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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.

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BACKGROUND: Abnormal angular and torsional alignment of the lower extremities during growth are a common reason for consultation of a paediatrician or orthopaedist. There is often uncertainty about the pathological value of these abnormalities and the need for treatment, even among specialists. In the course of physiological growth and development processes, the axial and torsional alignment of the legs sometimes change considerably and in characteristic patterns. DIAGNOSTICS: The ability to assess whether abnormal angular or torsional alignments of the lower limb in the course of growth should still be regarded as normal or already as pathological, depending on age and gender, is essential for the treating physician and requires precise knowledge of the physiological development processes and the tolerable limits in all three spatial dimensions. TREATMENT: After careful explanation to the frequently concerned parents, a restrictive approach with observation of the spontaneous course of correction on the basis of regular clinical check-ups makes sense in the majority of cases. Pathological deviations from the physiological conditions are rare overall, can be idiopathic or of secondary origin and should be further clarified diagnostically using imaging procedures. As conservative measures are ineffective, pronounced angular and/or torsional deformities of the legs requiring treatment can only be corrected by surgical intervention, even in children and adolescents. The surgical treatment modalities available are varied and differ in terms of their invasiveness and complication profile, depending on the localization, type and severity of the deformity, as well as the age and possible concomitant diseases of the affected child or adolescent.

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Importance: Ovarian torsion is a gynecological emergency caused by the twisting of the ovary and/or fallopian tube, further resulting in ischemic changes of the adnexa. Early diagnosis is likely to preserve ovarian function. Objective: The purpose of this review is to review the current findings of ovarian torsion including clinical presentations, diagnostic criteria, surgical procedures, and prognosis. Evidence Acquisition: The literature search is mainly available in PubMed and Web of Science platforms by searching "ovarian torsion" combined with one or several terms including "diagnosis" "risk factors" "surgery" and "torsion recurrence." Results: Abdominal pain, nausea, and vomiting were normal clinical presentations. In order to increase the accuracy of diagnosis, it is necessary to integrate clinical presentation and the findings of imaging and laboratory examinations. Computed tomography findings, plasma d-dimer level, and the time from pain onset play a critical role in distinguishing ovarian necrosis. The efficiency of oophoropexy on preventing recurrent ovarian torsion is controversial. Conclusion: Most patients with early diagnosis of ovarian torsion may have a better prognosis with conservative surgery. Relevance: Better understanding of ovarian torsion is critical for gynecologists to promote accuracy of diagnosis and select the optimal surgical procedure.

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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.

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In this case report, we present an unusual clockwise torsion of left colon around mesenteric root in a 10-month-old Arab filly, highlighting the clinical presentation, diagnostic approach and successful surgical intervention. A 10-month-old Arab filly weighing approximately 250 kg was referred with signs of acute abdominal pain. The history revealed anorexia, restlessness and severe abdominal pain that had begun the previous day. The local practitioner had previously administered flunixin meglumine, an analgesic, but it proved ineffective in relieving the pain. Upon physical examination, the filly exhibited sweating, a body temperature of 38.5°C, tachycardia (65 beats per minute) and tachypnea (25 breaths per minute). Due to the severity of the colic and the lack of response to the conservative treatments, surgical intervention was deemed necessary. An exploratory midline celiotomy was performed to evaluate the abdominal organs. During the examination, no obvious primary lesions were identified in the evaluated organs. However, a restriction in exteriorizing the left colon's length was observed. Further examination revealed an unusual clockwise torsion of the left colon that displaced in left to the right side around the mesenteric root; thereby, pelvic flexure was located in the normal anatomical position with a short length. To the best of our knowledge, this is the first reported case of clockwise torsion and an atypical displacement of the left colon in horses. The surgical correction of the displacement was successfully performed. The filly showed improvement post-surgery and did not exhibit any complications during the recovery period.

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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.

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Torsion is the twisting of an object along the axis, and various structures (organs and tumors) in the body can twist. Torsion causes initial lymphatic and venous outflow obstruction, leading to congestive edema, enlargement, venous hemorrhagic infarction, and surrounding edema. It can also cause subsequent arterial obstruction depending on the degree of torsion, leading to ischemia, infarction, necrosis, gangrene, and surrounding inflammation. Therefore, in several cases of torsion, immediate surgical intervention is required to improve blood flow and prevent serious complications. Clinical manifestations of torsion are often nonspecific and can affect individuals of varying ages and sex. Imaging plays an important role in the early diagnosis and management of torsion. Multiple imaging modalities, including US, radiography, CT, and MRI, are used to evaluate torsion, and each modality has its specific characteristics. The imaging findings reflect the pathophysiologic mechanism: a twisted pedicle (whirlpool sign), enlargement of the torsed structures, reduced blood flow, internal heterogeneity, and surrounding reactive changes. The whirlpool sign is a definitive characteristic of torsion. In some cases, despite poor internal enhancement, capsular enhancement is observed on contrast-enhanced CT and MR images and is considered to be associated with preserved capsular arterial flow or capsular neovascularization due to inflammation. Radiologists should be familiar with the pathophysiologic mechanisms, clinical characteristics, and imaging characteristics of torsion in various structures in the body. Since other articles about common organ torsions already exist, the authors of this article focus on the uncommon entities that manifest with torsion. ©RSNA, 2024.

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We aim to explore the alterations of objective ocular torsion after unilateral lateral rectus recession-medial rectus resection (R&R) for intermittent exotropia (IXT). Seventy-two IXT patients undergoing R&R between March and June 2023 were enrolled. Ophthalmological examinations were performed before surgery and at 1 week and 1 month after surgery, mainly including prism and alternate cover test and optical coherence tomography. The mean disc-foveal angle of eyes showing intorsion significantly increased from - 1.5 ± 0.9° preoperatively to 2.0 ± 2.0° at 1 week (P = 0.0227) and 2.2 ± 1.6° at 1 month postoperatively (P = 0.0054). The mean disc-foveal angle of eyes exhibiting extorsion significantly reduced from 12.8 ± 1.9° preoperatively to 9.8 ± 3.1° at 1 week (P < 0.0001) and 9.7 ± 2.7° at 1 month postoperatively (P < 0.0001). The improvement of ocular extorsion at postoperative 1 month was more pronounced in patients with extorsion in operative eye compared to those with extorsion in inoperative eye (P = 0.0101). The improvement of ocular torsion was observed following R&R for IXT, with a greater effect noted in cases where the surgery was performed on the eye exhibiting extorsion.

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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.

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Torsional disorders of the lower limb are common in childhood, and they are one of the primary reasons parents seek consultation with healthcare providers. While clinical manoeuvres can assess femoral and tibial torsion, their reliability is medium to low. Various imaging-based techniques, including computed tomography, magnetic resonance imaging, fluoroscopy, biplanar radiology and ultrasonography, have been used to evaluate torsional alterations of the lower extremity. Among these, ultrasound assessment offers certain advantages: it is a low-cost, non-irradiating technique, which allows the follow-up of children's torsional development. However, to the best of the authors' knowledge, its validity and reliability have not been summarised in a systematic review. This study aims to analyse the validity and reliability of ultrasonography in determining femoral and tibial torsion in children and adolescents. A search from Medline (via PubMed), Web of Science, Scopus and CINAHL databases were performed from inception to 16 March 2023. No restrictions were placed on the publication year or language. The methodological quality of all eligible studies was independently reviewed by two authors using QUADAS and STARD checklists. Overall, 1546 articles were identified through the searches; 30 were considered eligible for full-text screening; and 8 studies were finally included in this review. The included studies were conducted in Germany, Norway and the UK. Among them, 7 studies analysed the validity of ultrasonography compared with other imaging techniques such as computed tomography, magnetic resonance imaging and biplanar X-ray, and 4 studies assessed intra- and inter-observer reliability. All the studies assessed femoral torsion, but only one of them also included tibial torsion.     Conclusion: Ultrasound is a good alternative for routine evaluation and follow-up of femoral torsional alterations in children and adolescents due to its safety, accessibility and immediate results in the clinical examination room. Although ultrasound has good accuracy and reliability for routine evaluations, there is controversy about whether it is sufficient for surgical planning. In cases where greater accuracy is required, magnetic resonance imaging and biplanar radiography are the preferred imaging techniques. What is Known: • Several imaging-based techniques have been described for the assessment of torsional alterations of the lower extremity. • Computed tomography, magnetic resonance imaging, biplanar radiology and ultrasonography are the most used and studied methods. What is New: • Ultrasonography represents a good alternative for the assessment of femoral and tibial torsional alterations in children and adolescents, given its safety, accessibility and immediacy of results in the consultation room. • Its accuracy and reliability are good but not sufficient for surgical planning, in which case MRI and biplanar X-ray will be the preferred choices.

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ABSTRACT: Gallbladder torsion is a rare cause of acute surgical abdomen. Early recognition and surgical intervention are important for reducing complications and improving postoperative patient outcomes, but standard imaging and laboratory evaluation typically are indistinguishable from those of acute cholecystitis. This article describes a patient with gangrenous cholecystitis secondary to torsion and summarizes recommendations for evaluation and management.

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BACKGROUND Persistent truncus arteriosus is a rare congenital cyanotic heart defect characterized by a single ventricular outflow tract. Without surgical intervention, it has a poor prognosis in infancy. Here, we report an adult female patient with uncorrected truncus arteriosus type I, who presented with acute-onset abdominal pain due to torsion of a small bowel gastrointestinal stromal tumor (GIST). CASE REPORT A 41-year-old woman came to our Emergency Department with acute-onset lower abdominal pain for 2 days. Congenital heart disease, truncus arteriosus, had been diagnosed at birth, and there had been no surgical intervention. Abdominal computed tomography revealed a 10×9×12-cm mixed-density mass in the pelvic capacity. Transthoracic echocardiography revealed a 33-mm ventricular septal defect. The ascending aorta originated mainly from the right ventricle, and the pulmonary artery originated from the beginning of the aorta (type I truncus arteriosus, according to Collett and Edwards classification). After a quick and detailed preoperative workup, the patient underwent tumor resection by open surgery with general anesthesia. CONCLUSIONS This is the first case to report emergency surgery for a patient with uncorrected persistent truncus arteriosus due to torsion of a small bowel GIST. A multidisciplinary team with deep understanding of the disease entity was crucial. By considering the fixed hemodynamic and respiratory physiology, overtreatment and unrealistic goals were avoided. Eventually, the patient was discharged after being hospitalized for 2 weeks.

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We report four cases of isolated fallopian tube torsion (IFTT) successfully treated with laparoscopic surgery over the past 10 years. Two young women (each 19 years old) were IFTT with paraovarian cyst (POC) and tubal preservation was possible with detorsion and cystectomy. The other two patients (a 41-year-old woman with hydrosalpinx and a 50-year-old woman with hematosalpinx) underwent salpingectomy and adnexectomy, respectively, because there was no desire for tubal preservation. One patient had emergency surgery due to severe abdominal pain, one had semi-emergency surgery due to mild abdominal pain, and the other two were diagnosed during scheduled surgery without symptoms.Although IFTT was considered a very rare disease, our case series and recent reports suggest that it may have been underestimated, as it accounts for approximately 10% of adnexal torsion cases. Preoperative diagnosis of IFTT may be more difficult than for adnexal torsion because of its infrequency and nonspecific, vague clinical symptoms.　Since the prevalent age for this disease is young, as in our first 2 patients, early surgical intervention to preserve the fallopian tubes should be chosen when necessary, and it seems to be important for gynecologists to be aware of this disease for earlier diagnosis and appropriate surgical intervention.

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PURPOSE: The purpose of this study was to investigate whether double-level (femur + tibia) derotational osteotomy is superior to single-level femoral derotational osteotomy for recurrent patellar dislocation with severe femoral and tibial rotational deformities (femoral anteversion >30° and external tibial torsion >30°). METHODS: Between January 2015 and June 2020, a total of 115 knees with recurrent patellar dislocation treated with combined medial patellofemoral ligament reconstruction (MPFL-R) and derotational osteotomies were evaluated after a minimum follow-up of 2 years. Among these cases, 15 knees that underwent double-level derotational osteotomy were included in the double-level group, which was propensity-matched in a 1:2 ratio to a single-level group of patients who underwent single-level femoral derotational osteotomy (30 knees). The clinical and radiological outcomes were evaluated and compared between the groups. Furthermore, the foot progression angle was measured preoperatively and 2 years after surgery. RESULTS: The patient-specific variables did not differ significantly between the double- and the single-level groups after propensity score matching. The postoperative mean foot progression angle was significantly lower in the double-level group than in the single-level group (9° ± 8° vs. 15° ± 11°; p = 0.014); however, there were no statistically significant differences between the groups in terms of any other clinical and radiological assessments. CONCLUSION: For patients with severe femoral and tibial torsional deformities (femoral anteversion >30° and external tibial torsion >30°), the double-level derotational osteotomy is superior to single-level osteotomy in maintaining normal foot progression angle, but it does not show an advantage in terms of patient-reported outcomes, radiological results and redislocation rate at minimum 2 years of follow-up. Furthermore, concomitant excessive external tibial torsion (>30°) did not have an adverse effect on clinical outcomes in patients who underwent derotational distal femoral osteotomy with MPFL-R due to excessive femoral anteversion. LEVEL OF EVIDENCE: Level III.

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OBJECTIVE: To describe the presentation, diagnosis, and treatment of 4 cases of splenic torsion with associated spherocytosis. ANIMALS: 4 client-owned dogs with spherocytosis and splenic torsion. CLINICAL PRESENTATION: Each dog presented with nonspecific clinical signs, and 3 out of 4 dogs were anemic on presentation. RESULTS: The diagnosis of splenic torsion was made with abdominal ultrasound or CT and confirmed during exploratory laparotomy. Spherocytosis was described as occasional (patient 1), rare (patient 2), and low number (patients 3 and 4). Two dogs survived to hospital discharge, and 2 dogs died following cardiorespiratory arrest. CLINICAL RELEVANCE: Spherocytosis has not previously been reported in cases of splenic torsion, and identification of spherocytes on blood film evaluation warrants further investigation. The cause of spherocytosis in splenic torsion remains unknown but may be associated with microangiopathic fragmentation injury.

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