Digital analysis of external fixation area of proximal humerus fractures in elderly patients

Introduction The purpose is based on anatomical basis, combined with three-dimensional measurement, to guide the clinical repositioning of proximal humeral fractures, select the appropriate pin entry point and angle, and simulate surgery. Methods 11 fresh cadaveric specimens were collected, the distance of the marked points around the shoulder joint was measured anatomically, and the vertical distance between the inferior border of the acromion and the superior border of the axillary nerve, the vertical distance between the apex of the humeral head and the superior border of the axillary nerve, the vertical distance between the inferior border of the acromion and the superior border of the anterior rotator humeral artery, and the vertical distance between the apex of the humeral head and the superior border of the anterior rotator humeral artery were marked on the 3D model based on the anatomical data to find the relative safety zone for pin placement. Results Contralateral data can be used to guide the repositioning and fixation of that side of the proximal humerus fracture, and uniform data cannot be used between male and female patients. For lateral pining, the distance of the inferior border of the acromion from the axillary nerve (5.90 ± 0.43) cm, range (5.3-6.9) cm, was selected for pining along the medial axis of the humeral head, close to the medial cervical cortex, and the pining angle was measured in the coronal plane (42.84 ± 2.45)°, range (37.02° ~ 46.31°), and in the sagittal plane (28.24 ± 2.25)°, range (19.22° ~ 28.51°). The pin was advanced laterally in front of the same level of the lateral approach point to form a cross-fixed support with the lateral pin, and the pin angle was measured in the coronal plane (36.14 ± 1.75)°, range (30.32° ~ 39.61°), and in the sagittal plane (28.64 ± 1.37)°, range (22.82° ~ 32.11°). Two pins were taken at the greater humeral tuberosity for fixation, with the proximal pin at an angle (159.26 ± 1.98) to the coronal surface of the humeral stem, range (155.79° ~ 165.08°), and the sagittal angle (161.76 ± 2.15)°, with the pin end between the superior surface of the humeral talus and the inferior surface of the humeral talus. The distal needle of the greater humeral tuberosity was parallel to the proximal approach trajectory, and the needle end was on the inferior surface of the humeral talus. Conclusion Based on the anatomical data, we can accurately identify the corresponding bony structures of the proximal humerus and mark the location of the pin on the 3D model for pin placement, which is simple and practical to meet the relevant individual parameters.

The pharynx

The pharynx is the cranial limit of the alimentary tract and lies behind the nasal, oral and laryngeal cavities – extending from the skull base to the sixth cervical vertebrae. It consists of a thick muscular tube formed from the three constrictor muscles, stylopharyngeus, palatopharyngeus and salpingopharyngeus – lined by the pharyngobasilar fascia internally and buccopharyngeal fascia externally. The nasopharynx communicates with the nasal cavity anteriorly and laterally with the middle ear via the eustachian tubes. The oropharynx extends from the soft palate superiorly to the superior border of the epiglottis below, communicating with the nasopharynx above via the pharyngeal isthmus and oral cavity in front via the oropharyngeal isthmus. It is characterised by Waldeyer’s lymphatic ring. The hypopharynx extends from the epiglottis to the lower border of the cricoid cartilage, where it continues as the oesophagus. Its anterior wall is formed by the inlet of the larynx superiorly and posterior part of the cricoid cartilage inferiorly.

Determination of the normal conus medullaris level in term infants: the role of MRI in early infancy

OBJECTIVE This study aimed to explore the migration process of the conus medullaris (CM) in early infancy using infant MRI and to evaluate the application of MRI for locating the infant CM level. METHODS The authors retrospectively analyzed the CM level on the lumbosacral MR images of 26 term infants aged < 3 months who were classified into three groups according to age. The authors numbered the CM level in each patient and analyzed the range and average of the CM level of the cohort. The authors studied the linear correlation between CM level and postnatal days with linear regression analysis, 1-way ANOVA, and the least significant difference test. RESULTS The CM level ranged from the superior border of the L1 vertebra to the top third of the L3 vertebra. About 96.2% of infants had CM higher than the superior border of the L3 vertebra. On average, CM was located between the L1–2 intervertebral disc and the inferior border of the L2 vertebra (mean ± SD score 1.64 ± 1.14). The three groups had no significant statistical difference in CM level (F = 1.071 and p = 0.359; groups 1 and 2, p = 0.408; groups 1 and 3, p = 0.170; groups 2 and 3, p = 0.755). CM level had no linear regression correlation with postnatal days within the first month (r2 = 0.061, F = 0.654, p = 0.438) or within the first 3 months (r2 = 0.002, F = 0.056, p = 0.816). CONCLUSIONS The CM level reaches the normal adult level by birth in term infants and does not ascend during childhood. On average, the CM was between the L1–2 intervertebral disc and the inferior border of the L2 vertebra in term infants. Considering the possibility of physiologically low-lying CM, the authors agree that normal CM is located above the L3 level in term infants and CM at the L3 level could be equivocal and should be investigated with other clinical data. The study data suggest that MRI is an accurate and valuable method for determining the CM level in term infants.

Morphological Study of Splenic Notches and Fissures

Introduction: Spleen is the largest and secondary lymphoid organ in humans. It has two ends: Anterior and Posterior end. Two surfaces: Visceral and Diaphragmatic surfaces. Three borders: Superior, Inferior and Intermediate. Spleen begins to develop during the 5th week of intra-uterine life from a mass of mesenchymal cells, originating in the dorsal mesogastrium as a localized thickening of coelomic epithelium. The spleen is lobulated in foetus but the lobules normally disappear before birth. The imperfect fusion of splenic masses during embryonic life results in an accessory spleen. The spleen plays a vital role in regard to blood storage, formation of lymphocyte and defense against foreign particles. Materials and methods: The study was carried out in 50 formalin fixed spleen from the Department of Anatomy, Karpaga Vinayaga Institute of Medical Sciences, Madurantakam Taluk, Chengalpet Dt, Tamilnadu, India. Results: Out of 50 spleens, Wedge shape is seen in 33 spleens, Triangular shape is observed in 5 spleens, tetrahedral in 7 spleens, oval shape in 3 spleens, and dome-shaped in 2 spleen. The splenic notches were observed in the superior border in 44 spleens (88%) and notch seen in the inferior border in 4 spleens (8%) and the absence of a notch in both the superior and inferior border noted in 2 spleens (4%). The number of notches on the superior border is from 1 to 4 and the number of notches on the inferior border is 1. Fissures noted in 8 spleens (16%). In 5 specimens fissures extended to reach the visceral surface. Conclusion: The presence of abnormal fissures and lobes of the spleen might confuse the radiologists. Abnormal lobulation might cause misinterpretation as mass originating from the kidney. It is essential for surgeons and radiologists to be aware of the splenic variations. KEY WORDS: splenic surfaces, shapes, notches, fissures.

Digital Analysis of External Fixation Area of Proximal Humerus Fractures in Elderly Patients

Background:The purpose is based on anatomical basis, combined with three-dimensional measurement, to guide the clinical repositioning of proximal humeral fractures, select the appropriate nail entry point and angle, and simulate surgery.Methods: 11 fresh cadaveric specimens were collected, the distance of the marked points around the shoulder joint was measured anatomically, and the vertical distance between the inferior border of the acromion and the superior border of the axillary nerve, the vertical distance between the apex of the humeral head and the superior border of the axillary nerve, the vertical distance between the inferior border of the acromion and the superior border of the anterior rotator humeral artery, and the vertical distance between the apex of the humeral head and the superior border of the anterior rotator humeral artery were marked on the 3D model based on the anatomical data to find the relative safety zone for nail placement.Results:Contralateral data can be used to guide the repositioning and fixation of that side of the proximal humerus fracture, and uniform data cannot be used between male and female patients. For lateral nailing, the distance of the inferior border of the acromion from the axillary nerve (5.90±0.43) cm, range (5.3-6.9) cm, was selected for nailing along the medial axis of the humeral head, close to the medial cervical cortex, and the nailing angle was measured in the coronal plane (42.84±2.45)°, range (37.02°~46.31°), and in the sagittal plane (28.24±2.25)°, range ( 19.22°~28.51°). The nail was advanced laterally in front of the same level of the lateral approach point to form a cross-fixed support with the lateral nail, and the nail angle was measured in the coronal plane (36.14±1.75)°, range (30.32°~39.61°), and in the sagittal plane (28.64±1.37)°, range (22.82°~32.11°). Two pins were taken at the greater humeral tuberosity for fixation, with the proximal pin at an angle (159.26±1.98) to the coronal surface of the humeral stem, range (155.79°~165.08°), and the sagittal angle (161.76±2.15)°, with the pin end between the superior surface of the humeral talus and the inferior surface of the humeral talus. The distal needle of the greater humeral tuberosity was parallel to the proximal approach trajectory, and the needle end was on the inferior surface of the humeral talus.Conclusion: Based on the anatomical data, we can accurately identify the corresponding bony structures of the proximal humerus and mark the location of the nail on the 3D model for nail placement, which is simple and practical to meet the relevant individual parameters.

Thyroglossal Duct Cyst - An Observational Study from Visakhapatnam, Andhra Pradesh

BACKGROUND Thyroglossal duct cyst is a developmental cyst that occurs in 7 % of the population. These cysts are most commonly seen in paediatric patients. They occur due to failure of thyroglossal duct to involute and atrophy. Majority of them are found in infrahyoid region. The purpose of this research was to summarise our three years of clinical experience in different features of thyroglossal cysts and their surgical results, with an emphasis on the naked eye extent of a patent thyroglossal duct if present. METHODS This observational study was carried out in the Department of ENT, GVP IHC & MT – Visakhapatnam district, Andhra Pradesh for a period of three years from January 2016 to 2019. In our study, twenty patients were enrolled. Patients with cysts were initially diagnosed based on medical history, clinical examination, and ultrasound sonography (USG) reports. RESULTS Patients' clinical and surgical data, including cyst size and position, presence or absence of the thyroglossal duct, and so on, were analysed. The average age was 11 years. The majority (73.5 percent) were under the age of 15. Males accounted for 75 percent of the population, while females accounted for 25 %. Midline neck swelling was found in most of the patients (95 %). Majority (84.5 %) of cysts were located in the sub-hyoid region. Erythema over swelling was seen in 14.5 % of patients. Thyroglossal ducts were found to be patent at various lengths and areas. Majority of patients (75 %) had tract that began from cyst and ended at superior border of hyoid body while two patients (10 %) had patent thyroglossal duct from the cyst to the vallecular mucosa. Majority (70 %) cysts had size between 1.6 cm and 3 cm. Intraoperatively 15 % of cyst got ruptured. Most of them were present with visible midline neck swelling. None of the cysts had malignant characteristics in our study. CONCLUSIONS In most cases, a patent duct just disappeared at the superior border of body of hyoid. Complete patent thyroglossal duct from cyst to tongue musculature was rare. None of the cysts had malignant characteristics in our study. KEYWORDS Thyroglossal Cyst, Neck Swelling, Thyroglossal Duct

The addition of a conjunctival flap to a posterior lamella auricular cartilage graft: A technique to avoid corneal complications

Purpose: To present the benefits of the addition of a conjunctival flap when correcting lower eyelid retraction using an auricular cartilage graft. Methods: An auricular cartilage graft was obtained either from the concha o the scaphoid fossa. When preparing the receiving bed, the conjunctival incision was made 2 mm below the inferior margin of the lower eyelid tarsus, therefore, a conjunctival flap arising from the inferior border of the tarsus was obtained. The cartilage graft was placed in the lower eyelid. The inferior border of the graft was sutured to the retractors and conjunctiva using absorbable sutures. The superior border was sutured to the inferior tarsus, so that de conjunctival flap covered the superior portion of the graft. Results: Fourteen patients underwent the surgical technique. No corneal complications were observed in the early or late postoperative period. Donor site complications were not encountered. Conclusions: The confection of a conjunctival flap that lines the superior portion of an auricular cartilage graft in the lower eyelid provides protection against corneal postoperative complications until the graft is epithelized.

Avoiding mask-related artefacts in visual field tests during the COVID-19 pandemic

AimsTo assess visual field (VF) pseudoprogression related to face mask use.MethodsWe reviewed a total of 307 VFs performed with a face mask (FPP2/KN95 or surgical masks) and compared them with prior VFs, performed before the pandemic. VFs with suspected pseudoprogression due to mask artefacts (VF test 1) were repeated with a surgical mask and an adhesive tape on its superior border (VF test 2) to distinguish from true VF loss. Several parameters including reliability indices, test duration, VF index (VFI), mean defect (MD) and pattern deviation probability plots were compared among last pre-COVID VFs, VF tests 1 and VF tests 2, using the Wilcoxon signed-rank test.ResultsWe identified 18 VFs with suspected progression artefact due to masks (5.8%). In all of them, the median VFI and MD significantly improved after fitting the superior border of the mask, showing no significant differences with pre-COVID tests. The median fixation losses were significantly higher when wearing the unfitted mask (13% vs 6%,p=0.047). The inferior hemifield was the most affected, either as a new scotoma or as an enlargement of a prior defect.ConclusionUnfitted masks can simulate VF progression in around 6% of cases, mainly in the inferior hemifield, and increase significantly the rate of fixation losses. A similar rate of artefacts was observed using FPP2/KN95 or surgical masks. The use of a surgical mask with an adhesive tape covering the superior border may reduce mask-related artefacts, although concomitant progression cannot be ruled out in all cases.

The Relevant Anatomy of the Biceps Tendon When Performing Tenodesis in Filipino Cadaveric Specimens

Background: Biceps tenodesis is a technique frequently performed in shoulder surgeries. Various techniques have been described, but there is no consensus on which technique restores the length-tension relationship. Restoration of the physiologic length-tension relationship has been correlated to better functional outcomes, such as decreased incidence of residual pain or weakness of the biceps. The objective of this study was to measure the anatomic relationship of the origin of the biceps tendon with its zones in the upper extremity. This would provide an anatomic guide or an acceptable placement of the tenodesis to reestablish good biceps tension during surgery. Methods: The study used nine adult cadavers (five males, four females) from the [withheld for blinded review]. Nine shoulder specimens were dissected and markers were placed at five points along each biceps tendon: (1) Labral origin (LO) (2) Superior bicipital groove (SBG) (3) Superior border of the pectoralis tendon (SBPMT) (4) Musculotendinous junction (MTJ) and (5) Inferior border of the pectoralis tendon (IBPMT). Using the origin of the tendon as the initial point of reference, measurements were made to the four subsequent sites. The humeral length was recorded by measuring the distance between the greater tuberosity and the lateral epicondyle as well as the tendon diameter at the articular surface. Results: The intraclass correlation coefficient was excellent across all measures. A total of nine cadavers were included. Mean age of patients was 66.33 years old, ranging from 52-82 years old. These were composed of five male and four female cadavers. The mean tendon length was 24.83mm ± 4.32 from the origin to the superior border of the bicipital groove, 73.50mm ± 6.96 to the Superior Border Pectoralis Major Tendon, 100.89mm ± 6.88 to the Musculotendinous Junction, and 111.11mm ± 7.45 to the Inferior Border Pectoralis Major Tendon. The mean tendon diameter at the articular origin was 6.44mm ± 1.76. Conclusion: This study provided measurement guidelines that could restore the natural length-tension relationship during biceps tenodesis using the interference screw technique in Filipinos. A simple method of restoring a normal length-tension relationship is by doing tenodesis close to the articular origin and creating a bone socket of approximately 25mm in depth, using the superior border of the bicipital groove as a landmark.