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Scaphoid fractures represent 5-10% of nonunion rate and the treatment options consist of an open reduction with correction of deformity, restoration of the scaphoid length with autologous wedge grafting and fixation. However, there is still no consensus in the literature on the best fixation method. Therefore, the purpose of the study is to compare plate fixation and screw fixation in treating scaphoid nonunion with humpback deformity and carpal instability.Prospective, non-randomised study comparing the treatment of two groups of patients with scaphoid nonunion. A total of 19 patients were included in the study, the first ten patients were included in group 1 (plate fixation), subsequently nine patients were included in group 2 (screw fixation). The nonunion duration was longer than 6 months and patients did not present type III Scaphoid Nonunion Advanced Collapse (SNAC). Clinical evaluations included pain intensity, range of motion, grip strength, pinch test and functional scales Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Wrist Score. Radiographic evaluations consisted of radiographs of both wrists in AP, AP with ulnar deviation, lateral and oblique views. Patients further underwent a tomography of the affected wrist for bone deformity, carpal collapse and later consolidation evaluation.According to post-operative measurements, group 1 showed a significant improvement in the scapholunate angle (p = 0.011) and in the intrascaphoid angle (p = 0.002). Group 2 only showed an improvement in the scapholunate angle (p = 0.011). All patients in group 1 achieved consolidation in 8 weeks, while group 2 patients had a slower consolidation, with a mean of 14 weeks and standard deviation (SD) of 4.2, with statistical significance (p = 0.006).Our prospective study, despite the limitations, contributes to the literature for demonstrating a better fixation using plate, with a better correction of humpback deformity and Dorsal Intercalated Segment Instability (DISI) and a faster consolidation.II, therapeutics studies; prospective comparative study.

ResumoA transferência microcirúrgica do dedo do pé para a reconstrução do polegar é um procedimento desafiador, considerando-se a habilidade técnica necessária para realizá-la e a difícil avaliação pós-operatória dos aspectos estéticos e funcionais. Este é um relato do caso de uma criança de 3 anos que sofreu uma amputação traumática do polegar. A reconstrução do polegar foi realizada por meio de transferência microcirúrgica do dedo do pé, meses após a falha do reimplante. Uma avaliação subjetiva e outra objetiva dos resultados foram realizadas cinco anos após o procedimento. O resultado funcional foi avaliado por meio do Questionário de Avaliação da Saúde na Infância (Childhood Health Assessment Questionnaire, CHAQ, em inglês) e o Teste Funcional da Mão de Jebsen-Taylor (Jebsen-Taylor Hand Function Test, JTHFT, em inglês). Foram usados o dinamômetro Jamar (Sammons Preston, Bolingbrook, IL, EUA) e os instrumentos de medição Jamar Pinch Gauge (Sammons Preston) para avaliar as forças de preensão palmar e de pinças, respectivamente. Foram realizados os testes de monofilamento e de discriminação de dois pontos de Semmes-Weinstein. O paciente apresentou excelente resultado funcional, recuperação parcial da força, recuperação sensitiva completa, e mínima morbidade do sítio doador. Foi realizada também uma avaliação radiográfica, que demonstrou a preservação da placa epifisária e do potencial de crescimento no dedo do pé transplantado. Em todos os aspectos, os dados observados reforçam os benefícios e as indicações da transferência do dedo do pé para a reconstrução do polegar em crianças.

Objective: To assess and compare radiographic, tomographic and functional pre and postoperative parameters of patients submitted to treatment of nonunion of the scaphoid waist with locked plate for scaphoid. Methods: This is a case series of scaphoid waist nonunion, operated from March 2017 to March 2018 at the Institute of Orthopedics and Traumatology of HCFMUSP, using the technique of Fisk-Fernandez and osteosynthesis with locked plate for scaphoid APTUS®Hand from Medartis. The patients were submitted to radiographs, computed tomography and functional evaluation by the occupational therapy team in the pre and postoperative periods. Results: There was consolidation of the scaphoid waist nonunion in all cases, improvement in the parameters of carpal alignment in the imaging examinations, but functionally we observed reduction of the range of motion and grip strength in relation to the contralateral limb. Conclusions: The treatment of the scaphoid waist nonunion with locked plate was effective, with a high index of consolidation and improvement of the carpal alignment in the imaging tests, although with a reduction in the range of motion and grip strength in relation to the contralateral limb when evaluated with 12 weeks postoperatively. Level of Evidence IV, Case series. RESUMO Objetivos: Avaliar e comparar parâmetros radiográficos, tomográficos e funcionais pré e pós-operatórios de pacientes submetidos ao tratamento de pseudoartrose do colo do escafoide com placa bloqueada para escafoide. Métodos: Esta é uma série de casos de pseudoartrose do colo do escafoide, operados no período de março de 2017 a março de 2018 no Instituto de Ortopedia e Traumatologia do HCFMUSP, utilizando-se a técnica de Fisk-Fernandez e osteossíntese com placa bloqueada para escafoide APTUS®Hand da Medartis. Os pacientes foram submetidos a radiografias, tomografia computadorizada e avaliação funcional pela equipe de terapia ocupacional no pré e pós-operatório. Resultados: Houve consolidação da pseudoartrose do colo do escafoide em todos os casos e melhora nos parâmetros de alinhamento carpal nos exames de imagem, porém, funcionalmente, observamos redução da amplitude de movimento e força de preensão em relação ao membro contralateral. Conclusão: O tratamento da pseudoartrose do colo do escafoide com placa bloqueada se mostrou efetivo, com elevado índice de consolidação e melhora do alinhamento carpal nos exames de imagem, embora com redução da amplitude de movimento e força de preensão em relação ao membro contralateral, quando avaliados com 12 semanas de pós-operatório. Nível de Evidência IV, Série de casos.

Introduction The traumatic lesions of the brachial plexus in adults are devastating injuries causing continuous severe functional impairment for both work and daily living activities. The restoration of elbow flexion is one of the most important movements for patient recovery to previous activities. Free gracilis muscle transfer has good outcomes for cases with late presentation or as a rescue surgery to regain elbow flexion, however, bad results are present in all cohorts with insufficient recovery of muscle strength for elbow flexion. A number of hypotheses can be postulate to explain the fair results observed in some cases of free gracilis muscle transfer for elbow flexion. Most studies in the current literature compare the choice of the donor nerve used in neurotization and nerve grafts. The aim of this study is to evaluate if technical components of microvascular anastomosis could influence the functional outcome of free functional muscle transfer for elbow flexion in adult patients with traumatic brachial plexus injury. Material and methods Included all adult patients with traumatic brachial plexus injury submitted to free functional gracilis muscle transfer for elbow flexion. The complications and functional results according to British Medical Research Council (BMRC) score were recorded. Results We assessed 26 patients with mean age of 32.8 years. The most common donor nerve for gracilis muscle was the accessory nerve in 18 patients. Eighteen patients presented with good result (M3/M4). The mean ischemia time was higher for patients with bad results (132 minutes) comparing with patients with good results (122 minutes). Patients with only one venous anastomosis had 41% of poor functional outcome compared with 22% of cases with two venous anastomoses. No statistically significant difference in the ischemia time of the cases with good or poor functional outcome was observed (p = 0.657), as for the number of venous anastomoses (p = 0.418). Conclusion Our study observes that patients with only one venous anastomoses for drainage of free gracilis and those with longer intraoperative ischemia time had higher incidence of poor functional outcome of free gracilis muscle transfer for elbow flexion, but not statistically significant. Level of proof II; prospective cross-sectional study.

Objective: To evaluate histological changes in peripheral nerves of rats after sciatic nerve neurorrhaphy, according to the time of exposure to hyperbaric oxygen chamber treatment. Methods: Twenty-five Wistar rats were divided into 5 groups according to the amount of exposure to hyperbaric oxygen chamber treatment. Group 1 was the control and there was no use of hyperbaric oxygen chamber; group 2 received one week of therapy; group 3, two weeks; group 4, three weeks; and group 5, four weeks. After the fourth postoperative week, the animals were submitted to euthanasia and a sciatic nerve sample sent for histological analysis. Axons proximal and distal to the neurorrhaphy were counted with axonal regeneration index measurement. Results: We observed that the number of axons distal to neurorrhaphy increases with the amount of hyperbaric oxygen chamber exposure, the results were more expressive from the third week of treatment. However, the statistical analysis found no significant difference between the groups. Conclusion: The descriptive analysis suggests benefit of using hyperbaric oxygen chamber directly proportional to the time of therapy. The study, however, did not present statistically relevant results, probably due to the reduced sample size. Subsequent studies with more significant sampling would be of great value. Level of Evidence II, Prospective Comparative Study. RESUMO Objetivo: Avaliar as alterações histológicas nos nervos periféricos após neurorrafia do nervo ciático de ratos, de acordo com o tempo de exposição ao tratamento com câmara hiperbárica de oxigênio. Métodos: Vinte e cinco ratos da raça Wistar foram divididos em cinco grupos conforme o tempo de exposição ao tratamento com câmara hiperbárica de oxigênio. O grupo 1 não recebeu o tratamento; o grupo 2 recebeu uma semana de terapia; o grupo 3, duas semanas; o grupo 4, três semanas; e o grupo 5, quatro semanas. Após quatro semanas de pós-operatório, os animais foram submetidos à eutanásia e uma amostra do nervo ciático foi enviada para análise histológica. Foram feitas contagens do número de axônios proximalmente e distalmente à neurorrafia, com medição do índice de regeneração axonal. Resultados: Observamos que o aumento do número de axônios distais à neurorrafia foi diretamente proporcional ao tempo de exposição à câmara hiperbárica de oxigênio, sendo mais expressivo a partir da terceira semana de tratamento. Entretanto, a análise estatística não encontrou diferença significativa entre os grupos. Conclusão: A análise descritiva sugere benefício do uso da câmara hiperbárica de oxigênio. Porém, devido à amostra reduzida, o estudo não apresentou resultados estatisticamente relevantes, sendo necessária a realização de estudos subsequentes com amostragem mais significativa. Nível de Evidência II, Estudo Prospectivo Comparativo.

Heterodigital pedicle flaps have 2 possible patters of vascularization: anterograde flow (Littler) or reverse flow (Adani). The Adani's flap uses the Y-V pedicle lengthening principle. The flap is raised from the adjacent uninjured finger based on the digital artery. The common digital artery is ligated and a long pedicle is formed from the 2 converging digital arteries to supply a reverse flow flap. Four patients with severe fingertips injuries were submitted to surgical treatment with the Adani's flap. All flaps integrated and provided skin coverage. The Adani's flap has a long vascular pedicle that allows a wide arch of transposition. An easier vascular dissection in a site distant from the trauma which evolves a higher diameter digital artery and proximal interphalangeal arterial system promotes a high survival rate and good functional results. Adani's flap is a reliable technique for severe fingertip injuries.

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.