumatic injuries, 3 sports injuries, and 1 case of tumor resection. Results Among the 24 evaluated medical records, 16 patients were male, and 8 were female. Their age ranged from6 to 75 years old. Most of the patients evolved with total healing of the flap (n= 21). There was only one case of total necrosis of the flap in an insulin-dependent diabetic, high blood pressure patient, evolving to subsequent limb amputation. In two cases, there was partial necrosis and subsequent healing by secondary intention; one of these patients was a heavy smoker. Complications were associated with comorbidities and, unlike other studies, no correlation was observed with the learning curve. There was also no correlation with the site or size of the lesion to be covered. Conclusion It is clinically relevant that the success rate of the reverse-flow sural fasciocutaneous flap technique was of 87.5%. This is a viable and effective alternative in the therapeutic arsenal for complex lower limb lesions.

Resumo Objetivo Avaliar o uso do retalho fasciocutâneo sural de fluxo reverso na cobertura de lesões no terço distal dos membros inferiores. Métodos Foram analisados 24 casos, 20 de origem traumática, três por lesões esportivas e um por ressecção de lesão tumoral. Resultados Dos 24 prontuários avaliados, 16 eram homens e oito mulheres. A idade variou de seis a 75 anos. A maioria dos pacientes evoluiu com cicatrização total do retalho (21). Houve apenas um caso de necrose total do retalho em paciente diabético insulinodependente e hipertenso, evoluiu para posterior amputação do membro. Em dois casos, houve necrose parcial composterior cicatrização por segunda intenção, um desses pacientes era tabagista pesado. As complicações foram associadas às comorbidades e, ao contrário do evidenciado por outros estudos, não houve correlação com a curva de aprendizado. Também não houve correlação com o local ou o tamanho da lesão a ser coberta. Conclusão Tem-se como relevância clinica que a técnica de retalho fasciocutâneo sural de fluxo reverso usada obteve 87,5% de sucesso, é uma opção viável e eficaz no arsenal terapêutico das lesões complexas dos membros inferiores.

"Tennis Leg": Resultados de la evacuación bajo guía ecográfica, con o sin aplicación de plasma rico en plaquetas / Tennis Leg. Results of hematoma under ultrasound-guided aspiration with or without platelet-rich plasma application

Introducción: El Tennis Leg o pierna de tenista se llama a el desgarro de la unión miotendinosa distal del gemelo interno, con o sin la formación de hematoma interfascial. Objetivo: Evaluar los resultados de la evacuación del hematoma bajo guía ecográfica con o sin aplicación de plasma rico en plaquetas (PRP). Material y métodos: Se evaluaron retrospectivamente una serie de pacientes con cuadro de pierna de tenista con menos de un mes de evolución a los cuales se le realizó la aspiración del hematoma interfascial bajo guía ecográfica. A un grupo se les aplicó PRP interfascial y en la lesión y a otro grupo no. Se documentó la recidiva del hematoma, tiempo retorno deportivo y complicaciones. Resultados: Se evaluaron 17 pacientes con un seguimiento de 4,7 años (2,1 - 6,3) a nueve se les aplicó PRP (grupo A) y a ocho no se les aplicó PRP (grupo B). En el grupo B, cuatro pacientes (50%) presentaron una recidiva y dos de ellos (25%) una re-recidiva. El grupo A no presentó recidiva del hematoma. El tiempo de retorno al deporte fue para el grupo A de 9,6 semanas (7,8 ­ 12,2) y para el grupo B de 14,3 semanas (8,2 ­ 17,2). Dos pacientes (22,22%) del grupo A y cuatro pacientes (50%) del grupo B presentaron una fibrosis interfascial. Conclusión: Creemos que la evacuación ecoguiada del hematoma interfascial en pacientes con pierna de tenista, es un procedimiento válido para evitar complicaciones. La posterior aplicación del PRP interfacial y en el foco del desgarro disminuye el riesgo de recidiva del hematoma y acorta el tiempo de retorno al deporte. Nivel de evidencia: IV

Introduction: Tennis Leg, or the tear of the distal myotendinous junction of the inner calf muscle, with or without interfascial hematoma, is a frequently underdiagnosed injury. Objective: To evaluate the results of hematoma aspiration under ultrasound guidance, with or without the application of platelet-rich plasma (PRP). Material and methods: A number of patients with a clinical presentation of Tennis Leg were retrospectively evaluated. Those who presented with the case within the last 30 days were included. Ultrasound-guided aspiration of the interfascial hematoma was performed. Only one group received interfascial PRP and into the injury, while the other group did not. Recurrence of the hematoma, return-to-sport time and complications were documented. Results: Seventeen patients were evaluated with an average follow-up time of 4.7 years (2.1 - 6.3). Nine patients (group A) received a PRP injection whereas 8 (group B) did not. In group B, 4 patients (50%) presented with a recurrence of the hematoma and 2 patients (25%) with a re-recurrence of such lesion. On the other hand, group A did not experience a recurrence of the hematoma. On average, the return-to-sport time was 9.6 weeks (7.8 - 12.2) for group A and 14.3 weeks (8.2 - 17.2) for group B. Finally, 2 patients (22.22%) in group A and 4 patients (50%) in group B presented with interfascial fibrosis. Conclusion: We believe that ultrasound-guided aspiration of the interfascial hematoma in Tennis Leg is a fundamental procedure. The application of interfascial PRP and into the tear, lowers the risk of recurrence and reduces the return-to-sport time. Level of evidence: IV

Retalho sural reverso de pedículo fasciossubcutâneo: relato de caso / Reverse sural flap of the fasciosubcutaneous pedicle: a case report

Introdução: As perdas de substância no terço inferior da perna costumam exigir elaboradas estratégias cirúrgicas para sua reconstrução. Dentre as opções existentes, o uso do retalho sural reverso de pedículo fasciossubcutâneo ou adipofascial reverso, citado na literatura como interessante alternativa, é pouco relatado, se comparado às outras técnicas mais utilizadas. O objetivo deste estudo é apresentar o resultado do tratamento de uma lesão exposta do tendão de Aquiles, realizado com retalho sural reverso de pedículo fasciossubcutâneo, associado à enxertia de pele total no mesmo tempo cirúrgico, discutindo as alternativas técnicas e as vantagens do procedimento. Relato de caso: A.D., 28 anos, portador de lesão complexa em terço distal da perna, decorrente de evolução desfavorável de procedimento ortopédico de reconstrução do tendão de Aquiles rompido em acidente automobilístico, ocorrido há mais de 30 dias, foi submetido à reconstrução da ferida por meio do retalho sural reverso de pedículo fasciossubcutâneo. A evolução pós-operatória foi favorável, não havendo complicações ou intercorrências. Conclusão: A técnica relatada apresentou uma boa opção com resultado satisfatório para a cobertura de lesão de terço inferior da perna com exposição do tendão de Aquiles.

Introduction: Loss of substance in the lower third of the leg usually requires complex surgical procedures for tissue reconstruction. Among the existing options for tissue reconstruction, reverse sural flap of the fasciosubcutaneous pedicle or reverse adipofascial flap, described in the literature as a viable option, has been little studied compared with other techniques. The objectives of this study were to present the results of surgical treatment of a complex injury due to Achilles tendon rupture using the reverse sural flap of the fasciosubcutaneous pedicle concomitantly with total skin grafting and to discuss the advantages of the procedure as well as other surgical alternatives. Case report: A.D., a 28-year-old male patient, presented with a complex injury in the lower third of the leg because of a poor outcome of surgical repair of Achilles tendon rupture that had occurred during an automobile accident more than 30 days previously. The patient underwent injury reconstruction with the reverse sural flap of the fasciosubcutaneous pedicle. The postoperative result was favorable, without complications. Conclusion: The surgical technique described here is satisfactory for treating lesions in the lower third of the leg due to Achilles tendon rupture.

Prevalence of musculoskeletal symptoms in obese patients candidates for bariatric surgery and its impact on health related quality of life

ABSTRACT Objective This study was designed to identify the major musculoskeletal symptoms of individuals with obesity, to assess their health-related quality of life, and to evaluate the correlation between the musculoskeletal symptoms and the individuals' health-related quality of life. Materials and methods Cross-sectional study. Instruments used "Nordic Musculoskeletal Questionnaire" and "The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36)". Results In total, 41 subjects were evaluated, of which 90.15% were female. The mean age of the subjects was 40.78 ± 9.85 years and their mean body-mass index was 46.87 ± 8.08. All subjects reported musculoskeletal pain in at least one anatomical region and 80.49% had pain in three or more regions. The activity limitations due to pain were reported by 75.61% of them. The most affected regions by pain were the ankles and/or feet, lower back, knees and wrists/hands/fingers. The most associated regions with activity limitations due to pain were the ankles and/or feet, knees and lower back. The presence of pain showed a negative correlation with the domains physical functioning (PF), role-physical (RP) and body pain (BP). The activity limitations showed a negative correlation with the domains PF, BP, social functioning (SF) and role-emotional (RE). Conclusion Our data showed a high prevalence of musculoskeletal pain and limitation in activities due to pain in obese subjects. The musculoskeletal symptoms had negative correlations with physical and mental components of the health-related quality of life, highlighting the importance of ensuring that patients with obesity have access to interdisciplinary care, for the prevention and rehabilitation of musculoskeletal disorders.

Colgajo Perforante en Propela de la Arteria Tibial Posterior: Reporte de un caso / Posterior Tibial Artery Perforator Propeller Flap. A Case Report

ResumenHistóricamente la reconstrucción de tejidos blandos del tercio distal de la pierna ha constituido un gran desafío quirúrgico para el cirujano plástico, a pesar de los múltiples avances en materia de colgajos pediculados y libres. En la actualidad los colgajos perforantes en propela son una excelente opción reconstructiva muy utilizada para cubrir defectos de tejidos blandos a este nivel con o sin exposición ósea, tendinosa, vascular y/o nerviosa. Esta técnica reconstructiva tiene como ventajas que no requiere anastomosis microquirúrgicas lo cual reduce el tiempo operatorio y que la localización precisa de los vasos perforantes puede realizarse fácilmente con un doppler manual por parte de los cirujanos en sala de operaciones.Se presenta el caso clínico de un paciente masculino de 14 años de edad a quien se le realizó un colgajo perforante en propela de la Arteria Tibial Posterior para cubrir un defecto de tejidos blandos producido por la resección de una contractura cicatrizal a nivel del tercio distal de la pierna derecha y del dorso del pie derecho, que le afectaba funcional y estéticamente. Se pretende dar a conocer el procedimiento y sus resultados, con el fin de difundir otra opción reconstructiva de dicha zona anatómica, que no involucre técnicas microquirúrgicas.

AbstractHistorically soft tissue reconstruction of the distal third of the leg has been a significant surgical challenge for the plastic surgeon despite the many advances in pedicled and free flap subject. Among the various surgical alternatives to rebuild lower limb defects, reverse flow sural flap and the soleus flap may be mentioned and in many cases are viable options, taking into account the area to rebuild and the assessment by the surgeon. Nonetheless, at present, propeller perforator flaps are an excellent reconstructive option widely used in lower limbs to cover soft tissue defects with or without bone, tendon, vascular and/or nervous exposure. These techniques have the main advantage that they do not require performing vascular anastomosis, therefore, knowledge in microsurgery is not indispensable, it requires the precise location of the perforating arteries to use through a manual doppler, this represents less difficulty and operative time when performing the procedureThe authors present a clinical case of a 14-year-old male patient, who underwent a propeller perforator flap from the Posterior Tibial Artery to cover a soft tissue defect produced by the excision of a scar contracture of the third distal of the right leg and dorsal right foot that affected him functionally and esthetically. The authors intend to create awareness of the procedure and its results, in order to disclose another reconstructive option for foot and distal leg that does not involve microsurgical techniques.

Incidence and causes of lower-limb amputations in the city of Ribeirão Preto from 1985 to 2008: evaluation of the medical records from 3274 cases / Incidência e causas de amputações dos membros inferiores em Ribeirão Preto de 1985 a 2008: avaliação de 3274 casos

ABSTRACT: Objective: It was to identify trends of traumatic and non-traumatic causes of lower limb amputations, as well as the role played by population aging, traffic violence increase, public health policy of diabetes control program and drivers anti-alcohol laws on these amputations. Method: Hospitalization data recorded in the discharge forms of 32 hospitals located in the region of Ribeirão Preto, Brazil, from 1985 to 2008 were analyzed. Result: A total of 3,274 lower-limb amputations were analyzed, of which 95.2% were related to non-traumatic causes, mainly infectious and ischemic complications of diabetes mellitus. Cancer (2.8%) and congenital (1.3%) causes were included in this group. Only 4.8% were related to traumatic causes. Traumatic amputation average rate was 1.5 amputations in 100,000 habitants with a slight tendency of increase in the last 5 years. Non-traumatic causes showed an average rate of 30.0 amputations for 100,000 habitants and remained relatively constant during the whole period. Non-traumatic were much more predominant in patients older than 60 years and traumatic amputations occurred more frequently in patients younger than 39 years. Conclusion: The overall rates of amputation and the rates of traumatic and non-traumatic amputations remained nearly constant during the study period. The impact of diabetes control policies and the introduction of traffic safety laws could not be identified on the amputation rates.

RESUMO: Objetivo: Identificar as tendências temporais de causas traumáticas e não traumáticas de amputações de membros inferiores, e os efeitos do envelhecimento da população, do aumento de violência no trânsito, da política de saúde pública do programa de controle de diabetes e das leis de controle do uso de álcool em motoristas sobre as taxas de amputações. Método: Foram analisados os dados das folhas de alta de pacientes submetidos a amputações de todos os 32 hospitais localizados na região de Ribeirão Preto, Brasil, de 1985 a 2008. Resultado: De 3.274 amputações de membros inferiores, 95,2% estavam relacionadas a causas não traumáticas, principalmente complicações do diabetes mellitus. Câncer (2,8%) e causas congênitas (1,3%) foram incluídos neste grupo. Apenas 4,8% estavam relacionados às causas traumáticas. A taxa média de amputação traumática foi de 1,5 amputações por 100.000 habitantes, com uma ligeira tendência de aumento nos últimos 5 anos. As causas não traumáticas mostraram uma taxa média de 30 amputações por 100.000 habitantes e mantiveram-se relativamente constantes durante todo o período. As causas não traumáticas foram predominantes em pacientes com mais de 60 anos, e as amputações traumáticas ocorreram mais frequentemente em pacientes com menos de 39 anos. Conclusão: A taxa total de amputações e as taxas de amputações traumáticas e não traumáticas permaneceram praticamente constantes durante o período de estudo. O impacto das políticas de controle do diabetes e da introdução de leis de repressão do uso de álcool no trânsito não pode ser identificado nas taxas de amputação.

Versatility of the medial gastrocnemius muscle flap in reconstructing lower limb soft tissue lesions / Versatilidade do uso do retalho do músculo gastrocnêmio medial na reconstrução de lesões de partes moles de membros inferiores

Introduction: Covering complex lower limb wounds is a major challenge. The medial gastrocnemius muscle flap is usually indicated for reconstruction of loss of substance of the knee and proximal third of the leg. The objective of this study was to evaluate the results using gastrocnemius muscle flaps in lower limb wounds. Methods: A total of 28 patients with loss of substance in the lower limbs were treated with medial gastrocnemius muscle flaps. Data were obtained from clinical records of patients who underwent surgery from 2003 to 2012. Results: In 28 patients who underwent surgery, the age range was 4 to 57 years, with a mean of 30.6 years. The etiology of the lesions was a motorcycle accident in 16 cases (57.1%), being run over in 8 cases (28.6%), car crash in 2 cases (7.2%), meningococcemia in 1 case (3.6%), and snake bite in 1 case (3.6%). After an average follow-up of 15 months (range: 6 to 26 months), all patients had stable coverage. The mean number of preoperative debridements was 2.4 (range: 1 to 8). In 22 patients, the flaps were made without the release of the muscle origin and in 6 patients the muscle flaps were separated from their origin in the femur. Conclusions: Transfer of a gastrocnemius muscle flap is a simple and safe procedure in the treatment of lower limb injuries. The application of the medial gastrocnemius muscle flap was demonstrated in different situations, with satisfactory results and easy reproducibility.

Introdução: A cobertura de feridas complexas de membros inferiores é um grande desafio. O retalho muscular do gastrocnêmio medial é comumente indicado para reconstrução de perdas de substância do joelho e terço proximal da perna. O objetivo desse trabalho é avaliar os resultados da utilização do retalho muscular do gastrocnêmio nos casos de ferida em membros inferiores. Métodos: Um total de 28 pacientes com perda de substância de membros inferiores foi tratado com retalho muscular do gastrocnêmio medial. Os dados foram obtidos em registros clínicos dos pacientes operados no período de 2003 a 2012. Resultados: Vinte e oito pacientes foram operados, com idades variando de 4 a 57 anos, e média de 30,6 anos. A etiologia das lesões foi acidente por motocicleta em 16 casos (57,1%), atropelamentos em oito casos (28,6%), acidente automobilístico em dois casos (7,2%), meningococcemia em um caso (3,6%) e acidente ofídico em um caso (3,6%). Depois de um seguimento médio de 15 meses (variação de 6 a 26 meses), todos pacientes mostraram cobertura estável. O número médio de desbridamentos pré-operatórios foi 2,4 (variação de 1 a 8). Em 22 pacientes, os retalhos foram confeccionados sem a liberação da origem muscular e em seis pacientes os retalhos musculares foram separados de sua origem no fêmur. Conclusões: A transferência do retalho muscular do gastrocnêmio é um procedimento simples e seguro no tratamento de lesões de membros inferiores. Foi demonstrada a aplicação do retalho muscular do gastrocnêmio medial em diferentes situações, com resultados satisfatórios e fácil reprodução.

Reconstruções complexas de membros superiores e inferiores com retalhos de fluxo reverso: uma série de 32 casos / Complex reconstruction of the upper and lower limbs by using reverse-flow flaps: a series of 32 cases

Introdução: A reconstrução de partes moles após perdas de substância do terço distal dos membros superiores e inferiores, principalmente quando associada à exposição de estruturas nobres (osso, tendão, nervos ou vasos sanguíneos), continua a desafiar a cirurgia plástica. Os retalhos fasciocutâneos de fluxo reverso são uma eficiente opção cirúrgica na cobertura de lesões pequenas e médias nesta localização. Método: Foi realizado um estudo clínico retrospectivo, no período de janeiro de 2013 a dezembro de 2014, de uma série de 32 casos de traumas complexos em membros superiores e inferiores. Resultados: Foram realizados 24 retalhos de fluxo reverso nos membros inferiores e 8 nos membros superiores, observando-se uma cobertura eficaz dos defeitos. Conclusão: Os retalhos de fluxo reverso são confiáveis e apresentam arcos de rotação que permitem a cobertura de lesões diversas no terço distal de membros superiores e inferiores.

Introduction: Reconstruction of the soft tissues after loss of substance in the distal third of the upper and lower limbs, in particular when associated with the exposure of noble structures (bone, tendon, nerves, or blood vessels), remains a challenge in plastic surgery. Fasciocutaneous reverse flow flaps are an efficient surgical option for covering small and medium lesions in this location. Method: A retrospective clinical study was performed on a series of 32 cases of complex trauma of the upper and lower limbs treated between January 2013 and December 2014. Results: A total of 24 reverse-flow flaps were performed in the lower limbs and eight in the upper limbs, resulting in efficient coverage of the defects. Conclusion: Reverse-flow flaps are reliable and present rotation arcs that allow coverage of a variety of lesions in the distal third of the upper and lower limbs.

Lesiones combinadas complejas postraumáticas en la pierna. Tratamiento temprano frente a tratamiento diferido / Complex combined post-traumatic leg injuries. Early versus delayed treatment

Introducción: El objetivo de este trabajo es comparar los resultados obtenidos en las lesiones combinadas complejas postraumáticas del tercio medio y distal de la pierna, tratadas en forma temprana o tardía. Materiales y Métodos: Se evaluaron retrospectivamente 14 pacientes tratados entre 2004 y 2012. Se los dividió en dos grupos: con cobertura de partes blandas realizada en los primeros 10 días posteriores al trauma (grupo I, 6 casos) y con cobertura después de los 10 días (grupo II, 8 casos). En el grupo I, la cobertura se efectuó con seis colgajos musculares libres de dorsal ancho y, en el grupo II, con seis colgajos musculares libres y dos colgajos fasciocutáneos rotatorios surales de base distal. Resultados: El seguimiento promedio fue de 39.5 meses en el grupo I y de 50.6 meses en el grupo II; el promedio de días de internación fue de 20.8 y 42.4, respectivamente. En dos casos del grupo I y seis casos del grupo II, todos con pérdida ósea de la tibia distal, se efectuó la reconstrucción ósea en dos tiempos. En dos pacientes, uno de cada grupo, se necrosó el colgajo muscular libre y se practicó la amputación infrarrotuliana. Conclusiones: En lesiones agudas, es recomendable la cobertura con colgajos libres, pero en lesiones crónicas, nuestras indicaciones se han ido modificando, y los colgajos fasciocutáneos rotatorios son nuestra primera opción de cobertura en la actualidad. Nivel de evidencia: IV

Introduction: The objective of this study is to evaluate treatment of complex combined post-traumatic injuries of the distal and middle third of the leg, and compare the results obtained with early versus delayed treatment. Methods: Fourteen patients treated between 2004 and 2012 were retrospectively evaluated. They were divided into two groups: those with soft tissues coverage performed during the first 10 days following trauma (group I, 6 cases) and those with coverage performed after 10 days (group II, 8 cases). Coverage was performed using six latissimus dorsi free flaps in group I, and with six muscle free flaps and two rotational fasciocutaneous flaps in group II. Results: Follow-up averaged 39.5 months in group I and 50.6 months in group II. Hospital stay averaged 20.8 days for group I and 42.4 days for group II. Staged bony reconstruction was performed in two patients from group I and six patients from group II, all with distal tibia bone loss. In two patients, one in each group, the muscle free flap became necrotic, and an amputation was performed. Conclusions: In lesions treated early coverage using free flaps should be favored; but in chronic ones, our practice has changed towards using rotatory fasciocutaneous flaps when possible. Level of evidence: IV

Reconstrução de dorso do pé com retalho supramaleolar lateral de fluxo reverso em menor de 4 anos de idade / Reconstruction of the dorsal foot with a retrograde flow lateral supramalleolar flap in a 4-year-old child

INTRODUÇÃO: Lesões em terço distal da perna podem deixar expostas áreas nobres, que devem ser recobertas. O retalho supramaleolar lateral faz parte de uma série de retalhos descritos na última década, é fasciocutâneo elevado no aspecto lateral da perna inferior, sendo empregado como um retalho pediculado com base distal. O objetivo do presente relato de caso é apresentar os resultados cirúrgicos e a eficácia do retalho supramaleolar lateral em lesões extensas no membro inferior com perdas de substâncias significativas em criança de 4 anos. RELATO DE CASO: Paciente A.K.E.S., sexo feminino, foi internada há 13 anos, vítima de atropelamento, com lesão extensa em dorso de pé esquerdo com exposição de áreas nobres de aproximadamente seis centímetros de diâmetro. Após desbridamento, no quinto dia foi realizada cobertura da lesão com retalho fasciocutâneo supramaleolar lateral. A paciente teve alta para acompanhamento ambulatorial, evoluindo sem intercorrência. Ela retornou ao serviço apenas 13 anos após com sobrepeso e reclamando do aumento de volume no dorso do pé. Foi realizada lipectomia do terço distal do retalho, evoluindo sem intercorrência. Um segundo procedimento do terço proximal foi programado para seis meses após. DISCUSSÃO: Lesões no terço distal da perna podem expor áreas nobres. Os retalhos supramaleolar lateral, sural e de perfurantes pediculados possuem aplicações semelhantes, mas apresentam peculiaridades técnicas individuais. Como vantagens no retalho supramaleolar lateral: não há necessidade de microanastomoses, é rápido para ser executado e simula a área receptora em várias características locais. CONCLUSÃO: É um retalho de maior facilidade de execução e reprodutível, podendo ser realizado em crianças menores de 5 anos. Tem sua aplicação como alternativa para lesões em terços inferiores da perna, tornozelo e pé.

INTRODUCTION: Injuries in the distal third of the leg may expose noble areas that should be covered. The lateral supramalleolar flap is one of a series of flaps described in the last decade; it is an elevated fasciocutaneous flap in the lateral aspect of the lower leg, and is employed as a distally based pedicled flap. The purpose of this case report is to present the surgical results and the effectiveness of the lateral supramalleolar flap in extensive lower limb injuries with significant loss of substance in a 4-year-old child. CASE REPORT: Patient A. K. E. S., a girl, was admitted 13 years previously. She had been in an accident, and had extensive injuries on the dorsum of the left foot, with exposure of noble areas approximately 6 cm in diameter. After debridement, lesion coverage was performed on the fifth day by using a fasciocutaneous lateral supramalleolar flap. The patient was discharged for outpatient monitoring and progressed without complication. She only returned to the hospital 13 years later, overweight and complaining of swelling on the dorsal aspect of the foot. Lipectomy of the distal third of the flap was performed, with uncomplicated progress. A second procedure for the proximal third was scheduled six months later. DISCUSSION: Injuries in the distal third of the leg may expose noble areas. Lateral supramalleolar, sural, and pedicled perforating flaps have similar applications, but show individual technical peculiarities. The lateral supramalleolar flap has no need for microsurgery, is rapidly performed, and simulates the receiving area while considering several local characteristics. CONCLUSION: This flap is easily implemented and reproducible, and can be used in children younger than 5 years of age. It is an alternative for injuries in the lower third of the leg, the ankle, and the foot.