The proximal humeral locking plate positioning to the pectoralis major tendon in achieving the proper calcar screw location: a cadaveric study

Background Proximal humeral fracture is the third most common of osteoporotic fracture. Most surgical cases were treated by fixation with anatomical locking plate system. The calcar screw plays a role in medial support and improving varus stability. Proximal humerus fracture in elderly patients are commonly seen with greater tuberosity (GT) fracture. The GT fragment is sometimes difficult to use as an anatomic landmark for proper plate and screw position. Therefore, the insertion of pectoralis major tendon (PMT) may be used as an alternative landmark for appropriate plate and calcar screw position. The purpose of study is going to identify the vertical distance from PMT to a definite point on the position of locking plate. Methods 30 cadaveric shoulders at the department of clinical anatomy were performed. Shoulders with osteoarthritic change (n = 5) were excluded. Finally, 25 soft cadaveric shoulders were recruited in this study. The PHILOS™ plate was placed 2 mm posterior to the bicipital groove. A humeral head (HH) was cut in the coronal plane at the level of the anterior border of the PHILOS plate with a saw. A calcar screw was inserted close to the inferior cortex of HH. Distance from the upper border of elongated combi-hole (UB-ECH) to the upper border of pectoralis major tendon (UB-PMT) was measured. The plate was then moved superiorly until the calcar screw was 12 mm superior to the inferior border of HH and the distance was repeatedly measured. Results The range of distance from UB-PMT to the UB-ECH was from − 4.50 ± 7.95 mm to 6.62 ± 7.53 mm, when calcar screw was close to inferior border of HH and when the calcar screw was 12 mm superior to the inferior border of HH, respectively. The highest probability of calcar screw in proper location was 72% when UB-ECH was 3 mm above UB-PMT. Discussion and conclusion The GT fragment is sometimes difficult to use as an anatomic landmark for proper plate and screw position. PMT can be used as an alternative anatomic reference. UB-PMT can serve as a guide for proper calcar screw insertion. UB-ECH should be 3 mm above UB-PMT and three-fourths of cases achieved proper calcar screw location.

Morphometric Study of Cadaveric Spleen in Vidarbha Region

Background: Spleen is one of the largest lymphoid organs that are involved in haemopoitic function also during fetal life. Its anatomy is useful not only for Anatomist but also for Surgeons, Radiologists and Physicians. A lot of variations are observed in the spleen from its shape to size which is important to diagnose or treat the number of diseases. Methodology: This study was carried out on 60 spleens in the dissection hall of our medical college which were removed during routine undergraduate dissection. The parameters studies were shape of the spleen, number of notches (single or multiple), location of notches (Superior or inferior border), weight, breadth, width or length. Results: The 90% spleens has single notch. The weight of the spleens ranges from 89 gm to 220 gm with an average 142.6 gm. Range of breadth observed 3.5cm to7.4cm with an average 5.8cm, Range of width observed 2.8cm to 5.7cm with an average 4.1cm. Range of length observed 8.1cm to13.2cm with an average 11.7cm. Conclusion: Morphological variation is very common in spleen and varies according to the genetic, geographic, nutrition and work habits of individual and varies regions to regions of India. Morphological analysis is under reported and need to be carry out at different regions and places for obtaining more accurate data.

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.

Accuracy of Cone Beam CT Measurements for Assessment of Posterior Mandible: A Cadaver Study

Objectives: This study is aimed at analysing the accuracy and reliability of the cone beam CT (CBCT) measurements and direct physical measurements of the posterior mandible. Materials and methods: Eighteen cadaveric hemi-mandibles were dissected from the soft tissues and the CBCT images of the mandibles were taken. Direct physical and cone beam CT measurements of six landmarks which includes height of ramus (R), distance of lingula to sigmoid notch (LS), distance of lingula to inferior border (LI), position of lingula in relation to occlusal plane (L-OP), ramus thickness at crestal level (RT-C), and ramus thickness at midway between sigmoid notch and lingula (RT-M) were determined. Accuracy and reliability of the measurements were tested. Results: Four landmarks showed high accuracy when measuring the posterior mandible, while two landmarks, LI and RT-M, showed statistically significant weaker accuracy (p<0.05). Inter-reliability were good for all landmarks when measured directly physically on mandibles (ICC>0.7 and p>0.05), but were low on two landmarks, LI and RT-C, on CBCT measurement (ICC<0.5 and p<0.05). Conclusion: A generally strong accuracy between direct physical and CBCT measurements for most landmarks on posterior mandible were found. Reliability between two researchers were high on direct physical measurements. Meanwhile, two landmarks on CBCT which include LI and RT-C showed low inter-reliability. Hence, CBCT measurements proved to be a good tool for pre-operative assessment, since high inter-reliability and strong accuracy corresponding to direct physical were recorded.

Maxillofacial Radiology 194

CBCT imaging and analysis was performed. Observe unilateral expansion by the distending soft tissue outline illustrated through 3D rendering (Figure 2). Sagittal oblique (Figure 3) and axial (Figure 4) slices depict a round heterogenous predominantly high-density lesion with an encompassing thin uniform less dense peripheral band. Irregular root resorption, displacement of the inferior alveolar nerve canal, buccal-lingual cortical expansion, thinning, and interruption was apparent. Irregular thickening at the inferior border and surrounding osteosclerosis were noted. A macroscopic view (Figure 5), photomicrograph (Figure 6), and conventional radiograph (Figure 7) of vertically sectioned surgical specimens of similar lesions. Note the intimate relationship with the tooth roots.

The neck

The neck occupies the space between the clavicles and thoracic inlet inferiorly, to the base of the skull and inferior border of the mandible superiorly. The cervical part of the vertebral column provides the support for the skull above and strength and movement to the neck proper. The anterior neck provides passage for the major neurovascular supply to and drainage from the head, neck and intracranial region, transmits the upper aerodigestive tract and houses the thyroid and parathyroid glands. In the posterior neck a large mass of extensor musculature is situated posterior to the cervical vertebrae. Cranial nerves nine through twelve descend into the neck: nine (glossopharyngeal) and twelve (hypoglossal) meander towards the oropharynx and tongue, respectively; cranial nerve eleven (accessory) deflects backwards to supply the sternocleidomastoid and trapezius muscles whilst the tenth cranial nerve (vagus) wanders inferiorly within the carotid sheath between and posterior to the common carotid artery and internal jugular vein, before disappearing into the thoracic and abdominal cavities.

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.

The role of iliocapsularis in hip pathology: a scoping review

ABSTRACT The iliocapsularis is a relatively unheard-of muscle, located deep in the hip covering the anteromedial capsule of the hip joint. Little is known about this constant muscle despite its clinical relevance. The aims of this scoping review are to collate the various research studies reporting on the detailed anatomy and function of iliocapsularis and to demonstrate how inter-individual differences in iliocapsularis can be used as a clinical adjunct in guiding diagnosis and treatment of certain hip joint pathologies. A computer-assisted literature search was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our review found 13 studies including 384 cases meeting our inclusion criteria. About 53.8% of the studies involved human cadavers. The current scoping review indicates the relevant anatomy of the iliocapsularis, being a small muscle which arises from the inferior border of the anterior inferior iliac spine and anteromedial capsule of the hip joint, inserting distal to the lesser trochanter. Therefore, based upon these anatomical attachments, iliocapsularis acts as a dynamic stabilizer by tightening the anterior capsule of the hip joint. Implications of this association may be that the muscle is hypertrophied in dysplastic or unstable hips. Determining the size of the iliocapsularis could be of conceivable use in patients with hip symptoms featuring signs of both borderline hip dysplasia and subtle cam-type deformities. Although future research is warranted, this study will aid physicians to understand the clinical importance of the iliocapsularis.

Dosimetric Evaluation of Oesophagus in Hypofractionated Supraclavicular Nodal Irradiation in Breast Cancer - A Retrospective Observational Study in a Tertiary Care Cancer Centre in Alappuzha, Kerala

BACKGROUND Acute esophagitis (AE) is a common toxicity seen in patients undergoing radiotherapy (RT) for breast cancer, which can affect their quality of life. Thus, majority of our patients receiving hypo fractionated dose of 40 Gy in 15 fractions were having AE. We conducted this study to evaluate the dosimetric parameters of oesophagus and correlate with published literature. METHODS Treatment plans of 80 post mastectomy patients who underwent radiotherapy for carcinoma of breast (Ca breast) with a dose of 40 Gy in 15 fractions to the chest wall along with supra clavicular fossa (SCF) were selected. Out of these, 44 patients (22 each in right and left side) were simulated in neck straight position and 36 in neck tilted position (18 each in right and left side). The oesophageal volume was contoured in already executed plans from the inferior border of cricoid cartilage to the inferior border of the SCF planning target volume (PTV). No plan modification was done after contouring the oesophagus. Dosimetric parameters like the maximum dose (Dmax) and mean dose (Dmean) to oesophagus, volume of oesophagus receiving ≥ 5 Gy (V5), ≥ 10 Gy (V10), ≥ 15 Gy (V15), ≥ 20 Gy (V20), ≥ 25 Gy (V25), ≥ 30 Gy (V30) were derived from dose volume histogram (DVH) data and analysed. RESULTS Dmean in straight neck group irrespective of side was 18.57 (± 7.30) Gy and in tilted neck 22.94 (± 9.53,) Gy, P = 0.023. Subgroup analysis shows Dmean was significantly high in patients with left sided disease than those with right sided disease (24.10 vs. 13.03, P = 0.00) in the straight neck cases. In the neck tilted group there was a nonsignificant increase in Dmean in left sided cases (25.36 vs. 20.53, P = 0.13). CONCLUSIONS Evaluation of oesophageal dosimetric parameters in hypofractionated dose showed that DmeanEQD2 was within the values of published studies in conventional fractionation. KEYWORDS Oesophageal Dosimetric Parameters, Breast Cancer

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.