[Surgical repair of a thigh muscle herniation with synthetic mesh].

We present the case of a 14-year-old female patient with a big muscle hernia in the thigh after extraction of a fascia lata strip to repair bilateral congenital ptosis. After three weeks, a progressive emergence of a large bulge between the two thigh incisions in a standing position was noticeable, with local discomfort, dull pain on exertion and unsightly ap-pearance that worried the patient. On surgery three months later, a large tear in the fascia lata and muscle herniation was revealed. The fascial tear was debrided and a synthetic mesh was applied. Ten years later, the patient confirmed her continued asymptomatic condition. Muscular hernia of significant size as a consequence of a fascia lata strip harvest is extremely infrequent in adoles-cents. Surgical repair of big muscular hernias in extremities with synthetic mesh, usually used in groin hernia repair, is an infrequent orthopaedic tool but is safe, easy to apply and inexpensive.

[Slipped capital femoral epiphysis in an ambulant patient with spastic cerebral palsy. A long-term evolution].

We report the case of a boy aged 13 years and 9 months, with predominantly right-sided spastic tetraparesis, who could walk with assistance, GMFCS III, phenotype consistent with adiposogenital syndrome. He presented a 4-week history of left-sided limp without pain, radiologically classified as a stable, chronic slipped capital femoral epiphysis (SCFE) with mild slippage (<30º) on the Southwick classification. In situ fixation of the hip was performed using a full-headed screw, followed by six weeks of rest. Twelve years since the intervention, the patient remains asymptomatic with no clinical or radiological changes. SCFE in patients with cerebral palsy, while highly unusual, is possible. A high level of suspicion is required for diagnosing it. We would suggest ruling out the appearance of SCFE during surveillance screening of patients with cerebral palsy, =?10 years-old, particularly in obese individuals with or without adiposogenital phenotype and limited ability to communicate verbally.

Acute haematogenous septic arthritis of a lumbar facet joint in an otherwise healthy adolescent.

Facet joint septic arthritis is a rare cause of spinal infection in children with only four cases reported. The transmission pathway is believed to be haematogenous in 72% of cases. The authors present the case of a 13-year-old boy hospitalised for acute lumbosciatalgia, limp and fever, with pain upon palpation of the paravertebral muscles, a positive Laségue signal and elevated serum inflammatory markers. The initial lumbar computerised tomography (TC) scan revealed no abnormalities in the interapophyseal joints. After improving on treatment with analgesics and antibiotics, he was readmitted one month later due to clinical deterioration, and septic arthritis of left facet joint L3-L4 was confirmed by magnetic resonance imaging (MRI). The patient experienced a full recovery after treatment with systemic antibiotics (cefotaxime-cloxacilin) and rehabilitation. A high index of suspicion is necessary to diagnose this localization as a manifestation of lumbosciatalgia and/or limp in children. CT-scan or, preferably, MRI is mandatory to confirm this diagnosis.

Distal radial torus fracture in an adult. A new type of occult wrist fracture?

Torus or buckle fractures typically affect children who have suffered indirect minor wrist injuries. They are axial compression-type metaphyseal fractures of cortical and cancellous bone, which are stable and their treatment therefore consists in immobilisation of the joint for three to four weeks. We present an atypical case of distal radius torus fracture in a 19-year-old adult male, which has not been previously reported in adults and can be considered a new type of occult fracture. Knowledge of this possibility is mandatory to be able to make a differential diagnosis of wrist sprain in adults, and avoid performing superfluous complementary tests due to the persistence of pain and functional incapacity.

[Idiopatic chondrolysis of the hip. Long-term follow-up of a case]. / Condrolisis idiopática de cadera. Evolución a largo plazo.

Idiopathic chondrolysis of the hip is a very rare disease occurring during adolescence. Pain and limp are the most common symptoms and are a consequence of an accelerated loss of the articular cartilage with a lower range of move-ment producing rigidity in the last instance. The natural history is unpredictable and varies between complete and spon-taneous recovery and the ankylosis. The current recommended treatment is conservative, restricting the surgical option for residual stiffness. A clinical case of an eleven year old patient is presented. He consulted for a 2 year, torpid course of left groin pain with limp and rigidity. He received treatment with rest, discharge, analgesics and rehabilitation without any improvement initially. He was treated conservatively with NSAIDS, extremity discharge periods, soft traction in the hospital and at home and rehabilitation, recovering mobility and normal gait 6 years after the beginning of the symptoms. Twelve years after the onset of the symptoms the patient leads a normal life without symptoms and has a symmetric range of motion of both hips.

Cross-cultural adaptation of the Zurich Claudication Questionnaire.Validation study of the Spanish version.

BACKGROUND: In the last few years, instruments that measure outcomes and quality of life as perceived by the patient have become tools of great clinical value. The Zurich Claudication Questionnaire is one of the main instruments for the assessment of patients suffering from lumbar spinal stenosis. Nonetheless, no valid version has been published for use in the Spanish population. METHODS: The Zurich Claudication Questionnaire was translated and cross-culturally adapted to Spanish and the psychometric characteristics of the new version were then studied. Seventy-six patients were selected who were to undergo epidural steroid injection or were seen in the Hospital Complex of Navarre Spinal Unit. RESULTS: The Spanish version of the Zurich Claudication Questionnaire shows high Cronbach alpha internal consistency values, high reproducibility, a good correlation with the most important low back condition questionnaires used worldwide and good sensitivity for detecting clinical change in patients who undergo epidural steroid injection. CONCLUSION: This study resulted in a version of the Zurich Claudication Questionnaire or Swiss Spinal Stenosis Questionnaire translated and cross-culturally adapted to Spanish, with highly reliable, valid and sensitive psychometric characteristics. These proven properties make the Zurich Claudication Questionnaire available for the Spanish population, to evaluate outcomes and health status as perceived by patients with spinal stenosis and claudication syndrome.

[Mercury thermometers, still toxic, still present]. / Termómetros de mercurio, aún tóxicos aún presentes.

Mercury thermometers are and have been, despite their manufacture being banned, one of the main sources of exposure at the paediatric age to elementary mercury (Hg) in our environment. The toxicity produced by elementary Hg depends on the exposure channel and its length. Exposure through the digestive tract produces hardly any toxicity, but subcutaneous or intravenous inoculation and inhalation of mercury may produce damages at a local or system level. We present the case of a child who showed inoculation of liquid mercury in subcutaneous tissue after a liquid-in-glass thermometer broke. This provoked damages at a local level with steatonecrosis of the tissue. The diagnosis was decided through a radiological test and required urgent surgery with excision of skin and subcutaneous tissue, guided by radioscopy. Any spread at a system level was discarded. The levels of mercury in the bloodstream and in the urine were regular.

[Glenohumeral osteometry-scapulometry in anterior shoulder instabilities. Study of one of the static stabilizers through computer tomography]. / Osteometría-escapulometría glenohumeral en las inestabilidades anteriores recidivantes de hombro. Estudio etiopatogénico de uno de los estabilizadores.

We have carried out a scapulometric study, using CT-scan, of 98 shoulders: 36 with recurrent anterior shoulder dislocation (RAD), 37 stable contralateral shoulders (CSS) and 25 normal shoulders (NS). Six parameters were evaluated: Horizontal and Vertical glenohumeral index, glenoid tilt, anteversion angle of the scapula, glenoid angle and humeral retroversion. We found statistically significant differences between the RAD and CSS groups in the horizontal glenohumeral index. Both the RAD and CSS groups showed significant differences in comparison with the NS group in the horizontal glenohumeral index, glenoid tilt and anteversion angle of the scapula. An imbalance of the head-glenoid size and the anterior glenoid tilt are the anatomical factors which favour instability. The determination of these three parameters has great value when assessing patients with anterior shoulder instability. Our results confirm that although the aetiology of anterior glenohumeral instability is multifactorial, there is an anatomical congenital predisposition which favours instability and this predisposition affects (to a lesser extent) the stable contralateral side, confirming the role of subtle congenital dysplasic theory. In addition the following were revealed as relevant parameters in the study of anterior instability: the horizontal glenohumeral index, glenoid tilt and angle of anteversion of the scapula; while the value of the humeral retroversion is under discussion.

Post traumatic retroperitoneal fibrosis as a cause of low-back pain.

We present the case of a male patient with post traumatic retroperitoneal fibrosis whose main clinical expression was low-back pain. Diagnosis was established using CAT-scan and MRI, which revealed a large mass of soft tissue that almost entirely enveloped the abdominal aorta. Treatment with 40 mg of prednisone every 24 hours was established. This dose was reduced gradually, and progressive remission of clinical signs and symptoms was achieved, with a significant improvement of subsequent imaging-test results. Treatment was continued for one year. Two and a half years later the patient remains symptom-free, with no recurrence of his condition.

Valgus slipped capital femoral epiphysis.

Valgus slips of the epiphysis are rare, making radiological diagnosis difficult. A high degree of clinical suspicion is required to diagnose the condition. The patient was a 13-year, 7-month-old girl who had been suffering from pain in the left thigh for ten days. She had a limp and a positive Trendelenburg sign. Menstrual function had started when she was 12 years and 10 months old. Pain occurred with getting up from a chair. Hip radiographs revealed symmetrical, bilateral caput valgum, which was a potential cause of confusion given the valgus displacement of the proximal femoral epiphysis. Axial view showed an almost imperceptible posterior slip. The patient was diagnosed as having a valgus slipped capital femoral epiphysis (SCFE). Surgical treatment was performed using in-situ fixation with a cannulated, fully threaded percutaneous screw placed through the external cortex of the femoral neck. Non-weight-bearing for six weeks was prescribed. Although a medial approach is usually used for screw insertion using a more medial entry-point, preventing neurovascular risks, in-situ fixation (through a lateral approach) was performed more safely and distally. This was done through the outer cortex of the femoral neck (and centered in the axial view), to achieve fixation of the femoral head in the center of the femoral neck and head.

Unilateral non-traumatic radiocarpal volar dislocation in a child. A long-term evolution.

We report an eight year-old female with trisomy 21 referred to our clinic for limitation of wrist mobility. The patient had been diagnosed and treated by polyarticular juvenile chronic arthritis for six months. Clinical and radiological study revealed volar radiocarpal dislocation of the left wrist. She was treated surgically by open reduction, temporary K-w fixation with six weeks of immobilization. The dislocation relapsed but the joint remained painless. One year later she had 5 masculine of dorsal flexion and 25 masculine of volar flexion and absence of pain. In spite of this situation the family said that the girl lived normal life without any limitation because of her condition, refusing further treatment. Eight years later the girl remains asymptomatic and does a normal life without limitation because of her condition. The patient and her family refused any treatment. Based in the failure of surgical treatment performed in our case we think that abstention could be the most reasonable option, mainly in the immature patients.

[Medial dislocation of the talus. Medium term evolution]. / Enucleación medial de astrágalo abierta. Evolución a medio plazo.

Fifty-seven year old patient with open medial dislocation of the left talus, with suprasyndesmotic fracture of the fibula, due to indirect traumatism. The following were carried out: washing, cleaning the talus and the soft parts, Friedrich, reduction, fixing with Kirschner needles, suture of the deltoid ligament, and osteosynthesis of the fibula. There were neither surface nor deep post-operational infections. The patient underwent six weeks of immobilisation and spent three months on discharge. Two years later there were no radiological signs of avascular necrosis. In the osseous gammagraphy carried out 18 months after the lesion, partial avascular necrosis of the talus was observed. Three years after the lesion, the patient was able to carry out a normal life, without pain in repose but with pain whilst moving, and mobility with limitation of dorsoinflection (-20 masculine). Five and a half years after the lesion, the patient presented sinking of the talar dome due to avascular necrosis, with painful symptomatology whilst moving, and tibiofibular distal diastasis, which required ankle arthrodesis.

[Primary recurrent medial subdislocation of both patellae. Long-term review of an exceptional case of miserably malalignment syndrome]. / Subluxación primaria recidivante medial de rótulas. Revisión a largo plazo de un caso asociado a síndrome de desalineación torsional severa.

We present a long-term review of a girl aged 11 years and 4 months with medial primary recurrent subluxation of both patellae of several months evolution associated with miserably malalignment syndrome. Not one case of medial recurrent dislocation of the patellae has been described previously. Three years previously following a jump she had suffered a right patellar luxation - self-reduced and not immobilised - followed by 10 subsequent episodes of subluxation and three more medial luxations. She could hardly walk autonomously due to persistent or habitual subluxation and patellofemoral pain, mainly in the right knee. Physical examination revealed habitual medial subluxation of both patellae, with clear medial patellar displacement, quadriceps amyotrophy and medial instability. The medial subluxation suppression test was positive. She showed excessive femoral anteversion of the hips (IR: 90 degrees, ER: 30 degrees), genu varum, neutral tibial torsion, patella alta, dysplastic trochlear grooves with medial condyle hipoplasia and both patellae were dysplastic (Wiberg type III). We performed a derotation subtrochanteric femoral osteotomy and bilateral proximal patellar realignment. Following surgery, bilateral stability of both sides permitted normal walking and running, as well as apprehension and the Smillie test (-), with a hip mobility of 65 degrees ER and 50 degrees IR. Fifteen years after the surgery the patient complains of antero-external knee pain in the right knee during prolonged walking, in getting up and down stairs and when in a prolonged sitting position, diagnosed as excessive lateral pressure syndrome.

[Intra-articular dislocation of patella]. / Luxación intra-articular de rótula.

The case of a patient aged 73 years who, following an accidental fall on a staircase, suffered an acute intraarticular dislocation in the left knee-cap is presented. This exceptional dislocation presented incarceration of the proximal kneecap pole in the femoral intercondylar groove. A reduction was carried out under general anaesthetic due to pain and muscular contraction in the attempts at reduction without anaesthetic. We made a surgical check that ruled out associated lesions to the extensor apparatus, soft parts, joint structures and osteophytes. The patient presented advanced arthrosis, above all femoral-patellar. Following two weeks of immobilisation, the patient restarted mobility. There has been no relapse or other type of complication.

[Primary pyomyositis of the psoas muscles in a temperate climate. Review of two cases in children followed up over the long term]. / Piomiositis primaria del músculo psoas en clima templado. Revisión a propósito de dos casos en niños seguidos a largo plazo.

BACKGROUND: We review two cases of primary pyomyositis of the psoas in children that occurred in Navarre, their management and long-term evolution. Primary pyomyositis of the psoas muscle is a rare infection in a temperate climate. Its diagnosis is difficult due to the similarity of the symptoms with several infectious processes, mainly septic arthritis of the hip in children and adolescents. The rarity of the present cases is due to several facts: occurrence in children, in a temperate climate (Navarre), immunocompetent patients and without subjacent pathology, besides their monofocal situation that is contrary to the more frequent multifocal presentation. These factors, besides the poor specificity of the symptoms, constitute a diagnostic challenge. METHODS: We present two patients (10 and 12 years old) with fever and a painful hip. Neither of the patients had predisposing factors. Both of them showed hip flexion with limited range of motion in rotations. Confirmation of the diagnosis was made by ultrasound, CT-scan and/or MRI. Needle aspiration of the hip, under general anaesthesia, confirmed the reactive origin of the joint effusion in both patients. In neither of the two cases was there a significant diagnostic delay. Staphylococcus aureus was isolated in the purulent material in one case and in the hemoculture in the other. Both patients have been checked in a long-term revision (follow-up of 7 and 10 years). RESULTS: They were successfully treated by isolated antibiotherapy in one case and surgical drainage in the other. Healing was achieved in each case without relapse or sequels in a long-term revision. We carry out a global revision of this rare infection, emphasising the difficulty of its clinical diagnosis and the different treatment modalities and the proper indication. We suggest an algorithm as a clinical guide for its clinical-therapeutic management.