Primary segmental omental torsion, mimicking acute appendicitis.

Primary segmental omental torsion (PSOT) is a very rare cause of acute abdominal pain, and it may often imitate the clinical picture of acute appendicitis. In instances of acute abdominal pain without anorexia, nausea, and vomiting, omental torsion should be included in the differential diagnosis. Any misdiagnosis may lead to major complications such as intraabdominal abscesses and adhesions. A 63-year-old overweight man with a body mass index (BMI) of 41 Kg/m2 presented to the emergency department on a remote island with acute abdominal pain. His medical history included type 2 diabetes mellitus managed with insulin, essential hypertension, osteoarthritis, and no previous abdominal operations. He reported a sharp pain originating in the epigastrium and the right hypochondrium that started five days prior. Physical examination revealed rebound tenderness and guarding across the abdomen with a positive McBurney sign. However, the patient did not report vomiting and was not nauseous. Vital signs were as follows: blood pressure 116/56 mmHg, heart rate 98 beats/min, respiratory rate 19 breaths/min, and a temperature of 38.2 0C. Laboratory results showed a white blood cell count of 10.6, neutrophils of 8.11, C-reactive protein (CRP) 74 mg/l, haemoglobin11.6 g/dl, and hematocrit 36.9%. Due to the absence of a radiographer at the hospital during that period, no imaging investigations were conducted. Diagnostic laparoscopy demonstrated diffused hemoperitoneum and necrotic mass at the site of the hepatic flexure. Initially suspected to be an advanced colon cancer, the decision was made to proceed with open surgery. The necrotic segment of the omentum was found at the right superior point of attachment of the omentum to the hepatic flexure. Consequently, the necrotic segment of the omentum was resected. A thorough investigation of the abdominal cavity did not detect any other abnormalities or pathologies. The patient recovered uneventfully and was transferred to the surgical ward. Torsion of the omentum is a very rare cause of acute abdominal pain. This case highlights the necessity of considering PSOT in the differential diagnosis of acute abdominal pain, especially in cases where symptoms are suggestive of appendicitis but diagnostic findings are negative.

Increased tibial tuberosity torsion has the greatest predictive value in patients with patellofemoral instability compared to other commonly assessed parameters.

PURPOSE: The multifactorial nature of patellofemoral instability requires a comprehensive assessment of the affected patients. While an association between tibial tuberosity (TT) torsion and patellofemoral instability is known, its specific effect has not yet been investigated. This study investigated the effect of TT torsion on patellofemoral instability. METHODS: This retrospective cohort study compared patients who underwent surgical intervention for patellofemoral instability and asymptomatic controls. TT torsion was measured in addition to other commonly assessed risk factors for patellofemoral instability using standardised computed tomography (CT) data of the lower extremities. The diagnostic performances of the assessed parameters were evaluated using receiver operating characteristic curve analysis and odds ratios (ORs) were calculated. RESULTS: The patellofemoral instability group consisted of 79 knees, compared to 72 knees in the asymptomatic control group. Both groups differed significantly in all assessed parameters (p < 0.001), except for tibial torsion (n.s.). Among all parameters, TT torsion presented the best diagnostic performance for predicting patellar instability with an area under the curve of 0.95 (95% confidence interval [CI], 0.91-0.98; p < 0.001). A cut-off value of 17.7° yielded a 0.87 sensitivity and 0.89 specificity to predict patellar instability (OR, 55.2; 95% CI, 20.5-148.6; p < 0.001). CONCLUSION: Among the evaluated risk factors, TT torsion had the highest predictive value for patellofemoral instability. Patients with TT torsions ≥ 17.7° showed a 55-fold increased probability of patellofemoral instability. Therefore, TT torsion should be included in the assessment of patients with patellofemoral instability. LEVEL OF EVIDENCE: Level III.

Significant difference in femoral torsion between coronal plane alignment of the knee type 1 and 4.

PURPOSE: The purpose of this study was to find out whether the torsions of the femur and tibia are dependent on the coronal plane alignment of the knee (CPAK) type. METHODS: Five hundred patients (1000 legs) were included, who received a whole leg standing three-dimensional (3D) radiograph using EOS imaging (EOS Imaging, Paris, France). SterEOS software was used for digital reconstruction. Femoral and tibial torsions were determined by analysing 3D reconstructions of each leg. Femoral torsion was defined as the angle between the femoral neck axis (FNA) and the posterior condylar axis (PCA). Tibial torsion was defined as the angle between the axis tangent to the posterior part of the tibia plateau and the transmalleolar axis. Arithmetic hip-knee-ankle angle (aHKA) and joint-line obliquity (JLO) were also determined, allowing each leg to be assigned one of nine possible phenotypes according to CPAK. RESULTS: The mean femoral torsion in CPAK type 1 was significantly higher (+ 2.6° ± 0.8°) than in CPAK type 4 (p = 0.02). All other CPAK types did not differ in the degree of femoral torsions. No differences could be demonstrated for the tibial torsion. CONCLUSION: There is a correlation between the coronal alignment of the lower limb and femoral torsion. This may provide the basis for extending the CPAK classification beyond the coronal plane. LEVEL OF EVIDENCE: Level III.

Lung lobe torsion associated with chest wall defects in a dog.

An 8-year-old, spayed, female poodle presented with exercise intolerance, lethargy, respiratory distress, retching, hyporexia and diarrhoea. Thoracic radiographs revealed increased opacity in the left cranial thoracic region. The fifth and sixth ribs appeared to be bulging cranially to caudally, and CT and surgical exploration confirmed the presence of a thoracic wall defect in that area. CT showed abrupt occlusion of the bronchus that branches into the left cranial lobe and consolidation of the caudal segment of left cranial lung lobe, which led to the diagnosis of lung lobe torsion. A thoracotomy was performed, the twisted lung lobe was surgically excised, and the defect in the thoracic wall was repaired. Respiratory distress gradually improved after the surgery, and there were no identified complications within the 2-year period following the procedure. Based on our literature search, this is the first reported case of lung lobe torsion caused by a thoracic wall defect in a dog.

Left medial liver lobe torsion and postoperative acute gastric rupture in a 2.5-year-old male-castrated Flemish Giant rabbit (Oryctolagus cuniculus).

A 2.5-year-old male-castrated rabbit presented with acute abdominal pain, lethargy, and anorexia. Digital radiography revealed increased left-sided hepatomegaly, gastric dilation, and decreased peritoneal serosal detail. Abdominal ultrasonography identified a torsed left liver lobe, gastric dilation, and peritoneal effusion. Surgery confirmed a left medial liver lobe torsion, with subsequent lobectomy and seven days of hospitalization. The patient re-presented 2 days after discharge and suddenly died while hospitalized, with acute gastric rupture, fulminant peritonitis, and multifocal hepatic infarcts diagnosed on necropsy. We believe this is the first recorded imaging diagnosis of a left medial liver lobe torsion in a rabbit.

MRI-based torsion measurement of the lower limb is a reliable and valid alternative for CT measurement: a prospective study.

PURPOSE: The aim of this study was to compare MRI-based torsion measurements of the lower limb to a well-established CT-based assessment in a prospective inter- and intraindividual approach. METHODS: A total of 26 patients (age 28.8 years ± 11.0) were enrolled beginning in January 2021 until August 2022. Inclusion criteria were the clinical indication for torsion measurement of the lower limb. CT and MRI imaging were performed with a standard operating procedure, to ensure that all patients were examined in a standardized position. The examinations were planned on a coronal scout view based on prominent anatomical landmarks. Femoral and tibial torsion were measured individually. Torsion measurements were analysed twice: immediately after examination and after 3 weeks. Subsequently, intra-rater and parallel test reliability was calculated accordingly. RESULTS: High significant results for CT and MRI measurements for both tibia (MRI: r = 0.961; p ≤ 0.001; CT: r = 0.963; p ≤ 0.001) and femur (MRI: r = 0.980; p ≤ 0.001; CT: r = 0.979; p ≤ 0.001) were obtained by calculated intra-rater reliability, showing that measurements were highly consistent for MRI and CT, respectively. Parallel test reliability for time point 1 as well as time point 2 was also highly significant and ranged from r = 0.947 to r = 0.972 (all with p ≤ 0.001, respectively) for both tibia and femur, showing a high concordance between the two measurements. CONCLUSION: Measurement of tibial as well as femoral torsion was comparable for CT and MRI measurement. Therefore, this study supports MRI measurement as an equivalent alternative for CT measurement concerning torsional malalignment to reduce exposure to radiation. LEVEL OF EVIDENCE: Level II.

Fertility preserving management of ovarian torsion.

OBJECTIVE: To analyze characteristics of acute and chronic ovarian torsion, review treatment recommendations, and present possible surgical techniques for fertility preservation in young women. DESIGN: Literature review and demonstration of perioperative management of ovarian torsion using radiologic images and intraoperative video footage. Ovarian torsion is mostly mentioned in context of gynecologic emergencies, where acute ovarian torsion with arterial obstruction leads to ovarian ischemia and necrosis. However, ovarian torsion can also occur as a partial or intermittent torsion with venous and lymphatic obstruction, followed by ovarian swelling. In both cases, surgical management of ovarian torsion commonly includes oophorectomy, although leading guidelines recommend preservation of the ovary. We here aimed to raise awareness for the clinical features of ovarian torsion and demonstrate adequate perioperative management, thereby avoiding surgical overtreatment in young women. SETTING: Medical University of Vienna, Department of Obstetrics and Gynecology. PATIENT(S): We present a case of acute ovarian torsion with a consequently ischemic ovary as well as a case of chronic ovarian torsion with related massive ovarian edema. The patients included in this video gave consent for publication of the video and posting of the video online, including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.), and other applicable sites. INTERVENTION(S): Laparoscopic management with detorsion of the torquated ovaries, cystectomy on an ischemic ovary and oophoropexy to the pelvic side wall and utero-ovarian ligament to prevent recurrence. MAIN OUTCOME MEASURES: Postoperative relief of pain and normalization of ovarian size and morphology on ultrasound imaging. RESULTS: The current cases show successful conservative surgical management of ovarian torsion, hence preserving hormonal function and fertility in young women. CONCLUSION: Although it is recommended to preserve fertility in young women affected by ovarian torsion, surgical overtreatment by means of oophorectomy is still common in clinical routine. Increasing awareness for the clinical characteristics of acute and chronic ovarian torsion, as well as for the importance of preservation of the ovary, is crucial. We therefore believe that ovarian torsion and its surgical management deserve increased attention in the future.

Can Natural Language Processing Improve Adnexal Torsion Predictions?

STUDY OBJECTIVE: To create a decision support tool based on machine learning algorithms and natural language processing (NLP) technology, to augment clinicians' ability to predict cases of suspected adnexal torsion. DESIGN: Retrospective cohort study SETTING: Gynecology department, university-affiliated teaching medical center, 2014-2022. PATIENTS: This study assessed risk-factors for adnexal torsion among women managed surgically for suspected adnexal torsion based on clinical and sonographic data. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The dataset included demographic, clinical, sonographic, and surgical information obtained from electronic medical records. NLP was used to extract insights from unstructured free text and unlock them for automated reasoning. The machine learning model was a CatBoost classifier that utilizes gradient boosting on decision trees. The study cohort included 433 women who met inclusion criteria and underwent laparoscopy. Among them, 320 (74%) had adnexal torsion diagnosed during laparoscopy, and 113 (26%) did not. The model developed improved prediction of adnexal torsion to 84%, with a recall of 95%. The model ranked several parameters as important for prediction. Age, difference in size between ovaries, and the size of each ovary were the most significant. The precision for the "no torsion" class was 77%, with a recall of 45%. CONCLUSIONS: Using machine learning algorithms and NLP technology as a decision-support tool for the diagnosis of adnexal torsion is feasible. It improved true prediction of adnexal torsion to 84% and decreased cases of unnecessary laparoscopy.

In utero torsion of an accessory hepatic lobe mimicking a congenital tumor.

Accessory hepatic lobes are rare anatomic variants connected to the liver by a fibrous stalk or parenchymal attachments. They are usually detected incidentally, but torsion is a rare complication. Here, we report torsion of an accessory hepatic lobe occurring in utero with a focus on the MRI findings. The lesion mimicked a congenital tumor, and we provide potential clues that may have narrowed the differential diagnosis prior to surgical exploration.

The "Double Ovary" Sign: A Unique Sonographic Observation in Isolated Fallopian Tube Torsion.

Isolated fallopian tube torsion (IFTT) is a rare subset of adnexal torsion. Timely diagnosis of IFTT is essential for preservation of the fallopian tube. However, a pre-operative diagnosis is challenging due to nonspecific symptoms and findings on physical exam. In addition, ultrasound (US) is typically the initial imaging modality in this setting and adnexal torsion may not be considered when normal ovaries are seen. In this small case series, we introduce the "double ovary" sign, a unique observation on US characterized by two adjacent structures: the ovary and the twisted fallopian tube giving rise to an ovary-like, cystic structure. We present three cases in which IFTT was diagnosed preoperatively.

Scoring system for predicting ovarian necrosis in adnexal torsion using an ultra-short optimized MRI protocol.

PURPOSE: To evaluate a MRI scoring system predicting haemorrhagic necrosis in adnexal torsion with intraoperative and/or histopathological correlation using an abbreviated and optimized MRI protocol. METHODS: This retrospective observational study includes patients with adnexal torsion who underwent Magnetic Resonance Imaging(MRI) and surgery. T2 sequences were evaluated by three observers of varying experience for following findings: Hypo-intensity of ovarian stroma, around the follicle, cyst wall or ovarian capsule and the twisted pedicle. Hypo-intensities in the above and a thick cyst wall were considered as predictors of necrosis. A scoring system was created based on the number of positive findings. MRI was correlated with intraoperative and histopathological findings. Lesions showing haemorrhagic necrosis were considered true positives. RESULTS: 43 women with torsion were included. 74.4% were secondary to a lead point and 25.4% were without one. Hypointensity score of 2 or more had the highest diagnostic accuracy and inter-reader agreement in predicting necrosis (R1-sensitivity: 92%, specificity: 89%, positive predictive value (PPV): 92% and negative predictive value (NPV): 89%, R2-sensitivity: 92%, specificity: 94%, PPV: 96% and NPV: 90% and R3-sensitivity: 92%, specificity: 83%, PPV: 89% and NPV: 89%). CONCLUSION: In patients with suspected adnexal torsion, optimized MRI using T2 weighted sequences will serve as a rapid and effective single imaging modality for diagnosing adnexal torsion and accurately predicting necrosis thereby triaging the patients for appropriate management.

Sonographic Predictors of Ovarian Torsion in Premenarchal Girls.

STUDY OBJECTIVE: To identify preoperative transabdominal sonographic predictors of surgically confirmed ovarian torsion (OT) in premenarchal girls METHODS: We conducted a retrospective case-control study of 32 premenarchal girls aged 0-12 undergoing surgery for OT (cases) or a non-torsed ovarian mass (controls) from 2006 to 2017 at a single academic center. Cases had ICD-9/10 codes for torsion of the ovary, adnexa, ovarian pedicle, or fallopian tube and surgically confirmed OT; controls had codes for ovarian mass or cyst and surgically confirmed absence of OT. Preoperative transabdominal ultrasounds were analyzed by 3 radiologists blinded to final diagnosis. We used χ2, Fisher[s exact, and Student's t tests for statistical comparisons. RESULTS: From 2016 to 2017, 32 patients presented with acute abdominal pain or symptoms concerning for ovarian mass requiring ultrasound imaging and subsequent diagnostic laparoscopy; 24 (75.0%) had confirmed OT by laparoscopy, and 8 (25.0%) did not. The mean age in both groups was similar (7.3 ± 2.9 years). Preoperative sonographic variables significantly associated with OT included presence of a simple cyst (20.8% vs 12.5%), ovarian heterogeneity (100% vs 12.5%), presence of peripheralized follicles (70.8% vs 0%), and asymmetry of color Doppler (75.0% vs 37.5%; all P < .05). Presence of free fluid, arterial color Doppler, and a whirlpool sign were not predictive of OT. CONCLUSION: In premenarchal patients, although certain variables on transabdominal sonography predicted surgically confirmed OT, only the presence of peripheralized follicles was unique to girls with OT. The decision to proceed with diagnostic laparoscopy for suspected OT can be aided by these specific sonographic findings but should ultimately be based on high clinical suspicion.

Pregnancy-Associated Ovarian Torsion - a Single-Center Case-Control Study.

The etiology of OT is largely unknown. Any predisposition to rotation of the infundibulopelvic ligament and utero-ovarian ligament should be considered a possible etiology. Information with respect to ovarian torsion (OT) among pregnant is underreported and based on small studies. We aim to compare characteristics of confirmed OT to laparoscopies performed for the indication of suspected OT, in which no OT was found among pregnant women. This is a retrospective case-control study. We included pregnant women who underwent laparoscopy for a suspected OT between March 2011 and August 2020. Pregnant women with confirmed OT (torsion group) were compared to those without (no torsion group). There were 169 women with suspected OT. OT was confirmed in 140 (82.8%) women. There was higher proportion of assisted reproductive technology (ART) gestation in the torsion group [76 (54.3%) vs. 5 (17.2%), p < 0.001]. The rate of pregnant approaching evaluation within 8 h of symptoms onset was higher in the torsion group [57 (40.7%) vs. 2 (6.9%), p < 0.001]. The mean visual analogue score (VAS) was higher in the torsion group (8.5 vs. 7.1, p = 0.002). The mean pulse was lower in the torsion group (79 vs. 88 bpm, p < 0.001). From sonographic characteristics examined, the following was higher in the torsion group; mean maximal size of the ovary (70 mm in the torsion group vs. 54 mm in the no torsion group, p = 0.011). In a multivariable logistic regression analysis, number of hours of symptoms was negatively associated with AT [aOR, 95% CI 0.95 (0.91-0.98)] and pulse was negatively associated with OT [aOR, 95% CI 0.78 (0.63-0.95)]. Among the 29 cases in which no OT was found during laparoscopy, the following findings were noted: 16 (55.2%) no abnormality at all, 5 (17.2%) functional ovarian cyst, 2 (6.9%) mature teratoma and 6 cases of peritoneal adhesions (20.7%). The time from pain onset to approaching evaluation and women's pulse should be considered and acknowledged in the evaluation of OT during pregnancy.

The value of clinical symptoms, the neutrophil-to-lymphocyte ratio, and ultrasonographic features in predicting adnexal torsion: A case-control study.

AIM: Adnexal torsion remains a diagnostic challenge due to the nonspecific symptoms, sonographic features, and laboratory findings. The value of combining clinical, sonographic, and laboratory features is not well established, and controversy continues regarding their value in diagnosis. This study aimed to review sonographic, clinical, and laboratory features and to analyze their value separately and in combination, in managing and diagnosing adnexal torsions. METHODS: The study included 278 women who underwent urgent laparoscopic surgery due to suspected adnexal torsion, according to clinical suspicion, with or without sonographic concordance. Laparoscopy findings confirmed the definitive diagnosis of torsion. Clinical laboratory and sonographic features were compared between those with and without adnexal torsion. RESULTS: Adnexal torsion was confirmed in 110/278 (39.6%) women. In the torsion compared to nontorsion group, proportions were higher of women with acute abdominal pain in the preceding 24 h ([50] 45.5% vs. [35] 20.8%, p < 0.001), with vomiting ([45] 40.9% vs. [24] 14.3%, p < 0.001) and with suspected torsion by transvaginal sonography ([49] 44.5% vs. [23] 13.7%, p < 0.001). A high neutrophil-to-lymphocyte ratio (>3) was identified in 65 (59.1%) of the study group and 60 (35.7%) of the control group (p < 0.001). Combining the latter three findings, the predicted probability of torsion was 58%-85%, depending on the combinations. CONCLUSIONS: A simple predictive model based on combinations of clinical, laboratory, and sonographic findings can contribute to preoperative diagnosis of adnexal torsion, with predicted probability of 85%. Our model may assist clinicians in evaluating women with suspected adnexal torsion, and improve preoperative diagnostic accuracy.

Diagnostic accuracy of ultrasound signs for detecting adnexal torsion: systematic review and meta-analysis.

OBJECTIVE: To evaluate the diagnostic accuracy of different ultrasound signs for diagnosing adnexal torsion, using surgery as the reference standard. METHODS: This was a systematic review and meta-analysis of studies published between January 1990 and November 2021 evaluating ovarian edema, adnexal mass, ovarian Doppler flow findings, the whirlpool sign and pelvic fluid as ultrasound signs (index tests) for detecting adnexal torsion, using surgical findings as the reference standard. The search for studies was performed in PubMed/MEDLINE, CINAHL, Scopus, The Cochrane Library, ClinicalTrials.gov and Web of Science databases. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was used to evaluate the quality of the studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios were calculated separately, and the post-test probability of adnexal torsion following a positive or negative test was also determined. RESULTS: The search identified 1267 citations after excluding duplicates. Eighteen studies were ultimately included in the qualitative and quantitative syntheses. Eight studies (809 patients) analyzed the presence of ovarian edema, eight studies (1044 patients) analyzed the presence of an adnexal mass, 14 studies (1742 patients) analyzed ovarian Doppler flow, six studies (545 patients) analyzed the whirlpool sign and seven studies (981 patients) analyzed the presence of pelvic fluid as ultrasound signs of adnexal torsion. Overall, the quality of most studies was considered to be moderate or good. However, there was a high risk of bias in the patient-selection and index-text domains (with the exception of the whirlpool sign) in a significant proportion of studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios of each ultrasound sign were 58%, 86%, 4.0 and 0.49 for ovarian edema, 69%, 46%, 1.3 and 0.67 for adnexal mass, 65%, 91%, 7.6 and 0.38 for the whirlpool sign, 53%, 95%, 11.0 and 0.49 for ovarian Doppler findings and 55%, 69%, 1.7 and 0.66 for pelvic fluid. Heterogeneity was high for all analyses. CONCLUSIONS: The presence of an adnexal mass or pelvic fluid have poor diagnostic accuracy as ultrasound signs of adnexal torsion, while the presence of ovarian edema, the whirlpool sign and decreased or absent ovarian Doppler flow have good specificity but moderate sensitivity for detecting adnexal torsion. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Fetal Ovarian Torsion Presenting with Fetal Abdominal Solid Mass and Ascites.

Fetal ovarian torsion is quite a rare event during the antenatal period and usually seen because of an ovarian cyst complication. In this case report, we present a case of fetal ovarian torsion without any ovarian cyst or underlying detectable causes. A 27-year-old primigravid woman with no significant past medical history had a routine prenatal ultrasound at 30 weeks' gestation. The ultrasound showed abdominal ascites and a 47×42-cm intraabdominal solid diffuse mass at the left side under the stomach. Doppler examination showed no blood flow on the mass. Paracentesis was performed, cytological examination reported no abnormality. Based on these findings, the diagnosis was thought to be fetal ovarian torsion. There is lack of consistent recommendations to guide the prenatal and the postnatal management of cases with in-utero diagnosis of ovarian torsion. A "wait-and-see" policy is usually preferred, as in our case.

Clinical and radiologic factors associated with adnexal torsion in premenarchal and menarchal children and adolescents.

BACKGROUND: Adnexal torsion is a gynecologic emergency in children and adolescents but remains a challenging diagnosis, with no consistent clinical or radiologic diagnostic criteria. Our objective was to identify risk factors associated with adnexal torsion in premenarchal and menarchal patients with surgically confirmed torsion compared with those without torsion. METHODS: We conducted a retrospective chart review of all patients who underwent surgery between January 2016 and December 2019 for possible adnexal torsion. Data on demographics, clinical characteristics, radiologic variables, and operative findings were compared using descriptive statistics. Independent predictors of torsion were then examined in multivariate logistic regression models. RESULTS: Of the 291 patients who underwent surgery, 168 (57.7%) had torsion. Patients with torsion were younger than those without torsion (11.9 vs. 14.2 years, P < .01). Vomiting was significantly associated with torsion for all patients (P < .001). Large adnexal volume and absent arterial Doppler flow were associated with torsion for the total population and menarchal subgroup. A logistic regression model for the total population that controlled for age and menarchal status found that vomiting (adjusted odds ratio [aOR] 5.92, 95% confidence interval [CI] 2.87-12.22), highest adnexal volume category (aOR 4.92, 95% CI 2.25-10.75), and absent arterial Doppler flow (aOR 2.674, 95% CI 1.28-5.60) were associated with torsion. CONCLUSIONS: Vomiting, enlarged adnexal volume, and absent arterial Doppler flow were associated with adnexal torsion. However, no single risk factor accurately diagnosed torsion, and multiple factors should be interpreted together. LEVEL OF EVIDENCE: Study of Diagnostic Test, Level II.