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INTRODUCTION: The main innervation of the trapezius muscle is provided by the spinal accessory nerve. Several studies describe the contributions of cervical plexus roots to the trapezius muscle innervation, either directly or through connections with the spinal accessory nerve. There is no adequate understanding of how the trapezius muscle is affected after using the spinal accessory nerve in nerve transfer procedures with the usual technique, preserving at least 1 branch for the upper trapezius. METHODS: We evaluated 20 patients with sequelae of traumatic brachial plexus injury who underwent surgical procedures for brachial plexus repair or free muscle transfer, which included the spinal accessory nerve transfer technique and were followed for a minimum of 1 year. The three portions trapezius muscle were evaluated by physical examination, magnetic resonance imaging (analysis of fatty degeneration) and electromyography. RESULTS: In all evaluation methods, the middle and lower portions of the trapezius muscle showed more significant morphological and/or functional impairment than the upper portion, in most cases. There was a statistically significant difference in all the complementary exams results, between the affected side (with sacrifice of the nerve) versus the normal side, in the middle and lower portions of the trapezius muscle. CONCLUSIONS: Physical examination alone is not sufficient to determine the residual functionality of the trapezius muscle. Magnetic resonance imaging and electromyography are useful tools to assess both morphological involvement of the trapezius muscle and nerve conduction impairment of the trapezius muscle, respectively. The results suggest that the middle and lower portions of the trapezius muscle are affected by previous SAN transfer and should be considered with caution for further muscle transfer procedures.

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OBJECTIVE: To investigate, through magnetic resonance imaging, the occurrence of fatty degeneration of the trapezius in adult patients undergoing nerve transfer procedure, using the spinal accessory nerve. METHODS: A total of 13 patients meeting the criteria of unilateral brachial plexus injury and more than one year of postoperative care after nerve transfer surgery underwent an MRI scan of the trapezius. A T1-weighted 3D sequence was used, with the IDEAL technique using 8.0 mm cut thickness, 8.0 mm cut spacing, TR of 100 ms, TE of 3.45 ms, flip angle of 10 degrees, 20 cuts, on the sagittal plane. The images of the upper, transverse and lower parts of the trapezius muscle were then classified according to the degree of fatty degeneration, compared with the contralateral side, using the Goutallier score. RESULTS: For the upper trapezius there was a change of the degeneration state in 23% (p = 0.083), for the transverse section there was a change in 84.6% (p = 0.003), for the lower one there was a change in 92.3% (p = 0.002). CONCLUSION: The upper trapezius did not undergo significant degeneration after transfer. The lower and transverse trapezius suffered fatty degeneration in most patients, indicating severe functional impairment. Level of Evidence IV, Case series.

OBJETIVO: Através de imagens de ressonância magnética, investigar a ocorrência de degeneração gordurosa no músculo trapézio em pacientes adultos submetidos a procedimento de transferência de nervo envolvendo o nervo espinal acessório. MÉTODOS: 13 pacientes com lesão do plexo braquial unilateral e mais de um ano de cirurgia de transferência de nervo utilizando o nervo espinal acessório foram submetidos a exame de ressonância magnética do músculo trapézio. Foi obtida uma sequência 3D ponderada em T1, com a técnica IDEAL, espessura de corte de 8,0 mm, espaçamento entre os cortes de 8,0 mm, TR de 100 ms, TE de 3,45 ms, flip angle de 10 graus e 20 cortes, no plano sagital. As imagens das porções superior, transversa e inferior do músculo trapézio foram classificadas de acordo com o grau de degeneração gordurosa e comparadas com o lado contralateral, utilizando o score de Goutallier. RESULTADOS: Para o trapézio superior houve mudança no estado de degeneração em 23% (p = 0,083), para o trapézio transverso houve mudança em 84,6% (p = 0,003), e para o trapézio inferior houve mudança em 92,3% (p = 0,002). CONCLUSÃO: O trapézio superior não sofreu degeneração significativa após transferência. Os trapézios inferiores e médios sofreram degeneração gordurosa na maioria dos pacientes, indicando comprometimento funcional severo. Nível de Evidência IV, Série de casos .

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OBJECTIVES: Retrospective evaluation of cases of limb replantation after avulsion injuries. Evaluation of the techniques and tactics used, that contributed to success and good functional results. METHODS: Forty-three patients' records were assessed. All the cases had been submitted to limb replantation after avulsion injuries. RESULTS: The majority of the cases were young men. The most common injury was to the thumbs. The surgical techniques and tactics used were: nerve grafting, vein grafting, transposition of the digital vessels, limb shortening, and heterotopic replantation. The most commonly used technique was vein graft. The limb survival rate was high (93%), as was patient satisfaction. CONCLUSION: Replantation after avulsion injury depends on the correct diagnosis of the limb viability and the use of appropriate surgical techniques and tactics for each case. The experience of the team of surgeons and a good hospital structure are essential for good results. There are few articles in medical literature about the indications, techniques and results of limb replantation after avulsion injuries. We believe that this retrospective evaluation can bring new information and contributions to the correct management of this highly complex situation. Level of evidence IV, Case Series.

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OBJETIVOS: Avaliação retrospectiva criteriosa de casos de reimplantes após amputação por avulsão. Avaliação de técnicas e táticas utilizadas que determinaram evolução satisfatória e bom resultado funcional. METÓDOS: Foram avaliados, retrospectivamente, prontuários de 43 pacientes que tiveram membros amputados por mecanismo de avulsão e reimplantados nos últimos 21 anos. RESULTADOS: A maior parte dos casos envolvia homens adultos jovens. A localização de amputação mais frequente foi do polegar. As técnicas e táticas cirúrgicas utilizadas isoladas ou conjuntamente incluem: enxertos de nervo, enxertos vasculares (veia ou artéria), transposição de feixe vascular digital, encurtamento do membro e reimplante heterotópico. A técnica mais frequentemente utilizada foi o emprego de enxertos venosos. A taxa de sobrevida dos reimplantes foi alta (93%), assim como a satisfação dos pacientes. CONCLUSÃO: Os reimplantes por mecanismo de avulsão dependem do correto diagnóstico de viabilidade anatômica e utilização de técnicas e táticas cirúrgicas apropriadas para cada caso. A experiência da equipe cirúrgica e estrutura hospitalar adequada são fundamentais para obtenção de bons resultados. Existem poucos relatos na literatura sobre indicação, tática, técnicas e resultados de procedimentos de reimplantes em amputações por avulsão. Acreditamos que a avaliação retrospectiva desta série de casos possa trazer novas informações e contribuições no atendimento desta situação de alta complexidade. Nível de evidência IV, Série de casos.

OBJECTIVES: Retrospective evaluation of cases of limb replantation after avulsion injuries. Evaluation of the techniques and tactics used, that contributed to success and good functional results. METHODS: Forty-three patients' records were assessed. All the cases had been submitted to limb replantation after avulsion injuries. RESULTS: The majority of the cases were young men. The most common injury was to the thumbs. The surgical techniques and tactics used were: nerve grafting, vein grafting, transposition of the digital vessels, limb shortening, and heterotopic replantation. The most commonly used technique was vein graft. The limb survival rate was high (93%), as was patient satisfaction. CONCLUSION: Replantation after avulsion injury depends on the correct diagnosis of the limb viability and the use of appropriate surgical techniques and tactics for each case. The experience of the team of surgeons and a good hospital structure are essential for good results. There are few articles in medical literature about the indications, techniques and results of limb replantation after avulsion injuries. We believe that this retrospective evaluation can bring new information and contributions to the correct management of this highly complex situation. Level of evidence IV, Case Series.

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As fraturas distais do rádio são as mais freqüentes do membro superior. São classificadas em estáveis e instáveis. As instáveis requerem tratamento cirúrgico. Não está definido na literatura qual o melhor método de fixação, mas existe atualmente uma tendência à utilização das placas com parafusos bloqueados. Um dos aspectos técnicos importantes é o posicionamento dos parafusos distais junto ao osso subcondral, proporcionando suporte mais adequado. A avaliação da localização desses parafusos é feita com radioscopia e radiografias, mas freqüentemente existem dúvidas quanto ao correto posicionamento. Os objetivos deste estudo são: avaliar se é possível determinar com precisão por meio de radiografias, a localização dos parafusos distais no rádio e se a experiência do avaliadorinfluencia nesta análise. Foram utilizados punhos de cadáveres. Cada rádio recebeu três parafusos junto à superfície articular distal. Por meio de incidências radiográficas clássicas e anguladas, médicos especialistas e não-especialistas em cirurgia da mão avaliaram a posição de cada parafuso, se intra ou extra-articular. Os índices de acerto foram submetidos à análise estatística.As radiografias provaram ainda ser um bom método de avaliação, não havendo melhora da precisão na localização dos parafusos com as incidências anguladas. A experiência profissional do avaliador não teve influência nos resultados.

The distal radius fractures are the most common fractures on upper limbs. They are classified as stable and unstable. The unstable ones require surgical treatment. However, literature does not define the best fixation method, but, today, a trend is seen towards using the locked screw plate. An important technical aspect is the distal screws positioning in the subchondral bone, with an adequate support. Fluoroscopy and radiographs are used to evaluate screws position, but there are usually doubts about the accurate positioning. The objectives of this study are to evaluate if it is possible to determine precisely the screw positioning by means of radiographs and if the previous experience of the investigator may improve the results. Cadavers' fists were used in this study. Three screws were introduced to each radius next to the distal joint surface. Specialized hand surgeons and not specialized physicians evaluated the X-ray images, at classic and angled planes, to provide the accurate positioning of each screw, intra or extra joint. The accuracy rate was submitted to statistical analysis. The X-ray images were proven to be a good evaluation method. The X-ray images captured at angled plane resulted in no improvements in the analysis of the screws positioning. Neither did the evaluator experience influence the results.

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OBJETIVO: A isquemia prolongada leva a alterações na microcirculação tecidual e liberação de radicais livres do oxigênio conhecidas como fenômeno de não reperfusão. Foi testado um modelo experimental de reimplante de membro após isquemia quente e os efeitos do fármaco alopurinol e da terapia com oxigênio hiperbárico. MÉTODO: Foram realizadas amputações com preservação dos vasos e nervos dos membros posteriores direitos em 95 ratos. Os grupos modelos M1, M2, M3, M4 e M5 foram submetidos à isquemia quente de 0, 2, 4, 6 e 8 horas. As taxas de viabilidade dos membros isquêmicos após sete dias de avaliação foram 100 por cento, 80 por cento, 63,6 por cento, 50 por cento e 20 por cento. Os grupos experimentais E1 e E2 foram tratados, respectivamente, com alopurinol e terapia com oxigênio hiperbárico após isquemia de 6 horas. As taxas de viabilidade foram 70 por cento e 30 por cento. Os resultados foram analisados estatisticamente pelo teste do Qui-quadrado. RESULTADOS: Os grupos M1, M2, M3, M4 e M5 foram estatisticamente diferentes entre si exceto os grupos M3 e M4. E1 resultou em uma viabilidade de membros maior que M4 e E2 resultou em uma viabilidade de membros menor que M4(resultados estatisticamente significantes). CONCLUSÕES: Os resultados sugerem que a administração do alopurinol após isquemia do membro por 6 horas aumenta a taxa de viabilidade dos membros isquêmicos, e a terapia com oxigênio hiperbárico diminuiu a viabilidade dos membros isquêmicos.

BACKGROUND: Prolonged ischemia leads to alterations in tissue microcirculation and oxygen free radicals production. This event is called no reflow phenomenon and its management is a challenge to the surgeon dealing with replantation. It was tested a replantation model after warm ischemia in rats and the effectiveness of allopurinol and hyperbaric oxigen therapy. METHODS: Amputation with preservation of vessels and nerves of the right hind limb was proceeded in 95 rats. The groups M1, M2, M3, M4 and M5 were submitted to 0, 2, 4, 6 and 8 hours of ischemia. The limbs were observed for seven days and the survival limb rates in each group were 100 percent, 80 percent, 63,6 percent, 50 percent and 20 percent respectively. M4 was elected control for experimental groups. The groups E1 and E2 were submitted to 6 hours of ischemia and were treated with allopurinol and hyperbaric oxigen therapy. The survival limb rates were 70 percent and 30 percent respectively. RESULTS: M1, M2, M3, M4 and M5 were statistically different except for M3 and M4. E1 had a better limb survival than M4. E2 had a worse limb survival than M4. CONCLUSION: Our results suggest that the administration of allopurinol may be helpful to improve limb salvage after ischemia and hyperbaric oxigen therapy may not be helpful and even can be harmful to ischemic limbs.

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In children, chylothorax occurs mainly after cardiac and thoracic surgeries. One of the recommended postsurgery treatments is ligation of the thoracic tract, when all other conservative treatments have failed. We report 4 cases of chylothorax in patients who were successfully treated with this approach, which resulted in a decrease in pleural drainage without recurrent chylothorax.

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In children, chylothorax occurs mainly after cardiac and thoracic surgeries. One of the recommended postsurgery treatments is ligation of the thoracic tract, when all other conservative treatments have failed. We report 4 cases of chylothorax in patients who were successfully treated with this approach, which resulted in a decrease in pleural drainage without recurrent chylothorax

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A isquemia prolongada leva a alteracoes na microcirculacao tecidual e liberacao de radicais livres do oxigenio conhecidos como...

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