Postmortem Computed Tomography and Magnetic Resonance Imaging of an Abdominal Gunshot Wound.

The use of postmortem computed tomography (CT) has been described in many articles concerning gunshot injuries. Postmortem magnetic resonance imaging (MRI) for better assessment of soft tissue injuries has also been mentioned in the literature, albeit much less often. The use of postmortem MRI for abdominal gunshot wounds has not been previously presented in the literature. The present case report describes the findings of an abdominal gunshot wound detected by postmortem CT and MRI, followed by an autopsy. The main imaging findings on CT were a hyperdense ring at the entrance wound, which indicated the muzzle imprint mark, a hyperdense region beneath the skin, which was suggestive of combustion residue, gas cavities surrounding the bullet path, which might be related to the temporary cavity, and a fracture of the 13th rib on the left. Magnetic resonance imaging provided a clear depiction of defects in the muscle tissue and peritoneal fat, as well as an injury to the left kidney and a large volume of blood in the abdominal cavity. Computed tomography combined with MRI provided a descriptive presentation of the intracorporeal trajectory noninvasively. Autopsy confirmed the radiologic findings but additionally revealed further relevant findings, which were not detected radiologically, such as a duodenal perforation. Autopsy also detected subendocardial hemorrhages and shock kidney, which were consistent with severe blood loss.The imaging findings and their interpretations are discussed in this case report, as well as the role of CT and MRI in the assessment of abdominal gunshot wounds compared with autopsy.

Incidence and implications of fracture in core muscle injury.

OBJECTIVE: To determine the pubic bone fracture incidence and associated injury patterns in patients with core muscle injury. MATERIALS AND METHODS: Ninety-three consecutive patients with core muscle injury protocol MRI showing rectus abdominis-adductor longus aponeurotic plate injuries from June 2007 through August 2017 were independently analyzed in blinded fashion by two musculoskeletal radiologists for the presence or absence of pubic bone fracture. A variety of other osseous and soft tissue injury characteristics were recorded. Pain duration prior to MRI and return to play time were taken from the clinical record. Statistical analysis included fracture incidence as well as the association of fracture with other injury characteristics, duration of pain, and return to play time. RESULTS: Eighty-seven men and six women with a mean age of 34.4 years (range, 16-66 years) were included in the study cohort. Overall fracture incidence was 18.3% (17/93) including 13 fatigue fractures of the pubic body and four elevated cortical fractures/fragments. After correction for multiple comparisons, no strong association was identified with osseous or soft tissue injury characteristics, pain duration, or return to play time. CONCLUSIONS: Pubic fractures-particularly fatigue fractures-are a common co-existing injury in patients with a wide range of core muscle injury patterns. The presence of fracture did not have a strong correlation with injury patterns, pain duration, or return to play time but may have implications for patient management.

Characteristics of acute groin injuries in the hip flexor muscles - a detailed MRI study in athletes.

Hip flexor injuries account for one-third of acute groin injuries; however, little is known about specific injury characteristics. The aims of this study were to describe acute hip flexor injuries using magnetic resonance imaging (MRI) in athletes with acute groin pain and to compare specific muscle injuries with reported injury situations. Male athletes with acute groin pain were prospectively and consecutively included during three sports seasons. MRI was performed within 7 days of injury using a standardized protocol and a reliable assessment approach. All athletes with an MRI confirmed acute hip flexor muscle injury were included. A total of 156 athletes presented with acute groin pain of which 33 athletes were included, median age 26 years (range 18-35). There were 16 rectus femoris, 12 iliacus, 7 psoas major, 4 sartorius, and 1 tensor fascia latae injury. Rectus femoris injuries primarily occurred during kicking (10) and sprinting (4), whereas iliacus injuries most frequently occurred during change of direction (5). In 10 (63%) rectus femoris injuries, tendinous injury was observed. The iliacus and psoas major injuries were mainly observed at the musculotendinous junction (MTJ), and two included tendinous injury. We have illustrated specific injury locations within these muscles, which may be relevant for the clinical diagnosis and prognosis of these injuries. Most proximal rectus femoris injuries included tendinous injury. In contrast, distinct acute iliacus and psoas injuries predominantly occurred at the MTJ. Only the iliacus or psoas major were injured during change of direction, whereas rectus femoris injuries occurred primarily during kicking and sprinting.

Kinetics of implant-induced inflammatory angiogenesis in abdominal muscle wall in mice.

Injury of skeletal abdominal muscle wall is a common medical condition and implantation of synthetic or biological material is a procedure to repair musculofascial defects. We proposed to characterize the dynamics of inflammatory cell recruitment, newly formed blood vessels, cytokine production and fibrogenesis in the abdominal skeletal muscle in response to polyether-polyurethane sponge implants in mice. At 2, 4, 7 and 10days after implantation the muscle tissue underneath the sponge matrix was removed for the assessment of the angiogenic response (hemoglobin content, vascular endothelial growth factor and morphometric analysis of the number of vessels) and inflammation (myeloperoxidase and n-acethyl-B-d-glucosaminidase activities, cytokines). In addition, muscle fibrogenesis was determined by the levels of TGF-ß1 and collagen deposition. Hemoglobin content, wash out rate of sodium fluorescein (indicative of blood flow) and the number of vessels increased in the abdominal muscle bearing the synthetic matrix in comparison with the intact muscle. Neutrophil recruitment peaked in the muscle at day 2, followed by macrophage accumulation at day 4 post-injury. The levels of the cytokines, VEGF, TNF-α, CCL-2/MCP-1 were higher in the injured muscle compared with the intact muscle and peaked soon after muscle injury (days 2 to 4). Collagen levels were higher in sponge-bearing muscle compared with the non-bearing tissue soon after injury (day 2). The implantation technique together with the inflammatory and vascular parameters used in this study revealed inflammatory, angiogenic and fibrogenic events and mechanisms associated with skeletal muscle responses to synthetic implanted materials.

Trocar site herniation of the small bowel after laparoscopic bilateral adnexectomy despite fascial closure: a case report.

In this paper we report a case of an incarcerated hernia occurring through the peritoneal and muscular defect caused by a previous trocar insertion. The patient developed the hernia eight days after bilateral laparoscopic adnexectomy and presented small bowel obstruction signs. This hernia occurred despite correct closure of the internal oblique fascia. The patient was re-operated and exploratory laparoscopy confirmed the diagnosis. The hernia was reduced via a small extension of the previous incision, and the defect was repaired by separated stitches. This case shows that a trocar site hernia can appear despite correct closure of the fascia, which is poorly described except for obese patients. It suggests the need for careful closure of the abdominal wall including the peritoneum after a laparoscopic procedure. Trocar site hernia has to be considered in cases of post laparoscopic small bowel obstruction. We reviewed the literature and found no randomized control study concerning this problem: only reviews, retrospective studies, case reports and technical notes. These papers are discussed and compared with our case.

Core Muscle and Adductor Injury.

Core muscle injury is a common but difficult problem to treat. Although it can affect all individuals, it is most commonly seen in male athletes in cutting, twisting, pivoting, and explosive sports. Owing to the high association of femoroacetabular impingement, we believe these individuals are best treated with a multidisciplinary approach involving both orthopedic and general surgeons. Conservative treatment should be the first step in management. When conservative means are unsuccessful, operative intervention to correct all the pathologic issues around the pubis can have extremely high success rates.

Retraining motor control of abdominal muscles among elite cricketers with low back pain.

The purpose of this study was to document the effect of a staged stabilization training program on the motor control of the anterolateral abdominal muscles in elite cricketers with and without low back pain (LBP). Changes in the cross-sectional area of the trunk, the thickness of the internal oblique and transversus abdominis (TrA) muscles and the shortening of the TrA muscle in response to an abdominal drawing-in task were measured at the start and completion of a 13-week cricket training camp. Measures were performed using ultrasound imaging and magnetic resonance imaging. Participants from the group with LBP underwent a stabilization training program that involved performing voluntary contractions of the multifidus, TrA and pelvic floor muscles, while receiving feedback from ultrasound imaging. By the end of the training camp, the motor control of cricketers with LBP who received the stabilization training improved and was similar to that of the cricketers without LBP.

No relation between pelvic belt tests and abdominal muscle thickness behavior in athletes with long-standing groin pain. Measurements with ultrasound.

OBJECTIVE: To investigate whether abdominal muscle thickness in athletes with long-standing adduction-related groin pain (LAGP) differs between subgroups with a positive or no response to a pelvic belt. The response to a pelvic belt is defined positive in case of a decrease > or = 1 on a Likert pain scale (0-10) during the squeeze test (SQT) or a decrease > or = 1 on the active straight leg raise (ASLR) test score (0-10). DESIGN: Cross-sectional study. SETTING: Physical therapy practice. PATIENTS: Fifty athletes with LAGP. INDEPENDENT VARIABLES: Squeeze test and ASLR test. MAIN OUTCOME MEASURES: First, the effect of a pelvic belt on pain during the SQT and the ASLR test score was evaluated. Then, thickness of m. transversus abdominis (TA) and m. obliquus internus (OI) was measured using ultrasound during rest, ASLR left and right, and SQT. RESULTS: Of the 50 participants, 25 (50%) experienced a decrease in pain during the SQT when wearing a pelvic belt and 10 (20%) improved in ASLR performance with a pelvic belt. Thickness of TA and OI at rest (both cases P > .08) and relative thickness compared with rest during tasks (in all cases P > .12) revealed no significant difference when comparing the 2 subgroups based on the belt response during the SQT or ASLR. CONCLUSIONS: Using these methods, abdominal muscle thickness behavior in athletes with LAGP did not differ between the subgroups based on a positive or no response to a pelvic belt. However, the ultrasound method used may not have been sensitive enough to reveal differences between groups.

Abdominal wall sonography: a pictorial review.

The anterior abdominal wall, which is composed of three layers (skin and adipose tissues; the myofascial layer; and the deep layer, consisting of the transversalis fascia, preperitoneal fat, and the parietal peritoneum), has many functions: containment, support and protection for the intraperitoneal contents, and involvement in movement and breathing. While hernias are often encountered and well reviewed in the literature, the other abdominal wall pathologies are less commonly described. In this pictorial review, we briefly discuss the normal anatomy of the anterior abdominal wall, describe the normal ultrasonographic anatomy, and present a wide range of pathologic abnormalities beyond hernias. Sonography emerges as the diagnostic imaging of first choice for assessing abdominal wall disorders, thus representing a valuable tool for ensuring appropriate management and limiting functional impairment.

Avulsion Injuries of the Pelvis and Hip.

BACKGROUND: Avulsion injuries of the pelvis and hip region are typical injuries in adolescent athletes but can be found in adults as well. Typical sites for avulsion injuries include the origin/insertion of tendons and ligaments. Among adolescents, the not yet ossified apophysis is also frequently involved. The pelvis and hip are especially prone to such injuries due to their complex musculotendinous anatomy. Clinical history and physical examination in combination with the recognition of typical imaging findings are essential for correct diagnosis of these mostly acute, but sometimes also chronic injuries. METHODS: This review article describes typical avulsion injuries of the pelvis and hip and illustrates common radiological findings. Taking current literature into account, there is a special focus on the trauma mechanism, clinical examination, typical imaging findings and clinical management. RESULTS AND CONCLUSION: Detailed knowledge of musculotendinous anatomy and typical injury mechanisms allows a correct diagnosis of avulsion injuries often only based on clinical examination and radiographic findings. Further imaging with ultrasound and MRI may be necessary to evaluate tendon retraction in non-osseous avulsion injuries and extent of soft-tissue damage. Knowledge of potential complications of acute/chronic injuries can help to avoid unnecessary examinations or invasive interventions. Conservative management of avulsion injuries usually leads to functionally good results. However, in the case of competitive athletes, relatively wide bone fragment dislocation or marked tendon retraction, operative re-fixation may be considered in order to expedite the rehabilitation process. KEY POINTS: · Avulsion injuries are common injuries at the pelvic region especially in adolescent athletes, due to not yet ossified apophysis.. · Excellent anatomical knowledge is essential for proper diagnostic evaluation and predicting the mechanism of injury.. · Imaging plays a crucial role in diagnosing avulsion injuries starting from X-Ray and using MRI and CT for anatomical details by utilizing multiplanar capabilities.. CITATION FORMAT: · Albtoush OM, Bani-Issa J, Zitzelsberger T et al. Avulsion Injuries of the Pelvis and Hip. Fortschr Röntgenstr 2020; 192: 431 - 440.

Loss of size selectivity of the glomerular filtration barrier in rats following laparotomy and muscle trauma.

Posttraumatic microalbuminuria may be caused by either charge- or size-selective alterations in the glomerular filtration barrier, or both, and/or to a reduction in proximal tubular protein reabsorption. This study was performed to elucidate the pathophysiology of the increases in glomerular permeability occurring in rats exposed to a laparotomy or to a laparotomy and muscle trauma. In anesthetized Wistar rats (250-280 g), the left ureter was cannulated for urine collection, while simultaneously blood access was achieved. Rats were exposed to trauma by a laparotomy (L; n = 8), or by a combination of L and muscle trauma (MT; L+MT) induced by topical blunt injury of the abdominal muscles bilaterally. After L, muscles were crushed using hemostatic forceps at either 2 x 2 sites ("small" MT; n = 9), or at 2 x 5 sites ("large" MT; n = 9). Sham groups (n = 16), not exposed to a laparotomy, were used as controls. The glomerular sieving coefficients (theta) to polydisperse FITC-Ficoll-70/400 (molecular radius 13-80 A) were determined at 5 or 60 min after L and L+MT, respectively, from plasma and urine samples, and analyzed by high-performance size-exclusion chromatography. A tissue-uptake technique was used to assess theta for (125)I-labeled serum albumin. L, with or without MT, increased theta for Ficoll(55-80A) and albumin rapidly and markedly. Theta-Ficoll(70A) thus increased approximately threefold, and theta for albumin significantly, for all trauma groups. According to the "two-pore model" of glomerular permeability, these changes mainly reflect an increase in the number of large pores in the glomerular filter without any primary changes in the charge-selective properties of the filter.

Sonographic appearance of side strain injury.

OBJECTIVE: The purpose of this study was to evaluate the role of sonography in assessing side strain in athletes. CONCLUSION: Sonography is a useful tool for imaging the lateral abdominal musculature in patients with side strain, which occurs as a result of tearing of the internal oblique muscle from the lower four ribs or costal cartilage. Sonographic findings can be used to confirm the diagnosis, localize the site, and assess the characteristics of a tear.

Fascia, muscle and peritoneal rupture without any skin lesion as a result of blunt abdominal trauma--a case report.

BACKGROUND: Blunt abdominal trauma is one of the important causes of morbidity and mortality in childhood. Rapid and correct diagnosis is critical for blunt abdominal trauma cases. METHODS: A twelve-year-old male was admitted to our emergency service following a bicycle accident. He had mild abdominal discomfort by palpation located at the lower right abdominal quadrant. A hyperaemic area of 1 x 4 cm, was present on the skin surface. During the CT scan examination, a 1 x 1.8 cm rupture of the right rectus abmominis muscle at the pelvic inlet level was detected. Intra-operatively, we detected an approximately 10 cm irregular fascial rupture, an 8-10 cm muscular rupture of the rectus abdominis muscle and also a 10 cm peritoneal rupture. CONCLUSION: Blunt abdominal trauma may cause severe intra-abdominal tissue and visceral injuries, even if no important clinical findings are present. So, all standard diagnostic procedures must be called into mind in order not to overlook severe intra-abdominal injuries.

Exercise-Induced Abdominal Wall Muscle Injury Resulting in Rhabdomyolysis and Mimicking an Acute Abdomen.

BACKGROUND: Rhabdomyolysis is characterized by muscle necrosis and release of intracellular constituents, causing muscle pain, weakness, and myoglobinuria. This can be attributed to muscle injury after strenuous exercise. If the abdominal wall is involved, clinical presentation may resemble an acute abdomen. CASE: A 27-year-old woman, gravida 4 para 2, presented with swelling and pain of the mons pubis and abdominal pain after intense powerlifting 2 days prior. A computed tomography scan was performed, revealing abdominal wall inflammation. Although myoglobinuria was absent, there was high suspicion for rhabdomyolysis, which was confirmed by an elevated creatine kinase level. The patient improved after receiving intravenous fluids and abstaining from physical activity. CONCLUSION: Abdominal wall muscle injury resulting in rhabdomyolysis can imitate an acute abdomen in a healthy woman presenting with abdominal pain and swelling.

Ultrasound elastography reliably identifies altered mechanical properties of burned soft tissues.

Although burn injury to the skin and subcutaneous tissues is common in both civilian and military scenarios, a significant knowledge gap exists in quantifying changes in tissue properties as a result of burns. In this study, we present a noninvasive technique based on ultrasound elastography which can reliably assess altered nonlinear mechanical properties of a burned tissue. In particular, ex vivo porcine skin tissues have been exposed to four different burn conditions: (i) 200°F for 10s, (ii) 200°F for 30s, (iii) 450°F for 10s, and (iv) 450°F for 30s. A custom-developed instrument including a robotically controlled ultrasound probe and force sensors has been used to compress the tissue samples to compute two parameters (C10 and C20) of a reduced second-order polynomial hyperelastic material model. The results indicate that while the linear model parameter (C10) does not show a statistically significant difference between the test conditions, the nonlinear model parameter (C20) reliably identifies three (ii-iv) of the four cases (p<0.05) when comparing burned with unburned tissues with a classification accuracy of 60-87%. Additionally, softening of the tissue is observed because of the change in structure of the collagen fibers. The ultrasound elastography-based technique has potential for application under in vivo conditions, which is left for future work.

Outcomes of utilizing absorbable mesh as an adjunct to posterior sheath closure during complex posterior component separation.

BACKGROUND: A minority of patients undergoing posterior component separation (PCS) have abdominal wall defects that preclude complete reconstruction of the visceral sac with native tissue. The use of absorbable mesh bridges (AMB) to span such defects has not been established. We hypothesized that AMB use during posterior sheath closure of PCS is safe and provides favorable outcomes. METHODS: We performed a retrospective review of consecutive patients undergoing PCS with AMB at two hernia centers. Main outcome measures included demographics, comorbidities, and post-operative complications. RESULTS: 36 patients were identified. Post-operative wound complications included five surgical site infections. At a median of 27 months, there were five recurrent hernias (13.9%), 2 of which were parastomal, but no episodes of intestinal obstruction/fistula. CONCLUSIONS: Utilization of AMB for large posterior layer deficits results in acceptable rates of perioperative wound morbidity, effective PCS repairs, and does not increase intestinal morbidity or fistula formation.

Use of a latissimus dorsi myocutaneous flap for one-stage reconstruction of the thoracic wall after en bloc resection of primary rib chondrosarcoma in five dogs.

OBJECTIVE: To describe a thoracic wall reconstructive technique using a latissimus dorsi myocutaneous flap after en bloc resection of primary rib chondrosarcoma and report outcome in 5 dogs. STUDY DESIGN: Retrospective study. ANIMALS: Dogs (n=5) with primary rib chondrosarcoma. METHODS: Medical records (2003-2005) were reviewed for signalment, staging investigations, surgical findings, complications, and outcomes. Owners and veterinary surgeons were contacted for outcome information. RESULTS: A latissimus dorsi myocutaneous flap provided an air-tight thoracic wall closure after chondrosarcoma resection. Paradoxical respiratory movement of the flap occurred; however, from physical examination and blood gas analysis (2 dogs), ventilation was adequate. All flaps survived, 1 had superficial skin necrosis distally and 2 had minor wound dehiscence. One dog without tumor-free margins died of tumor-related disease 56 days after surgery. Tumor recurrence did not occur in 4 dogs with tumor-free margins. One dog was euthanatized 10 months after surgery for unrelated disease; 3 dogs were alive at writing (median follow-up: 20 months; range, 18-27 months) and all had a satisfactory functional and cosmetic outcome. CONCLUSIONS: Reconstruction of ventral thoracic wall defects using a latissimus dorsi myocutaneous flap yields a functional, cosmetic outcome. CLINICAL RELEVANCE: A latissimus dorsi myocutaneous flap can be used as a successful 1-stage reconstructive technique for ventral thoracic wall defects.

[Imaging findings of muscle traumas in sports medicine]. / Le muscle du sportif.

Traumatic muscular pathology is frequent in the athlete. Usually, these lesions heal spontaneously leaving no sequelae. One must be able to predict how long the healing process will last in order to avoid a long period of inactivity and to protect the patient from a recurrent tear. Medical imaging can define the precise location and severity of muscle traumas and detect critical elements that will delay complete repair. Sonography is the most useful and the least expensive imaging technique for analyzing muscular trauma. It provides a good study of muscle fibers, tendons, and aponeurosis but is limited in its poor visualization of the deep structures such as hamstring tendons and the difficulty in detecting muscular scar. MRI is the most sensitive imaging technique for analyzing muscular trauma. However, muscular fibers themselves are not visualized with MRI. It remains a secondary technique, adapted to the insufficiencies of sonography. Nevertheless, the exact place of medical imaging in traumatic muscular pathology remains and leaves the door open to many later studies.

A new clinical test for measurement of lower limb specific range of motion in football players: Design, reliability and reference findings in non-injured players and those with long-standing adductor-related groin pain.

OBJECTIVE: The association between groin pain and range of motion is poorly understood. The aim of this study was to develop a test to measure sport specific range of motion (SSROM) of the lower limb, to evaluate its reliability and describe findings in non-injured (NI) and injured football players. DESIGN: Case-controlled. SETTING: 6 Dutch elite clubs, 6 amateur clubs and a sports medicine practice. PARTICIPANTS: 103 NI elite and 83 NI amateurs and 57 football players with unilateral adductor-related groin pain. MAIN OUTCOME MEASURES: Sport specific hip extension, adduction, abduction, internal and external rotation of both legs were examined with inclinometers. Test-retest reliability (ICC), standard error of measurement (SEM) and minimal detectable change (MDC) were calculated. Non-injured players were compared with the injured group. RESULTS: Intra and inter tester ICCs were acceptable and ranged from 0.90 to 0.98 and 0.50-0.88. SEM ranged from 1.3 to 9.2° and MDC from 3.7 to 25.6° for single directions and total SSROM. Both non-injured elite and amateur players had very similar total SSROM in non-dominant and dominant legs (188-190, SD ± 25). Injured players had significant (p < 0.05) total SSROM deficits with 187(SD ± 31)° on the healthy and 135(SD ± 29)° on the injured side. CONCLUSION: The SSROM test shows acceptable reliability. Loss of SSROM is found on the injured side in football players with unilateral adductor-related groin pain. Whether this is the cause or effect of groin pain cannot be stated due to the study design. Whether restoration of SSROM in injured players leads to improved outcomes should be investigated in new studies.