Conceptos actuales en el tratamiento de la parálisis obstétrica del plexo braquial: Revisión analítica a propósito de una serie de casos
DOI:
https://doi.org/10.28957/rcmfr.v24n1a5Palabras clave:
parálisis obstétrica, plexo braquial, traumatismos del nacimiento, neuropatías del plexo braquial.Resumen
Se trata de una revisión analítica y una serie de casos de la parálisis obstétricadel plexo braquial, enfocados al estado actual en el tratamiento. La recuperación del bíceps braquial entre el tercero y el sexto mes es la clave para decidir cirugía o no. La colocación de injertos nerviosos y de transferencias nerviosas es lo más frecuente. La recuperación es lenta y requiere controles hasta los dos o tres años para ver resultados finales. Después de los 18 meses de edad no hay lugar a reconstrucción sobre los nervios y las acciones se dirigirán a liberaciones, transferencias miotendinosas y osteotomías.
Materiales y métodos: una serie de 25 pacientes intervenidos para reconstruir en el hombro las secuelas de una Parálisis Braquial Obstétrica (PBO). Se realizaron liberaciones del subescapular y trasferencia del dorsal ancho para mejorar la abducción y rotación externa del hombro.
Resultados: de acuerdo con la clasificación de Mallet y de Gilbert, todos los pacientes mejoraron funcionalmente.
Discusión: la no recuperación de la flexión de codo entre los tres y seis meses es un criterio aceptado de exploración del plexo braquial. Cuando la flexión del codo inicia, pero no supera el 50% del arco de flexión contra gravedad a los seis meses, es también una indicación de que se debe practicar cirugía. Todos los pacientes del estudio recibieron transferencia del dorsal ancho y mejoraron la abducción y rotación externa, y en las escalas funcionales. Se ha reportado una ligera pérdida de la funcionalidad en seguimientos a largo plazo, posiblemente por exclusión funcional de la extremidad que deteriora la función.
Biografía del autor/a
Enrique Vergara Amador
epartamento de Ortopedia y Traumatalogía, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá,
Colombia.
Colombia.
Referencias bibliográficas
1. Haerle M, Gilbert A. Management of Complete Obstetric Brachial Plexus Lesions. J PediatrOrthop. 2004; 24: 194–200.
2. Borschel GH, Clarke HM. Obstetrical brachial plexus palsy. PlastReconstr Surg. 2009 Jul; 124(1 Suppl):144e-155e. Review.
3. Al-Qattan MM. Obstetric brachial plexus injuries. Journal of the American society for surgery of hand. 2003; 3, No. (1): 41-54.
4. Levine MG, Holroyde J, Woods JR, et al. Birth traumas: incidence and predisposing factors. Obstet Gynecol. 1984; 63: 792–795.
5. Hardy AE. Birth injuries of the brachial plexus: Incidence and prognosis. J Bone Joint Surg Br. 1981; 63: 98–101.
6. Michelow BJ, Clarke HM, Curtis CG, Zuker RM, Seifu Y, Andrews DF. The natural history of obstetrical brachial plexus palsy. PlastReconstr Surg. 1994; 93:675–680.
7. Thatte MR, Mehta R. Obstetric brachial plexus injury. Indian J Plast Surg. 2011;44(3): 380–389.
8. McFarland LV, Raskin M, Daling JR, et al. Erb/Duchenne’s palsy: a consequence of fetal macrosomia and method of delivery. Obstet Gynecol. 1986; 68:784–788.
9. Al-Qattan MM, Al-Kharfy TM. Obstetric brachial plexus injury in subsequent deliveries. AnnPlast Surg. 1996; 37: 545–548.
10. Gilbert A, Brockman R, Carlioz H. Surgical treatment of brachial plexus birth palsy. Clin OrthopRelatRes.1991; 264:
39–47.
11. Chalain TM, Clarke HM, Curtis CG. Case report: Unilateral combined facial nerve and brachial plexus palsies in a neonate following a midlevel forceps delivery. Ann Plast Surg. 1997; 38: 187–190.
12. Oppenheim WL, Davis A, Growdon WA, Dorey FJ, Davlin LB. Clavicle fractures in the newborn. ClinOrthopRelat Res. 1990;250: 176–180.
13. Geutjens G, Gilbert A, Helsen K. Obstetric brachial plexus palsy associated with breech delivery. A different pattern of injury. J Bone Joint Surg Br. 1996; 78: 303–306.
14. Al-Qattan MM, Clarke HM, Curtis CG. Klumpke’s birth palsy: does it really exist? J Hand Surg Br. 1995; 20: 19–23.
15. Gilbert A. Obstetrical brachial plexus palsy. In: Tubiana R, ed. The Hand. Vol. 4. Philadelphia: WB Saunders, 1993: 575-601.
16. Michelow BJ, Clarke HM, Curtis CG, et al. The natural history of obstetrical brachial plexus palsy. PlastReconstrSurg. 1994. 93:675–681.
17. Gilbert A. Paralysie obstetricale du plexus brachial. In: Alnot JY, Narakas A, eds. Les Paralysis du Plexus Brachial. 2nd ed. Monographie de la Société Française de Chirurgie de la Main. Paris, France: Expansion Scientifique Française; 1995. 270.
18. Clarke H, Curtis C. Examination and prognosis. In: Gilbert A, ed. Brachial plexus injuries. London, United Kingdom: Martin-Dunitz, 2001. 159-172.
19. Bertelli JA, Ghizoni MF. The towel test: a useful technique for the clinical and electromyographic evaluation of obstetric brachial
plexus palsy. J Hand Surg Br. 2004; 29 (2): 155-8.
20. Vredeveld JW. Clinical neurophysiological investigations. In: Gilbert A, ed. Brachial plexus injuries. London, United Kingdom: Martin-Dunitz, 2001. 42.
21. Laurent JP, Lee R, Shenaq S, Parke JT, Solis IS, Kowalik L. Neurosurgical correction of upper brachial plexus birth injuries. J
Neurosurg.1993; 79: 197–203.
22. Hoeksma AF, terSteeg AM, Nelissen RG, Van Ouwerkerk WJ, Lankhorst GJ, de Jong BA. Neurological recovery in obstetric brachial plexus injuries: an historical cohort study. Dev Med Child Neurol. 2004; 46: 76–83.
23. Pondaag W, Lee R, Shenaq S, Parke JT, Solis IS, Kowalik L. Natural history of obstetric brachial plexus palsy: a systematic
review. Dev Med Child Neurol. 2004; 46:138 –144.
24. Hale HB, Bae DS, Waters PM. Current Concepts in the Management of Brachial Plexus Birth Palsy. J Hand Surg. 2010;
35A: 322–331.
25. Gilbert A, Tassin JL. Reparation chirurgicale du plexus brachial dans la paralysie obstétricale. Chirurgie. 1984; 110: 70–75.
26. Gilbert A, Tassin JL. Obstetrical palsy: a clinical, pathological and surgical review. In: Terzis JK, ed. Micro reconstruction of nerve injuries. Philadelphia: WB Saunders, 1987: 529.
27. Gilbert A. Long-term evaluation of brachial plexus surgery in obstetrical palsy. Hand Clin. 1995; 11: 583–594.
28. Waters PM. Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy. J Bone Joint Surg Am. 1999; 81: 649–659.
29. Clarke HM, Curtis CG. An approach to obstetrical brachial plexus injuries. Hand Clin. 1995; 11: 563–581.
30. O’Brien DF, Park TS, Noetzel MJ, Weatherly T. Management of birth brachial plexus palsy. Childs Nerv Syst. 2006; 22:103–112.
31. Pearl M L, Edgerton BW. Glenoid deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am. 1998; 80: 659–667.
32. Birch R. Medial rotation contraction and posterior dislocation of the shoulder. In:Gilbert A, ed. Brachial plexus injuries. London, United Kingdom: Martin-Dunitz, 2001. 249-259.
33. Pearl ML, Edgerton BW, Kon DS, Darakjian AB, Kosco AE, Kazimiroff PB, Burchette RJ. Comparison of arthroscopic findings with magnetic resonance imaging and arthrography in children with glenohumeral deformities secondary to brachial plexus birth palsy. J Bone Joint Surg Am. 2003; 85: 890–898.
34. Van GeleinVitringa VM, Van Kooten EO, Jaspers RT, Mullender MG, Van Doorn-Loogman MH, Van der Sluijs JA. An MRI study on the relations between muscle atrophy, shoulder function and glenohumeral deformity in shoulders of children with obstetric brachial plexus injury. J Brachial PlexPeripher Nerve Inj. 2009; 4: 5. 7)
35. Rollnik JD, Hierner R, Schubert M, Shen ZL, Johannes S, Tröger M, et al. Botulinum toxin treatment of cocontractions after birth-related brachial plexus lesions. Neurology. 2000; 55: 112–114.
36. Price AE, Ditaranto P, Yaylali I, Tidwell MA, Grossman JA. Botulinum toxin type A as an adjunct to the surgical treatment of the medial rotation deformity of the shoulder in birth injuries of the brachial plexus. J Bone Joint Surg Br. 2007; 89:327–329.
37. Hoffer M M, Wickenden R, Roper B. Brachial plexus birth palsies. Results of tendon transfers to rotator cuff. J Bone Joint Surg Am. 1978; 60: 691–695.
38. Pagnotta A, Haerle M, Gilbert A. Longterm results on abduction and external rotation of the shoulder after latissimus dorsi transfer for sequelae of obstetric palsy. ClinOrthopRelat
Res. 2004; 426: 199–205.
39. Waters PM, Bae DS. Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy. J Bone Joint Surg Am. 2005; 87: 320–325.
40. Vergara- Amador E. Latissimus dorsi transposition for sequelae of obstetric palsy. Colom Med. 2010; 41: 248-255.
41. Waters PM. Management of Shoulder Deformities in Brachial Plexus Birth Palsies. J PediatrOrthop. 2010; 30: S53–S56.
42. Strecker WB, McAllister JW, Manske PR, Schoenecker PL, Dailey LA. Sever-L’Episcopo transfers in obstetrical palsy: a retrospective review of twenty cases. JPediatrOrthop. 1990 Jul-Aug; 10(4): 442-4. 11)
43. Narakas AO. Muscle transpositions in the shoulder and upper arm for sequelae of brachial plexus palsy. ClinNeurolNeurosurg. 1993; 95 Suppl: S89-91.
44. Al-Qattan MM. Total Obstetric Brachial Plexus Palsy in Children With Internal Rotation Contracture of the Shoulder, Flexion Contracture of the Elbow, and Poor Hand Function: Improving the Cosmetic Appearance of the Limb With Rotation Osteotomy of the Humerus. AnnPlast Surg. 2010; 65 (1):38-42.
45. Kozin SH. Nerve Transfers in Brachial Plexus Birth Palsies: Indications, Techniques and Outcomes. Hand Clin. 2008; 24:363–376.
46. Kozin SH. Brachial Plexus Microsurgical Indications. J PediatrOrthop. 2010; 30:S49–S52.
47. Borschel GH, Clarke HM. Obstetrical Brachial Plexus Palsy. PlastReconstr Surg. 2009; 124 (Suppl.): 144e.
48. Bertelli JA, Ghizoni MF. Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers: spinal accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateral head branch to axillary nerve. J Hand Surg. 2004; 29A: 131-9.
49. Vergara-Amador E. Combinación de transferencias nerviosas en el tratamiento de lesiones altas del plexo braquial. Revista Cubana de Ortopedia y Traumatología. 2012; 26(2)
50. Clarke HM, Al-Qattan MM, Curtis CG, Zuker RM. Obstetrical brachial plexus palsy. Results following neurolisis of conducting neuromas in continuity. PlastReconstr Surg. 1996; 97: 974-982.
51. Capek L, Clarke HM, Curtis CG. Neuroma in continuity resection; early outcome in obstetrical brachial plexus palsy. Plast Reconstr Surg. 1998; 102:1555-1564.
52. Oberlin C, Beal D, Leechavengvongs S, Salon A, Dauge MC, Sarcy JJ. Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg Am. 1994; 19(2): 232–7.
53. Yin HW, Jiang S, Xu WD, Xu L, Xu JG, Gu YD. Partial ipsilateral C7 transfer to the upper trunk for C5-C6 avulsion of
the brachial plexus. Neurosurgery. 2012; 70(5):1176-82.
54. Vergara- Amador E, Ramirez A. Ipsilateral brachial plexus C7 roottransfer. Presentation of a case and a literature review. Neurocirugia (Astur). 2013 Mar: S1130-1473.
55. Mallet J. Paralysie obstétrical du plexus brachial. Traitement des sequelles. Priorité du traitement de l’épaule. Methode d’expression des resultats. RevChirOrthop. 1972; 58 (suppl):166-170.
56. Narakas AO. Obstetrical brachial plexus injuries. In: Lamb DW, ed. The Paralyzed Hand. The Hand and Upper Limb. Vol 2. Edinburgh: Churchill Livingstone, 1987:116
2. Borschel GH, Clarke HM. Obstetrical brachial plexus palsy. PlastReconstr Surg. 2009 Jul; 124(1 Suppl):144e-155e. Review.
3. Al-Qattan MM. Obstetric brachial plexus injuries. Journal of the American society for surgery of hand. 2003; 3, No. (1): 41-54.
4. Levine MG, Holroyde J, Woods JR, et al. Birth traumas: incidence and predisposing factors. Obstet Gynecol. 1984; 63: 792–795.
5. Hardy AE. Birth injuries of the brachial plexus: Incidence and prognosis. J Bone Joint Surg Br. 1981; 63: 98–101.
6. Michelow BJ, Clarke HM, Curtis CG, Zuker RM, Seifu Y, Andrews DF. The natural history of obstetrical brachial plexus palsy. PlastReconstr Surg. 1994; 93:675–680.
7. Thatte MR, Mehta R. Obstetric brachial plexus injury. Indian J Plast Surg. 2011;44(3): 380–389.
8. McFarland LV, Raskin M, Daling JR, et al. Erb/Duchenne’s palsy: a consequence of fetal macrosomia and method of delivery. Obstet Gynecol. 1986; 68:784–788.
9. Al-Qattan MM, Al-Kharfy TM. Obstetric brachial plexus injury in subsequent deliveries. AnnPlast Surg. 1996; 37: 545–548.
10. Gilbert A, Brockman R, Carlioz H. Surgical treatment of brachial plexus birth palsy. Clin OrthopRelatRes.1991; 264:
39–47.
11. Chalain TM, Clarke HM, Curtis CG. Case report: Unilateral combined facial nerve and brachial plexus palsies in a neonate following a midlevel forceps delivery. Ann Plast Surg. 1997; 38: 187–190.
12. Oppenheim WL, Davis A, Growdon WA, Dorey FJ, Davlin LB. Clavicle fractures in the newborn. ClinOrthopRelat Res. 1990;250: 176–180.
13. Geutjens G, Gilbert A, Helsen K. Obstetric brachial plexus palsy associated with breech delivery. A different pattern of injury. J Bone Joint Surg Br. 1996; 78: 303–306.
14. Al-Qattan MM, Clarke HM, Curtis CG. Klumpke’s birth palsy: does it really exist? J Hand Surg Br. 1995; 20: 19–23.
15. Gilbert A. Obstetrical brachial plexus palsy. In: Tubiana R, ed. The Hand. Vol. 4. Philadelphia: WB Saunders, 1993: 575-601.
16. Michelow BJ, Clarke HM, Curtis CG, et al. The natural history of obstetrical brachial plexus palsy. PlastReconstrSurg. 1994. 93:675–681.
17. Gilbert A. Paralysie obstetricale du plexus brachial. In: Alnot JY, Narakas A, eds. Les Paralysis du Plexus Brachial. 2nd ed. Monographie de la Société Française de Chirurgie de la Main. Paris, France: Expansion Scientifique Française; 1995. 270.
18. Clarke H, Curtis C. Examination and prognosis. In: Gilbert A, ed. Brachial plexus injuries. London, United Kingdom: Martin-Dunitz, 2001. 159-172.
19. Bertelli JA, Ghizoni MF. The towel test: a useful technique for the clinical and electromyographic evaluation of obstetric brachial
plexus palsy. J Hand Surg Br. 2004; 29 (2): 155-8.
20. Vredeveld JW. Clinical neurophysiological investigations. In: Gilbert A, ed. Brachial plexus injuries. London, United Kingdom: Martin-Dunitz, 2001. 42.
21. Laurent JP, Lee R, Shenaq S, Parke JT, Solis IS, Kowalik L. Neurosurgical correction of upper brachial plexus birth injuries. J
Neurosurg.1993; 79: 197–203.
22. Hoeksma AF, terSteeg AM, Nelissen RG, Van Ouwerkerk WJ, Lankhorst GJ, de Jong BA. Neurological recovery in obstetric brachial plexus injuries: an historical cohort study. Dev Med Child Neurol. 2004; 46: 76–83.
23. Pondaag W, Lee R, Shenaq S, Parke JT, Solis IS, Kowalik L. Natural history of obstetric brachial plexus palsy: a systematic
review. Dev Med Child Neurol. 2004; 46:138 –144.
24. Hale HB, Bae DS, Waters PM. Current Concepts in the Management of Brachial Plexus Birth Palsy. J Hand Surg. 2010;
35A: 322–331.
25. Gilbert A, Tassin JL. Reparation chirurgicale du plexus brachial dans la paralysie obstétricale. Chirurgie. 1984; 110: 70–75.
26. Gilbert A, Tassin JL. Obstetrical palsy: a clinical, pathological and surgical review. In: Terzis JK, ed. Micro reconstruction of nerve injuries. Philadelphia: WB Saunders, 1987: 529.
27. Gilbert A. Long-term evaluation of brachial plexus surgery in obstetrical palsy. Hand Clin. 1995; 11: 583–594.
28. Waters PM. Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy. J Bone Joint Surg Am. 1999; 81: 649–659.
29. Clarke HM, Curtis CG. An approach to obstetrical brachial plexus injuries. Hand Clin. 1995; 11: 563–581.
30. O’Brien DF, Park TS, Noetzel MJ, Weatherly T. Management of birth brachial plexus palsy. Childs Nerv Syst. 2006; 22:103–112.
31. Pearl M L, Edgerton BW. Glenoid deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am. 1998; 80: 659–667.
32. Birch R. Medial rotation contraction and posterior dislocation of the shoulder. In:Gilbert A, ed. Brachial plexus injuries. London, United Kingdom: Martin-Dunitz, 2001. 249-259.
33. Pearl ML, Edgerton BW, Kon DS, Darakjian AB, Kosco AE, Kazimiroff PB, Burchette RJ. Comparison of arthroscopic findings with magnetic resonance imaging and arthrography in children with glenohumeral deformities secondary to brachial plexus birth palsy. J Bone Joint Surg Am. 2003; 85: 890–898.
34. Van GeleinVitringa VM, Van Kooten EO, Jaspers RT, Mullender MG, Van Doorn-Loogman MH, Van der Sluijs JA. An MRI study on the relations between muscle atrophy, shoulder function and glenohumeral deformity in shoulders of children with obstetric brachial plexus injury. J Brachial PlexPeripher Nerve Inj. 2009; 4: 5. 7)
35. Rollnik JD, Hierner R, Schubert M, Shen ZL, Johannes S, Tröger M, et al. Botulinum toxin treatment of cocontractions after birth-related brachial plexus lesions. Neurology. 2000; 55: 112–114.
36. Price AE, Ditaranto P, Yaylali I, Tidwell MA, Grossman JA. Botulinum toxin type A as an adjunct to the surgical treatment of the medial rotation deformity of the shoulder in birth injuries of the brachial plexus. J Bone Joint Surg Br. 2007; 89:327–329.
37. Hoffer M M, Wickenden R, Roper B. Brachial plexus birth palsies. Results of tendon transfers to rotator cuff. J Bone Joint Surg Am. 1978; 60: 691–695.
38. Pagnotta A, Haerle M, Gilbert A. Longterm results on abduction and external rotation of the shoulder after latissimus dorsi transfer for sequelae of obstetric palsy. ClinOrthopRelat
Res. 2004; 426: 199–205.
39. Waters PM, Bae DS. Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy. J Bone Joint Surg Am. 2005; 87: 320–325.
40. Vergara- Amador E. Latissimus dorsi transposition for sequelae of obstetric palsy. Colom Med. 2010; 41: 248-255.
41. Waters PM. Management of Shoulder Deformities in Brachial Plexus Birth Palsies. J PediatrOrthop. 2010; 30: S53–S56.
42. Strecker WB, McAllister JW, Manske PR, Schoenecker PL, Dailey LA. Sever-L’Episcopo transfers in obstetrical palsy: a retrospective review of twenty cases. JPediatrOrthop. 1990 Jul-Aug; 10(4): 442-4. 11)
43. Narakas AO. Muscle transpositions in the shoulder and upper arm for sequelae of brachial plexus palsy. ClinNeurolNeurosurg. 1993; 95 Suppl: S89-91.
44. Al-Qattan MM. Total Obstetric Brachial Plexus Palsy in Children With Internal Rotation Contracture of the Shoulder, Flexion Contracture of the Elbow, and Poor Hand Function: Improving the Cosmetic Appearance of the Limb With Rotation Osteotomy of the Humerus. AnnPlast Surg. 2010; 65 (1):38-42.
45. Kozin SH. Nerve Transfers in Brachial Plexus Birth Palsies: Indications, Techniques and Outcomes. Hand Clin. 2008; 24:363–376.
46. Kozin SH. Brachial Plexus Microsurgical Indications. J PediatrOrthop. 2010; 30:S49–S52.
47. Borschel GH, Clarke HM. Obstetrical Brachial Plexus Palsy. PlastReconstr Surg. 2009; 124 (Suppl.): 144e.
48. Bertelli JA, Ghizoni MF. Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers: spinal accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateral head branch to axillary nerve. J Hand Surg. 2004; 29A: 131-9.
49. Vergara-Amador E. Combinación de transferencias nerviosas en el tratamiento de lesiones altas del plexo braquial. Revista Cubana de Ortopedia y Traumatología. 2012; 26(2)
50. Clarke HM, Al-Qattan MM, Curtis CG, Zuker RM. Obstetrical brachial plexus palsy. Results following neurolisis of conducting neuromas in continuity. PlastReconstr Surg. 1996; 97: 974-982.
51. Capek L, Clarke HM, Curtis CG. Neuroma in continuity resection; early outcome in obstetrical brachial plexus palsy. Plast Reconstr Surg. 1998; 102:1555-1564.
52. Oberlin C, Beal D, Leechavengvongs S, Salon A, Dauge MC, Sarcy JJ. Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg Am. 1994; 19(2): 232–7.
53. Yin HW, Jiang S, Xu WD, Xu L, Xu JG, Gu YD. Partial ipsilateral C7 transfer to the upper trunk for C5-C6 avulsion of
the brachial plexus. Neurosurgery. 2012; 70(5):1176-82.
54. Vergara- Amador E, Ramirez A. Ipsilateral brachial plexus C7 roottransfer. Presentation of a case and a literature review. Neurocirugia (Astur). 2013 Mar: S1130-1473.
55. Mallet J. Paralysie obstétrical du plexus brachial. Traitement des sequelles. Priorité du traitement de l’épaule. Methode d’expression des resultats. RevChirOrthop. 1972; 58 (suppl):166-170.
56. Narakas AO. Obstetrical brachial plexus injuries. In: Lamb DW, ed. The Paralyzed Hand. The Hand and Upper Limb. Vol 2. Edinburgh: Churchill Livingstone, 1987:116
Cómo citar
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Vergara Amador E. Conceptos actuales en el tratamiento de la parálisis obstétrica del plexo braquial: Revisión analítica a propósito de una serie de casos. Rev. Colomb. Med. Fis. Rehabil. [Internet]. 27 de agosto de 2014 [citado 18 de abril de 2024];24(1):55-67. Disponible en: https://revistacmfr.org/index.php/rcmfr/article/view/100
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