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Scientific and Technological Research
Infraclavicular block in paediatric anaesthesia: Concordance between the modified Wilson approach and ultrasound in determining the ideal puncture site
Abordaje infraclavicular en pediatría: concordancia del abordaje de Wilson modificado y el ultrasonido para la localización del sitio de punción ideal
Andrea Carolina Pérez-Pradillaa,b,
Corresponding author
cperezpradilla@gmail.com

Corresponding author at: Calzada México Xochimilco N° 289, Colonia Arenal de Guadalupe, CP 14389, Torre de Ortopedia, División de Anestesiología, Mexico, Distrito Federal, México.
, Ana Angélica Peña-Riverónc, Laura Catalina Chaparro-Gómezb, Lailigh Citlallis Castro-Ortizb, Elizabeth Velázquez-Delgadob, Rosangel Acevedo de la Peñab
a Paediatric Anaesthetist, Instituto Roosevelt de Ortopedia Infantil, Bogotá D.C., Colombia
b Anaesthetist, Higher Specialization Postgraduate Resident, Instituto Nacional de Rehabilitación, Mexico, Federal District, Mexico
c Anaesthetist and Pain Specialist, Anaesthesia Division, Instituto Nacional de Rehabilitación, Mexico, Federal District, Mexico
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">According to studies conducted in the Netherlands&#44; distal radius and wrist fractures account for approximately 25&#37; of all paediatric fractures<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">1</span></a> and traumatic injuries involving the hand range between 1800 and 2600 per 100&#44;000 inhabitants per year in the Netherlands and Denmark&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">2</span></a> There are also congenital disorders involving the upper limb in 0&#46;16&#8211;0&#46;18&#37; of live births in the United Kingdom&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Significant technological and scientific advances in the field of regional anaesthesia over the past decade have led to improvements in our knowledge of the anatomy&#44; and to better surgical approaches&#44; with improved safety profiles&#46; Together with greater availability of resources&#44; this has promoted the use of regional anaesthesia in paediatric patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">4&#8211;9</span></a> However&#44; the use of regional anaesthesia techniques in children is limited by the size of the structures&#44; the proximity of the neural structures to critical structures &#40;pleura&#44; blood vessels&#41;&#44; poorly defined superficial landmarks&#44; a tight safety margin&#44; a higher potential for toxicity related to local anaesthetics&#44; and the need for sedation or general anaesthesia&#44; which might mask any signs of alarm &#40;paraesthesias&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The infraclavicular approach for brachial plexus blocks is indicated for hand&#44; forearm&#44; elbow and arm surgery &#40;the shoulder excluded&#41;&#46; Its advantages include a higher probability of achieving axillary and musculocutaneous nerve blocks when compared with the axillary approach&#59; ease of fixation of the continuous analgesia catheters&#59; lower impact on pulmonary function when compared to the supraclavicular and the interscalene approaches&#59; and no arm abduction requirement&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">12&#44;13</span></a> Disadvantages include the possibility of not achieving adequate posterior cord block when single injections are used&#59; also&#44; in the event of vascular puncture due to the depth of the structures&#44; it is difficult to apply compressive manoeuvres&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">12</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There are variations to the infraclavicular block&#58; the coracoid approach&#44;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">14&#44;15</span></a> the lateral sagittal approach&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">16</span></a> the vertical approach&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">17</span></a> and the modified Raj approach&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">18&#44;19</span></a> The coracoid approach is the most popular in the United States&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">20</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The coracoid approach was first described by Whiffler<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">21</span></a> and later modified by Wilson who&#44; with the help of nuclear magnetic resonance imaging &#40;NMR&#41;&#44; determined that the ideal puncture site in adults was 2<span class="elsevierStyleHsp" style=""></span>cm medial and 2<span class="elsevierStyleHsp" style=""></span>cm caudal to the lateral tip of the coracoid process&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In paediatric patients&#44; the optimal injection site for the infraclavicular approach is still controversial&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">11</span></a> The modified Raj and the vertical approaches are considered &#8220;dangerous&#8221; because of the proximity of the puncture site to the cervical pleura&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">22&#44;23</span></a> There are no publications at the present time in relation to Whiffler&#39;s approach or Wilson&#39;s modification in children&#46; However&#44; a modified Wilson technique for paediatric patients was developed at the National Rehabilitation Institute&#44; consisting of using the coracoid process as the anatomical landmark and finding the puncture site medial and caudal to it according to the patient&#39;s weight&#46; This modification has not been published before&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In 1999&#44; Kapral described another modification of Whiffler&#39;s technique called the &#8220;lateral vertical&#8221; approach&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a> Kapral reported a high rate of success using this technique &#40;100&#37;&#41; with a broad range of nerve blocks with a broad range of nerve block spectrum &#40;including the musculocutaneous&#44; thoracodorsal&#44; axillary and medial cutaneous brachial nerves&#41; and absence of complications in adult patients&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a> Later&#44; Fleischmann and Ponde reported the use of this technique in paediatric patients&#44; modifying the location of the puncture site&#44; this time 0&#46;5<span class="elsevierStyleHsp" style=""></span>cm caudal to the coracoid process&#44; with similar results as those found by Kapral&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">25&#44;26</span></a> In 2004&#44; Klaastad described the &#8220;lateral sagittal&#8221; technique in adults&#59;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">27</span></a> however&#44; there are few reports on the use of this technique in paediatric patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">28&#44;29</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The first report of an ultrasound-guided brachial plexus block through the infraclavicular approach in paediatric patients was described by Marhofer&#44; who compared this technique with a neurostimulation-guided lateral vertical approach in a randomized clinical trial&#46; He found shorter latency periods and longer block durations in the ultrasound group&#44; with no difference in block quality after 30<span class="elsevierStyleHsp" style=""></span>min&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">30</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Despite the many advantages of ultrasound-guided techniques&#44; the main limitations are still the cost of the equipment and the need for specialized training&#46; Moreover&#44; it does not totally eliminate the risk of inadvertent intraneural injection&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">31</span></a> On the other hand&#44; safety recommendations in regional anaesthesia include triple monitoring &#40;i&#46;e&#46;&#44; neurostimulation&#44; ultrasound and injection pressure measurements&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">32</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The objective of our study was to determine concordance between the modified Wilson infraclavicular approach and the use of ultrasound for the anatomic localization of nerve structures and of the ideal puncture site&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Materials and methods</span><p id="par0055" class="elsevierStylePara elsevierViewall">A descriptive observational study was conducted&#46; Patient recruitment was initiated once the approval of the Scientific Research Commission and the Ethics and Research Committee of the National Rehabilitation Institute was obtained&#46; Patients included healthy children 1&#8211;16 years of age scheduled for open or closed reduction surgery for fractures of any extremity&#59; patients with anatomical variants obscuring the visualization of the cords in the infraclavicular region were excluded&#46; The parents of the children signed an informed consent and patients 12 or older signed an informed assent&#46; Puncture site &#40;C point&#41; marking was done in accordance with the modified Wilson infraclavicular &#40;MWIA&#41; coracoid approach&#44; as follows&#58; for patients weighing less than 10<span class="elsevierStyleHsp" style=""></span>kg&#44; 1<span class="elsevierStyleHsp" style=""></span>cm caudal and 1<span class="elsevierStyleHsp" style=""></span>cm medial to the coracoid process&#59; for patients weighing 10&#8211;20<span class="elsevierStyleHsp" style=""></span>kg&#44; 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm caudal and 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm medial to the coracoid process&#59; for patients weighing more than 20<span class="elsevierStyleHsp" style=""></span>kg&#44; 2<span class="elsevierStyleHsp" style=""></span>cm caudal and 2<span class="elsevierStyleHsp" style=""></span>cm medial to the coracoid process &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">A Sonosite Micromaxx &#40;Bothell&#44; WA&#44; USA&#41; ultrasound machine with a high-frequency linear transducer &#40;13&#8211;6<span class="elsevierStyleHsp" style=""></span>MHz&#41; was used for making measurements of any of the two extremities&#46; The centre point of the transducer was placed on the C point marked as MWIA in a parasagittal orientation &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; and the necessary depth and focus adjustments were made in order to ensure visualization of the target structures&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Localization was rated as &#8220;successful&#8221; when the axillary artery and the brachial plexus cords were visualized in the central third of the screen&#59; &#8220;poor&#8221; if the axillary artery and the brachial plexus cords were seen on the lateral or medial third of the image&#59; and &#8220;failed&#8221; when these structures were not visualized &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The Vienna classification described by Marhofer et al&#46; was used to evaluate quality of imaging visualization&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">33</span></a> Additionally&#44; distance measurements were made from the most prominent point in the coracoid process to the brachial plexus cords&#44; from the skin to the cords&#44; from the pleura to the coracoid process&#44; and the position of the cords in relation to axillary artery was described &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; For image acquisition&#44; the transducer was positioned on an oblique sagittal plane&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Measurements were made with the arm in adduction and 90&#176; of abduction with the patient under sedation or general anaesthesia for the scheduled surgical procedure&#46; It is important to mention that the ultrasound scans were performed by two investigators wit experience in ultrasound-guided infraclavicular blocks&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The sample size was determined on the basis of convenience&#44; requiring 100 patients over a 5-month period&#46; The data were entered in an Excel database&#44; and the STATA 10 software was used for data analysis&#46; A measurement of central tendency was made for continuous variables&#46; Kappa statistics were used to evaluate concordance between nominal variables&#46; A linear regression was also performed in order to confirm the correlation between the distance from the coracoid process to the posterior cord and weight and height&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">The study enrolled 100 patients&#46; Demographic characteristics are shown by age group &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The patients were distributed homogenously among age groups&#46; Gender distribution was also homogenous except in the 6&#8211;10 group &#40;33&#37; female patients&#41;&#46; Children under 5 tended to have a low BMI &#40;body mass index&#41; &#40;&#60;18&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">There is a significant difference in distances measured from the coracoid process to the brachial plexus in adduction and abduction between patients &#60;10<span class="elsevierStyleHsp" style=""></span>kg and those 11&#8211;20<span class="elsevierStyleHsp" style=""></span>kg&#46; However&#44; in patients of more than 20<span class="elsevierStyleHsp" style=""></span>kg there is no significant difference&#46; Distances from the skin to the cords&#44; the coracoid process to the cords&#44; and from the coracoid process to the pleura were shorter in abduction in all age groups&#46; However&#44; the difference was not statistically significant &#40;<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Localization of the target anatomical structures using ultrasound on &#8220;C point&#8221; in patients under 10<span class="elsevierStyleHsp" style=""></span>kg failed in 8&#46;4&#37; of patients&#44; both in adduction as well as abduction&#59; it was poor in 41&#37; of patients in adduction and in 33&#46;3&#37; in abduction&#59; and it was successful only in 66&#37; of patients in adduction and 58&#46;3&#37; of patients in abduction&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In patients 10&#8211;20<span class="elsevierStyleHsp" style=""></span>kg&#44; localization of the target anatomical structures using ultrasound on &#8220;point C&#8221; failed in 13&#37; of patients in adduction and 0&#37; in abduction&#59; it was poor in 41&#37; of patients in adduction and in 43&#37; in abduction&#59; and was successful in 46&#37; of patients in adduction and 56&#37; in abduction&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In patients over 20<span class="elsevierStyleHsp" style=""></span>kg&#44; localization of the target anatomical structures using ultrasound on &#8220;point C&#8221; failed in 13&#37; of patients in adduction and in 4&#46;1&#37; in abduction&#59; it was poor in 49&#37; in adduction and in 59&#46;1&#37; in abduction&#59; and it was successful in 38&#37; in adduction and in 36&#37; in abduction&#46; No statistically significant differences were found in terms of successful ultrasound identification in adduction or abduction according to the weight of the patients&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In terms of the quality of the visualization&#44; 88&#37; of the measurements were given a score of 2&#44; and the rest were given a score of 3 under the Vienna classification&#46; There were no statistically significant differences between age groups regarding the quality of visualization&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A multivariate analysis was conducted in order to determine the correlation between the distance from the coracoid process to the posterior cord in accordance with weight and height&#44; and a statistically significant correlation was found in adduction &#40;weight&#58; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;015&#44; height&#58; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; and in abduction &#40;weight and height <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Position of the cord in the brachial plexus in relation to the axillary artery was evaluated in adduction and abduction&#44; using a clock distribution&#46; Considering that no intervention was performed and cords were&#44; therefore&#44; not identified using neurostimulation&#44; cord positions described in previous anatomical studies were used&#46; The lateral cord was defined as the most superficial and closest to the coracoid process&#59; the posterior cord was defined as the most posterior in relation to the artery&#59; and the medial cord was defined as the one most frequently located between the axillary artery and vein&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The lateral cord was found between 7 and 12 o&#8217;clock&#44; and the most frequent location was at 10 o&#8217;clock in adduction &#40;50&#37;&#41; and 9 o&#8217;clock in abduction &#40;47&#37;&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0025">Figs&#46; 5 and 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">The posterior cord was found between 5 and 11 o&#8217;clock&#46; The most frequent location was at 6 o&#8217;clock in adduction &#40;30&#37;&#41; and at 8 o&#8217;clock in abduction &#40;42&#37;&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0035">Figs&#46; 7 and 8</a>&#41;&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">The greatest location variability was found for the medial cord&#44; mainly in abduction&#46; The most frequent location was at 2 o&#8217;clock in adduction &#40;37&#37;&#41; and at 10 o&#8217;clock in abduction &#40;27&#37;&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0045">Figs&#46; 9 and 10</a>&#41;&#46;</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><elsevierMultimedia ident="fig0050"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">Concordance between the modified Wilson approach and ultrasound for determining the ideal puncture site was 0&#46;47 in adduction and abduction&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0145" class="elsevierStylePara elsevierViewall">The objective of this study was to determine concordance between the MWIA and ultrasound for the location of the ideal anatomical puncture site&#44; considering the lack of clinical studies regarding this topic in the literature&#44; and the fact that there is only one similar study in adult patients&#46; The study by Kuo et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">34</span></a> assessed the accuracy of Wilson&#39;s coracoid approach for the location of the ideal puncture site and compared it with ultrasound in adult patients&#46; It was found that the accuracy rate for the landmark-based approach was 74&#46;4&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">34</span></a> In our study&#44; concordance between anatomical landmarks &#40;MWIA&#41; and ultrasound for identifying the ideal puncture site was only 0&#46;47&#44; suggesting that the landmark-based approach might not be adequate for predicting the ideal puncture site in paediatric patients&#46; However&#44; due to the usual individual anatomical variability&#44; it is not very probable that a method guided by anatomical landmarks can be successful in 100&#37; of cases without the need for needle repositioning&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">It is important to mention that&#44; given the size of paediatric patients&#44; a 1<span class="elsevierStyleHsp" style=""></span>cm distance difference&#44; perhaps irrelevant in adults&#44; might be quite significant in a child&#46; There are other factors influencing success with the first attempt&#44; including the entry angle of the needle in relation to the skin&#44; which might lead to a failed block even when the exact entry point is determined by anatomical landmarks or by other means&#46; In this regard&#44; ultrasound provides the advantage of direct visualization of needle orientation&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Multiple studies have been conducted in adult populations using nuclear magnetic resonance &#40;NMR&#41; in order to advance the development of landmark-based approaches&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">15&#44;27&#44;35&#44;36</span></a> However&#44; the use of NMR or computed tomography-based studies in healthy children is limited by the need to provide sedation or general anaesthesia&#44; mainly in smaller children who might suffer adverse events associated with anaesthetic agents or the exposure to ionizing radiation&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">37&#8211;40</span></a> From this perspective&#44; studies using ultrasound are warranted&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The study by Ruiz et al&#46; assessed the influence of arm abduction on the distance of the axillary artery from the skin&#44; the coracoid process and the pleura&#44; using ultrasound in adult patients&#46; They reported a shorter depth of the axillary artery in abduction&#44; but they did not find any differences in pleural depth in abduction&#44; or regarding the distance between the coracoid process and the axillary artery&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">41</span></a> The study by Greher et al&#46; sought to identify the accuracy of the vertical infraclavicular approach developed by Kilka by means of ultrasound measurements in healthy adults&#46; They found that the overall accuracy of Kilka&#39;s vertical approach was not sufficient to predict the optimal puncture site&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">22</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In our study&#44; there was no statistically significant difference in the depth of the brachial plexus&#44; the distance between the cords and the coracoid process&#44; or the distance between the coracoid process and the pleura in abduction&#46; This is consistent with the results from studies performed in adults&#46; Ultrasound may possibly underestimate the depth of the brachial plexus structures due to the compressive effect from the transducer&#46; The measurements obtained suggest that the distance between the coracoid process and the brachial plexus is modified to a greater degree in children under 20<span class="elsevierStyleHsp" style=""></span>kg&#46; Additionally&#44; it was found that weight and height are independent variables that modify the distance between the coracoid process and the posterior cord&#46; This suggests that a formula based on weight and height should be developed for children under 20<span class="elsevierStyleHsp" style=""></span>kg in order to calculate the distance between the coracoid process and the brachial plexus when it comes to performing infraclavicular blocks&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">As for the location of the brachial plexus cords in relation to the axillary artery&#44; it was found to be highly variable in particular for the medial cord&#46; In an earlier study by Sauter et al&#46; using NMR in adult patients&#44; the authors found the brachial plexus cords between 3 and 11 o&#8217;clock&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">35</span></a> A limitation of our study was that the cords were not identified using neurostimulation&#44; hence our inability to assert that they were correctly identified&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Patients were not studied bilaterally&#44; and this may also be a limitation of this study&#44; considering reports of individual right&#47;left asymmetry in 61&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">12</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">In one of its publications&#44; the Paediatric Regional Anaesthesia Network &#40;PRAN&#41; reported a higher tendency towards performing ultrasound-guided peripheral blocks in the upper extremity &#40;82&#37;&#41;&#44; leading to the assumption that ultrasound availability may explain the increasing number of peripheral nerve blocks&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">4</span></a> In the most recent study by ADARPEF &#40;<span class="elsevierStyleItalic">L&#8217;Association Des Anesth&#233;sistes-R&#233;animateurs P&#233;diatriques d&#8217;Expression Fran&#231;aise</span>&#41;&#44; there was also a higher trend towards the performance of peripheral nerve blocks in paediatric patients&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">42</span></a> Despite the advantages of ultrasound&#44;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">31</span></a> availability of these machines is low in many developing countries&#44; hence the continuing use of landmark and neurostimulation-guided approaches&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0185" class="elsevierStylePara elsevierViewall">There is low concordance between the modified Wilson infraclavicular coracoid approach and the use of ultrasound for determining the ideal puncture site&#59; however&#44; no clinical studies have been conducted to assess the success&#44; the need for needle repositioning or the complications of this approach&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Weight and height are independent factors that determine the distance between the coracoid process and the posterior cord in adduction as well as in abduction&#46; The infraclavicular brachial plexus is slightly more superficial and lies closer to the coracoid process in upper limb abduction&#59; there is also variability in the distribution of the cords around the axillary artery in adduction as well as in abduction&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors did not receive sponsorship to undertake this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interest</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ethical disclosures</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Protection of human and animal subjects</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Confidentiality of data</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work centre on the publication of patient data&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Right to privacy and informed consent</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span></span>"
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          "titulo" => "Conflict of interest"
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          "titulo" => "Ethical disclosures"
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              "titulo" => "Protection of human and animal subjects"
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              "identificador" => "sec0050"
              "titulo" => "Confidentiality of data"
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              "titulo" => "Right to privacy and informed consent"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2014-01-26"
    "fechaAceptado" => "2015-07-01"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:5 [
            0 => "Anesthesia"
            1 => "Conduction ultrasonography"
            2 => "Brachial plexus"
            3 => "Pediatrics"
            4 => "Nerve block"
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        ]
      ]
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:5 [
            0 => "Anestesia de conducci&#243;n"
            1 => "Ultrasonograf&#237;a"
            2 => "Plexo braquial"
            3 => "Pediatr&#237;a"
            4 => "Bloqueo nervioso"
          ]
        ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The modified Wilson infraclavicular approach &#40;MWIA&#41; was described in our institution for brachial plexus blocks in paediatric patients&#46; However&#44; concordance studies between this approach and ultrasound for the identification of ideal puncture site have not been reported&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To determine the concordance between MWIA and ultrasound for localization of the ideal puncture site&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Materials and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Descriptive observational study&#59; we included 100 healthy patients between 1 and 16 years of age&#44; with parental consent&#44; over a 5-month period&#46; Continuous variables were described and kappa statistics were used for concordance evaluation&#46; We also conducted a multivariate analysis to confirm the relationship between the measured distances and weight and height&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The distance from the skin to the brachial plexus&#44; as well as the distance between the coracoid process and the brachial plexus&#44; and the distance from the coracoid process to the pleura were all smaller in abduction&#44; with no statistically significant difference&#46; Height and weight are independent factors that determine the distance between the coracoid process and the posterior cord&#44; both in adduction and abduction&#46; The concordance of MWIA vs&#46; ultrasound for determining the ideal puncture site was 47&#37; in both positions&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Concordance between MWIA and ultrasound for the determination of the ideal puncture site is low when it comes to anatomic localization&#59; however&#44; this technique must be evaluated in randomized clinical studies in order to determine its efficacy and usefulness&#46; Height and weight are independent factors that determine the distance between the coracoid process and the posterior cord in adduction and abduction&#46;</p></span>"
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            "titulo" => "Objective"
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            "titulo" => "Materials and methods"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">En pacientes pedi&#225;tricos&#44; el sitio &#243;ptimo de inyecci&#243;n para el abordaje infraclavicular sigue siendo sujeto de debate&#59; no hay estudios de concordancia entre el abordaje infraclavicular de Wilson modificado para bloqueo del plexo braquial &#40;AIWM&#41; y el ultrasonido para la localizaci&#243;n del sitio ideal de punci&#243;n&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Determinar la concordancia entre AIWM y ultrasonido para localizar el sitio ideal de punci&#243;n&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Materiales y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">estudio observacional descriptivo&#59; se incluyeron 100 ni&#241;os sanos entre 1-16 a&#241;os&#44; en un periodo de 5 meses&#46; Se describieron variables continuas y se evalu&#243; la concordancia mediante la estad&#237;stica kappa&#46; Se realiz&#243; an&#225;lisis multivariado para confirmar la correlaci&#243;n entre las distancias&#44; el peso y la talla&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se encontr&#243; una menor profundidad del plexo braquial y menor distancia entre el plexo braquial y la ap&#243;fisis coracoides y entre la coracoides y la pleura en abducci&#243;n&#44; sin significancia estad&#237;stica&#46; El peso y la talla son factores independientes que determinan la distancia entre la ap&#243;fisis coracoides y el cord&#243;n posterior en abducci&#243;n y en aducci&#243;n&#46; La concordancia del sitio ideal de punci&#243;n entre AIWM y ultrasonido fue 0&#44;47 en ambas posiciones&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La concordancia entre el AIWM y el ultrasonido para determinar el sitio ideal de punci&#243;n es sorprendentemente baja&#46; Sin embargo&#44; desde el punto de vista de utilidad y eficacia cl&#237;nica&#44; estas t&#233;cnicas deben ser comparadas y evaluadas con estudios cl&#237;nicos aleatorizados&#46; El peso y la talla determinan de forma independiente la distancia entre el cord&#243;n posterior y la ap&#243;fisis coracoides en aducci&#243;n y abducci&#243;n del brazo&#46;</p></span>"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; P&#233;rez-Pradilla AC&#44; Pe&#241;a-River&#243;n AA&#44; Chaparro-G&#243;mez LC&#44; Castro-Ortiz LC&#44; Vel&#225;zquez-Delgado E&#44; Acevedo-de la Pe&#241;a R&#46; Abordaje infraclavicular en pediatr&#237;a&#58; concordancia del abordaje de Wilson modificado y el ultrasonido para la localizaci&#243;n del sitio de punci&#243;n ideal&#46; Rev Colomb Anestesiol&#46; 2015&#59;43&#58;269&#8211;277&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Patient no&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Gender &#40;female proportion&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Left laterality &#40;proportion&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&#8211;2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;1 &#40;10&#8211;12&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;9 &#40;15&#46;3&#8211;18&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">44&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&#8211;5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;9 &#40;14&#46;7&#8211; 17&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;4 &#40;14&#46;4&#8211;16&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&#8211;10 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;5 &#40;22&#46;6&#8211;28&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;21 &#40;1&#46;16&#8211;1&#46;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#46;3 &#40;15&#46;6&#8211;18&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&#8211;16 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&#46;1 &#40;44&#46;9&#8211;59&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;52 &#40;1&#46;46&#8211;1&#46;58&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;9 &#40;19&#46;7&#8211;24&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Weight&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AdductionLateral &#8211; coracoid &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AdductionPosterior &#8211; coracoid &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AdductionMedial &#8211; coracoid &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AdductionCoracoid &#8211; pleura &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AdductionSkin &#8211; lateral &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AdductionSkin &#8211; posterior &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AdductionSkin &#8211; medial &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">&#60;10<span class="elsevierStyleHsp" style=""></span>kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;12 &#40;0&#46;97&#8211;1&#46;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;34 &#40;1&#46;19&#8211;1&#46;48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;54 &#40;1&#46;36&#8211;1&#46;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;35 &#40;2&#46;09&#8211;2&#46;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;3 &#40;1&#46;18&#8211;1&#46;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;6 &#40;1&#46;43&#8211;1&#46;76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;41 &#40;1&#46;3&#8211;1&#46;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&#8211;20<span class="elsevierStyleHsp" style=""></span>kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;76 &#40;1&#46;66&#8211;1&#46;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;01 &#40;1&#46;88&#8211;2&#46;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;24 &#40;2&#46;14&#8211;3&#46;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;99 &#40;2&#46;86&#8211;3&#46;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;63 &#40;1&#46;55&#8211;1&#46;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;94 &#40;1&#46;84&#8211;2&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;64 &#40;1&#46;54&#8211;1&#46;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">21&#8211;30<span class="elsevierStyleHsp" style=""></span>kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;24 &#40;2&#46;07&#8211;2&#46;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;64 &#40;2&#46;47&#8211;2&#46;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;7 &#40;2&#46;51&#8211;2&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;39 &#40;3&#46;18&#8211;3&#46;61&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;87 &#40;1&#46;75&#8211;1&#46;98&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;21 &#40;2&#46;06&#8211;2&#46;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;84 &#40;1&#46;72&#8211;1&#46;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">31&#8211;40<span class="elsevierStyleHsp" style=""></span>kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;72 &#40;2&#46;31&#8211;3&#46;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;03 &#40;2&#46;54&#8211;3&#46;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;26 &#40;2&#46;81&#8211;3&#46;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;43 &#40;3&#46;1&#8211;3&#46;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;01 &#40;1&#46;57&#8211;2&#46;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;41 &#40;1&#46;84&#8211;2&#46;98&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;97 &#40;1&#46;39&#8211;2&#46;54&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">41&#8211;50<span class="elsevierStyleHsp" style=""></span>kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;79 &#40;2&#46;3&#8211;3&#46;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;81 &#40;2&#46;37&#8211;3&#46;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;34 &#40;2&#46;89&#8211;3&#46;78&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">51&#8211;60<span class="elsevierStyleHsp" style=""></span>kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;23 &#40;3&#46;12&#8211;3&#46;34&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;85 &#40;3&#46;71&#8211;3&#46;98&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;69 &#40;2&#46;97&#8211;4&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;96 &#40;3&#46;39&#8211;4&#46;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;35 &#40;2&#46;65&#8211;4&#46;04&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;96 &#40;3&#46;39&#8211;4&#46;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;37 &#40;3&#46;12&#8211;3&#46;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">&#62;60<span class="elsevierStyleHsp" style=""></span>kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;19 &#40;2&#46;98&#8211;3&#46;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;67 &#40;2&#46;85&#8211;4&#46;49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;68 &#40;3&#46;34&#8211;4&#46;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Weight&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AbductionLateral &#8211; coracoid &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AbductionPosterior &#8211; coracoid &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AbductionMedial &#8211; coracoid &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AbductionCoracoid &#8211; pleura &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AbductionSkin &#8211; lateral &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AbductionSkin &#8211; posterior &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">AbductionSkin &#8211; medial &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">&#60;10<span class="elsevierStyleHsp" style=""></span>kg&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;14 &#40;0&#46;97&#8211;1&#46;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;29 &#40;1&#46;13&#8211;1&#46;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;97 &#40;1&#46;73&#8211;2&#46;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;23 &#40;1&#46;11&#8211;1&#46;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;43 &#40;1&#46;26&#8211;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;19 &#40;1&#46;07&#8211;1&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&#8211;20<span class="elsevierStyleHsp" style=""></span>kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;44 &#40;1&#46;33&#8211;1&#46;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;68 &#40;1&#46;55&#8211;1&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;84 &#40;1&#46;71&#8211;1&#46;98&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;66 &#40;2&#46;49&#8211;2&#46;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;39 &#40;1&#46;33&#8211;1&#46;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;63 &#40;1&#46;56&#8211;1&#46;69&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;37 &#40;1&#46;3&#8211;1&#46;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">21&#8211;30<span class="elsevierStyleHsp" style=""></span>kg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;81 &#40;1&#46;66&#8211;1&#46;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;06 &#40;1&#46;93&#8211;2&#46;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;22 &#40;2&#46;07&#8211;2&#46;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;8 &#40;2&#46;59&#8211;3&#41;&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 22562087
Original language: English
DOI:10.1016/j.rcae.2015.07.002
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