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Ultrasound Diagnosis and Surgical Management of Symptomatic Muscle Herniations of the Extremities: A Retrospective Review

Sunday, October 21, 2012: 9:45 AM
Melrose (Hilton Riverside)
Dennis E. Kramer, MD, Delma Jarrett, James L. Pace, Mininder S Kocher and Lyle J Micheli, Orthopaedic Surgery, Childrens Hospital Boston, Boston, MA

Purpose

Muscle hernias are activity related protrusions of muscle through a defect in the overlying fascia.  Many are seen in association with chronic exertional compartment syndrome (CECS).  Some patients with muscle herniations experience significant pain that interferes with athletic activities.  There is a paucity of published literature on their diagnosis and surgical management.  Most of the reported cases are in males between ages 18-40.  We present a retrospective case series of younger patients with symptomatic muscle hernias treated surgically with fasciotomy. 

Methods

Over a ten year period all patients who underwent surgical management for a symptomatic muscle herniation at our institution were identified.  Retrospective chart review recorded patient demographics, history of trauma or prior surgery, primary sport played, compartment involved, preoperative symptoms and workup, surgical procedure, ability to return to sport and complications.  Questionnaires were mailed to all patients with questions assessing satisfaction with surgery, ability to return to sports and residual symptoms.  

Results

32 patients (24 females, 8 males -13 runners) mean age 19.4 (14.2 – 31.7) underwent fasciotomies for symptomatic muscle herniation.  Our series is unusual in that most patients were women (75%) and were aged 18 or under (18 of 32 – 56.2%) at the time of surgery.  17 patients had underlying CECS (53%).  Eight patients had known trauma, 9 prior surgery and 13 no obvious cause of the herniation.  Tibialis anterior was the most common location. Mean time from symptom onset to diagnosis was 11.5 months (1.2-38.1) and mean time from diagnosis to surgery was 16.2 months (2.6-38.7).  17 patients saw another orthopaedist prior to diagnosis and 6 patients saw a non-orthopaedic consulting physician prior to diagnosis.  MRI identified the hernia in 3 of 23 cases while dynamic ultrasound made the diagnosis in 5 of 5 cases.  Fasciotomy was done through the site of muscle herniation and in compartments with CECS.  There were 6 neurolyses done. At mean follow up of 25.8 months (range 0.4-126.6), 18/27 patients (66.7%) had returned to sports, 9 patients (28.1%) noted the presence of pain.  Of the 15 patients (43%) who completed the Return to Sports questionnaire, 11 (73.3%%) were satisfied and 7 patients reported residual symptoms.  Two patients required re-release of the muscle hernia a third required repeat fasciotomy for CECS.

Conclusions

Muscle herniations may be more common than reported.  Adolescent females and runners have a higher incidence. Many patients have underlying CECS.  Dynamic ultrasonography provides an effective and efficient way to supplement the diagnosis.  MRI is unneccesary and rarely identifies muscle hernia.  Minimally invasive fasciotomy through the site of muscle herniation provides a safe and effective surgical option which allows the majority of patients to return to sports.  Residual symptoms are common.