Imaging in the diagnosis of symptomatic forearm muscle herniation

Pediatric Forearm Muscle Herniation Treated With an Acellular Dermal Allograft

Muscle herniations occur through acquired fascial defects in the lower extremities; upper-extremity herniations are rare. The affected patients are typically adult men engaging in strenuous exercise or with injury; pediatric cases are infrequent. We a pediatric patient with a symptomatic, forearm herniation treated with fascial defect closure using an acellular dermal allograft. This case report highlights not only the presence of this rare condition in pediatrics but also a safe and viable treatment option for this patient population. The patient presented with pain and soft-tissue swelling of the forearm, was diagnosed with muscular herniation, and was surgically treated with fascial defect closure using an acellular dermal allograft. All symptoms resolved, without the recurrence of herniation and with return to sport. Upper-extremity muscle herniations are rare but should be considered in pediatric patients following trauma/surgery and can be treated successfully with acellular dermal allografts.

Semimembranosus: A Rare Muscle Herniation and Review of the Literature

Extremity muscle hernias are rare pathologies, most of which are managed conservatively. In symptomatic cases, surgical intervention may be required. This study represents a case of a rarer muscle hernia, semimembranosus, in a 43-year-old patient and describes the surgical technique of grafting with synthetic nonabsorbable polypropylene surgical mesh as well as the review of the literature about extremity muscle hernias.

Multimodality evaluation of transfascial muscle and other soft tissue herniations of the extremities

This review illustrates the multimodality assessment of transfascial muscle and other soft tissue herniations of the extremities. Transfascial herniations of the extremities can develop from congenital or acquired disruptions of the deep fascia, resulting in herniation of the underlying muscle, nerve, or soft tissue tumor into the subcutaneous tissues. While most patients present with a painless subcutaneous nodule that may change in size with muscle activation, some may experience focal or diffuse extremity symptoms such as pain and paresthesias. Although the diagnosis may be clinically suspected, radiologic evaluation is useful for definitive diagnosis and characterization. Ultrasound is the preferred modality for initial workup through a focused and dynamic examination. Magnetic resonance imaging can be utilized for equivocal, complicated, and preoperative cases. Computed tomography is less useful in the evaluation of transfascial herniations in the extremities due to similarities in the attenuation between muscle and fascia, which can decrease the conspicuity of small defects.

Muscle herniae: Conservative and surgical management. Systematic review

BACKGROUND

Muscle herniae are often unrecognized. The primary objective of this systematic review is to evaluate the outcomes of conservative and surgical management for muscle herniae. The secondary objective is to define the most appropriate management for muscle herniae depending on aetiology and size of the fascial defect.

METHODS

The PRISMA guidelines were used to organize this systematic review to assess the different management modalities and identify possible criteria useful to guide the management of muscle herniae. An electronic search of PubMed and Scopus databases was performed.

RESULTS

A total of 132 patients were identified. Conservative management was carried out in 22 (16.7%) patients, and 110 (83.3%) patients underwent surgical procedures. Pain was reported in 3/22 (13.6%) patients managed conservatively. Post-surgical pain was reported in 0/5 (0%) patients treated with autologous graft repair, 1/15 (6.7%) patient with mesh repair, 2/13 (15.4%) patients with direct repair and 11/77 (14.3%) patients with fasciotomy. Return to normal activity was possible in 16/22 (72.7%) patients treated conservatively, 5/5 (100%) patients undergoing autologous graft repair, 13/15 (86.7%) with mesh repair, 62/77 (80.52%) with fasciotomy and 4/12 (33.3%) with direct repair.

CONCLUSION

In congenital muscle herniae, fasciotomy should be considered the surgical choice to prevent complications. In post-traumatic muscle hernia, a small fascial defect can be treated with the direct suture repair, while mesh repair and autologous graft repair should be considered the most appropriate procedures to avoid severe complications such as compartment syndrome.

Muscle Hernias in the Upper Limb: Treatment and Literature Review

PURPOSE

A muscle hernia is defined as a protrusion of the muscle belly through an acquired or congenital fascial defect. A nontraumatic herniation may occur through congenital fascial defects or be acquired by means of exertion, blunt trauma, or a penetrating injury. In this study, our aim was to review our experience with this rare condition and report the results of surgical treatment of these cases.

METHODS

During the period between January 1, 2014, and August 30, 2018, 12 cases of symptomatic muscle hernia in the upper limb were included in our study: 9 cases involving the forearm and 3 cases involving the arm. All patients underwent direct repair of their fascial defect with overlapping of the deep fascia using nonabsorbable sutures.

RESULTS

There were improvements in postoperative pain, swelling, appearance, weakness, and paresthesia. There was significant improvement in the Disabilities of the Arm, Shoulder and Hand score from a mean of 51.8 before surgery to 6.9 after surgery. The mean period to return to activities of daily living was 18 days (range, 15-20 days).

CONCLUSIONS

Muscle hernia in the upper limb is an uncommon condition that can be successfully treated.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Bilateral non-traumatic lower leg fascial defects causing peroneal muscle herniation and novel use of a GraftJacket to repair the fascial defect

Constitutional bilateral defects in the peroneal fascial compartment leading to muscle herniation are extremely rare. We present the case of a twenty-nine year old male carpenter with non-traumatic bilateral peroneal fascial defects, in which the symptomatic right side was successfully repaired using a GraftJacket^®. This case report highlights the need for clinicians to remain aware of the diagnosis of muscle herniation as a cause of a painful mass in the lower limbs, especially when related to exercise. The judicious use of further imaging such as ultrasound in combination with MRI can be useful in differentiating a muscle hernia from other more sinister causes, such as malignancy.

The value of ultrasound in the preoperative diagnosis of muscle herniation: A comparison with magnetic resonance imaging

OBJECTIVES

To evaluate the clinic value of ultrasound (US) in the diagnosis of muscle herniation.

METHODS

This retrospective study was performed on 26 patients with muscle herniation confirmed by surgery. All patients were examined by US and magnetic resonance imaging (MRI) preoperatively. The final histopathologic findings were retrospectively compared with the results of US and MRI.

RESULTS

The accuracy of ultrasonography and MRI were 92.3%(24/26) and 84.6%(22/26) respectively. There was no significant difference between two methods (χ²=0.25, P>0.05).

CONCLUSIONS

US can be used to observe the shape, size, location, internal echo and fascial defect of the mass of muscle herniation in a dynamical way. Ultrasound is a convenient method with high accuracy, it can be used as the first choice of imaging modality for the diagnosis of muscle herniation.

Soleus Muscle Herniation With Magnetic Resonance Imaging and Ultrasound Correlation in a Female Long-Distance Runner: A Case Report

This is a case of a 40-year-old female endurance athlete with right leg pain while running. A comprehensive workup revealed a fascial defect with soleus muscle herniation. Although historically in many practice settings magnetic resonance imaging is the diagnostic imaging modality of choice for suspected muscle herniation through the fascia, the use of ultrasound is increasing because of lower cost, ease of access, and dynamic evaluation. To the authors' knowledge, there has not been a direct comparison between the accuracy of magnetic resonance imaging versus ultrasound in determining the size or location of a soleus muscle herniation.

LEVEL OF EVIDENCE

Not applicable.

Diagnosis and management of symptomatic muscle herniation of the extremities: a retrospective review

BACKGROUND

There is a paucity of published literature on diagnosis and surgical management of muscle herniation of the extremities, with most reported cases involving military personnel and men aged 18 to 40 years. Hypothesis/

PURPOSE

The purpose of this study is to describe the presentation, diagnosis, and results of fasciotomy for symptomatic muscle herniation in young athletes. We hypothesize that fasciotomy can be a safe and effective treatment option that allows the majority of athletes to return to sports.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From 2001 to 2011, 26 athletes (19 women; 11 runners) with a mean age 19.0 ± 4.0 years (range, 14.2-28.4 years) underwent fasciotomy for symptomatic muscle herniation at the authors' institution. Retrospective chart review recorded pertinent patient data and clinical course. Questionnaires were sent to all patients to assess satisfaction with surgery, ability to return to sports, and residual symptoms.

RESULTS

Muscle hernias were classified as primary (n = 8, 31%), postsurgical (n = 8, 31%), and associated with underlying untreated chronic exertional compartment syndrome (n = 10, 38%). The tibialis anterior muscle (n = 12, 46%) was most commonly involved. The mean time from onset of symptoms to surgery was 15.1 ± 8.6 months (range, 3-38 months). Dynamic ultrasound (5/6 patients, 83%) was more accurate than magnetic resonance imaging (3/18, 17%) at identifying the hernia. At median follow-up of 28 months (range, 12-127 months), 17 patients (65%) had returned to sports. Seventeen patients (65%) completed the postoperative questionnaire; 14 reported being satisfied with their results (82%). Mild residual symptoms were common (9 of 17 respondents, 53%), especially in runners (5 of 7, 71%), all of whom were satisfied with surgery. Patients with a postsurgical muscle herniation took the longest to return to sports and were the least likely to return to sports, had the highest rate of dissatisfaction with surgery, and were most likely to have persistent symptoms not improved by surgery.

CONCLUSION

Fasciotomy is a safe surgical option for symptomatic muscle herniation in young athletes. Many patients are able to return to sports and most are satisfied with surgery. Residual symptoms are common, especially in runners. Patients with postsurgical muscle herniations may have the worst clinical outcome.

US diagnosis of pediatric muscle hernias of the lower extremities

Muscle hernias result from the protrusion of muscle through acquired or congenital fascial defects. They most often occur in the lower extremities of young adults, typically men. There has been limited description in the literature of this entity in children. Our purpose is to evaluate the demographics, presentation and imaging findings of muscle hernias diagnosed by US in our pediatric patient population. We conducted a retrospective review of all lower extremity muscle hernias diagnosed by US in patients younger than 19 years of age, from January 2001 to March 2011, evaluating the reason for referral, imaging performed before and after US, and subsequent clinical course. Sixteen children were diagnosed with muscle hernia by US, 11 girls and 5 boys, ages 3 to 18 years (mean 13.8). Sixty-nine percent (n = 11) involved the tibialis anterior. Clinical suspicion for muscle hernia was present in seven patients (44%). Of the four cases where MR was performed before US, three were interpreted as normal. In 13 cases (81%), the radiologist reported that dynamic imaging with provocative maneuvers (plantar flexion, standing, squatting) was either necessary or helpful in visualizing the muscle hernia. Four children had surgery to treat symptoms. Muscle hernias are often not suspected clinically in children. US with dynamic imaging and provocative maneuvers is key to diagnosis. US confirmation of a muscle hernia provides a reassuring diagnosis and helps exclude the presence of an aggressive lesion. Surgical intervention is an option for persistent symptoms, but is often not necessary.

Treatment of a symptomatic forearm muscle herniation with a mesh graft

Symptomatic muscle herniations are an unusual cause of upper extremity pain in the athlete that is rarely reported in the literature. Out of 18 reported cases of upper extremity herniations, only 3 were caused by strenuous exertion. This article describes a successful repair of a 21-year-old rock climber’s ventral forearm herniation with polypropylene mesh.

Gastrocnemius muscle herniation as a rare differential diagnosis of ankle sprain: case report and review of the literature

Background

Muscle herniation of the leg is a rare clinical entity. Yet, knowing this condition is necessary to avoid misdiagnosis and delayed treatment. In the extremities, muscle herniation most commonly occurs as a result of an acquired fascial defect, often due to trauma. Different treatment options for symptomatic extremity muscle herniation in the extremities, including conservative treatment, fasciotomy and mesh repair have been described.

Case presentation

We present the case of a patient who presented with prolonged symptoms after an ankle sprain. The clinical picture showed a fascial insufficiency with muscle bulging under tension. Ultrasound and MRI imaging confirmed the diagnosis of muscle hernia of the medial gastrocnemius on the right leg. Conservative treatment did not lead to success. Therefore, the fascial defect was treated surgically by repairing the muscle herniation using a synthetic vicryl propylene patch.

Conclusions

Muscle hernias should be taken into consideration as a rare differential diagnosis whenever patients present with persisting pain or soft tissue swelling after ankle sprain. Diagnosis is mainly based on clinical aspect and physical examination, but can be confirmed by radiologic imaging techniques, including (dynamic) ultrasound and MRI. If conservative treatment fails, we recommend the closure with mesh patches for large fascial defects.

Repair of symptomatic forearm hernias using acellular dermal matrix--two case reports

Symptomatic forearm hernias are troublesome conditions infrequently presented in the literature. We describe a novel approach using cadaveric acellular dermal matrix in an inlay technique to restore fascia integrity. In 2 patients who perform heavy labor, this technique resolved their hernia-related symptoms and allowed them to resume work activities.

Bilateral tibialis anterior muscle herniation simulating a soft tissue tumour in a young amateur football player

Muscle herniation is a focal protrusion of muscle tissue through a defect in the deep fascial layer. Anterior tibial muscle is the most commonly affected muscle of the lower extremities because its fascia is the most vulnerable to trauma. Clinically it is characterized by asymptomatic or painful, skin-coloured, soft, subcutaneous nodules of various size depending on the position. The diagnosis is usually made clinically based on its typical manifestations, but ultrasonographic examination is useful for detecting the fascial defect and excluding other conditions caused by soft tissue tumours such as lipomas, angiolipomas, fibromas, schwannomas or varicosities. Although this entity is not rare, it has been less well documented in the dermatological literature. We report a case of bilateral tibialis anterior muscle herniation mimicking a soft tissue tumour in a young amateur football player.

Treatment of a symptomatic forearm muscle herniation with a wrap-around fascia lata graft

Muscle herniation in the extremity is a well-recognized cause of symptomatic pain on exertion. Only 17 cases involving the upper limb has been previously described, 11 of them involving the anterior compartment of the forearm and only 2 were caused by strenuous exertion. Treatment for this condition ranged from nonsurgical, primary closure with palmaris longus interweave, formal fasciotomy, to closure with a tensor fascia lata graft.This is a study of a 28-year-old man who had a symptomatic swelling on the volar aspect of his left forearm while working on a car-door assembly line that resulted in a significant decreased of his grip strength, work capacity and median nerve symptoms. It did not improve after 6 months of conservative management including hand therapy and splintage. The patient subsequently underwent a tensor fascia lata graft wrap-around. Postoperatively his symptoms resolved with improvement in his grip strength and hand function. The rationale for the treatment option chosen is discussed.