Ulnar-Sided Wrist Pain in the Athlete: Sport-Specific Demands, Clinical Presentation, and Management Options.

ABSTRACT: Ulnar-sided wrist injuries are common in sports that require repeated pronosupination, wrist radial/ulnar deviation, axial loading, and gripping equipment. Common anatomic structures affected include the triangular fibrocartilage complex, extensor carpi ulnaris tendon, distal radioulnar and ulnocarpal joints, and hamate bone. Presenting symptoms include pain with activity, swelling, possible snapping or clicking, and reproduction of symptoms with provocative maneuvers. Imaging may confirm or rule out pathologies, but abnormal findings also may present in asymptomatic athletes. Initial treatment is usually nonoperative with splinting, load management, activity modification, strengthening the components of the kinetic chain of the particular sport, and pain management. Surgery is usually indicated in ulnar-wrist pain pathology such as hook of hamate fractures and required in associated instability. Future research should address specific treatment and rehabilitation protocols, emphasizing the complete kinetic chain along with the injured wrist.

El peroné: mal alumno, pero buen profesor. (¿Qué tiene prioridad biológica: la integridad, o la supervivencia?) / Fibula: a bad pupil but a good profesor. (What comes first, integrity or survival?)

La concepción original del mecanostato como un regulador de la rigidez estructural ósea orientado a mantener un determinado 'factor de seguridad' en todos los esqueletos parece no corresponder por igual a cualquier hueso y para cualquier tipo de estímulo. Hemos descubierto que la estructura cortical diafisaria del peroné humano manifiesta un comportamiento ambiguo del sistema, referido al uso del pie. La diáfisis peronea, además de ser insensible al desuso, se rigidiza, como sería de esperar, por entrenamientos en disciplinas deportivas que rotan o revierten el pie (hockey, fútbol, rugby); pero, llamativamente, se flexibiliza en su mitad proximal por entrenamiento en carrera larga, que optimiza el rendimiento del salto que acompaña a cada paso. La referida rigidización robustecería la región peronea de inserción de los músculos que rotan o revierten el pie, favoreciendo la locomoción sobre terrenos irregulares o 'gambeteando', propia de especies predadoras como los leopardos. La 'inesperada' flexibilización proximal, pese a reducir la resistencia a la fractura por flexión lateral (poco frecuente en el hombre), favorecería la absorción elástica de la energía contráctil de la musculatura inserta, optimizando el rendimiento del salto al correr, condición vital para especies presas como las gacelas. La falta de analogía de estas respuestas de la estructura peronea a distintos entrenamientos, incompatible con el mantenimiento de un factor de seguridad, sugiere su vinculación preferencial con la optimización de aptitudes esqueléticas con valor selectivo. Esto ampliaría el espectro regulatorio del mecanostato a propiedades esqueléticas 'vitales', más allá del control de la integridad ósea. Su manifestación en el hombre, ajena a connotaciones selectivas (quizá resultante del mantenimiento de genes ancestrales), permitiría proponer la indicación de ejercicios orientados en direcciones preferenciales a este respecto, especialmente cuando estas coincidieran con las de las fuerzas que podrían fracturar al hueso. (AU)

The original notion of the mechanostat as a regulator of bone structural rigidity oriented to maintain a certain 'safety factor' in all skeletons does not seem to correspond equally to every bone and for any type of stimulus. We have discovered that the diaphyseal cortical structure of the human fibula shows an ambiguous behavior of the system, with reference to the use of the foot. The peroneal shaft, in addition to being insensitive to disuse, becomes stiffened, as might be expected, by training in sport disciplines that involve rotating or reversing the foot (hockey, soccer, rugby); but, remarkably, it becomes more flexible in its proximal half by long-distance running training, which optimizes the performance of the jump that accompanies each step. The stiffening would strengthen the peroneal region of insertion of the muscles that rotate or reverse the foot, favoring locomotion on uneven terrain or 'dribbling', typical of predatory species such as leopards. The 'unexpected' proximal flexibilization, despite reducing the resistance to lateral flexion fracture (rare in human), would favor the elastic absorption of contractile energy from the inserted muscles, optimizing jumping performance when running, a vital condition for prey species such as gazelles. The lack of analogy of these responses of the peroneal structure to different training, incompatible with the maintenance of a safety factor, suggests its preferential link with the optimization of skeletal aptitudes with selective value. This would expand the regulatory spectrum of the mechanostat to 'vital' skeletal properties, beyond the control of bone integrity. Its manifestation in humans, oblivious to selective connotations (perhaps resulting from the maintenance of ancestral genes), would make it possible to propose the indication of exercises oriented in preferential directions, especially when they coincide with the direction of the forces that could fracture the bone. (AU)

Examination of gas exchange and blood lactate thresholds in Paralympic athletes during upper-body poling.

OBJECTIVES: The primary aim was to compare physiological and perceptual outcome parameters identified at common gas exchange and blood lactate (BLa) thresholds in Paralympic athletes while upper-body poling. The secondary aim was to compare the fit of the breakpoint models used to identify thresholds in the gas exchange thresholds data versus continuous linear and curvilinear (no-breakpoint) models. METHODS: Fifteen elite Para ice hockey players performed seven to eight 5-min stages at increasing workload until exhaustion during upper-body poling. Two regression lines were fitted to the oxygen uptake (VO2)-carbon dioxide (VCO2) and minute ventilation (VE)/VO2 data to determine the ventilatory threshold (VT), and to the VCO2-VE and VE/VCO2 data to determine the respiratory compensation threshold (RCT). The first lactate threshold (LT1) was determined by the first rise in BLa (+0.4mmol·L-1 and +1.0mmol·L-1) and a breakpoint in the log-log transformed VO2-BLa data, and the second lactate threshold (LT2) by a fixed rise in BLa above 4mmol·L-1 and by employing the modified Dmax method. Paired-samples t-tests were used to compare the outcome parameters within and between the different threshold methods. The fit of the two regression lines (breakpoint model) used to identify thresholds in the gas exchange data was compared to that of a single regression line, an exponential and a 3rd order polynomial curve (no-breakpoint models) by Akaike weights. RESULTS: All outcome parameters identified with the VT (i.e., breakpoints in the VO2-VCO2 or VE/VO2 data) were significantly higher than the ones identified with a fixed rise in BLa (+0.4 or +1.0mmol·L-1) at the LT1 (e.g. BLa: 5.1±2.2 or 4.9±1.8 vs 1.9±0.6 or 2.3±0.5mmol·L-1,p<0.001), but were not significantly different from the log-log transformed VO2-BLa data (4.3±1.6mmol·L-1,p>0.06). The outcome parameters identified with breakpoints in the VCO2-VE data to determine the RCT (e.g. BLa: 5.5±1.4mmol·L-1) were not different from the ones identified with the modified Dmax method at the LT2 (5.5±1.1mmol·L-1) (all p>0.53), but were higher compared to parameters identified with VE/VCO2 method (4.9±1.5mmol·L-1) and a fixed BLa value of 4mmol·L-1 (all p<0.03). Although we were able to determine the VT and RCT via different gas exchange threshold methods with good fit in all 15 participants (mean R2>0.931), the continuous no-breakpoint models had the highest probability (>68%) of being the best models for the VO2-VCO2 and the VCO2-VE data. CONCLUSIONS: In Paralympic athletes who exercise in the upper-body poling mode, the outcome parameters identified at the VT and the ones identified with fixed methods at the LT1 showed large differences, demonstrating that these cannot be used interchangeably to estimate the aerobic threshold. In addition, the close location of the VT, RCT and LT2 does not allow us to distinguish the aerobic and anaerobic threshold, indicating the presence of only one threshold in athletes with a disability exercising in an upper-body mode. Furthermore, the better fit of continuous no-breakpoint models indicates no presence of clear breakpoints in the gas exchange data for most participants. This makes us question if breakpoints in the gas exchange data really exist in an upper-body exercise mode in athletes with disabilities.

Vitamin D status and its relation to exercise performance and iron status in young ice hockey players.

OBJECTIVES: The aim was to examine the association between serum vitamin D concentration and isometric strength of various muscle groups, vertical jump performance, and repeated sprint ability in young ice hockey players. The secondary aim was to determine the association between vitamin D deficiency and indices of iron status. METHODS: Fifty male ice hockey players (17.2±0.9 years) participated in this cross-sectional study. Exercise performance was evaluated using isometric strength measures of upper and lower extremities, vertical jump performance and repeated sprint ability (RSA). Blood samples were collected for the determination of serum 25-hydroxyvitamin D (25(OH)D) and multiple indicies of iron status. RESULTS: The mean serum 25(OH)D concentration was 30.4 ng·ml-1 and ranged from 12.5 to 91.4 ng·ml-1. Eleven participants (22%) had vitamin D deficiency and 20 athletes (40%) had vitamin D insufficiency. Serum 25(OH)D concentration was not positively correlated with isometric muscle strength, vertical jump performance, or RSA after adjusting for age, training experience, fat mass, fat free mass and height. Serum 25(OH)D concentration was not associated with indices of iron status. CONCLUSION: Vitamin D insufficiency is highly prevalent in ice hockey players, but 25(OH)D concentration but it is not associated with exercise performance or indices of iron status.

Individual fluid plans versus ad libitum on hydration status in minor professional ice hockey players.

BACKGROUND: Despite exercising in cool environments, ice hockey players exhibit several dehydration risk factors. Individualized fluid plans (IFPs) are designed to mitigate dehydration by matching an individual's sweat loss in order to optimize physiological systems and performance. METHODS: A randomized control trial was used to examine IFP versus ad libitum fluid ingestion on hydration in 11 male minor professional ice hockey players (mean age = 24.4 ± 2.6 years, height = 183.0 ± 4.6 cm, weight = 92.9 ± 7.8 kg). Following baseline measures over 2 practices, participants were randomly assigned to either control (CON) or intervention (INT) for 10 additional practices. CON participants were provided water and/or carbohydrate electrolyte beverage to drink ad libitum. INT participants were instructed to consume water and an electrolyte-enhanced carbohydrate electrolyte beverage to match sweat and sodium losses. Urine specific gravity, urine color, and percent body mass change characterized hydration status. Total fluid consumed during practice was assessed. RESULTS: INT consumed significantly more fluid than CON (1180.8 ± 579.0 ml vs. 788.6 ± 399.7 ml, p = 0.002). However, CON participants replaced only 25.4 ± 12.9% of their fluid needs and INT 35.8 ± 17.5%. Mean percent body mass loss was not significantly different between groups and overall indicated minimal dehydration (<1.2% loss). Pre-practice urine specific gravity indicated CON and INT began hypohydrated (mean = 1.024 ± 0.007 and 1.024 ± 0.006, respectively) and experienced dehydration during practice (post = 1.026 ± 0.006 and 1.027 ± 0.005, respectively, p < 0.001). Urine color increased pre- to post-practice for CON (5 ± 2 to 6 ± 1, p < 0.001) and INT (5 ± 1 to 6 ± 1, p < 0.001). CONCLUSIONS: Participants consistently reported to practice hypohydrated. Ad libitum fluid intake was not significantly different than IFP on hydration status. Based on urine measures, both methods were unsuccessful in preventing dehydration during practice, suggesting practice-only hydration is inadequate to maintain euhydration in this population when beginning hypohydrated.

Cardiac remodeling indicators in adolescent athletes / Indicadores de remodelagem cardíaca em atletas adolescentes

Summary Objective: The idea that different sports and physical training type results in different cardiac adaptations has been widely accepted. However, this remodelling process among different sport modalities is still not fully understood. Thus, the current study aims to investigate the heart morphology variation associated with a set of different modalities characterized by distinct models of preparation and different methods and demands of training and completion. Method: The sample comprises 42 basketball players, 73 roller hockey players, 28 judo athletes and 21 swimmers. Anthropometry was assessed by a single and experienced anthropometrist and the same technician performed the echocardiographic exams. Analysis of variance was used to study age, body size and echocardiograph parameters as well as different sport athlete's comparison. Results: Basketball players are taller (F=23.448; p<0.001; ES-r=0.553), heavier (F=6.702; p<0.001; ES-r=0.334) and have a greater body surface area (F=11.896; p<0.001; ES-r=0.427). Basketball and hockey players have larger left auricle diameters compared with judo athletes (F=3.865; p=0.011; ES-r=0.316). Interventricular end-diastolic septal thickness (F=7.287; p<0.001; ES-r=0.347) and left ventricular posterior wall thickness (F=8.038; p<0.001; ES-r=0.362) of the judokas are smaller compared to the mean values of other sports participants. In addition, relative left parietal ventricular wall thickness is lower among swimmers compared with judokas (F=4.127; p=0.008; ES-r=0.268). Conclusion: The major contributors to changes in heart morphology are for the most part associated with sport-specific training and competition and the specific dynamics and adaptive mechanisms imposed by each sport.

Resumo Objetivo: Os efeitos decorrentes da prática de diferentes modalidades desportivas resultam em padrões divergentes de adaptação cardíaca. A presente pesquisa procura estudar a variação da morfologia do coração associada a um conjunto de modalidades desportivas distintas quanto à natureza do esforço e aos modelos de preparação, incluindo metodologias de treino e sistemas de competição. Método: Foram estudados 42 basquetebolistas, 73 hoquistas, 28 judocas e 21 nadadores. A antropometria foi avaliada por um único e experiente antropometrista e os exames ecocardiográficos foram realizados pelo mesmo operador. Recorreu-se à análise da variância para estudar a variação associada a idade, medidas de tamanho corporal e parâmetros ecocardiográficos, bem como para a comparação entre os atletas de diferentes modalidades desportivas. Resultados: Os basquetebolistas são os atletas mais altos (F=23,448; p<0,001; ES-r=0,553), mais pesados (F=6,702; p<0,001; ES-r=0,334), com maior superfície corporal (F=11,896; p<0,001; ES-r=0,427) e, com os hoquistas, apresentam um diâmetro da aurícula esquerda superior ao dos judocas (F=3,865; p=0,011; ES-r=0,316). A espessura telediastólica do septo interventricular (F=7,287; p<0,001; ES-r=0,347) e da parede posterior do ventrículo esquerdo (F=8,038; p<0,001; ES-r=0,362) dos judocas é inferior à dos outros atletas, mesmo quando controlado para o tamanho corporal. Os nadadores apresentam uma espessura parietal relativa do ventrículo esquerdo superior à dos judocas (F=4,127; p=0,008; ES-r=0,268). Conclusão: As diferentes fontes de variação da morfologia cardíaca prendem-se com as dinâmicas do processo de treino, competição e correspondentemente com os mecanismos adaptativos, sobrepondo-se ao processo de formação desportiva a longo prazo.

Femoroacetabular Impingement in Elite Ice Hockey Goaltenders: Etiological Implications of On-Ice Hip Mechanics.

BACKGROUND: Femoroacetabular impingement (FAI) is particularly prevalent in ice hockey. The butterfly goalie technique is thought to involve extreme ranges of hip motion that may predispose goaltenders to FAI. PURPOSE: To quantify hip mechanics during 3 common goaltender movements and interpret their relevance to the development of FAI. STUDY DESIGN: Descriptive laboratory study. METHODS: Fourteen collegiate and professional goaltenders performed skating, butterfly save, and recovery movements on the ice. Hip mechanics were compared across the 3 movements. RESULTS: The butterfly did not exhibit the greatest range of hip motion in any of the 3 planes. Internal rotation was the only hip motion that appeared close to terminal in this study. When subjects decelerated during skating­shaving the blade of their skate across the surface of the ice­the magnitude of peak hip internal rotation was 54% greater than in the butterfly and 265% greater than in the recovery. No movement involved levels of concomitant flexion, adduction, and internal rotation that resembled the traditional impingement (FADIR) test. CONCLUSION: The magnitude of internal rotation was the most extreme planar hip motion (relative to end-range) recorded in this study (namely during decelerating) and appeared to differentiate this cohort from other athletic populations. Consequently, repetitive end-range hip internal rotation may be the primary precursor to symptomatic FAI in hockey goaltenders and provides the most plausible account for the high incidence of FAI in these athletes. Resection techniques should, therefore, focus on enhancing internal rotation in goaltenders, compared with flexion and adduction. While the butterfly posture can require significant levels of hip motion, recovering from a save and, in particular, decelerating during skating are also demanding on goaltenders' hip joints. Therefore, it appears critical to consider and accommodate a variety of sport-specific hip postures to comprehensively diagnose, treat, and rehabilitate FAI.

Performance-based outcomes after nonoperative treatment, discectomy, and/or fusion for a lumbar disc herniation in National Hockey League athletes.

BACKGROUND: Ice hockey players have a high incidence of lumbar spine disorders; however, there is no evidence in the literature to guide the treatment of an ice hockey player with a herniated lumbar disc. PURPOSE: To determine the performance-based outcomes in professional National Hockey League (NHL) athletes with a lumbar disc herniation after either nonsurgical or surgical treatment. STUDY DESIGN: Descriptive epidemiological study. METHODS: Athletes in the NHL with a lumbar disc herniation were identified through team injury reports and archives on public record. The return-to-play rate, games played per season, points per game, and performance score for each player were determined before and after the diagnosis of a lumbar disc herniation. Statistical analysis was used to compare preinjury and postinjury performance measures for players treated with either nonsurgical or surgical treatment. RESULTS: A total of 87 NHL players met the inclusion criteria; 31 underwent nonoperative care, 48 underwent a discectomy, and 8 underwent a single-level fusion. The return-to-play rate for all players was 85%. There was a significant decrease in performance in all players after a lumbar disc herniation in games played per season, points scored per game, and performance score. A comparison of the posttreatment results for the nonsurgical and surgical patient groups revealed no significant difference in performance measures. Notably, the lumbar fusion group did not show a decrease in games played per season or performance score after surgery, likely secondary to a small sample size. CONCLUSION: National Hockey League players with a lumbar disc herniation have a high return-to-play rate regardless of the type of treatment; however, performance-based outcomes may decrease compared with preinjury levels. The study data suggest that a lumbar fusion is compatible with a return to play in the NHL, which is in contrast to other professional sports.

Functional knee brace use effect on peak vertical ground reaction forces during drop jump landing.

PURPOSE: The aim of the study was to investigate the landing strategies used by non-injured athletes while wearing functional knee braces (FKB, BR condition) during a drop jump task compared with non-injured, non-braced (NBR condition) subjects and also to ascertain whether accommodation to a FKB was possible by non-injured BR subjects. METHODS: Twenty-three healthy male provincial and national basketball and field hockey athletes (age, 19.4 ± 3.0 years) were tested. Each subject was provided with a custom-fitted FKB. Five NBR testing sessions were performed over 3 days followed by five BR testing sessions also over 3 days, for a total of 17.5 h of testing per condition. Each subject performed eight trials of the drop jump task during each testing session per condition. Single-leg peak vertical ground reaction forces (PVGRF) and the time to PVGRF were recorded for each NBR and BR trail. RESULTS: The BR group mean PVGRF at landing was significantly lower (1,628 ± 405 N, 2.1 ± 0.5 BW versus 1,715 ± 403 N, 2.2 ± 0.5 BW, F (1,22) = 6.83, P = 0.01) compared with NBR subjects, respectively. The group mean time to PVGRF was not statistically longer during the BR condition (F (1,22) = 0.967, P = 0.3). Further, an accommodation trend was noted as percent performance difference decreased with continued FKB use. CONCLUSIONS: The significantly lower group mean PVGRF while using a FKB could keep traumatic forces from reaching the ACL until the active neuromuscular restraints are activated to provide protection to the knee joint ligaments. Also, accommodation to FKB is possible after approximately 14.0 h of brace use. The results of this paper will assist clinicians in providing information to their patients regarding a FKB ability to offer protection to an ACL-deficient knee or to address concerns about early muscle fatigue, energy expenditure, heart rate, and decrease in performance level. LEVEL OF EVIDENCE: Prospective study, Level I.

Cellular responses in skeletal muscle to a season of ice hockey.

We hypothesized that a season of ice hockey would result in extensive remodeling of muscle. Tissue sampled from the vastus lateralis of 15 players (age = 20.6 ± 0.4 years; mean ± SE) prior to (PRE) and following (POST) a season was used to characterize specific adaptations. Measurement of representative metabolic pathway enzymes indicated higher maximal activities in POST than in PRE (p < 0.05) for succinic dehydrogenase (3.26 ± 0.31 vs. 3.91 ± 0.11 mol mg protein(-1) min(-1)), citrate synthase (7.26 ± 0.70 vs. 8.70 ± 0.55 mol mg protein(-1) min(-1)), and phosphofructokinase (12.8 ± 1.3 vs. 14.4 ± 0.96 mol mg protein(-1) min(-1)) only. The season resulted in an increase in Na+-K+-ATPase concentration (253 ± 6.3 vs. 265 ± 6.0 pmol g(-1) wet weight), a decrease (p < 0.05) in maximal activity of the sarcoplasmic reticulum Ca2+-ATPase (107 ± 4.2 micromol g protein(-1) min(-1) vs. 92.0 ± 4.6 micromol g protein(-1) min(-1)), and no change in the distribution (%) of fibre types. A smaller (p < 0.05) cross-sectional area (CSA) for both type I (-11.7%) and type IIA (-18.2%) fibres and a higher (p < 0.05) capillary count/CSA for type I (+17.9%) and type IIA (+17.2%) were also found over the season. No changes were found in peak oxygen consumption (51.4 ± 1.2 mL kg(-1) min(-1) vs. 52.3 ± 1.3 mL kg(-1) min(-1)). The results suggest, based on the alterations in oxidative and perfusion potentials and muscle mass, that the dominant adaptations are in support of oxidative metabolism, which occurs at the expense of fibre CSA and possibly force-generating potential.

Total hemoglobin mass, iron status, and endurance capacity in elite field hockey players.

The aims of this study were as follows: To evaluate total hemoglobin mass (tHbmass) in international field hockey players; to examine the correlation between tHbmass and maximum oxygen uptake (VO2max); and to assess influences of iron status on tHbmass and on VO2max. The players of the German women's (N = 17, aged 24.8 +/- 3.0 [21-31] years) and men's (N = 17, aged 24.2 +/- 2.9 [19-32] years) national field hockey team were investigated. tHbmass was measured by an optimized carbon monoxide rebreathing method. The following parameters were measured in venous blood: Hemoglobin concentration (Hbconc), hematocrit (Hct), number and percentage of reticulocytes, reticulocyte hemoglobin content, serum iron, serum ferritin, serum transferrin, unsaturated iron-binding capacity, and serum soluble transferrin receptor concentration. VO2max was determined in a treadmill test. tHbmass (women: 10.6 +/- 1.1 g/kg; men: 12.5 +/- 0.9 g/kg) correlated to VO2max (women: 46.6 +/- 2.9 mL/min/kg; men: 55.8 +/- 4.0 mL/min/kg) in women (r = 0.56, p < 0.05) and in men (r = 0.57, p < 0.05), whereas Hbconc and Hct did not. The investigated parameters of iron status showed no association to tHbmass or to VO2max. In conclusion, tHbmass can be used as an indicator for endurance capacity in elite field hockey players, whereas Hbconc may not. tHbmass or VO2max were not influenced by the actual iron status of the investigated athletes.

Bloqueio do plexo braquial, por via infraclavicular vertical, em paciente com doença pulmonar obstrutiva crônica: relato de caso / Infraclavicular vertical brachial plexus blockade in patients with chronic obstructive pulmonary disease: case report

JUSTIFICATIVA E OBJETIVOS: Os pacientes com doença pulmonar obstrutiva crônica (DPOC) têm risco aumentado de complicações pós-operatórias, sobretudo quando submetidos à anestesia geral. O bloqueio do plexo braquial representa uma alternativa para estes pacientes em intervenções cirúrgicas de membros superiores. O objetivo deste relato foi apresentar um caso de bloqueio do plexo braquial, por via infraclavicular vertical em paciente com DPOC com fratura de cotovelo. RELATO DO CASO: Paciente do sexo feminino, 67 anos, 52 kg, estado físico ASA III, com indicação de osteossíntese de cotovelo, portadora de bronquiectasias desde nove anos de idade após uma pneumonia. Apresentava tosse produtiva habitualmente, e fora submetida à avaliação de seu pneumologista que a liberou para o procedimento. Após instalação de monitorização com pressão arterial não-invasiva, ECG e oxímetro de pulso, foi realizado bloqueio do plexo braquial por via infraclavicular vertical com 30 mL de ropivacaína a 0,5 por cento. A intervenção cirúrgica foi realizada sem intercorrências. A paciente recebeu alta hospitalar no dia seguinte ao procedimento cirúrgico. CONCLUSÕES: O bloqueio do plexo braquial por via infraclavicular vertical é uma técnica alternativa para portadores de DPOC e fratura de cotovelo, por sua menor morbidade quando comparado com a anestesia geral e com a via supraclavicular.

BACKGROUND AND OBJECTIVES: Patients with Chronic Obstructive Pulmonary Disease (COPD) have a higher risk of postoperative complications, especially when undergoing general anesthesia. Brachial plexus blockade is an alternative for these patients when they undergo upper limb surgeries. The objective of this report is to present a case of infraclavicular brachial plexus blockade in patients with COPD and a fractured elbow. CASE REPORT: A female patient, 67 years old, 52 kg, physical status ASA III, with post-pneumonia bronchiectasis since nine years of age and an indication of osteosynthesis of the elbow. She presented productive cough regularly; after evaluation, her pneumologist cleared her for the surgery. The patient was monitored with non-invasive blood pressure. ECG, and pulse oximeter. Infraclavicular brachial plexus blockade with 0.5 percent ropivacaine 30 mL was performed, without intercurrences. The patient was discharged from the hospital the following day. CONCLUSIONS: Infraclavicular brachial plexus blockade is an alternative for patients with COPD and fracture of the elbow, due to its lower morbidity when compared to general anesthetic.

JUSTIFICATIVA Y OBJETIVOS: Los pacientes con enfermedad pulmonar obstructiva crónica (DPOC) presentan riesgo mayor de complicaciones postoperatorias especialmente cuando se les someten a la anestesia general. El bloqueo del plexo braquial representa una alternativa para esos pacientes en intervenciones quirúrgicas de miembros superiores. El objetivo de este relato fue el de presentar un caso de bloqueo del plexo braquial, por vía infraclavicular vertical en paciente con DPOC con fractura de codo. RELATO DEL CASO: Paciente del sexo femenino, 67 años, 52 kg, estado físico ASA III, con indicación de osteosíntesis de codo, portadora de bronquiectasias desde los nueve años de edad después de una pneumonía. Presentaba una tos productiva habitualmente, y fue sometida a la evaluación de su neumólogo que la liberó para el procedimiento. Después de la instalación de monitorización con presión arterial no invasiva, ECG y oxímetro de pulso, se realizó un bloqueo del plexo braquial por vía infraclavicular vertical con 30 mL de ropivacaína a 0,5 por ciento. La intervención quirúrgica fue realizada sin incidencias. La paciente recibió alta hospitalaria al día siguiente del procedimiento quirúrgico. CONCLUSIONES: El bloqueo del plexo braquial por vía infraclavicular vertical es una alternativa técnica para portadores de DPOC y fractura de codo, por su menor morbidez cuando se le compara a la anestesia general y a su vía supraclavicular.

Hemodynamic during a postexertional asystolia in a healthy athlete: a case study.

Hemodynamic events leading to spontaneous postexertional vasovagal syncope are not completely understood because of the lack of beat-to-beat data. We report a case study of a young athlete who undergoes a syncopal episode during the recovery period following a maximal cycle-ergometer test. The episode was monitored by an impedance cardiograph which can gather noninvasively beat-to-beat the flow of heart rate (HR), stroke volume (SV), cardiac output (CO), diastolic filling rate (SV/DT), and myocardial contractility index (PEP/LVET). The most important findings of this report are the dramatic reduction of SV/DT preceding the syncope, the increment of SV together with the reduction of HR preceding and following the syncope, the prompt recovery of CO values after the syncopal episode despite the bradycardia, and the reduction of PEP/LVET after the syncope. This report confirms the importance of active recovery immediately after strenuous exercise and supports the hypothesis that the reduction of SV/DT in the presence of an inotropic stimulation can trigger the vasovagal reaction.