Search

A woman in her 30s presented to emergency with complaints of acute lower abdominal pain for 3 days, not associated with any menstrual, bowel or urinary symptoms. Examination revealed an abdominopelvic mass corresponding to an 18-week gravid uterus with diffuse tenderness and guarding over her lower abdomen. The patient was a follow-up case of subserosal fibroid uterus, chronic kidney disease stage 4 and rheumatic heart disease on anticoagulants. Fibroid degeneration or torsion was suspected. Ultrasound revealed a large posterior wall subserosal fibroid with free fluid in the pelvis. As findings did not suggest degeneration or pedunculated fibroid, noncontrast CT was done, which showed a similar mass with a pedicle arising from the uterine fundus with free fluid with no other evident cause of acute abdomen. The patient was taken up for emergency laparotomy. Intraoperatively, it was found to be a case of subserosal fibroid with greater omentum adhered to it and twisted around its axis about eight times. This case is being reported to highlight a rare cause of acute abdomen., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Tubal mesosalpinx cysts are paratubal cysts, that account for approximately 10% of adnexal masses, and the presence of these cysts combined with adnexal torsion is a rare acute abdominal condition, with few cases reported in the literature. We reported two cases of adolescent tubal mesosalpinx cysts combined with adnexal torsion and reviewed the literature to help improve the diagnosis of the disease., Case Reports: The first patient was an 11-year-old girl with left lower abdominal pain for 5 days and fever with nausea and vomiting for 3 days, who was found to have a cystic pelvic mass on preoperative imaging and was diagnosed intraoperatively and postoperatively on pathology as having a left tubal mesosalpinx cyst combined with adnexal torsion. The second patient was a 13-year-old girl with right lower abdominal pain for 16 h and a palpable mass in the lower and middle abdomen on examination, which was hard and tender to palpate. Preoperative imaging revealed a large cystic mass in the right adnexal region, and intraoperative and postoperative pathology revealed a right tubal mesosalpinx cyst combined with adnexal torsion., Conclusions: Tubal mesosalpinx cysts combined with adnexal torsion are rare causes of acute lower abdominal pain. Early diagnosis and timely surgery are necessary to ensure ovarian and tubal function. Accurate preoperative imaging diagnosis is challenging, and MRI is a beneficial supplement to ultrasound and CT examinations, providing more objective imaging information and reducing the incidence of adverse outcomes., (© 2024. The Author(s).)

Objective: Ovarian torsion (OT) represents a severe gynecological emergency in female pediatric patients, necessitating immediate surgical intervention to prevent ovarian ischemia and preserve fertility. Prompt diagnosis is, therefore, paramount. This retrospective study set out to assess the utility of combined clinical, ultrasound, and laboratory features in diagnosing OT., Methods: The authors included 326 female pediatric patients aged under 14 years who underwent surgical confirmation of OT over a five-year period. Logistic regression analysis was employed to pinpoint factors linked with OT, and the authors compared clinical presentation, laboratory results, and ultrasound characteristics between patients with OT (OT group) and without OT (N-OT group). The authors conducted receiver operating characteristic (ROC) curve analysis to gauge the predictive capacity of the combined features., Results: Among 326, OT was confirmed in 24.23 % (79 cases) of the patients. The OT group had a higher incidence of prenatal ovarian masses than the N-OT (22 cases versus 7 cases) (p < 0.0001). Similarly, the authors observed significant differences in the presence of lower abdominal pain, suspected torsion on transabdominal ultrasound, and a high neutrophil-lymphocyte ratio (NLR > 3) between the OT and non-OT groups (p ˂ 0.05). Furthermore, when these parameters were combined, the resulting area under the curve (AUC) was 0.868, demonstrating their potential utility in OT diagnosis., Conclusion: This study demonstrates a prediction model integrating clinical, laboratory, and ultrasound findings that can support the preoperative diagnosis of ovarian torsion, thereby enhancing diagnostic precision and improving patient management. Future prospective studies should concentrate on developing clinical predictive models for OT in pediatric patients., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (Copyright © 2024 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.)

Many patients who cannot squat well in a neutral toe position can only squat in an excessively out-toeing position. This excessive out-toeing squat is thought to be caused by rotational problems of the lower extremities. In this study, we aimed to identify the cause for the inability to squat by measuring and comparing femoral and tibial torsion between an excessive out-toeing squat patient group and a control group representing the general population. Between 2008 and 2022, a patient group comprising 50 lower extremities with excessive out-toeing squats was established. A control group representing the general population was selected from patients aged 0 to 29 years, who underwent lower-extremity CT angiography between 2012 and 2022, using the Clinical Data Warehouse with exclusion criteria applied. A total of 94 lower extremities were included in the control group. The femoral torsional angle (FTA) and tibial torsional angle (TTA) of both groups were measured and compared using Student t test. Additionally, 30 each of those with the highest and lowest 30 FTA values were selected from the patient and control groups, and the TTA was compared between the high- and low-FTA groups using Student t test. The mean FTA was 0.34° (SD, 11.11°) in the patient group and 10.14° (SD, 11.85°) in the control group, with a mean difference of 9.8° and P < .001. The mean TTA was 27.95° (SD, 7.82°) in the patient group and 32.67 ° (SD, 7.58°) in the control group, with a mean difference of 4.72° (P = .001). The mean TTA was 34.3° (SD, 7.72°) in the high-FTA group and 28.17° (SD, 8.35°) in the low-FTA group, with a mean difference of 6.13° (P = .005). Patients with excessive out-toeing squat showed lower FTA and TTA values than the general population. Furthermore, although a correlation between FTA and TTA was not established through Pearson correlation analysis, a tendency was observed where a decrease in FTA was associated with a decrease in TTA. Based on these results, decreased FTA was demonstrated to be one of the major causes of excessive out-toeing squats., Competing Interests: Each author certifies that there are no commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

This case report discusses a diagnosis of uterine torsion in an 84-year-old woman who presented with five days of right lower quadrant abdominal pain, nausea, vomiting, constipation, and poor intake. Computed tomography (CT) imaging demonstrated a whorled configuration at the junction of the cervix and lower uterine segment, with the left gonadal vein crossing midline, and two previously known right leiomyomas now appearing on the left. These findings were consistent with the diagnosis of uterine torsion. She then underwent an urgent exploratory laparotomy, and the uterus was found to be dextroverted 270 degrees, with dark mottled purple tissue and engorged vessels. A supracervical hysterectomy and bilateral salpingo-oopherectomy were performed. Final pathology demonstrated extensive necrosis. This case reviews the classic presentation and imaging findings for the rare diagnosis of uterine torsion and options for management of both non-gravid and gravid patients., (Copyright Journal of Radiology Case Reports.)

Competing Interests: Competing interests: None declared.

Primary segmental omental torsion (PSOT) is a very rare cause of acute abdominal pain, and it may often imitate the clinical picture of acute appendicitis. In instances of acute abdominal pain without anorexia, nausea, and vomiting, omental torsion should be included in the differential diagnosis. Any misdiagnosis may lead to major complications such as intraabdominal abscesses and adhesions. A 63-year-old overweight man with a body mass index (BMI) of 41 Kg/m 2 presented to the emergency department on a remote island with acute abdominal pain. His medical history included type 2 diabetes mellitus managed with insulin, essential hypertension, osteoarthritis, and no previous abdominal operations. He reported a sharp pain originating in the epigastrium and the right hypochondrium that started five days prior. Physical examination revealed rebound tenderness and guarding across the abdomen with a positive McBurney sign. However, the patient did not report vomiting and was not nauseous. Vital signs were as follows: blood pressure 116/56 mmHg, heart rate 98 beats/min, respiratory rate 19 breaths/min, and a temperature of 38.2 0 C. Laboratory results showed a white blood cell count of 10.6, neutrophils of 8.11, C-reactive protein (CRP) 74 mg/l, haemoglobin11.6 g/dl, and hematocrit 36.9%. Due to the absence of a radiographer at the hospital during that period, no imaging investigations were conducted. Diagnostic laparoscopy demonstrated diffused hemoperitoneum and necrotic mass at the site of the hepatic flexure. Initially suspected to be an advanced colon cancer, the decision was made to proceed with open surgery. The necrotic segment of the omentum was found at the right superior point of attachment of the omentum to the hepatic flexure. Consequently, the necrotic segment of the omentum was resected. A thorough investigation of the abdominal cavity did not detect any other abnormalities or pathologies. The patient recovered uneventfully and was transferred to the surgical ward. Torsion of the omentum is a very rare cause of acute abdominal pain. This case highlights the necessity of considering PSOT in the differential diagnosis of acute abdominal pain, especially in cases where symptoms are suggestive of appendicitis but diagnostic findings are negative., Competing Interests: The authors declare no conflict of interest., (© 2024 by the authors.)

Torsional, angular, and linear measurements in a paediatric population are clinically important but not well defined and understood. Different methods of measurement and discrepancies between assessors leads to a lack of understanding of what should be defined as typical or atypical for the growing skeleton. From a large dataset of 333 paediatric CT scans, we extracted three-dimensional torsional, angular, and linear measurements from the pelvis, femur, and tibia/fibula. Sex differences in linear measurements were observed in bones of children aged 13+ (around puberty), but femoral and tibial torsion were similar between males and females. The rotational profile (femoral anteversion minus tibial torsion) tended to increase with growth. Epicondylar, condylar, and malleolar widths were smaller in females than males for the same bone length after the age of 13 years, which could explain why females may be more at risk for sport injuries during adolescence. This rich dataset can be used as an atlas for researchers and clinicians to understand typical development of critical rotational profiles and linear bone measurements in children., (© 2023. The Author(s).)

Objective: To evaluate the diagnostic accuracy of different ultrasound signs for diagnosing adnexal torsion, using surgery as the reference standard., Methods: This was a systematic review and meta-analysis of studies published between January 1990 and November 2021 evaluating ovarian edema, adnexal mass, ovarian Doppler flow findings, the whirlpool sign and pelvic fluid as ultrasound signs (index tests) for detecting adnexal torsion, using surgical findings as the reference standard. The search for studies was performed in PubMed/MEDLINE, CINAHL, Scopus, The Cochrane Library, ClinicalTrials.gov and Web of Science databases. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was used to evaluate the quality of the studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios were calculated separately, and the post-test probability of adnexal torsion following a positive or negative test was also determined., Results: The search identified 1267 citations after excluding duplicates. Eighteen studies were ultimately included in the qualitative and quantitative syntheses. Eight studies (809 patients) analyzed the presence of ovarian edema, eight studies (1044 patients) analyzed the presence of an adnexal mass, 14 studies (1742 patients) analyzed ovarian Doppler flow, six studies (545 patients) analyzed the whirlpool sign and seven studies (981 patients) analyzed the presence of pelvic fluid as ultrasound signs of adnexal torsion. Overall, the quality of most studies was considered to be moderate or good. However, there was a high risk of bias in the patient-selection and index-text domains (with the exception of the whirlpool sign) in a significant proportion of studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios of each ultrasound sign were 58%, 86%, 4.0 and 0.49 for ovarian edema, 69%, 46%, 1.3 and 0.67 for adnexal mass, 65%, 91%, 7.6 and 0.38 for the whirlpool sign, 53%, 95%, 11.0 and 0.49 for ovarian Doppler findings and 55%, 69%, 1.7 and 0.66 for pelvic fluid. Heterogeneity was high for all analyses., Conclusions: The presence of an adnexal mass or pelvic fluid have poor diagnostic accuracy as ultrasound signs of adnexal torsion, while the presence of ovarian edema, the whirlpool sign and decreased or absent ovarian Doppler flow have good specificity but moderate sensitivity for detecting adnexal torsion. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology., (© 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.)

Objective: To share our experience of intravenous indocyanine green (ICG) application during conservative ovarian surgery in a young patient with adnexal torsion, a large ovarian cyst, and apparent ovarian necrosis., Design: This confirmatory video of ovarian reperfusion uses footage from the laparoscopic treatment and ICG application in a young patient with adnexal torsion and apparent necrosis., Setting: Academic, multisite medical center., Patient(s): A 24-year-old patient with a 12-cm dermoid cyst, adnexal torsion, and apparent tissue necrosis., Intervention(s): Five milligrams intravenous ICG, de-torsion, ovarian cystectomy, and ovarian reconstruction. The patient approved the ICG off-label use., Main Outcome Measure(s): Ovarian preservation and perioperative morbidity., Result(s): This video demonstrates the surgical treatment of a patient with adnexal torsion. The perfusion patterns before and after the surgical treatment, i.e., cyst de-torsion and cyst removal are documented using intravenous ICG. The perfusion patterns guided the surgeon to perform ovarian conservation despite apparent initial ischemia. The patient recovered well, and no postoperative 30-day morbidity occurred., Conclusion(s): Intraoperative subjective overestimation of the true ovarian ischemia may lead to unnecessary oophorectomy. Per the American College of Obstetrics and Gynecology recommendation, patients with adnexal torsion should be treated surgically with ovarian conservation regardless of the appearance of the ovary. As demonstrated, ovaries reperfuse despite multiple twists along the infundibulopelvic pedicle, apparent necrosis, and large cysts. Unilateral salpingo-oophorectomies are avoidable even in these cases., (Copyright © 2022 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Torsion of the greater omentum is an uncommon cause of acute abdominal pain. Omental torsion can be divided into primary and secondary. Owing to its nonspecific abdominal pain, preoperative diagnosis is difficult. Ultrasound sonography and abdominal computed tomography scans do not have a major role in preoperative diagnosis. The definite diagnosis is usually made during operation., Case Presentation: A 7-year-old Persian boy was referred with right lower quadrant pain associated with nausea and vomiting. Laboratory blood tests and urinalysis were requested that revealed normal values. Ultrasonography was performed, revealing inflammatory changes with mild free fluid collection in the interloop. The patient underwent an open appendectomy, confirming a normal appendix with omental torsion. Two days later, he was discharged home without postoperative complications., Conclusions: In patients with acute abdomen, particularly those with acute appendicitis symptoms, omental torsion should be considered in the differential diagnosis., (© 2022. The Author(s).)

Background: Pediatric splenic torsion is a rare entity, and the most common cause is wandering spleen. This study aimed to summarize our clinical experience in the diagnosis and surgical treatment pediatric patients with splenic torsion, and to use preoperative thrombocytosis as a preoperative predictive factor for splenic infarction., Methods: From January 1st, 2016 to December 31st, 2021, 6 children diagnosed as splenic torsion were included. All patients were surgically treated and followed up. The clinical data was collected including clinical presentations, laboratory tests, imaging results, surgical procedures, and prognosis. Clinical experience of diagnosis and surgical treatment were summarized., Results: There were 4 females and 2 males, with median age at surgery 102.6 (range 9.4-170.7) months. Abdominal pain and abdominal mass were the most common presentations. The diagnosis of splenic torsion depended on imaging studies, and adjacent organ involvement (gastric and pancreas torsion) was observed on contrast CT in one patient. Five patients were diagnosed as torsion of wandering spleen, and one was torsion of wandering accessory spleen. Emergent laparoscopic or open splenectomy was performed in all patients. Pathology revealed total splenic infarction in 4 patients, partial infarction in 1 patient, and viable spleen with congestion and hemorrhage in 1 patient. Preoperative platelet counts were elevated in all 4 patients with splenic infarction, but normal in the rest 2 with viable spleen. Postoperative transient portal vein branch thromboembolism occurred in one patient., Conclusions: Imaging modalities are crucial for the diagnosis of pediatric splenic torsion and adjacent organ involvement. Preoperative thrombocytosis may predict splenic infarction. Spleen preserving surgery should be seriously considered over splenectomy in patients with a viable spleen., (© 2022. The Author(s).)

We herein report a rare case of torsion of a wandering spleen in a patient with myeloproliferative disease. A 66-year-old Japanese woman presented to our hospital with abdominal pain and a fever. She had a medical history of polycythemia and secondary myelofibrosis. Abdominal enhanced computed tomography showed an enlarged spleen without enhancement in the lower pelvic region. The clinical diagnosis was severe torsion of a wandering spleen in a patient with myeloproliferative disease, necessitating surgical intervention. Splenectomy was performed after de-rotating to revascularize the spleen. After the operation, the platelet count gradually increased, and aspirin was administered to prevent thrombosis.

Objective: To compare features of pre-menarchal and post-menarchal patients with adnexal torsion., Methods: We reviewed hospital records to note examination findings, laboratory work-up, imaging results, operative findings and course during hospital stay for 56 girls aged from 7 days to 17 years with adnexal torsion presenting between January, 2012 and December, 2020., Results: 31 girls were pre-menarchal. Pain was the most common symptom. There were significant differences in the volume of the ovary visualized in ultrasound in amenorrheic and menstruating girls [median (IQR) 78234 (39600, 183600) mm3 vs 243432 (158661, 388800) mm3; P=0.004]. Pain was the most common symptom. Over the years, there was an increase in laparoscopic procedures, and efforts to preserve the ovary after the torsion., Conclusions: The differential diagnosis in the case of abdominal pain should include adnexal torsion both in non-menstruating and menstruating girls.

Competing Interests: Competing interests: None declared.

A 4-year-old, neutered male, mixed breed Old English sheepdog was presented for evaluation and treatment of anorexia, vomiting, and diarrhea. Presumptive severe pancreatitis was diagnosed based on the referral bloodwork. Abdominal ultrasonography identified a suspected liver lobe torsion based on the presence of a normal spleen. However, an exploratory laparotomy identified a splenic torsion in addition to a grossly normal spleen. Key clinical message: This case demonstrates that a second, potentially large area of splenic tissue (ectopic or accessory) can be present in the dog; therefore, the presence of a normal appearing spleen on abdominal ultrasonography does not rule out splenic torsion., (Copyright and/or publishing rights held by the Canadian Veterinary Medical Association.)

Objectives: We performed a meta-analysis of studies examining the computed tomography (CT) features of adnexal torsion (AT)., Methods: We searched PubMed, Embase, Web of Science, and the Cochrane Library for studies involving the proportion of CT features in patients with AT and that used surgery as the reference test. Study quality was assessed using the Newcastle-Ottawa scale and the Agency for Healthcare Research and Quality tool., Results: Twelve articles involving 483 patients were included. The pooled proportion of right-sided adnexal lesion was 54% (95% confidence interval [CI]: 49%-56%). The pooled proportions of the ovarian lesion histopathological types were: benign germ cell tumors, 33% (95% CI: 28%-37%); benign cystic lesions, 26% (95% CI: 21%-30%); benign epithelial neoplasms, 24% (95% CI: 20%-29%); sex cord-stromal tumors, 4% (95% CI: 2%-6%); borderline neoplasms, 3% (95% CI: 1%-6%); and hemorrhagic cysts, 2% (95% CI: 0%-3%). The pooled proportions of CT features were: Adnexal enlargement, 99% (95% CI: 98%-99%); adnexal with mass, 98% (95% CI: 97%-100%); twisted pedicle, 81% (95% CI: 78%-83%); mass with thickened wall, 77% (95% CI: 73%-81%); tubal thickening, 73% (95% CI: 68%-77%); abnormal location of adnexa, 69% (95% CI: 63%-75%), pelvic ascites, 43% (95% CI: 38%-49%); pelvic fat infiltration, 41% (95% CI: 34%-48%); uterine deviation, 37% (95% CI: 31%-42%); and lack of enhancement, 20% (95% CI: 14%-25%)., Conclusion: Adnexal enlargement, adnexal mass, and twisted pedicle may be the most important CT features for diagnosing AT., Competing Interests: Declaration of Competing Interest The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article., (Copyright © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Background: Pulmonary torsion is a rare complication following thoracic surgery., Case Presentation: A man in his seventies was diagnosed with stage IIIA lung cancer occupying the right upper lobe, and lobectomy was performed through posterolateral thoracotomy. Postoperative chest X-rays revealed extensive, progressive middle lobe opacities on postoperative day 0 and 1, with no corresponding clinical or bronchoscopic findings. Contrast-enhanced computed tomography raised suspicion of middle lobe torsion, and exploratory surgery confirmed the finding of a necrotic middle lobe with 180 degrees of torsion. The middle lobe was resected and the patient recovered well., Interpretation: Pulmonary lobar torsion is a rare but potentially life-threatening complication following thoracic surgery that should not be overlooked even in the absence of symptoms that raise concern. Bronchoscopy and radiological imaging may suggest the condition, but the final diagnosis is made surgically.

Abnormal torsion of the lower limbs may adversely affect joint health. This study developed and validated a deep learning-based method for automatic measurement of femoral and tibial torsion on MRI. Axial T2-weighted sequences acquired of the hips, knees, and ankles of 93 patients (mean age, 13 ± 5 years; 52 males) were included and allocated to training (n = 60), validation (n = 9), and test sets (n = 24). A U-net convolutional neural network was trained to segment both femur and tibia, identify osseous anatomic landmarks, define pertinent reference lines, and quantify femoral and tibial torsion. Manual measurements by two radiologists provided the reference standard. Inter-reader comparisons were performed using repeated-measures ANOVA, Pearson's r, and the intraclass correlation coefficient (ICC). Mean Sørensen-Dice coefficients for segmentation accuracy ranged between 0.89 and 0.93 and erroneous segmentations were scarce. Ranges of torsion as measured by both readers and the algorithm on the same axial image were 15.8°-18.0° (femur) and 33.9°-35.2° (tibia). Correlation coefficients (ranges, .968 ≤ r ≤ .984 [femur]; .867 ≤ r ≤ .904 [tibia]) and ICCs (ranges, .963 ≤ ICC ≤ .974 [femur]; .867 ≤ ICC ≤ .894 [tibia]) indicated excellent inter-reader agreement. Algorithm-based analysis was faster than manual analysis (7 vs 207 vs 230 s, p < .001). In conclusion, fully automatic measurement of torsional alignment is accurate, reliable, and sufficiently fast for clinical workflows., (© 2021. The Author(s).)

This report describes a rare case of isolated fallopian tube torsion (IFTT) in a premenarchal 11-year-old girl. The patient presented with subacute abdominal pain, associated with nausea and vomiting. Sonographic findings revealed left tube enlargement with free intraperitoneal fluid. Doppler mapping was not unequivocal. During exploratory laparoscopy, a large pelvic necrotic mass was found to be a twisted left fallopian tube. After detorsion, salpingectomy was performed and the patient recovered promptly, showing no complications 3 months post operation. IFTT should be considered as a differential diagnosis of lower abdominal pain in adolescent girls with normal-appearing ovaries on ultrasound. Conservative management for fertility preservation is the ideal approach. Therefore, avoiding delay in laparoscopy is crucial., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

BACKGROUND Ovarian torsion is a rare surgical emergency in premenarchal girls. Early diagnosis and surgical detorsion are required to restore blood flow and limit tissue damage. CASE REPORT Here, we present a case of ovarian torsion and appendicitis in an 11-year-old premenarchal girl who presented to our emergency room with a 4-day history of right iliac fossa pain, limping, and fever. Upon initial evaluation in our hospital, her vital signs were stable and clinical examination revealed abdominal guarding and right lower quadrant rebound tenderness with positive Rovsing's sign. Abdominal ultrasound and computed tomography scans showed adnexal cysts and torsion, an inflamed appendix, and free fluid in the abdomen. Intraoperative findings included a twisted gangrenous ovary and an edematous appendix. The patient underwent emergency laparoscopic oophorectomy and appendectomy. CONCLUSIONS This case demonstrates that reactive appendicitis can occur secondary to inflammation of adjacent structures such as the ovary.

Background: Gait deviation and associated torsional problems are common in patients with cerebral palsy (CP). Although femoral anteversion in CP has been extensively reviewed in previous studies, only a few studies have focused on tibial torsion. Therefore, this study aimed to evaluate tibial torsion in patients with CP and investigate the affecting factors., Methods: Consecutive patients with cerebral palsy who underwent 3-dimensional computed tomography for the assessment of rotational profiles were reviewed. Femoral anteversion and tibial torsion were measured, and the demographic characteristics of the patients were recorded. A linear mixed model was implemented to overcome the retrospective nature of the study., Results: After the implementation of inclusion and exclusion criteria, 472 patients were enrolled for this study. With age, external tibial torsion increased, while femoral anteversion decreased. The factors affecting external tibial torsion were increased femoral anteversion (p = 0.0057), increased age (p < 0.0001), higher Gross Motor Function Classification System (GMFCS) level (p < 0.0001), and involved/uninvolved limbs of hemiplegia (p = 0.0471/p = 0.0047)., Conclusions: Older age, GMFCS level IV/V, hemiplegia, and increased femoral anteversion were the independent risk factors of increased external tibial torsion; therefore, performing an imaging study is recommended for assessing the extent of tibial torsion in patients with such characteristics., (© 2021. The Author(s).)

Paratubal cysts are fluid-filled sacs that grow adjacent to the fallopian tube which can rarely result in torsion. Isolated fallopian tube torsion (IFTT) is a gynaecological emergency that warrants urgent laparoscopic detorsion to salvage the affected tube. IFTT has a proclivity to affect adolescents between the ages of 12 and 15 years and is rarely seen in premenarchal or perimenopausal women. Due to a lack of pathognomonical features, IFTT is difficult to diagnose. Adnexal torsion, including IFTT is a surgical diagnosis and no clinical or imaging criteria is sufficient to diagnose IFTT. Urgent laparoscopy and detorsion are required for preservation of the affected fallopian tube. However, given the diagnostic ambiguity, IFTT diagnosis is often delayed. IFTT should be included in the differential diagnoses for adolescent patients with acute abdomen when imaging demonstrates a normal appendix and ovaries. We report a 15-year-old girl with a 4-day history of abdominopelvic pain and bilateral paratubal cysts resulting in right IFTT., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Rubinstein-Taybi syndrome is an extremely rare autosomal dominant genetic disorder that occurs in 1/125,000 and is characterized by distinctive facial appearance, short stature, mild to severe mental retardation, and higher risk for cancer. In addition, variable organ anomalies had been reported. Paraovarian cyst causing torsion of the ipsilateral fallopian tube is less common, with an estimated incidence of 1/1,500,000, but it can adversely affect tubal function. It occurs mainly in women in the reproductive age and is very rare in prepubescent girls. Here, we described the successful treatment of an extremely rare case of paraovarian cyst causing torsion of the ipsilateral fallopian tube in a patient with Rubinstein-Taybi syndrome. A 14-year-old girl with Rubinstein-Taybi syndrome was referred to our hospital for abdominal pain. Her medical history was unremarkable, except for moderate hirsutism and keloid scar. Physical examination revealed tenderness in the lower abdominal midline. The preoperative diagnosis was torsion of a left ovarian cyst. An exploratory laparoscopy was performed because of acute abdominal pain and revealed a left fallopian tube that was twisted twice due to an ipsilateral paraovarian cyst. The huge paraovarian cyst required laparotomy cystectomy, and the left ovary was preserved. Her postoperative course was uncomplicated. Preoperative diagnosis of paraovarian cysts can be difficult. The moderate hirsutism seen in our patient suggested the presence of a large paraovarian cyst due to androgen receptor-mediated effects. Therefore, Rubinstein-Taybi syndrome patients with hirsutism should be screened and assessed by pediatric surgeons for the presence of paraovarian cysts.

Background: Wandering spleen is a rare clinical entity with a less than 0.2% reporting incidence rate. In this case, the spleen is present abnormally in the abdominal or pelvic cavity instead of its normal anatomical location. The aetiology is either congenital or acquired. The condition is caused by the absence or maldevelopment of the spleen's suspensory ligaments, which holds the spleen static in the left hypochondrium., Case Presentation: A 27-year-old female patient presented to the emergency department with complaints of abdominal pain, fever, nausea, vomiting, and constipation for three days. A palpable movable mass was found during the physical examination, and torsion of the wandering spleen's pedicle was confirmed by CT scan. Open splenectomy was performed, and the patient was recovered uneventfully., Conclusion: Even though ectopic spleen is a rare disease, clinicians should be aware of its incidence. Early diagnosis in the case of an acute abdomen is vital for the preservation of the spleen. Patients presented with acute abdomen and absence of splenic shadow under left hemidiaphragm should be suspected, and further radiological investigation will confirm the diagnosis. Surgery is the gold standard for wandering spleen with either splenopexy or splenectomy, depending on the spleen's condition during surgery.

Gastroschisis is an uncommon congenital defect of the abdominal wall resulting in intestinal prolapse, most commonly associated with short gut syndrome or bowel obstruction. Wandering spleen, movement of the spleen due to the underdevelopment of splenic ligaments, has a prevalence of 0.25% and is asymptomatic in 15% of paediatric cases. An 11-year-old patient, admitted with a history of gastroschisis repaired at birth, presents with 18 months of intermittent, worsening abdominal pain. Imaging demonstrated splenomegaly and tortuosity of the splenic vein with abnormal positioning of the superior mesenteric artery and vein. The patient was found to have a wandering spleen with subacute splenic infarct secondary to splenic torsion, necessitating emergent surgical intervention. This patient experienced an extremely rare complication of gastroschisis that has not previously been reported. This complication is caused by a lack of appropriate abdominal fixation points for the spleen., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Individualized pre-operative assessment of the patterns of the lower extremity anatomy and deformities in patients undergoing total knee arthroplasty seems essential for a successful surgery. In the present study, we investigated the relationship among the coronal alignment and the rotational profile of the lower extremities in the Caucasian population with end-stage knee osteoarthritis. We conducted a prospective study of 385 knees that underwent a pre-operative three-dimensional computed tomography-based model. The lower extremity alignment was determined (mechanical tibiofemoral or hip-knee-ankle angle, supplementary angle of the femoral lateral distal angle, and proximal medial tibial angle). For each case, the femoral distal rotation (condylar twist angle), the femoral proximal version, and the tibial torsion were determined. As the coronal alignment changed from varus to valgus, the femoral external rotation increased (r = 0.217; p < 0.0005). As the coronal alignment changed from varus to valgus, the external tibial torsion increased (r = 0.248; p < 0.0005). No correlation was found between the global coronal alignment and the femoral version. The present study demonstrates a linear relationship between the coronal alignment and the rotational geometry of the distal femur. This correlation also occurs with the tibial torsion. Perhaps outcomes of total knee arthroplasty surgery might be improved by addressing these deformities as well.

Adnexal torsion is the twisting of the ovary, and often of the fallopian tube, on its ligamental supports, resulting in vascular compromise and ovarian infarction. The definitive management is surgical detorsion, and prompt diagnosis facilitates preservation of the ovary, which is particularly important because this condition predominantly affects premenopausal women. The majority of patients present with severe acute pain, vomiting, and a surgical abdomen, and the diagnosis is often made clinically with corroborative US. However, the symptoms of adnexal torsion can be variable and nonspecific, making an early diagnosis challenging unless this condition is clinically suspected. When adnexal torsion is not clinically suspected, CT or MRI may be performed. Imaging has an important role in identifying adnexal torsion and accelerating definitive treatment, particularly in cases in which the diagnosis is not an early consideration. Several imaging features are characteristic of adnexal torsion and can be seen to varying degrees across different modalities: a massive, edematous ovary migrated to the midline; peripherally displaced ovarian follicles resembling a string of pearls; a benign ovarian lesion acting as a lead mass; surrounding inflammatory change or free fluid; and the uterus pulled toward the side of the affected ovary. Hemorrhage and absence of internal flow or enhancement are suggestive of ovarian infarction. Pertinent conditions to consider in the differential diagnosis are a ruptured hemorrhagic ovarian cyst, massive ovarian edema, ovarian hyperstimulation, and a degenerating leiomyoma. Online supplemental material is available for this article. © RSNA, 2021.

Pelvic adnexal torsion is a collective term referring to twisting of an ovary, fallopian tube, or paraovarian cyst on its axis with varying degrees of vascular compromise. Although it is the fifth most common gynecologic emergency, the diagnosis is challenging and often missed due to symptoms, physical examination findings, and imaging features that are nonspecific. Delay in salvage surgery may lead to ovarian or tubal loss, dysfunction, and infertility. The tips shared herein are based on the authors' observations of key clinical and imaging features of torsion, with the intent of heightening radiologists' index of suspicion and diagnostic accuracy in a clear and memorable fashion. Clinically, severe acute pain with a known adnexal mass or of severity to elicit nausea or vomiting should raise concern. At imaging, features of ovarian edema are key to the diagnosis, including asymmetric ovarian enlargement, peripheralized follicles, adjacent free fluid, and foci of stromal hemorrhage. The converse finding of symmetric nonenlarged ovaries in a normal location with any imaging modality has a high negative predictive value for torsion, obviating the need for additional imaging. The whirlpool sign (twisted vascular pedicle), abnormal ovarian location, and uterine tilting are additional key imaging manifestations. The presence of color Doppler flow or contrast enhancement only suggests that an ovary is still viable and should not be used to exclude the diagnosis of torsion. In cases of isolated tubal or paraovarian cyst torsion, the ovaries may appear normal; therefore, recognition of this entity along with appreciation of several key imaging findings may assist with this difficult diagnosis. An invited commentary by Dighe is available online. Online supplemental material is available for this article . © RSNA, 2021.

A 7-year-old girl presented with a 2-day history of right iliac fossa pain, fever and elevated inflammatory markers. Clinical examination supported a diagnosis of appendicitis. The patient was taken to theatre for an open appendicectomy the following morning. Intraoperatively, a right-sided ovarian haemorrhagic cyst with 360 degrees torsion was discovered. The ovary was torted along with the cyst. Both were detorted and the abdomen was closed. The patient was discharged 48 hours later, with gynaecology outpatient follow-up 6-8 weeks later. Paediatric ovarian torsions caused by a haemorrhagic cyst greater than 2 cm are rare. Here, we discuss an atypical presentation of ovarian torsion and how the clinical presentation can mimic appendicitis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

A 68-year-old man visited a physician with a chief complaint of difficulty breathing. Right pleural effusion was noted, and he was referred to our department for a close examination and treatment. Thoracoscopy was performed under local anesthesia, and pleural dissemination of lung adenocarcinoma was noted, so a chest drain was placed. Since poor right lung inflation persisted and whole right lung torsion was observed on computed tomography, thoracoscopy-assisted thoracotomic reduction of lung torsion was performed. In this patient, the right middle lobe and anterior chest wall were adhered, suggesting that whole right lung torsion occurred when atelectasis was formed due to pleural effusion.

This case highlights a 37-year-old woman with primary sclerosing cholangitis awaiting liver transplantation who presented with torsion of a wandering spleen with associated gastric and pancreatic volvulus. The patient underwent emergent exploratory laparotomy with splenectomy. She had an uncomplicated postoperative course and recovered well., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

A 39-year-old multiparous Afro-Caribbean woman attended the emergency department with sudden-onset severe right iliac fossa pain. Her inflammatory markers were mildly elevated. Computerised tomography of the abdomen demonstrated features of fat stranding in the right iliac fossa suspicious of acute appendicitis. The scan also noted uterine leiomyomas. The patient was taken to theatre for an emergency diagnostic laparoscopy where her appendix was found to be macroscopically normal. A necrotic heavily calcified parasitic leiomyoma was seen in the right adnexa, free of the uterus and adherent to the greater omentum on a long torted pedicle. The parasitic leiomyoma was successfully removed piecemeal laparoscopically. Complications of leiomyomas, namely, torsion and necrosis, are important differentials in women presenting with sudden-onset lower abdominal pain. A history of sudden-onset severe lower abdominal pain with a background of known leiomyoma should prompt the clerking surgeon to consider a complication of leiomyoma as part of the differential diagnoses., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Ovarian torsion is a gynecological surgical emergency whose diagnosis remains a challenge. Torsion occurs most frequently in women of reproductive age. It is usually associated with the presence of benign masses in the ovary, as malignant tumors are less frequent and less prone to undergo torsion., Case Presentation: We report the case of a 17-year-old Caucasian patient who presented to the emergency department with lower abdominal pain. Ultrasonography evaluation revealed a unilateral ovarian lesion, 11.2 cm, with features suspicious for malignancy and torsion. The patient was referred for surgical torsion treatment and underwent unilateral salpingo-oophorectomy. The pathology report confirmed a serous borderline ovarian tumor with torsion., Conclusions: Malignant ovarian torsion in pediatric age groups is rare. Ultrasound examination should be recognized as a powerful tool for diagnosis and management, especially when performed by an experienced ultrasonographer.

Hepatic lobe torsion is a rare condition in domestic animals. Clinical signs are variable, with some cases remaining subclinical and others resulting in death. Most cases are diagnosed either by laparotomy or during postmortem examination. During postmortem inspection of 670 slaughtered dromedary camels, hepatic lobe torsion of the quadrate lobe was detected in 3 adult female camels. Clinical signs had not been noted on antemortem veterinary inspection, and hepatic lobe torsion was likely an incidental finding. Histologically, the affected liver lobe exhibited severe hepatocellular loss with replacement by fibrous connective tissue. When investigating abdominal pain in camels, veterinarians should include hepatic lobe torsion in the list of differential diagnoses.

Purpose: The purpose of this study was to assess the performance of magnetic resonance imaging (MRI) in children and adolescents with suspected adnexal torsion (AT) after inconclusive initial ultrasound examination., Materials and Methods: Twenty-eight girls with a mean age of 12±4 (SD) years (range: 1 month to 18years) were included. All had clinically suspected AT and inconclusive initial ultrasound findings followed by pelvic MRI as a second-line imaging modality. The final diagnosis was obtained by surgery or follow-up. Two radiologists blinded to the clinical, ultrasound and surgical data, retrospectively and independently reviewed MRI examinations. Clinical and MRI features associated with AT were searched for using univariate analyses., Result: Among the 28 patients, 10/28 patients (36%) had AT and 22/28 (79%) had an ovarian or tubal mass. AT was associated with an age<13years (OR: 10.7; 95% CI: 1.3-148.2) (P=0.022) and a whirlpool sign at MRI (OR: 61.0; median unbiased estimate, 7.2) (P<0.0001). When a mass was present, the best quantitative MRI criteria for AT were mass volume and ovary-corrected volume≥30cm 3 (κ=0.72 and 0.61, respectively), mass axis length≥5cm (κ=0.90), and mass surface area≥14 cm 2 (κ=0.58), with moderate to almost perfect interobserver agreement. The overall sensitivity, specificity and accuracy of MRI for the diagnosis of AT were 100% (10/10; 95% CI: 69-100), 94% (17/18; 95% CI: 73-100) and 96% (27/28; 95% CI: 82-100) respectively, with perfect interobserver agreement (κ=1)., Conclusion: In pediatric patients with suspected AT and inconclusive initial ultrasound examination, a strategy including MRI as a second-line imaging modality should be considered if MRI does not delay a potential surgery., (Copyright © 2020 Société française de radiologie. Published by Elsevier Masson SAS. All rights reserved.)

A 23-year-old female presents with right lower quadrant pain that has been intermittent for the past several days. The pain suddenly worsened 1 hour ago. She denies vaginal bleeding or discharge, dysuria, fever, and back pain, but she has had several episodes of nausea with nonbloody, nonbilious vomiting. On examination, she is tender in the right lower quadrant, but her abdomen is not rigid.

A 61-year-old male patient presented to our hospital's emergency department with a history of worsening abdominal pain. The symptoms began as epigastric pain and later localized to the right lower quadrant. On physical examination, there was rebound tenderness mainly in the right lower quadrant and in the right upper quadrant. The laboratory results showed leukocytosis. Abdominopelvic computed tomography scan revealed that a definite twisting on the long axis with three complete counter-clockwise turns was observed in the vascular structures of greater omentum. At operation, the greater omentum was found to be twisted and gangrenous. The infarcted omentum was ligated at the pedicle and excised. Primary torsion of the omentum is one of the uncommon causes of acute abdominal pain. Although rarely diagnosed, the entity is important to the surgeon because it mimics the common causes of the acute surgical abdomen. Omental torsion usually occurs on the right side. Abdominal pain starts suddenly after a heavy meal or hard exercise, and is not accompanied with nausea, vomiting and anorexia. Abdominal computed tomography may show peculiar features suggestive of omental torsion. Treatment consists of ligation and resection of the involved portion of the omentum and recovery is usually rapid, uneventful and complete. Primary omental torsion should be considered in the differential diagnosis of acute abdomen. The surgeon must remain aware of the disease and search for it if, at laparotomy, other adequate cause is not found to explain the symptoms, especially if free sero-sanguineous fluid is found in the peritoneal cavity. KEY WORDS: Acute abdomen, Greater omentum, Omental torsion, Omental infarction, Omental necrosis.

Background: Abdominal pain is one of the most common complaints by patients in the emergency department. Diarrhea, constipation, and urinary tract infection are the commonest etiologies among these patients, but there are surgical emergencies, such as appendicitis and volvulus of the intestine, which are less common. Torsion of the ovary is rarer than all of the above conditions. Ovarian torsion occurs following the twisting of the ovary on its ligamentous attachment, possibly with a cyst, leading to the impediment of blood flow. Prompt diagnosis with a high clinical suspicion is essential to salvage the ovaries and to prevent complications, including death., Case Presentation: Here, we present a case of ovarian torsion in a 2-year-old Sri Lankan girl who presented with nonspecific abdominal symptoms after being symptomatically treated twice by her general practitioners for 3 days. Following biochemical and radiological investigations, she was diagnosed with a twisted necrotic ovarian torsion and underwent laparoscopic right-sided oophorectomy., Conclusions: Finding the etiology of a child with abdominal pain is challenging, especially because of the limited history, examination findings, the difficulty in carrying out radiological investigations, and the poor specificity of the results compared with adults. This is a case presentation and a brief discussion about the dilemmas and difficulties in the diagnosis and treatment of ovarian torsion in young children.

Background: Isolated fallopian tube torsion associated with hydrosalpinx is a rare condition in the pediatric population. We present this unusual clinical case study in a sexually inactive girl., Case Presentation: a12-year-old Caucasian girl presented symptoms of acute abdominal pain. Pelvic ultrasound revealed a normal looking uterus and ovaries and next to left ovary a imaging compatible with hydrosalpinx. She was discharged 48 hours later after clinical monitoring with oral analgesia and normal blood workup. At 3 weeks, she was readmitted for acute abdominal pain. Leukocytosis with left shift and raised C-reactive protein were observed. Her clinical condition worsened, and complication of the preexisting hydrosalpinx was suspected. Exploratory laparoscopy confirmed torsion of the fallopian tube. Left salpingectomy was performed. Histopathologic study confirmed a fallopian tube with hemorrhagic infarct., Conclusion: Torsion of the fallopian tube must be considered in the event of acute abdominal pain. Early diagnosis and trying conservative management with a view to preserving fertility in this group of patients are essential.

Rationale: Wandering spleen (WS) is a rare clinical entity characterized by splenic hypermobility caused by absent or abnormal laxity of the suspensory ligaments, which fix the spleen in its normal position. Due to abnormal attachment, the spleen is predisposed to torsion and a series of complications. Pediatric WS is mostly reported in children aged <10 years, especially among infants aged <1 year; it is uncommon among toddlers between 1 and 3 years. To the authors' knowledge, only seven cases of WS have been described previously. Herein, we present the case of a 3-year-old toddler with WS and splenic torsion., Patient Concerns: A 3-year-old boy was presented to the pediatric emergency room with a 2-day history of abdominal pain and vomiting. The ultrasonographic examination revealed a mass in the left upper abdomen cavity and absence of spleen in its normal position. Computed tomography showed an enlarged displaced spleen occupying the left abdomen cavity with an elongated splenic vascular pedicle (whirl sign), suggesting splenic torsion., Diagnoses: The patient was diagnosed that had WS and splenomegaly, with or without complications due to splenic torsion., Interventions: The patient underwent emergency laparotomy and splenectomy due to nonviability after detorsion., Outcomes: The postoperative course was uneventful, and the patient was discharged on the 7th day postoperatively without complications. The patient had favorable outcome over a 1-year follow-up., Lessons: Herein, we reported the case of a toddler with WS with splenic torsion. Moreover, after reviewing relevant studies in literature, we presented our findings on the diagnosis and treatment of toddlers with WS. Toddlers with WS are characterized by acute abdominal pain, unclear history description, examination restrictions, and high rates of life-threatening complications. High level of suspicion, careful physical examination, detailed history collection, and objective investigation are crucial in the management of toddlers with WS.

BACKGROUND Wandering spleen is a rare condition in which the spleen lacks the usual peritoneal attachments, resulting in increased intra-abdominal mobility. Complications can occur due to the torsion of the splenic vascular pedicle, resulting in symptoms ranging from an incidental finding to an acute abdomen as a result of an ischemic necrosis of the spleen. CASE REPORT We present the case of a 25-year-old female patient who presented with a recurring abdominal pain associated with serum lipase and C-reactive protein elevation. The computed tomography scan revealed torsion of the splenic pedicle and hypoperfusion of the spleen. A surgical exploration was performed and a wandering spleen was diagnosed perioperatively. It was characterized by the lack of peritoneal ligaments, thus resulting in a splenic volvulus. A splenectomy was carried out due to the definite ischemic necrosis of the spleen. CONCLUSIONS The diagnosis of this rare condition can be very challenging since it can be presented with a vast variety of symptoms, mimicking other abdominal pathologies. The intermittent nature of an ultimate splenic torsion can add to the diagnostic challenge. Medical literature concerning the wandering spleen and knowledge about this pathology originates mainly from individual case reports. Despite the evolving diagnostic modalities available, this rare and ambiguous disorder remains misdiagnosed, and a high index of suspicion is needed for the appropriate diagnosis to be established.

Background: Isolated fallopian tube torsion is a very rare cause of acute abdominal pain in women and, as can be expected, its being bilateral is an extremely rare condition. It is more common in women in reproductive age compared to other age groups. Symptoms, physical examination, imaging and laboratory findings being nonspecific makes it difficult to establish the correct diagnosis and often the diagnosis can be made during surgery. Despite being a very rare condition in general, it is important in terms of preservation of tube and thus the fertility especially in women of reproductive age with early diagnosis and treatment. Therefore, keeping in mind the fallopian tube torsion among the differential diagnoses in women presenting with acute abdominal pain will contribute to early diagnosis and treatment., Case Presentation: A 38-year-old white Arabian woman, gravida 1, parity 0, abort 1, sought medical advice in our outpatient clinic with a complaint of lower abdominal pain that had started 2 days earlier. The pain had first started as mild cramps, which then suddenly intensified nearly 2 hours before her presentation to our clinic, spread to the groin and femur, more prominent on the right side, and became an ongoing pain. As preoperative diagnoses of the patient, ovarian cyst rupture and ectopic pregnancy were suspected, and fallopian tube torsion was also suspected due to the normal appearance of the ovaries and the appearance of the hydrosalpinx on ultrasonography. The patient underwent laparotomy with a Pfannenstiel incision. Both tubes had hydrosalpinx, and the fimbrial ends were blunt and obliterated. Bilateral salpingectomy was performed because the right tube had a prominent necrotic appearance, and there was a significant hydrosalpinx in both tubes., Conclusion: Bilateral fallopian tube torsion should be considered among the differential diagnoses in women presenting with acute pelvic pain.