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.

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.

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.

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.

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.

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.

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.

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.

Hematoma espontáneo de recto anterior del abdomen: experiencia en nuestro centro / Rectus sheath haematoma: experience in our center

Fundamento: Describir las características clínicas de los pacientes diagnosticados de hematoma espontáneo de músculo recto abdominal (HEMR), los factores predisponentes y precipitantes y el manejo terapéutico. Pacientes y métodos: Estudio descriptivo retrospectivo de 46 HEMR diagnosticados desde 2002 hasta 2016. Se analizan datos epidemiológicos, clínicos, pruebas diagnósticas y modalidad de tratamiento. Resultados: La mediana de edad fue de 81 años, 61% mujeres. Los factores desencadenantes más frecuentes fueron la tos persistente y la inyección de heparina de bajo peso molecular. El 70% estaban anticoagulados, de ellos el 57% presentaba INR en rango supraterapéutico y en el 45% se suspendió la anticoagulación de manera definitiva tras el ingreso. El 41% presentaban insuficiencia renal crónica y la creatinina en el momento del diagnóstico fue superior a la basal (p<0,001). El tratamiento fue conservador en la mayoría de casos; se realizó radiología intervencionista en tres pacientes (6,5%) y cirugía abierta en cuatro (8,7%). El tratamiento invasivo se aplicó a pacientes con hematomas de mayor tamaño y con mayores requerimientos transfusionales, y se asoció a una mayor estancia media (p<0,001). Conclusiones: El HEMR es más frecuente en pacientes ancianos, tratados con acenocumarol y en rango supraterapéutico y conlleva con frecuencia la suspensión definitiva del tratamiento anticoagulante. La insuficiencia renal aparece relacionada con la sobredosificación del tratamiento anticoagulante y con la producción del hematoma. El tamaño del HEMR y los requerimientos transfusionales son factores que parecen relacionados con mayor necesidad de tratamiento invasivo mediante embolización arterial o cirugía (AU)

Background: To describe the clinical characteristics of patients diagnosed with spontaneous abdominal rectus muscle hematoma (RSH), predisposing and precipitating factors, and therapeutic management. Method: Retrospective descriptive study of 46 RSH diagnosed from 2002 to 2016. Epidemiological, clinical, diagnostic tests and treatment were analyzed. Results: The median age of patients was 81 years, 61% were female. The most frequent triggers were persistent coughing and injection of low molecular weight heparin. Seventy percent were anticoagulated, of which 57% had INR in the supratherapeutic range, and in 45% anticoagulation was definitively discontinued after admission. Forty-one percent presented chronic renal failure; moreover, creatinine at the time of diagnosis was higher tan baseline (p <0.001). In most cases, treatment was conservative; interventional radiology was performed on three patients (6.5%) and open surgery on four (8.7%). Invasive treatment was employed with patients who had larger hematomas and higher transfusion requirements, and this was associated with a longer mean stay (p<0.001). Conclusions: RSH is more frequent in elderly patients, treated with acenocumarol and in the supratherapeutic range, and frequently entails permanent suspension of anticoagulant therapy. Renal insufficiency is related to the overdosage of the anticoagulant treatment and to the production of the hematoma. The size of RSH and transfusión requirements are factors that seem to be related to a greater need for invasive treatment through arterial embolization or surgery (AU)

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.

Effect of dexmedetomidine added to ropivacaine on ultrasound-guided transversus abdominis plane block for postoperative analgesia after abdominal hysterectomy surgery: a prospective randomized controlled trial.

BACKGROUND: To identify the effect of dexmedetomidine added to ropivacaine on ultrasound-guided transversus abdominis plane block for postoperative analgesia after abdominal hysterectomy surgery. METHODS: Sixty patients were enrolled in the study and divided into two groups. Bilateral 20 mL 0.3% ropivacaine and 2 mL 0.9% normal saline for ropivacaine group (group R), and bilateral 20 mL 0.3% ropivacaine and 2 mL dexmedetomidine (0.5 µg/kg) for dexmedetomidine group (group RD). Visual Analogue Scale (VAS) pain scores, frequency of PCA pressed, sufentanil consumption, and postoperative nausea and vomiting (PONV) were recorded. RESULTS: There was no significant difference in VAS pain scores between the two groups at different time intervals (P>0.05). Compared with group RD, the frequency of PCA pressed and integrated consumption of sufentanil were significantly higher in Group R at 0-2, 2-4, 4-6, 6-8, time intervals (P<0.05) except for 8-12,12-24 time intervals (P>0.05), and the 24h total sufentanil consumption and frequency of PCA pressed were also higher in group R (63.9±10.0 vs. 51.8±9.1, 8.3±1.7 vs. 5.4±1.6) (P<0.05). There was no difference in PONV between the two groups (P>0.05). CONCLUSIONS: Ultrasound-guided TAP block could be as an effective component of multimodal postoperative analgesic regimen; adding dexmedetomidine to ropivacaine in TAP block potentiated the analgesic properties of ropivacaine, reduced sufentanil consumption and provided better pain control after abdominal hysterectomy surgery.

Groin injuries in athletes--development of clinical entities, treatment, and prevention.

The doctoral thesis is based on eight papers published in peer-reviewed journals and a review of the literature. The papers are published between 1997 and 2013 in cooperation with Sankt Elisabeth Hospital, Herlev Hospital, Glostrup Hospital, Rigshospitalet, Hvidovre Hospital, Amager Hospital, Copenhagen Trial Unit, and Institute of Preventive Medicine, Copenhagen. Groin injuries in sport are very common and in football they are among the most common and most time-consuming injuries. These injuries are treated very differently around the world. There is no consensus in the literature regarding definitions, examination methods, diagnosis or treatment and in general the level of evidence is very low. There is a need for identification of the painful anatomical structures, how to examine them and how to define clinical entities to develop effective treatment and prevention. The aim of these studies were: - To review the literature to create an overview of the ideas and the knowledge in order to plan future studies in this field. - Develop and test clinical examination techniques of the relevant tendons and muscles in the region. - Since no evidence-based diagnosis exist; to develop a set of clinical entities to identify the different groups of patients. - To test the effect of a dedicated exercise program developed for treatment of long-standing adductor-related groin pain in athletes in a randomised clinical trial comparing it to the treatment modalities used at that time. - To examine the long-term effect of the above mentioned training program for treatment of long-standing adductor-related groin pain. - To develop a training program for prevention of groin injuries in soccer and test it in a randomised clinical trial. - To describe the occurrence and presentation in clinical entities of groin injuries in male football and to examine the characteristics of these injuries. - Evaluate if radiological signs of femuro-acetabular impingement (FAI) or dysplasia affect the clinical outcome of treatment of long-standing adductor-related groin pain, initially and at 8-12 year follow-up.   The main findings of the eight papers were: - No randomised trials existed in this area; there was no consensus in the literature and the majority of the literature was Level 4 and 5. From the existing literature and the author' experience an injury mechanism was suggested and the term ''adductor-related groin injury'' was suggested. - A well-defined clinical examination of the adductor-, iliopsoas, and abdominal muscles and the symphysis joint for pain, strength, and flexibility was reproducible with only limited intra- and inter-observer variation. - By utilising a well-defined classification long-standing groin injuries could be classified with a system of clinical entities.

Rectus-Sparing Technique for Driveline Insertion of Ventricular Assist Device.

We present a new technique for driveline insertion of the HeartWare ventricular assist device (HVAD) designed to preserve the integrity of the abdominal wall structure. Because of the size of the HVAD driveline connector (12 mm in diameter: triple the size of the driveline cable), the standard tunneling maneuver can result in tearing of the abdominal wall muscle layer, which is a primary mechanism to prevent ascending driveline infection. We find that our technique is particularly useful in children because their abdominal wall muscles are more fragile and thereby prone to accidental injury with blunt penetration when the standard technique is used.

Técnica neuromuscular de la vaina rectal abdominal / No disponible

La Técnica Neuromuscular (TNM) permite simultanear exploración, diagnóstico y tratamiento, y tiene como objetivo normalizar el tejido muscular y conjuntivo. La técnica permite localizar las induraciones y/o dificultades del deslizamiento dentro de tejido conjuntivo, que se interpretan como una disminución de las propiedades viscoelásticas de dicho tejido, lo que limita la doble función de filtro iónico y difusión de nutrientes. Consta de una serie de trazos realizados con el pulgar, de forma lenta, que permiten centrar la atención tanto en la sensación palpatoria como en la respuesta del paciente. La técnica abdominal básica trata las zonas abdominales y consta de varias partes. Debe prestarse especial atención a la línea alba y la vaina rectal abdominal, por su gran variedad de factores funcionales y estructurales, y su repercusión tanto a nivel local como sobre la salud en su conjunto (AU)

No disponible

Uncommon external abdominal oblique muscle strain in a professional soccer player: a case report.

BACKGROUND: This is the first report of external abdominal oblique muscle injury occurring in a professional soccer player. CASE PRESENTATION: A 28-year-old Caucasian professional soccer player presented after experiencing a popping sensation associated with strong parietal pain localized between the left 11th and 12th ribs. Ultrasound examination revealed a collection of fluid under the 11th rib, suggesting injury of the left external oblique muscle. Platelet-rich plasma treatment was administered and the soccer player returned to competition on the 21st day after treatment. CONCLUSION: This rare injury results from a sudden intrinsic eccentric contraction of the internal oblique muscle while in a stretched position. Ultrasound can help to confirm the diagnosis and to monitor clinical follow-up. Platelet-rich plasma treatment could aid recovery in high-level athletes.

Hip range of motion and association with injury in female professional tennis players.

BACKGROUND: Adequate hip range of motion is required for the transfer of energy from the lower to the upper extremity along the kinetic chain. Repetitive rotational stresses in the lower extremities during tennis may lead to sport-specific range of motion adaptations, which may increase the risk of injury to other joints along the kinetic chain. PURPOSE: To assess whether such range of motion adaptations occur in the hip, and if so, to identify whether they are associated with injury. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 125 female professional tennis players, the majority of whom were ranked in the top 200 World Tennis Association singles rankings, underwent a comprehensive preparticipation physical health status examination. Hip range of motion was assessed using a digital inclinometer and side-to-side differences in rotational parameters calculated, and associations with previous injuries were identified. RESULTS: A history of an abdominal strain was reported by 10% of players, and there was an association between abdominal strains and the presence of hip flexion contractures (odds ratio, 6.1; P = .006). Hip flexion contractures were bilateral in 85% of those found, affected only the nondominant side in 9%, and affected only the dominant side in 6%. We were unable to identify any specific side-to-side rotational adaptations in the dominant or nondominant hips, and no association between loss of hip range of motion and shoulder, lower back, hip, knee, or ankle injuries was found. CONCLUSION: We report an association in female professional tennis players between abdominal strains and flexion contractures of the hip with iliopsoas tightness. We did not find evidence of specific hip adaptations in rotational range of motion. If hip flexion contractures are found on clinical examination, a stretching program may be indicated. Further studies are required to assess whether such a program can reduce the risk of abdominal injury.

Dissection of the transversus abdominis muscle for whole-mount neuromuscular junction analysis.

Analysis of neuromuscular junction morphology can give important insight into the physiological status of a given motor neuron. Analysis of thin flat muscles can offer significant advantage over traditionally used thicker muscles, such as those from the hind limb (e.g. gastrocnemius). Thin muscles allow for comprehensive overview of the entire innervation pattern for a given muscle, which in turn permits identification of selectively vulnerable pools of motor neurons. These muscles also allow analysis of parameters such as motor unit size, axonal branching, and terminal/nodal sprouting. A common obstacle in using such muscles is gaining the technical expertise to dissect them. In this video, we detail the protocol for dissecting the transversus abdominis (TVA) muscle from young mice and performing immunofluorescence to visualize axons and neuromuscular junctions (NMJs). We demonstrate that this technique gives a complete overview of the innervation pattern of the TVA muscle and can be used to investigate NMJ pathology in a mouse model of the childhood motor neuron disease, spinal muscular atrophy.