Ricardo Kaempf de Oliveira

Fratura simultânea bilateral do colo do fêmur

Fratura simultânea bilateral do colo do femur e uma patologia rara e geralmente esta relacionada a doencas metabolicas ou outras patologias previas. Esse tipo de fratura pode passar despercebida, piorando o prognostico desses pacientes. Neste relato, os autores apresentam o caso de um paciente do sexo masculino de 27 anos de idade com fratura simultânea bilateral do colo do femur apos um episodio de convulsao. Serao discutidos aspectos sobre o mecanismo do trauma, os tipos de tratamento e a dificuldade no diagnostico nesse tipo de fratura.

Biplanar carpal wedge osteotomy in the treatment of the arthrogrypotic patients

Objective To describe the results of the surgical treatment of patients with congenital arthrogryposis with wrist deformity through biplanar carpal wedge osteotomy. Method This study analyzed nine patients through a retrospective evaluation with severe deformity in flexion and ulnar deviation of the wrist in the period between January 2004 and December 2009. They were submitted to carpal osteotomy with a biplanar dorsal resection wedge, with a minimum evaluation of 48 months of postoperative evolution. In three patients the osteotomy was bilateral, totalling 12 cuffs analyzed. The indication for the technique described was deformity and stiffness for over six months, without improvement with the conservative treatment. Results The mean age of the patients on the day of surgery was five years and eight months. The initial mean wrist mobility was 35°, and the joints presented a mean flexion of 72.5° in a resting position. Osteotomy union occurred in all patients at an average period of 5.7 weeks. The final position of the resting wrist was 12° of flexion and the mean mobility was 26.6°, slightly lower than preoperatively but in a much better position. No serious complications arising from surgery or in the immediate postoperative period were observed. Conclusions Carpal osteotomy with biplanar dorsal resection wedge was useful and effective in helping to correct the deformities in flexion and ulnar deviation of the wrist, maintaining a reasonable mobility. It is a preservation surgery, which has low morbidity and avoids the progression of deformity and future degenerative changes.

Lunate Grafting Into the Radius for Lunate Fossa Reconstruction in Madelung Deformity

A 40-year-old woman presented with Madelung deformity and severe arthritic changes at both the radiocarpal and the distal radioulnar joints. She was treated by using her lunate as an osteochondral graft into the radius allowing reconstruction of the lunate fossa. The scaphoid and triquetrum were removed concomitantly and a Sauve-Kapandji procedure was performed. Complete bone healing was achieved. Ten years later, an excellent functional result was maintained, with a pain-free wrist, an acceptable wrist joint range of motion, as well as a favorable aesthetic appearance. This procedure may be indicated for patients with severe Madelung deformity with painful radiocarpal and distal radioulnar joints associated with severe arthritis changes.

Fat Grafting for Esthetic Correction of the Muscle Atrophy Secondary to Ulnar Nerve Lesion

Patients with hand muscular atrophy due to damage of the ulnar nerve could be stigmatized for their appearance. Unsatisfactory results in the attempt to correct the atrophy are reported in the literature. Fat grafting is an autologous and easily obtainable graft, antigenic response is very unlikely, it does not require any special material, and the procedure has a low cost. The technique of autologous fat grafting by using fat block, to remodel the first interdigital space, is useful and safe in correcting muscle atrophy of the first interdigital space caused by the injury of the ulnar nerve. This technique is suitable for muscular atrophy caused by injury of the ulnar nerve and nerve compression as well as patients present with esthetic complaints. Fifteen cases were operated using this technique. After the surgery, the resorption of the graft ranged between 12.5% and 66.7%, averaging 28%. Patients were able to check the benefit provided by filling of the atrophied area, which allowed a serene return to their daily life activities, living with others, reducing the need to hide their hands, and even facilitating their reintegration into the labor market.

The Zitelli Bilobed Flap on Skin Coverage After Mucous Cyst Excision: A Retrospective Cohort of 33 Cases

PURPOSE To study the time to wound healing and recurrence rate achieved in the treatment of distal interphalangeal joint mucous cysts using the Zitelli modified bilobed flap. METHODS We surgically treated 33 patients from January 2006 to June 2015. We assessed demographic data, comorbidities, location and size of the cyst, time to wound healing, and complications. RESULTS The most affected finger was the right middle finger. All flaps survived and wounds healed in 14 days on average. The mucous cyst recurred in 1 of 33 cases. There were no major complications. CONCLUSIONS The Zitelli bilobed flap can provide good-quality skin coverage over the distal interphalangeal joint in a short period. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Pediatric Trigger Finger due to Osteochondroma: A Report of Two Cases

Background: The trigger finger is characterized by the painful blocking of finger flexor tendons of the hand, while crossing the A1 pulley. It is a rare disease in children and, when present, is usually located in the thumb, and does not have any defined cause. Methods: We report 2 pediatric trigger finger cases affecting the long digits of the hand that were caused by an osteochondroma located at the proximal phalanx. Both children held the diagnosis of juvenile multiple osteochondromatosis. They had presented at the initial visit with a painful finger blocking. Surgical approach was decided with wide regional exposure, as compared with the trigger finger traditional surgical techniques, with the opening of the A1 pulley and the initial portion of the A2 pulley, along with bone tumor resection. Results: Patients evolved uneventfully, and recovered the affected finger motion. Conclusion: It is important to highlight that pediatric trigger finger is a distinct ailment from the adult trigger finger, and also in children is important to differentiate whenever the disease either affects the thumb or the long fingers. A secondary cause shall be sought whenever the long fingers are affected by a trigger finger.

Factitious lesions of the hand

Objective The presence of a lesion with atypical presentation, obscure clinical history, which does not improve with classic treatments, shall raise the red flag of the medical team. In such cases, the hypothesis of a factitious lesion shall be considered. Many times the correct diagnosis on the initial assessment may avoid high-cost diagnostic tests, unnecessary treatments, and time consumption of the medical team. We present here two classic cases of factitious lesions that, similar to those described in the literature, is difficult to diagnose and difficult to treat.

OSTEOTOMY OF THE DISTAL RADIUS USING A FIXED-ANGLE VOLAR PLATE.

Objective: Skewed consolidation of the distal radius, due to sequelae of fractures, may cause functional incapacity, thus leading such patients to present pain, loss of strength and diminished mobility. Based on the excellent results obtained from surgical treatment of unstable fractures of the distal radius through a volar approach and use of rigid fixation with a fixed-angle volar plate, we started to use the same method for osteotomy of the distal radius. Methods: A retrospective review was conducted, and 20 patients treated between February 2002 and October 2009 were found. The mean length of follow-up was 43.9 months (range: 12 to 96 months). The surgical indications were persistent pain, deformity and functional limitation subsequent to a dorsally displaced fracture. Results: The mean preoperative deformity was 27° of dorsal tilt of the distal radius, 87° of ulnar tilt, and 7.3 mm of shortening of the radius. All the osteotomies consolidated and the final mean volar tilt was 6.2°, with ulnar tilt of 69.3° and shortening of 1 mm. The mean mobility of the wrist increased by 19.9° (flexion) and by 24° (extension). Mean forearm supination increased by 23.5° and pronation by 21.7°. Grip strength increased from 13.4 to 34.5 pounds. Conclusion: Use of a fixed-angle volar plate for a volar approach towards osteotomy of the distal radius enables satisfactory correction of the deformities and eliminates the need for removal of the synthesis material caused by tendon complications

Osteotomias do rádio distal com uso de placa volar de ângulo fixo

OBJETIVO: A consolidacao viciosa do radio distal, por sequela de fratura, pode causar incapacidade funcional, levando o paciente a apresentar dor, perda de forca e diminuicao da mobilidade. Baseando-se nos excelentes resultados obtidos com o tratamento cirurgico das fraturas instaveis do radio distal com a utilizacao de abordagem volar e o uso de fixacao rigida com a placa volar de ângulo fixo, comecamos a utilizar o mesmo metodo para as osteotomias do radio distal. METODO: Foi realizada uma revisao retrospectiva e encontrou-se 20 pacientes, no periodo de fevereiro de 2002 a outubro 2009. O tempo de acompanhamento medio foi de 43,9 meses (variando de 12-96 meses). A indicacao cirurgica foi de dor persistente, deformidade e limitacao funcional apos fratura de deslocamento dorsal. RESULTADOS: A deformidade media pre-operatoria foi de 27o de inclinacao dorsal do radio distal, 87o de angulacao ulnar e 7,3 milimetros de encurtamento do radio. Todas as osteotomias consolidaram e a media final de angulacao volar do radio distal foi de 6,2o, com 69,3o de angulacao ulnar e um milimetro de encurtamento. A mobilidade media do punho aumentou em 19,9o na flexao e em 24o na extensao. No antebraco, a supinacao media aumentou em 23,5o e em 21,7o na pronacao. A forca do punho aumentou de 13,4 para 34,5 libras. CONCLUSAO: O uso da placa volar de ângulo fixo por abordagem volar para as osteotomias do radio distal permite uma correcao satisfatoria das deformidades e elimina a necessidade de remocao do material de sintese por complicacoes nos tendoes.