Role of the signs of obturator hernia in clinical practice
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LETTER TO THE EDITOR
Role of the signs of obturator hernia in clinical practice S. H. Yale1 · H. Tekiner2 · E. S. Yale3 Received: 26 August 2020 / Accepted: 1 September 2020 © Springer-Verlag France SAS, part of Springer Nature 2020
Schizas et al.’s systematic review of obturator hernias (OH) highlights key aspects of this rare disease [1]. In their report of 74 studies representing 146 total patients, 13 were case series (85 patients) and 61 (61 patients) were case reports. The Howship–Romberg sign was performed in only 64 (44%) patients, positive in 52% (22 of 42 patients) in the case series and 64% (14 of 22 patients) in the case reports [1]. In these studies, the method of performing the sign was not uniformly reported or accurately described, with the Hannington–Kiff sign, another bedside test, not included in this review. The Howship–Romberg sign was named in honor of John Howship (1781–1841) and Moritz Heinrich Romberg (1795–1873). Howship was the first to report this clinical syndrome, “She was seized with violent spasmodic pain in the left side of the abdomen running down the left leg with sickness, vomiting, and, as she said diarrhea (p. 324).” [2]. Romberg described the pathophysiologic features of this hernia: Pressure and distortion of the obturator nerve may be found in every obturator hernia and if the content of the hernia is bowel, symptoms of nerve entrapment is associated with the intestinal entrapment. Both the sensory fiber of the obturator nerve, which spread as cutaneous nerves on the inner side of the thigh as well as motor-fibers, destined for the gracilis and adductor muscles of the thigh, confirm this disorder by the presence of severe pain located in the inner thigh, paresthesias, and the inability to adduct the thigh (p. 624–625) [3]. * S. H. Yale [email protected] 1
John G Hannington–Kiff described a method for diagnosing a strangulated OH: A firm blow from a patellar hammer over the thumb or index finger laid at right angles across the adductor muscle about 5 cm above the medial epicondyle of the femur. In this way any contraction of the adductor muscle can be felt as well as seen, and the patient will be saved some discomfort from the blow of the hammer (p. 180) [4]. Hannington–Kiff sign, an objective method for diagnosing OH, is believed to be more sensitive and specific compared to the Howship–Romberg sign which may be explained by the different routes that the hernia takes as it enters the obturator canal following either the anterior or posterior portion branch of the obturator nerve [5]. The sign was found to be more commonly present in patients where the hernia follows the anterior compared to the posterior branch [5]. Schizas et al.’s review highlights limitations when assessing the literature regarding these signs [1]. The Howship–Romberg sign was performed in only 30 of the 74 (41%) studies included in their paper. We recommend that future case reports and series report the method of performing the signs using the techniques originally described by the origin
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