MUSCULAR TUBERCULOSIS: RARE PRESENTATION OF A COMMON ENTITY

Tuberculosis is a global health problem mainly affecting people in developing countries although muscular involvement is rarely seen. Authors hereby, describe a case of tuberculosis of triceps muscle in a 35-year-old immunocompetent female who presented with swelling in right upper arm. Radiological examination ruled out involvement of underlying bones. Excision biopsy was performed and on histopathological examination cyst wall showed presence of foamy macrophages in sheets, inammatory cells and few scattered epithelioid cells but no well-formed granulomas or giant cells were seen. ZN stain for acid fast bacilli was positive. Based on the above ndings a diagnosis of tuberculosis of triceps muscle was made. The patient responded well to antituberculosis therapy and is currently on follow up.

Triceps and cutaneous radial nerve branches investigated via an axillary anterior arm approach: new findings in a fresh-cadaver anatomical study

OBJECTIVE The authors sought to describe the anatomy of the radial nerve and its branches when exposed through an axillary anterior arm approach. METHODS Bilateral upper limbs of 10 fresh cadavers were dissected after dyed latex was injected into the axillary artery. RESULTS Via the anterior arm approach, all triceps muscle heads could be dissected and individualized. The radial nerve overlaid the latissimus dorsi tendon, bounded by the axillar artery on its superior surface, then passed around the humerus, together with the lower lateral arm and posterior antebrachial cutaneous nerve, between the lateral and medial heads of the triceps. No triceps motor branch accompanied the radial nerve’s trajectory. Over the latissimus dorsi tendon, an antero-inferior bundle, containing all radial nerve branches to the triceps, was consistently observed. In the majority of the dissections, a single branch to the long head and dual innervations for the lateral and medial heads were observed. The triceps long and proximal lateral head branches entered the triceps muscle close to the latissimus dorsi tendon. The second branch to the lateral head stemmed from the triceps lower head motor branch. The triceps medial head was innervated by the upper medial head motor branch, which followed the ulnar nerve to enter the medial head on its anterior surface. The distal branch to the triceps medial head also originated near the distal border of the latissimus dorsi tendon. After a short trajectory, a branch went out that penetrated the medial head on its posterior surface. The triceps lower medial head motor branch ended in the anconeus muscle, after traveling inside the triceps medial head. The lower lateral arm and posterior antebrachial cutaneous nerve followed the radial nerve within the torsion canal. The lower lateral brachial cutaneous nerve innervated the skin over the biceps, while the posterior antebrachial cutaneous nerve innervated the skin over the lateral epicondyle and posterior surface of the forearm. The average numbers of myelinated fibers were 926 in the long and 439 in the upper lateral head and 658 in the upper and 1137 in the lower medial head motor branches. CONCLUSIONS The new understanding of radial nerve anatomy delineated in this study should aid surgeons during reconstructive surgery to treat upper-limb paralysis.

Inveterate elbow dislocation: surgical reduction with triceps lengthening

Inveterate elbow dislocations remain common in developing countries. We report the case of a 17-year-old child who consulted us after six months of trauma to the left elbow. Clinical examination revealed a deformed elbow, locked in extension with a mobility sector of 5°. The Mayo Clinic Elbow performance score was sixty-six; the downstream vasculo-nervous examination was normal. The face and profile X-ray of the elbow showed a pure posterolateral elbow dislocation. We used the posterior medial para-tricipital and lateral approach, a first stage of arthrolysis was performed. A complete reduction was achieved by progressive and non-traumatic gentle maneuvers. Intraoperative elbow flexion was less than 80°, indicating a retraction of the triceps muscle, so a Z-lengthening plasty was necessary. This reduction was then fixed with two olecranon-humeral K-wires. At the third week, the plaster cast and K-wires were removed. The patient was subsequently referred to a physical therapist. After a ten-month follow-up, an undistorted and functional elbow with a gain of twenty-one points according to the Mayo Clinic score was obtained. Surgical reduction of a neglected elbow dislocation with triceps lengthening plasty, followed by a codified physical therapy program, results in a remarkable restoration of elbow function and stability. Keyword : elbow, dislocation, inveterate, reduction, triceps.

Considerations on the human Achilles tendon moment arm for in vivo triceps surae muscle–tendon unit force estimates

Moment arm-angle functions (MA-a-functions) are commonly used to estimate in vivo muscle forces in humans. However, different MA-a-functions might not only influence the magnitude of the estimated muscle forces but also change the shape of the muscle’s estimated force-angle relationship (F-a-r). Therefore, we investigated the influence of different literature based Achilles tendon MA-a-functions on the triceps surae muscle–tendon unit F-a-r. The individual in vivo triceps torque–angle relationship was determined in 14 participants performing maximum voluntary fixed-end plantarflexion contractions from 18.3° ± 3.2° plantarflexion to 24.2° ± 5.1° dorsiflexion on a dynamometer. The resulting F-a-r were calculated using 15 literature-based in vivo Achilles tendon MA-a-functions. MA-a-functions affected the F-a-r shape and magnitude of estimated peak active triceps muscle–tendon unit force. Depending on the MA-a-function used, the triceps was solely operating on the ascending limb (n = 2), on the ascending limb and plateau region (n = 12), or on the ascending limb, plateau region and descending limb of the F-a-r (n = 1). According to our findings, the estimated triceps muscle–tendon unit forces and the shape of the F-a-r are highly dependent on the MA-a-function used. As these functions are affected by many variables, we recommend using individual Achilles tendon MA-a-functions, ideally accounting for contraction intensity-related changes in moment arm magnitude.

Effects of ziclague phytotherapic associated with kinesitherapy on the equine foot of children with spastic cerebral palsy

Background: Spasticity is the most common disorder of Cerebral Palsy (CP) and has the characteristics of decreased active movement,elastic hypertonia and hyperreflexia. Because of this, one of the main purposes of treatment is to decrease hypertonia. Thus, the herbalmedicine Ziclague®, having an antispasmodic action, may offer a new possibility in addition to physiotherapy. Objective: Verify theeffects of the application of the herbal medicine Ziclague on hypertonia of the sural triceps muscle of children with spasticCP. Methods: Ten children, between one and seven years of age, received application of Ziclague® spray on the triceps sural musclebefore the physiotherapy sessions, during the period of twelve weeks. Evaluations were performed using the Modified Ashworth Scale(MAS), Durigon Protocol (DP) and goniometry, before and after application on the first day, after four weeks and at the end of twelveweeks. The four evaluations were compared. Results: After twelve weeks the results were more evident, with a decrease in hypertoniaof the right lower limb (RLL) and left lower limb (LLL) verified by MAS (p= 0.06 and p= 0.13), and by the DP (p= 0.003 and p= 0.007).Goniometry showed increased range of motion for dorsiflexion of the RLL (p= 0.002) and LLL (p= 0.111). Conclusion: The use ofZiclague® associated with physiotherapy had a positive effect in decreasing hypertonia of the sural triceps muscle and in increasing theankle dorsiflexion range of motion.

One-Step Lower Leg Reconstruction with Vascularized Functional Vastus Lateralis Muscle Flap in the Treatment of Embryonal Rhabdomyosarcoma for a Six-Month-Old Boy: A Case Report

Rhabdomyosarcoma (RMS) is a common soft tissue sarcoma in childhood, however, it is very rare in the neonatal period (0.4–2% of cases). This case depicts a boy, who presented with RMS at two weeks of age, but officially diagnosed at the age of three months. MRI and scintigraphy determined a soft tissue tumor in the soleus muscle, while biopsy confirmed embryonal RMS with high mitotic activity (Ki67 (monoclonal antibodies) ~80%). CWS (Cooperative Weichteilsarkom Studiengruppe)-2012 with I2VA (ifosfamide, vincristine, actinomycin) chemotherapy regimen was administered per protocol. Surgical treatment was performed at age of six months and 18 days. The operation consisted of radical tumor resection and total triceps surae with partial fibula resection. Immediate reconstruction of triceps muscle was accomplished using a vascularized functional musculocutaneous vastus lateralis flap. Functional outcome was measured using the Lower Extremity Functional Scale (LEFS) and the Foot and Ankle Outcome Score (FAOS) with the results of 92.5% and 99% respectively.