Premature pubarche refers to the early appearance of pubic hair before 8 years of age in girls and 9 years in boys and is most commonly due to premature adrenarche.Premature adrenarche refers to the early appearance of clinical signs of adrenal androgen action, including pubic or axillary hair, body odour, acne, or mild seborrhoea. It is usually a benign variant of normal development. However, similar features may also reflect central precocious puberty, non-classical congenital adrenal hyperplasia, androgen-secreting tumours or exogenous androgen exposure. Distinguishing premature adrenarche from these conditions helps avoid unnecessary investigations while ensuring timely recognition of clinically significant endocrine pathology. This practical 15-minute consultation guide outlines a structured approach to history taking, examination, initial investigations, differential diagnosis and indications for specialist referral.

Chondromyxoid fibroma (CMF) is a rare benign bone tumor characterized by lobulated growth, chondromyxoid stroma, and GRM1 rearrangement. Here, we describe 3 cases of CMF with limited or no chondromyxoid stroma. The patients (2 males and 1 female) were 14-18 years old and had lesions in the tibial diaphysis, rib, and pubic bone. The tumors measured 24-60 mm, and were central in 2 cases and juxtacortical in 1 case. Treatment included curettage and resection, and the tumors did not recur for 2 to 8 years after surgery. Histologically, all 3 tumors comprised sheets of uniform, non-atypical, ovoid or short spindle cells interspersed with numerous osteoclast-like giant cells. Delicate pericellular eosinophilic matrix was focally deposited in all cases, which showed chicken-wire calcification in 2 cases. Osteoid deposition in a conglomerate pattern was observed in 2 cases. Aneurysmal bone cystic changes were present in all cases. Chondromyxoid stroma was present only in ~ 10% and < 5% of the tumor volume in 2 cases, whereas it was absent in the remaining case. All 3 cases showed diffuse immunohistochemical expression of GRM1, and GRM1 rearrangement was confirmed with fluorescence in situ hybridization. CMF with limited or no chondromyxoid stroma is a rare variant that histologically overlaps with other giant cell-rich tumors. Recognition of this pattern is essential for appropriate clinical management, and the demonstration of GRM1 rearrangement and overexpression provides strong support for this challenging diagnosis.

Assimilation of coccygeal vertebrae with the sacrum can be an obstetrical impediment in humans. This study evaluates homeotic transformation of the thoracic-lumbar (T-L) and lumbar-sacral (L-S) boundaries and position of the diaphragmatic vertebra (DV) as proximate determinants of this assimilation. Sample is 311 females and 791 males, ages 20-49 years, who died in the United States from the 19th to 21st centuries. Results show 33% of females and 42% of males have fusion of coccygeal vertebrae with the sacrum. In both sexes, cranial transformation of the T-L and L-S boundaries is associated with assimilation of coccygeal vertebrae with the sacrum, whereas caudal transformation of these boundaries is associated with inhibition of this assimilation. Males, but not females, also show assimilation of coccygeal vertebrae with the sacrum with cranial transformation of DV, and inhibition of this assimilation with caudal transformation of DV. Females have higher prevalence of caudal transformation of the T-L and L-S boundaries than males (15% and 7%, respectively), and males have higher prevalence of cranial transformation of these boundaries than females (22% and 11%, respectively). Assimilation of coccygeal vertebrae with the sacrum contracts posterior space of the pelvic outlet. Dual contraction of posterior and anterior spaces of the outlet can be obstetrically perilous. High prevalence of assimilation of coccygeal vertebrae with the sacrum contributes to selection for sexual dimorphism of the pubic arch and angulation of the sacrum, with females larger than males.

IntroductionTopical oestradiol gel is now widely used in hormone replacement therapy (HRT), but the risk of inadvertent secondary transfer to children is under-recognised. While accidental exposure to testosterone gels has been documented, oestradiol gel transfer as a cause of precocious puberty in prepubertal girls is rare.We undertook a 20-year literature review and discuss the case of a 5-year-old girl presented with Tanner stage 3 breast development, pubic hair stage 2, growth acceleration and mood changes. Laboratory evaluation revealed markedly elevated oestradiol levels with suppressed gonadotrophins, consistent with peripheral precocious puberty. Bone age was advanced by 4 years 6 months. Imaging, karyotype, endocrine and dermatology investigations excluded central precocious puberty, ovarian or adrenal tumours and McCune-Albright syndrome. History, previously not disclosed, revealed daily co-sleeping with her mother, who had been applying oestradiol gel to her upper arms for 18 months as part of HRT. No other oestrogen sources were identified. Maternal oestradiol gel was discontinued and replaced with a transdermal patch. The child's oestradiol levels normalised and pubertal signs regressed over subsequent months.This review highlights a rare but important cause of peripheral precocious puberty due to unintentional transfer of topical oestradiol gel through routine parent-child contact, including co-sleeping. As topical hormone therapies become increasingly common, clinicians must counsel patients on safe application practices and consider exogenous hormone exposure in children presenting with unexplained pubertal development. Switching caregivers from gel to patch formulations can reverse hormone excess in exposed children.

BACKGROUND: Pelvic insufficiency fractures (PIFs) are a debilitating complication of pelvic radiotherapy (RT) for pelvic cancer in female patients, which could lead to a sharp decline in patients’ quality of life. A 2019 meta-analysis by Lucas Gomes Sapienza reported a PIF rate of 14%, but advancements in RT techniques (IMRT, VMAT, C-ion RT) and new published studies necessitate an updated analysis. This study aimed to re-evaluate PIF incidence, fracture location, and associated factors using recent high-quality evidence. METHODS: A systematic search of PubMed, Web of Science and Cochrane Library (1980–April 2025) with cohort studies for gynecologic/anal/rectal cancers, pelvic insufficiency fractures. Data on PIF incidence, location, and RT methods were extracted. Random-effects models were used to address expected high heterogeneity. Subgroup analyses were explored in detail. RESULTS: The pooled PIF incidence was 17% (95% CI: 15–20%), higher than the prior 14% estimate. Sacral bone/sacroiliac joint involvement dominated (71%), followed by pubic bone (11.6%). Subgroup analyses revealed higher PIF rates with definitive RT (25%) vs. adjuvant RT (6%). Modern RT techniques (IMRT: 8%, 3D-CRT: 11%) reduced PIF risk vs. historical methods (AP/PA: 22%, 4-field: 18%). However, VMAT and C-ion RT showed elevated rates (30%), likely due to higher doses (≥ 55 Gy). Regional difference indicates Europe (23%) > Asia (20%) > USA (9%). MRI detected more PIFs (19%) than other modalities (14%). Low BMI (16%) and menopause (18%) correlated with higher PIF risk. CONCLUSION: The incidence of PIF after pelvic RT has risen in recent years. Sacral regions are highly likely to develop PIF. Modern RT techniques like IMRT are required, along with routine MRI surveillance.

Prune Belly Syndrome (PBS) is a rare congenital disorder characterized by severe abdominal wall muscle deficiency, leading to significant impairment of respiratory, urinary, and gastrointestinal function. Despite numerous reconstructive attempts, no technique has achieved full functional restoration of the anterior abdominal wall. This paper introduces a novel dynamic reconstructive approach using bilateral pedicled musculo-fascial Vastus Lateralis (VL) flaps for functional abdominal wall reconstruction in PBS. Unlike traditional abdominoplasty-based procedures that mainly address cosmetic deformity, this method focuses on restoring true muscle dynamics and physiological function. The technique involves harvesting innervated, vascularized VL flaps from both thighs and transposing them to the anterior abdominal wall through a subcutaneous tunnel while preserving their neurovascular pedicles. The muscles are anchored to the costal arch superiorly and the pubic symphysis inferiorly, effectively recreating the functional vector of the rectus abdominis. This configuration enables dynamic contraction of the abdominal wall and reinstates the ability to generate intra-abdominal pressure required for coughing, defecation, and postural control. Follow-up assessment, including electromyography (EMG) and motor testing, confirmed active muscle contraction and marked improvement in core function. Patients demonstrated restored abdominal wall activity, enhanced motor abilities, and reduced symptoms related to ineffective intra-abdominal pressure, such as constipation and respiratory infections. This study presents the first reproducible surgical solution achieving both anatomical reconstruction and functional reanimation of the abdominal wall in PBS. The described technique offers a transformative step in pediatric reconstructive surgery, combining microsurgical precision with physiological restoration to improve long-term quality of life.

Objective: To evaluate the feasibility of linear cutting stapler-assisted en bloc lateral pelvic resection technique in pelvic exenteration (PE) for patients with locally advanced rectal cancer (LARC) or locally recurrent rectal cancer (LRRC) presenting with significant pelvic tumor mass effect and concurrent pelvic vascular invasion, and to summarize preliminary clinical experience. Methods: Indications for this surgical technique: (1) Preoperative imaging and pathological biopsy confirmed cT4b stage LARC or LRRC. (2) Preoperative contrast-enhanced pelvic MRI, contrast-enhanced pelvic CT, or CT angiography of iliac vessels confirmed significant lateral pelvic tumor invasion with obvious pelvic mass effect; the tumor invaded the lateral pelvic wall but did not penetrate the first layer, and no involvement of the common iliac or external iliac arteries and veins was noted. (3) Concurrent invasion of at least one branch of the anterior trunk, posterior trunk, or main trunk of the internal iliac vessels, requiring en bloc resection with the tumor. Contraindications: (1) Eastern Cooperative Oncology Group (ECOG) performance status score > 1 or Karnofsky Performance Status (KPS) score < 70; (2) Progressive distant metastases (e.g., liver, lung) or confirmed extensive intra-abdominal peritoneal dissemination during intraoperative exploration. Key steps of linear cutting stapler-assisted en bloc lateral pelvic resection: (1) The stapler cartridge and anvil were inserted into the lateral and medial spaces of the internal iliac vascular pedicle, respectively, to selectively divide the anterior trunk of the internal iliac artery alone or the anterior trunks of both internal iliac artery and vein simultaneously. (2) The distal stump was lifted, and blunt dissection was performed caudally along the surface of the lumbosacral trunk, sacral nerves, and piriformis fascia to dissect the loose lateral space of the internal iliac vascular pedicle to the vicinity of the sacral nerve roots. After freeing the lateral space beneath the piriformis fascia, the internal iliac vascular pedicle was en bloc elevated from the surface of the sacral nerves. The stapler cartridge and anvil were then inserted into the space on the surface of the sacral nerves and the medial space of the internal iliac vascular pedicle, respectively, and division was performed adjacent to the sacral bone surface to maximize lateral pelvic tissue resection. (3) The Marcille triangle approach (bounded by the lateral border of the L5 vertebra, the medial border of the iliopsoas muscle, and the cephalad aspect of the sacral promontory) was adopted. Dissection was performed distally along the common iliac vessels or proximally along the external iliac vessels to free and expose the roots of the common iliac, external iliac, and internal iliac vessels as well as their deep anatomical planes, along with the obturator nerve and lumbosacral trunk. (4) The root of the internal iliac artery was transected, and the common iliac vein and external iliac vein were suspended separately. The linear cutting stapler was inserted through the Marcille triangle to divide the root of the common iliac vein. (5) The internal pudendal vessels and inferior gluteal vessels were transected using the linear cutting stapler on the surface of the sacral nerves and piriformis muscle, medial to the ischial spine. If the pelvic floor muscles were elevated by incising the tendinous arch of the levator ani muscle, the linear cutting stapler could simultaneously divide the levator ani muscle, the lateral aspect of the levator ani muscle, and the recurrent internal pudendal vessels passing through the lesser sciatic foramen if necessary. Results: Between January 2023 and December 2024, 13 patients with LARC or LRRC and significant pelvic tumor mass effect underwent PE with linear cutting stapler-assisted en bloc lateral pelvic resection in the Department of Anorectal Surgery, The Second Affiliated Hospital of Naval Medical University (Shanghai Changzheng Hospital). Among them, 10 were diagnosed with LARC and 3 with LRRC. The ratio of tumor diameter to pelvic diameter was 91.1% in the transverse plane (line connecting the bilateral ischial spines) and 90.9% in the sagittal plane (line connecting the L5-S1 interspace and the pubic bone). The mean time for lateral pelvic tumor resection was 49 (31-80) minutes, and the intraoperative blood loss was 900 (300-2 000) ml. The number of stapler cartridges used was (3.1±1.6), with a staple height of 1.5 (1.0-1.5) mm. R0 resection was achieved in 12 patients, and 6 patients developed severe complications of Clavien-Dindo classification ≥ grade III during the perioperative period. Conclusion: For LARC or LRRC patients with significant pelvic tumor mass effect and invasion of major lateral pelvic vessels, the application of linear cutting stapler-assisted en bloc lateral pelvic resection during PE may help shorten the operation time, reduce intraoperative blood loss, and decrease pelvic-related complications.

An adductor strain or injury to the adductor muscle group is a common cause of medial leg and groin pain, especially among athletes. The adductor complex includes the 3 adductor muscles (magnus, longus, and brevis), of which the adductor longus is most commonly injured. All 3 muscles primarily provide adduction of the thigh. The adductor longus also provides some medial rotation. In open-chain movement, the adductor magnus primarily adducts the hip, while in closed-chain movement, it helps stabilize the pelvis and lower extremity during the stance phase of gait (see Image. Medial Compartment of the Thigh). Because the adductor magnus attaches to the ischial tuberosity, the muscle also contributes to hip extension. The adductor muscle complex: Adductor Magnus: Origin: Inferior pubic ramus, ischial tuberosity. Insertion: Linea aspera, adductor tubercle. Adductor Longus: Origin: Anterior pubic ramus. Insertion: Linea aspera. Adductor Brevis: Origin: Inferior pubic ramus. Insertion: Linea aspera, pectineal line. The adductor complex is supported by 3 additional muscles that contribute to hip adduction: Gracilis: Also assists with internal rotation and hip flexion. Origin: Inferior pubic symphysis, pubic arch. Insertion: Proximal medial tibia, pes anserine. Obturator Externus: Contributes to external rotation. Origin: Obturator foramen. Insertion: Posterior aspect of the greater trochanter. Pectineus: Aids in hip flexion. Origin: Pectineal line of the pubis. Insertion: Pectineal line of the femur. The obturator nerve (L2 to L4), arising from the lumbar plexus, innervates most of the adductor musculature. The adductor magnus is also innervated by the tibial nerve (L4 through S3), and the pectineus is often innervated by the femoral nerve (L2 to L3).