Synkinesis in Bell's palsy in a randomised controlled trial.

OBJECTIVES: To study the development of synkinesis in Bell's palsy. Frequency, severity, gender aspects and predictors were analysed. DESIGN: Data from the randomised controlled Scandinavian Bell's palsy trial including 829 patients. MAIN OUTCOME MEASURES: Frequency and severity of synkinesis at 12 months were the main outcome measures. Mean Sunnybrook synkinesis scores, voluntary movement scores and composite scores between 6 and 12 months were compared. RESULTS: In 743 patients with a 12-month follow-up, synkinesis frequency was 21.3%. There was no gender difference. Synkinesis was moderate to severe in 6.6% of patients. Those with synkinesis at 6 months had a synkinesis score of 4.1 (±2.8 sd), which increased to 4.7 (±3.2) (P = 0.047) at 12 months (n = 93). Sunnybrook composite score at 1 month was the best predictor for synkinesis development with receiver operating characteristics and area under the curve (AUC) 0.87. Risk for synkinesis increased with a lower Sunnybrook composite score. Furthermore, at 1 month, symmetry of voluntary movement had higher predictive value for synkinesis than resting symmetry with AUC 0.87 and 0.77, respectively. Gentle eye closure and open-mouth smile were the only independent significant predictive items (AUC 0.86). CONCLUSIONS: Moderate-to-severe synkinesis was present in 6.6% of patients. The mean synkinesis score increased between 6 and 12 months, and outcome should therefore be evaluated after at least 12 months. Sunnybrook composite score and symmetry of voluntary movement at 1 month were good predictors for synkinesis.

[Early reconstruction of congenital pseudoarthrosis of the tibia with free vascularized fibular grafts]. / Reconstrucción precoz de pseudoartrosis congénita de tibia con injerto libre vascularizado de peroné.

Congenital pseudoarthrosis of the tibia (CPT) is an uncommon disease presenting a tibial nonunion since birth and frequently associated to neurofibromatosis type 1. Surgical management by wide excision of the pseudoarthrosis and sustitution of the defect with vascularized bone in an early stage has proven to be the most effective technique in terms of bone consolidation. We present a clinical case of a 22-month-old patient with CPT treated successfully by reconstruction with a free vascularized fibula graft with an excellent functional result.

[Acute renal failure in a young male with cellulitis in the lower leg]. / Fallo renal agudo en varón joven con celulitis en extremidad inferior.

Necrotizing fascitiis due to Streptococcus Pyogenes has a high mortality rate. Detection of the infection before it developes to the streptococcal toxic shock syndrome is quite challenging and its one of the main goals of its management because at this final stage the treatment is in most of the cases ineffective. In a secuence of events of the progression of the infection to shock, renal failure occurs before hipotension very often. We report the case of a 38-year-old patient affected by a fulminant necrotizing fascitiis by Streptococcus Pyogenes which presented at admission with lower leg cellulitis and acute renal failure.

[Ultrasound of the large abdominal vessels]. / Ecografía de los grandes vasos abdominales.

Ultrasound has recently become an indispensable tool for the family physician, whether exercised in primary care and emergency department; and likewise it has spread to many other specialties: internal medicine, critical care, neurology, pneumology, digestive, etc. and that ultrasound has proven to be a safe diagnostic tool and have great capacity. We firmly believe that ultrasound done to «bedside¼ the patient by the family doctor, can greatly complement the physical examination and greatly improve clinical effectiveness, allowing the browser an immediate view of the anatomy and physiology of certain structures. It is within this context is particularly relevant ultrasonography of the Aorta and large abdominal vessels, made by the family doctor or the emergency itself, which will develop along this chapter.

[Pancreatic ultrasonography]. / Ecografía pancreática.

Despite the recent technological advances in imaging, abdominal ultrasonography continues to be the first diagnostic test indicated in patients with a suspicion of pancreatic disease, due to its safety, accessibility and low cost. It is an essential technique in the study of inflammatory processes, since it not only assesses changes in pancreatic parenchyma, but also gives an indication of the origin (bile or alcoholic). It is also essential in the detection and tracing of possible complications as well as being used as a guide in diagnostic and therapeutic punctures. It is also the first technique used in the study of pancreatic tumors, detecting them with a sensitivity of around 70% and a specificity of 90%.

[Abdominal ultrasound course an introduction to the ultrasound technique. Physical basis. Ultrasound language]. / Curso de ecografía abdominal. Introducción a la técnica ecográfica. Principios físicos. Lenguaje ecográfico.

Ultrasound is a non-invasive, accessible, and versatile diagnostic technique that uses high frequency ultrasound waves to define outline the organs of the human body, with no ionising radiation, in real time and with the capacity to visual several planes. The high diagnostic yield of the technique, together with its ease of uses plus the previously mentioned characteristics, has currently made it a routine method in daily medical practice. It is for this reason that the multidisciplinary character of this technique is being strengthened every day. To be able to perform the technique correctly requires knowledge of the physical basis of ultrasound, the method and the equipment, as well as of the human anatomy, in order to have the maximum information possible to avoid diagnostic errors due to poor interpretation or lack of information.

[Normal abdominal ultrasound anatomy. Examination procedure]. / Anatomía ecográfica abdominal normal. Sistemática de exploración.

To carry out an abdominal ultrasound examination with the highest degree of accuracy and thoroughness, it is essential to have a good knowledge of the anatomy and the normal measurements of the different organs. In this way, we can determine their normal condition and identify the pathology and its location more easily. It is very important to adopt a correct examination procedure, systematically sweeping the scan in the same direction and not leaving any organ unexamined. We suggest a procedure consisting of longitudinal, cross-sectional and oblique scans to view all the abdominal organs, starting the examination in the epigastric region, scanning first the right upper quadrant, then the left upper quadrant, both iliac fossa, and lastly the hypogastric region.

Dolor abdominal recurrente. Síndrome de atrapamiento del nervio cutáneo abdominal a propósito de tres casos / Recurrent abdominal pain. Abdominal cutaneous nerve entrapment syndrome: A report of three cases

No disponible

Ecografía de los grandes vasos abdominales / Ultrasound of the large abdominal vessels

La ecografía se ha convertido en los últimos tiempos en una herramienta indispensable para el médico de familia, tanto si ejerce en atención primaria como en urgencias; y del mismo modo se ha extendido a muchas otras especialidades: medicina interna, cuidados intensivos, neurología, neumología, digestivo, etc., ya que los ultrasonidos han demostrado ser una herramienta segura y tener gran capacidad diagnóstica. Nosotros creemos firmemente que la ecografía realizada a 'pie de cama' del paciente, realizada por el médico de familia, puede complementar en gran medida la exploración física y mejorar sobremanera la eficacia del clínico, permitiendo al explorador una visión inmediata a la anatomía y fisiología de determinadas estructuras. Es dentro de este contexto donde cobra especial relevancia el estudio ecográfico de la aorta y de los grandes vasos abdominales, realizado por el propio médico de familia o de urgencias, que vamos a desarrollar a lo largo de este artículo (AU)

Ultrasound has recently become an indispensable tool for the family physician, whether exercised in primary care and emergency department; and likewise it has spread to many other specialties: internal medicine, critical care, neurology, pneumology, digestive, etc. and that ultrasound has proven to be a safe diagnostic tool and have great capacity. We firmly believe that ultrasound done to 'bedside' the patient by the family doctor, can greatly complement the physical examination and greatly improve clinical effectiveness, allowing the browser an immediate view of the anatomy and physiology of certain structures. It is within this context is particularly relevant ultrasonography of the Aorta and large abdominal vessels, made by the family doctor or the emergency itself, which will develop along this chapter (AU)

Outcomes of nerve reconstruction for radial nerve injuries based on the level of injury in 244 operative cases.

We report a single surgeon series of 244 patients with radial nerve injuries who had nerve repair, neurolysis, or nerve graft over a 17-year period. 44 patients had a Level I or infraclavicular injury, 37 had a Level II injury within the spiral groove of the humerus, 104 had a Level III injury from the lateral arm to antebrachial fossa and 64 had a Level IV injury affecting the posterior interosseous nerve. Nerve grafting was used most frequently in all groups, and was the only method of reconstruction for level II injury. At 21.5 months follow up, Level IV injuries had significantly better outcome of finger and thumb extension, while wrist extension recovered in at least 80% of the patients irrespective of the level of injury. The radial nerve recovered better if repaired or reconstructed within 5 months of injury.

Ecografía pancreática / Pancreatic ultrasonography

La ecografía abdominal continúa siendo la primera exploración a realizar en los pacientes con sospecha de enfermedad pancreática. Pese a los recientes avances tecnológicos en las pruebas de imagen, la ecografía no ha sido desplazada como primer escalón diagnóstico debido a su inocuidad, accesibilidad y bajo coste. Se trata de una técnica fundamental en el estudio de los procesos inflamatorios, ya que no solo valora las alteraciones del parénquima pancreático, sino que orienta la etiología (biliar o alcohólica), es fundamental en la detección y el seguimiento de las posibles complicaciones y sirve como guía en las punciones tanto diagnósticas como terapéuticas. Es también la primera técnica a utilizar en el estudio de los tumores pancreáticos, con una sensibilidad en la detección de los mismos en torno al 70%, y una especificidad del 90% (AU)

Despite the recent technological advances in imaging, abdominal ultrasonography continues to be the first diagnostic test indicated in patients with a suspicion of pancreatic disease, due to its safety, accessibility and low cost. It is an essential technique in the study of inflammatory processes, since it not only assesses changes in pancreatic parenchyma, but also gives an indication of the origin (bile or alcoholic). It is also essential in the detection and tracing of possible complications as well as being used as a guide in diagnostic and therapeutic punctures. It is also the first technique used in the study of pancreatic tumors, detecting them with a sensitivity of around 70% and a specificity of 90% (AU)

Anatomy of the motor nerve to the gracilis muscle and its implications in a one-stage microneurovascular gracilis transfer for facial reanimation.

BACKGROUND: The present study was conducted to investigate the anatomy of the motor nerve to the gracilis muscle (MNG) to provide the anatomical basis for harvesting a one-stage gracilis transfer with a long nerve for re-animation of the paralysed face. METHODS: An anatomical study was performed on 24 lower-limb specimens (from the pelvis down to the knee) from 12 embalmed cadavers. The MNG was dissected from the surface of the muscle to the obturator foramen. Two anatomical regions were defined in the course of the nerve. The first region includes the part of the nerve that can easily be reached through a standard incision in the medial aspect of the thigh, that is, from the surface of the muscle to the posterior border of the adductor brevis muscle and the second region from there to the obturator foramen. Measurements of both anatomical regions and the maximum length of the nerve were taken with a calliper. The anatomical relations of the nerve were also noted and photo-documented. RESULTS: The median maximum length of the MNG from the surface of gracilis to the posterior border of adductor brevis ('first anatomical region') was 7.7 cm (Range 6.3-10.5 cm); from there to the obturator foramen ('second anatomical region') the length was 3.7 cm (Range 2-6 cm), giving a median length of dissection of the nerve as 11.5 cm (Range 9.9-13.6 cm). Intraneural dissection of the MNG has to be performed proximally in the course of the nerve (the part corresponding to the second anatomical region), just where it runs inside the fascia over the obturator externus muscle. CONCLUSIONS: Over 10-cm length of the MNG can be obtained when dissected along the course of the nerve up to the obturator foramen. To achieve the maximum length, intraneural dissection must normally be performed after the nerve passes the posterior border of the adductor brevis. An endoscopic approach or extended proximal incision is recommended to easily reach the proximal part of the nerve as far as the obturator foramen.

Curso de ecografía abdominal. Introducción a la técnica ecográfica. Principios físicos. Lenguaje ecográfico / Abdominal ultrasound course an introduction to the ultrasound technique. Physical basis. Ultrasound language

La ecografía es una técnica diagnóstica no invasiva, asequible y versátil que emplea el ultrasonido para definir los órganos del cuerpo humano, sin radiaciones ionizantes, en tiempo real y con capacidad de visualizar varios planos. La gran rentabilidad diagnóstica de la técnica, unida a su facilidad de realización, y a las características antes mencionadas, la han colocado en la actualidad como un método de rutina en la práctica médica diaria. Es por esto por lo que, día tras día, se refuerza el carácter multidisciplinario de la técnica. Para una adecuada realización de la técnica se requiere tener conocimientos de los principios físicos del ultrasonido, del método e instrumental y de la anatomía humana, para así conseguir recopilar la máxima información posible y evitar errores de diagnóstico por mala interpretación u omisión de información (AU)

Ultrasound is a non-invasive, accessible, and versatile diagnostic technique that uses high frequency ultrasound waves to define outline the organs of the human body, with no ionising radiation, in real time and with the capacity to visual several planes. The high diagnostic yield of the technique, together with its ease of uses plus the previously mentioned characteristics, has currently made it a routine method in daily medical practice. It is for this reason that the multidisciplinary character of this technique is being strengthened every day. To be able to perform the technique correctly requires knowledge of the physical basis of ultrasound, the method and the equipment, as well as of the human anatomy, in order to have the maximum information possible to avoid diagnostic errors due to poor interpretation or lack of information (AU)

Trombosis venosa profunda tras tennis leg. Papel de la ecografía en atención primaria / Deep vein thrombosis after tennis leg. Role of ultrasound in primary care

No disponible

Anatomía ecográfica abdominal normal. Sistemática de exploración / Normal abdominal ultrasound anatomy. Examination procedure

Para realizar una exploración ecográfica abdominal lo más completa y precisa posible es fundamental conocer bien la anatomía y las medidas normales de los distintos órganos. De esta manera conoceremos la normalidad y con mayor facilidad identificaremos la patología y su localización. Es muy importante tener una adecuada sistemática de exploración con el fin de llevar siempre la misma dirección de barrido y así no dejar ningún órgano sin explorar. Proponemos una sistemática realizando cortes longitudinales, transversales y oblicuos para visualizar todos los órganos abdominales, iniciando la exploración en el epigastrio, barriendo primero el hipocondrio derecho, posteriormente el hipocondrio izquierdo, ambos fosas ilíacas y la zona hipogástrica (AU)

To carry out an abdominal ultrasound examination with the highest degree of accuracy and thoroughness, it is essential to have a good knowledge of the anatomy and the normal measurements of the different organs. In this way, we can determine their normal condition and identify the pathology and its location more easily. It is very important to adopt a correct examination procedure, systematically sweeping the scan in the same direction and not leaving any organ unexamined. We suggest a procedure consisting of longitudinal, cross-sectional and oblique scans to view all the abdominal organs starting the examination in the epigastric region, scanning first the right upper quadrant, then the left upper quadrant, both iliac fossa, and lastly the hypogastric region (AU)

Colgajo libre de perforantes de tensor de fascia lata como procedimiento de rescate de un colgajo anterolateral de muslo / Tensor fasciae latae perforator free flap as a backup procedure for an anterolateral thigh flap

El colgajo anterolateral de muslo es uno de los colgajos más utilizados para la reconstrucción de una amplia variedad de defectos. En aproximadamente un2% de los casos este colgajo presenta una distribución vascular considerada como difícil, lo que hace necesario plantear opciones reconstructivas alternativas intraoperatoriamente. En el presente artículo presentamos un caso clínico en el que se resolvió con éxito esta situación reconvirtiendo un colgajo de perforantes anterolateral del muslo, basado en una perforante de pequeño calibre y con una disección intramuscular muy larga, en un colgajo de perforantes de Tensor de Fascia Lata (AU)

Anterolateral thigh flap is one of the most popular flaps used for reconstruction of a wide variety of defects. A difficult vascular pattern can be found in 2% of the cases in this flap which makes neccessary to shift to an alternative reconstructive option through a decision that it is usually made intraoperatively. In the current study we report a case in which this situation was successfully resolved by shifting an anterolateral thigh flap, based on a small perforator with a long intramuscular course, to a Tensor Fasciae Latae perforator flap (AU)

Anatomía arterial de los colgajos musculares de extensor carpi radialis longus y extensor carpi radialis brevis para su uso en transferencia muscular funcional libre / Arterial anatomy of the extensor carpi radialis longus and extensor carpi radialis brevis muscle flaps related to its use in free functioning muscle transfer

El objetivo de este trabajo es documentar el aporte arterial y el patrón vascular intramuscular de los músculos Extensor Carpi Radialis Longus(ECRL) y Extensor Carpi Radialis Brevis (ECRB) para analizar su utilización como colgajos libres en transferencia muscular funcional para reanimación facial. Realizamos un estudio anatómico en 29 brazos humanos en fresco. Las técnicas de inyección utilizadas fueron la modificada de óxido de plomo y gelatina en 11 cadáveres y la de inyección pulsátil de látex color en 18. Disecamos los músculos ECRL y ECRB y sus pedículos, los fotodocumentamos y radiografiamos valorando los resultados en función del patrón vascular intramuscular, relaciones anatómicas, calibres y longitud de pedículos. Encontramos dos patrones vasculares diferentes en las 29disecciones siguiendo la clasificación de Mathes y Nahai de la anatomía vascular de los músculos (en función del número de pedículos vasculares y su dominancia): Tipo I( 37,9% ECRL y 20,7% ECRB) y Tipo II (62,1%del ECRL y 79,3% del ECRB). El pedículo principal del ECRL (de diámetro medio 1,73 mm y longitud de pedículo media de 32,32 mm) es en el 100% de los casos rama de la arteria recurrente radial y el pedículo principal del ECRB (de diámetro medio 1,11 mm y longitud de pedículo media de 27,77 mm) es rama de la arteria radial en el 68,9% de los casos y de la arteria recurrente radial en el 31,1% de los casos. Concluimos que ElECRL y ECRB presentan dos tipos de patrones vasculares: tipo I y tipo II, siendo más frecuente en nuestro trabajo el tipo II, que hacen que ambos puedan ser transferidos como colgajos libres por su pedículo principal. Ambos músculos presentan un tamaño, contorno, contenido fascial importante para el anclaje de suturas y una longitud de pedículo y calibre vascular adecuados para su transferencia microvascular libre en reanimación facial. De los dos, el más realizable como colgajo libre es el ECRB ya que la relación anatómica del nervio radial con el pedículo del ECRL hace que no sea posible su transferencia como colgajo libre sin sacrificar la ramamotora del nervio radial en la mayor parte de los casos (AU)

The arterial anatomy of the Extensor Carpi Radialis Longus and Brevis(ECRL, ECRB) flaps is herein described in order to provide the vascular basis to be used as free muscle transfer for facial reanimation. Weused 29 fresh above-elbow human arms injected by means of two different techniques. Latex-injection was performed in 18 arms and the modified lead oxide-gelatine injection technique was performed in 11 arms. The ECRL and ECRB with their pedicles were dissected, photodocumented and radiographied. The number, length and calibers of the muscle pedicles were recorded. The intramuscular vascular pattern and the relations of the main pedicles of the muscles with the radial nerve were also noted. Two vascular patterns were found following the Mathes and Nahai Classification of the Vascular Anatomy of the Muscles (number of pedicles and its dominance): Type I (37,9% of ECRL and 20,7% of ECRB dissections) and Type II (62,1% of ECRL and 79,3% of ECRB dissections). The dominant pedicle for the ECRL (with an average caliber of 1,73 mm and an average length of pedicle of 32,32 mm) is a branch of the radial recurrent artery in100% of the dissections and the dominant pedicle for the ECRB (with anaverage caliber of 1,11 mm and an average length of pedicle of 27,77 mm)is a branch of the radial artery in 68,9% of the dissections and a branch of the radial recurrent artery in 31,1% of the cases. As a conclusion, ECR Land ECRB muscle flaps present two types of vascular patterns: type I and type II. Type II pattern is the most common in our study. The anatomical features of both muscles (vascular basis, presence of an important fascial layer, contour and length of the muscle,) make them reliable as free muscles flaps for facial reanimation, however, the relation between the dominant pedicle for the ECRL muscle flap with the posterior interosseous branch of the radial nerve make not possible to free the flap without sacrificing the nerve in most of the cases (AU)

Síndrome del shock tóxico estreptocócico tras fascitis necrotizante por estreptococo pyogenes / Streptococcal toxic shock syndrome after necrotizing fascitis due to streptococcus pyogenes

La fascitis necrotizante por Estreptococo Pyogenes es una emergencia quirúrgica con una tasa de mortalidad elevada por la rápida progresión a shock y fallo multiorgánico. El reto supone realizar un diagnóstico precoz, ya que suele ser confundido con una infección leve de tejidos blandos. Presentamos dos casos clínicos de fascitis necrotizante que presentaron en 24 horas un Síndrome de Shock Tóxico Estreptocócico. Revisamos el mecanismo patogénico, diagnóstico y tratamiento descritos para este cuadro y discutimos las recomendaciones para su manejo establecidas en la literatura (AU)

Necrotizing fascitis by Streptococcus Pyogenes is a surgical emergency with a high mortality task due to a rapid progression of the illness to shock and organ failure. The challenge is to perform a prompt diagnosis because it is often confused with a minor soft-tissue infection. We present two cases of necrotizing fascitis by Streptococcus Pyogenes who in 24 hours developed a Streptococcal Toxic Shock Syndrome. In addition, we review the pathogenic mechanism, diagnosis and treatment of this syndrome and we discuss its management following literature recommendations (AU)