A NOTE ON SYMMETRICAL THINNING OF
THE PARIETAL BONES
BY ARCHIBALD DURWARD, M.B., CH.B.
(From the Department of Anatomy, University of Otago, New Zealand)
INTRODUCTION
IN the museum of this department there are now five skulls exhibiting the
condition known as "Symmetrical thinning of the parietal bones."
Although Elliot Smith(2) found the condition to be relatively common in
Egyptian cemeteries of certain dynasties, the literature does not suggest that
to-day symmetrical thinning is at all common. Sir George Humphry(4) had
located six specimens in European museums in 1858, and mentioned two others
of a doubtful nature. Since that time little has been heard as to the frequency
of the condition; but one can hardly suppose that museums possessing large
osteological collections can be devoid of examples. Perhaps this reference to
''symmetrical thinning" may lead to further information from other sources
concerning this very definite, though puzzling, condition.
Examination of about 1000 skulls, both in the dissecting-room and in the
museum collection of Maori and Moriori skulls, has yielded five cases of symmetrical
thinning-a frequency of approximately 1 in 200. This would appear
to be a higher rate of frequency than Humphry had noted in European
museums. In 400 Maori and Moriori skulls examined only one case was found.
Two of the cases reported belonged to Chinese, but the number of Chinese
dissected here, 25 to date, is so limited that conclusions cannot fairly be drawn
from this fact.
DESCRIPTION OF CASES
In all cases the process of thinning has operated entirely from without,
affecting the outer table and the diploe most constantly. The inner table has,
however, been definitely involved in one case (fig. 2) where a perforation has
resulted. In no case does the interior of the skull show any abnormality. The
condition affects that portion of the parietal between the sagittal suture and
the temporal ridge and is about equidistant from both coronal and lambdoid
sutures.
The symmetrical nature of the condition is very apparent in all cases,
though there may be, as in the skull shown in fig. 3, a difference in the extent
of the thinning on the two sides both as to the area of bone involved and the
depth of the thinning.
The edges have a characteristic shelving nature so that usually a fairly
wide rim of diploe surrounds the central area of exposed inner table. In one
Coronal Sutu|
ridge
Diploe -
expose
Fig. 1. Skull of a male subject from the dissecting room. The sutures are largely obliterated. The
proximity of the thinning to the temporalJridge is evident. The inner table presents a smooth
surface compared with the finely nodular surface of the exposed diploe.
Diploe _ _
exposed
Perforation -= n ne
La ~Ie
Lambdoid suture
Fig. 2. This skull, removed from the dissecting room, has the sutures almost completely obliterated.
Sex not recorded. On the left side the thinning has proceeded so far as to expose the
grooves for meningeal vessels in the interior of the skull, an irregular perforation resulting.
Other minute foramina exist on both sides leading into the grooves for meningeal vessels.
Archibald Durward
case (fig. 5), which is somewhat atypical, the shelving nature of the edge is
not so apparent and the diploe is not exposed at all, but the symmetrical
nature of the condition and its position on the bone are typical.
Both the size and the contour of the areas involved vary very considerably
in the different cases of this series, but in every skull the lateral border of the
thinned area lies closely against the temporal ridge. In those cases which
present a considerable area of thinning (figs. 1, 2, and 3) the lateral border
skirts round the temporal ridge in a remarkable manner, and the shelving edge
on this aspect is as a rule much steeper than the edge elsewhere. In no case
does the thinning extend beyond the temporal ridge, and as shown in the
figures the parietal foramina, when present, are not involved.
In the better marked cases the areas of thinning are plainly seen with
transmitted light, and where the grooves for meningeal vessels have crossed
the field the thinning is very clearly accentuated.
DISCUSSION
Sir George Humphry(4) described the condition briefly in its typical form,
mentioning that it is situated midway between the sagittal suture and the
parietal eminence, and that the parietal ¶oramina always escape. In this series
the areas of thinning would certainly appear to lie nearer the parietal eminence
than Humphry found. From the symmetrical nature of the process and from
the absence of disease in the specimens he examined, Humphry considered the
thinning to be of a congenital nature. He had, moreover, seen a case in a living
child, a fact which supported the suggestion of the congenital nature of the
condition. In another place (5) Humphry suggested as a possible causal factor
the pressure of the occipito-frontalis; but this does not seem likely in view of
the very definitely localised areas .of thinning.
Elliot Smith (2) had the opportunity of examining over 70 examples of this
condition in Egyptian skulls, and from the fact that the thinning was present
only in the skulls of the wealthy of certain dynasties when heavy wigs were
apparently worn continuously, he concluded that continuous pressure from
the exterior, with its resultant interference with the blood supply to the bone,
was probably the causative factor. From the skulls he examined he was able
to show definitely that the condition was not necessarily a senile one and that
both sexes were affected. The thinning appeared to have taken place by erosion
of a properly developed cranial wall, and moreover there was not a single
instance of its occurrence in an individual under 25, or perhaps even 30, years
of age. For the Egyptian cases, then, it appears clear that the condition was
not congenital and that it had as its cause continuous pressure from the exterior.
Shepherd (8) also describes the typical form of the condition and records
three cases one of which, an adult female, was in the living. In this latter case
the evidence pointed strongly to the congenital nature of the condition, and
there was a suggestion also of its being hereditary. Shepherd mentions senile
358
Symmetrical Thinning of the Parietal Bones
Temporal ridge Outline of
meningeal
vessel
Fig. 3. Skull of a male Chinese, aged 74, from the dissecting room. The sutures are largely obliterated.
On the left side the thinning has proceeded no further than to expose the diploe.
Tempordl
ridge
Diploe
Fig. 4. Skull of a male Chinese, aged 74, from the dissecting room. All sutures closed. The areas
of thinning are small and shallow, the inner table being nowhere uncovered.
359
Archibald Durward
changes in the temporal artery as a possible causal factor, leading to atrophy
of the outer table and the diploe, but leaving the inner table unaffected. He
notes that this cannot explain all cases.
The condition is referred to by Maier(6) and Ziegler (9), both of whom regard
it as a senile change.
There is the possibility that if this condition be progressive, it may ultimately
lead to symmetrical perforations. Greig (3), Derry (1), and Paterson and
Lovegrove (7) have written of parietal perforations. While Greig and Derry do
not mention symmetrical thinning, Paterson and Lovegrove draw attention
to it and state that there is no apparent relationship between symmetrical
thinning and such perforation as they described. One skull of the series
described in this paper (fig. 2) shows a perforation on one side, but it is not of
the type figured by these writers; it has obviously resulted from the thinning
process meeting the grooves for the meningeal vessels. Paterson and Lovegrove
also state that they have seen symmetrical depressions in foetal parietal bones.
Reviewing the various causes that have been suggested, certain of them
may be discounted when applied to the skulls of this series. Continuous
pressure from some external object, which adequately explains the Egyptian
cases described by Elliot Smith, will not explain the cases of this series where
no history of pressure of such a type is forthcoming. Humphry's suggestion
of pressure from the occipito-frontalis does not appear to be sufficient in view
of the definitely localised areas of bone involved in this series.
It would certainly appear that the condition is most frequently met in aged
skulls, and the view that it is really a senile change has had not a few supporters.
But Elliot Smith found the condition in relatively young skulls in
Egypt; also there are cases on record of its occurrence in the living of such ages
that senile changes may be safely excluded; and one skull of this series (fig. 5)
is certainly not senile. These facts prove that, though the condition is commonest
in advanced life, it is not necessarily a senile change.
Humphry, Shepherd, and Paterson and Lovegrove have all mentioned the
likelihood of the condition being congenital, and the former two writers
reported cases in the living which were suggestive of being congenital. Though
this is not so convincing as the production of the actual skull, yet it must be
admitted as a possibility. Elliot Smith did not consider it likely to be congenital
so far as the Egyptian skulls were concerned. In view of these facts,
then, it must be admitted that, however likely this suggestion may be, direct
proof is lacking.
The possibility of symmetrical thinning of the parietal bones being a progressive
condition appears not unlikely. The most constant position of the
thinning is just above the temporal ridge and about midway from before back
on the bone. From this spot spread would take place forwards, medially
towards the sagittal suture, and backwards, and also the thinning would
become progressively deeper. This would account for the varying areas of
thinning met in different skulls. The constant proximity to the temporal ridge
360
Symmetrical Thinning of the Parietal Bones 3
seems certainly to have some significance. The blood supply to the bone would
be assured from the level of the temporal ridge downwards owing to fascial
and muscular attachments, whereas above this level the nourishment of the
bone would not be assured by any such attachment. The possibility exists
therefore that the condition may be progressive and that it may depend upon
some deficiency in the blood supply. No cause for this deficiency which would
account for all the cases of this series is evident.
TempordI
BIse formed
byouter tdble
Fig. 5. Maori skull with all sutures open; over 25 years of age. The diploe is not exposed and the
edges are not so typically shelving as in the other cases.
SUMMARY
1. Five cases of symmetrical thinning of the parietal bones are described.
2. The literature available is briefly reviewed and existing theories as to
causation are mentioned.
3. The constant proximity of the thinning to the temporal ridge in the
cases of this series is stressed.
4. It is suggested that the condition may be progressive, and that it may
be caused by a deficiency in the blood supply to the bone above the level of
the temporal ridge. No cause for such deficiency is suggested.
In conclusion I wish to express my thanks to Prof. W. P. Gowland for
permission to publish the cases which have occurred in the Museum and in the
dissecting-room of this department.
361
362 Archibald Durward
REFERENCES
(1) DERRY, D. E. (1914). Journ. of Anat. and Physiol. xLVII. p. 417.
(2) ELLIOT SMITH, G. (1907). Journ. of Anat. and Phy8siol. xII. p. 232.
(3) GREIG, D. M. (1892). Journ. of Anat. and Phyiol. xxvi. p. 187.
(4) HuxpEuy, G. (1858). The Human Skeeton. Cambridge. Pp. 242-243.
(5) - (1890). Journ. of Anat. and Phy8iol. xxrv. p. 598.
(6) MAIER. Virchow'8 Archiv, vIi. p. 336. (Quoted by ELLIOT SMITE.)
(7) PATERSoN, A. M. and LOVEGROVE, F. T. (1900). Journ. of Anac. and Phy8iol. xxxiv. p. 228.
(8) SHEPHERD, F. J. (1893). Journ. of Anat. and Phy8iol. xxvir. p. 501.
(9) ZIEGLER. Text Book of Special Pathological Anatomy, transl. MACALsSTER and CATTELL, 1896,
sections i-viii, p. 143. (Quoted by ELLIOT SmX[T.)
lunes, 28 de enero de 2008
Articulo anexado Alejandro Arvizo
CHEMICAL TREATMENT OF THE PERIOSTEUM IN THORACOPLASTY
TO INHIBIT RIB REGENERATION
BY C. M. VAN ALLEN, M.D.
OF PEIPING, CHINA
FROM THE DEPARTMENT OF SURGERY, PEIPING UNION MEDICAL COLLEGE
FIVE years ago, Jerome Head' described experiments in which he tested
the effectiveness of various chemical agents for preventing osteogenesis after
subperiosteal costectomy. He removed pieces of several ribs from each of
a number of dogs and then painted the rib-free periosteum with the chemicals
before closing the wound. After a lapse of time amply sufficient for bone to
regenerate, the animals were sacrificed and the rib beds were examined by
X-rays and dissection. Zenker's solution seemed the most suitable of the
agents employed, since it prevented osteogenesis completely without producing
appreciable necrosis. Meiss2 reported a similar investigation in I930.
Although he found Zenker's solution quite effective in preventing the formation
of new bone, he noted perforation into the pleural cavity in one instance
and symptoms (undescribed) of systemic poisoning. He preferred IO per
cent. solution of formalin-an agent not tested by Head-for it had all the
advantages of Zenker's solution and none of the disadvantages.
Both authors suggested clinical uses for their methods in certain types of
thoracoplasty. Thus, it was recalled that where ribs have to be resected in
stages for producing collapse of the chest-wall, "the true collapse occurs only
with the removal of the last ribs. Until then the part of the wall of the chest
which is already mobilized hangs from the ribs like the curtain of a tent, and,
if the bones reform in this position, the final collapse is compromised."'
Furthermore, the lapse of three weeks between the first and last stages of
operation may be sufficient to bring about this undesired result, and yet
that or even a much greater interval between the stages is often advantageous
or imperative, in order to replenish the patient's strength and morale, to
prevent advancement of associated diseases, to permit infected wounds to
heal, to test the effectiveness of preceding stages, etc. It seemed to Meiss that
the method would be useful in paravertebral extrapleural thoracoplasty for
pulmonary tuberculosis because it would allow wider intervals between the
stages of operation and would permit the chest-wall to continue collapsing
slightly for several months after operation, in response to the gradual
fibrosis and shrinkage of the lung that occurs with the healing of the disease.
He believed that the prevention of rib regeneration would not leave
the thoracic wall sufficiently unstable to jeopardize the healing of the pulmonary
lesion, for he knew of a patient who had received paravertebral
thoracoplasty by supraperiosteal costectomy and had obtained full benefit
to the tuberculous lesion of the lung. Head advised against this application
368
TREATMIENT OF PERIOSTEUM IN THORACOPLASTY
of the method, on the theoretical grounds of mural instability. Other uses
suggested by these authors were as follows: Employment in the graded
Estlander operation for chronic empyaema or bronchiectasis, to permit wider
spacing of the stages and more prolonged collapse; use in the Brauer cardiolysis,
to ensure permanent pliability of the precordium; use in the rib
resection for drainage of empyema or lung abscess, to prevent new bone
from forming in, and encroaching upon, the sinus; and use in the rib resection
for cautery pneumectomy, to obviate the difficulty which may arise
from regeneration of bone in the field of cauterization.
Neither one of the authors has reported clinical experience with his
method, and the only reference of the kind that I can find is the bare statement
of Trout3 that he had used the method of Head with satisfaction in
thoracoplasty for pulmonary tuberculosis. I began to use Zenker's solution
in plastic operations for chronic empyema soon after the appearance of
Head's publication, but changed later to formalin. Twelve cases of that
type have been treated with one or the other chemical, and, besides, twentythree
cases with drainage of empyaema, three with drainage of lung abscess,
and two with cautery pneumectomy. While this experience is quite insufficient
for final evaluation of the methods, the results have been satisfactory
and consistent enough to warrant preliminary report.
The first case to be treated was that of a white male, aged thirty-two years. At
the time of admission to the hospital, he had been ill for eleven months with productive
cough, fever, dyspncea, and weakness. Five months before the symptoms had become
so exaggerated that the patient had to stop work. His physician at the time made the
diagnosis of empyema of the left pleural cavity and established drainage by intercostal
catheter. Considerable improvement followed, but soon the cough and fever returned.
On admission the patient was found to be emaciated, weak, and toxic. The left half
of the chest was markedly retracted and fixed, and it exhibited a narrow sinus at the
seventh intercostal space in the posterior axillary line. Tubercle bacilli were abundant
in the sputum and in the pus from the sinus. X-ray examination showed an empyaema
cavity on the left side with very thick walls, extending from the third rib to the diaphragm
and from the anterior axillary line to the vertebral column. An operation
was done immediately to widen the sinus. A specimen of the pleura which was obtained
at the time revealed the presence of tuberculous infection. The drainage thus established
and the supportive treatment that followed produced great improvement of the constitutional
condition within two months; but the cavity was unchanged in size, so the
decision was made to obliterate it with the graded thoracoplasty of Schede. At the
first stage, the lower one-third of the roof of the cavity was removed; but the shock
was very severe. So, two months later, when the patient's strength was sufficiently
restored, the milder operation of Estlander was resorted to, with the addition that
the rib-free portions of periosteum were painted with Zenker's solution. The parts
of the ribs lying over the cavity, together with a part of one rib (second) above, were
removed in two sittings, with an interval of six weeks between to allow for delayed
wound healing. The immediate effect of this was only partial obliteration of the
empyaema cavity; but the collapse proved to be progressive and fourteen months after
the last operation the cavity was closed, the sinus was healed, and the patient felt well.
In the three other cases of tuberculous empyama treated since then, the
entire lengths of the ribs overlying the cavities were removed subperiosteally
24 369
C. M. VAN ALLEN
in small and widely spaced steps, with application of one or the other chemical
to the periosteum. The cavities collapsed satisfactorily, and only one
(see the case report below), which was operated upon very recently, has
not yet healed. Graded subperiosteal resection of only the posterior segments
of ribs was employed for the patients with extenisive non-tuberctnlous
empyaema. This included the ribs over the cavity-and onie above if
the cavity was subtotal. The result was that the anterolateral segments of
ribs, the thickened parietal pleura, and the superficial tissues, which remailled
over the cavity, fell progressively during and after the operations until obliteration
was complete. One of these cases required further work, to uniroof a
small residual cavity. Thus, in both types of empyema, the Estlander operation
almost entirely replaced the Schede procedure, which hitherto had been
indispensable. Since the parietal pleura and intercostal structures were not
removed, as in the Schede thoracoplasty, the operations were accompanied by
relatively little blood loss and shock and by no paralysis of the abdominal
wall. A comparatively small but noteworthy advantage of the chemical treatment
was that, after resection of the posterior segments of ribs, the posterior
ends of the anterolateral segments developed no spurs.* No appreciable (lisadvantage
was experienced from paradoxical respiratory movements of the
clhest-wall. Scoliosis developed, but it was no greater-indeed, uisually mucl
less-than that after Schede resections for equally extenisive cavities. Chemical
poisoning was watched for but was not detected. Chronic empy.sema cavities,
-which were so small as to extend under no more than three ribs, were
still treated by the Schede thoracoplasty.
The expected benefits were derived, also, in connection with rib resection
in the other types of cases. Although the benefits were comparatively
sliglht, they were worth while.
One case was outstandinig, because it made possible a direct comparison
between Zenker's ancd forniialin solution-s as to their effectiveness in prevenltinlg
osteogeniesis.
A Chinese male, aged twenty-three years, was admitted to the hospital with a
history of productive cough for two and one-half years. Slight weakness was the only
accompanying symptom, until one day three months before when, during unusually
strenuous coughing, sudden pain occurred in the right side of the chest and marked
dyspncea developed. He took to bed at once and soon had a chill and started to run
a high fever. On admission the man was extremely emaciated and feeble, orthopneeic,
cyanotic, and disturbed by a frequent productive cough. The sputum was fetid and
containied myriads of tubercle bacilli. Physical and r6ntgenographical examination of
the chest revealed complete collapse of the right lung, fluid and air in the right pleural
cavity, extenisive displacement of the mediastinum to the left, depression of the right
hemidiaphragm, and a light infiltration of the left upper lobe which was suspected to
he tuberculous. The chest was tapped. The fluid proved to be thick pus, containing
tubercle bacilli, streptococci, staphylococci, and other organisms, and the air was found
to be under pressure of plus 3 to 8 centimetres H20. The initial treatment consisted
* Hedblom4 has emphasized the danger of laceration of the pleura and lung that
exists during anterolateral costectomy for pulmonary tuberculosis, in removing ribs
that carry these sharp, upward curved projections.
370
TREATMIENT OF PERIOSTEUM IN THORACOPLASTY
in bi-daily aspiration of large quantities of pus anid air and in general supportive measures.
Within four weeks the dyspncea was greatly relieved and the mediastinum was
returned to the mid-position (Fig. i) ; but the secondary infection and fever persisted,
so that open drainage was done. At the same operation, ten centimetres of each of
ribs II, IO and 9 were resected paravertebrally alnd the rib-free periosteum was painted
with Zenker's solution, which constituted the first stage of an Estlander operation to
de-rib the entire right half of the chest. The paravertebral wound became infected
slightly from its close proximity to the drainiage wound. The operation was well
borne, nevertheless, so it was decided not to wait for complete healing of the paravertebral
incision but to abandon the usual orderly progression of resection and operate
the second time at a considerable distance. Consequenitly, the second stage was performed
twenty-six days after the first and consisted in the resection of four to ten
centitmletres of the posterior extremities of ribs 4 to I, inclusive, with application of
Zenker's solutioni. The wounid healed well. But shortly after this, the temperature
becamie somewlhat elevated, the cough inicreased, and a rontgenogram (Fig. 2) showed
FIG. .. Fio. 2.
FIG. I.Thoracic rontgenogram of a case with secondarily infected, tuberculous empyaema and
comiplete collapse of one lung, taken just before the beginning of a graded subperiosteal costectomy
wherein Zenker's and formalin solutions were compared for effectiveness in preventing rib regeneirationi
FIG. 2.-Same case, thirty-six days after the establishment of open drainage and the resection
of the posterior segments of ribs IIto 9, and ten days after the resectioni of the posterior segments
of ribS 4 to I. The rib-free periosteum was painted with Zenker's solution. Arrows ind:cate the foci of
new bone from the first operation.
a slight increase in the lesion of the left lung. The same r6ntgenogram was initerestinig
from the fact that it gave an exceptionally distinct view of the beds of some of the
resected ribs-due to the persistence of a bridge of ribs (8 to 5) across the middle of
the hemithorax which held the beds widely out-and that it showed definlite traces of
new bone in the field of the first operation performed thirty-six days previously. The
infection in the left lung quieted sufficiently to permit the third stage to be performed
fifty-one days after the second, with removal of the anter-olateral segm'ents of the
upper four ribs; but this time i0 per cent. solution of formalin was used in place of
Zenker's solution, according to Meiss' suggestion. The wound healed per Prima,.
And once more the condition of the left lung demanded a long wait. A rdntgen-film
(Fig. 3), taken fifty days after the third stage, showed that the formalin-treated peniosteum
was free from appreciable amounts of new bonle, while the Zenker's treated
periosteum of the first operation((127 days before) had developed inicomplete but welldefined
ribs. The field of the second operation lay too close to the spine to permit clear
371
C. M. VAN ALLEN
discernment of the degree of rib regeneration. The fourth operation came the day after
this examination and the fifth came twenty-seven days later, whereby the remaining
ribs and portions of ribs were taken out and the periosteum was painted with formalin.
Figure 4 gives the appearance ten days after the last operation when the chest-wall
was completely collapsed and the merest slit remained of the empyama cavity. The
patient's condition was satisfactory in other respects, also. The cough was absent, the
temperature normal, the pulse rate only slightly elevated, and the body weight increased
by four kilograms. The lesion of the left lung seemed about the same as at admission.
A prolonged period of rest was then indicated, to permit that infection and the one in
the collapsed empyama cavity to heal, but the prognosis was fair.
The results in this case suggest that formalin is much more effective than
Zenker's solution. In view of the fact that the collapse of the chest was complete,
both in this and in the other cases treated with Zenker's solution, it is
very likely that the ribs which regenerated after the use of that agent were
FIG. 3. FiG. 4-.
FIG. 3.-Same case, fifty days after the resection of the anterolateral segments of ribs 4 toI with
application of formalin solution (third costectomy). No new hone is visible. Arrows indicate the
enlarged, fragmenta'ry deposits of bone 1 27 days after the first operation.
FIG. 4 -Same case, five months and five days after the fir$t and ten days after the last (fifth)
costectomy. Ribs i i to iare absent and the empyaema cavity is totally collapsed.
fragmentary rather than solid. Although formalin seemed to prevent osteogenesis
entirely in the instance cited above, proof has since appeared that
it permits a slight amount of bone to form. In a case being treated at present
by cautery pneumectomy, the slough of the thoracic wall from the first burning
contained tiny spicules of bone along the lines of the periosteal beds which
had been stripped of ribs and painted with formalin thirty-six days before
the burning. The partial regeneration that occurs after both agents
probably accounts for the satisfactory degree of stability of the chest-wall
that resulted in all of the cases of chronic empyaema. Furthermore, it suggests
that the method of periosteal treatment can be applied to paravertebral
thoracoplasty for pulmoniary tuberculosis without danger of instability of
the thorax. This will soon be tested, first with Zenker's solution.
The solutions were applied as follows. After each rib was removed, its
372
TREATMENT OF PERIOSTEUM IN THORACOPLASTY
periosteum was sponged free from blood and then wiped throughout with a
small gauze swab, which had been dipped in the solution and shaken out.
The periosteum was again sponged dry and painted with a fresh swab; and
the process was repeated five or six times. This insured that the rib bed
received thorough contact with the agent, without much contamination of the
surrounding tissues.
SUMMARY.-The discoveries of Head and Meiss are recounted, that bone
regeneration after subperiosteal costectomy in dogs can be prevented completely
by application to the periosteum of Zenker's or formalin solution,
as well as the suggestions of these authors as to possible clinical applications.
Personal experience with both agents for this purpose is briefly reported,
which concerned forty-three clinical cases, including twelve with chronic
empyaema. It is concluded that, in man, both solutions inhibit the reformation
of bone markedly but do not prevent it entirely, that formalin is much
the more effective, and that the use of one or the other of these chemicals
is advantageous in certain operations of rib resection. The chief advantages
occur in the treatment of large chronic empyaema cavities, because the
Estlander thoracoplasty can be used in place of the more destructive and
shock-producing procedure of Schede, the stages of resection can be placed
as far apart as desired, spurs do not form on the ribs, the chest-wall continues
to collapse long after the last operation.
BIBLIOGRAPHY
'Head, J.: Prevention of Regeneration of the Ribs. A Problem in Thoracic Surgery.
Arch. Surg., vol. xiv, p. I209, I927.
2 Meiss, W.: Experimenteller Beitrag zur Vereinfachung der Thoracoplastik in mehreren
Tempi. Zentralbl. f. Chir., vol. lvii, p. 349, 1930.
3 Trout, H.: The Release of Pericardial Adhesions. Arch. Surg., vol. xxiii, p. 966, I93I.
'Hedblom, C.: Anterolateral Costectomy for Inadequate Collapse Following Posterior
Extrapleural Thoracoplasty. Arch. Surg., vol. xxi, p. III4, I930.
373
TO INHIBIT RIB REGENERATION
BY C. M. VAN ALLEN, M.D.
OF PEIPING, CHINA
FROM THE DEPARTMENT OF SURGERY, PEIPING UNION MEDICAL COLLEGE
FIVE years ago, Jerome Head' described experiments in which he tested
the effectiveness of various chemical agents for preventing osteogenesis after
subperiosteal costectomy. He removed pieces of several ribs from each of
a number of dogs and then painted the rib-free periosteum with the chemicals
before closing the wound. After a lapse of time amply sufficient for bone to
regenerate, the animals were sacrificed and the rib beds were examined by
X-rays and dissection. Zenker's solution seemed the most suitable of the
agents employed, since it prevented osteogenesis completely without producing
appreciable necrosis. Meiss2 reported a similar investigation in I930.
Although he found Zenker's solution quite effective in preventing the formation
of new bone, he noted perforation into the pleural cavity in one instance
and symptoms (undescribed) of systemic poisoning. He preferred IO per
cent. solution of formalin-an agent not tested by Head-for it had all the
advantages of Zenker's solution and none of the disadvantages.
Both authors suggested clinical uses for their methods in certain types of
thoracoplasty. Thus, it was recalled that where ribs have to be resected in
stages for producing collapse of the chest-wall, "the true collapse occurs only
with the removal of the last ribs. Until then the part of the wall of the chest
which is already mobilized hangs from the ribs like the curtain of a tent, and,
if the bones reform in this position, the final collapse is compromised."'
Furthermore, the lapse of three weeks between the first and last stages of
operation may be sufficient to bring about this undesired result, and yet
that or even a much greater interval between the stages is often advantageous
or imperative, in order to replenish the patient's strength and morale, to
prevent advancement of associated diseases, to permit infected wounds to
heal, to test the effectiveness of preceding stages, etc. It seemed to Meiss that
the method would be useful in paravertebral extrapleural thoracoplasty for
pulmonary tuberculosis because it would allow wider intervals between the
stages of operation and would permit the chest-wall to continue collapsing
slightly for several months after operation, in response to the gradual
fibrosis and shrinkage of the lung that occurs with the healing of the disease.
He believed that the prevention of rib regeneration would not leave
the thoracic wall sufficiently unstable to jeopardize the healing of the pulmonary
lesion, for he knew of a patient who had received paravertebral
thoracoplasty by supraperiosteal costectomy and had obtained full benefit
to the tuberculous lesion of the lung. Head advised against this application
368
TREATMIENT OF PERIOSTEUM IN THORACOPLASTY
of the method, on the theoretical grounds of mural instability. Other uses
suggested by these authors were as follows: Employment in the graded
Estlander operation for chronic empyaema or bronchiectasis, to permit wider
spacing of the stages and more prolonged collapse; use in the Brauer cardiolysis,
to ensure permanent pliability of the precordium; use in the rib
resection for drainage of empyema or lung abscess, to prevent new bone
from forming in, and encroaching upon, the sinus; and use in the rib resection
for cautery pneumectomy, to obviate the difficulty which may arise
from regeneration of bone in the field of cauterization.
Neither one of the authors has reported clinical experience with his
method, and the only reference of the kind that I can find is the bare statement
of Trout3 that he had used the method of Head with satisfaction in
thoracoplasty for pulmonary tuberculosis. I began to use Zenker's solution
in plastic operations for chronic empyema soon after the appearance of
Head's publication, but changed later to formalin. Twelve cases of that
type have been treated with one or the other chemical, and, besides, twentythree
cases with drainage of empyaema, three with drainage of lung abscess,
and two with cautery pneumectomy. While this experience is quite insufficient
for final evaluation of the methods, the results have been satisfactory
and consistent enough to warrant preliminary report.
The first case to be treated was that of a white male, aged thirty-two years. At
the time of admission to the hospital, he had been ill for eleven months with productive
cough, fever, dyspncea, and weakness. Five months before the symptoms had become
so exaggerated that the patient had to stop work. His physician at the time made the
diagnosis of empyema of the left pleural cavity and established drainage by intercostal
catheter. Considerable improvement followed, but soon the cough and fever returned.
On admission the patient was found to be emaciated, weak, and toxic. The left half
of the chest was markedly retracted and fixed, and it exhibited a narrow sinus at the
seventh intercostal space in the posterior axillary line. Tubercle bacilli were abundant
in the sputum and in the pus from the sinus. X-ray examination showed an empyaema
cavity on the left side with very thick walls, extending from the third rib to the diaphragm
and from the anterior axillary line to the vertebral column. An operation
was done immediately to widen the sinus. A specimen of the pleura which was obtained
at the time revealed the presence of tuberculous infection. The drainage thus established
and the supportive treatment that followed produced great improvement of the constitutional
condition within two months; but the cavity was unchanged in size, so the
decision was made to obliterate it with the graded thoracoplasty of Schede. At the
first stage, the lower one-third of the roof of the cavity was removed; but the shock
was very severe. So, two months later, when the patient's strength was sufficiently
restored, the milder operation of Estlander was resorted to, with the addition that
the rib-free portions of periosteum were painted with Zenker's solution. The parts
of the ribs lying over the cavity, together with a part of one rib (second) above, were
removed in two sittings, with an interval of six weeks between to allow for delayed
wound healing. The immediate effect of this was only partial obliteration of the
empyaema cavity; but the collapse proved to be progressive and fourteen months after
the last operation the cavity was closed, the sinus was healed, and the patient felt well.
In the three other cases of tuberculous empyama treated since then, the
entire lengths of the ribs overlying the cavities were removed subperiosteally
24 369
C. M. VAN ALLEN
in small and widely spaced steps, with application of one or the other chemical
to the periosteum. The cavities collapsed satisfactorily, and only one
(see the case report below), which was operated upon very recently, has
not yet healed. Graded subperiosteal resection of only the posterior segments
of ribs was employed for the patients with extenisive non-tuberctnlous
empyaema. This included the ribs over the cavity-and onie above if
the cavity was subtotal. The result was that the anterolateral segments of
ribs, the thickened parietal pleura, and the superficial tissues, which remailled
over the cavity, fell progressively during and after the operations until obliteration
was complete. One of these cases required further work, to uniroof a
small residual cavity. Thus, in both types of empyema, the Estlander operation
almost entirely replaced the Schede procedure, which hitherto had been
indispensable. Since the parietal pleura and intercostal structures were not
removed, as in the Schede thoracoplasty, the operations were accompanied by
relatively little blood loss and shock and by no paralysis of the abdominal
wall. A comparatively small but noteworthy advantage of the chemical treatment
was that, after resection of the posterior segments of ribs, the posterior
ends of the anterolateral segments developed no spurs.* No appreciable (lisadvantage
was experienced from paradoxical respiratory movements of the
clhest-wall. Scoliosis developed, but it was no greater-indeed, uisually mucl
less-than that after Schede resections for equally extenisive cavities. Chemical
poisoning was watched for but was not detected. Chronic empy.sema cavities,
-which were so small as to extend under no more than three ribs, were
still treated by the Schede thoracoplasty.
The expected benefits were derived, also, in connection with rib resection
in the other types of cases. Although the benefits were comparatively
sliglht, they were worth while.
One case was outstandinig, because it made possible a direct comparison
between Zenker's ancd forniialin solution-s as to their effectiveness in prevenltinlg
osteogeniesis.
A Chinese male, aged twenty-three years, was admitted to the hospital with a
history of productive cough for two and one-half years. Slight weakness was the only
accompanying symptom, until one day three months before when, during unusually
strenuous coughing, sudden pain occurred in the right side of the chest and marked
dyspncea developed. He took to bed at once and soon had a chill and started to run
a high fever. On admission the man was extremely emaciated and feeble, orthopneeic,
cyanotic, and disturbed by a frequent productive cough. The sputum was fetid and
containied myriads of tubercle bacilli. Physical and r6ntgenographical examination of
the chest revealed complete collapse of the right lung, fluid and air in the right pleural
cavity, extenisive displacement of the mediastinum to the left, depression of the right
hemidiaphragm, and a light infiltration of the left upper lobe which was suspected to
he tuberculous. The chest was tapped. The fluid proved to be thick pus, containing
tubercle bacilli, streptococci, staphylococci, and other organisms, and the air was found
to be under pressure of plus 3 to 8 centimetres H20. The initial treatment consisted
* Hedblom4 has emphasized the danger of laceration of the pleura and lung that
exists during anterolateral costectomy for pulmonary tuberculosis, in removing ribs
that carry these sharp, upward curved projections.
370
TREATMIENT OF PERIOSTEUM IN THORACOPLASTY
in bi-daily aspiration of large quantities of pus anid air and in general supportive measures.
Within four weeks the dyspncea was greatly relieved and the mediastinum was
returned to the mid-position (Fig. i) ; but the secondary infection and fever persisted,
so that open drainage was done. At the same operation, ten centimetres of each of
ribs II, IO and 9 were resected paravertebrally alnd the rib-free periosteum was painted
with Zenker's solution, which constituted the first stage of an Estlander operation to
de-rib the entire right half of the chest. The paravertebral wound became infected
slightly from its close proximity to the drainiage wound. The operation was well
borne, nevertheless, so it was decided not to wait for complete healing of the paravertebral
incision but to abandon the usual orderly progression of resection and operate
the second time at a considerable distance. Consequenitly, the second stage was performed
twenty-six days after the first and consisted in the resection of four to ten
centitmletres of the posterior extremities of ribs 4 to I, inclusive, with application of
Zenker's solutioni. The wounid healed well. But shortly after this, the temperature
becamie somewlhat elevated, the cough inicreased, and a rontgenogram (Fig. 2) showed
FIG. .. Fio. 2.
FIG. I.Thoracic rontgenogram of a case with secondarily infected, tuberculous empyaema and
comiplete collapse of one lung, taken just before the beginning of a graded subperiosteal costectomy
wherein Zenker's and formalin solutions were compared for effectiveness in preventing rib regeneirationi
FIG. 2.-Same case, thirty-six days after the establishment of open drainage and the resection
of the posterior segments of ribs IIto 9, and ten days after the resectioni of the posterior segments
of ribS 4 to I. The rib-free periosteum was painted with Zenker's solution. Arrows ind:cate the foci of
new bone from the first operation.
a slight increase in the lesion of the left lung. The same r6ntgenogram was initerestinig
from the fact that it gave an exceptionally distinct view of the beds of some of the
resected ribs-due to the persistence of a bridge of ribs (8 to 5) across the middle of
the hemithorax which held the beds widely out-and that it showed definlite traces of
new bone in the field of the first operation performed thirty-six days previously. The
infection in the left lung quieted sufficiently to permit the third stage to be performed
fifty-one days after the second, with removal of the anter-olateral segm'ents of the
upper four ribs; but this time i0 per cent. solution of formalin was used in place of
Zenker's solution, according to Meiss' suggestion. The wound healed per Prima,.
And once more the condition of the left lung demanded a long wait. A rdntgen-film
(Fig. 3), taken fifty days after the third stage, showed that the formalin-treated peniosteum
was free from appreciable amounts of new bonle, while the Zenker's treated
periosteum of the first operation((127 days before) had developed inicomplete but welldefined
ribs. The field of the second operation lay too close to the spine to permit clear
371
C. M. VAN ALLEN
discernment of the degree of rib regeneration. The fourth operation came the day after
this examination and the fifth came twenty-seven days later, whereby the remaining
ribs and portions of ribs were taken out and the periosteum was painted with formalin.
Figure 4 gives the appearance ten days after the last operation when the chest-wall
was completely collapsed and the merest slit remained of the empyama cavity. The
patient's condition was satisfactory in other respects, also. The cough was absent, the
temperature normal, the pulse rate only slightly elevated, and the body weight increased
by four kilograms. The lesion of the left lung seemed about the same as at admission.
A prolonged period of rest was then indicated, to permit that infection and the one in
the collapsed empyama cavity to heal, but the prognosis was fair.
The results in this case suggest that formalin is much more effective than
Zenker's solution. In view of the fact that the collapse of the chest was complete,
both in this and in the other cases treated with Zenker's solution, it is
very likely that the ribs which regenerated after the use of that agent were
FIG. 3. FiG. 4-.
FIG. 3.-Same case, fifty days after the resection of the anterolateral segments of ribs 4 toI with
application of formalin solution (third costectomy). No new hone is visible. Arrows indicate the
enlarged, fragmenta'ry deposits of bone 1 27 days after the first operation.
FIG. 4 -Same case, five months and five days after the fir$t and ten days after the last (fifth)
costectomy. Ribs i i to iare absent and the empyaema cavity is totally collapsed.
fragmentary rather than solid. Although formalin seemed to prevent osteogenesis
entirely in the instance cited above, proof has since appeared that
it permits a slight amount of bone to form. In a case being treated at present
by cautery pneumectomy, the slough of the thoracic wall from the first burning
contained tiny spicules of bone along the lines of the periosteal beds which
had been stripped of ribs and painted with formalin thirty-six days before
the burning. The partial regeneration that occurs after both agents
probably accounts for the satisfactory degree of stability of the chest-wall
that resulted in all of the cases of chronic empyaema. Furthermore, it suggests
that the method of periosteal treatment can be applied to paravertebral
thoracoplasty for pulmoniary tuberculosis without danger of instability of
the thorax. This will soon be tested, first with Zenker's solution.
The solutions were applied as follows. After each rib was removed, its
372
TREATMENT OF PERIOSTEUM IN THORACOPLASTY
periosteum was sponged free from blood and then wiped throughout with a
small gauze swab, which had been dipped in the solution and shaken out.
The periosteum was again sponged dry and painted with a fresh swab; and
the process was repeated five or six times. This insured that the rib bed
received thorough contact with the agent, without much contamination of the
surrounding tissues.
SUMMARY.-The discoveries of Head and Meiss are recounted, that bone
regeneration after subperiosteal costectomy in dogs can be prevented completely
by application to the periosteum of Zenker's or formalin solution,
as well as the suggestions of these authors as to possible clinical applications.
Personal experience with both agents for this purpose is briefly reported,
which concerned forty-three clinical cases, including twelve with chronic
empyaema. It is concluded that, in man, both solutions inhibit the reformation
of bone markedly but do not prevent it entirely, that formalin is much
the more effective, and that the use of one or the other of these chemicals
is advantageous in certain operations of rib resection. The chief advantages
occur in the treatment of large chronic empyaema cavities, because the
Estlander thoracoplasty can be used in place of the more destructive and
shock-producing procedure of Schede, the stages of resection can be placed
as far apart as desired, spurs do not form on the ribs, the chest-wall continues
to collapse long after the last operation.
BIBLIOGRAPHY
'Head, J.: Prevention of Regeneration of the Ribs. A Problem in Thoracic Surgery.
Arch. Surg., vol. xiv, p. I209, I927.
2 Meiss, W.: Experimenteller Beitrag zur Vereinfachung der Thoracoplastik in mehreren
Tempi. Zentralbl. f. Chir., vol. lvii, p. 349, 1930.
3 Trout, H.: The Release of Pericardial Adhesions. Arch. Surg., vol. xxiii, p. 966, I93I.
'Hedblom, C.: Anterolateral Costectomy for Inadequate Collapse Following Posterior
Extrapleural Thoracoplasty. Arch. Surg., vol. xxi, p. III4, I930.
373
Articulo anexado Nery Salazar
Reconstrucción de hueso malar mediante
injerto de calota
Dra. María Iliana Picco Díaz,*
Dra. María de Lourdes López
Haro,** Dra. Edelmira Lara
Vázquez***
* Médico Adscrito y Profesor Adjunto
del Curso de Cirugía Maxilofacial del
H.R. 1o. de octubre, Instituto de Seguridad
y Servicios Sociales para los
Trabajadores del Estado (ISSSTE) México,
D.F.
** Médico Adscrito y Profesor Titular del
Curso de Cirugía Maxilofacial del H.R.
1o. de octubre, ISSSTE, México, D.F.
*** Residente de 3er. año del Curso de
Cirugía Maxilofacial del H.R. 1o. de
octubre ISSSTE, México, D. F.
Resumen
Realizando una revisión bibliográfica de las diferentes técnicas quirúrgicas de injertos e implantes
para la reconstrucción del hueso malar se presenta un caso clínico con la aplicación de injerto de
hueso de calota en un paciente masculino de cuarenta y nueve años de edad con fractura antigua
de hueso malar derecho con hundimiento y deformidad facial.
Palabras clave: Injertos, cirugía facial.
Abstract
Performing a bibliographic review of diferents surgical procedures of grafts and implants for cigomatic
bone reconstruction, we are making the presentation of a clinical case with reconstruction of
cigomatic bone by calvarian bone graft in a 40 years old male patient with and ancient fracture of
the right cigomatic bone and severe deformity and facial depression of the area.
Key words: Graft, facial surgery.
Hay un sinfín de clasificaciones para este tipo de fracturas,
pero probablemente el factor más importante para
clasificar dichas fracturas sea el observar la relación entre
la alteración de la posición del hueso y el desarrollo de
signos y síntomas clínicos.2
Se pueden observar los siguientes hallazgos:
• Enoftalmos, cuando el malar está deprimido y rotado;
• Hipoestesia de la región geniana y de la dentición
superior, por lesión al nervio infraorbitario;
• Hiperoftalmos cuando el hueso está rotado hacia
adentro;
• Trismus y dolor a la masticación cuando el hueso
está desplazado hacia adentro o afuera y compromete
el espacio ocupado por la apófisis coronoides;
• Epistaxis unilateral, por desgarro de la mucosa del
seno;
• Hemorragia subconjuntival;
• Equimosis periorbitaria.7
Para la realización de una reducción abierta y fijación
rígida quizá la principal indicación sea la presencia de
signos y síntomas clínicos, tales como: trismus, diplopía,
distopia, seguida de fractura malar asociada con fractura
de piso orbitario; una indicación controversial sería la
presencia de hipoestesias pues no se ha probado que la
reducción de la fractura retorne la función del nervio
infraorbitario; sin embargo se presume lógicamente que
este daño lo ocasiona la comprensión del nervio y que al
realizar la descompresión se pueden obtener buenos resultados
en el tratamiento de las secuelas7
Las deficiencias cigomáticas por secuelas de trauma
facial se pueden tratar con una amplia gama de materiales
de reconstrucción entre los que se encuentran:
• Materiales aloplásticos.
• Cartílago: autoinjerto, aloinjerto y xenoinjerto.
• Hueso: Autoinjerto (calota, costilla, cresta iliaca) o
colgajos de hueso de calota.4
Dichos materiales tienen sus ventajas y desventajas y
sus indicaciones específicas, así tenemos los implantes
de silicón sobre el complejo malar (Hinderer, 1975) utilizados
frecuentemente en pacientes que solicitan el aumento
de la prominencia cigomática para mejorar el aspecto
de la cara ovalada, caras alargadas o excesivamente
redondas, los resultados estéticos con el uso de este
material son adecuados.1
Se ha utilizado también cartílago para aumentar el complejo
cigomático como autoinjerto, aloinjerto y xenoinjerto,
sin embargo su valoración a largo plazo ha demostrado la
distorsión o desviación del injerto. Los aloinjertos de cartílago
muestran tendencia a la reabsorción (Gibson, 1977).
Los aloinjertos y xenoinjertos (Gillies y Millard, 1975) han
tenido problemas de distorsión o desviación, sin embargo
tienen su mérito y su principal problema parece ser la
posibilidad de infección del seno maxilar abierto.
Cuando se usa hueso (Tessier, 1982) (MacCarthy y Zide,
1984); se debe tener en mente que eventualmente habrá
resorción, por lo que se debe tomar un volumen adecuado
de hueso, el hueso de calota tiene grandes ventajas
en cuanto que es un hueso muy vascularizado, dentro
de la misma zona quirúrgica lo que disminuye el tiempo
quirúrgico en relación a tomas de injerto de cresta
iliaca o costilla, además el posoperatorio del paciente
cursa con morbilidad disminuida en relación al sitio de
donación. Tenemos así que el hueso de calota lo forman
los huesos parietales y temporales, así como el frontal y
occipital, la calota consiste en tres capas: Interna y externa
separadas por una capa de hueso esponjoso.8
La mayor ventaja de la dura liofilizada, hueso, cartílago
y productos biorreabsorbibles sobre los implantes
aloplásticos; es que no sólo proveen soporte necesario al
tejido orbitario sino que además son incorporados o reemplazados
dentro del cuerpo, minimizando las posibilidades
de una reacción de rechazo temprano o tardío.7
Cuando se trata de una fractura antigua donde existe
deformidad facial los materiales usados para la reconstrucción
del hueso malar ya sea como fines estéticos o
posteriores a trauma facial son de una gran diversidad. El
uso de injerto de calota es común debido a que el sitio
donador se encuentra en el mismo campo operatorio, además
debido a su característica morfológica de ser un hueso
membranoso y a su vasta irrigación sanguínea, que
provee su propio suplemento sanguíneo, osteoinductor,
osteoconductor y osteogénico; lo que impide su necrosis y
disminuye los riesgos de reabsorción que se presentan en
los injertos cartilaginosos, éstas son las ventajas que el
injerto de calota tiene sobre el de costilla, de cresta iliaca
y de cartílago, una de las desventajas es la limitación que
se obtiene en su tamaño y grosor.8.
Bibliografía
1. Craft PD, Sargent LA. Plastic Surgery Clinics l989;
16(1):11-18.
2. Epker BN, Fish LC. Dentofacial deformities. 868-961.
3. Fonseca RJ, Walker RV. Oral and Maxillofacial Trauma.
4. lvy EJ, Lorence P, Astron SJ. Plastic Surgery 1995: 63-70".
5. Jensen J, Riche-Fischel O, Sindents-P S. Journal Oral
Maxillofacial Surgery 1995; 58: 88-90.
6. Jones RHB, Ching M. Journal Oral Maxillofacial Surgery
1995; 53: 483-485.
7. Mathog RN. Atlas of craneofacial trauma; 257-282.
8. Rowe NL, Killey HC. Fracturas of the facial skeleton.
Edimburgh, Livingstone, 1968.
9. Yaremchuk MJ. Clinics in Plastic Surgery 1989; 16 (1): 29-30.
10. Yoel J. Atlas de cirugía de cabeza y cuello. 139-157.
injerto de calota
Dra. María Iliana Picco Díaz,*
Dra. María de Lourdes López
Haro,** Dra. Edelmira Lara
Vázquez***
* Médico Adscrito y Profesor Adjunto
del Curso de Cirugía Maxilofacial del
H.R. 1o. de octubre, Instituto de Seguridad
y Servicios Sociales para los
Trabajadores del Estado (ISSSTE) México,
D.F.
** Médico Adscrito y Profesor Titular del
Curso de Cirugía Maxilofacial del H.R.
1o. de octubre, ISSSTE, México, D.F.
*** Residente de 3er. año del Curso de
Cirugía Maxilofacial del H.R. 1o. de
octubre ISSSTE, México, D. F.
Resumen
Realizando una revisión bibliográfica de las diferentes técnicas quirúrgicas de injertos e implantes
para la reconstrucción del hueso malar se presenta un caso clínico con la aplicación de injerto de
hueso de calota en un paciente masculino de cuarenta y nueve años de edad con fractura antigua
de hueso malar derecho con hundimiento y deformidad facial.
Palabras clave: Injertos, cirugía facial.
Abstract
Performing a bibliographic review of diferents surgical procedures of grafts and implants for cigomatic
bone reconstruction, we are making the presentation of a clinical case with reconstruction of
cigomatic bone by calvarian bone graft in a 40 years old male patient with and ancient fracture of
the right cigomatic bone and severe deformity and facial depression of the area.
Key words: Graft, facial surgery.
Hay un sinfín de clasificaciones para este tipo de fracturas,
pero probablemente el factor más importante para
clasificar dichas fracturas sea el observar la relación entre
la alteración de la posición del hueso y el desarrollo de
signos y síntomas clínicos.2
Se pueden observar los siguientes hallazgos:
• Enoftalmos, cuando el malar está deprimido y rotado;
• Hipoestesia de la región geniana y de la dentición
superior, por lesión al nervio infraorbitario;
• Hiperoftalmos cuando el hueso está rotado hacia
adentro;
• Trismus y dolor a la masticación cuando el hueso
está desplazado hacia adentro o afuera y compromete
el espacio ocupado por la apófisis coronoides;
• Epistaxis unilateral, por desgarro de la mucosa del
seno;
• Hemorragia subconjuntival;
• Equimosis periorbitaria.7
Para la realización de una reducción abierta y fijación
rígida quizá la principal indicación sea la presencia de
signos y síntomas clínicos, tales como: trismus, diplopía,
distopia, seguida de fractura malar asociada con fractura
de piso orbitario; una indicación controversial sería la
presencia de hipoestesias pues no se ha probado que la
reducción de la fractura retorne la función del nervio
infraorbitario; sin embargo se presume lógicamente que
este daño lo ocasiona la comprensión del nervio y que al
realizar la descompresión se pueden obtener buenos resultados
en el tratamiento de las secuelas7
Las deficiencias cigomáticas por secuelas de trauma
facial se pueden tratar con una amplia gama de materiales
de reconstrucción entre los que se encuentran:
• Materiales aloplásticos.
• Cartílago: autoinjerto, aloinjerto y xenoinjerto.
• Hueso: Autoinjerto (calota, costilla, cresta iliaca) o
colgajos de hueso de calota.4
Dichos materiales tienen sus ventajas y desventajas y
sus indicaciones específicas, así tenemos los implantes
de silicón sobre el complejo malar (Hinderer, 1975) utilizados
frecuentemente en pacientes que solicitan el aumento
de la prominencia cigomática para mejorar el aspecto
de la cara ovalada, caras alargadas o excesivamente
redondas, los resultados estéticos con el uso de este
material son adecuados.1
Se ha utilizado también cartílago para aumentar el complejo
cigomático como autoinjerto, aloinjerto y xenoinjerto,
sin embargo su valoración a largo plazo ha demostrado la
distorsión o desviación del injerto. Los aloinjertos de cartílago
muestran tendencia a la reabsorción (Gibson, 1977).
Los aloinjertos y xenoinjertos (Gillies y Millard, 1975) han
tenido problemas de distorsión o desviación, sin embargo
tienen su mérito y su principal problema parece ser la
posibilidad de infección del seno maxilar abierto.
Cuando se usa hueso (Tessier, 1982) (MacCarthy y Zide,
1984); se debe tener en mente que eventualmente habrá
resorción, por lo que se debe tomar un volumen adecuado
de hueso, el hueso de calota tiene grandes ventajas
en cuanto que es un hueso muy vascularizado, dentro
de la misma zona quirúrgica lo que disminuye el tiempo
quirúrgico en relación a tomas de injerto de cresta
iliaca o costilla, además el posoperatorio del paciente
cursa con morbilidad disminuida en relación al sitio de
donación. Tenemos así que el hueso de calota lo forman
los huesos parietales y temporales, así como el frontal y
occipital, la calota consiste en tres capas: Interna y externa
separadas por una capa de hueso esponjoso.8
La mayor ventaja de la dura liofilizada, hueso, cartílago
y productos biorreabsorbibles sobre los implantes
aloplásticos; es que no sólo proveen soporte necesario al
tejido orbitario sino que además son incorporados o reemplazados
dentro del cuerpo, minimizando las posibilidades
de una reacción de rechazo temprano o tardío.7
Cuando se trata de una fractura antigua donde existe
deformidad facial los materiales usados para la reconstrucción
del hueso malar ya sea como fines estéticos o
posteriores a trauma facial son de una gran diversidad. El
uso de injerto de calota es común debido a que el sitio
donador se encuentra en el mismo campo operatorio, además
debido a su característica morfológica de ser un hueso
membranoso y a su vasta irrigación sanguínea, que
provee su propio suplemento sanguíneo, osteoinductor,
osteoconductor y osteogénico; lo que impide su necrosis y
disminuye los riesgos de reabsorción que se presentan en
los injertos cartilaginosos, éstas son las ventajas que el
injerto de calota tiene sobre el de costilla, de cresta iliaca
y de cartílago, una de las desventajas es la limitación que
se obtiene en su tamaño y grosor.8.
Bibliografía
1. Craft PD, Sargent LA. Plastic Surgery Clinics l989;
16(1):11-18.
2. Epker BN, Fish LC. Dentofacial deformities. 868-961.
3. Fonseca RJ, Walker RV. Oral and Maxillofacial Trauma.
4. lvy EJ, Lorence P, Astron SJ. Plastic Surgery 1995: 63-70".
5. Jensen J, Riche-Fischel O, Sindents-P S. Journal Oral
Maxillofacial Surgery 1995; 58: 88-90.
6. Jones RHB, Ching M. Journal Oral Maxillofacial Surgery
1995; 53: 483-485.
7. Mathog RN. Atlas of craneofacial trauma; 257-282.
8. Rowe NL, Killey HC. Fracturas of the facial skeleton.
Edimburgh, Livingstone, 1968.
9. Yaremchuk MJ. Clinics in Plastic Surgery 1989; 16 (1): 29-30.
10. Yoel J. Atlas de cirugía de cabeza y cuello. 139-157.
Articulo anexado eugenio Torres
SISTEMA OSEO Y DM2 EN RELACION
Los huesos podrían jugar un papel más activo de lo que se creía en la regulación de la química del cuerpo, afirman científicos.
Un equipo internacional descubrió que la molécula osteocalcina, producida por las células de los huesos, cumple un activo papel en la regulación de los niveles de azúcar en la sangre de las ratones.
Esto es importante en el desarrollo de la diabetes y la obesidad, y por eso el hallazgo publicado en la revista Cell, ofrece la esperaza de nuevas formas de tratamiento contra estas enfermedades.
Pero expertos han advertido que se necesita muchas más investigación para confirmar esta vinculación.
Los investigadores analizaron dos variedades de ratas con actividad alterada de osteocalcina, que es producida por células osteoblásticas en los huesos.
Una de las variedades carecía del gen de la osteocalcina y por tanto no tenía esta molécula, y la otra variedad tenía niveles aumentados de osteocalcina.
Función original
El director de la investigación, el profesor Gerard Karsenty de
Sin embargo, el equipo encontró una función novedosa de la molécula.
Usualmente, un incremento de los niveles de insulina en la sangre va acompañado de una reducción en la sensibilidad a la insulina.
En ratones, un incremento de la actividad de la molécula estimuló las células pancreáticas a producir más insulina y, simultáneamente, condujo las células grasas a liberar una hormona llamada adiponectina, que mejora la sensibilidad a la insulina.
También estimula la producción de las células productoras de la propia insulina, que en la actualidad se considera uno de los mejores (aunque inasequible) potenciales tratamientos para la diabetes.
El aumento de la actividad de la osteocalcina también previno el desarrollo de diabetes tipo 2 y de obesidad en el primer ratón; y el que no producía osteocalcina desarrolló diabetes tipo 2 y mostró un incremento de la masa de grasa.
Nuevos tratamientos
“El descubrimiento de que nuestros huesos son responsables de la regulación del azúcar en la sangre en modos que no se conocían antes, cambia completamente nuestra comprensión de la función del esqueleto y deja al descubierto un aspecto crucial de la energía del metabolismo”, señaló Karsent.
“Estos resultados revelan un importante aspecto de la endocrinología que no había sido apreciado hasta ahora”.
El hallazgo podría proporcionar un nuevo objetivo terapéutico para ayudar en el tratamiento de la diabetes también en humanos, pues las personas con diabetes tipo 2 han mostrado bajos niveles de osteocalcina.
Los investigadores explorarán ahora el rol de la osteocalcina en la regulación de los niveles de azúcar en la sangre en humanos.
Mark Hunt, director de información científica en Diabetes del Reino Unido, calificó al estudio de “muy interesante.”
“La investigación de la diabetes nunca había planteado la idea de que el esqueleto estuviera involucrado en el desarrollo de la diabetes”.
“Potencialmente, esto podría abrir una nueva área de investigación”
Hunt dijo que esto podría conducir a un mejoramiento de la comprensión de las causas de la diabetes, pero advirtió que había que realizar nuevos estudios para establecer un vínculo concluyente entre la osteocalcina y la diabetes.
BBC
[BWN]
Dr_RVillanueva @ August 12, 2007
Articulo anexado Marco Torres
La importancia pericial del estudio
comparativo histomorfológico del
hueso humano y de otros géneros
Saturnino Aparecido Ramalho,*
Eduardo Daruge,† Belkys
Valentina De La Cruz,‡ Mónica
Aparecida Francesquini,‡ Sávio
D.R. Pereira,‡ Luíz Francesquini
Júnior,§ Eduardo Daruge
Júnior,|| Glaúcia M.B.
Ambrosano,¶ Célía M. Rizzatti-
Barbosa, **
* Doctor en Radiología, Área de Concentración
en Odontología Legal y Deontología.
Profesor de la Universidad Camilo
Castelo Branco–UNICASTELO.
† Prof. Titular en Odontología Legal.
‡ Maestro(a) en Odontología Legal y
Deontología.
§ Doctorado en Radiología, Área de Concentración
en Odontología Legal y Deontología.
Doctor en Clínicas Odontológicas
Integradas.
| | Coordinador del Curso de Odontología
Legal y Deontología.
¶ Profesora, Doctora en Bioestadística.
** Profesora, Doctora en Clínica Odontológica.
Facultad de Odontología de Piracicaba.
Universidad Estadual de Campinas FOP/
UNICAMP, Brasil.
Resumen
Es un hecho notable que la identificación de huesos o fragmentos de éstos, contribuye sobremanera
en el esclarecimiento de problemas judiciales. Cuando no se dispone del esqueleto
completo o de huesos íntegros, el análisis de características histomorfológicas óseas se
torna un factor decisivo en la elucidación de ciertos casos de identificación. El propósito del
presente estudio fue ampliar o buscar nuevas posibilidades en la identificación de fragmentos
óseos de seres humanos y de otros 19 mamíferos. Así, analizamos los sistemas de
Havers, los canales de Havers, los osteocitos y los canalículos de los osteocitos, del hombre,
anta, aracambé, buey, cabra, perro montés, perro, capivara, carnero, cateto, caballo, conejo,
cutia, gato, mono-clavo, jaguar, puerco espín, cerdo, oso hormiguero y venado. Fueron r e a -
l i z a dos cortes histológicos por desgaste del tejido óseo de cada mamífero estudiado, en
sentido longitudinal y transversal; y analizados con microscopio de luz. Los resultados demuestran
con claridad y precisión que el análisis histomorfológico de las estructuras citadas
posibilita la identificación y diferenciación de los géneros estudiados o excluyen la posibilidad
de que fragmentos óseos examinados pertenezcan al género Homo sapiens.
Palabras clave: Hueso, histología, forma, identificación, forense.
Abstract
It is well known that the identification of the bone or a bone fragment means an extremely
valuable contribution when the clarification of juridical issues is being performed. When the
complete skeleton or whole bones are not available, the analysis of the osseous histomorphologic
characteristics becomes a decisive factor for the elucidation of certain cases of
identification. The present study has been conducted aiming at enlarging or searching for new
possibilities for identifying osseous fragments of human beings and of some nineteen mammals
with characteristics closest to those of the human beings. Thus, the systems and the
canals of Havers as well as the osteocytes and the canaliculi of the osteocytes of the human
beings, anta, aracambé, ox, goat, grison, dog, capivara, sheep, cateto, horse, rabbit, agouti,
cat, capuchin-monkey, puma, hedgehog, pig, tamanduá-bandeira (the great anteater), and
the veado-cervo (any deer) have been analyzed. The osseous tissue of the mammals have
been histologically cut by abrasion – in the longitudinal and transversal way – and analyzed
under light microscopy. The results have clearly and accurately shown that the histomorphologic
analysis of the above mentioned structures makes it possible either to identify and
differentiate the genders studied or to exclude the possibility that the osseous fragment may
belong to the gender Homo sapiens.
Key words: Bone, histology, morphology, identification, forensic.
El presente estudio tiene por objetivo, resaltar la importancia
pericial del estudio comparativo histomorfológico
del hueso humano y de otros animales.
Proposición
El objetivo de este estudio fue ampliar o buscar nuevas
posibilidades en la identificación de fragmentos óseos
pertenecientes a seres humanos y otros mamíferos.
Fueron analizadas las características morfológicas del
tejido óseo, como el sistema de Havers, canales de Havers,
osteocitos y sus canalículos, con el propósito de identificar
evidencias de este tejido en cada mamífero estudiado, pudiendo
auxiliar en la identificación o diferenciación entre
remanentes óseos humanos y de otras especies.
La importancia pericial de este estudio se verifica
cuando, algunas veces, son encontrados fragmentos mineralizados
que pueden ser de tejido óseo o dental, en
los casos de grandes tragedias en las que exista una
gran cantidad de personas no identificadas, así como en
situaciones en que, restos mineralizados presentes para
examen, estén carbonizados y calcinados, constituyendo
los únicos indicios restantes para la identificación de
una o más personas o para excluir la posibilidad de tratarse
de fragmentos de huesos humanos.
Material y métodos
Para la realización del siguiente estudio fueron utilizados,
además de hueso humano, huesos de tres animales de
cada especie, investigando un hueso largo (tibia, peroné,
radio y húmero) de cada uno de los siguientes mamíferos
(Cuadro 1):
Los huesos humanos fueron obtenidos en el Departamento
de Morfología de la Facultad de Odontología de la
Pontificia Universidad Católica de Campinas, todos de
individuos adultos y leucodermas. Los huesos restantes
fueron obtenidos de animales adultos muertos, algunos
en estado de putrefacción, otros ya esqueletizados.
Luego de la obtención de estos huesos, fueron lavados
en agua corriente e inmersos en solución de hipoclorito
de sodio al 0.5% por 10 minutos para remover
partículas de tejido blando adheridas. Posteriormente,
fueron lavados en agua corriente removiendo así, vestigios
de la solución.
De cada hueso fueron obtenidas dos láminas histológicas
por desgaste, realizándose cortes histológicos en
sentido longitudinal y transversal de cada hueso en la
porción de la diáfisis del hueso largo, siguiendo la técnica
preconizada por Ramalho & Daruge,7 con algunas
adaptaciones que permitieron una mayor nitidez.
La primera etapa fue la de corte del hueso, utilizando
disco diamantado de 7/8 de pulgada, montado en man
dril de motor odontológico con chorros de agua con la
finalidad de humedecer el hueso para no ocasionar microfracturas
o quemaduras, obteniéndose de esta manera,
muestras de 1 mm de grosor. Para el desgaste de
estas muestras se utilizó lija de esmeril números: 80,
100, 240, 400, 500, 600 y 1200, lijando en ambos lados
de las muestras (también humedeciéndolas) para mantener
la uniformidad.
Se obtuvieron muestras de 10 a 12 micras de grosor
que fueron pulidas con piedra de Arkansas y Blanco de
España, humedeciéndolas con agua. Tras cada paso, las
muestras eran observadas al microscopio de luz para verificarse
la presencia de posibles fallas o fracturas.
Las muestras fueron lavadas con agua y detergente
(aquil benzeno sulfanato de sodio) al 0.5% por 20 minutos
y posteriormente secadas y deshidratadas con alcohol
por 30 minutos. Luego de un nuevo secado en estufa
a 37ºC por 24 horas, cada pieza era bañada en xilol por
diez minutos para aclararlas.
De esta forma se dio inicio al montaje de las muestras
utilizándose lámina de vidrio, laminilla y resina epoxi
con polimercaptanos (Araldite®). Cada muestra ósea fue
colocada sobre una lámina vertiéndose en ellas una gota
de Araldite®, cubiertas con una laminilla, presionándolas
levemente (para evitar la formación de burbujas de
aire) y llevadas a la estufa a 37º C por 24 horas para la
absorción de Araldite®.
Destacamos que fue usada Araldite® por poseer alta
densidad, lo que mantiene las cavidades y canalículos
óseos llenos de aire, eliminando el uso de coloraciones.
Por poseer índice de refracción diferente al Araldite® y
del vidrio, estas formaciones se mostraron en negro, obteniéndose
así gran nitidez.
Las láminas fueron observadas a través de fotomicroscopio
Zeiss, modelo MC 80 DX, con filtro verde y
objetivas de 10x y 40x y 100x (inmersión) veces, obteniéndose
fotomicrografías con película en blanco y negro
ILFORD-50 ISO, cuyos aumentos fueron aproximadamente
70, 280 y 700 veces.
De los 60 huesos analizados pertenecientes a seres
humanos y de los 19 animales restantes, fueron obtenidas
120 láminas histológicas, siendo seleccionados y fotomicrografiados
apenas los campos mejores y más nítidos,
obteniéndose 3 fotomicrografías de cada corte totalizando
120 fotomicrografías numeradas de 01 al 60.
Resultados
Análisis e interpretación de las fotomicrografías
Los exámenes histológicos periciales fueron analizados
a partir de las fotomicrografías de los huesos en cortes
longitudinales y transversales con aumentos de 70, 280
y 700 veces, para cada corte.
Las interpretaciones se encuentran disponibles en el
cuadro II.
Discusión
Una buena parte de la literatura consultada en este trabajo,
aborda los caracteres histomorfológicos de los huesos
humanos como el sistema y canales de Havers, los
osteocitos y sus canalículos.
Entre estos autores están Dyce et al.,15 Junqueira &
Carneiro13 y Stevens et al.,16 cuyas afirmaciones se corroboran
con nuestros hallazgos.
Trabajos como los de Arbenz (1988) Whittaker & Mac-
Donald,12 Fávero,3 França4 y Calabuig5 nos ofrecen subsidios
en la histomorfología de los tejidos óseos con finalidad
pericial, permitiendo la comparación con los resultados
obtenidos en este trabajo, por presentar metodologías
semejantes, confirmando las pesquisas en lo que se
refiere a las formas del sistema de Havers, los diámetros
de los canales de Havers, forma, distribución y disposición
de los osteocitos y las características de distribución,
forma, número, cantidad de anastosmosis de los
canalículos presentes en los osteocitos.
Las técnicas de preparación y análisis microscópico
preconizados por Ramalho & Daruge7 fueron seguidos,
con excepción de la utilización del Bálsamo de Canadá,
sustituido por Araldite®, en el montaje de las láminas,
dando éste mayor nitidez.
Bibliografía
1. Arbenz GO. Contribuição para o estudo da estimativa da
idade pelo número de dentes permanentes irrompidos, em
escolares da cidade de São Paulo, brancos, nascidos no Brasil.
Anais da Faculdade de Farmácia e Odontologia da Universidade
de São Paulo. São Paulo. 1962; 19(2): 159-76.
2. Arbenz GO. Medicina legal e antropologia forense. Rio de
Janeiro, Atheneu. 1988: 199-206.
3. Favero F. Medicina legal: introdução ao estudo da medicina
legal, identidade, traumatologia, infortunística, tanatologia.
9 ed. São Paulo, Martins Fontes. 1993: 63-7.
4. França GV. Medicina legal. 4 ed. Rio de Janeiro, Guanabara
Koogan. 1995: 30.
5. Calabuig JAG. Medicina legal y toxicología. 4a ed. Masson,
Ediciones Científicas y Técnicas. 1998: 1016.
6. Owsley DW, Mires AM, Keith MS. Case involving differentiation
of deer and human bone fragment. J Forensic Sci,
Philadelphia. 1985; 30(2): 572-8.
7. Ramalho SA, Daruge EA. Importância pericial do estudo
comparativo histomorfológico do esmalte, dentina e cemento
de dentes humanos e de outros animais. Piracicaba.
1994, Tese (Mestrado em Odontologia Legal e Deontologia)–
Faculdade de Odontologia de Piracicaba. Universidade
Estadual de Campinas.
8. Snow C, Luke J. The Oklahoma City child disappearances of
1967: forensic anthropology in the identification of skeletal
remains. J Forensic Sci, Philadelphia. 1970; 15(2): 125-53.
9. Sopher IM. The dentist, the forensic pathologist, and the
identification of human remains. J Dent Am Assoc, Chicago.
1972; 85(6): 1324-9.
10. Getty R. Osteologia geral. In: Anatomia dos animais domésticos.
5 ed. Rio de Janeiro, Interamericana. 1981; 2(2):
19-23. Tradução de: Sisson and Grossman’s the anatomy
of the domestic animals.
11. Buchner A. The identification of human remains. Int Dent
J, London. 1985; 35(4): 307-11.
12. Whittaker D, MacDonald D. A color atlas of forensic dentistry.
Ipswich, England, Wolfe Publishing. 1989; 11: 81-9.
13. Junqueira LC, Carneiro J. Tecido ósseo. In: Histologia. 7
ed. Rio de Janeiro, Guanabara Koogan. 1990; 8: 101-19.
14. Hall BK. Bone matrix and bone specific products. Boca
Raton, CRC Press. 1991: 2-25, 47-59.
15. Dyce KM, Sack WO, Wensing C. Tratado de anatomia veterinária.
Rio de Janeiro, Guanabara Koogan. 1990: 6-30.
16. Stevens A, Lowe JS. Sistema muscular esquelético. In:
Histologia. São Paulo, Manole. 1995; 14: 226-48. Tradução
de: Histology. Original inglês.
Lecturas complementarias
– Bass WM. Developments in the identification of human
skeletal material (1968-1978). Am J of Phys Anthropol,
Philadelphia, 1979; 51(4): 555-62.
comparativo histomorfológico del
hueso humano y de otros géneros
Saturnino Aparecido Ramalho,*
Eduardo Daruge,† Belkys
Valentina De La Cruz,‡ Mónica
Aparecida Francesquini,‡ Sávio
D.R. Pereira,‡ Luíz Francesquini
Júnior,§ Eduardo Daruge
Júnior,|| Glaúcia M.B.
Ambrosano,¶ Célía M. Rizzatti-
Barbosa, **
* Doctor en Radiología, Área de Concentración
en Odontología Legal y Deontología.
Profesor de la Universidad Camilo
Castelo Branco–UNICASTELO.
† Prof. Titular en Odontología Legal.
‡ Maestro(a) en Odontología Legal y
Deontología.
§ Doctorado en Radiología, Área de Concentración
en Odontología Legal y Deontología.
Doctor en Clínicas Odontológicas
Integradas.
| | Coordinador del Curso de Odontología
Legal y Deontología.
¶ Profesora, Doctora en Bioestadística.
** Profesora, Doctora en Clínica Odontológica.
Facultad de Odontología de Piracicaba.
Universidad Estadual de Campinas FOP/
UNICAMP, Brasil.
Resumen
Es un hecho notable que la identificación de huesos o fragmentos de éstos, contribuye sobremanera
en el esclarecimiento de problemas judiciales. Cuando no se dispone del esqueleto
completo o de huesos íntegros, el análisis de características histomorfológicas óseas se
torna un factor decisivo en la elucidación de ciertos casos de identificación. El propósito del
presente estudio fue ampliar o buscar nuevas posibilidades en la identificación de fragmentos
óseos de seres humanos y de otros 19 mamíferos. Así, analizamos los sistemas de
Havers, los canales de Havers, los osteocitos y los canalículos de los osteocitos, del hombre,
anta, aracambé, buey, cabra, perro montés, perro, capivara, carnero, cateto, caballo, conejo,
cutia, gato, mono-clavo, jaguar, puerco espín, cerdo, oso hormiguero y venado. Fueron r e a -
l i z a dos cortes histológicos por desgaste del tejido óseo de cada mamífero estudiado, en
sentido longitudinal y transversal; y analizados con microscopio de luz. Los resultados demuestran
con claridad y precisión que el análisis histomorfológico de las estructuras citadas
posibilita la identificación y diferenciación de los géneros estudiados o excluyen la posibilidad
de que fragmentos óseos examinados pertenezcan al género Homo sapiens.
Palabras clave: Hueso, histología, forma, identificación, forense.
Abstract
It is well known that the identification of the bone or a bone fragment means an extremely
valuable contribution when the clarification of juridical issues is being performed. When the
complete skeleton or whole bones are not available, the analysis of the osseous histomorphologic
characteristics becomes a decisive factor for the elucidation of certain cases of
identification. The present study has been conducted aiming at enlarging or searching for new
possibilities for identifying osseous fragments of human beings and of some nineteen mammals
with characteristics closest to those of the human beings. Thus, the systems and the
canals of Havers as well as the osteocytes and the canaliculi of the osteocytes of the human
beings, anta, aracambé, ox, goat, grison, dog, capivara, sheep, cateto, horse, rabbit, agouti,
cat, capuchin-monkey, puma, hedgehog, pig, tamanduá-bandeira (the great anteater), and
the veado-cervo (any deer) have been analyzed. The osseous tissue of the mammals have
been histologically cut by abrasion – in the longitudinal and transversal way – and analyzed
under light microscopy. The results have clearly and accurately shown that the histomorphologic
analysis of the above mentioned structures makes it possible either to identify and
differentiate the genders studied or to exclude the possibility that the osseous fragment may
belong to the gender Homo sapiens.
Key words: Bone, histology, morphology, identification, forensic.
El presente estudio tiene por objetivo, resaltar la importancia
pericial del estudio comparativo histomorfológico
del hueso humano y de otros animales.
Proposición
El objetivo de este estudio fue ampliar o buscar nuevas
posibilidades en la identificación de fragmentos óseos
pertenecientes a seres humanos y otros mamíferos.
Fueron analizadas las características morfológicas del
tejido óseo, como el sistema de Havers, canales de Havers,
osteocitos y sus canalículos, con el propósito de identificar
evidencias de este tejido en cada mamífero estudiado, pudiendo
auxiliar en la identificación o diferenciación entre
remanentes óseos humanos y de otras especies.
La importancia pericial de este estudio se verifica
cuando, algunas veces, son encontrados fragmentos mineralizados
que pueden ser de tejido óseo o dental, en
los casos de grandes tragedias en las que exista una
gran cantidad de personas no identificadas, así como en
situaciones en que, restos mineralizados presentes para
examen, estén carbonizados y calcinados, constituyendo
los únicos indicios restantes para la identificación de
una o más personas o para excluir la posibilidad de tratarse
de fragmentos de huesos humanos.
Material y métodos
Para la realización del siguiente estudio fueron utilizados,
además de hueso humano, huesos de tres animales de
cada especie, investigando un hueso largo (tibia, peroné,
radio y húmero) de cada uno de los siguientes mamíferos
(Cuadro 1):
Los huesos humanos fueron obtenidos en el Departamento
de Morfología de la Facultad de Odontología de la
Pontificia Universidad Católica de Campinas, todos de
individuos adultos y leucodermas. Los huesos restantes
fueron obtenidos de animales adultos muertos, algunos
en estado de putrefacción, otros ya esqueletizados.
Luego de la obtención de estos huesos, fueron lavados
en agua corriente e inmersos en solución de hipoclorito
de sodio al 0.5% por 10 minutos para remover
partículas de tejido blando adheridas. Posteriormente,
fueron lavados en agua corriente removiendo así, vestigios
de la solución.
De cada hueso fueron obtenidas dos láminas histológicas
por desgaste, realizándose cortes histológicos en
sentido longitudinal y transversal de cada hueso en la
porción de la diáfisis del hueso largo, siguiendo la técnica
preconizada por Ramalho & Daruge,7 con algunas
adaptaciones que permitieron una mayor nitidez.
La primera etapa fue la de corte del hueso, utilizando
disco diamantado de 7/8 de pulgada, montado en man
dril de motor odontológico con chorros de agua con la
finalidad de humedecer el hueso para no ocasionar microfracturas
o quemaduras, obteniéndose de esta manera,
muestras de 1 mm de grosor. Para el desgaste de
estas muestras se utilizó lija de esmeril números: 80,
100, 240, 400, 500, 600 y 1200, lijando en ambos lados
de las muestras (también humedeciéndolas) para mantener
la uniformidad.
Se obtuvieron muestras de 10 a 12 micras de grosor
que fueron pulidas con piedra de Arkansas y Blanco de
España, humedeciéndolas con agua. Tras cada paso, las
muestras eran observadas al microscopio de luz para verificarse
la presencia de posibles fallas o fracturas.
Las muestras fueron lavadas con agua y detergente
(aquil benzeno sulfanato de sodio) al 0.5% por 20 minutos
y posteriormente secadas y deshidratadas con alcohol
por 30 minutos. Luego de un nuevo secado en estufa
a 37ºC por 24 horas, cada pieza era bañada en xilol por
diez minutos para aclararlas.
De esta forma se dio inicio al montaje de las muestras
utilizándose lámina de vidrio, laminilla y resina epoxi
con polimercaptanos (Araldite®). Cada muestra ósea fue
colocada sobre una lámina vertiéndose en ellas una gota
de Araldite®, cubiertas con una laminilla, presionándolas
levemente (para evitar la formación de burbujas de
aire) y llevadas a la estufa a 37º C por 24 horas para la
absorción de Araldite®.
Destacamos que fue usada Araldite® por poseer alta
densidad, lo que mantiene las cavidades y canalículos
óseos llenos de aire, eliminando el uso de coloraciones.
Por poseer índice de refracción diferente al Araldite® y
del vidrio, estas formaciones se mostraron en negro, obteniéndose
así gran nitidez.
Las láminas fueron observadas a través de fotomicroscopio
Zeiss, modelo MC 80 DX, con filtro verde y
objetivas de 10x y 40x y 100x (inmersión) veces, obteniéndose
fotomicrografías con película en blanco y negro
ILFORD-50 ISO, cuyos aumentos fueron aproximadamente
70, 280 y 700 veces.
De los 60 huesos analizados pertenecientes a seres
humanos y de los 19 animales restantes, fueron obtenidas
120 láminas histológicas, siendo seleccionados y fotomicrografiados
apenas los campos mejores y más nítidos,
obteniéndose 3 fotomicrografías de cada corte totalizando
120 fotomicrografías numeradas de 01 al 60.
Resultados
Análisis e interpretación de las fotomicrografías
Los exámenes histológicos periciales fueron analizados
a partir de las fotomicrografías de los huesos en cortes
longitudinales y transversales con aumentos de 70, 280
y 700 veces, para cada corte.
Las interpretaciones se encuentran disponibles en el
cuadro II.
Discusión
Una buena parte de la literatura consultada en este trabajo,
aborda los caracteres histomorfológicos de los huesos
humanos como el sistema y canales de Havers, los
osteocitos y sus canalículos.
Entre estos autores están Dyce et al.,15 Junqueira &
Carneiro13 y Stevens et al.,16 cuyas afirmaciones se corroboran
con nuestros hallazgos.
Trabajos como los de Arbenz (1988) Whittaker & Mac-
Donald,12 Fávero,3 França4 y Calabuig5 nos ofrecen subsidios
en la histomorfología de los tejidos óseos con finalidad
pericial, permitiendo la comparación con los resultados
obtenidos en este trabajo, por presentar metodologías
semejantes, confirmando las pesquisas en lo que se
refiere a las formas del sistema de Havers, los diámetros
de los canales de Havers, forma, distribución y disposición
de los osteocitos y las características de distribución,
forma, número, cantidad de anastosmosis de los
canalículos presentes en los osteocitos.
Las técnicas de preparación y análisis microscópico
preconizados por Ramalho & Daruge7 fueron seguidos,
con excepción de la utilización del Bálsamo de Canadá,
sustituido por Araldite®, en el montaje de las láminas,
dando éste mayor nitidez.
Bibliografía
1. Arbenz GO. Contribuição para o estudo da estimativa da
idade pelo número de dentes permanentes irrompidos, em
escolares da cidade de São Paulo, brancos, nascidos no Brasil.
Anais da Faculdade de Farmácia e Odontologia da Universidade
de São Paulo. São Paulo. 1962; 19(2): 159-76.
2. Arbenz GO. Medicina legal e antropologia forense. Rio de
Janeiro, Atheneu. 1988: 199-206.
3. Favero F. Medicina legal: introdução ao estudo da medicina
legal, identidade, traumatologia, infortunística, tanatologia.
9 ed. São Paulo, Martins Fontes. 1993: 63-7.
4. França GV. Medicina legal. 4 ed. Rio de Janeiro, Guanabara
Koogan. 1995: 30.
5. Calabuig JAG. Medicina legal y toxicología. 4a ed. Masson,
Ediciones Científicas y Técnicas. 1998: 1016.
6. Owsley DW, Mires AM, Keith MS. Case involving differentiation
of deer and human bone fragment. J Forensic Sci,
Philadelphia. 1985; 30(2): 572-8.
7. Ramalho SA, Daruge EA. Importância pericial do estudo
comparativo histomorfológico do esmalte, dentina e cemento
de dentes humanos e de outros animais. Piracicaba.
1994, Tese (Mestrado em Odontologia Legal e Deontologia)–
Faculdade de Odontologia de Piracicaba. Universidade
Estadual de Campinas.
8. Snow C, Luke J. The Oklahoma City child disappearances of
1967: forensic anthropology in the identification of skeletal
remains. J Forensic Sci, Philadelphia. 1970; 15(2): 125-53.
9. Sopher IM. The dentist, the forensic pathologist, and the
identification of human remains. J Dent Am Assoc, Chicago.
1972; 85(6): 1324-9.
10. Getty R. Osteologia geral. In: Anatomia dos animais domésticos.
5 ed. Rio de Janeiro, Interamericana. 1981; 2(2):
19-23. Tradução de: Sisson and Grossman’s the anatomy
of the domestic animals.
11. Buchner A. The identification of human remains. Int Dent
J, London. 1985; 35(4): 307-11.
12. Whittaker D, MacDonald D. A color atlas of forensic dentistry.
Ipswich, England, Wolfe Publishing. 1989; 11: 81-9.
13. Junqueira LC, Carneiro J. Tecido ósseo. In: Histologia. 7
ed. Rio de Janeiro, Guanabara Koogan. 1990; 8: 101-19.
14. Hall BK. Bone matrix and bone specific products. Boca
Raton, CRC Press. 1991: 2-25, 47-59.
15. Dyce KM, Sack WO, Wensing C. Tratado de anatomia veterinária.
Rio de Janeiro, Guanabara Koogan. 1990: 6-30.
16. Stevens A, Lowe JS. Sistema muscular esquelético. In:
Histologia. São Paulo, Manole. 1995; 14: 226-48. Tradução
de: Histology. Original inglês.
Lecturas complementarias
– Bass WM. Developments in the identification of human
skeletal material (1968-1978). Am J of Phys Anthropol,
Philadelphia, 1979; 51(4): 555-62.
articulo anexado por Magdalena Espinoza
EL SISTEMA ESQUELETICO
Forma y resistencia
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Oculto bajo la piel y los músculos, rico en un mineral llamado calcio, y dotado de una increíble fortaleza, se encuentra un sistema que nos sostiene y da forma por dentro. Es el sistema esquelético, nuestra estructura ósea, que posibilita al cuerpo enderezarse y arquearse, y a los órganos conservar un espacio apropiado para su funcionamiento. Punto de anclaje para los músculos, los cuales al contraerse generan movimiento.
El esqueleto humano es el conjunto organizado de huesos y cartílagos que forman y estabilizan el armazón del cuerpo. Está formado por 206 huesos, piezas rígidas y resistentes; pero también por partes más blandas llamadas cartílagos. Ellos recubren los extremos de los huesos, y forman ciertas estructuras como la nariz, el pabellón de las orejas y parte de las costillas. Los huesos se unen en las articulaciones por medio de los ligamentos.
Podemos dividir al esqueleto humano en dos categorías:
• el esqueleto axial: sus huesos forman el eje principal del cuerpo (cabeza y tronco), e inclusive constituyen las paredes de cavidades corporales como por ejemplo: cráneo, columna vertebral, costillas, esternón, etc.
• el esqueleto apendicular, está compuesto por los huesos de las extremidades tanto superiores como inferiores y los huesos de los hombros (cintura pectoral) y la cadera (pelvis) que conectan los miembros con el esqueleto axial.
Las piezas rígidas
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Nuestros huesos están formados químicamente por un 33% de materia orgánica y por 66% aproximadamente de materia inorgánica:
• la parte orgánica está formada principalmente por una proteína, el colágeno, que les confiere elasticidad, flexibilidad y resistencia;
• la parte inorgánica está formada por sales minerales, principalmente calcio y fosfato, que son la causa de la dureza y rigidez a las piezas óseas.
Las proporciones entre materia orgánica e inorgánica varían de acuerdo a los requerimientos de cada etapa de la vida. En los niños, por ejemplo, la parte orgánica es comparativamente mayor y los huesos son más flexibles y pueden doblarse. Si en esta etapa no se reciben las cantidades necesarias de calcio pueden ocurrir deformidades como el raquitismo.
El calcio aporta rigidez a los huesos y a los dientes. Pero también interviene en muchos otros procesos orgánicos, tales como la contracción muscular, transmisión de impulsos nerviosos, coagulación de la sangre, etc.
Existen dos tipos de tejido óseo:
• el hueso compacto, de gran dureza y densidad, se ubica en la parte externa, debajo del periostio (membrana que recubre a los huesos); su grosor depende de las exigencias mecánicas. Se dispone en forma de laminillas concéntricas, que forman parte de los llamados sistemas Haversianos.
• el hueso esponjoso es más liviano y tiene forma de enrejado; tiene espacios en los cuales se aloja la médula ósea. Se ubica generalmente en la parte interna del cuerpo
de los huesos (diáfisis) y en los extremos (epífisis) de los huesos largos y en los huesos cortos, planos e irregulares.
Funciones y conformación celular
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Las funciones principales de los huesos son aportar rigidez y sostener al cuerpo y proporcionar puntos de inserción a los músculos, de modo que se puedan producir movimientos. Los huesos, junto con los músculos y las articulaciones forman parte del aparato locomotor.
Protegen a los órganos internos como el cerebro, pulmones, etc. formando cavidades rígidas donde estos se alojan, por ejemplo cráneo o la caja torácica.
Otra función fundamental es la de generar las células sanguíneas. Los huesos poseen una parte llamada médula ósea roja, donde se producen los glóbulos rojos, glóbulos blancos y plaquetas.
Existen tres clases principales de células óseas:
• Los osteoblastos están a cargo de la formación del hueso. Sintetizan y secretan colágeno, que se alinea organizadamente formando una matriz orgánica conocida como osteoide. Sobre ella se deposita calcio y fosfato en forma de masa amorfa. Luego, con la adición de iones hidróxido y bicarbonato a la parte mineral se forman los cristales maduros.
• Cuando el hueso mineralizado se acumula y rodea a los osteoblastos hace que pierdan su actividad sintética y de esta forma se conviertan en osteocitos, células que mantienen la matriz.
• Los osteoclastos son las células que tienen a su cargo la resorción y la remodelación del hueso. Este proceso libera calcio al medio y puede responder a necesidades del organismo.
Ya hemos mencionado al periostio, una membrana de característica fibrosa que se adhiere firmemente al hueso. En su cara interna posee a los osteoblastos que intervienen en el crecimiento y reparación del hueso. Su vascularización permite que por medio de sus vasos sanguíneos lleguen los nutrientes a las células óseas.
Clases de huesos
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Los huesos largos tienen más longitud que anchura, como el humero, el fémur, las falanges de los dedos, etc. Actúan como palancas para producir movimiento en la contracción muscular. Los huesos largos de los miembros inferiores soportan el peso corporal. Llamamos diáfisis al eje o cuerpo de los huesos de característica hueca y epífisis a sus extremos. Podemos distinguir en la diáfisis una capa externa de hueso compacto de aprox.
encontramos la médula ósea amarilla (principalmente grasa). Esta puede volver a transformarse en médula ósea roja. En la epífisis o extremos, los intersticios de los huesos esponjosos están llenos de médula ósea roja o tejido hematopoyético.
Los huesos planos son, como su nombre lo indica, aplanados y levemente curvos. Podemos nombrar el omóplato, los huesos del cráneo, etc.
En los huesos del cráneo, por ejemplo, el hueso compacto forma una tabla externa y otra interna, en el medio de las dos encontramos hueso esponjoso, el cuál es rico en venas y se llama diploe. Estas dobles capas compactas cumplen una función de protección ya que un golpe en la cabeza puede fracturar la capa externa y no la interna de esa forma no se daña y se protege al encéfalo.
Huesos cortos son, por ejemplo, los huesos del carpo (huesos de la muñeca), los huesos del tarso (huesos del tobillo), etc. Se hallan agrupados. Permiten el movimiento formando puentes de conexión. Intervienen más en cuestiones de estabilidad, como por ejemplo en el caso del tobillo.
Por último están los irregulares, que no se incluyen en ninguna de las otras clasificaciones. Por ejemplo las vértebras que forman la columna vertebral, huesos de la base del cráneo, etc.
Encontramos medula ósea roja en un adulto, solo en las epífisis de los huesos largos, en los huesos planos, en los cortos y en los irregulares.
Referencias Bibliográficas
• Fisiología Humana. Philippe Meyer.
• Anatomía. Basmajian. Séptima Edición.
• Fisiología. R. Berne - M. Levy
• Lippert Anatomía Texto y Atlas. 4ª Edición. España.
Articulo anexado Maria Torres
Anatomía del Hueso
Anatomía del Hueso
¿Qué es el hueso?
El hueso es el tejido vivo que constituye el esqueleto humano. Existen tres tipos de tejido óseo:
Tejido compacto - el tejido exterior y más duro de los huesos.
Tejido esponjoso - tejido de consistencia esponjosa presente en la parte interna de los huesos.
Tejido subcondral - tejido liso de los extremos de los huesos, cubierto por otro tipo de tejido denominado cartílago. El cartílago es el tejido conectivo cartilaginoso especializado que tienen los adultos y a partir del cual se forman todos los huesos de los niños.
Juntos, el tejido compacto y el esponjoso se denominan periostio. Debajo de la capa dura exterior del periostio existen túneles y canales a través de los cuales pasan los vasos sanguíneos y linfáticos que nutren el hueso. Puede haber músculos, ligamentos y tendones adheridos al periostio.
Según su forma los huesos se clasifican en largos, cortos, planos e irregulares. Principalmente se dividen en largos y cortos.
Existen 206 huesos en el esqueleto humano, sin contar los dientes y los huesos sesamoideos (pequeños huesos que se encuentran dentro del cartílago):
80 huesos axiales, que incluyen los huesos de la cabeza, faciales, hioideos, auditivos, del tronco, las costillas y el esternón.
126 huesos apendiculares, que incluyen los de los brazos, hombros, muñecas, manos, piernas, caderas, tobillos y pies.
¿Cuáles son las funciones del hueso?
El hueso proporciona forma y soporte al cuerpo y protege ciertos órganos. También actúa como sitio de almacenamiento de minerales y proporciona el medio, la médula ósea, para el desarrollo y almacenamiento de las células sanguíneas.
¿Cuáles son los distintos tipos células óseas?
Los distintos tipos de células óseas incluyen los siguientes:
Osteoblasto - se encuentra dentro del hueso; su función consiste en formar el tejido y los minerales que dan resistencia al hueso.
Osteoclasto - célula de gran tamaño que se forma en la médula ósea y cuya función consiste en absorber y eliminar el tejido no deseado.
Osteocito - se encuentra dentro del hueso; su función consiste en mantener vivo el tejido óseo.
Dentro de la médula ósea también existen células adiposas y hematopoyéticas. Las células hematopoyéticas son las que producen células sanguíneas.
Debido a la complejidad de las funciones de los huesos, que van desde proporcionar fuerza y soporte al cuerpo hasta hacer las veces de receptáculo para el desarrollo y almacenamiento de células sanguíneas, existen muchos trastornos y enfermedades que pueden afectar a los huesos.
Bibliografía: http://www.terra.com/salud/articulo/html/sal5930.htm
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