Laceração de canalículo lacrimal em centro de referência do centro-oeste paulista / Lacrimal canaliculus laceration in a reference center in the Center-West of the state of São Paulo

RESUMO Objetivo: Descrever as características clínico-epidemiológicas, técnicas cirúrgicas e resultado do tratamento das lacerações canaliculares operadas em nosso serviço. Métodos: Estudo retrospectivo, realizado de janeiro de 2012 a junho de 2020, considerando-se as lesões de canalículo lacrimal operadas em um serviço de referência. Dados demográficos, características das lesões, detalhes das cirurgias e resultado do tratamento foram obtidos de prontuários eletrônicos e analisados estatisticamente. Resultados: Foram incluídos 26 portadores de lesões canaliculares, com idade entre 2 e 71 anos, sendo 73,1% homens. A lesão acometia o canalículo superior em 53,9%; 80,8% pacientes procuraram pelo serviço nas primeiras 24 horas, e 46,2% tiveram a cirurgia realizada entre 24 e 72 horas após o traumatismo. Todos os pacientes tiveram intubação mono ou bicanalicular, e o tempo transcorrido entre a cirurgia e a retirada do silicone, variou de zero a 183 dias. Após a cirurgia, 21 pacientes (80,8%; p<0,05) não apresentaram complicações, 2 (7,7%) evoluíram com obstrução canalicular, 2 (7,7%) com granuloma e 1 (3,8%) com ectrópio de ponto lacrimal. Conclusão: As lesões de canalículo encontradas em nossa prática são mais comuns em crianças ou homens jovens, acometem mais o canalículo superior e as nossas condutas levam a sucesso no tratamento na maior parte dos casos. As grandes controvérsias no assunto persistem, como o tipo e o tempo de permanência do tubo de silicone na via lacrimal. Somente estudos com grandes amostras podem consolidar esses conceitos.

ABSTRACT Objective: To describe the clinical and epidemiological characteristics, surgical techniques, and results of the canalicular laceration treatment at our service. Methods: A retrospective study was carried out from January 2012 to June 2020, considering canalicular injuries operated at a reference center. Demographic data, lesion characteristics, surgical details, and treatment outcomes were obtained from electronic medical records and were statistically analyzed. Results: Twenty-six cases of people with canalicular lesions aged between 2 to 71 years old were included, of whom 73.1% were men. The superior canaliculus was affected in 53.9%; 80.8% of patients searched for care within the first 24 hours, and 46.2% had the surgery performed between 24-72 hours after trauma. All patients had mono or bicanalicular intubation and the time elapsed between surgery and silicone removal ranged from 0 to 183 days. After surgery, 21 patients (80.8%, p<0.05) did not present any complications, two (7.7%) evolved with canalicular obstruction, two (7.7%) with granuloma, and one (3.8 %) with lacrimal puncta ectropion. Conclusion: In our practice, canalicular injuries are more common in children or young men, affecting mainly the superior canaliculus, and treatment success using our approach can be achieved in most of the cases. However, great controversies remain on the subject, such as type of intubation and when to remove the silicone tube from the lacrimal pathway. Larger series are required to consolidate controversial concepts.

Use of surgical glue versus suture to repair perineal tears: a randomised controlled trial.

BACKGROUND: Surgical glue has been used in several body tissues, including perineal repair, and can benefit women. OBJECTIVES: To evaluate the effectiveness of n-butyl-2-cyanoacrylate surgical glue compared to the polyglactin 910 suture in repairing first- and second-degree perineal tears and episiotomy in vaginal births. DESIGN: A parallel randomised controlled open trial. SETTING: Birth centre in Itapecerica da Serra, São Paulo, Brazil. PARTICIPANTS AND METHODS: The participants were 140 postpartum women allocated into four groups: two experimental groups repaired with surgical glue (n = 35 women with a first-degree tear; n = 35 women with a second-degree tear or episiotomy); two control groups sutured with thread (n = 35 women with a first-degree tear; n = 35 women with a second-degree tear or episiotomy). The outcomes were perineal pain and the healing process. Data collection was conducted in six stages: (1) up to 2 h after perineal repair; (2) from 12 to 24 h postpartum; (3) from 36 to 48 h; (4) from 10 to 20 days; (5) from 50 to 70 days; and (6) from 6 to 8 months. ANOVA, Student's t, Monte Carlo, x-square and Wald tests were used for the statistical analysis. RESULTS: One hundred forty women participated in the first three stages, 110 in stage 4, 122 in stage 5, and 54 in stage 6. The women treated with surgical glue had less perineal pain (p ≤ 0.001). There was no difference in the healing process, but the CG obtained a better result in the coaptation item (p ≤ 0.001). CONCLUSIONS: Perineal repair with surgical glue has low pain intensity and results in a healing process similar to suture threads. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials (UTN code: U1111-1184-2507; RBR-2q5wy8o); date of registration 01/25/2018; www.ensaiosclinicos.gov.br/rg/RBR-2q5wy8/.

Anatomical and Functional Success Analysis of Lacrimal Canalicular Lacerations Repaired with Bicanalicular Stents in a Tertiary Referral Teaching Center in Mexico.

INTRODUCTION: Functional and anatomical success after canalicular laceration repair using only Crawford bicanalicular stents was evaluated in a ophthalmological teaching center. The objective of this study was to evaluate functional and anatomical success after canalicular laceration repair using Crawford bicanalicular stents. MATERIALS AND METHODS: Records of patients with canalicular laceration repair performed from 2010 to 2019 at Ophthalmology Institute Conde de Valenciana in Mexico City were reviewed. Demographic data, injury mechanism and complications were recorded. Anatomical success was assessed with canalicular irrigation and functional success was evaluated using Munk score. Phi correlation coefficient was used to compare the correlation between epiphora and lack of permeability of injured canaliculus and the presence of complications at 6th month postoperative visit. RESULTS: Two-hundred eight patients with lacrimal canalicular injury reconstruction were documented during the study period. The most common age of presentation and etiology was from 21 to 30 years old and injury with a sharp object, respectively. 96 patients were included for the correlation analysis. At 6th month, anatomical success was found in 75% and functional success was found in 77.8%. A statistically significant and directly proportional linear was found between the presence of epiphora and lack of permeability of injured canaliculus, (rφ 0.76, p <0.05) and between the presence of epiphora and postoperative complications, (rφ 0.509, p <0.05). CONCLUSION: Crawford bicanalicular stents are a valid and accessible option for canalicular laceration repair. Our success rate of lacrimal canalicular lacerations repaired with bicanalicular stents in a Mexican teaching hospital matches worldwide literature. Factors involved in the functional and anatomical success of the reconstruction include presence of postoperative complications and permeability of canaliculus after surgery.

Duodenal Laceration Due to Blunt Trauma Caused by Horse Kick: A Case Report and Literature Review.

BACKGROUND Duodenal trauma usually consists of retroperitoneal lesions. Its management can be complicated by the location of the injury and difficulty in making an early diagnosis. Duodenal injuries are divided into blunt and penetrating trauma, and the possible results are hematoma, laceration, and devascularization. Duodenal lesions due to blunt trauma are usually accompanied by lesions of nearby organs. We present a rare case of a single duodenal laceration due to blunt abdominal trauma caused by a horse kick, along with a literature review. CASE REPORT A 13-year-old boy presented to our emergency department after being kicked by a horse in his abdomen. He was stable and complained of abdominal pain without any other specifications. Computed tomography imaging revealed a retropneumoperitoneum and free fluid in the abdominal cavity. The patient was taken for an emergency laparotomy, which showed a single duodenal laceration of the second and third portions of the duodenum. The laceration was repaired with a double-layer closure using monofilament 3-0 polypropylene suture. The patient recovered from his injuries and was well at his last follow-up. CONCLUSIONS This case highlights the possible outcomes of an innocent blunt trauma and the importance of early diagnosis for the best outcome of a duodenal laceration. It also identifies the dissociation between the patient's clinical presentation and his significant intra-abdominal injury.

Laceração palpebral e canalicular neonatal em parto cesárea / Neonatal eyelid and canalicular laceration in cesarean delivery

Resumo Na medicina moderna, lesões traumáticas neonatais durante o parto são raras. Mais raras ainda são as relatadas por ocasião de um parto cesárea. Reporta-se o primeiro caso descrito de laceração palpebral e canicular neonatal em parto cesáreo. Descreve-se o trabalho conjunto de diagnóstico oportuno por parte da equipe de pediatria e a pronta intervenção cirúrgica oftalmológica num caso bem conduzido de laceração palpebral e canalicular à direita. O lactente apresenta-se sem prejuízo funcional permanente durante seguimento pós-operatório.

Abstract In modern medicine, neonatal traumatic injuries during childbirth are rare. More rarely are those during a cesarean birth. That is the first reported case of palpebral laceration and neonatal canicular cesarean section. We describe the joint work of early diagnosis by the pediatric team and the prompt ophthalmologic surgical intervention in a well-conducted case of right palpebral and canalicular laceration. The infant presents without permanent functional impairment during postoperative follow-up.

Technique tip: EDL-to-EHL double loop transfer for extensor hallucis longus reconstruction.

BACKGROUND: Extensor hallucis longus (EHL) tendon injuries often occur in the setting of lacerations to the dorsum of the foot. End-to-end repair is advocated in acute lacerations, or in chronic cases when the tendon edges are suitable for tension free repair. Reconstruction with allograft or autograft is advocated for cases not amenable to a primary direct repair. This is often seen in cases with tendon retraction and more commonly in the chronic setting. In many countries the use of allograft is very limited or unavailable making reconstruction with autograft and tendon transfers the primary choice of treatment. Tendon diameter mismatch and diminished resistance are common issues in other previously described tendon transfers. METHODS: We present the results of a new technique for reconstruction of non-reparable EHL lacerations in three patients using a dynamic double loop transfer of the extensor digitorum longus (EDL) of the second toe that addresses these issues. RESULTS: At one-year follow up, all patients recovered active/passive hallux extension with good functional (AOFAS Score) and satisfaction results. No reruptures or other complications were reported in this group of patients. No second toe deformities or dysfunction were reported. CONCLUSIONS: Second EDL-to-EHL Double Loop Transfer for Extensor Hallucis Longus reconstruction is a safe, reproducible and low-cost technique to address EHL ruptures when primary repair is not possible. LEVEL OF EVIDENCE: IV (Case Series).

A Simple, Reproducible and Low-cost Simulator for Teaching Surgical Techniques to Repair Obstetric Anal Sphincter Injuries.

OBJECTIVE: To describe and evaluate the use of a simple, low-cost, and reproducible simulator for teaching the repair of obstetric anal sphincter injuries (OASIS). METHODS: Twenty resident doctors in obstetrics and gynecology and four obstetricians participated in the simulation. A fourth-degree tear model was created using low-cost materials (condom simulating the rectal mucosa, cotton tissue simulating the internal anal sphincter, and bovine meat simulating the external anal sphincter). The simulator was initially assembled with the aid of anatomical photos to study the anatomy and meaning of each component of the model. The laceration was created and repaired, using end-to-end or overlapping application techniques. RESULTS: The model cost less than R$ 10.00 and was assembled without difficulty, which improved the knowledge of the participants of anatomy and physiology. The sutures of the layers (rectal mucosa, internal sphincter, and external sphincter) were performed in keeping with the surgical technique. All participants were satisfied with the simulation and felt it improved their knowledge and skills. Between 3 and 6 months after the training, 7 participants witnessed severe lacerations in their practice and reported that the simulation was useful for surgical correction. CONCLUSION: The use of a simulator for repair training in OASIS is affordable (low-cost and easy to perform). The simulation seems to improve the knowledge and surgical skills necessary to repair severe lacerations. Further systematized studies should be performed for evaluation.

OBJETIVO: Descrever e avaliar a utilização de um simulador simples, de baixo custo e reprodutível para o ensino de sutura de lacerações perineais de 4° grau. MéTODOS: Participaram da simulação 20 residentes de ginecologia e obstetrícia e quatro profissionais especialistas. Um modelo de laceração de 4° grau foi criado com materiais de baixo custo (preservativo simulando a mucosa retal, tecido de algodão simulando o esfíncter anal interno e carne bovina simulando o esfíncter anal externo). O simulador foi inicialmente montado com ajuda de fotos anatômicas, para estudar a anatomia e o significado de cada componente do modelo. A laceração foi criada e suturada, utilizando técnicas de borda a borda e de sobreposição do esfíncter anal. RESULTADOS: O modelo custou menos de R$ 10,00 e foi montado sem dificuldade, aprimorando os conhecimentos dos participantes sobre anatomia e fisiologia. As suturas das camadas (mucosa retal, esfíncter interno e esfíncter externo) foram realizadas seguindo a técnica cirúrgica. Todos os participantes ficaram satisfeitos com a simulação e consideraram que esta melhorou seus conhecimentos e habilidades. Entre 3 a 6 meses após o treinamento, 7 participantes presenciaram em sua prática lacerações graves e relataram que a simulação foi útil para a correção cirúrgica. CONCLUSãO: A utilização de um simulador para treinamento de sutura de lacerações obstétricas graves é acessível (baixo custo e fácil execução). A simulação parece aprimorar conhecimentos e habilidades cirúrgicas para sutura de lacerações graves. Mais estudos sistematizados devem ser realizados para avaliação.

A simple, reproducible and low-cost simulator for teaching surgical techniques to repair obstetric anal sphincter injuries / Um Simulador simples, reproduzível e de baixo custo para o ensino de técnicas cirúrgicas para reparar lesões obstétricas do esfíncter anal

Abstract Objective To describe and evaluate the use of a simple, low-cost, and reproducible simulator for teaching the repair of obstetric anal sphincter injuries (OASIS). Methods Twenty resident doctors in obstetrics and gynecology and four obstetricians participated in the simulation. A fourth-degree tear model was created using lowcost materials (condom simulating the rectal mucosa, cotton tissue simulating the internal anal sphincter, and bovine meat simulating the external anal sphincter). The simulator was initially assembled with the aid of anatomical photos to study the anatomy and meaning of each component of the model. The laceration was created and repaired, using end-to-end or overlapping application techniques. Results The model cost less than R$ 10.00 and was assembled without difficulty, which improved the knowledge of the participants of anatomy and physiology. The sutures of the layers (rectal mucosa, internal sphincter, and external sphincter) were performed in keeping with the surgical technique. All participants were satisfied with the simulation and felt it improved their knowledge and skills. Between 3 and 6 months after the training, 7 participants witnessed severe lacerations in their practice and reported that the simulation was useful for surgical correction. Conclusion The use of a simulator for repair training in OASIS is affordable (low-cost and easy to perform). The simulation seems to improve the knowledge and surgical skills necessary to repair severe lacerations. Further systematized studies should be performed for evaluation.

Resumo Objetivo Descrever e avaliar a utilização de um simulador simples, de baixo custo e reprodutível para o ensino de sutura de lacerações perineais de 4° grau. Métodos Participaram da simulação 20 residentes de ginecologia e obstetrícia e quatro profissionais especialistas. Um modelo de laceração de 4° grau foi criado com materiais de baixo custo (preservativo simulando a mucosa retal, tecido de algodão simulando o esfíncter anal interno e carne bovina simulando o esfíncter anal externo). O simulador foi inicialmente montado com ajuda de fotos anatômicas, para estudar a anatomia e o significado de cada componente do modelo. A laceração foi criada e suturada, utilizando técnicas de borda a borda e de sobreposição do esfíncter anal. Resultados O modelo custou menos de R$ 10,00 e foi montado sem dificuldade, aprimorando os conhecimentos dos participantes sobre anatomia e fisiologia. As suturas das camadas (mucosa retal, esfíncter interno e esfíncter externo) foram realizadas seguindo a técnica cirúrgica. Todos os participantes ficaram satisfeitos coma simulação e consideraram que estamelhorou seus conhecimentos e habilidades. Entre 3 a 6 meses após o treinamento, 7 participantes presenciaram em sua prática lacerações graves e relataram que a simulação foi útil para a correção cirúrgica. Conclusão A utilização de um simulador para treinamento de sutura de lacerações obstétricas graves é acessível (baixo custo e fácil execução). A simulação parece aprimorar conhecimentos e habilidades cirúrgicas para sutura de lacerações graves. Mais estudos sistematizados devem ser realizados para avaliação.

Abordaje supraclavicular para el traumatismo vascular subclavio / Supraclavicular approach for subclavian vascular injuries

Introducción: la lesión traumática de los vasos subclavios no es frecuente. La causa fundamental está centrada en las heridas por armas de fuego y por objetos perforo-cortantes. La hemorragia o un hematoma en la zona de la base del cuello o tórax superior nos hacen pensar en esta lesión. El tratamiento depende principalmente de la estabilidad hemodinámica del paciente y los recursos disponibles. Este puede ser quirúrgico convencional o reparación endovascular. Objetivos: exponer los beneficios del abordaje supraclavicular para el tratamiento quirúrgico urgente de la lesión de vasos subclavios. Métodos: se realizó un estudio observacional, retro y prospectivo para recolectar la información de los pacientes atendidos por lesión traumática de vasos subclavios en nuestro centro, desde noviembre de 2011 hasta octubre de 2015. Resultados: de los pacientes intervenidos, 10 fueron hombres y una mujer. Todas las lesiones fueron por objetos perforo-cortantes. El tipo de lesión más frecuente fue la laceración de vena subclavia (63,6 por ciento). La vía de abordaje más utilizada fue la cervicotomía en tercio inferior con prolongación supraclavicular con clavicectomía y osteosíntesis ulterior. Hubo 3 fallecidos (27,3 por ciento). Conclusiones: la herida de vasos subclavios sucede más frecuente por objetos perforo-cortantes y tiene una alta mortalidad, la vía supraclavicular resultó la de mejor exposición para repararla. La prontitud del tratamiento fue la variable que más influyó en la morbilidad y mortalidad de esta afección(AU)

Introduction: traumatic injury of the subclavian vessels is rare. The main cause is focused on ballistic trauma and pierced-sharp objects. Bleeding or hematoma in the areas of the neck base or the upper chest lead us to think of this injury. Treatment depends mainly on the patient's hemodynamic stability and available resources. This may be conventional surgical or endovascular repair. Objectives: expose the benefits of supraclavicular approach to the urgent surgical treatment of the subclavian vessel lesions. Methods: a prospective and retro observational study was performed to gather information from patients treated for traumatic lesion of subclavian vessels in our hospital from November 2011 to October 2015. Results: out of the operated patients, 10 were men and one was woman. All lesions were drilled-sharp objects. The most common type of injury was the subclavian vein laceration (63.6 percent). The most commonly used approach was the cervicotomy in the lower third with supraclavicular clavicotomy clavicectomía and further extension with osteosynthesis. There were 3 deaths (27.3 percent). Conclusions: subclavian vessel wounds most frequently occur due to perforating-cutting objects and has a high mortality. The supraclavicular approach was the best access for repair. The promptness of treatment was the variable that most influenced the morbidity and mortality of this condition(AU)

Double-blind Randomized Controlled Trial of Intranasal Dexmedetomidine Versus Intranasal Midazolam as Anxiolysis Prior to Pediatric Laceration Repair in the Emergency Department.

OBJECTIVE: The objective of this study was to compare anxiolysis with intranasal dexmedetomidine, an alpha-2 agonist, versus intranasal midazolam for pediatric laceration repairs. METHODS: We performed a double-blind, randomized controlled trial of 40 patients 1-5 years with lacerations requiring suture repair in an academic pediatric emergency department (ED). Patients were randomized to receive either intranasal dexmedetomidine or intranasal midazolam. Our primary outcome measure was the anxiety score at the time of patient positioning for the laceration repair. We chose this time point to isolate the anxiolysis from the medications prior to intervention. Patient encounters were videotaped and scored for anxiety at multiple time points using the modified Yale Preoperative Anxiety Scale. The scale is 23.3-100 with higher scores indicating higher anxiety. We also evaluated these scores as a secondary outcome by dichotomizing them into anxious versus not anxious with a previously validated score cutoff. RESULTS: Of the 40 patients enrolled, 20 in the dexmedetomidine group and 18 in the midazolam group completed the study and were included in the analysis. The median age was 3.3 years (range = 1.0-5.4 years). The median baseline anxiety score was 48.3. The anxiety score at position for procedure for patients receiving dexmedetomidine was 9.2 points lower than those receiving midazolam (median difference = 9.2, 95% confidence interval = 5 to 13.3; median score for dexmedetomidine = 23.3, median score for midazolam = 36.3). The proportion of patients who were classified as not anxious at the position for procedure was significantly higher in the dexmedetomidine group (70%) versus the midazolam group (11%). The number needed to treat with dexmedetomidine instead of midazolam to obtain the result of a not anxious patient at this time point was 1.7 patients. There were also significantly more patients who were classified as not anxious at the time of wound washout in the dexmedetomidine group compared to the midazolam group (35% vs. 6%). Dexmedetomidine and midazolam performed similarly with respect to all other measures including anxiety at other time points, parental perceived anxiety, parent and proceduralist satisfaction, procedural success, complications, and time in the ED. There were no serious adverse events seen in either group. CONCLUSIONS: Intranasal dexmedetomidine is an alternative anxiolytic medication to intranasal midazolam for pediatric laceration repairs, performing similarly in our study, except that patients who received dexmedetomidine had less anxiety at the time of positioning for procedure.

Flexor Digitorum Superficialis and Flexor Digitorum Profundus with separated sheaths, a new normal variation in human / Flexor superficial de la y Flexor profundo de los con vainas separadas, una nueva variación normal en humanos

Case description: A 25 years old man presented with a laceration on radial side of proximal phalanx of 4th finger (zone II flexor) which was due to cut with glass. Clinical findings: The sheaths of Tendons of flexor digitorum sperficialis and profundus were not the same and each tendon had a separate sheath. Treatment and outcome: The tendons were reconstructed by modified Kessler sutures, after 15 months the patient had a 30 degrees of extension lag even after physiotherapy courses. Clinical relevance: This is the first reported of such normal variation in human hand tendon anatomy.

Descripción del caso: Se presentó un hombre de 25 años con una laceración en la parte radial de la falange proximal del cuarto dedo de la mano (zona flexor II) causada por el corte con un vidrio. Hallazgos clínicos: Las cubiertas de los tendones del flexor digitorum sperficialis y profundus estaban separadas en diferentes cubiertas. Tratamiento y resultado: Los tendones se reconstruyeron por la suturas modificadas de Kessler. Después de 15 meses el paciente presentó una pérdida del 30% en la extensión , aun después de la fisioterapia. Relevancia clínica: Es el primer reporte de la variación en la anatomía de la mano.

[Spleen-preserving surgery after blunt abdominal trauma with splenic hilum involvement]. / Cirugía preservadora de órgano tras traumatismo esplénico cerrado con implicación hiliar.

BACKGROUND: Splenic involvement secondary to blunt abdominal trauma is often treated by performing a splenectomy. The severity of the post-splenectomy syndrome is currently well known (blood loss, sepsis), so there is an increasing tendency to preserve the spleen. The case is presented of splenic preservation after blunt abdominal trauma with hilum involvement, emphasising the role of Floseal as a haemostatic agent, as well as the use of resorbable meshes to preserve the spleen. CLINICAL CASE: A 22-year-old woman presenting with a grade IV splenic lesion secondary to a blunt abdominal trauma after a traffic accident. Partial splenic resection was performed and bleeding was controlled with Floseal and use of a reinforcing polyglycolic acid mesh. No postoperative complications occurred, being discharged on day 5. The long-term follow-up has been uneventful. CONCLUSION: The use of haemostatic agents such as thrombin and the gelatine gel (FloSeal) and the use of polyglycolic acid meshes enable spleen-preserving surgery, making it a feasible and reproducible procedure and an alternative to classical splenectomy.

Flexor Digitorum Superficialis and Flexor Digitorum Profundus with separated sheaths: a new normal variation in human.

CASE DESCRIPTION: A 25 years old man presented with a laceration on radial side of proximal phalanx of 4(th) finger (zone II flexor) which was due to cut with glass. CLINICAL FINDINGS: The sheaths of Tendons of flexor digitorum superficialis and profundus were not the same and each tendon had a separate sheath. TREATMENT AND OUTCOME: The tendons were reconstructed by modified Kessler sutures, after 15 months the patient had a 30 degrees of extension lag even after physiotherapy courses. CLINICAL RELEVANCE: This is the first reported of such normal variation in human hand tendon anatomy.

DESCRIPCIÓN DEL CASO: Se presentó un hombre de 25 años con una laceración en la parte radial de la falange proximal del cuarto dedo de la mano (zona flexor II) causada por el corte con un vidrio. HALLAZGOS CLÍNICOS: Las cubiertas de los tendones del flexor digitorum sperficialis y profundus estaban separadas en diferentes cubiertas. TRATAMIENTO Y RESULTADO: Los tendones se reconstruyeron por la suturas modificadas de Kessler. Después de 15 meses el paciente presentó una pérdida del 30% en la extensión , aun después de la fisioterapia. RELEVANCIA CLÍNICA: Es el primer reporte de la variación en la anatomía de la mano.

Ultrasound biomicroscopy confirmation of corneal overriding due to improper suturing of full-thickness corneal laceration / Confirmação por biomicroscopia ultrassônica de encavalamento corneano devido à sutura inadequada de laceração de espessura total da córnea

We herein present a case with corneal overriding due to improper suturing of a full-thickness corneal laceration. There was a 2.5-mm difference between horizontal and vertical white-to-white measurements in the cornea. However, slit lamp examination failed to demonstrate the exact architecture of the laceration. Ultrasound biomicroscopy defined the wound edges thoroughly and confirmed the presence of corneal overriding. Six weeks after suture enhancement, the abnormal oval appearance of the cornea was absent and correct apposition of the corneal edges was seen on ultrasound biomicroscopy. Ultrasound biomicroscopy can be used in preoperative surgical planning of cases with complicated corneal lacerations. It can be used to adjust and enhance wound architecture in eyes with penetrating injury.

Apresentamos um caso com encavalamento corneano devido à sutura inadequada de uma laceração da córnea de espessura total. Houve uma diferença 2,5 mm entre as medidas do branco ao branco horizontais e verticais na córnea. No entanto, o exame da lâmpada de fenda não conseguiu demonstrar a arquitetura exata da laceração. A biomicroscopia ultrassônica definiu as bordas da ferida completamente e confirmou a presença de encavalamento da córnea. Seis semanas após a melhora da sutura, a aparência oval anormal da córnea havia desaparecido, e a correta aposição das bordas da córnea foi identificada na biomicroscopia ultrassônica. A biomicroscopia ultrassônica pode ser usada no planejamento cirúrgico pré-operatório de casos com lacerações corneanas complicadas. Ela pode ser utilizada para ajustar e melhorar a arquitetura da ferida em olhos com lesão penetrante.

Ultrasound biomicroscopy confirmation of corneal overriding due to improper suturing of full-thickness corneal laceration.

We herein present a case with corneal overriding due to improper suturing of a full-thickness corneal laceration. There was a 2.5-mm difference between horizontal and vertical white-to-white measurements in the cornea. However, slit lamp examination failed to demonstrate the exact architecture of the laceration. Ultrasound biomicroscopy defined the wound edges thoroughly and confirmed the presence of corneal overriding. Six weeks after suture enhancement, the abnormal oval appearance of the cornea was absent and correct apposition of the corneal edges was seen on ultrasound biomicroscopy. Ultrasound biomicroscopy can be used in preoperative surgical planning of cases with complicated corneal lacerations. It can be used to adjust and enhance wound architecture in eyes with penetrating injury.

A video-assisted endotracheal suture technique for correction of distal tracheal laceration after intubation.

The incidence of tracheal laceration is 1 of 20,000 intubations. The most frequently affected area is the posterior tracheal wall (membranous). Risk factors include several forced attempts at intubation, inexperience of the clinician, tracheal introducers (guidewires) that protrude beyond the tip of the tube, and emergency procedures. Surgical treatment of tracheal lacerations can be by a transtracheal suture technique or a right thoracotomy. Using the concept of minimally invasive surgical procedures, we reported the treatment of 2 patients with tracheal lacerations greater than 5 cm in the distal trachea that were treated with endotracheal video-assisted suturing using a cervical incision.

Consequences and treatment after multiple avulsions of deciduous teeth--a case report.

The prevalence of traumatisms with avulsion of deciduous teeth varies from 7 to 13%, usually involving one tooth only. In this case report, a trauma with multiple losses of deciduous teeth and laceration of soft tissue is described as a consequence of a horse backward kick. After suture of extra-oral tissue wounds and application of anti-tetanic vaccine, the patient was referred to the emergency ambulatory of Sacred Heart University. Treatment procedures included radiographic analysis, removal of bone fragments and of a residual root of the tooth involved, remodeling and suture of intra-oral tissues. The patient was observed periodically and after full recovery, a prosthetic appliance was installed for functional and esthetic rehabilitation.

Engaging needles: a simple technique for arthroscopic side-to-side rotator cuff repair.

We present a simplified technique for the side-to-side arthroscopic rotator cuff repair. The instruments required for this technique are a 45 degrees Suture Lasso (SL; Arthrex, Naples, FL) and a 17F spinal needle (SN). With the arthroscope in the lateral portal, the SL is inserted through the posterior cannulas to grab healthy tissue at the posterior margin of the cuff. Through the anterior cannulas or through a skin puncture, the SN is inserted to catch healthy tissue at the anterior margin. Once both instruments are through the tissues, we manipulate them to make their tips converge. Because the SN diameter is small, it is very easy to engage its tip into the SL tip. Once engaged, a No. 1 PDS monofilament suture is easily passed through both instruments. When the suture comes out of the SL handle, both instruments can be pulled out, leaving the suture in place. Using a suture retriever clamp, the sutures are retrieved through a cannula for knot tying. This technique can be repeated as many times as necessary to place enough sutures in a side-to-side fashion to achieve the repair.