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Lynne S. Steinbach - One of the best experts on this subject based on the ideXlab platform.
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Lesser Tuberosity Avulsions in Adolescents
HSS Journal ®, 2014Co-Authors: Lorenzo Nardo, Benjamin C. Ma, Lynne S. SteinbachAbstract:Background Subscapularis tendon Avulsions of the lesser tuberosity are relatively rare and often missed acutely and their characteristic appearance is frequently not recognized or is misinterpreted for an osteochondroma or a neoplastic process. Questions/Purposes This report reviews our experience with six adolescents who had subscapularis tendon Avulsions of the lesser tuberosity. Methods Six male adolescents (12–15 years) presented with shoulder pain following history of trauma during amateur sport. Clinical notes including range of motion, strength tests, and pain assessment were reviewed along with imaging studies pre- and post treatment. Treatment consisted of either surgical or conservative measures. Results Two of the six patients had a large Avulsion that simulated an exostosis of the proximal humerus that was misdiagnosed as an osteochondroma at two different outside institutions. All six cases were diagnosed with subscapularis tendon Avulsion of the lesser tuberosity following clinical and imaging evaluation at our institution. Five of the patients underwent surgical repair and fixation of the tendon and the lesser tuberosity with suture anchors. One patient was treated conservatively. All patients had a good outcome with recovery of full shoulder strength and motion upon follow-up. Conclusion Clinicians should have a high index of suspicion of lesser tuberosity Avulsions in adolescents who present with loss of internal rotation and anterior shoulder pain following traumatic injuries. In addition, an osseous fragment or exostosis along the inferomedial humeral head should suggest a subscapularis tendon Avulsion and also should not be confused with an osteochondroma or a neoplastic process.
Sakari Orava - One of the best experts on this subject based on the ideXlab platform.
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total proximal tendon Avulsion of the rectus femoris muscle
Scandinavian Journal of Medicine & Science in Sports, 2006Co-Authors: T Irmola, Sakari Orava, J Heikkila, Janne SarimoAbstract:Total proximal Avulsions of the quadriceps femoris muscle group are rare injuries. Between the years 2001 and 2004 five patients with a total proximal Avulsion of the tendon of the rectus femoris muscle were treated surgically in Mehilainen Hospital in Turku, Finland. The median age of the patients was 21 years (range, 19–27) and the patients were all men. There were four soccer players and one hurdler. In all cases an Avulsion of the proximal tendon of the rectus femoris muscle was confirmed by MRI. All of the patients were operated on and the delay from the injury to surgery ranged from 18 to 102 days. The result of the surgical treatment was rated good in all cases. All of the patients were able to return to their pre-injury level of activity 5–10 months after surgery. The median follow-up time was 20 months (range, 9–38). Surgical treatment of a total proximal Avulsion of the tendon of the rectus femoris muscle seems to result in return to the pre-injury activity level in most cases.
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Ischial tuberosity apophysitis and Avulsion among athletes.
International Journal of Sports Medicine, 1997Co-Authors: Urho M. Kujala, Sakari Orava, Jarmo Karpakka, Jenni Leppävuori, K. MattilaAbstract:Ischial tuberosity pain in athletes may be caused by several clinical entities, which include acute and old bony or periosteal Avulsions and apophysitis. We studied the natural course of these injuries based on our clinical case series of fourteen patients with apophysitis and twenty-one with Avulsion of the ischial tuberosity. Only patients with the diagnosis confirmed by X-ray finding were included. The clinical diagnostic criteria by ischial apophysitis consisted of gradually increasing functional and palpatory pain at the ischial tuberosity without any major trauma at the beginning of the symptoms. Typically there was asymmetry on plain radiographs of the ischial tuberosities in apophysitis; the involved apophyseal area became sclerotic, wider than the non-symptomatic apophysis, osteoporotic patches developed and the lower margin of the ischial tuberosity became irregular. The patients with Avulsion reported an acute trauma at the beginning of the symptoms and an Avulsion fragment was immediately after injury or later seen in plain radiographs. The mean age of the patients with apophysitis (14.1 yrs) was lower than that of the subjects with Avulsions (18.9 yrs). Apophysitis of the ischial tuberosity usually healed well without complications. Avulsions often caused more prolonged pain with referral pain to the posterior parts of the thigh which often required operative interventions. A small bony or periosteal Avulsion sometimes grew to a pseudotumor calcification. We recommend conservative treatment as the primary treatment modality for both ischial tuberosity apophysitis and Avulsion fractures.
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Ischial Apophysis Injuries in Athletes
Sports Medicine, 1993Co-Authors: Urho M. Kujala, Sakari OravaAbstract:The diagnosis and treatment of ischial tuberosity pain in athletes include several clinical entities. These injuries include apophysitis, adult tug lesion, painful unfused apophysis, and acute and old Avulsions. In some Avulsion injuries a bony fragment can be seen, but they can also be x-ray-negative, especially in children. An insertional tendon rupture is also possible. Conservative treatment of apophysitis includes modification of activities and anti-inflammatory medication. Avulsions, if diagnosed early, usually heal with conservative therapy, especially if the displacement is not marked. Urgent surgical treatment is recommended in cases with total or nearly total soft-tissue hamstring muscle insertion rupture. Surgery has to be considered also in cases with dislocation of the apophysis or bony Avulsion of more than 2cm. Excision of the excessive mass or poorly united fragment provides relief of pain in some cases of old Avulsions.
Ranee Thakar - One of the best experts on this subject based on the ideXlab platform.
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the natural history of levator ani muscle Avulsion 4 years following childbirth
Ultrasound in Obstetrics & Gynecology, 2020Co-Authors: M A Van Gruting, Ranee Thakar, Abdul H Sultan, K W Van DelftAbstract:OBJECTIVES The primary aim was to prospectively study the natural history of levator ani muscle (LAM) Avulsion four years following first delivery and correlate to signs and symptoms of pelvic floor dysfunction (PFD). The secondary aim was to investigate the effect of a second vaginal delivery on the incidence of LAM Avulsion and PFD. METHODS Nulliparae at 36 weeks of gestation, three months, one year and four years postpartum were assessed at all visits for signs and symptoms of PFD. Transperineal ultrasound was performed to assess LAM integrity and hiatal biometry. Differences in signs and symptoms of PFD over time were evaluated using a linear mixed model in women with one and ≥2 deliveries. RESULTS Of 269 nulliparae, 147 (55%) were examined 3.8 (0.4 SD) years after their first delivery. 74 (50%) had a subsequent delivery. Prevalence of LAM Avulsion four years after first vaginal delivery was 13% with no difference between one or more vaginal deliveries. Women with intact LAM showed no change in signs and symptoms of PFD. In women with previous LAM Avulsion, four years after one delivery 42% was no longer evident, however significant worsening in pelvic floor muscle strength, prolapse on clinical examination and hiatal area on ultrasound were found. After subsequent vaginal delivery LAM Avulsion became more extensive in 44% and hiatal area increased. CONCLUSIONS The first vaginal delivery is at greatest risk for LAM Avulsion to occur, with impact on PFD four years later. A second vaginal delivery could result in deterioration of LAM Avulsion, but no new Avulsions were found. This article is protected by copyright. All rights reserved.
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levator hematoma at the attachment zone as an early marker for levator ani muscle Avulsion
Ultrasound in Obstetrics & Gynecology, 2014Co-Authors: K Van Delft, Ranee Thakar, Abbas S Shobeiri, Abdul H SultanAbstract:Objectives Childbirth causes overstretching of the levator ani muscle (LAM), predisposing to Avulsion. LAM Avulsion has not been evaluated early postpartum using endovaginal ultrasound (EVUS). The aim of this study was to evaluate the relationship between hematomas and LAM Avulsion using EVUS and palpation early and late postpartum. Methods Nulliparous women were studied prospectively at 36 weeks' gestation and within 4 days and 3 months postpartum. Palpation and high-frequency three-dimensional EVUS were performed. Two independent investigators reviewed the scans. Results No antenatal LAM Avulsions were found (n = 269). 114/199 (57.3%) women seen early postpartum agreed to examination. 27/114 (23.7%) had well delineated, hypoechoic areas consistent with hematomas (100% agreement), 26 following vaginal delivery, one following emergency Cesarean section. In total, 38 hematomas were found (11 bilateral, 16 unilateral). Hematomas away from the attachment zone of the LAM to the pubic bone (n = 22) resolved. Hematomas at the attachment zone (n = 16) manifested as pubococcygeus Avulsions 3 months postpartum. In addition to these 16 Avulsions, we found another 20 at 3 months postpartum. 13/20 were not scanned early postpartum and in seven no hematomas were seen, but Avulsion was seen early postpartum. Overall, LAM Avulsion was found in 23/191 (12.0%) women (13 bilateral, 10 unilateral) 3 months postpartum. Hematomas were significantly associated with episiotomy, instrumental delivery and increased hiatal measurements. Palpation was unreliable early postpartum as only seven Avulsions were diagnosed. Conclusion Hematomas at the site of LAM attachment to the pubic bone always result in Avulsion diagnosed 3 months postpartum. However, one third of Avulsions are not preceded by a hematoma at the site of LAM attachment to the pubic bone. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.
Jose Antonio Garciamejido - One of the best experts on this subject based on the ideXlab platform.
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type of levator ani muscle Avulsion as predictor for the disappearance of Avulsion
Neurourology and Urodynamics, 2020Co-Authors: Jose Antonio Garciamejido, Jose Antonio SainzAbstract:OBJECTIVES The objective of our study was to establish whether the type of levator ani muscle (LAM) Avulsion diagnosed 6 months after delivery influences the integrity of the LAM at 1 year after delivery and determine its influence on the levator hiatus area. STUDY DESIGN This observational prospective cohort study included 192 primiparous women with vaginal delivery. Transperineal ultrasound examinations were performed at 6 months and 1 year postpartum. Levator hiatus measurements (anteroposterior diameter, transverse diameter, and area) were performed in the plane of minimal dimensions. Complete Avulsion was defined based on maximum contraction in multislice mode. Type I LAM Avulsion was present when most lateral fibers of the pubovisceral muscle were observed at its insertion at the pubic level (the arch of the elevator remained intact). Type II LAM Avulsion was defined as a complete detachment of the pubovisceral muscle from its insertion at the pubic level. RESULTS In total, 192 patients were recruited after delivery; 48 patients were diagnosed with complete LAM Avulsion, and 13 patients with Avulsion did not attend the second ultrasound follow-up at 1 year after delivery. Thirty-five patients with complete LAM Avulsion were included in the study. At 6 months after delivery, 51 LAM Avulsions were observed in 35 patients (including bilateral LAM Avulsion in 16 cases), of which 54.9% were right Avulsions and 45.1% left Avulsions. Furthermore, 11 (five right and six left) were type I LAM Avulsions at the 6-month assessment, and all of these had disappeared 1 year after delivery. However, none of the type II LAM Avulsions (23 right and 17 left) observed at 6 months had disappeared at the second ultrasound examination. There were no differences between the LAM areas detected at the first and second ultrasound examinations (10.2 ± 3.3 vs 9.3 ± 1.8; P = .404). CONCLUSIONS The type of LAM Avulsion observed at 6 months after childbirth predicts LAM persistence at 1 year postpartum.
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can we predict levator ani muscle Avulsion in instrumental deliveries through intrapartum transperineal ultrasound
Journal of Maternal-fetal & Neonatal Medicine, 2019Co-Authors: Jose Antonio Garciamejido, Paloma De La Fuentevaquero, Adriana Aquisepino, Laura Castroportillo, Ana Fernandezpalacin, Jose Antonio SainzbuenoAbstract:Introduction: To determine whether intrapartum translabial ultrasound (ITU) is useful for the prediction of levator ani muscle (LAM) Avulsions in instrumental deliveries (vacuum and forceps). Materials and methods: Prospective, observational study, including (1/2016 - 5/2016) 77 nulliparous women, with singleton pregnancies of ≥37 weeks of gestation and with cephalic presentation, who required vacuum or forceps instrumentation to complete the delivery. The ITU parameters evaluated were Angle of Progression (AoP), Progression Distance (PD), Head Direction (HD), and Midline Angle (MLA), both at rest and with maternal push. Evaluation of LAM Avulsion was performed at 6 months postpartum with 3-4D transperineal ultrasound. Complete Avulsion was defined as an abnormal insertion of LAM in the lower pubic branch identified in all three central slices. Results: Data from 48 nulliparous women were finally included in the study (34 vacuum and 14 forceps). We observed no difference in obstetric parameters between the two study groups (group with Avulsion of LAM -14 cases, 29.2% - and group without Avulsion of LAM -34 cases, 70.8%). The "LAM Avulsion group" had an AoP and a PD of 136.7 ± 22.4 and 43.5 ± 15.6, respectively, versus 141.6 ± 21.3 and 47.2 ± 16.8 recorded in the group without Avulsion (NS), respectively. We obtained a ROC curve for AoP and PD with a push of 0.66 (95% CI, 0.28-1.00) and 0.57 (95% CI, 0.39-0.75), respectively. Conclusions: ITU is not a useful technique to predict the occurrence of LAM Avulsion in instrumental deliveries with vacuum or forceps.
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factors that influence the development of Avulsion of the levator ani muscle in eutocic deliveries 3 4d transperineal ultrasound study
Journal of Maternal-fetal & Neonatal Medicine, 2016Co-Authors: Jose Antonio Garciamejido, Ana Fernandezpalacin, Laura Gutierrezpalomino, Carlota Borrero, Pamela Valdivieso, Jose Antonio SainzbuenoAbstract:AbstractIntroduction: Levator ani muscle (LAM) lesions are the most frequent injuries of the pelvic floor during delivery. Ten to 36% of women report this lesion during their first delivery. Many risk factors have been proposed but very few evaluate the aspects that can influence during natural vaginal delivery.Method: A prospective observational trial was conducted involving 74 primiparous women following vaginal delivery. Maternal, fetal and obstetric characteristics were analyzed. A transperineal three or four-dimensional (3D–4D) ultrasound was offered six months after delivery in order to evaluate Avulsions and anomalies of the hiatus.Results: Seventy four women were included, three of them did not show up for ultrasound evaluation. Sixty two (87.3%) demonstrated no Avulsion in comparison with nine (12.7%) who did. Five of these lesions were unilateral and four bilateral. Mean newborn weight was 3193 g in the “no Avulsion group” versus 3470 g in the “Avulsion” group (p=0.025).Discussion: According to ...
Abdul H Sultan - One of the best experts on this subject based on the ideXlab platform.
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the natural history of levator ani muscle Avulsion 4 years following childbirth
Ultrasound in Obstetrics & Gynecology, 2020Co-Authors: M A Van Gruting, Ranee Thakar, Abdul H Sultan, K W Van DelftAbstract:OBJECTIVES The primary aim was to prospectively study the natural history of levator ani muscle (LAM) Avulsion four years following first delivery and correlate to signs and symptoms of pelvic floor dysfunction (PFD). The secondary aim was to investigate the effect of a second vaginal delivery on the incidence of LAM Avulsion and PFD. METHODS Nulliparae at 36 weeks of gestation, three months, one year and four years postpartum were assessed at all visits for signs and symptoms of PFD. Transperineal ultrasound was performed to assess LAM integrity and hiatal biometry. Differences in signs and symptoms of PFD over time were evaluated using a linear mixed model in women with one and ≥2 deliveries. RESULTS Of 269 nulliparae, 147 (55%) were examined 3.8 (0.4 SD) years after their first delivery. 74 (50%) had a subsequent delivery. Prevalence of LAM Avulsion four years after first vaginal delivery was 13% with no difference between one or more vaginal deliveries. Women with intact LAM showed no change in signs and symptoms of PFD. In women with previous LAM Avulsion, four years after one delivery 42% was no longer evident, however significant worsening in pelvic floor muscle strength, prolapse on clinical examination and hiatal area on ultrasound were found. After subsequent vaginal delivery LAM Avulsion became more extensive in 44% and hiatal area increased. CONCLUSIONS The first vaginal delivery is at greatest risk for LAM Avulsion to occur, with impact on PFD four years later. A second vaginal delivery could result in deterioration of LAM Avulsion, but no new Avulsions were found. This article is protected by copyright. All rights reserved.
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levator hematoma at the attachment zone as an early marker for levator ani muscle Avulsion
Ultrasound in Obstetrics & Gynecology, 2014Co-Authors: K Van Delft, Ranee Thakar, Abbas S Shobeiri, Abdul H SultanAbstract:Objectives Childbirth causes overstretching of the levator ani muscle (LAM), predisposing to Avulsion. LAM Avulsion has not been evaluated early postpartum using endovaginal ultrasound (EVUS). The aim of this study was to evaluate the relationship between hematomas and LAM Avulsion using EVUS and palpation early and late postpartum. Methods Nulliparous women were studied prospectively at 36 weeks' gestation and within 4 days and 3 months postpartum. Palpation and high-frequency three-dimensional EVUS were performed. Two independent investigators reviewed the scans. Results No antenatal LAM Avulsions were found (n = 269). 114/199 (57.3%) women seen early postpartum agreed to examination. 27/114 (23.7%) had well delineated, hypoechoic areas consistent with hematomas (100% agreement), 26 following vaginal delivery, one following emergency Cesarean section. In total, 38 hematomas were found (11 bilateral, 16 unilateral). Hematomas away from the attachment zone of the LAM to the pubic bone (n = 22) resolved. Hematomas at the attachment zone (n = 16) manifested as pubococcygeus Avulsions 3 months postpartum. In addition to these 16 Avulsions, we found another 20 at 3 months postpartum. 13/20 were not scanned early postpartum and in seven no hematomas were seen, but Avulsion was seen early postpartum. Overall, LAM Avulsion was found in 23/191 (12.0%) women (13 bilateral, 10 unilateral) 3 months postpartum. Hematomas were significantly associated with episiotomy, instrumental delivery and increased hiatal measurements. Palpation was unreliable early postpartum as only seven Avulsions were diagnosed. Conclusion Hematomas at the site of LAM attachment to the pubic bone always result in Avulsion diagnosed 3 months postpartum. However, one third of Avulsions are not preceded by a hematoma at the site of LAM attachment to the pubic bone. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.
