Lateral Border Research Articles

Comparison of Single Versus Two Non-Compression Miniplates in the Management of Unfavourable Angle Fracture of the Mandible Orginal Research.

To compare the postoperative complications of fixing Mandibular angle fractures with two non-compression mini plates, on the superior and lateral the aspects of the mandible, to the standard technique of using a single non-compression miniplate on the superior border. Fifty patients with MAF were divided equally into two groups. Patients in Group 1 were secured with two mini plates at the lateral and superior border of the MA using an extraoral approach; for patients in Group 2 a single non-compression miniplate was used via an intraoral extended third molar approach as described by Champy et al. The post-operative complications in both groups were compared statistically. The findings of this study revealed that there was no significant difference in postoperative complications between the two groups when fixing MAF with two non-compression mini plates versus the standard technique of using a single non compression miniplate on the superior border of the mandible. However, the surgery time with one miniplate was significantly more than the dual plate approach. We advocate using two mini plates to treat an unfavorable angle fracture.

Poster 276: Assessment of Trochlear Cartilage Thickness and Volume Using Sagittal Magnetic Resonance Images to Quantify Trochlear Dysplasia: A Matched-Cohort Study

Objectives: Trochlear dysplasia is considered a major contributing factor for patellar instability. More recently, trochleoplasty procedures have become popularized to address this morphological abnormality. Both thick and thin flap trochleoplasty techniques exist, with the goal to deepen the trochlea while avoiding perforation of the trochlear cartilage during the procedure. However, the relative cartilage thickness in the dysplastic trochlea has not been well described. This study aimed to assess trochlear cartilage thickness and volume in knees with and without patellar instability and the relationship to measurements of trochlear dysplasia. Methods: 25 knees with symptomatic patellar instability were compared with 25 gender-matched knees. Retrospective chart review was performed to obtain demographic data. On sagittal images, trochlear cartilage thickness (TCT) and trochlear cartilage volume (TCV) were analyzed at the center, medial border, and lateral border of the trochlea. TCT was defined as the cartilage thickness halfway along the trochlear length at its maximum dimension. TCV was defined by total area of cartilage proximal to the plane of the intercondylar midpoint. Symptomatic and control values were compared using paired sample t-test. Stepwise multivariate linear regression was performed to assess for associations with standard radiographic parameters of trochlear dysplasia. Results: TCT was significantly different between the medial, central and lateral trochlea in both the symptomatic and control groups (p<0.001). Only lateral TCT demonstrated a significant difference between groups, which was 20.3% (p=0.035) thicker in the symptomatic cohort compared to controls. No significant differences existed in TCV between symptomatic and control groups. In females, central TCT was 28.3% thicker in the symptomatic cohort (p=0.024), while medial TCV was 2.3x greater (p = 0.019). Males failed to demonstrate gender specific differences. Regression analysis demonstrated that patient height showed a significant relationship with all measurements except for medial TCV. Central TCT demonstrated a significant, independent relationship with trochlear depth (Coefficient 0.38, p = 0.011), while central TCV demonstrated a significant, independent relationship with trochlear depth (Coefficient 9.9, p <0.001), sulcus angle (Coefficient 1.1, p <0.001), and lateral trochlear inclination (Coefficient -1.1, p <0.001). Conclusions: While trochlear dysplasia typically refers to abnormal bony morphology, this study demonstrates the role of differential contributions of chondral thickness and volume between knees with and without patellar instability, and that these measurements correlated with severity of dysplasia. Future studies should further investigate the relationship between TCT and TCV with other dysplasia parameters to better inform the surgical considerations of performing trochleoplasty in the treatment of patellar instability. [Table: see text]

Surgical Technique for the Latarjet Procedure Using Non-Cannulated Screws

Background: The Latarjet procedure is effective for patients with anterior glenohumeral instability with substantial glenoid bone loss due to its triple blocking effect. Indications: Indications include high-risk patients with recurrent anterior glenohumeral instability with any glenoid bone loss or low-risk patients with 15% to 30% glenoid bone loss. Technique Description: An incision is made lateral to the coracoid and the deltopectoral interval is established. The pectoralis minor is released medially off the coracoid and the coracoacromial (CA) ligament is released close to the acromion. The coracoid is cut with a right-angle saw and the inferior coracoid is decorticated with a burr. Two holes are pre-drilled in the coracoid. The subscapularis is split between the upper two-thirds and lower one-third with the arm in external rotation. The capsule is split vertically at the joint line and the humeral head is retracted. The anterior glenoid is decorticated with a burr, and a hole is drilled inferiorly. The depth is measured and added to the depth of the inferior bone block hole. A fully threaded 3.5-mm solid stainless steel screw is placed in the inferior hole. Care is taken to ensure that the lateral border of the bone block is flush with the articular margin. This is repeated for the superior hole. A 1.8-mm knotless suture anchor is placed between the screws. The repair stitch is passed through the capsule and loaded onto the anchor and tensioned. The CA ligament is laid over the capsule and repaired. The subscapularis split is repaired side to side and the wound is closed in layers. Results: High return-to-sport rates, including at the same level of play, have been observed among young competitive athletes with significant glenoid bone loss who underwent a Latarjet, with similarly favorable results in older patients. Ninety-day complication rates have been reported around 9%, 5% of which constituted graft or hardware failures. Discussion/Conclusion: The Latarjet procedure is an effective option for indicated patients with anterior glenohumeral instability and may be enhanced with solid screws, proper anatomic technique, and capsulolabral repair augmentation. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Morphologic and Morphometric Study of Lungs in Adult Indigenous Peafowl ‎‎(Pavo cristatus)


 
 
 
 Peafowl are a species of bird for which there is limited scientific research, despite the ‎importance of the respiratory system on bird health. This study aimed to provide a detailed ‎anatomical examination and comparative description of the lungs in adult male and female ‎indigenous peafowl (Pavo cristatus) to further our understanding of the respiratory system in ‎this species. Sixteen healthy adult peafowl (8 peacocks and 8 peahens) were obtained from ‎commercial markets in Dyalla, and Baghdad, Iraq. The birds had a mean live weight of 3.5±0.59 kg for females ‎and 3.0±0.39 kg for males. After being anesthetized, the birds were sacrificed by cutting off major ‎blood vessels in the neck. Subsequently, the lungs were carefully dissected and examined to ‎identify their shape, color, position, dimensions, and overall structure. Detailed photographs of ‎the lungs were taken, and various measurements were recorded for each lung in male and ‎female peafowl. The lungs of the peafowl were found to have an elongated, triangular shape, ‎extending from the first to the sixth vertebral ribs. Each lung exhibited two borders (medial and ‎lateral) and three surfaces (vertebral, costal or dorsal, and septal). Notably, the lateral border ‎and dorsal surface of each lung had four deep grooves resulting from the embedding of the ‎second to fifth ribs, which led to the division of the lung into five lobes in both peacocks and ‎peahens. To the best of our knowledge, this study represents the first scientific research on the ‎anatomical features of the lungs in indigenous peafowl. The findings from this study contribute ‎to a better understanding of the lung structure in this bird species, which can be valuable for ‎future studies on avian respiratory physiology and health.‎‎‎
 
 
 

Avoiding Pretarsal Denervation in Lower Blepharoplasty Incisions: Refined Pretarsal Motor Nerve Anatomy.

Pretarsal atrophy is not uncommonly found in patients who have undergone a transcutaneous or transconjunctival lower blepharoplasty because of intraoperative denervation of the pretarsal orbicularis oculi. The motor-supplying concept to the lower eyelid was recently updated; however, there have not yet been any guidelines to preserve motor nerves in lower blepharoplasty incisions based on the refined knowledge. Forty-six fresh cadaveric hemifaces were examined to find a safe zone for a lower blepharoplasty muscle incision and a danger zone for an infraorbital incision in the transblepharoplasty midface approach. In addition, practical anatomy about the pretarsal motor supply was also investigated in detail. The medial, lateral, superior, and inferior borders of the safe zone for a lower blepharoplasty muscle incision were 9.4 mm from the medial canthus line, 3 mm from the lateral canthal crease, and 6.0 and 6.5 mm from the eyelid margin, respectively. The danger zone for an infraorbital incision ranged from 9.4 mm medial to the midpupillary line to 9.7 mm lateral to the midpupillary line. The motor nerve in the danger zone abutted the distal roof of the preseptal pocket, making it vulnerable to electrocautery heat. Motor nerve distribution of the lower pretarsal orbicularis oculi was fully identified. There is a safe zone for the lower blepharoplasty muscle incision which, if adhered to, will preserve the pretarsal motor supply and prevent muscle atrophy. There is an infraorbital danger zone, where surgeons should pay special attention to avoid electrocautery heat injury.

Transmastoid/Infralabyrinthine Approach to the Jugular Foramen: 2-Dimensional Operative Video.

This approach is intended for tumors centered in the jugular foramen with extensions between intracranial and extracranial spaces, possible spread to the middle ear, and variable bony destruction. 1,2. Jugular foramen paragangliomas are complex lesions that usually invade and fill related venous structures. They present complex relationships with skull base neurovascular structures as internal carotid artery, lower cranial nerves (CNs), middle ear, and mastoid segment of facial nerve. In this way, it is essential to perform an adequate preoperative vascular study to evaluate sinus patency and the tumor blood supply, besides a computed tomography scan to depict bone erosion. Mastoidectomy through an infralabyrinthine route up to open the lateral border of jugular foramen, allowing exposure from the sigmoid sinus to internal jugular vein. Skeletonization of facial canal without exposure of facial nerve is performed and opening of facial recess to give access to the middle ear in way of a fallopian bridge technique. 2-10. If there is preoperative preservation of lower CN function, it is important to not remove the anteromedial wall of the internal jugular vein and jugular bulb. In addition, facial nerve should be exposed just in case of preoperative facial palsy to decompress or reconstruct the nerve. Variations are related mainly with temporal bone drilling depending on the extensions of the lesion, its source of blood supply, and preoperative preservation of CN function.Informed consent was obtained from the patient for the procedure and publication of his image.Anatomy images were used with permission from:• Ceccato GHW, Candido DNC, and Borba LAB. Infratemporal fossa approach to the jugular foramen. In: Borba LAB and de Oliveira JG. Microsurgical and Endoscopic Approaches to the Skull Base. Thieme Medical Publishers. 2021.• Ceccato GHW, Candido DNC, de Oliveira JG, and Borba LAB. Microsurgical Anatomy of the Jugular Foramen. In: Borba LAB and de Oliveira JG. Microsurgical and Endoscopic Approaches to the Skull Base. Thieme Medical Publishers. 2021.

Measurement of Thickness at the Inferior Border of the Mandible Using Computed Tomography Images: A Retrospective Study including 300 Japanese Cases.

Vascularised fibular free flaps are integral to reconstructive surgery for head and neck tumours. We investigated the morphological characteristics of the mandible to improve the incidence of plate-related complications after surgery. Using standard radiological software, thickness measurements of the inferior or posterior margin of the mandible were obtained from computed tomography images of 300 patients at seven sites: (1) mandibular symphysis, (2) midpoint between the mandibular symphysis and mental foramen, (3) mental foramen, (4) midpoint between the mental foramen and antegonial notch, (5) antegonial notch, (6) mandibular angular apex (gonion), and (7) neck lateral border of the dentate cartilage. Relationships between age, sex, height, weight, the number of remaining teeth in the mandible, and the thickness of each mandible were also investigated. Measurement point 1 had the largest median mandibular thickness (11.2 mm), and measurement point 6 had the smallest (5.4 mm). Females had thinner measurements than males at all points, with significant differences at points 1, 2, 3, 4, and 7 (p < 0.001). Age and number of remaining teeth in the mandible did not correlate with mandibular thickness; however, height and weight correlated at all points except point 6. Thickness measurements obtained at the sites provide a practical reference for mandibular reconstruction. Choosing the fixation method based on the measured thickness of the mandible at each site allows for sound plating.

AN UNUSUAL CLINICAL MANIFESTATION OF ORAL SQUAMOUS CELL CARCINOMA

A 64-year-old white female patient went to a dental service to investigate a lesion on her tongue that she had observed herself but could not tell how long this change had been in her mouth. On examination, a sessile, friable, normochromic nodule, measuring about 5mm, on the lateral border of the left tongue was detected, and the diagnostic hypothesis was a verrucous lesion. An excisional biopsy was performed, and the histopathological report was compatible with oral squamous cell carcinoma. This case report shows that oral malignant lesions do not always have a classical clinical manifestation, and often surprise even experienced professionals with this diagnosis. Therefore, it is essential to conduct a thorough diagnostic process of all oral lesions, regardless of the clinical diagnostic hypothesis of malignancy. A 64-year-old white female patient went to a dental service to investigate a lesion on her tongue that she had observed herself but could not tell how long this change had been in her mouth. On examination, a sessile, friable, normochromic nodule, measuring about 5mm, on the lateral border of the left tongue was detected, and the diagnostic hypothesis was a verrucous lesion. An excisional biopsy was performed, and the histopathological report was compatible with oral squamous cell carcinoma. This case report shows that oral malignant lesions do not always have a classical clinical manifestation, and often surprise even experienced professionals with this diagnosis. Therefore, it is essential to conduct a thorough diagnostic process of all oral lesions, regardless of the clinical diagnostic hypothesis of malignancy.

INCIPIENT ORAL SQUAMOUS CELL CARCINOMA MIMICKING TRAUMATIC ULCER

Squamous cell carcinoma (SCC) is the main histological type of oral cancer and is usually diagnosed at a late stage. The most common clinical feature is an infiltrating and chronic ulcer with hardened edges. However, it can present other manifestations, mimicking different conditions. Case report: Two Caucasians patients, smokers, 53 and 59 years old, were referred, complaining of tongue sores. Upon clinical examination, superficial ulcers were observed on the posterior lateral border of the tongue. The main diagnostic hypothesis was traumatic ulcers. However, as no improvement was observed after polishing of the cusps (case 1) and extraction (case 2), incisional biopsies were performed and revealed squamous cell carcinoma. Partial glossectomy, neck dissection, and radiotherapy were performed. The two cases exemplify the importance of a correct diagnosis, especially for oral lesions that mimic non-neoplastic processes. Squamous cell carcinoma (SCC) is the main histological type of oral cancer and is usually diagnosed at a late stage. The most common clinical feature is an infiltrating and chronic ulcer with hardened edges. However, it can present other manifestations, mimicking different conditions. Case report: Two Caucasians patients, smokers, 53 and 59 years old, were referred, complaining of tongue sores. Upon clinical examination, superficial ulcers were observed on the posterior lateral border of the tongue. The main diagnostic hypothesis was traumatic ulcers. However, as no improvement was observed after polishing of the cusps (case 1) and extraction (case 2), incisional biopsies were performed and revealed squamous cell carcinoma. Partial glossectomy, neck dissection, and radiotherapy were performed. The two cases exemplify the importance of a correct diagnosis, especially for oral lesions that mimic non-neoplastic processes.

CORRELATION BETWEEN EPITHELIAL DYSPLASIA AND ORAL SQUAMOUS PAPILLOMA AS A RESULT OF MULTIPLE RISK FACTORS: A CLINICAL CASE

This study is a clinical case of a 64-year-old leukoderma female patient, smoker for more than 45 years, who, after being diagnosed with Hepatitis A and B in different periods, presented a single leukoplastic, verrucous, pedunculated nodule, of the "cauliflower" type, on the lower alveolar edge of the right side (lesion I). It also presented homogeneous leukoplastic plaque, with verrucous surface, in the region of the lateral border of the tongue on the left side (lesion II). Both lesions were asymptomatic, with an undefined onset. The probable diagnostic hypotheses were squamous papilloma (lesion I) and leukoplakia (lesion II), with a differential diagnosis of condyloma (lesion I) and lichen planus (lesion II). Biopsy was performed by excisional removal of lesion I and incisional removal of lesion II, with the diagnosis of oral squamous papilloma and moderate to severe oral epithelial dysplasia, respectively. There was no radiographic lesion. Patient is undergoing follow-up. This study is a clinical case of a 64-year-old leukoderma female patient, smoker for more than 45 years, who, after being diagnosed with Hepatitis A and B in different periods, presented a single leukoplastic, verrucous, pedunculated nodule, of the "cauliflower" type, on the lower alveolar edge of the right side (lesion I). It also presented homogeneous leukoplastic plaque, with verrucous surface, in the region of the lateral border of the tongue on the left side (lesion II). Both lesions were asymptomatic, with an undefined onset. The probable diagnostic hypotheses were squamous papilloma (lesion I) and leukoplakia (lesion II), with a differential diagnosis of condyloma (lesion I) and lichen planus (lesion II). Biopsy was performed by excisional removal of lesion I and incisional removal of lesion II, with the diagnosis of oral squamous papilloma and moderate to severe oral epithelial dysplasia, respectively. There was no radiographic lesion. Patient is undergoing follow-up.

PITFALLS IN THE CLINICAL DIAGNOSIS OF ORAL SQUAMOUS CELL CARCINOMA

Oral squamous cell carcinoma (OSCC) may have several clinical manifestations, which can be confused with other more common lesions found in the oral cavity, delaying diagnoses and treatment, consequently worsening prognoses. We present two clinical cases of patients diagnosed with OSCC and no previous history of smoking or alcoholism. A 74-year-old man presented a small, symptomatic white plaque on the right lateral border of the tongue for 3 months. The initial diagnosis was frictional keratosis due to close contact to the lower second molar. The other patient was a 51-year-old man with symptomatic red area on the gingiva with 3 years of evolution. Initial clinical diagnosis was a possible lichen planus. Both patients underwent incisional biopsy, confirming the diagnosis of OSCC. In summary, it is important to recognize the different aspects of OSCC and establish the diagnosis as soon as possible, since clinical stages are directly related to prognoses. Oral squamous cell carcinoma (OSCC) may have several clinical manifestations, which can be confused with other more common lesions found in the oral cavity, delaying diagnoses and treatment, consequently worsening prognoses. We present two clinical cases of patients diagnosed with OSCC and no previous history of smoking or alcoholism. A 74-year-old man presented a small, symptomatic white plaque on the right lateral border of the tongue for 3 months. The initial diagnosis was frictional keratosis due to close contact to the lower second molar. The other patient was a 51-year-old man with symptomatic red area on the gingiva with 3 years of evolution. Initial clinical diagnosis was a possible lichen planus. Both patients underwent incisional biopsy, confirming the diagnosis of OSCC. In summary, it is important to recognize the different aspects of OSCC and establish the diagnosis as soon as possible, since clinical stages are directly related to prognoses.

SUBGEMMAL NEUROGENOUS PLAQUE: A SERIES OF 6 CASES

Subgemmal neurogenous plaque (SNP) is a structure generally found on the tongue, showing varied and non-specific clinical characteristics. Our study describes the clinicopathological characteristics of six patients, four females and two males, who had lesions on the lateral border of the tongue. The mean age was 46 years (ranging from 29-63 years). Although all cases were at the same anatomical site, the clinical characteristics varied from erythematous ulcer to white nodule, including two painful lesions. Lesion duration was provided in 4 cases, ranging from 0.5 to 120 months. All patients were submitted to biopsy procedures. The histological analysis displayed clusters of neural and lymphoid cells below the epithelial tissue. In four cases, this histological pattern was associated with lymphoepithelial cysts. The histologic diagnosis of SNP with or without associated lesions was made for all cases. After the biopsy procedure, none of the patients required additional treatment. Funding: FAPEMIG. Subgemmal neurogenous plaque (SNP) is a structure generally found on the tongue, showing varied and non-specific clinical characteristics. Our study describes the clinicopathological characteristics of six patients, four females and two males, who had lesions on the lateral border of the tongue. The mean age was 46 years (ranging from 29-63 years). Although all cases were at the same anatomical site, the clinical characteristics varied from erythematous ulcer to white nodule, including two painful lesions. Lesion duration was provided in 4 cases, ranging from 0.5 to 120 months. All patients were submitted to biopsy procedures. The histological analysis displayed clusters of neural and lymphoid cells below the epithelial tissue. In four cases, this histological pattern was associated with lymphoepithelial cysts. The histologic diagnosis of SNP with or without associated lesions was made for all cases. After the biopsy procedure, none of the patients required additional treatment. Funding: FAPEMIG.

ORAL HAIRY LEUCOPLAKIA IN AN HIV-POSITIVE PATIENT: A CASE REPORT

Our clinic received a 33-year-old male patient, complaining of an oral burning sensation and white lesions on the lateral border of the tongue for 7 months. He also reported weight loss and nausea, and was recently diagnosed with HIV (viral load of 1,260,000 copies/ml and LTCD4 of 86 cells/uL). Intraoral exam showed white, verrucous, and irregular plaques located bilaterally on the tongue. An incisional biopsy was performed and anatomopathological examination showed superficial squamous epithelium with ballooning epithelial cells with bare nuclei, confirming the diagnosis Oral Hairy Leucoplakia (OHL). The in-situ hybridization for Epstein-Barr Virus (EBER) was positive. The patient began antiretroviral treatment, taking dolutegravir, tenofovir, and lamudivine. One month later, he presented undetectable viral load and LTCD4 of 294 cells/uL. After 2 months of follow-up, OHL showed complete clinical regression. AIDS is under control in Brazil, but clinicians must bear in mind the diagnosis of OHL in HIV+ patients. Our clinic received a 33-year-old male patient, complaining of an oral burning sensation and white lesions on the lateral border of the tongue for 7 months. He also reported weight loss and nausea, and was recently diagnosed with HIV (viral load of 1,260,000 copies/ml and LTCD4 of 86 cells/uL). Intraoral exam showed white, verrucous, and irregular plaques located bilaterally on the tongue. An incisional biopsy was performed and anatomopathological examination showed superficial squamous epithelium with ballooning epithelial cells with bare nuclei, confirming the diagnosis Oral Hairy Leucoplakia (OHL). The in-situ hybridization for Epstein-Barr Virus (EBER) was positive. The patient began antiretroviral treatment, taking dolutegravir, tenofovir, and lamudivine. One month later, he presented undetectable viral load and LTCD4 of 294 cells/uL. After 2 months of follow-up, OHL showed complete clinical regression. AIDS is under control in Brazil, but clinicians must bear in mind the diagnosis of OHL in HIV+ patients.

Celiac plexus neurolysis in pancreatic neoplasm with celiacomesenteric trunk: a case report

BackgroundCeliac plexus neurolysis is an effective mode of long-term palliation of somatic pain in inoperable upper gastro-intestinal neoplasm. CT guidance is the most accepted method of localising the tip of the needle, through which, the neurolytic agent, commonly Absolute Alcohol, is introduced along the celiac ganglion. Three dimensional assessment of the retroperitoneal anatomy avoids injury to adjacent viscera and vascular structures. Para-aortic needle tip position between the origins of celiac and superior mesenteric arteries is an accepted position to inject neurolytic agent. We report a case of successful celiac plexus neurolysis in a patient with a celiacomesenteric trunk. Till date no such case has been reported, primarily due to the Low incidence of celiacomesenteric trunk.Case presentationA 63-year-old man developed progressive icterus and severe abdominal pain over 3 months. The pain severity was 6/10. An Ultrasonography and contrast enhanced CT of the abdomen revealed inoperable carcinoma of head of pancreas and a celiacomesenteric trunk. The pancreatic mass extended along the right lateral border of the celiacomesenteric trunk, not extending upto the aorta. Considering the severity of pain, poor compliance to opioid pain medication, and a possibility of early tumour extension upto the aortic margin, celiac plexus neurolysis was considered. The procedure was performed under CT guidance and local anaesthesia, using a mixture of absolute alcohol, Bupivacaine and diluted iodinated contrast. Bilateral paravertebral antecrural access was performed, using 22 gauge Chiba needles, after localisation on preprocedural CT-scan. On the left, hydrodissection was performed using normal saline, to displace the left renal parenchyma from the trajectory of the needle to be used for neurolysis. The patient’s pain visual analogue scale score reduced to 0/10, immediately after the procedure. He had a post procedural hypotension, managed conservatively by complete bed rest for 1 day and intravenous fluid administration.ConclusionsCeliac plexus neurolysis can safely be done in aberrant upper abdominal vascular anatomy, under CT guidance and local anaesthesia. To avoid periprocedural complications, hydrodissection may be effectively used to displace normal anatomical structures from the trajectory of the access needle, through which a mixture of absolute alcohol and local anaesthetic may be delivered.

Diagnostic imaging for elbow TRASH lesions in children and usefulness of ultrasonography using standard planes.

Fractures around the elbow in children should be carefully evaluated because the main portion is cartilaginous, and radiographs are not completely reliable. This study aimed to assess the diagnostic imaging for pediatric elbow fractures that require special attention and consider the usefulness of ultrasonography with seven standard planes for the diagnosis. Patients diagnosed with elbow fractures wherein TRASH (The Radiographic Appearance Seemed Harmless) lesions were evaluated retrospectively. The diagnoses on initial radiographs, final diagnoses, additional imaging excluding radiographs, and the treatments were investigated. The standard planes for ultrasonography to detect elbow fractures included an anterior transverse scan at the level of the capitellum and proximal radioulnar joint, an anterior longitudinal scan at the level of the humeroradial and humeroulnar joints, a longitudinal scan along the lateral and medial border of the distal humerus, and a posterior longitudinal scan at the level of the distal humerus. A total of 107 patients with an average age of 5.8 years (range, 0-12 years) at the time of diagnosis were included. Of 46 (43.0%) patients misdiagnosed at the initial radiograph, 19 (17.8%) needed additional treatments due to inappropriate initial management. Ultrasonography using the standard planes was useful for prompt diagnosis and appropriate treatment. Prompt and appropriate evaluation with ultrasonography can prevent the mismanagement of pediatric elbow injuries. Level of evidence: Level IV-retrospective case series.

Nonspecific ulcers on the edge of the tongue

A 56-year-old patient was sent to our Oral Pathology service with a chief complaint of “painful sores on her tongue”. She also complained of difficulty chewing any solid food. According to the patient, the change had been present for 6 months, but the pain had worsened in the last 2 months. She also reported frequent abdominal pain. Pain started just before the appearance of the oral lesions and weight loss in these last few months. No palpable cervical lymph nodes were found. Intraoral examination revealed ulcers on the right and left lateral border of the tongue, with red, irregular patches and raised edges. The marginal gingiva was swollen and erythematous (Figures 1A and 1B). The medical history was non-contributory.

Differentiation of strains in the lateral and medial bands of the iliofemoral ligament: A segmental approach.

Iliofemoral ligament strains have been assessed in a circumscribed portion, limiting the information regarding the strains in the proximal, mid and distal portions. The purpose of this study is to describe the longitudinal and transversal strain within the proximal, mid and distal portions of the lateral and medial bands of the iliofemoral ligament. Ten fresh cadaveric specimens were assessed. The iliofemoral ligaments were divided into medial and lateral bands. Hemispherical beads (2.6 mm) were placed on the lateral and medial borders of each band. Four positions were assessed: abduction, extension, internal and external rotations combined with extension. The hemispherical beads were scanned at the end range of motion using a laser scanner. The three-dimensional position of each bead was used to estimate longitudinal and transversal strains. A three-factor ANOVA was used to compare movements, borders, and portions within each ligament for longitudinal strains. A one-way ANOVA was used to compare transversal strains between portions. This technique showed mean reliability (ICC: 2, 1) of 0.90 ± 0.06. The external rotation showed the highest strains in both ligaments (p < 0.05). Abduction showed a significant difference between the lateral and medial borders in both bands (p = 0.001). Eight movement-border combinations showed a significant difference between proximal, medial, and lateral portions (p < 0.005). According to our results, there is a clear effect of portions (proximal, mid and distal) within the ligament and movements. Abduction shows the lowest strains longitudinally but the largest strains transversally. Although we do not know the impact of this phenomenon, future studies should assess the strains following hip arthroscopies. The latter might improve the impact of this procedure on hip biomechanics. Lastly, the iliofemoral ligament should be assessed using a segmental approach rather than as a complete unit.

The Occipitalis Muscle as an Adjunct Superficial Landmark for the Transverse Sinus and Transverse-Sigmoid Junction: An Anatomical Study With Application to Posterior Cranial Fossa Surgery.

Although neuronavigation systems are widely used for identifying deep intracranial structures, additional superficial anatomical landmarks can be useful when this technology is not available or is not working properly. Herein, we investigate the potential of the occipitalis muscle (OM), rarely mentioned in neurosurgical literature, as a superficial landmark for the transverse sinus (TS) and transverse-sigmoid sinus junction (TSJ). Eighteen adult cadaveric heads underwent dissection. The borders of the OM were identified and measured. The muscle was then removed and the bone underlying the muscle was drilled. The relationships between the OM and the underlying dural venous sinuses were then investigated by using a surgical microscope. The OM is a quadrangular-shaped muscle, that invariably crosses the lambdoid suture, showing relationships with the TS inferiorly and the TSJ laterally. The medial border was located a mean of 2.7 cm from the midline and its lower edge was a mean of 1.6 cm above the TS. The inferior border was found between the lambdoid suture and the superior nuchal line in all the specimens. The medial half of the inferior margin was placed on average 1.1 cm superiorly to the TS while the lateral margin ran just above or over the TS. The lateral border was located a mean of 1.1 cm medially to the asterion and approximated the mastoid notch, being within 1-2 cm from it. The TSJ was between 2.1 and 3.4 cm lateral to OM lateral border. A combination of superficial anatomical landmarks can be useful for surgical planning. We found that the OM represents a valuable aide for neurosurgeons and is a reliable landmark for the deeper-lying TS and TSJ.

(019) Complete Sub-Epithelial Vestibulectomy: Refinement of Surgery for Neuroproliferative Vestibulodynia

Abstract Introduction Complete vestibulectomy (CV) was first described by Goldstein and Marinoff, detailing an excision 3 mm cephalad to the hymen and caudad to Hart’s line. A vaginal advancement flap (VAF) to cover the defect left by excised vestibule was also described. Since neuroproliferative vestibulodynia is a field disease, The CV with VAF surgery has become widely utilized practiced by sexual medicine surgeons to treat neuroproliferative vestibulodyniaby surgeons practicing sexual medicine. However, the depth of dissection for the vestibular mucosal excision (VME) was not clearly defined. To gain a better appreciation for appropriate depth of the VME during CV with VAF, we have reviewed the results of immunohistochemical staining (IHC) of excised vestibular specimens (n=564) since 2019. In all cases, tissue depth of the excess positive CD117 and PGP9.5 staining, consistent with excess mast cells and nerves respectively, were &amp;lt; 600 μm (0.6 mm) from the epithelial surface. Objective Our objective is to describe safety and efficacy of vestibulectomy surgical technique modifications made in 2021 based on this finding. Methods We refined the CV and VAF surgery based on the observation that the IHC pathology resides very close to the vestibular epithelium. This modification has been termed complete subepithelial vestibulectomy (CSEV). These modifications keep the VME thickness as close as possible to 1-2 mm. Liposomal bupivicaine (20 ml) is injected subcutaneously throughout the vestibule to hydrodissect the mucosa. The lateral border at Hart’s line and medial border 3 mm cephalad to the hymen is incised. The mucosal surface of the vestibule is grasped with an atraumatic vascular clamp and dissected sharply with the tissue stretched over a finger to maintain a very thin VME. Excised specimens are sent for IHC staining. Patients who underwent CSEV with VAF surgery from 2021 onward were followed for ≥ 6 months. Results A total of 13 individuals (mean age 29 ± 8yrs) underwent CSEV with VAF, with a mean follow-up of 8 ± 4 months. Photomicrographs of surgical specimen confirmed the thickness to be approximately 1-2 mm (Fig 1). Blood loss was minimal, &amp;lt;100 ml in 11/13. Post-operative use of narcotics was minimal with all patients reporting less than 5 oxycodone 5mg tablets used. At 6 months post-op, 10/13 reported their vestibulodynia was much better/better based on PGI-I. Conclusions We report CSEV as a refinement of the Goldstein/Marinoff procedure. The depth of dissection and thickness of VME was 1-2 mm with this new procedure. Early results in our small case series show excellent vestibulodynia resolution and reduced pain medication requirements post-operatively. To date, the success rate of CSEV is equivalent to the outcomes from previous vestibulectomy series, ~77%, with minimal less operative blood loss. Disclosure No

Cavernous Hemangioma of Tongue in an Adult Male: A Rare Case Report

Hemangiomas are benign tumors of endothelial cells and most common tumors of the childhood but rarely found in adults. They appear a few weeks after birth and grow rapidly, and in most cases undergo involution. Hemangiomas occur more common in females than males. The treatment depends upon patient’s age, lesion location, size, and evolution stage. Here, we report a rare case of cavernous hemangioma in a 44-year-old male present on right lateral border of anterior two-thirds of tongue.