Cerebral fat embolism with turbid urine as the initial sign.

BACKGROUND: Cerebral fat embolism (CFE) is a rare but potentially fatal complication that can occur after long bone fractures. It represents one subcategory of fat embolisms (FE). Diagnosing CFE can be challenging due to its variable and nonspecific clinical manifestations. We report a case of CFE initially presenting with turbid urine, highlighting an often neglected sign. CASE PRESENTATION: A 69-year-old male was admitted after a traffic accident resulting in bilateral femoral fractures. Sixteen hours post-admission, grossly turbid urine was noted but received no special attention. Four hours later, he developed rapid deterioration of consciousness and respiratory distress. Neurological examination revealed increased upper limb muscle tone and absent voluntary movements of lower limbs. Brain MRI demonstrated a 'starfield pattern' of diffuse punctate lesions, pathognomonic for CFE. Urine microscopy confirmed abundant fat droplets. Supportive treatment and fracture fixation were performed. The patient regained consciousness after 3 months but had residual dysphasia and limb dyskinesia. CONCLUSION: CFE can present with isolated lipiduria preceding overt neurological or respiratory manifestations. Heightened awareness of this subtle sign in high-risk patients is crucial for early diagnosis and intervention. Prompt urine screening and neuroimaging should be considered when gross lipiduria occurs after long bone fractures.

Ética del cuidado de los pacientes con el diagnóstico de fractura del tercio proximal del fémur / Ethics in the care of patients diagnosed with fracture of the third proximal of the femur

Fundamentación: la intervención de los anestesiólogos durante el preoperatorio de los pacientes con fractura del tercio proximal del fémur no queda reducida a la recopilación de datos científicos de carácter biológico, es una exigencia actual enfrentarse al paciente con una profunda comprensión de su esencia social y desde una posición humanista. Objetivo: determinar las condiciones sociales del sufrimiento de los pacientes con fractura del tercio proximal del fémur durante el preoperatorio. Método:se realizó un estudio de revisión sistemática cualitativa, con la información cualitativa descriptiva a través de la recolección, evaluación, verificación y síntesis de las evidencias existentes. Resultados: si está indicada la intervención quirúrgica, se asegura la prevención de la discapacidad en la población envejecida vulnerable o frágil con alto riesgo quirúrgico. La fragilidad como proceso dinámico produce la transición a mayor fragilidad y su vez conduce a un espiral de resultados adversos de salud con carácter multidimensional y progresivo. Discusión: la ética del cuidado destaca la importancia de valorar el sufrimiento del paciente, la necesidad y sensibilidad para responder de tal forma que se proteja al paciente y sus familiares de la sensación de aislamiento, abandono y discapacidad propios de la enfermedad. El cuidado es una actividad permanente y cotidiana de la vida de las personas, el cuidado por parte de los anestesiólogos incluye profesionalidad a lo cotidiano(AU)

Background: the intervention of the anesthesiologists during the preoperatory of the patients with fracture of the third proximal of the femur is not reduced to the summary of scientific data of biological character; it is a current demand to face the patient with a deep understanding of its social essence and from a humanist position. Objective: to determine the social conditions of the suffering of the patients with fracture of the third proximal of the femur during the preoperatory. Method: it was carried out a study of qualitative systematic revision, with the descriptive qualitative information through the gathering, evaluation, verification and synthesis of the existent evidences. Results:if it is suitable the surgical intervention.The fragility like dynamic process produces the transition to more fragility and its time it drives to a hairspring ofadverse resultsof health with multidimensional character and progressive.Discusión: the ethics of the care highlights the importance of valuing the patient's suffering, the necessity and sensibility to respond in such a way that is protected to the patient and its relatives of the isolation sensation, abandonment of the illness. The care is a permanent and daily activity of the life of people the care on the part of the anesthesiologists(AU)

Fracturas periprotésicas distales de fémur / Periprosthetic distal femoral fractures

El número de artroplastias totales de rodilla que se realizan en nuestro país aumenta anualmente, por lo que se espera que sus complicaciones también aumenten. Entre ellas, la incidencia de fracturas periprotésicas distales de fémur, sobre la que trataremos en este artículo de revisión, que analiza algunos de los artículos más relevantes de la literatura reciente. Los factores de riesgo más importantes son la osteoporosis y la muesca femoral durante la cirugía (notching) femoral, aunque éste último controvertido. La obesidad se ha demostrado no ser un factor de riesgo. Aún no existen estudios sólidos que demuestren diferencias significativas en cuando a tasas de pseudoartrosis entre las placas bloqueadas y el enclavado intramedular, e incluso las revisiones más recientes determinan que ambos consiguen reducciones igual de estables. Aunque con precaución, las prótesis tumorales comienzan a utilizarse cada vez más en éste tipo de fracturas. El factor clave a la hora de escoger la mejor opción de tratamiento de estas fracturas consiste en determinar el estado de la prótesis, la cantidad de stock óseo remanente y el grado de desplazamiento de la fractura

The number of Total Knee Replacement surgeries performed in our country increases annually, so it is expected that so will increase their complications. Among them, Periprosthetic distal femoral fractures, which we deal with in this review article. The most important risk factors are both, osteoporosis and anterior femoral notch (although this one is still controversial). Obesity has been shown not to be a risk factor. There are no solid studies yet showing significant differences related to pseu-doarthrosis between locked plates and intramedullary nails. Recent reviews even determine that both achieve similar stability rates. Megaprostheses (tumoral prostheses) are beginning to be used more and more in this type of fractures. The key factor when choosing the best treatment option for periprosthetic distal femoral fractures is to determine the state of the prosthesis, the amount of distal bone stock and the degree of displacement

¿Qué hay nuevo sobre traumatismos en edad pediátrica? / What’s new in children orthopaedic trauma?

Cada vez son más frecuentes la aparición en la bibliografía de artículos relacionados con problemas en edad pediátrica. Con el objetivo de actualizar información hemos realizado una revisión de la bibliografía publicada en las principales revistas relacionadas con la ortopedia y traumatología infantil durante el año 2015 seleccionando aquellos que trataban sobre traumatismos en edad pediátrica. El artículo ha sido divido en bloques por región anatómica y se resume la información más destacada de las publicaciones

Increasingly frequent occurrence in the literature related problems in childhood items. In order to update information we have conducted a review of the literature published in leading journals related to orthopedics and traumatology child during 2015 selecting those that dealt with trauma age pediatric. The article has been divided into blocks by anatomical region and the most important information is summarized publications

Rotura por fatiga de la zona central del vástago Exeter(R): una complicación excepcional / Fatigue fracture of the central zone of Exeter stem: an unusual complication

Objetivos: Conocer una complicación rara pero con importante morbimortalidad como es la rotura de vástagos protésicos cementados. Material y métodos: En nuestro caso nos referimos a la rotura de un vástago pulido Exeter(R) (Stryker(R)), fabricado en acero inoxidable y ampliamente utilizado en todo el mundo. Tras implantar dicho vástago en una paciente de 74 años que sufrió una fractura subcapital, se observa a los 8 años de la cirugía una rotura del vástago en la zona central; por lo que se recambia dicho vástago por uno de anclaje diafisario con buena evolución. Resultados y conclusiones: tras analizar las posibles causas que generaron el fracaso del vástago, identificamos un defecto en la cementación como el principal causante del fallo del implante

Objetives: explain a rare but important complication for patient that is the breakage of cemented stem. Methods: in our case, we refer to a polished stem Exeter(R) (Stryker(R)), made of stainless steel and widely used around the world. We implant Exeter® stem in a 74 year old patient and 8 years after the surgery, is observed a rupture in the central area of the stem; that stem is exchanged for one of diaphyseal anchorage with good evolution. Results: after analyzing the possible causes of the failure of this stem, we identified a defect in the cement as the main cause of implant failure

Evaluación intraobservador e interobservador en el diagnóstico radiográfico de fracturas asociadas a la ingestión de bifosfonatos / Intraobserver and interobserver evaluation in the radiological diagnosis of biphosphonate-related fractures

Determinar la utilidad de la evaluación radiográfica, como único elemento, en el diagnóstico de las fracturas asociadas a la ingestión de bifosfonatos. Materiales y Métodos: De 2006 a 2011, se evaluaron las radiografías de pacientes con fracturas subtrocantéricas y diafisarias de fémur; se excluyeron las fracturas de fémur proximal, distal, patológicas y a los pacientes pediátricos. Se obtuvieron radiografías de 167 pacientes con 169 fracturas (2 bilaterales): 109 mediodiafisarias y 60 subtrocantéricas. Veintinueve de las 169 fracturas estaban asociadas a la ingestión de bifosfonatos. La evaluación estuvo a cargo de siete traumatólogos con distintos años de experiencia: a) 3 con 3 años de formación (3er año de residencia); b) 2 con 6 años de formación (fellowships en hombro y rodilla) y c) 2 con 15 años de formación (especialistas en pie y cadera). Los evaluadores observaron, en forma independiente y en dos oportunidades, las radiografías de los 169 casos. Durante la evaluación, se registraron los resultados en una grilla según: 1) Sí: presentaban 3 criterios; 2) No sé: presentaban 1 o 2 criterios; 3) No: no presentaban criterios. Se utilizó el índice kappa para evaluar el acuerdo intraobservador y el programa G-string para la confiabilidad interobservador. La evaluación fue realizada sobre el resultado “Sí”, con la presencia de los tres criterios radiográficos. Resultados: El acuerdo intraobservador evidenció un valor de kappa de 0,2-0,5 y la confiabilidad interobservador fue del 54% en promedio. Conclusión: La evaluación radiográfica no ha demostrado ser suficiente para arribar al diagnóstico de fractura atípica por ingestión de bifosfonatos. Nivel de Evidencia: III...

To evaluate the usefulness of X-rays for diagnosing bisphosphonate-related atypical fractures. Methods: Patients with a subtrochanteric and diaphyseal femur fracture admitted from 2006 to 2011 were retrospectively evaluated. Exclusion criteria included neck, intertrochanteric and supracondylar femoral fractures, pathological fractures and pediatric patients. Radiographies were taken in 167 patients with 169 fractures (2 bilateral): 109 diaphyseal and 60 subtrochanteric fractures. Twenty nine were bisphosphonate-related atypical femoral fractures. Seven orthopaedics physicians with different expertise levels reviewed independently the X-rays twice: a) 3 third-year residents; b) 2 with fellowships in knee and shoulder; and c) 2 hip, foot and ankle specialists. During the evaluation, results were included in a data collection sheet as follows: 1) Yes: three criteria were present, 2) I don´t know: two criteria present, and 3) No: no criteria. The intraobserver agreement was calculated with kappa coefficient while the interobserver agreement was calculated with the G-string program. The statistical analysis was performed on the Yes result with the three criteria. Results: Kappa coefficient for intraobserver agreement was 0.2 to 0.5. The interobserver agreement was on average 54%. Conclusion: Radiographs alone are not reliable enough for distinguishing complete femoral fractures related to bisphosphonates. Level of Evidence: III...

Déficit de vitamina D en una cohorte de pacientes mayores de 69 años con fractura de fémur atendidos en la Unidad Geriátrica de Agudos del Hospital de Igualada / Vitamin D deficiency in a cohort of patients over 69 years with femoral fracture admitted to an Acute Geriatric Unit of Hospital Igualada

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Benzodiazepinas en ancianos: a propósito de un caso / Benzodiazepines in aged patients: a case report

Las benzodiazepinas son los fármacos hipnótico-sedantes más consumidos, sobre todo entre la población geriátrica. En la presente publicación se describe el caso clínico de un paciente que ha sufrido una caída con consecuencia de rotura de fémur y que se encontraba en tratamiento con dos benzodiazepinas a dosis mayores a las recomendadas para ancianos, en el momento de sufrir la caída. Dichos fármacos fueron ketazolam y lorazepam, a dosis de 30 mg y 5 mg, respectivamente. Recalcamos la importancia de prestar especial atención a la dosificación de estos fármacos en los ancianos y de seguir las recomendaciones de elegir benzodiazepinas de vida media corta o ultracorta, a la menor dosis posible y durante el menor periodo de tiempo necesario

Benzodiazepines are the most consumed sedative-hypnotic drugs, especially among geriatric population. In this publication, we report the case of a patient who suffered a fall and broked his femur and who was treated with two benzodiazepines at higher doses tan recommended for elderly patients, at the time of suffering the fall. Such drugs were ketazolam and lorazepam, prescribed at 30 mg/ day and 5 mg/day respectively. We emphasize the need of pay special attention to the dosage of these drugs in the elderly and to follow the recommendations of choicing those ones of short or ultrashorthalf-life, at the lowest dose possible and for the shortest time necessary

Uso de yeso pelvipédico inmediato en fracturas femorales pediátricas / Inmediate use of spica in pediatric femoral fractures

Objetivo: Evaluar los resultados del tratamiento con yeso pelvipédico inmediato en fracturas diafisarias de fémur en pacientes con edades comprendidas entre los 6 y 24 meses. Material y métodos: Realizamos un estudio observacional analizando pacientes tratados entre 2009 y 2012 por fractura de fémur, mediante yeso pelvipédico inmediato, con edades entre 6 y 24 meses. Se recopilaron 46 pacientes. Registrando tipo de fractura, acortamiento inicial, demora hasta la colocación del yeso, tipo de anestesia, angulaciones y discrepancia de longitud entre miembros inferiores. Resultados: Se observa un predominio de fracturas espiroideas (63%). Un acortamiento inicial de 6 mm de mediana, que guarda relación con la angulación frontal y sagital finales. No se ha constatado relación entre el peso y discrepancia de longitud y/o angulaciones. En el 61% de los pacientes no fue precisa la anestesia general, no existiendo relación entre su uso, y la obtención de mejores resultados radiográficos. La media de la demora en la aplicación del yeso fue de 15 horas. No se han detectado complicaciones graves. Conclusiones: El uso del yeso pelvipédico inmediato en el manejo de la fracturas de fémur en pacientes menores de 24 meses y mayores de 6 ofrece resultados óptimos con escasas complicaciones

Objetive: To evaluate the treatment results with immediate hip spica in diaphyseal femur fractures in patients age between 6 and 24 months. Methods: This was an observational study that retrospectively analyzed patients between 6 and 24 months of age who had suffered a femur fractures and were treated with immediate spica casting in our hospital between 2009 and 2012. Forty six patients were collected. The data recorded were: fracture type, initial shortening, delay until casting, general anesthesia requirement or not, degree of angulation in the frontal and sagittal plane, and leg length discrepancy at follow up. Results: We analyzed the data obtained and observed a predominance of spiral fractures (63%). An initial shortening of 6 mm median that relates with the frontal and sagittal angulation. Five patient's angles were initially out of tolerance range but did not require treatment at the end of follow up. There was no relationship between weight and leg length discrepancy or angulations. Sixty one percent of the patients did not require general anesthesia, with no relationship between its use and better radiographic results. Average in casting delay was 15 hours. No serious complications were detected. Conclusions: The use of immediate hip spica cast in the management of femur fractures in patients younger between 6 and 24 months of age provides optimal results with few complications

False Femoral Neck Fracture Detected during Shaft Nailing: A Mach Band Effect

Femoral neck fractures are associated with femoral shaft fractures in 1% to 9% of cases. Undisplaced neck fractures are susceptible to displacement during shaft nailing. We report the case of a 57-year-old male patient in whom we performed standard intramedullary nailing for a femoral shaft fracture. In doing so, we identified a vertical radiolucent line at the femoral neck, which was thought to be further displacement of a hidden silent fracture or an iatrogenic fracture that developed during nail insertion. Consequently, we decided to switch to reconstructive femoral nailing. Postoperative hip imaging failed to show the femoral neck fracture that we saw in the operating room. Here, we discuss the aforementioned case and review the literature concerning this artifact.

Proximal femoral epiphysis anatomy in chilean population: orthopedic and forensic aspects / Anatomía del epífisis proximal del fémur en la población chilena. Aspectos traumatológicos y forenses

From a biomechanical standpoint, bone geometry and density are factors correlated to the bone resistance of the femur when supporting body weight, with geometric parameters like the diameter of the femoral head and neck, the length of the femoral neck, and the femoral neck angle as determinant factors in the incidence of hip fractures, which increase in frequency and seriousness in osteoporotic patients. In Chile, morphometric data that contributes to relating the anatomy of the proximal epiphysis of the femur as an associated factor in hip fractures does not exist; likewise, there are no anthropometric indexes that may contribute to the forensic sciences. The purpose of this study is to establish average measurements of the proximal epiphysis of the femur in the adult Chilean population. Descriptive Study. The proximal epiphyses of 81 dry adult femurs were analyzed (44 right and 37 left bones), measuring the following parameters: length of the femoral neck (LN), femoral neck angle (FNA), circumference of the femoral head (CH) and circumference of the femoral neck (CN). The statistical relationship between the measurements and the side of each sample was analyzed (t-test p=0.05). The average lengths were LN= 3.59cm (+/- 0.43 cm); FNA= 124.17 (+/- 6.37), CH= 14.34 cm (+/- 1.27 cm) and CN= 9.7 cm (+/- 0.87 cm). No significant differences between the left and right sides were found. Average numbers were obtained for the anatomy of the proximal femoral epiphysis from a sample in the Chilean population. With the data obtained, we propose to carry out anatomo-clinical, epidemiologic and forensic studies in this population.

Desde un punto de vista biomecánico, la geometría y la densidad ósea son factores correlacionados con la resistencia del hueso del fémur al apoyar el peso corporal, con los parámetros geométricos, como el diámetro de la cabeza femoral y el cuello, la longitud del cuello del fémur, y el ángulo del cuello femoral factores determinantes en la incidencia de fracturas de cadera, que aumentan en frecuencia y gravedad en los pacientes con osteoporosis. En Chile, no existen datos morfométricos que relacionen la anatomía de la epífisis proximal del fémur como un factor asociado a las fracturas de cadera ni índices antropométricos que pueden contribuir a las ciencias forenses. El propósito de este estudio es establecer las medidas promedio de la epífisis proximal de fémur en población adulta chilena. Estudio Descriptivo. Se analizaron la epífisis proximal de 81 fémures adultos secos (44 derechos y 37 izquierdos), midiendo los siguientes parámetros: longitud del cuello femoral (LC) , ángulo cérvico-diafisiario femoral (ACD), circunferencia de la cabeza femoral (CCa) y circunferencia del cuello femoral (CCu). Se analizó la relación estadística de las medidas con el lado de cada muestra (test Chi cuadrado p:0,05) Las longitudes promedios fueron LC: 3,59 cm (+/- 0,43 cm); ACD: 124,17 (+/- 6,37 cm); CCa: 14,34 cm (+/- 1,27 cm) y CCu: 9,7 cm (+/- 0,87 cm). No se encontraron diferencias significativas entre el lado derecho e izquierdo. Los resultados proponen la necesidad de realizar estudios anatomo-clínicos y epidemiológicos actualizados en población chilena donde la geometría de la epífisis proximal del fémur se incluya dentro del análisis.

Avaliação de pacientes com fratura de fêmur estabilizada com fixador externo linear em um hospital referência em trauma

Introdução: As fraturas são lesões definidas como toda e qualquer perda da integridade estrutural do osso, que ocorre quando este sofre uma força maior do que sua elasticidade. Os locais fraturados são diversos, entretanto é de grande valia ressaltar as fraturas de membros inferiores, principalmente as de diáfise de fêmur, em virtude do impacto sobre a autonomia e funcionalidade do indivíduo. Objetivo: Realizar avaliação fisioterapêutica em pacientes vítimas de fraturas diafisárias de fêmur, estabilizadas com fixador externo linear, admitidos nas clínicas ortopédicas I, TI e III e clínica cirúrgica do Hospital Metropolitano de Urgência e Emergência (HMUE) , localizado na região metropolitana de Belém/PA. Metodologia: Realizou-se um estudo transversal analítico, que delineou o perfil e as alterações clínicofuncionais, como a amplitude de movimento, o grau de força muscular e a perimetria dos participantes. Resultados: Foram avaliados 37 pacientes no período de maio a novembro de 2015, sendo, do sexo masculino (89,18%), idade entre 18-28 anos (62,16%), procedentes, principalmente, da região metropolitana de Belém (62,16%), com ensino fundamental incompleto (43,24%), bem como sem nenhum tipo de ocupação (35,13%), além de solteiros (35,13%). No tocante ao mecanismo de trauma, predominaram os acidentes de trânsito (54,5%), acometendo o fêmur esquerdo em 54,05%, gerando fratura fechada (56,75%), do tipo cominutiva (54,05%). Quanto ao aspecto da pele, predominou a hidratada com escoriação (56,75%); e em relação à presença de edema, todos os pacientes apresentaram-no, sendo a maioria do tipo sem cacifo (81,08%), destes 72,97% apresentaram edema nos quatro segmentos avaliados: coxa, joelho, panturrilha e tornozelo. Já em relação ao tipo de lesão, 45,94% apresentaram lesões de tecidos moles, sendo que 13,51% tiveram lesão circulatória. O nível de dor predominante, segundo a escala visual analógica de dor, foi 5 (45,94%). Através da avaliação da perimetria, amplitude de movimento e grau de força muscular, verificou-se uma alteração estatisticamente significativa na comparação do membro fraturado com o membro são. Na perimetria, houve significância estatística para a coxa proximal (p=0,0055), coxa média (p=0,0056) e tornozelo (p=0,0000); em relação à amplitude de movimento, pode-se verificar que houve diferença estatisticamente significante para os movimentos de flexão de joelho (p=0,0000); abdução da articulação coxofemural (p=0,0203); flexão plantar (p=0,0008), inversão (p=0,0003) e eversão (p=0,0138) do tornozelo. Quando realizada a avaliação do grau de força muscular, constatou-se que houve diferença significativa para os movimentos de flexão (p=0,0000) e extensão de joelho (p=0,00000); abdução da articulação coxofemoral (p=0,0000); dorsiflexão (0,0000), flexão plantar (p=0,0000), inversão (p=0,0000) e eversão (p=0,0000) do tornozelo. Conclusão: Desta forma, estes resultados reafirmam a necessidade de se implantar políticas preventivas para redução dos agravos citados anteriormente, e assim, espera-se que este trabalho possa contribuir para aqueles que se interessem pela temática

Introduction: Fractures are injuries defined as any loss of structural integrity of bone, which occurs when it undergoes a force greater than its elasticity. There are several places of fractures, but it is of great value to stress fractures of the lower limbs, especially the femoral shaft, due to the impact on autonomy and individual functionality. Objective: The study aimed to perform physical therapy assessment in patients suffering from diaphyseal femur fractures, admitted to the orthopedic clinics I, II and III and Surgical Clinic at Hospital Metropolitano de Urgência e Emergência (HMUE), located in the metropolitan region of Belém / PA. Methods:The study was analytical, cross-sectional that outlined the profile and clinical and functional changes, such as range of motion, strength level and perimetry of the participants. Results: 37 patients were assessed in the period of May to November 2015, with predominance of male sex (89.18%), aged 18-28 years (62.16%), coming mainly from the metropolitan area of Belém (62, 16%), with incomplete primary education (43.24%), without any occupation (35.13%), and unmarried 35.13%. Regarding the mechanism of injury, the traffic accidents predominanted (54.5%), affecting the left femur in 54.05%, generating closed fracture (56.75%), the comminuted type (54.05%). As for the appearance of the skin, prevailed hydrated with excoriation (56.75%); for the presence of edema, all patients presented it, mostly the type without locker (81.08%), 72.97% of these showed edema in the four evaluated segments: thigh, knee, calf and ankle. In relation to the type of injury, 45.94% had soft tissue injuries, of which 13.51% had circulatory injury. The prevailing level of pain according to the visual analogue scale of pain was 5 (45.94%). Through the evaluation of the circumference, range of motion and the degree of muscle, there was a statistically significant change in comparison with the fractured limb with the healthy limb. In perimetry there was statistical significance for the proximal thigh (p=0,0055), medial thigh (p=0,0056) and ankle (p=0,0000); Regarding the range of motion it can be seen that there was relevance to the knee flexion movements (p=0,0000); abduction of the hip joint (p=0,0203); plant flexion (p=0,0008), inversion (p=0,0003) and eversion (p=0,0138) of the ankle. When performed to assess the degree of muscle strength we saw that there was statistical significance for the movements of flexion (p=0,0000) and knee extension (p=0,0000); abduction of the hip joint (p=0,0000); dorsiflexion (p=0,0000), plant-flexion (p=0,0000), inversion (p=0,0000) and eversion (p=0,0000) of the ankleîen

Bursite peritrocantérica: descrição de nova manobra semiológica para auxílio diagnóstico / Peritrochanteric bursits: a description of a new semiologic maneuver for diagnostic assistance

O estudo tem como objetivo testar a validade de nova manobra semiológica no diagnóstico de bursite peritrocantérica. Foram avaliados 30 pacientes, com diagnóstico clínico de bursite do grande trocanter. Todos os pacientes foram submetidos à radiografia de bacia AP e Perfil. Quando necessário, outros exames de imagem foram realizados, com a finalidade de descartar doenças associadas; os pacientes foram submetidos a duas manobras semiológicas no quadril são e afetado. TESTE 1: paciente em decúbito dorsal, o membro examinado é aduzido em extensão cruzando sobre o membro contralateral, com o calcâneo em contato com a maca, faz-se a flexão do quadril até aproximadamente 90º, o quadril ao final da manobra estará em flexão, adução e leve rotação externa, durante a manobra poderá ser referida dor na região do trocanter maior. TESTE 2: a posição final do TESTE 1, é a posição inicial desta, faz-se a adução forçada do quadril, pode haver referencia de dor ou exacerbação. Os resultados das manobras foram submetidos ao estudo estatístico, que demonstrou serem os exames diferentes entre si, porém complementares. O teste 2 mostrou ser positivo em 96,6 por cento. As manobras semiológicas denominadas de TESTE 1 e 2, podem ser utilizadas como auxiliares nos diagnósticos clínicos das bursites peritrocanterianas.

The objective of the present study was to test the validity of a semiologic maneuver on the diagnosis of peritrochanteric bursitis. Thirty patients with a clinical diagnosis of great trochanter bursitis were assessed. All patients were submitted to X-ray studies at AP and LP. Whenever necessary, other imaging tests were performed, intending to rule out any associated diseases; the patients were submitted to two semiologic maneuvers on both hips, the affected and the normal one. TEST 1: with patient at supine position, the examined limb is adduced in extension and crossing it over the contralateral limb, with the calcaneus touching the bed, a hip flexion is produced at approximately 90º; at the end of this maneuver, the hip will be flexed, adduced and slightly externally rotated; during this maneuver, the patient may report pain at major trochanter region. TEST 2: the final position of TEST 1 is the initial position of TEST 2, with a forced hip adduction where pain or exacerbation may be reported. The maneuver results were submitted to statistical analysis, with both tests showing to be different from each other while supplementary. Test 2 was shown to be positive in 96.6 percent. Semiologic maneuvers referred as TEST 1 and TEST2 may be used to assist on providing a clinical diagnosis of peritrochanteric bursitis.

Artroplastia de cadera con vástago convencional en fracasos de osteosíntesis de fracturas del fémur proximal / Hip arthroplasty with conventional stem as rescue treatment after failed treatment of intertrochanteric hip fractures

Objetivo. El objetivo de este estudio es evaluar los resultados del tratamiento del fracaso de la osteosíntesis en fracturas del fémur proximal mediante artroplastia de cadera con vástago convencional. Material y métodos. Estudio retrospectivo de 17 pacientes (edad media 76 años), en las que se implantó una prótesis de cadera tras haber fracasado la osteosíntesis de una fractura pertrocantérica, entre 1997 y 2011. En todos los casos se implantó un vástago femoral convencional. El seguimiento medio fue de 6 años (1-14 años). Se ha evaluado el dolor, la movilidad y la marcha (Merle d’Aubigné) y el resultado funcional (Barthel), así como la estabilidad radiológica del implante según los criterios de Harris y de Engh. Resultados. Excluyendo un caso de exitus (6%) y una infección tratada mediante artroplastia de resección tipo Girdlestone, a los 6 meses de la cirugía protésica todos los pacientes habían recuperado la deambulación autónoma. El 87% presentaban dolor leve en su cadera o no tenían dolor. Tras las 2 cirugías el Barthel medio había disminuido en 15 puntos (de 81 a 66). Únicamente se ha observado un caso de aflojamiento aséptico del vástago femoral (6%). Discusión. La artroplastia de cadera es un procedimiento efectivo en el rescate del fracaso de la osteosíntesis de fracturas proximales de fémur. Permite un rápido alivio del dolor y una eficaz recuperación funcional, aunque la morbimortalidad asociada es elevada. La utilización de vástagos convencionales y no vástagos largos de revisión permite simplificar la cirugía y disminuir el tiempo quirúrgico (AU)

Objective. The purpose of this study is to evaluate the results and complications of hip arthroplasty with conventional stem performed as a salvage procedure after the failed treatment of an intertrochanteric hip fracture. Material and methods. Between 1997 and 2011, 17 patients with a mean age of 76 years were treated with hip arthroplasty for failed treatment of intertrochanteric hip fracture. In all cases a conventional stem was used. The mean follow-up was 6 years (range 1-14 years). Pain, range of motion (Merle d’Aubigné) and functional results (Barthel), as well as implant fixation (Harris and Engh), were evaluated during the follow-up. Results. Except for one case of death (6%) and one case of infection (Girdlestone arthroplasty), all patients were able to walk independently at 6 months. The majority of the patients (87%) had no or mild pain. After 2 surgeries (osteosynthesis and hip arthroplasty) the mean Barthel Score had decreased from 81 to 66 points. Just one case (6%) of stem loosening has been observed. Discussion. In older patients, prosthetic replacement after failed proximal femoral fixation is a reliable salvage option. Most patients have good pain relief and functional improvement, although the rate of perioperative medical complications is high. Surgery is less demanding and the operating time is shorter when conventional femoral stems are used (AU)

Efecto del fresado y enclavado endomedular sobre la producción de factores de crecimiento en el callo de fractura de fémur en ratas / Effect of intramedullary reaming and nailing on the production of growth factors in the femur fracture callus in rats

Introducción. Existen muchos estudios referentes a los diferentes efectos producidos por el fresado intramedular en el callo de fractura, pero no existe evidencia en la literatura del efecto de dicho fresado en la osteogénesis. Realizamos un estudio prospectivo para analizar el efecto del fresado endomedular y enclavado en la producción de factores de crecimiento durante el proceso de consolidación de la fractura en el fémur producida en ratas. Material y métodos. Producimos una fractura diafisaria, transversa, no conminuta de fémur en 64 ratas: 34 ratas no recibieron ningún tratamiento y las otras 30 se trataron mediante un procedimiento quirúrgico estandarizado, consistente en fresado del canal medular de distal a proximal y fijación de la fractura con una aguja de Kirschner. Las ratas fueron sacrificadas a las 24 h, 4.°, 7.° y 15.° días después de la fractura. Medimos la cantidad de factores de crecimiento (PDGFA, TGF2 y TGFBeta-R2) en el callo de fractura mediante estudio anatomopatológico en los diferentes momentos del sacrificio. Resultados. Los resultados de las variables primarias del estudio, estratificadas por tiempo hasta el sacrificio, no mostraron diferencias estadísticas significativas. Discusión. Aunque la presencia de una aguja intramedular facilita la estabilización de la fractura y la formación del callo de fractura, no hemos encontrado ninguna evidencia significativa de que el fresado endomedular produzca cambios en la expresión de los factores de crecimiento estudiados (TGFBEta-R2, PDGFA y TGFBeta2) durante la formación del callo de fractura de fémur en ratas (AU)

Introduction: Many studies have been conducted to determine the different effects that reaming or intramedullary nailing have on fracture healing, but there is no evidence in the literature of the effect of intramedullary reaming on osteogenesis. We performed a prospective study to analyse the effect of intramedullary reaming and nailing on the production of growth factors during the process of fracture healing in the femur of rats. Material and methods: A transverse mid-shaft non-comminuted femur fracture was produced in 64 rats; 34 rats did not receive any treatment, and a standardized surgical procedure was performed on 30 rats, by exposing the left knee, reaming the medullary canal from distal to proximal, and then fixing the fracture with a steel pin. The rats were sacrificed at the 24th hour, 4th, 7th and 15th days after the fracture. The amount of growth factors that appeared in the callus fracture was measured using histopathology studies. The primary categorical variables analysed were PDGFA, TGF2 and TGFBeta-R2. These variables were analysed in each group at the different sacrifice times. Results: The results of the primary variables of the study, stratified by the time until sacrifice, showed no statistically significant differences. Discussion: Even if the presence of an intramedullary wire facilitates the fracture repair and the stabilising the bridge of bone between both edges of the fracture site, no evidence was found that reaming changes the expression of the growth factors studied (PDGFA, TGFBeta-R2 and TGFBeta) during the callus formation in rats (AU)

Enclavado intramedular en fractura de fémur proximal: rotura doble con sistemas de implante distintos / Intramedullary nailing in proximal femur fracture: double breakage with different implants

Presentamos un caso clínico de una doble rotura de clavo en el cual los errores en la técnica quirúrgica pueden explicar, en parte, la causa del fallo de los implantes. Finalmente se resolvió la fractura con el uso de una placa de osteosíntesis con un contrafuerte. Aunque el enclavado intramedular es una de las técnicas más frecuentemente realizadas en COT, tenemos que utilizar una técnica quirúrgica lo más cuidadosa posible, prestando atención para evitar problemas que puedan complicar la evolución (AU)

We present a clinical report of a double failure in which errors in surgical technique can explain, in part, the cause of the breakage of the nails. Finally we resolved the fracture with an osteosynthesis plate with a strut. Although intramedullary nailing is one of the most frequent techniques in orthopedics, we have to use the most accurate technique and pay attention to avoid surgical problems that can complicate the evolution of the healing of the fractures of the hip (AU)

Luxación del polietileno en prótesis patelo-femoral con patela móvil. Caso clínico / Dislocation of the polyethylene in a patello-femoral replacement with a movable patella

La artroplastia femoro-patelar continúa siendo una técnica quirúrgica poco utilizada por los discutidos resultados obtenidos. En un intento de mejorar sus resultados se introdujo el diseño con polietileno móvil. Presentamos un caso clínico con una complicación poco frecuente: la luxación del polietileno de la base metálica de la patela; y a propósito realizamos una revisión bibliográfica de esta complicación (AU)

Patellofemoral arthroplasty is an infrequently used surgical technique because of its controversial results. In an attempt to improve the results, a design with a mobile-bearing poliethylene patellar component has been developed. We describe a clinical case with an unusual complication: the dislocation of poliethylene from the metal backing; and accordingly, we carried out a literature review of this complication (AU)

Estudio observacional para evaluar en el tiempo el sangrado por los drenajes de una cohorte prospectiva de pacientes intervenidos de fractura pertrocantérica de fémur / A prospective observational study to evaluate the blood loss in a cohort of patients with pertrochanteric femoral fracture

Objetivo: Evaluar la cantidad del sangrado por los drenajes en las fracturas pertrocantéricas de fémur en el tiempo, durante el postoperatorio inmediato, para saber el momento más apropiado para retirarlos. Pacientes y métodos: Estudio descriptivo, longitudinal y unicéntrico de una cohorte prospectiva de pacientes consecutivos intervenidos de fractura pertrocantérica de fémur, tratada con una osteosíntesis con tornillo y placa deslizante. Se incluyeron 100 pacientes, con edad media de 86 (DE: 8) años; el 74% fueron mujeres. En 96 casos se colocó un drenaje profundo y en 17 superficial. La variable principal fue el sangrado postoperatorio de los drenajes que se recogieron horariamente durante las tres primeras horas del postoperatorio, a las 24 y 48 horas antes de retirarlos. Resultados: El sangrado medio intraoperatorio fue de 278,1 (DE: 148,2) mL y el sangrado total medio postoperatorio de 76,2 (DE: 83,4) mL. El 74% de los pacientes sangraron durante las primeras 24 horas y el 52% lo hicieron hasta las 48 horas. Requirieron transfusión sanguínea perioperatoria 68 pacientes. Conclusión: El sangrado postoperatorio de los pacientes con fractura pertrocantérica de fémur es bajo. Tan solo unos pocos pacientes se beneficiarían del uso de drenajes, por lo que cabría evaluar el riesgo-beneficio de no utilizarlos (AU)

Objective: To evaluate the blood loss intraoperatively and through the drainages during the postoperative procedure of pertrochanteric femoral fractures, in order to know when is appropriated time to take them out. Patients and methods: A descriptive, longitudinal and unicenter study of a prospective and consecutive cohort of patients with pertrochanteric femoral fracture treated with a Dynamic Hip Screw. 100 patients were included, with a mean age 86 (DE: 8) years old; 74% were women. Deep drainages were inserted in 96 and superficial drainages in 17 cases. The principal outcome was the blood loss collected through the drainages during the first three hours of the postoperative, at 24 hours and at 48 hours. Results: The mean intraoperative blood loss was 278.1 (SD: 148.2) mL, and the mean blood loss through the drainages during the postoperative period was 76,2 (SD: 83.4) mL. Within the first postoperative 24 hours, 74% of the patients had blood losses whereas 52% did so within 48 hours. Sixty eight patients required blood transfusion. Conclusion: The main postoperative blood loss in the pertrochanteric fracture is small. A few patients can take benefit of drainages, therefore if we not use them, it would be advisable to perform a risk-benefit analysis (AU)

Síndrome de Maroteaux-Lamy en un niño de 10 años / Maroteaux-Lamy’ Syndrom in a 10 years old child

No disponible

Fracturas diafisarias del fémur en el niño: actualización en el tratamiento / Diaphyseal femur fractures in children. Treatment update

El tratamiento de las fracturas de la diáfisis del fémur en el niño, está sometido a una gran controversia, debido a que los procedimientos que se emplean en los adultos no son aplicables durante el período de crecimiento. No obstante, parece que existe un cierto consenso en que el método que elijamos debe ir encaminado a acortar el tiempo de estancia hospitalaria, que sea confortable para el paciente, que proporcione una adecuada estabilidad a la fractura y origine en menor número de complicaciones y secuelas. Parece existir cierta unanimidad en que en menores de 5 años los métodos conservadores (arnés de Pavlik, yeso precoz,...) son los métodos de elección salvo en situaciones complejas. Es a partir de los 6 años y hasta los 13 años, el período en el cual la indicación de un método u otro puede estar más en discusión, si bien hoy en día el enclavado intramedular elástico es el método de predilección por parte de la mayoría de los autores, sobre todo para fracturas transversales y que asientan en el tercio medio, excepto en casos de gran inestabilidad. En estas situaciones de fracturas conminutas o con trazos oblícuos, la fijación externa monolateral, los clavos rígidos introducidos desde la región trocantérica y las placas atornilladas percutáneas submuscular pueden ser una buena opción. En la actualidad no existe un método que pueda aplicarse a la totalidad de los diferentes tipos de fractura. La opción terapéutica elegida deberá basarse en la estabilidad clínica del paciente, características de la fractura, diámetro de la cavidad medular y peso del paciente (AU)

The treatment of diaphyseal femur fractures in children is a subject of great controversy due to the procedures employed in adults not being applicable during the growth period. However, there appears to be some consensus in that the method we choose must lead to shortening the hospital stay, is comfortable for the patient, provides suitable stability to the fracture and has less complications and after effects. There is some unanimity in that the methods of choice should be conservative in children less than 5 years-old (Pavlik harness, early cast), except in complex situations. It is from 6 years to 13 years, the period in which one method or the other that should be discussed more. Nowadays, elastic intramedullary nailing is the method preferred by many authors, particularly for transverse fractures and those located in the middle third, except in cases of great instability. In these situations of comminuted or oblique fractures with monolateral external fixation, the rigid nails introduced from the trochanteric region and percutaneous plating can be a good option. There is currently no method that could be applied to all the different types of fracture. The chosen therapeutic option should be based on the clinical stability of the patient, the characteristics of the fracture, diameter of the medullary cavity and weight of the patient (AU)