Muscle Herniation Research Articles

Abnormal presentation of tibialis anterior herniation

Herniation of muscle tissue through a defect in the fascial sheath is rare; it is extremely uncommon for a patient to present in a clinic with a symptomatic muscle hernia. The usual presentation of a tibialis anterior muscle herniation is a bulge seen at the level of a fascial defect which decreases in size or disappears when the muscle contracts. We report an abnormal presentation of a tibialis anterior herniation in which the herniation swelling became more prominent on muscle contraction instead of diminishing. It is hypothesized that an increased pressure in leg compartment leads to a partially avascular and less responsive posterior portion of tibialis anterior muscle. This fixed volume of non-contracting muscle is then pushed out through the fascial defect during active muscle contraction. The herniation in this particular case was treated by enlarging the fascial defect. No recurrence was noted in a 12 months follow-up.

Epifascial accessory palmaris longus muscle

In hand reconstructive surgery the palmaris longus muscle is one of the most utilized donor site for tendon reconstruction procedures. However, its anatomic position is variable and anatomic variations may be responsible for median nerve compression. We report the case of a 40-year-old, right-handed woman, who presented with numbness and paresthesias in the palm and in the flexor aspect of the first, second, and third fingers of her right hand for the preceding 5 months, coinciding with increase of office work (typing). The clinical examination and radiological investigations (ultrasound and magnetic resonance) revealed a subcutaneous mass (15 mm x 2.3 mm x 6 cm), with a lenticular shape and definite edges at the level of the volar aspect of the distal third of the forearm. The fine-needle aspiration biopsy revealed the presence of striated muscle fibers. During surgery, a muscle belly was found in the epifascial plane. This muscle originated from subcutaneous septa in the middle forearm and inserted on to the superficial palmar aponeurosis with fine short tendon fibers. Exposure of the antebrachial fascia did not reveal any area of weakness or muscle herniation. The palmaris longus tendon, flexor digitorum superficialis tendons, and flexor carpi radialis tendon showed usual topography under the antebrachial fascia. The accessory muscle was excised and histology revealed unremarkable striated muscle fibers, limited by a thin connective sheath. The presence of an accessory palmaris longus (APL) located in the epifascial plane could be ascribed to an unusual migration of myoblasts during the morphogenesis. Although extremely rare, APL is worth bearing in mind as a possible cause of median nerve compression and etiology of a volar mass in the distal forearm.

ULTRASOUND ASSISTED DIAGNOSIS OF THE PAINFUL CALF

The efficiency of ultrasound usage in the diagnosis of the painful calf has been discussed in previous reports. We report our experience with the use of this modality as an accurate diagnostic tool for calf pain in young adults. Twenty-nine patients (16 males, 13 females) underwent dynamic ultrasonographic examination due to calf pain. Nine patients had tears of the gastrocnemius medial head, 2 had an intramuscular haematoma, 2 had distal fibula fractures, 3 had peroneal muscle herniation and 2 had herniation of the gastrocnemius medial head. One patient had cellulitis, one polymyositis and one dermatomyositis. Two patients had myositis ossificans, 2 patients had haemangiomas, and 4 patients had lipomas. All the diagnoses were confirmed by other imaging modalities and/or histological evaluation. We found ultrasound, as a very helpful tool to achieve a correct diagnosis of the painful calf.

Patient-Reported Donor-Site Morbidity Following Anterolateral Thigh Free Flaps

This study evaluated donor-site morbidity (retrospective chart review and followup questionnaire) in patients following reconstruction using an anterolateral thigh free flap. Twenty-one flaps were performed in 20 consecutive patients (mean age: 45.0 +/- 3.8 years). Primary wound closure was obtained in 52.4 percent. The perforators were intramuscular in 68 percent and septocutaneous in 32 percent. The early complications included infection (n = 2), wound dehiscence (n = 2), delayed healing (n = 8), and seroma (n = 1). Wound healing took 4.5 +/- 0.7 weeks, and leg weakness resolved completely (n = 13) by 6.6 +/- 2.0 weeks. More chronic complications (n = 19) included weakness (n = 5), pain/tightness (n = 6), contour deformity (n = 14), muscle herniation (n = 6), and unsatisfactory scar appearance (n = 6). No statistically significant differences existed in aesthetics or healing between wound-closure groups, nor in pain or weakness between perforator groups. Pain and weakness were significantly related to sacrifice of the deep fascia from the thigh through its elevation in the flap.

Autologous Pedal Extensor Tendon for Frontalis Suspension in the Correction of Blepharoptosis with Poor Levator Function

Introduction: Blepharoptosis with poor levator function is commonly repaired with a frontalis suspension procedure. A variety of suspension materials have been used, including autologous fascia lata, banked fascia lata, Supramid, Gortex, silicone, and Mersilene. Autologous materials offer the advantage of less rejection and granuloma formation, and lower rates of ptosis recurrence. Autologous fascia lata, although commonly used, has been associated with hemorrhage, scar problems, pain, and muscle herniation over the harvest site. Additionally, sufficiently long autogenous fascia is sometimes not readily available. We describe the use of autologous pedal extensor (extensor digitorum longus) tendon for frontalis suspension. Materials and Methods: In a retrospective study, the authors evaluate 19 frontalis sling suspension surgeries using pedal extensor tendon in 17 consecutive patients with ptosis with poor levator function. The method of harvesting the pedal extensor tendon is described in detail. Results: Of 19 ptotic eyelids, 18 were successfully corrected with good final lid position. One eyelid was undercorrected. No recurrence of ptosis was encountered. No wound infection, eyelid contour abnormality, or ptosis overcorrection occurred. One eye developed exposure keratopathy that resolved with conservative treatment. There were no major complications associated with the pedal extensor tendon donor site. Discussion: Frontalis suspension with an autogenous pedal extensor tendon appears to be cosmetically sound and an effective treatment for ptosis with poor levator function. Its use as an alternative material to fascia lata for frontalis sling surgery can be considered.

Radial half of extensor carpi radialis longus tendon as graft to elongate muscle tendon unit for correction of finger clawing.

In 12 patients, the extensor carpi radialis longus muscle tendon unit was elongated using the radial half of the parent tendon so that it could reach the site of new insertion, the A1-A2 pulley of flexor sheath or lateral bands, after routing the transfer through the carpal tunnel. The tendon was of appropriate thickness and could be split into two halves to be used as a graft. Further splitting of the tendon into four tails was possible. The transferred slips retained adequate strength to activate the fingers after the operation. It is suggested that splitting of the extensor carpi radialis longus tendon to use one half as a tendon graft be considered in patients in whom extensor carpi radialis longus transfer is planned to correct finger clawing. This technique is simple, needs minor modification in the sequence of operative steps, reduces operating time, and saves the patient from postoperative discomfort, muscle herniation, and scarring at the donor site (usually the thigh).

Sonography of muscle hernias.

Sonography of muscle hernias.

Forearm muscle hernia: a case report

An unusual case of muscle hernia in the forearm flexor compartment is reported. This was repaired with a fascia lata onlay graft from the patient's thigh. At 6 months after surgery there was no recurrence and the patient remained symptom free at the time of this report.

Dynamic ultrasound findings of bilateral anterior tibialis muscle herniation in a pediatric patient

Muscular hernias represent focal muscular protrusions through an acquired or congenital fascial defect. The anterior tibialis muscle is most frequently affected. The ultrasound (US) findings in a pediatric patient with bilateral anterior tibialis muscle herniation are presented. US examination performed following exercise enhanced sonographic visualization of the fascial defect and the associated muscular herniation.

Video-assisted endoscopic lumbar discectomy

The optimal management of symptomatic lumbar disc herniations (LDH) remains controversial. This study examines the feasibility and safety of a video-assisted endoscopic intracanalicular technique for managing symptomatic LDH. From September 1999 to June 2000, we used the current technique, the Vertebroscope System, on 11 patients (six men, five women), aged from 18 to 61 years (mean, 45), who had suffered symptomatic LDH. The disc levels involved were at L4-L5 (n = 8), and L5-S1 (n = 3). The Vertebroscope, which has a 30 degrees viewing angle and a working channel 1.7 cm in diameter, was used for the minimally invasive endoscopic procedures. The mean follow-up period was 12 months (range, 6-15). The operating time ranged from 60 to 335 min (mean, 136.5), and the estimated blood loss during operation was minimal to 200 ml. The mean length of the paramedian skin incisions was 2 cm. No drainage tube was used postoperatively. The mean hospital stay was 3 days (range, 2-5), with five patients discharged on the 1st postoperative day. Complications included one superficial wound infection, one conversion to an open procedure when muscle herniation into the working channel created a technical difficulty in approaching the ligamatum flavum, and one minor tear of the nerve root sleeve that did not require further surgery. In the first five patients studied herein, the mean operating time was significantly longer than that for the later five patients (201 vs 72 min, p < 0.001). The advantages of the current endoscopic disectomy technique include its minimally invasive character, with less paraspinal muscle trauma, direct address to the lesion site that resembles the open technique, and enhanced operative field visualization with a paramedian skin incision of just 2 cm. Practice is needed to perfect such an endoscopic approach for lumbar disc excision, so the operating time decreased significantly as the surgeons became more familiar with this endoscopic technique. It has proved to be safe and effective for treating patients with symptomatic LDH.

Long-term sequelae of fasciotomy wounds

A retrospective study of patients admitted to an Orthopaedic Trauma Unit over an 8-year period requiring fasciotomies, of either upper or lower limb, to reduce the risk of compartment syndrome was performed. Sixty patients were studied, of which 49 had an underlying fracture. The long-term morbidity of the wounds was studied. Ongoing symptoms such as pain related to the wound occurred in six patients (10%) and altered sensation within the margins of the wound occurred in 46 patients (77%). Examination revealed 24 patients (40%) with dry scaly skin, 20 patients (33%) with pruritus, 18 patients (30%) with discoloured wounds, 15 patients (25%) with swollen limbs, 16 patients (26%) with tethered scars, eight patients (13%) with recurrent ulceration, eight patients (13%) with muscle herniation and four patients (7%) with tethered tendons. The appearance of the scars affected patients such that 14 (23%) kept the wound covered, 17 (28%) changed hobbies and seven (12%) changed occupation. This study reveals a significant morbidity associated with fasciotomy wounds. In light of these findings, further consideration should be given to techniques that reduce both the symptoms and examination findings mentioned above and the aesthetic insult to the affected limb.

Evaluation of abdominal sensibility after TRAM flap breast reconstruction.

One commonly expressed concern regarding transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction surgery is the return of sensation to the abdomen. Although many studies have focused on abdominal wall muscle incompetence or herniation, there is limited literature discussing postoperative abdominal sensation. The purpose of this study was to assess abdominal sensation a minimum of 1 year after pedicled TRAM flap surgery for breast reconstruction. Twenty-five female patients who underwent TRAM flap breast reconstruction a minimum of 1 year before the study were compared with 10 female volunteer controls. Subject and control abdomens were specifically divided into 12 zones, then assessed for superficial touch, superficial pain, temperature, and vibration using various techniques. Fischer's exact test was used for analysis with the p value set at p = 0.05. The degree to which superficial touch was affected was then tested using Semmes-Weinstein monofilaments. Student's t test was used for analysis with the p value set at p = 0.05. For all four sensory modalities, subjects were found to have decreased sensation in zones 5 and 8, the supraumbilical and infraumbilical regions. This was statistically significant. When assessed with Semmes-Weinstein monofilaments, the sensation of the subjects' abdomens was significantly decreased compared with controls. Significance was found in all zones. This study clearly demonstrates that there is a significant and persistent reduction in abdominal sensibility following TRAM flap surgery. The distribution of the deficits is consistent and involves the midline supraumbilical and infraumbilical regions. The TRAM flap has become the procedure of choice for postmastectomy autogenous breast reconstruction. It provides the plastic surgeon with a relatively safe, reliable, and aesthetically pleasing method of breast reconstruction. Since its inception, the TRAM flap and its abdominal closure have undergone numerous modifications designed to minimize donor-site morbidity and create a natural-looking breast. In addition to creating an aesthetically pleasing breast, the TRAM flap has the potential advantage of postoperative improvement in abdominal contour.

Symptomatic Forearm Muscle Hernia: Repair by Autologous Fascia Lata Inlay

Eleven cases of symptomatic muscle hernias of the forearm requiring surgical intervention have been described previously. Pain on extremity exertion and an unaesthetic bulge of the forearm were the primary indications for surgery. Advocated treatment modalities range from forearm fasciotomy to anatomic repair of the fascial defect. Although fasciotomy relieves the narrow fascial constriction around the herniated muscle reliably, it often yields an unappealing forearm deformity and incomplete resolution of pain on extremity exertion. Anatomic repair provides the theoretical advantage of restoring normal muscle fascia relationships while concomitantly improving the aesthetic appearance of the extremity. The authors report a case of symptomatic forearm muscle herniation treated successfully with an autologous fascia lata inlay graft. Golshani SD, Lee C, Sydorak R. Symptomatic forearm muscle hernia: repair by autologous fascia lata inlay. Ann Plast Surg 1999;43:204-206

Symptomatic Forearm Muscle Hernia: Repair by Autologous Fascia Lata Inlay

Eleven cases of symptomatic muscle hernias of the forearm requiring surgical intervention have been described previously. Pain on extremity exertion and an unaesthetic bulge of the forearm were the primary indications for surgery. Advocated treatment modalities range from forearm fasciotomy to anatomic repair of the fascial defect. Although fasciotomy relieves the narrow fascial constriction around the herniated muscle reliably, it often yields an unappealing forearm deformity and incomplete resolution of pain on extremity exertion. Anatomic repair provides the theoretical advantage of restoring normal muscle fascia relationships while concomitantly improving the aesthetic appearance of the extremity. The authors report a case of symptomatic forearm muscle herniation treated successfully with an autologous fascia lata inlay graft.

Wirksame Entlastung einer großen Muskelhernie durch lokale Botulinumtoxin-Anwendung

A 53-year-old patient developed an impairing muscle hernia when a fascia lata graft was harvested as a substitute for a cruciate ligament of the knee and closure of the defect was not possible. The fascial defect enlarged with time, extending along the whole upper leg. The large muscle protrusion and incarceration in the distal fascial slit was extremely painful during walking and getting up from a chair. Since autologous grafts were disregarded because of the high tissue pressure and alloplastic substitutes seemed problematic, the large hernia was successfully reduced by local muscle denervation with injections of botulinum-A toxin into the protruding vastus lateralis muscle. This procedure achieved relief of pain and enabled the patient to walk without complaints. Side effects were not observed.

Lung herniation into the neck associated with congenital absence of the sternocleidomastoid muscle

This is a case report and literature review involving congenital absence of the sternocleidomastoid muscle (SCM) and simultaneous herniation of the left lung into the neck. The date there have been eight cases of absence of the SCM muscle, but no records of lung herniation alone or in combination with SCM muscle absence. Included is the management course taken to correct this patient's defect, CAT scans of the neck, fluroscopic imaging of the lung and neck, and photographic documentation of the defect.

Unilateral abdominal muscle herniation with pain: a distinctive variant of diabetic radiculopathy

Thoracic diabetic radiculopathy causing truncal pain and abdominal muscle bulging is a recognized though extremely rare complication of diabetes. We report here six cases, describing their clinical features and natural history in detail: the condition affects predominantly middle-aged men, usually on the right side of the abdominal wall, involving three to five adjacent nerve roots between T6 and T12. It may be accompanied by profound weight loss which is not normally due to poorly controlled diabetes. Complete resolution of this syndrome occurs after 3 to 12 months. ©1997 by John Wiley & Sons Ltd.

Painful piezogenic pedal papules: response to local etectro-acupuncture

We report the case of a woman who had pain in both heels which was exacerbated by long periods of exercise. On examination, there were small flesh-coloured papules which appeared over the medial and lateral aspects of the heels only on weight bearing. Coincidentally, she was noted to have larger flesh-coloured papules over the anterior surface of the shins. The diagnoses of painful piezogenic pedal papules and bilateral tibialis anterior muscle herniation, respectively, were made. After many attempts to control the pain, a course of electro-acupuncture was commenced. A good subjective clinical response was achieved which has been maintained by fortnightly treatments. We discuss the prevalence, pathogenesis and treatment of painful piezogenic pedal papules. We believe that our patient is the first to have 'herniations' at both heel and shin sites and the first to have successful sustained pain relief for painful piezogenic pedal papules.

Symptomatic forearm fascial hernia

We retrospectively reviewed the records of seven patients with forearm fascial hernias that were painful with activity. Pain was due to muscle protrusion and hernia course against the proximal fascial edge of the defect. All but one of the symptomatic forearm fascial hernias were located in the midforearm. Theoretically, proximal hernias do not have sufficient muscle excursion to elicit pain. Likewise, distal fascial hernias do not overlie muscle bellies to protrude through the hernia. Based on this concept, each patient was treated by fasciotomy extending from the proximal and distal fascial edges. At least 1 year after surgery, six patients had improvement of their symptoms, three of whom had complete relief.

Surgical management of chronic compartment syndromes of the leg

Surgical management of chronic compartment syndromes requires a solid knowledge of the compartmentanatomy and the peripheral nerves.A muscle hernia in the distal portion of the leg's lateral compartment is often present at the point of exit of the superficial peroneal nerve.A fasciotome allows for easy decompression of a chronic compartment syndrome with minimal dissection through a small incision.