Howship-Romberg Sign is Characteristic of Obturator Hernia
The Howship-Romberg sign is pathognomonic of obturator hernia (answer choice c). This sign is present in approximately 37% of patients with obturator hernia and represents pain radiating from the inner thigh to the knee due to compression of the obturator nerve 1.
Clinical Characteristics of Obturator Hernia
Obturator hernia is a rare type of hernia with specific features:
- Accounts for less than 1% of all abdominal wall hernias 2
- Occurs predominantly in elderly, thin women (often called "the little old lady's hernia") 3
- Characterized by protrusion of intra-abdominal contents (usually small bowel) through the obturator foramen 2
- Most common presenting symptoms include:
The Howship-Romberg Sign
The Howship-Romberg sign is considered pathognomonic (specifically characteristic) of obturator hernia, though it is only present in about 37% of cases 1. This sign manifests as:
- Pain along the medial aspect of the thigh
- Pain referred to the knee
- Caused by compression of the obturator nerve as it passes through the obturator canal 2
This sign can be misleading when confused with symptoms of gonarthrosis or lumbar vertebral disc pathology 3.
Diagnostic Challenges
Obturator hernia presents significant diagnostic challenges:
- Often diagnosed late due to non-specific symptoms 4
- Clinical diagnosis is made preoperatively in only 3% of cases without imaging 1
- CT scan provides the most accurate preoperative diagnosis (27% of cases) 1
- High morbidity (30%) and mortality (10%) rates due to delayed diagnosis 1
Management Considerations
Early surgical intervention is critical for obturator hernia:
- Patients with suggestive signs and symptoms (especially in "skinny old lady") should undergo immediate operative intervention 1
- CT imaging is recommended but should not delay surgery if clinical suspicion is high 1
- Surgical approaches include both open and laparoscopic techniques 3
- Small bowel resection is required in approximately 47% of cases due to strangulation 1
Clinical Pearls
- Consider obturator hernia in elderly, thin women presenting with intestinal obstruction without previous abdominal surgery 5
- The classic triad of obturator hernia includes intestinal obstruction, pain along the medial thigh, and a palpable mass in the obturator region (though rarely all present) 2
- Patients with a preoperative CT diagnosis have lower rates of postoperative complications 1
- No recurrences have been reported after proper surgical repair 1
Remember that while the Howship-Romberg sign is characteristic of obturator hernia, its absence does not rule out the diagnosis, as it is present in only about one-third of cases.