Introduction and importance A Littre's hernia (LH) is defined by the presence of Meckel's diverticulum (MD) in any kind of hernia sac. Preoperative diagnosis of LH is a challenge because of its rarity and the absence of specific radiological findings and clinical presentation. Surgery is the appropriate treatment of complicated LH that is an extremely rare condition with approximately 50 cases reported in the literature over the past 300 years. Case presentation A 46-year-old Caucasian female was admitted to the Emergency Department with a two-day history of abdominal pain. Physical examination revealed an irreducible and painfull mass in umbilical region. Abdominal computed tomography scan showed the protrusion of greater omentum and small bowel loop through the umbilical ring. Laboratory tests were unremarkable. After diagnosis of strangulated umbilical hernia, the patient underwent exploratory laparotomy: the irreducible umbilical hernial sac was opened with presence of incarcerated and strangulated omentum and uncomplicated MD. Resection of incarcerated and ischemic greater omentum alone was performed. The postoperative course of patient was uneventful. Clinical discussion Meckel's diverticulum (MD) is a vestigial remnant of the omphalomesenteric duct, representing the most common congenital malformation of the gastrointestinal tract. Preoperative diagnosis of LH is very difficult and surgery represents the correct treatment of complicated LH. Conclusion LH represents an extremely rare complication of MD difficult to diagnose and suspect because of the lack of specific radiological findings and clinical presentation. Surgery represents the appropriate treatment of abdominal wall hernias and complicated MD.
We report on three Italian children who presented with unilateral ankle tuberculosis (TB) consecutively during a short time period and in the same geographical area. A 6-year-old-girl with a family history of TB had limited mobility of the right leg at age 9 months; Mantoux test and radiographs at that age yielded normal findings. When severe right tibiotarsal swelling, reddening, pain and restriction of motion became apparent at age 4.6 years, the typical lesions of TB were evident on radiographs and computed tomographic (CT) scans. Mantoux test and synovial biopsy confirmed TB. A three-drug regimen of treatment proved useless: articular cartilage destruction and diffuse osteosclerosis ensued. Only a four-drug prolonged regimen of treatment proved to be somewhat effective. A 5-year-old girl had a 6-month history of painless swelling and limited mobility of the ankle; radiographs and CT showed osteopenia with marginal erosion of cartilages. A 14-month-old boy presented with a 2-week history of painless swelling ankle. Radiographs showed decreased bone density of talocalcanear bones. Mantoux test and synovial biopsy confirmed TB in both patients; treatment with a three-drug regimen greatly reduced symptoms. A careful suspicion of the diagnosis of tuberculosis is paramount in children with chronic or subacute monoarticular arthritis, even in absence of a positive tuberculin test or abnormalities on chest radiograph. When negative early on, the tuberculin test should be repeated after 6 weeks of arthritis, and a needle biopsy of the synovium is required in those children with monoarticular arthritis and a positive tuberculin test. Careful therapy is necessary to avoid sequelae that may lead to severe osteoarticular damage.
Introduction and importance Left-sided acute appendicitis (LSAA) is a very rare cause of acute abdomen, developing in association with two types of congenital anomalies like as situs viscerum inversus (SVI) and midgut malrotation (MM). Preoperative diagnosis of LSAA is a challenge because of its rarity and atypical presentation. Imaging may be helpful for determining the correct diagnosis. Surgery represents the standard treatment of LSAA. Case presentation A 67-year-old Caucasian male with presented to the Emergency Department with a two-day history of left lower quadrant (LLQ) abdominal pain, nausea, vomiting, diarrhea and fever. Physical examination revealed LLQ abdominal rebound tenderness with guarding. Laboratory tests reported high levels of C-reactive protein and neutrophilic leukocytosis. Abdominal contrast-enhanced computed tomography showed a LSAA with intraluminal appendicoliths, fat infiltration and pericecal fluid collection in a patient with SVI. The patient underwent laparoscopic appendectomy: a gangrenous and perforated appendicitis was sectioned and removed with drainage of pericecal abscess. The postoperative course of the patient was uneventful. Clinical discussion LSAA is characterized by anatomical variation of appendix and atypical presentation. Preoperative clinical diagnosis of LSAA is very difficult and imaging may be helpful for determining the correct diagnosis, as well as confirming SVIT or MM. Laparoscopic appendectomy represents the correct treatment of LSAA. Conclusion LSAA is a rare surgical emergency that should be considered in the differential diagnosis of patients with LLQ abdominal pain. Preoperative diagnosis of LSAA needs a high index of suspicion and is facilitated by imaging. Surgery represents the appropriate treatment of LSAA.
BACKGROUND Monteggia fractures are uncommon injuries in paediatric age. Treatment algorithms assert that length-unstable fractures are treated with plate fixation. In this case report, intramedullary fixation of an acute length-unstable Monteggia fracture allowed a stable reduction to be achieved, along with an appropriate ulnar length and alignment as well as radio capitellar reduction despite the fact that the orthopaedic surgeon did not use a plate for the ulnar fracture. The scope of treatment is to avoid the use of a plate that causes periosteal stripping and blood circulation disruption around the fracture. CASE SUMMARY A four-year-old girl presented at the Emergency Department following an accidental fall off a chair onto the right forearm. The X-ray highlighted a length-unstable acute Bado type 1 Monteggia fracture of the right forearm. On the same day, the patient underwent surgical treatment of the Monteggia fracture. The surgeon preferred not to use a plate to avoid a delay in fracture healing and to allow the micromotion necessary for callus formation. The operation comprised percutaneous fixation with an elastic intramedullary K-wire of the ulnar fracture and, subsequently, humeroradial joint reduction through manual manipulation. The orthopaedic surgeon assessed the stability of the radial head reduction under fluoroscopic control through flexion, extension, pronation and supination of the forearm. Healing of the fracture occurred within six weeks after surgery, as indicated by the presence of calluses on at least three cortices on standard radiographs. Dislocation/subluxation or loss of ulnar reduction was not apparent at the final X-ray examination. CONCLUSION Intramedullary fixation of unstable Monteggia fractures results in excellent outcomes, provides reliable reduction and causes fewer complications.
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