Howship-Romberg sign
Description
Pain and paraesthesia along the inner (medial) aspect of the thigh, down to the knee; and pain on internal rotation of the hip along the distribution of the obturator nerve. Caused by compression of the obturator nerve most commonly associated with entrapment of the small bowel in the obturator canal which may lead to ileus, incarceration, and strangulation of the hernia sac.
John Howship (1781 – 1841) was the first to describe the clinical syndrome (1840) whilst Moritz Heinrich Romberg (1795 – 1873) reported on the diagnostic criteria and explained the pathophysiology of an incarcerated obturator hernia in 1847.
Small studies have observed that the Howship-Romberg sign was identified in 15% – 50% of cases of obturator hernia. Sign found to occur more frequently in patients where the hernia affected the anterior branch of the obturator nerve (innervating pectineus, adductor brevis/longus and gracilis)
History
1840 – Howship published a case entitled ‘Strangulated Thyroidal Hernia – Diagnostic Symptom – Appearances on Dissection‘ in 1840. He describes then case of an aged and emaciated female under the care of Mr. Weatherfield.
In November 1838 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, diarrhoea…March 23, 1839 Mr. W. found her again suffering under extreme pain and tenderness in the abdomen, especially in the left side, with constant vomiting, preceded by diarrhoea, and attended with the same pain as before, down the left leg. The symptoms, those of strangulated hernia, Mr. W. made a careful inquiry and examination but could nowhere ascertain outward tumour.
Howship 1840: 323
Postmortem examination revealed:
…a portion of small intestine was seen stretched towards the obturator foramen, where a knuckle was firmly impacted, forming a small hernia, no larger than a nutmeg, protruding through the opening. The intestine, highly inflamed, was almost gangrenous. The parts were carefully removed and admirably dissected; demonstrating the hernia to the best advantage
Howship 1840: 324
1847 – Romberg described his findings of an obturator hernia and their clinical significance (published in 1848)
Original
English
Was diesem Falle ein besonderes Interesse verleiht, ist nicht seine Seltenheit, sondern die Aufklärung der Diagnose durch ein Nervenphänomen. Druck und Zerrung des Nervus obturatorius muss bei jeder Hernia obturatoria stattfinden, und, wenn der Inhalt des Bruches eine Darmsclilinge ist, werden sich mit den Symptomen der Darmeinklemmung die Symptome der Nerveneinklemmung verbinden. Sowohl die sensibeln Fasern des N. obturatorius, welche sich als Hautnerven an der inneren Seite des Oberschenkels verbreiten, als auch die für den Muse, gracilis und die Adductoren des Schenkels bestimmten motorischen Fasern werden diese Störung kundgeben durch mehr, oder minder lebhaften Schmerz an der inneren Seite des Oberschenkels, durch Gefühl von Erstarrung und Formication, durch Unfähigkeit, den Schenkel anzuziehen. In einigen älteren Beobachtungen finden wir eme Erwähnung dieses Schmerzes als Begleiters des vorhandenen Ileus, ohne dass ihm jedoch diagnostischer Werth beigelegt wird.
Romberg 1847: 624
What gives this case a special interest is not that it is rare, but elucidating the diagnosis by its neurologic phenomenon. Pressure and distortion of the obturator nerve must be found in every obturator hernia, and if the content of the hernia is a bowel disease, symptoms of nerve entrapment will be associated with the symptoms of intestinal entrapment. Both the sensory fibers of the obturator nerve, which spread as cutaneous nerves on the inner side of the thigh, as well as the motor-fibers, destined for the muscles gracilis and adductors of the thigh, will manifest this disorder by more or less severe pain located in the inner side of the thigh, stiff with paresthesia, and the inability to adduct the thigh.. In some older observations we find a mention of this pain as a companion to the existing ileus, but without adding diagnostic value to it.
Romberg 1847: 624
Romberg summarised the diagnostic criteria for obturator hernia thus:
Original
English
Für die Hernia obturatoria ist ein diagnostisches Kriterium, wie es der Verein der Schmerzen und der gestörten Beweglichkeit des Oberschenkels mit der unterbrochenen Permeabilität des Darmcanals darbietet, um so bedeutungsvoller, weil dieser Bruch nur allmälig, gleichsam chronisch entsteht, selten eine von aussen sichtbare Geschwulst bildet, und, wie kein anderer Bruch, temporären, wiederholten Incarcerationen ausgesetzt ist.
Romberg 1847: 625
Obturator hernia is associated with pain; disturbed movement of the thigh; and altered intestinal movement. Most important, because this condition is chronic it rarely forms a tumor visible from the outside, and is subjected to temporary, repeated incarceration.
Romberg 1847: 625
Associated Persons
- John Howship (1781 – 1841)
- Moritz Heinrich Romberg (1795-1873)
References
- Howship J. Strangulated Thyroideal Hernia-Diagnostic Symptom Appearances on Dissection. In: Practical Remarks on the Discrimination and Appearance of Surgical Disease. 1840: 323-4
- Romberg MH. Die Operation des eingeklemmten Bruches des eirunden Loches. Operatio hernia foraminis ovales incarceratae. In: Die operative Chirurgie. Dieffenbach JF 1848: 619-626
- Bjork KJ, Mucha P Jr, Cahill DR. Obturator hernia. Surg Gynecol Obstet. 1988; 167(3): 217-22.
- Rizk TA, Deshmukh N. Obturator hernia: a difficult diagnosis. South Med J. 1990; 83(6): 709-12.
- Yamashita K, Hayashi J, Tsunoda T. Howship-Romberg sign caused by an obturator granuloma. Am J Surg. 2004; 187(6): 775-6.
- Mantoo SK, Mak K, Tan TJ. Obturator hernia: diagnosis and treatment in the modern era. Singapore Med J. 2009 Sep;50(9):866-70.
- Rastogi V et al. Abdominal Physical Signs and Medical Eponyms: Movements and Compression. Clin Med Res. 2018; 16(3-4): 76-82.
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