Injury, Int. J. Care Injured 45 (2014) 639–641
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case Report
Adductor longus tendon rupture mistaken for incarcerated inguinal hernia Bas R.J. Aerts, Peter W. Plaisier, Tijs S.C. Jakma * Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 6 October 2013
An incarcerated inguinal hernia is a common diagnosis, since the risk of an inguinal hernia incarcerating or strangulating is around 0.3–3%. An acute rupture of the adductor longus tendon is rarely seen and mostly affects (semi-) professional sportsmen. We present a case of a patient with an assumed incarcerated inguinal hernia which turned out to be a proximal adductor longus tendon rupture. If patients without a history of inguinal hernia present themselves with acute groin pain after suddenly exorotating the upper leg, a rupture of the adductor longus tendon should be considered. Both surgical and non-surgical treatment can be performed. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Adductor longus rupture Inguinal hernia Differential diagnosis Treatment
Introduction Inguinal hernia surgery is performed in 30,000 patients each year in The Netherlands. The risk of an inguinal hernia incarcerating is 0.3–3% [1,2]. The life-time risk of inguinal hernia surgery in a male is around 27% [3]. In contrast to these numbers, an acute rupture of the adductor longus tendon of the femur is a rarely diagnosed injury. Few case reports describe these injuries and the ruptures mostly affect (semi-) professional sportsmen. Most of these ruptures are in the distal part of the tendon. Only a few cases describe a proximal rupture [4–7]. This article describes a case in which a patient was diagnosed with an incarcerated inguinal hernia. At exploration the hernia turned out to be a proximal adductor longus tendon rupture. An overview of the literature of proximal adductor longus tendon ruptures is also provided.
Case report A 50 year old, healthy, scaffolding worker presented himself in our Emergency Department with acute pain in the left inguinal region. The night before, he experienced acute pain in his left leg while lifting his granddaughter and exorotating his leg at the same time. During the night the pain had worsened and oral analgesics did not give any improvement. Prior to the injury he did not have
* Corresponding author at: Department of Surgery, Albert Schweitzer Hospital, P.O. Box 444, 3300 AK Dordrecht, The Netherlands. Tel.: +31 78 6541111; fax: +31 78 6541736. E-mail address: [email protected] (Tijs S.C. Jakma). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.10.049
an inguinal hernia or pain in the inguinal region. Swelling without haematoma was observed in the left inguinal region and was extremely painful during palpation. Under the diagnosis ‘incarcerated inguinal hernia’, an ultrasound was performed, that confirmed the assumed diagnosis. Consequently, the patient underwent inguinal exploration under general anaesthesia. An inguinal incision was performed. In the subcutis, a haematoma was observed but no inguinal hernia was found after opening the aponeurosis. Also no femoral hernia was seen. Following the haematoma a complete rupture of the adductor longus tendon at the origin of the pubic bone was observed (Fig. 1). The adductor tendon was re-attached on the original footprint with three suture anchors (Mitek, Mitek Products Inc., Westwood, Mass). Post-operative XR of the pelvis to determine the position of the suture anchors was performed and showed a correct position on the pubic bone (Fig. 2). Patient was discharged pain free the next day. He was advised not to perform heavy physical activity for two weeks. After these weeks the patient returned to our outpatient clinic and the left hip had a full range of motion. He was allowed to return back to work. The next four weeks he suffered only mild pain during heavy physical activity. After two months he was free of complaints and had a full range of motion of the left hip. Discussion The adductor longus muscle finds its origin at the pubic bone near the symphysis and inserts at the linea aspera of the femur. It provides adduction of the hip joint (Fig. 3). Acute ruptures are painful injuries and occur mostly in (semi-) professional athletes, in contrast to that, our patient did not perform any sports. Patients present themselves with acute pain in
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B.R.J. Aerts et al. / Injury, Int. J. Care Injured 45 (2014) 639–641
Fig. 1. Intra-operative situation: left: caudal, right: cranial, top: right side of the patient and bottom: left side of the patient. The clamp holds the proximal end of the adductor longus tendon. Suture anchors are placed in the pubic bone.
the groin region and in most cases with a heamatoma at the point of rupture. Diagnosis can be made by ultrasonography or Magnetic Resonance Imaging (MRI). The sensitivity, specificity and positive predictive value for an inguinal hernia diagnosed by ultrasonography are respectively 97%, 85%, and 93% [8]. To our knowledge, no literature is available for the sensitivity or positive predictive value for ultrasongraphy in case of an incarcerated inguinal hernia or an adductor longus tendon rupture. Due to local pain, however, it is sometimes difficult to perform an ultrasound. This may cause misinterpretation, such as in our case, where the haematoma of the tendon rupture was mistaken for abdominal tissue. Operative correction consists of fixation of the tendon with suture anchors and is described in several case reports [5–7]. All patients are able to perform full physical activity after a period ranging from eight to twelve weeks. In two articles (Vogt et al. and Rizio et al.) with a follow-up of respectively one and two years, all athletes returned to their old level of activity. They did not suffer from groin or leg pain [5,6].
Fig. 3. The arrow indicates the point of rupture of the adductor longus tendon from its original footprint at the pubic bone next to the symphysis. Copyright 2003–2004 University of Washington. All rights reserved including all photographs and images. No re-use, re-distribution or commercial use without prior written permission of the authors and the University of Washington.
As opposed to surgical management of adductor longus tendon ruptures, Schleger et al. described a non-operative approach in fourteen National Football League athletes and compared the outcomes with 5 surgical approaches in a retrospective study [9]. Non-operative approach consisted of anti-inflammatory drugs, mild electrical stimulation and a training programme. Surgical approach consisted of repair of the rupture with suture anchors. Non-operative approach showed a faster return to play without the risks of surgery (6 versus 12 weeks). Both surgical and non-surgical treatments resulted in an equal likelihood of return to play at professional level. In conclusion, acute rupture of the adductor longus tendon is a rarely seen injury but should always be considered if patients without a history of inguinal hernia or groin pain present themselves with acute groin pain after suddenly exorotating the upper leg. Since surgical and non-surgical treatment of a rupture of the adductor longus tendon have equal results, diagnostic imaging at presentation may be valuable, although ultrasonography may be misleading as in our case.
Conflict of interest Fig. 2. Post-operative XR of the pelvis shows the three suture anchors at the point of re-attachment of the tendon.
None.
B.R.J. Aerts et al. / Injury, Int. J. Care Injured 45 (2014) 639–641
Acknowledgements Musculoskeletal Images are from the University of Washington ‘‘Musculoskeletal Atlas: A Musculoskeletal Atlas of the Human Body’’ by Carol Teitz, M.D. and Dan Graney, Ph.D.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.injury.2013.10.049.
References [1] Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br J Surg 1991;78:1171–3.
641
[2] Rai S, Chandra SS, Smile SR. A study of the risk of strangulation and obstruction in groin hernias. Aust N Z J Surg 1998;68:650–4. [3] Primatesta P, Goldacre MJ. Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol 1996;25:835–9. [4] Ippolito E, Postacchini F. Rupture and disinsertion of the proximal attachment of the adductor longus tendon. Case report with histochemical and ultrastructural study. Ital J Orthop Traumatol 1981;7:79–85. [5] Rizio 3rd L, Salvo JP, Schurhoff MR, Uribe JW. Adductor longus rupture in professional football players: acute repair with suture anchors: a report of two cases. Am J Sports Med 2004;32:243–5. [6] Vogt S, Ansah P, Imhoff AB. Complete osseous avulsion of the adductor longus muscle: acute repair with three fiberwire suture anchors. Arch Orthop Trauma Surg 2007;127:613–5. [7] Dimitrakopoulou A, Schilders EM, Talbot JC, Bismil Q. Acute avulsion of the fibrocartilage origin of the adductor longus in professional soccer players: a report of two cases. Clin J Sport Med 2008;18:167–9. [8] Robinson A, Light D, Kasim A, Nice C. A systematic review and meta-analysis of the role of radiology in the diagnosis of occult inguinal hernia. Surg Endosc 2013;27:11–8. [9] Schlegel TF, Bushnell BD, Godfrey J, Boublik M. Success of nonoperative management of adductor longus tendon ruptures in National Football League athletes. Am J Sports Med 2009;37:1394–9.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Case Report
Adductor longus tendon rupture mistaken for incarcerated inguinal hernia Bas R.J. Aerts, Peter W. Plaisier, Tijs S.C. Jakma * Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 6 October 2013
An incarcerated inguinal hernia is a common diagnosis, since the risk of an inguinal hernia incarcerating or strangulating is around 0.3–3%. An acute rupture of the adductor longus tendon is rarely seen and mostly affects (semi-) professional sportsmen. We present a case of a patient with an assumed incarcerated inguinal hernia which turned out to be a proximal adductor longus tendon rupture. If patients without a history of inguinal hernia present themselves with acute groin pain after suddenly exorotating the upper leg, a rupture of the adductor longus tendon should be considered. Both surgical and non-surgical treatment can be performed. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Adductor longus rupture Inguinal hernia Differential diagnosis Treatment
Introduction Inguinal hernia surgery is performed in 30,000 patients each year in The Netherlands. The risk of an inguinal hernia incarcerating is 0.3–3% [1,2]. The life-time risk of inguinal hernia surgery in a male is around 27% [3]. In contrast to these numbers, an acute rupture of the adductor longus tendon of the femur is a rarely diagnosed injury. Few case reports describe these injuries and the ruptures mostly affect (semi-) professional sportsmen. Most of these ruptures are in the distal part of the tendon. Only a few cases describe a proximal rupture [4–7]. This article describes a case in which a patient was diagnosed with an incarcerated inguinal hernia. At exploration the hernia turned out to be a proximal adductor longus tendon rupture. An overview of the literature of proximal adductor longus tendon ruptures is also provided.
Case report A 50 year old, healthy, scaffolding worker presented himself in our Emergency Department with acute pain in the left inguinal region. The night before, he experienced acute pain in his left leg while lifting his granddaughter and exorotating his leg at the same time. During the night the pain had worsened and oral analgesics did not give any improvement. Prior to the injury he did not have
* Corresponding author at: Department of Surgery, Albert Schweitzer Hospital, P.O. Box 444, 3300 AK Dordrecht, The Netherlands. Tel.: +31 78 6541111; fax: +31 78 6541736. E-mail address: [email protected] (Tijs S.C. Jakma). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.10.049
an inguinal hernia or pain in the inguinal region. Swelling without haematoma was observed in the left inguinal region and was extremely painful during palpation. Under the diagnosis ‘incarcerated inguinal hernia’, an ultrasound was performed, that confirmed the assumed diagnosis. Consequently, the patient underwent inguinal exploration under general anaesthesia. An inguinal incision was performed. In the subcutis, a haematoma was observed but no inguinal hernia was found after opening the aponeurosis. Also no femoral hernia was seen. Following the haematoma a complete rupture of the adductor longus tendon at the origin of the pubic bone was observed (Fig. 1). The adductor tendon was re-attached on the original footprint with three suture anchors (Mitek, Mitek Products Inc., Westwood, Mass). Post-operative XR of the pelvis to determine the position of the suture anchors was performed and showed a correct position on the pubic bone (Fig. 2). Patient was discharged pain free the next day. He was advised not to perform heavy physical activity for two weeks. After these weeks the patient returned to our outpatient clinic and the left hip had a full range of motion. He was allowed to return back to work. The next four weeks he suffered only mild pain during heavy physical activity. After two months he was free of complaints and had a full range of motion of the left hip. Discussion The adductor longus muscle finds its origin at the pubic bone near the symphysis and inserts at the linea aspera of the femur. It provides adduction of the hip joint (Fig. 3). Acute ruptures are painful injuries and occur mostly in (semi-) professional athletes, in contrast to that, our patient did not perform any sports. Patients present themselves with acute pain in
640
B.R.J. Aerts et al. / Injury, Int. J. Care Injured 45 (2014) 639–641
Fig. 1. Intra-operative situation: left: caudal, right: cranial, top: right side of the patient and bottom: left side of the patient. The clamp holds the proximal end of the adductor longus tendon. Suture anchors are placed in the pubic bone.
the groin region and in most cases with a heamatoma at the point of rupture. Diagnosis can be made by ultrasonography or Magnetic Resonance Imaging (MRI). The sensitivity, specificity and positive predictive value for an inguinal hernia diagnosed by ultrasonography are respectively 97%, 85%, and 93% [8]. To our knowledge, no literature is available for the sensitivity or positive predictive value for ultrasongraphy in case of an incarcerated inguinal hernia or an adductor longus tendon rupture. Due to local pain, however, it is sometimes difficult to perform an ultrasound. This may cause misinterpretation, such as in our case, where the haematoma of the tendon rupture was mistaken for abdominal tissue. Operative correction consists of fixation of the tendon with suture anchors and is described in several case reports [5–7]. All patients are able to perform full physical activity after a period ranging from eight to twelve weeks. In two articles (Vogt et al. and Rizio et al.) with a follow-up of respectively one and two years, all athletes returned to their old level of activity. They did not suffer from groin or leg pain [5,6].
Fig. 3. The arrow indicates the point of rupture of the adductor longus tendon from its original footprint at the pubic bone next to the symphysis. Copyright 2003–2004 University of Washington. All rights reserved including all photographs and images. No re-use, re-distribution or commercial use without prior written permission of the authors and the University of Washington.
As opposed to surgical management of adductor longus tendon ruptures, Schleger et al. described a non-operative approach in fourteen National Football League athletes and compared the outcomes with 5 surgical approaches in a retrospective study [9]. Non-operative approach consisted of anti-inflammatory drugs, mild electrical stimulation and a training programme. Surgical approach consisted of repair of the rupture with suture anchors. Non-operative approach showed a faster return to play without the risks of surgery (6 versus 12 weeks). Both surgical and non-surgical treatments resulted in an equal likelihood of return to play at professional level. In conclusion, acute rupture of the adductor longus tendon is a rarely seen injury but should always be considered if patients without a history of inguinal hernia or groin pain present themselves with acute groin pain after suddenly exorotating the upper leg. Since surgical and non-surgical treatment of a rupture of the adductor longus tendon have equal results, diagnostic imaging at presentation may be valuable, although ultrasonography may be misleading as in our case.
Conflict of interest Fig. 2. Post-operative XR of the pelvis shows the three suture anchors at the point of re-attachment of the tendon.
None.
B.R.J. Aerts et al. / Injury, Int. J. Care Injured 45 (2014) 639–641
Acknowledgements Musculoskeletal Images are from the University of Washington ‘‘Musculoskeletal Atlas: A Musculoskeletal Atlas of the Human Body’’ by Carol Teitz, M.D. and Dan Graney, Ph.D.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.injury.2013.10.049.
References [1] Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br J Surg 1991;78:1171–3.
641
[2] Rai S, Chandra SS, Smile SR. A study of the risk of strangulation and obstruction in groin hernias. Aust N Z J Surg 1998;68:650–4. [3] Primatesta P, Goldacre MJ. Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol 1996;25:835–9. [4] Ippolito E, Postacchini F. Rupture and disinsertion of the proximal attachment of the adductor longus tendon. Case report with histochemical and ultrastructural study. Ital J Orthop Traumatol 1981;7:79–85. [5] Rizio 3rd L, Salvo JP, Schurhoff MR, Uribe JW. Adductor longus rupture in professional football players: acute repair with suture anchors: a report of two cases. Am J Sports Med 2004;32:243–5. [6] Vogt S, Ansah P, Imhoff AB. Complete osseous avulsion of the adductor longus muscle: acute repair with three fiberwire suture anchors. Arch Orthop Trauma Surg 2007;127:613–5. [7] Dimitrakopoulou A, Schilders EM, Talbot JC, Bismil Q. Acute avulsion of the fibrocartilage origin of the adductor longus in professional soccer players: a report of two cases. Clin J Sport Med 2008;18:167–9. [8] Robinson A, Light D, Kasim A, Nice C. A systematic review and meta-analysis of the role of radiology in the diagnosis of occult inguinal hernia. Surg Endosc 2013;27:11–8. [9] Schlegel TF, Bushnell BD, Godfrey J, Boublik M. Success of nonoperative management of adductor longus tendon ruptures in National Football League athletes. Am J Sports Med 2009;37:1394–9.
