Bernardo Barcellos Terra

Clinical Considerations for the Surgical Treatment of Pectoralis Major Muscle Ruptures Based on 60 Cases A Prospective Study and Literature Review

Background: Early recognition of the clinical signs of ruptures of the pectoralis major muscle (PMM) in athletes by orthopaedic surgeons, physical therapists, and physical trainers may prove to be critical for patient access to surgical treatment while the injury is still in the acute phase. Hypothesis: Total ruptures of the PMM may yield a better outcome with surgical treatment than with nonoperative treatment in athletes. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective study was performed on 60 patients with total ruptures of the PMM. The patients were followed from 1997 to 2012, with a physical examination every 6 months for the first 2 years and every 12 months thereafter. The patients’ mean age was 31.21 years, and the mean length of follow-up was 48.25 months. The surgical treatment methods included reinsertion of the tendon in 51% of the patients and nonoperative treatment in 49% of the patients. All of the patients were evaluated using the Bak criteria. Results: The bench-press exercise was associated with 80% of the PMM ruptures (48 patients). Forty-one of the patients with chronic ruptures were seen after 3 months (80%). The outcomes were poor in 9 patients from the nonoperative group (31%) and in 3 patients from the surgical group (9.7%); the outcomes were fair in 12 patients from the nonoperative group and in no patients from the surgical group. Excellent results were not observed in any patient from the nonoperative group and were observed in 21 patients from the surgical group (67.7%). The isokinetic evaluation at 60 deg/s showed a decrease in strength of 41.7% in the nonsurgical group and 14.3% for the surgical group, which was significant at P < .05. Conclusion: Total ruptures of the PMM exhibit better outcomes with surgical treatment than with nonoperative treatment based on the Bak criteria in athletes.

Anatomic study of the coracoid process: safety margin and practical implications.

PURPOSE The aim of this study was to define a safety margin for coracoid process osteotomy that does not compromise the coracoclavicular ligaments and that can be used in the coracoid transfer procedures. METHODS Thirty shoulders from 15 cadavers were dissected, exposing the coracoid process and attached anatomic structures. The distance of the insertion of these structures to the coracoid process apex was measured. RESULTS The average length of the coracoid process was 4.26 ± 0.26 cm. The average width and height at the tip were 2.11 ± 0.2 and 1.49 ± 0.12 cm, respectively. The average distance from the tip to the anterior and posterior margin of the pectoralis minor was 0.1 ± 1.17 and 1.59 ± 0.27 cm, respectively. The average distance from the tip to the posterior margin of the coracoacromial ligament was 2.79 ± 0.33 cm. The average distance from the apex to the most anterior part of the trapezoid ligament was 3.33 ± 0.38 cm. We obtained a constant value of 0.85 cm for this measure, and the value increased with each 1.0-cm increase in the distance from the tip to the posterior margin of the pectoralis minor. The safety margin for osteotomy (i.e., available bone distance for the coracoid process transfer) was 2.64 cm. CONCLUSIONS This study established a safety margin of 2.64 cm for the osteotomy of the coracoid process and its relation with the posterior margin of the pectoralis minor. The anatomic descriptions of bone and soft tissue, as well as a measure of correlation for the safety margin of the coracoid, provide tools for surgeons performing anatomic surgical procedures to correct glenohumeral instability with significant bone loss. CLINICAL RELEVANCE Knowing the safety margin allows the surgeon to perform a safe osteotomy without direct visualization of the coracoclavicular ligaments attachments, thereby making procedures more anatomic.

Evolução etária do ângulo de carregamento do cotovelo: estudo clínico-radiográfico

Objective: This paper has the purpose of evaluate the elbow carrying angle by clinic and radiographic examination in normal children and determine the range of normality according to age from childhood to skeletal maturity and also check if there is a statistically significant difference between the clinical and radiographic measurements. Methods: We evaluated 510 persons with ages varying from 1 to 18 years distributed in groups with 30 subjects according to the age group with 1-year interval. We performed radiographic examination of the elbow and measured the angle formed by the long axis of the humerus and ulna. The data were statistically analyzed using the student t-test. Results: We determined a normal curve of the study population where there was an increase of this parameter with the progression of age. No statistically significant difference between the clinical and radiographic measures. Conclusion: The average of the elbow carrying angle was 12,78 ± 5,35 degrees for females and 11,20 ± 4,45 degrees for males. This values increase progressively from childhood until 16 years when we notice stabilization. There was no statistical difference between the clinical and radiographic measurements.

Subacromial bursitis related to HIV infection: case report.

OBJECTIVE Describe a subacromial bursitis at the right shoulder of a 45-year-old male subject. The patient has been living with HIV/AIDS for 22 years. METHODS The ultrasonography and the MRI revealed the presence of a pronounced subacromial effusion, with an inflammatory reaction of adjacent tissues. The tumoration was handled firstly with a needle-puncture aspiration, with a thick liquid outflow, followed by an open drainage. Histopathological evaluation showed no evidence of any AIDS defining disease. There was complete remission of the infection after five months thereafter the symptoms had started. CONCLUSION After reviewing the scarce literature in the area, no reports of subacromial bursitis in HIV/AIDS patients were found. The authors point out that, although rare, this disease should be considered as differential diagnosis of shoulder diseases in HIV-infected subjects.

The pectoralis major footprint: An anatomical study

Objective To study the insertion of the pectoralis major tendon to the humerus, through knowledge of its dimensions in the coronal and sagittal planes. Methods Twenty shoulders from 10 cadavers were dissected and the pectoralis major tendon insertion on the humerus was identified and isolated. The dimensions of its “footprint” (proximal to distal and medial to lateral borders) and the distance from the top edge of the pectoralis major tendon to apex of the humeral head structures were measured. Results The average proximal to distal border length was 80.8 mm (range: 70–90) and the medial-to-lateral border length was 6.1 mm (5–7). The average distance (and range) from the apex of the pectoralis major tendon to the humeral head was 59.3 mm. Conclusions We demonstrate that the insertion of the pectoralis major tendon is laminar, and the pectoralis major tendon has an average footprint height and width of 80.8 mm and 6.1 mm, respectively.

Child abuse: review of the literature

Non-accidental injuries in children are an important cause of morbidity and mortality in this population. Fractures are the second most common clinical manifestation of child abuse. The fracture of the femur is associated in more than 60% of child abuse in children younger than 3 years. The objective was to review the literature on child abuse in the major databases and report a rare case of bilateral subtrochanteric femur fractures associated with unilaterall humeral fracture in a 28-day newborn. The orthopedic surgeon is often the first physician to evaluate these children, so a high degree of suspicion, and a physical examination and a detailed clinical history is mandatory when evaluating a newborn with musculoskeletal injuries.

Osteotomias do processo coracoide: um estudo anatômico

AbSTRACT Objective: Relate the main tendinous and ligamentous structures attached in the coracoid process, correlating it to several levels of osteotomy and describing the involved structures. Methods: Thirty shoulders were dissected. The coracoid process with mainly inserted anatomic structures was dissected, and five levels of osteotomy (1.0; 1.5; 2.0; 2.5; 3.0 cm) were made from the apex of the process and the mainly involved structures were recorded. Results: In osteotomies of 1.0 cm, in 100% of the cases only the conjoint tendon (CT). In osteotomies of 1.5 cm there were 63.33% of cases involved with the CT and the Pectoralis minor (PMi), in 20% of cases only the CT, and in 16.66% the CT, PMi, and the coracohumeral ligament (CUL). In osteotomies of 2.0 cm, in 80% of the shoulders, the osteotomies embraced the CT, PMi and the CUL, and in 20% only the CT and the PMi were involved. In the osteotomies of 2.5cm there was involvement of the CT, PMi and CUL in 100% of cases. In the osteotomies of 3.0cm, six cases (20%) have presented an injury on the trapezoid ligament, and in 100% of these osteotomies, the osteotomized distal fragment had embraced the CT, PMi, CUL. Conclusion: The knowledge of anatomic structures inserted and involved in the osteotomies cuts of the coracoid process is very importan to lead with osteotomies performed in the treatment techniques of the coracoid process. Osteotomies of 3.0 cm can injure the trapezoid ligament.

Radial head fracture associated with posterior interosseous nerve injury.

Fractures of the radial head and radial neck correspond to 1.7–5.4% of all fractures and approximately 30% may present associated injuries. In the literature, there are few reports of radial head fracture with posterior interosseous nerve injury. This study aimed to report a case of radial head fracture associated with posterior interosseous nerve injury. Case report A male patient, aged 42 years, sought medical care after falling from a skateboard. The patient related pain and limitation of movement in the right elbow and difficulty to extend the fingers of the right hand. During physical examination, thumb and fingers extension deficit was observed. The wrist extension showed a slight radial deviation. After imaging, it became evident that the patient had a fracture of the radial head that was classified as grade III in the Mason classification. The patient underwent fracture fixation; at the first postoperative day, thumb and fingers extension was observed. Although rare, posterior interosseous nerve branch injury may be associated with radial head fractures. In the present case, the authors believe that neuropraxia occurred as a result of the fracture hematoma and edema.

Arthroscopic treatment for chronic lateral epicondylitis

Objective To report the clinical and functional results from arthroscopic release of the short radial extensor of the carpus (SREC) in patients with chronic lateral epicondylitis that was refractory to conservative treatment. Methods Over the period from January 2012 to November 2013, 15 patients underwent arthroscopic treatment. The surgical technique used was the one described by Romeo and Cohen, based on anatomical studies on cadavers. The inclusion criteria were that the patients needed to present lateral epicondylitis and that conservative treatment (analgesics, anti-inflammatory agents, corticoid infiltration or physiotherapy) had failed over a period of more than six months. The patients were evaluated based on the elbow functional score of the Mayo Clinic, Nirschls staging system and a visual analog scale (VAS) for pain. Results A total of 15 patients (9 men and 6 women) were included. The mean Mayo elbow functional score after the operation was 95 (ranging from 90 to 100). The pain VAS improved from a mean of 9.2 before the operation to 0.64 after the operation. On Nirschls scale, the patients presented an improvement from a mean of 6.5 before the operation to approximately one. There were significant differences from before to after the surgery for the three functional scores used (p < 0.01). No correlations were observed using the Spearman test between the results and age, gender, length of time with symptoms before the operation or injury mechanism (p > 0.05). Conclusion Arthroscopic treatment for lateral epicondylitis was shown to be a safe and effective therapeutic option when appropriately indicated and performed, in refractory cases of chronic lateral epicondylitis. It also allowed excellent viewing of the joint space for diagnosing and treating associated pathological conditions, with a minimally invasive procedure.

Acromioclavicular dislocation: treatment and rehabilitation. Current perspectives and trends among Brazilian orthopedists.

Objective To evaluate the approaches and procedures used by Brazilian orthopedic surgeons in treatment and rehabilitation of acromioclavicular dislocation of the shoulder. Methods A questionnaire comprising eight closed questions that addressed topics relating to treatment and rehabilitation of acromioclavicular dislocation was applied to Brazilian orthopedic surgeons over the three days of the 45th Brazilian Congress of Orthopedics and Traumatology, in 2013. Results A total of 122 surgeons completely filled out the questionnaire and formed part of the sample analyzed. Most of them came from the southeastern region of the country. In this sample, 67% of the participants would choose surgical treatment for patients with grade 3 acromioclavicular dislocation. Regarding the preferred technique for surgical treatment of acute acromioclavicular dislocation, a majority of the surgeons used subcoracoid ligature with acromioclavicular fixation and transfer of the coracoacromial ligament (25.4%). Regarding complications found after surgery had been performed, 43.4% and 32.8% of the participants, respectively, stated that residual deformity of the operated joint and pain were the complications most seen during the postoperative period. Conclusions Although there was no consensus regarding the treatment and rehabilitation of acromioclavicular dislocation, evolution had occurred in some of the topics analyzed in this questionnaire applied to Brazilian orthopedists. However, further controlled prospective studies are needed in order to evaluate the clinical and scientific benefit of these trends.