Study of the nerve endings and mechanoreceptors of the medial meniscotibial ligament of the knee: A structural and distribution analysis.

BACKGROUND: The aim of the present study is to describe the morphology and distribution of the nerve endings of the meniscotibial ligament (MTL) of the knee, in order to understand the interaction between the proprioceptive system and knee mechanics. METHODS: Twenty medial MTLs were obtained from deceased organ donors. The ligaments were measured, weighed and cut. Sections (10 mm) were prepared on hematoxylin and eosin-stained slides for analysis of tissue integrity, and 50 mm sections were submitted to immunofluorescence with the protein gene product (PGP) 9.5 as primary antibody and Alexa Fluor 488 as secondary antibody, followed by microscopic analysis. RESULTS: The medial MTL was identified in 100% of the dissections, with average length, width, thickness and weight of 7.07 ± 1.34 mm, 32.25 ± 3.09 mm, 3.53 ± 0.27 mm and 0.67 ± 0.13 g, respectively. The hematoxylin and eosin-stained histological sections exhibited typical ligament structure, with dense well-organized collagen fibers and vascular tissue. All the specimens analyzed contained type I (Ruffini) mechanoreceptors and free (type IV) nerve endings, varying from parallel to intertwined fibers. Nerve endings not classified with different irregular shapes were also found. Most type I mechanoreceptors were found close to the MTL insertions on the tibial plateau, while the free nerve endings were found adjacent to the capsule. CONCLUSION: The medial MTL showed a peripheral nerve structure, primarily type I and IV mechanoreceptors. These findings suggest that the medial MTL is important for proprioception and medial knee stabilization.

THE IMPACT OF COVID-19 ON THE EPIDEMIOLOGICAL PROFILE OF FRACTURES.

Objective: To analyze the epidemiological transition of fractures in patients who were treated in a tertiary hospital which is reference in traumatology during the COVID-19 pandemic to assess the changes in trauma service. Methods: This is a retrospective and descriptive analysis of data on orthopedics lesions treated at Instituto Doutor Jose Frota between December 16, 2019 and June 16, 2020 (three months before and after the first case of COVID-19 in Ceará). Results: In total, we evaluated 913 patients, 28.5% of which were women and 71.5%, men. We found a significative reduction (p < 0.05) in the proportion of female patients operated in the analyzed time. We also observed an increase in patients' mean age, 35.4 years before the pandemic, and 38.48 (p = 0.04) during the consecutive period. Trauma mechanisms significantly changed (p < 0.05), with a proportional increase of high-energy traumas and reduction of instances of falling. We found a 11.9% reduction in orthopedic surgeries, from 655 to 577 at the time after the first case of COVID-19 (p = 0.071). Mean hospitalization length (p < 0.001) and time until surgeries decreased (p < 0.001). Conclusion: We observed the impact of lockdown in this hospital of trauma especially via the decreased number of operated cases and the change in patients' profile and trauma mechanism. Level of Evidence III, Retrospective Comparative Study.

Objetivo: Analisar a transição do perfil epidemiológico de fraturas de pacientes atendidos em um hospital terciário referência em traumatologia durante a pandemia de COVID-19, a fim de verificar mudanças no atendimento traumatológico. Métodos: Análise retrospectiva e descritiva dos dados de lesões ortopédicas admitidas no Instituto Doutor José Frota entre 16 de dezembro de 2019 e 16 de junho de 2020 (três meses antes e depois do primeiro caso de COVID-19 no Ceará). Resultados: Dos 913 pacientes avaliados, 28,5% eram mulheres e 71,5% homens. Houve redução significativa (p < 0,05) nas proporções de mulheres operadas no tempo analisado. Houve aumento na média da idade, sendo 35,40 anos pré-pandemia, e 38,48 (p = 0,04) no período seguinte. Os mecanismos de trauma mudaram significativamente (p < 0,05), com aumento proporcional de fraturas por alta energia e redução no número daquelas por queda ao solo. A quantidade de cirurgias ortopédicas reduziu em 11,9%, de 655 antes do primeiro caso de COVID-19 para 577 posteriormente (p = 0,071). A média do número de dias diminuiu para duração do internamento (p < 0,001) e para o tempo até a realização da cirurgia (p < 0,001). Conclusão: O impacto do lockdown neste hospital de trauma se deu principalmente pela diminuição na quantidade de casos operados e pela mudança do perfil e mecanismo de trauma dos pacientes. Nível de Evidência III, Estudo Retrospectivo Comparativo.

EPIDEMIOLOGY, CLASSIFICATION, AND TREATMENT OF BILATERAL FRACTURES OF THE DISTAL RADIUS.

Objective: To study epidemiology, fracture pattern, associated injuries, and treatment of individuals with bilateral distal radius fracture, in a tertiary hospital. Methods: Retrospective cross-sectional study developed based on patients with bilateral distal radius fracture from January 2012 to November 2017. Demographic data, trauma mechanism, radiological patterns, degree of deviation, associated injuries, classification of fractures according to the Association of Osteosynthesis (AO), the Salter-Harris (SH) and Frykman scales, and type of treatment used in each case. Results: 13 cases were included in the trial, 10 adults and three children. In infants, the mean age was 9.6 years (7-11 years), and low-energy trauma was described in all these cases. In total, 66.6% of the children presented the SHII classification . In adult patients, the mean age observed was 43.5 years (27-56 years), with high-energy trauma reported in four (40%) cases. The AO 23C.3 and 23B.2 classifications were the most prevalent in adults. Conclusion: In adult individuals, there was a higher incidence of open fractures, wrist joint involvement, ulna fracture, and concomitant injuries, with high-energy trauma observed only in this group, corresponding to half of the cases. Level of Evidence IV, Case Series.

Objetivo: Estudar epidemiologia, padrão de fraturas, lesões associadas, e tratamento dos indivíduos com fratura de rádio distal bilateral, em um hospital terciário. Métodos: Estudo transversal retrospectivo desenvolvido a partir de pacientes com fratura de rádio distal bilateral no período entre janeiro de 2012 e novembro de 2017. Foram analisados dados demográficos, mecanismo de trauma, padrões radiológicos, grau de desvio, lesões associadas, classificação das fraturas de acordo com AO, Salter Harris (SH) e Frykman, e tipo de tratamento empregado em cada caso. Resultados: 13 casos foram incluídos no ensaio, sendo 10 adultos e três crianças. Nos infantes, a média de idade foi de 9,6 anos (7-11 anos), e o trauma de baixa energia esteve descrito na totalidade destes casos. A classificação SHII esteve presente em 66,6% das crianças. Nos pacientes adultos, a média de idade observada foi de 43,5 anos (27-56 anos), com o mecanismo de trauma de alta energia relatado em quatro (40%) casos. A classificação AO 23C.3 e 23B.2 foram as mais prevalentes nos adultos. Conclusão: Em indivíduos esqueleticamente maduros, observou-se maior incidência de fraturas expostas, acometimento articular do punho, fratura de ulna e lesões concomitantes, sendo o trauma de alta energia observado apenas neste grupo, correspondendo a metade dos casos. Nível de Evidência IV, Série de Casos.

DOES ULNA FIXATION ALTER THE OUTCOME FOR DISTAL-THIRD FOREARM FRACTURES IN CHILDREN?

Introduction: Fractures of the distal third of the forearm are common in the pediatric population. Conservative treatment of an ipsilateral fracture of the distal ulna metaphysis is one of the risk factors for loss of reduction. Percutaneous fixation of the fracture with K-wires is recommended. This study aims to evaluate the outcome of percutaneous fixation of both bones performed as the primary treatment. Materials and Methods: A randomized, open, prospective, clinical trial was conducted, including skeletally immature patients who underwent surgery for fractures of the distal radius and ulna. They were randomized into two groups, one with fixation only of the radius fracture and the other with fixation of both the radius and the ulna fractures, and they were followed clinically and radiologically for up to 12 weeks postoperatively. Results: Sixteen children were selected. In the intraoperative period, fluoroscopy was activated for a longer time when fixing the ulna (p = 0.011) and the surgical time was longer in this group (p = 0.014). In the postoperative evaluations, the group whose surgery involved the fixation of both bones had a lower postoperative pain score (p <0.001) and less time away from school (p <0.001). Conclusions: In this study, postoperative pain and absence from school were both less when fixation of the radius and ulna was performed. Evidence Level II; Randomized Controlled Study.

Introdução: As fraturas do terço distal do antebraço são comuns na população pediátrica. O tratamento conservador da fratura ipsilateral da metáfise distal da ulna é um dos fatores de risco para a perda da redução. Recomenda-se a fixação percutânea da fratura com fios K. Este estudo tem como objetivo avaliar o resultado da fixação percutânea de ambos os ossos realizada como tratamento primário. Materiais e Métodos: Foi realizado um estudo clínico randomizado, aberto e prospectivo, que incluiu pacientes com esqueleto imaturo que foram submetidos à cirurgia para fraturas da parte distal do rádio e a ulna. Os participantes foram randomizados em dois grupos, um com fixação apenas da fratura do rádio e outro com fixação das fraturas do rádio e da ulna, e foram acompanhados clínica e radiologicamente por até 12 semanas de pós-operatório. Resultados: Dezesseis crianças foram selecionadas. No intraoperatório, a fluoroscopia foi ativada por mais tempo na fixação da ulna (p = 0,011) e o tempo cirúrgico foi maior nesse grupo (p = 0,014). Nas avaliações pós-operatórias, o grupo cuja cirurgia envolveu a fixação de ambos os ossos teve escore de dor menor depois da cirurgia (p < 0,001) e menos tempo de afastamento da escola (p < 0,001). Conclusões: Neste estudo, a dor pós-operatória e o afastamento da escola foram menores quando se realizou fixação do rádio e da ulna. Nível de Evidência II; Estudo randomizado controlado.

The impact of covid-19 on the epidemiological profile of fractures / O impacto da covid-19 sobre o perfil epidemiológico de fraturas

ABSTRACT Objective: To analyze the epidemiological transition of fractures in patients who were treated in a tertiary hospital which is reference in traumatology during the COVID-19 pandemic to assess the changes in trauma service. Methods: This is a retrospective and descriptive analysis of data on orthopedics lesions treated at Instituto Doutor Jose Frota between December 16, 2019 and June 16, 2020 (three months before and after the first case of COVID-19 in Ceará). Results: In total, we evaluated 913 patients, 28.5% of which were women and 71.5%, men. We found a significative reduction (p < 0.05) in the proportion of female patients operated in the analyzed time. We also observed an increase in patients' mean age, 35.4 years before the pandemic, and 38.48 (p = 0.04) during the consecutive period. Trauma mechanisms significantly changed (p < 0.05), with a proportional increase of high-energy traumas and reduction of instances of falling. We found a 11.9% reduction in orthopedic surgeries, from 655 to 577 at the time after the first case of COVID-19 (p = 0.071). Mean hospitalization length (p < 0.001) and time until surgeries decreased (p < 0.001). Conclusion: We observed the impact of lockdown in this hospital of trauma especially via the decreased number of operated cases and the change in patients' profile and trauma mechanism. Level of Evidence III, Retrospective Comparative Study.

RESUMO Objetivo: Analisar a transição do perfil epidemiológico de fraturas de pacientes atendidos em um hospital terciário referência em traumatologia durante a pandemia de COVID-19, a fim de verificar mudanças no atendimento traumatológico. Métodos: Análise retrospectiva e descritiva dos dados de lesões ortopédicas admitidas no Instituto Doutor José Frota entre 16 de dezembro de 2019 e 16 de junho de 2020 (três meses antes e depois do primeiro caso de COVID-19 no Ceará). Resultados: Dos 913 pacientes avaliados, 28,5% eram mulheres e 71,5% homens. Houve redução significativa (p < 0,05) nas proporções de mulheres operadas no tempo analisado. Houve aumento na média da idade, sendo 35,40 anos pré-pandemia, e 38,48 (p = 0,04) no período seguinte. Os mecanismos de trauma mudaram significativamente (p < 0,05), com aumento proporcional de fraturas por alta energia e redução no número daquelas por queda ao solo. A quantidade de cirurgias ortopédicas reduziu em 11,9%, de 655 antes do primeiro caso de COVID-19 para 577 posteriormente (p = 0,071). A média do número de dias diminuiu para duração do internamento (p < 0,001) e para o tempo até a realização da cirurgia (p < 0,001). Conclusão: O impacto do lockdown neste hospital de trauma se deu principalmente pela diminuição na quantidade de casos operados e pela mudança do perfil e mecanismo de trauma dos pacientes. Nível de Evidência III, Estudo Retrospectivo Comparativo.

Does ulna fixation alter the outcome for distal-third forearm fractures in children? / A fixação da ulna altera o desfecho das fraturas do terço distal do antebraço?

ABSTRACT Introduction Fractures of the distal third of the forearm are common in the pediatric population. Conservative treatment of an ipsilateral fracture of the distal ulna metaphysis is one of the risk factors for loss of reduction. Percutaneous fixation of the fracture with K-wires is recommended. This study aims to evaluate the outcome of percutaneous fixation of both bones performed as the primary treatment. Materials and Methods A randomized, open, prospective, clinical trial was conducted, including skeletally immature patients who underwent surgery for fractures of the distal radius and ulna. They were randomized into two groups, one with fixation only of the radius fracture and the other with fixation of both the radius and the ulna fractures, and they were followed clinically and radiologically for up to 12 weeks postoperatively. Results Sixteen children were selected. In the intraoperative period, fluoroscopy was activated for a longer time when fixing the ulna (p = 0.011) and the surgical time was longer in this group (p = 0.014). In the postoperative evaluations, the group whose surgery involved the fixation of both bones had a lower postoperative pain score (p <0.001) and less time away from school (p <0.001). Conclusions In this study, postoperative pain and absence from school were both less when fixation of the radius and ulna was performed. Evidence Level II; Randomized Controlled Study.

RESUMO Introdução As fraturas do terço distal do antebraço são comuns na população pediátrica. O tratamento conservador da fratura ipsilateral da metáfise distal da ulna é um dos fatores de risco para a perda da redução. Recomenda-se a fixação percutânea da fratura com fios K. Este estudo tem como objetivo avaliar o resultado da fixação percutânea de ambos os ossos realizada como tratamento primário. Materiais e Métodos Foi realizado um estudo clínico randomizado, aberto e prospectivo, que incluiu pacientes com esqueleto imaturo que foram submetidos à cirurgia para fraturas da parte distal do rádio e a ulna. Os participantes foram randomizados em dois grupos, um com fixação apenas da fratura do rádio e outro com fixação das fraturas do rádio e da ulna, e foram acompanhados clínica e radiologicamente por até 12 semanas de pós-operatório. Resultados Dezesseis crianças foram selecionadas. No intraoperatório, a fluoroscopia foi ativada por mais tempo na fixação da ulna (p = 0,011) e o tempo cirúrgico foi maior nesse grupo (p = 0,014). Nas avaliações pós-operatórias, o grupo cuja cirurgia envolveu a fixação de ambos os ossos teve escore de dor menor depois da cirurgia (p < 0,001) e menos tempo de afastamento da escola (p < 0,001). Conclusões Neste estudo, a dor pós-operatória e o afastamento da escola foram menores quando se realizou fixação do rádio e da ulna. Nível de Evidência II; Estudo randomizado controlado.

Epidemiology, classification, and treatment of bilateral fractures of the distal radius / Epidemiologia, classificação e tratamento de fraturas bilaterais do raio distal

ABSTRACT Objective: To study epidemiology, fracture pattern, associated injuries, and treatment of individuals with bilateral distal radius fracture, in a tertiary hospital. Methods: Retrospective cross-sectional study developed based on patients with bilateral distal radius fracture from January 2012 to November 2017. Demographic data, trauma mechanism, radiological patterns, degree of deviation, associated injuries, classification of fractures according to the Association of Osteosynthesis (AO), the Salter-Harris (SH) and Frykman scales, and type of treatment used in each case. Results: 13 cases were included in the trial, 10 adults and three children. In infants, the mean age was 9.6 years (7-11 years), and low-energy trauma was described in all these cases. In total, 66.6% of the children presented the SHII classification . In adult patients, the mean age observed was 43.5 years (27-56 years), with high-energy trauma reported in four (40%) cases. The AO 23C.3 and 23B.2 classifications were the most prevalent in adults. Conclusion: In adult individuals, there was a higher incidence of open fractures, wrist joint involvement, ulna fracture, and concomitant injuries, with high-energy trauma observed only in this group, corresponding to half of the cases. Level of Evidence IV, Case Series.

RESUMO Objetivo: Estudar epidemiologia, padrão de fraturas, lesões associadas, e tratamento dos indivíduos com fratura de rádio distal bilateral, em um hospital terciário. Métodos: Estudo transversal retrospectivo desenvolvido a partir de pacientes com fratura de rádio distal bilateral no período entre janeiro de 2012 e novembro de 2017. Foram analisados dados demográficos, mecanismo de trauma, padrões radiológicos, grau de desvio, lesões associadas, classificação das fraturas de acordo com AO, Salter Harris (SH) e Frykman, e tipo de tratamento empregado em cada caso. Resultados: 13 casos foram incluídos no ensaio, sendo 10 adultos e três crianças. Nos infantes, a média de idade foi de 9,6 anos (7-11 anos), e o trauma de baixa energia esteve descrito na totalidade destes casos. A classificação SHII esteve presente em 66,6% das crianças. Nos pacientes adultos, a média de idade observada foi de 43,5 anos (27-56 anos), com o mecanismo de trauma de alta energia relatado em quatro (40%) casos. A classificação AO 23C.3 e 23B.2 foram as mais prevalentes nos adultos. Conclusão: Em indivíduos esqueleticamente maduros, observou-se maior incidência de fraturas expostas, acometimento articular do punho, fratura de ulna e lesões concomitantes, sendo o trauma de alta energia observado apenas neste grupo, correspondendo a metade dos casos. Nível de Evidência IV, Série de Casos.

Evaluation of the Interobserver Agreement of the Fraser and Blake & McBryde Classifications for Floating Knee.

Objective To evaluate the interobserver agreement of two classifications for floating knee: Fraser and Blake & McBryde. Method Thirty-two observers, subdivided according to the degree of titration (26 resident physicians and 6 orthopedic physicians specialized in orthopedic trauma), classified 15 fractures of the ipsilateral femur and tibia. Interobserver agreement was evaluated by using the Kappa coefficient . Result When evaluating the agreement between the 9 R1, a Kappa index of 0.58 was obtained for the Fraser classification and of 0.46 for the Blake & McBryde classification. Among the 7 R2, a rate of 0.59 was obtained for the Fraser rating and 0.51 for the Blake & McBryde rating. Among the 10 R3, the agreement index was higher for both classifications: 0.72 for the Fraser and 0.71 for the Blake & McBryde classification. Considering the 3 groups (R1, R2, R3) as one large group, the general Kappa index was calculated, which resulted in 0.63 for the Fraser classification and 0.56 for the Blake & McBryde classification. In the group of trauma and orthopedic knee specialists, in turn, an agreement of 0.597 was obtained for the Blake and McBryde classification and of 0.843 for the Fraser classification. Conclusion Comparatively, the two classifications presented a weak to moderate degree of agreement. Fraser classification had better agreement in both groups. The agreement was higher when evaluating orthopedic trauma physicians.

Evaluation of the Interobserver Agreement of the Fraser and Blake & McBryde Classifications for Floating Knee / Avaliação da concordância interobservador das classificações de Fraser e Blake & McBryde para joelho flutuante

Abstract Objective To evaluate the interobserver agreement of two classifications for floating knee: Fraser and Blake & McBryde. Method Thirty-two observers, subdivided according to the degree of titration (26 resident physicians and 6 orthopedic physicians specialized in orthopedic trauma), classified 15 fractures of the ipsilateral femur and tibia. Interobserver agreement was evaluated by using the Kappa coefficient. Result When evaluating the agreement between the 9 R1, a Kappa index of 0.58 was obtained for the Fraser classification and of 0.46 for the Blake & McBryde classification. Among the 7 R2, a rate of 0.59 was obtained for the Fraser rating and 0.51 for the Blake & McBryderating. Among the 10 R3, theagreement index was higher for both classifications: 0.72 for the Fraser and 0.71 for the Blake & McBryde classification. Considering the 3 groups (R1, R2, R3) as one large group, the general Kappa index was calculated, which resulted in 0.63for the Fraser classification and 0.56 for the Blake & McBryde classification. In the group of traumaand orthopedic knee specialists, in turn, an agreement of 0.597 was obtained for the Blake and McBryde classification and of 0.843 for the Fraser classification. Conclusion Comparatively, the two classifications presented a weak to moderate degree of agreement. Fraser classification had better agreement in both groups. The agreement was higher when evaluating orthopedic trauma physicians.

Resumo Objetivo Avaliar a concordância interobservador de duas classificações para joelho flutuante: Fraser e Blake & Mcbryde. Método Trinta e dois observadores, subdivididos de acordo com o grau de titulação (26 médicos residentes e seis médicos ortopedistas especialistas em trauma ortopédico) classificaram 15 fraturas de fêmur e tíbia ipsilaterais. A concordância interobservador foi avaliada pelo coeficiente Kappa. Resultado Ao avaliar a concordância entre os 9 R1, obteve-se índice Kappa para classificação de Fraser de 0,58 e para a classificação de Blake & McBryde de 0,46. Entre os 7 R2, obteve-se índice de 0,59 para a classificação de Fraser e 0,51 para a classificação de Blake & McBryde. Entre os 10 R3, o índice de concordância foi maior para as duas classificações: 0,72 para a classificação de Fraser e 0,71 para a de Blake & McBryde. Considerando os 3 grupos (R1, R2, R3) como um só grande grupo, calculou-se o índice Kappa geral, que teve como resultado 0,63 para a classificação de Fraser e 0,56 para a classificação de Blake & McBryde. No grupo dos traumato-ortopedistas especialistas em joelho, por sua vez, obteve-se uma concordância para a classificação de Blake e McBryde de 0,597 e para a de Fraser de 0,843. Conclusão Comparativamente, as duas classificações apresentaram grau de concordância fraco a moderado. A classificação de Fraser teve melhor concordância em ambos os grupos. A concordância foi maior quando se avaliou médicos ortopedistas especialistas em trauma ortopédico.

Bilateral Avulsion Fracture of the Fibula Head of the Knee Associated with Avulsion Fracture of the Iliotibial Band: A Rare Case of Fracture Segond Associated with Arcuate Fracture.

Fibular head avulsion fractures are rare and are so-called the arcuate signal. Avulsion fracture of the iliotibial band and anterolateral ligament is known as a Segond fracture, and it is another rare entity. We describe the case of a 27-year-old woman who was hit by a car and suffered polytrauma, mainly suffering injuries to both knees. Radiographs of the knees showed a Segond fracture associated with the arched signal bilaterally. The aim of this study is to present a rare case report and literature review of a bilateral fibular head avulsion fracture associated with an anterolateral tibial avulsion fracture.

"M" line: New anatomical landmark for the maxillary sinus natural ostium.

OBJECTIVE: Describe a reliable anatomical landmark that can be used to locate the maxillary sinus natural ostium (MSNO) during endoscopic surgery, even if the uncinate process is preserved. DESIGN: Descriptive anatomical. SETTING: An anatomical and radiological study was performed to evaluate the consistency of the landmark, denominated "M" line. SUBJECTS AND METHODS: Dissections were performed in 57 cadaver heads (114 sides). In addition, 73 computerised tomography (CT) scans (146 sides) of patients with chronic inflammatory sinonasal disease were analysed using a three-dimensional (3D) reconstruction computer program. RESULTS: The "M" line crossed the MSNO in 112 dissected sides (98.2%) and 140 sides at CT 3D reconstruction (95.9%). CONCLUSION: The "M" line is a reliable anatomical landmark for predicting MSNO location. As such, it could improve and facilitate endoscopic sinus surgery, using traditional, minimally invasive or uncinate preserving techniques.

Florid Reactive Periostitis of the Proximal Phalanx-Case Report and Literature Review.

Florid reactive periostitis is a benign and rare lesion that is a recurrent diagnostic problem. Its etiopathogenesis remains unknown. Florid reactive periostitis consists of a fibrotic, cartilage-producing tumor accompanied by an aggressive inflammatory periosteal and soft tissue reaction. It typically occurs in adolescents and young adults, mostly female; it often affects hand and foot bones, and it may occur in long bones. Its diagnosis remains a major challenge due to the vast possibility of differential diagnoses. Therefore, careful clinical, radiological, and pathological evaluation is required to establish a proper diagnosis. We report the case of a patient with florid reactive periostitis in the proximal phalanx of the right index finger, who underwent surgical excision with a wide margin, from the second ray to the proximal third of the second metacarpal bone, and evolved without complications, with satisfactory range of motion and strength.

Maisonneuve Variant Lesion with Proximal Tibiofibular Dislocation.

Maisonneuve lesion is a rare entity, accounting for 7% of all ankle fractures. One of its variants includes a proximal tibiofibular dislocation, which is an even more unusual injury. This article reports the case of a 34-year-old male patient admitted to the emergency room with left lower limb edema after a sports trauma. A knee X-ray revealed an anterolateral subluxation of the proximal tibiofibular joint, with no signs of fracture. After limb evaluation, the diagnosis of Maisonneuve variant lesion with proximal tibiofibular dislocation was confirmed. The authors describe this case, addressing the clinical, radiological and surgical features of such variant.

Maisonneuve Variant Lesion with Proximal Tibiofibular Dislocation / Lesão variante de Maisonneuve com luxação tibiofibular proximal

Abstract Maisonneuve lesion is a rare entity, accounting for 7% of all ankle fractures. One of its variants includes a proximal tibiofibular dislocation, which is an even more unusual injury. This article reports the case of a 34-year-old male patient admitted to the emergency room with left lower limb edema after a sports trauma. A knee X-ray revealed an anterolateral subluxation of the proximal tibiofibular joint, with no signs of fracture. After limb evaluation, the diagnosis of Maisonneuve variant lesion with proximal tibiofibular dislocation was confirmed. The authors describe this case, addressing the clinical, radiological and surgical features of such variant.

Resumo A lesão de Maisonneuve é uma entidade rara, correspondendo a 7% das fraturas de tornozelo. Uma de suas variantes inclui a lesão da sindesmose tibiofibular distal com luxação tibiofibular proximal, tornando-a uma injúria ainda mais incomum. O presente artigo apresenta o caso de um paciente de 34 anos admitido na emergência de traumato-ortopedia de hospital terciário com dor e edema em membro inferior esquerdo, após trauma esportivo. A radiografia do joelho evidenciou luxação anterolateral da articulação tibiofibular proximal com subluxação lateral do tornozelo, sem sinais de fratura. Após avaliação tomográfica do membro, confirmou-se o diagnóstico de uma lesão variante de Maisonneuve com luxação tibiofibular proximal. Os autores descrevem o caso, abordando aspectos clínicos, radiográficos e cirúrgicos desta variante.

Florid Reactive Periostitis of the Proximal Phalanx-Case Report and Literature Review / Periostite reativa florida da falange proximal - relato de caso e revisão de literatura

Abstract Florid reactive periostitis is a benign andrare lesion that is a recurrent diagnostic problem. Its etiopathogenesis remains unknown. Florid reactive periostitis consists of a fibrotic, cartilage- producing tumor accompanied by an aggressive inflammatory periosteal and soft tissue reaction. It typically occurs in adolescents and young adults, mostly female; it often affects hand and foot bones, and it may occur in long bones. Its diagnosis remains a major challenge due to the vast possibility of differential diagnoses. Therefore, careful clinical, radiological, and pathological evaluation is required to establish a proper diagnosis. We report the case of a patientwith florid reactive periostitis in the proximal phalanx of the right index finger, who underwent surgical excision with a wide margin, from the second ray to the proximal third of the secondmetacarpal bone, and evolved without complications,with satisfactory range of motion and strength.

Resumo A periostite reativa florida éumalesão benigna e rara que constitui umproblema recorrente de diagnóstico. Sua etiopatogênese permanece desconhecida. A periostite reativa florida caracteriza- se por ser uma reação periosteal agressiva e inflamatória de tecido mole e por ser um tumor portador de fibrose e produtor de cartilagem. Ocorreemadolescentes e adultos jovens, com predomínio no sexo feminino, e acomete com frequência os ossos das mãos e pés, podendoacometer tambémossos longos.Odiagnósticopermaneceumgrandedesafiodevido à enorme possibilidade de diagnósticos diferenciais. Por isso, uma cuidadosa avaliação clínica, radiológica e patológica é necessária para fechar o diagnóstico. Relata-se o caso de umpaciente com periostite reativa florida na falange proximal do segundo dedo da mão direita, que foi submetida à excisão cirúrgica com margem ampla do segundo raio até o terço proximal do segundometacarpo, e evoluiu semqueixas, comamplitude demovimento e força satisfatória.

Anterolateral ligament of the knee: a step-by-step dissection.

BACKGROUND: The number of studies and clinical interest in the anterolateral ligament of the knee (ALL) has grown in recent years. A meticulous and accurate ALL dissection is vital in anatomic and biomechanical studies, and a standardized technique is not yet established. As such, the aim of this study was to describe a step-by-step ALL dissection technique that could help authors consistently identify the ALL. METHODS: Twenty knees from frozen adult cadavers, with no preference for sex or age, were included in the study. All the cadavers were dissected using the same technique to determine the incidence of the ALL. RESULTS: A transverse incision is performed in the iliotibial band (ITB), around 10 cm proximal to the topography of the lateral epicondyle of the femur. Next, the ITB undergoes anterograde blunt dissection until its insertion at Gerdy's tubercle in the tibia. Maintaining biceps femoris insertion, a dissection is performed anteriorly to it, until the lateral collateral ligament (LCL) is found. Using the LCL, internal rotation and 30 to 60° flexion as references, the ALL can be located in the anterolateral topography of the knee, with its origin near the lateral epicondyle (proximal and posterior) and insertion between Gerdy's tubercle and the fibula (4.0 mm to 7.0 mm below the tibial plateau), expanding to the lateral meniscus (between the body and anterior horn), exhibiting a mean length of 4.0 ± 0.4 cm and mean width of 5.5 ± 0.8 mm. CONCLUSIONS: The present article describes an effective and reproducible ALL dissection technique that made it was possible to identify the ligament in 100% of the cases in the present study.

Fracture of the Humeral Shaft Associated to Elbow Dislocation and Fracture of the Distal-third of the Forearm: Case Report / Fratura da diáfise de úmero associada a luxação de cotovelo e fratura do terço distal do antebraço: relato de caso

Abstract Humeral shaft fractures combined with elbow dislocation and fracture of the distal third of the bones of the forearm are uncommon. No description of this simultaneous association has been found in the same patient. Some studies report the association of these two lesions; however, no reports on the three ipsilateral lesions have been found at the PubMed, Lilacs and Bireme databases. The present report describes a case that occurred in a 13-yearold boywho suffered a fall froma height of approximately threemeters andwas admitted to a trauma hospital. Radiographs showed an ipsilateral humeral shaft fracture combinedwith elbowdislocation anda fracture of thedistal-third of thebonesof the forearm.Undergeneral anesthesia, the injurieswere readily reduced by closedmanipulation, obtaininga satisfactory reduction of the injuries. Following this, an antebrachiopalmar splint and a commercial Velpeau shoulder immobilizer for the treatment of the humerus diaphyseal fracture were used. After 1 week, the patient presented non-alignment of the diaphyseal fracture of the humerus and was submitted to surgical treatment with flexible retrograde intramedullary nailing, antebrachiopalmar cast, and a commercial Velpeau shoulder immobilizer.

Resumo A fratura da diáfise do úmero associada a luxação posterolateral do cotovelo e fratura de terço distal dos ossos do antebraço é uma lesão rara, não relatada na literatura pesquisada. Alguns estudos reportam a associação de duas dessas lesões, porém não foram encontrados relatos com as três ipsilateralmente nas bases PubMed, Lilacs e Bireme. Os autores apresentam o caso de um paciente de 13 anos, do sexo masculino, comhistória de queda de aproximadamente três metros de altura. Foi atendido em um hospital terciário de referência em traumatologia com diagnóstico de fratura diafisária do úmero associada a luxação do cotovelo, lesão da placa fisária do rádio e fratura de terço distal da ulna ipisilateral esquerda. O paciente foi submetido a redução incruenta de todas as lesões sob sedação anestésica; posteriormente à redução, optou-se pelo uso de tala antebraquiopalmar e tipoia comercial tipo Velpeau como tratamento da fratura diafisária de úmero. Após uma semana, o paciente apresentou desvio da fratura diafisária do úmero, foi submetido a tratamento cirúrgico com hastes flexíveis de forma retrógrada, gesso antebraquiopalmar e tipoia comercial do tipo Velpeau.

Index of fatigue quadriceps in soccer athletes after anterior cruciate ligament reconstruction.

OBJECTIVE: The present study aimed to evaluate the muscle fatigue of the quadriceps muscle in high-performance soccer players undergoing (anterior cruciate ligament) ACL reconstruction. METHODS: We evaluated 17 high-performance soccer players from three professional soccer teams of a state in Brazil from August 2011 to July 2012. All subjects were evaluated between 5.5 and 7 months after ACL reconstruction with a Biodex® isokinetic dynamometer (System 4 Pro) with test protocol CON/CON at 60°/s and 300°/s with 5 and 15 repetitions, respectively. In the calculation of local muscle fatigue, the fatigue index was used, which is calculated by dividing the labor done in the first one-third of the repetitions by that done at the final one-third of the repetitions, and multiplying by 100 to express a unit in percentage (i.e., as a discrete quantitative variable). RESULTS: All subjects were male, with a mean age of 21.3 ± 4.4 years and mean BMI 23.4 ± 1.53 cm; left dominance was observed in 47% (n = 8) of athletes, and right dominance, in 53% (n = 9) of athletes; and the limb involved in the lesion was the dominant in 29% (n = 5) and the non-dominant in 71% (n = 12). Fatigue rates were 19.6% in the involved limb and 29.0% in the non-involved limb. CONCLUSION: The results allow us to conclude that there was no significant difference between the limbs involved and not in ACL injuries regarding local muscle fatigue. No association was observed between the dominant side and the limb involved in the ACL injury.

OBJETIVOS: O presente estudo propõe avaliar a fadiga muscular do músculo quadríceps em atletas de futebol de alto rendimento submetidos à ligamentoplastia do ligamento cruzado anterior (LCA). MÉTODOS: Foram avaliados 17 atletas de futebol com alto rendimento que pertenciam conjuntamente a três times de futebol profissional de um determinado estado brasileiro, de agosto de 2011 a julho de 2012. Todos foram avaliados entre 5,5 e 7 meses de pós-operatório de ligamentoplastia do LCA no dinamômetro isocinético da marca Biodex® (System 4 Pro) com protocolo de teste CON/CON nas velocidades de 60°/s e 300°/s com 5 e 15 repetições, respectivamente. No cálculo da fadiga muscular local, usamos o índice de fadiga que é calculado com a divisão do trabalho feito no terço inicial das repetições pelo terço final das repetições e a multiplicação por 100 para expressar uma unidade em porcentagem (i.e., variável quantitativa discreta). RESULTADOS: Todos eram do sexo masculino, com média de 21,3 ± 4,4 anos; IMC médio de 23,4 ± 1,53 cm; com dominância à esquerda em 47% (n = 8) dos atletas; e a direita em 53% (n = 9) dos atletas; o membro envolvido na lesão foi o dominante em 29% (n = 5) dos casos e o não dominante em 71% (n = 12). Os índices de fadiga foram de 19,6% no membro envolvido e de 29,0% nos membros não envolvidos. CONCLUSÃO: Os resultados nos permitem concluir que não há diferença significativa entre os membros envolvidos e não envolvidos na lesão de LCA no que diz respeito à fadiga muscular local. Também não foi observada associação entre ser destro ou canhoto com o membro envolvido na lesão de LCA.

Index of fatigue quadriceps in soccer athletes after anterior cruciate ligament reconstruction / Índice de fadiga do músculo quadríceps femoral em atletas de futebol após reconstrução do ligamento cruzado anterior

ABSTRACT OBJECTIVE: The present study aimed to evaluate the muscle fatigue of the quadriceps muscle in high-performance soccer players undergoing (anterior cruciate ligament) ACL reconstruction. METHODS: We evaluated 17 high-performance soccer players from three professional soccer teams of a state in Brazil from August 2011 to July 2012. All subjects were evaluated between 5.5 and 7 months after ACL reconstruction with a Biodex(r) isokinetic dynamometer (System 4 Pro) with test protocol CON/CON at 60°/s and 300°/s with 5 and 15 repetitions, respectively. In the calculation of local muscle fatigue, the fatigue index was used, which is calculated by dividing the labor done in the first one-third of the repetitions by that done at the final one-third of the repetitions, and multiplying by 100 to express a unit in percentage (i.e., as a discrete quantitative variable). RESULTS: All subjects were male, with a mean age of 21.3 ± 4.4 years and mean BMI 23.4 ± 1.53 cm; left dominance was observed in 47% (n = 8) of athletes, and right dominance, in 53% (n = 9) of athletes; and the limb involved in the lesion was the dominant in 29% (n = 5) and the non-dominant in 71% (n = 12). Fatigue rates were 19.6% in the involved limb and 29.0% in the non-involved limb. CONCLUSION: The results allow us to conclude that there was no significant difference between the limbs involved and not in ACL injuries regarding local muscle fatigue. No association was observed between the dominant side and the limb involved in the ACL injury.

RESUMO OBJETIVOS: O presente estudo propõe avaliar a fadiga muscular do músculo quadríceps em atletas de futebol de alto rendimento submetidos à ligamentoplastia do ligamento cruzado anterior (LCA). MÉTODOS: Foram avaliados 17 atletas de futebol com alto rendimento que pertenciam conjuntamente a três times de futebol profissional de um determinado estado brasileiro, de agosto de 2011 a julho de 2012. Todos foram avaliados entre 5,5 e 7 meses de pós-operatório de ligamentoplastia do LCA no dinamômetro isocinético da marca Biodex(r) (System 4 Pro) com protocolo de teste CON/CON nas velocidades de 60°/s e 300°/s com 5 e 15 repetições, respectivamente. No cálculo da fadiga muscular local, usamos o índice de fadiga que é calculado com a divisão do trabalho feito no terço inicial das repetições pelo terço final das repetições e a multiplicação por 100 para expressar uma unidade em porcentagem (i.e., variável quantitativa discreta). RESULTADOS: Todos eram do sexo masculino, com média de 21,3 ± 4,4 anos; IMC médio de 23,4 ± 1,53 cm; com dominância à esquerda em 47% (n = 8) dos atletas; e a direita em 53% (n = 9) dos atletas; o membro envolvido na lesão foi o dominante em 29% (n = 5) dos casos e o não dominante em 71% (n = 12). Os índices de fadiga foram de 19,6% no membro envolvido e de 29,0% nos membros não envolvidos. CONCLUSÃO: Os resultados nos permitem concluir que não há diferença significativa entre os membros envolvidos e não envolvidos na lesão de LCA no que diz respeito à fadiga muscular local. Também não foi observada associação entre ser destro ou canhoto com o membro envolvido na lesão de LCA.

Short-term complementary and alternative medicine on quality of life in women with fibromyalgia.

BACKGROUND: Fibromyalgia (FMS) is a syndrome characterized by chronic widespread musculoskeletal pain, whose etiology is not completely understood. Different therapeutic approaches have been used with inconsistent results. This observation does not invalidate the continued search for alternative treatments aimed at improving quality of life (QoL) in FMS. OBJECTIVE: This study compared three classical traditional Chinese medicine (TCM) therapies: acupuncture (AC), electroacupuncture (EAC) and moxibustion (MX) in the management of pain and promotion of QoL in FMS patients. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS: A preliminary, group-assigned, comparative study enrolled 30 women, mean age (46.90±9.24) years (range 20-60 years), who met the 1990 American College of Rheumatology criteria for FMS diagnosis and a pain-pressure threshold (PPT) < 4 kg/cm(2). The study was conducted in a teaching tertiary-care medical institution from May 2010 through April 2012. AC, EAC and MX were delivered for 30 min, once a week, for 8 weeks, bilaterally at Neiguan (PC6), Hegu (LI4), Yanglingquan (GB34), Sanyinjiao (SP6) and Taichong (LR3) acupoints. MAIN OUTCOME MEASURES: Each week, immediately before treatment and after treatment, subjects were tested for PPTs, Wong-Baker Faces Pain Scale (WBFPS; for pain intensity) and Medical Outcomes Study 36-item Short Form Health Survey (SF-36: for QoL). RESULTS: There was no significant improvement in pain or reduction of tender points in any of the groups studied, at the end of the 8th session. Significant improvement of QoL was perceived in vitality (after AC treatment) and in mental health (after EAC and MX treatments). CONCLUSION: TCM therapies (AC, EAC and MX) promoted an improvement in the QoL in two areas (vitality and mental health) in FMS women. Further large-scale clinical trials are required to confirm this effect.