Palpable Defect Research Articles

Pectoralis major rupture in the elderly: Clinical and sonographic findings

We describe clinical and sonographic features of pectoralis major rupture in the elderly, which is relatively rare and unknown. Patients presented with a large pectoral ecchymosis extending to the axilla, chest wall, breast and arm. The pectoral area was sensitive, sometimes with a visible and palpable defect in the axilla. Ultrasound examination showed a large hypoechoic, well-circumscribed structure representing a hematoma within the pectoralis major muscle, partially replacing the normal echo muscle pattern. Ultrasonography is a useful, low cost diagnostic tool, and is recommended in the investigation of pectoralis major rupture in the elderly.

HIP INJURY IN A COLLEGE FOOTBALL PLAYER

HISTORY A college football defensive back was injured when his extended left leg was forced into the ground while making a tackle. He followed through over the top of the engaged player making a second contact with the ground on a bent knee. He complained of left hip pain and was unwilling to move his left lower extremity. There were no obvious gross deformities during the on-field assessment. Unable to bear weight, the player was helped to the sideline for further evaluation. PHYSICAL EXAMINATION Sideline exam revealed pain in left hip at an intensity of 10/10 without radiation to his groin or down his leg. He repeatedly described the pain as “deep in there.” There was no left knee, ankle or foot pain. No back pain or radicular symptoms. No swelling of affected area. Left hip range of motion testing was limited by pain with flexion to 50 degrees, extension to 0 degrees, internal rotation to 30 degrees, external rotation to 40 degrees, abduction to 30 degrees and adduction to 0 degrees. He was tender to palpation over his left ASIS and proximal hip flexors without a palpable defect. Manual muscle testing revealed 4 out of 5 strength throughout his left hip secondary to pain. FABER test was positive. Sensation of left lower extremity was normal. Left knee exam was normal. Player was given 60 mg Toradol IM and iced on the field for the remainder of the game. He reported decreased pain and increased stiffness over the next hour. DIFFERENTIAL DIAGNOSIS Avulsion fracture of ASIS. Proximal hip flexor tear. Hip subluxation/dislocation. Acetabular labral tear. Traumatic femoral neck fracture. TEST AND RESULTS X-ray views of the pelvis and hip that night: No evidence of fractures or subluxation MRI the following day: Joint space widening with effusion beyond the joint capsule. Labral detachment and probable posterior acetabular avulsion fracture. Contusion in the anterior femoral neck, probable osteochondral fracture of the anterosuperior femoral head. Ligamentum teres appears somewhat thickened and hyperintense with some edema. MRI of left hip (eight weeks later): Labral tear still apparent but in normal anatomic position. Bone bruise to femoral head with no fracture seen. Ligamentum teres is intact. No rupture of joint capsule noted. Digital video of play from gamefilm: Mechanism appeared to be anterior to posterior axial loading of left hip in flexion. FINAL WORKING DIAGNOSIS Left hip posterior subluxation with posterior acetabular labral tear. TREATMENT AND OUTCOMES After orthopedic consultation, strict non weight bearing with crutches for eight weeks. NSAID's PRN for pain. Electrical stimulation to left leg. After the second MRI at 8 weeks weight bearing was allowed with progression to running over a six week period. If pain or clicking occurs with progressing of activity the patient will have an arthroscopic hip evaluation.

TRICEPS INJURY-SOFTBALL PLAYER

History: A 39-year-old softball player injured his right elbow playing softball. The injury occurred secondary to a fall with impact of his posterior elbow onto a hard object. He had immediate pain and swelling. He was seen in the emergency room one week later due to continued pain with increasing swelling over the back of his elbow as well as forearm and hand. A Doppler study was negative for a DVT. No x-rays were done. He was seen in out-patient follow-up one week later with primary complaints of pain, swelling, and weakness. He was unable to play softball, but otherwise was not limited by the injury. He denied any significant numbness or tingling. ROS negative for neck, shoulder or wrist pain. Physical Exam: generally well developed and muscular male in no distress. Right arm with swelling noted to involve upper arm, elbow, forearm and wrist. There was swelling of the olecranon bursa. There was a 2 × 3 cm mass present 3–4 cm proximal to the olecranon. There was associated tenderness over the bursa and mass. No increased skin temperature or errythema. ROM 0–140 degrees flexion, 90 degrees pronation and supination. (+) Pain with passive and active elbow flexion and extension. Strength 5/5 with flexion, 4/5 extension. Neurologic and vascular status intact with 2+ radial pulses. DIFFERENTIAL DIAGNOSIS: Traumatic bursitis with myositis ossificans Olecranon or occult fracture DVT Triceps tendon tear TEST AND RESULTS: Radigraphs Small area of calcification in triceps just proximal to the olecranon. No fracture or bony abnormalities present. DRAINAGE OF HEMATOMA: Sixty milliliters of serosanguineous fluid was removed with an 18 gauge needle. A palpable defect was present over the posterior olecranon with a palpable firm mass over distal/posterior arm. MRI: Sagital T1, T2, short tau inversion recovery (STIR) and axial images were performed. Pattern consistent with post-traumatic olecranon bursitis associated with edema and fluid within and adjacent to the triceps tendon and lateral triceps head suggesting of partial tear of the muscle fibers, and myositis. No fracture or bony abnormalities. FINAL/WORKING DIAGNOSIS: Triceps tendon tear TREATMENT AND OUTCOMES: Orthopedic referral Surgical repair of the triceps tendon with drill holes and suturing Cast Immobilization post-operatively for 3 weeks Early motion followed by strengthening Return to sports 4–6 months after repair

ACHILLES TENDON RUPTURE IN A SNOWBOARDER

HISTORY: 20 year old male snowboard presented to a ski-area sports medicine clinic with sudden onset of calf and lower leg pain after an off-balanced landing from a jump in the snowboard of the ski area. The patient reported that he was attempting to rotate 180 degrees during the jump (from the left-foot forward position to the right-foot forward position). He lost his balance in mid-air, and landed with extreme dorsiflexion of his feet and flexion of the knees. The patient stated that the calf pain was immediate upon landing from the jump, however he was able to snowboard down the rest of the run and seek medical treatment at the clinic. The patient denied any previous calf muscle, foot or ankle injuries. PHYSICAL EXAM: 20 year old male in moderate pain, complaining of left calf and posterior ankle pain. Musculoskeletal exam Left Knee Exam: No effusion and no palpable joint line tenderness. Full range of motion (0 to 135 degrees). Negative Lachman's, anterior and posterior drawer. No pain with valgus and varus stress. Left Lower Leg Exam: Normal proximal calf muscle bulk. Significant swelling distal calf at 6 to 10 cm proximal of Achilles tendon insertion. Significant pain with palpation of Achilles tendon with palpable defect approximately 6 to 7 cm proximal of calcaneal insertion. Positive Thompson's test (No plantar flexion with calf muscle contraction/squeeze) Left Ankle/Foot Exam: No significant effusions or pain with palpation at lateral or medial malleoli. No anterior ankle joint line pain. Unable to actively plantar flex foot. Significant pain with passive plantar and dorsiflexion of foot. DIFFERENTIAL DIAGNOSIS: Tibia/Fibula fracture, calcaneal fracture, talar dome fracture, ankle sprain, calf muscle strain/tear, Achilles tendon rupture, Plantaris muscle tear/rupture. TEST AND RESULTS: Xrays - Left ankle series with mortisse view - No fractures evident. No widening of joint space. Left tibia/fibula (AP and lateral) - No fractures evident. FINAL/WORKING DIAGNOSIS: Acute and complete rupture of the Achilles tendon TREATMENT AND OUTCOMES: Patient was referred to local orthopedics group and had surgery for repair of a complete achilles tendon rupture. Patient did well in the post-operative period but was lost to follow-up approximately two months following surgery.

ACHILLES INJURY - RECREATIONAL ATHLETE

HISTORY - A 30-year-old athletic corrections officer felt a painful “pop” in his left heel, while sprinting, during a softball game on 5/21/00. The patient has a history of a complete right Achilles tendon rupture in January of 1999, while playing football. His right tendon was sugically repaired at that time. PHYSICAL EXAMINATION - Swelling and tenderness along the left Achilles tendon. Palpable defect 2cm above the calcaneus. Positive Thompson test. DIFFERENTIAL DIAGNOSIS Partial Achilles Tendon Rupture Complete Achilles Tendon Rupture TEST AND RESULTS NONE FINAL/WORKING DIAGNOSIS Complete left Achilles tendon rupture TREATMENT Conservative Treatment for left Achilles tendon rupture - May 2000 SLC/NWB in gravity equinus, initially SLC/NWB in partial equinus at 3 weeks post injury CAM Walker, progressive weight bearing, ROM exercises at 8 weeks Hinged CAM Walker, calf strengthing exercises at 10 weeks Heel lifts at 12 weeks Return to full activity at 16 weeks post injury. Surgical Treatment for right Achilles tendon rupture - January 1999 Surgical repair, SLC/NWB/Equinus Staples removed, SLC/NWB/dorsiflexion increased by 10 degrees at 10 days post injury SLC/NWB/dorsiflexion increased by second increment of 10 degrees at 4 weeks SLC/Weight bearing as tolerated at 6 weeks Cast removed, physical therapy at 8 weeks Light duty at 12 weeks Return to full activities at 16 weeks post injury OUTCOME The patient had equal functional results with both treatments, but preferred the conservative method over the surgical.

‘Fat fracture’ – a physical sign mimicking tendon rupture

The imaging techniques available to aid the diagnosis of ruptures of tendo Achillis, the rotator cuff and the tendon of tibialis posterior in rheumatoid patients are well described. However, ruptures of tendon or muscle at other sites are uncommon and may be overlooked. Diagnosis is often made by localised tenderness, swelling and a lack of active movement associated with a palpable defect. Clinical examination may be inconclusive and can be aided by imaging studies. We report two cases in which ruptures of a tendon were suspected, and ultrasound imaging demonstrated the palpable defect to be a cleavage plane in the subcutaneous fat – a ‘fat fracture’.

Intramuscular corticosteroid injection for hamstring injuries. A 13-year experience in the National Football League.

The purpose of this study was to assess the safety of intramuscular corticosteroid injection in selected, severe hamstring injuries in professional football players. Clinicians have been reluctant to use corticosteroid injections in or around muscle-tendon units because of concern of incomplete healing or rupture. We retrospectively reviewed the computer database of one National Football League team for all hamstring injuries requiring treatment between January 1985 and January 1998. We found that 431 players had suffered such injury. We developed a clinical grading system to identify hamstring injury severity and to stratify players for treatment. Fifty-eight players (13%) sustained severe, discrete injuries with a palpable defect within the substance of the muscle and were treated with intramuscular injection of corticosteroid and anesthetic. There were no complications related to the injection of corticosteroid. Only nine players (16%) missed any games as a result of their injury. Final examination revealed no strength deficits, normal muscle bulk and tone, and the ability to generate normal power. We believe that the grading system we developed can assist in selection of injury type for injection. Although lack of a control group limits statements of efficacy of injection, our impression is that intramuscular corticosteroid injection hastens players' return to full play and lessens the game and practice time they miss.

Incisional hernias in midline incisions: An eight-year follow up

The aim of this study was to report the incidence of incisional hernias following midline laparotomy incisions after 12 months and after 8 years. 374 patients who underwent midline laparotomy between August 1989 and December 1990 were included. The wounds were closed with a continuous suture and the technique was monitored by the suture length to wound length ratio. The incidence of incisional hernia, defined as a palpable defect in the fascia or a protrusion beyond this level, was monitored at 12 months and after 8 years. Early wound dehiscence occurred in 3 patients (1%) and wound infection in 32 (9%). At the 12-month examination 58 (20%) incisional hernias were detected in 292 patients. After 8 years 142 patients were examined and 5 (3%) hernias were found. All hernias that caused inconvenience or required surgical repair were detected at 12 months follow-up. Most hernias appearing later have probably been overlooked at the first examination.

Extensor Mechanism Rupture

Summary: Extensor-mechanism disruption is the result of both direct and indirect trauma. The location of the rupture is somewhat age dependent (quadriceps tendon, >40 years; patellar tendon, <40 years) and occurs only through diseased tendon. The diagnosis is generally straightforward in cases of a typical history of injury and a clinical examination demonstrating an extensor lag with a palpable defect and effusion. Incomplete ruptures, however, are often misdiagnosed. Surgical treatment predominates and tends to provide reproducible results. Postoperative stiffness, loss of full extension power, and patellofemoral pain may occur despite a solid repair.

Patellar Tendon Ruptures.

Rupture of the patellar tendon is a relatively infrequent, yet disabling, injury, which is most commonly seen in patients less than 40 years of age. It tends to occur during athletic activities when a violent contraction of the quadriceps muscle group is resisted by the flexed knee. Rupture usually represents the final stage of a degenerative tendinopathy resulting from repetitive microtrauma to the patellar tendon. This injury may also occur during less strenuous activity in patients whose tendons are weakened by systemic illness or the administration of local or systemic corticosteroid medications. The diagnosis is made on the basis of the presence of a painful, palpable defect in the substance of the tendon; an inability to completely extend the knee against gravity; and the existence of patella alta confirmed by lateral radiographs. Ultrasonography and magnetic resonance imaging are useful in identifying a neglected rupture, as well as when the diagnosis is in question or an intra-articular injury is suspected. The prognosis after a patellar tendon rupture depends in large part on the interval between injury and repair. Surgery soon after the injury is recommended for optimal results. This is best accomplished by accurate reapproximation of the ruptured tendon ends, repair of the torn extensor retinacula, and placement of a reinforcing cerclage suture. An aggressive rehabilitation program, emphasizing early range-of-motion exercises, protected weight bearing, and quadriceps strengthening, will enhance the results of surgery. Patients who undergo delayed repair are at risk for a compromised result secondary to loss of full knee flexion and decreased quadriceps strength, although a functional extensor mechanism is likely to be reestablished.

The value of MRI in the early diagnosis of growing skull fracture.

Growing skull fracture (GSF) is a progressive enlargement of a fracture due to an underlying tear of the dura mater. It is a rare complication of severe head injury mainly reported in young children. Classically, the diagnosis is made during follow-up, late after the original injury, when a palpable skull defect or a bulging mass is discovered clinically. Initial skull radiographs show a diastatic fracture developing later into a large bony defect. CT will show the brain damage which is usually present beneath the fracture. We present the MRI findings of GSF in a series of eight children. All patients initially had a large linear fracture and underlying brain damage on CT. In all cases MRI showed a zone of the same intensity as the brain contusion or cerebrospinal fluid advancing through the bone margins of the fracture to the subcutaneous plane. This finding was interpreted as an indirect sign of the dural tear. Seven patients were operated on with surgical confirmation of GSF. MRI can make an early diagnosis of GSF possible so that surgical repair with closure of the dura can be carried out before the dural tear enlarges.

Management of gunshot injuries to the penis and anterior urethra.

To verify the appropriate methods of diagnosis and treatment of gunshot injuries to the penis and anterior urethra. Retrospective study. Fourteen patients presented over 5 years with gunshot wounds to the male genitalia with injuries involving the penis and or the anterior urethra. All patients underwent a full physical examination and retrograde urethrogram to fully stage suspected injuries. Of the nine patients sustaining penile wounds, four were superficial, requiring only debridement, and five involved the corpus cavernosum, necessitating formal repair. Physical findings of an expanding hematoma, a palpable corporeal defect, and excessive bleeding via the wounds were indicative of cavernosal injury and warranted a penile exploration. All patients were potent in follow-up, although two patients with extensive injuries did complain of curvatures. Retrograde urethrograms noted anterior urethral injuries in eight patients, three of whom also had sustained cavernosal injuries. Five were repaired primarily, and three were treated by urinary diversion via a suprapubic tube. Three patients developed urethral strictures: one in the primary repair group and two in the diversion group. The preferred method of handling low-velocity gunshot wounds to the penis and anterior urethral includes debridement of superficial wounds, repair of cavernosal defects, and primary repair of urethral injuries wherein tissue loss is not extensive to result in high-potency rates and lower rates of urethral stricture disease.

Pectoralis Major Rupture

In brief Ruptures of the pectoralis major are unusual, but may be underrecognized; fewer than 100 case reports have been published. This injury is often associated with performing the bench press. Physical examination usually will reveal a palpable defect, acute pain on range of motion, and weakness to resisted adduction and internal rotation. An MRI may be helpful in determining the location and degree of injury. The literature supports the surgical treatment of complete pectoralis nuuor ruptures; results have generally been excellent. A case of complete rupture with successful surgical repair is reported.

Avulsion of the Hamstring Muscles from the Ischial Tuberosity

In two rare cases with avulsion of the hamstring muscles from the ischial tuberosity without fracture of the ischium, the clinical features were: (1) sudden onset of pain in the buttock; (2) difficulty on standing after trauma; (3) a palpable defect and tenderness on the area distal from the ischial tuberosity; and (4) weakness of flexion of the knee with a loss of normal outline of the hamstring muscles on the dorsal aspect of the knee. There was no roentgenologic evidence of fracture of the ischium. Surgical repair with reattachment of avulsed muscles to the ischium and proximal tendinous sheaths of the muscles restored function or corrected deformity.

Procidentia in the newborn

Complete uterine prolapse was noted shortly after birth in a female infant with a meningomyelocele at the level of the iliac crest with a palpable dimpled defect caudal to the primary lesion. The vagina and uterus were restored to their normal position with a rubber nipple placed into the vagina. The prolapse resolved on the sixth day of life after a repair of the meningomyelocele. Thus, conservative therapy with temporary support provides a satisfactory solution for newborn procidentia.

Spontaneous partial subcutaneous ruptures of the tendo achillis. Review of the literature and evaluation of 16 involved tendons.

Partial subcutaneous rupture of the Achilles tendon has been considered a rare condition. Physical signs and symptoms have not been well established. The current review of 11 patients with 16 involved subcu taneous ruptures of the Achilles tendon treated at Southwestern Orthopedic Medical Group between the years 1971 and 1976 is intended to delineate the entity more clearly. Preoperative and postoperative symptoms and physical findings were evaluated and operatively and nonoperatively treated groups were compared. All tendons treated demonstrated either a palpable, partial defect in the Achilles tendon or were found at surgery to have a partial rupture. Thompson's test was negative in all patients. Eighty-one percent of injuries occured in males (13 of 16). The average age at diagnosis was 47.6 years. Pretherapy symp toms existed an average of 6½ months before defini tive therapy was instituted. Eighty-one percent of in juries were incurred during athletic activity (13 of 16). Forty-four percent had had from one to five prior injections of corticosteroid into the Achilles tendon area (7 of 16). The most common pretherapy symp toms were pain after variable degrees of activity (100%), limping (100%), the sensation of weakness (81 %), and intermittent or continuous swelling (35%). Seven of 16 tendons were treated with nonoperative therapy. The remaining nine tendons underwent sur gical exploration and repair. Those treated surgically were repaired by excision of the defect, suture of the opposing ends, and reinforcement of the repair with fascial strips turned down from the posterior gastroc nemius. All patients completed detailed question naires after therapy. This study concludes (1) Partial subcutaneous rup ture of the tendo achillis occurs predominantly in young and middle-aged males involved in strenuous athletic activities; (2) predominant symptoms are pain, limping, weakness, and intermittent swelling; (3) pal pation of the Achilles tendon will generally reveal a palpable partial defect but Thompson's test will remain negative; (4) ablation of symptoms can usually be obtained nonoperatively but if symptoms persist be yond six months surgical exploration and repair is indicated; (5) the majority of patients can be expected to return to their preinjury level of activity.

The diagnosis of intracranial cysts by means of the brain scan.

Brain scanning has proved a valuable diagnostic aid in intracranial disease (1). Although an early report suggested that an intracranial cyst could be diagnosed by decreased count rate (2), most reports deal with increased activity seen on the scan with neoplasm, inflammatory changes, hematomata, surgery, and vascular abnormalities. We know of only two reported cases demonstrating a negative defect or area of reduced activity on the brain scan secondary to an avascular lesion such as a cyst (3, 4). This communication reports five cases showing a negative defect on the brain scan secondary to a cyst and demonstrates the features on the brain scan suggestive of the diagnosis of a cyst. Case Reports Case I: A one-year-old girl had been developing normally until a few weeks before admission to the hospital when her parents noted increasing head size and irritability. Examination disclosed slight proptosis of the right eye and an enlarged occipital-frontal circumference of 51.1 cm. The right side of the head transilluminated. Skull films demonstrated slight widening of the suture lines and asymmetry of the skull, which was enlarged on the right. The right parietal bone was thinned, the right middle cranial fossa was elongated and depressed, and the sagittal sinus groove was displaced to the left (Fig. 1, A). The brain scan had a large area of decreased activity on the right with displacement of the normal cerebral structures to the left, especially well demonstrated on the vertex view (Fig. 1, B–D). Pneumoencephalography combined with air introduced into a cystic cavity through the cranial sutures showed marked displacement of the ventricles by the right frontoparietal cyst (Fig. 1, E). Surgery revealed a large arachnoid cyst occupying almost the entire right hemisphere. Case II: A 3-year-old boy had been delivered prematurely, weighing 4 lb. 8 oz. at birth. The child did not appear normal at birth and at the age of two months the diagnosis of “brain tumor” had been made by means of cerebral ventriculography. The child never crawled, sat, stood, or talked. He screamed while awake. The head was elongated with bulging of the right frontoparietal area, and there was a palpable defect of the skull in this area. The interorbital distance was increased. The right side of the head transilluminated. An electroencephalogram showed generalized slowing of electrical activity, more marked on the left. The cerebrospinal fluid had a protein content of 109 mg per 100 cc but was otherwise normal. Skull films demonstrated bulging and thinning of the right frontal and parietal bones with septation of the thinned bone and widening of the interorbital distance (Fig. 2, A and B). The brain scan revealed displacement of the sagittal sinus to the left with a large area of decreased activity occupying the right frontoparietal area.