2. INTRODUCTION
Have you ever heard of Myositis Ossificans? Do you
know of anyone who has this condition?
In this presentation we are going to inform you on this
condition by telling you what it is, the risk factors
involved, the different types, signs and symptoms,
how to prevent a person from getting it, how to
diagnose a patient, and the proper management
needed to help the patient relieve his/her symptoms
and prevent further injury.
3. WHAT IS MYOSITIS OSSIFICANS
Myositis ossificans and heterotopic ossifican are often used
interchangeably to describe the formation of bone in atypical
location of the body.
Myositis ossificans is an unusual condition that often occurs in
people who sustain a blunt injury that causes damage to the
sheath that surrounds a bone (periostium) as well as to the
muscle and deep tissue. The soft-tissues that were injured in the
traumatic event initially develops a hematoma, and subsequently
develop the myositis ossificans. The word myositis ossificans
means that bone forms within the muscle, and this occurs at the
site of the hematoma. The bone will grow 2 to 4 weeks after the
injury and be mature bone within 3 to 6 months. No one knows
exactly why this occurs in some people.
Myositis ossificans can occur in any collagenous supportive tissue
of skeletal muscles, tendons, ligaments, and fascia.
4. RISK FACTORS OF MYOSITIS OSSIFICANS
Serious traumatic injury
Previous history of ossificans
Hypertrophic osteoarthritis
Ankylosing spondylitis
Diffuse idiopathic skeletal hyperostosis
Men at higher risk
Paget’s disease
Rheumatoid arthritis
Posttraumatic arthritis
Neural axis
Thermal injuries
Osteonecrosis
Multiple surgeries in a short period of
time
Burn injuries
Not applying cold therapy and
compression immediately after the
injury.
Having intensive physiotherapy or
massage too soon after the injury.
Returning too soon to training after
exercise.
8. HOW DO YOU DIAGNOSE MYOSITIS
OSSIFICANS?
Radiography
Bone scanning
Ultrasounography
CT Scan
Disadvantages:
Radiographs cannot detect mineralization during the first 1-2
weeks after the inciting trauma or onset of symptoms.
Radiography nor CT scanning should be performed in the pelvic
region during pregnancy
10. MANAGEMENT
Acute Phase: first 1 to 2 weeks
Inflammatory Phase: 2 to 6 weeks
Fibrotic Phase: 6 to 12 weeks
Recovery Phase: 3 to 6 months
Surgery
11. REFERENCES
Goodman, Catherine Cavallaro., and Kenda S. Fuller. "Chapter 27: Soft Tissue,
Joint, and Bone Disorders." Pathology: Implications for the Physical Therapist. 3rd
ed. St. Louis, MO: Saunders/Elsevier, 2009. Print.
"Heterotopic Ossification: EMedicine Radiology." EMedicine - Medical Reference.
Web. 18 Nov. 2010. <http://emedicine.medscape.com/article/390416-overview>.
Kisner, Carolyn, and Lynn Allen. Colby. "Myositis Ossificans." Therapeutic Exercise:
Foundations and Techniques. Philadelphia: F.A. Davis, 2007. 574. Print.
"Myositis Ossificans." The Virtual Sports Injury Clinic - Sports Injuries, Symptoms,
Diagnosis and Treatment. Web. 17 Nov. 2010.
<http://www.sportsinjuryclinic.net/cybertherapist/front/frontthigh/myositis.htm>.
Nims, By. "Myositis Ossificans." HubPages. Web. 17 Nov. 2010.
<http://hubpages.com/hub/Myositis-Ossificans>.
All pictures from www.google.com
Hinweis der Redaktion
Myositis ossificans progressiva is rare and can be genetic. It usually occurs between the ages of 5 and 10 years (younger than age 20) and proceeds relentlessly to progressive ossification of skeletal muscles. It is often present in the shoulders and neck as firm subcutaneous masses, which can be hot and tender and can undergo ossification. Often associated are microdactyly of the great toes and thumbs, ankylosis of the interphalangeal and metatarsophalangeal joints, and bilateral hallux valgus. Minor trauma often causes exacerbations.
Treatment may include diphosphonate combined with surgery for severe joint malpositioning and functional impairment.
Myositis ossificans paralytica occurs in proximal paralyzed muscles. The ossification occurs 1 to 10 months after a spinal cord injury. This process causes decreased passive range of motion. The three classic sites are in the vastus medialis, the quadratus femoris, and the hip abductors. Surgical treatment is indicated only if the position and function of the extremity are unacceptable and when the ossification has matured. After excision, the dead space created must be drained by closed suction and the wound carefully observed for a hematoma.
Myositis ossificans circumscripta can be idiopathic but is more commonly caused by focal trauma and is common as a sports injury in the contact setting. It is more common in teenage or young adult males. It presents as an uncomfortable, indistinct mass that shows local induration and a local increase of temperature. The lesion occurs 80% of the time in the arm (biceps brachialis) but also occurs in the thigh (abductors and quadratus femoris). Roentgenograms show fluffy calcification 2 to 4 weeks after injury. In 14 weeks, the calcification has matured, and in 5 months, ossification has occurred. The differential diagnosis includes osteosarcoma and periosteal osteogenic sarcoma. Treatment is by excision, only if the lesion is unusually large or painful and after ossification is mature.
Myositis ossificans traumatica, the most common type of hetertopic ossification presents the same way as the circumscripta type except for a clear history of trauma, with ossification of a single muscle group in the traumatized area . Treatment is controversial but generally is aimed at the prevention of ossification by immediate application of cold and compression to the area of muscle injury. Later, heat is applied. An operation is indicated only when the ossification causes permanent impairment and only after the process has stabilized, often as soon as 6 to 8 months after injury. The precise pathophysiology of myositis ossificans is not known.
Preventive treatment should be designed to stop the sequence of osteogenesis. Pharmacologic treatment is generally prophylactic and has historically included bisphosphonates to inhibit hydroxyapatite crystallization, mithramycin to interfere with mobilization of calcium, and cortisone to decrease bone formation at the site of injury. None of these drugs, however, has proved to be an extremely beneficial therapeutic agent. Indomethacin and Naprosyn have been shown to help minimize posttraumatic heterotopic ossification associated with acetabular fractures and arthroplasty . Similarly, low-dose irradiation with 800 to 1,000 rad has been shown to be very effective at preventing heterotopic ossification .
When surgical treatment is indicated, traditional teaching has been to wait until the ossification is mature that is, when the bone scan is negative and the alkaline phosphatase level is decreasing. Many authors have recently advocated earlier resection before these tests have returned to normal.
Pain and loss of motion are the most common presenting symptoms, often within 2 weeks of the precipitating trauma, surgery, burn, or neurologic insult.
Swelling, warmth, erythema and tenderness mimic a low grade infection or in the case of surgery, the normal postoperative inflammation that is often present.
The hallmark sign of Heterotopic ossificans is a progressive loss of joint motion at a time when posttraumatic inflammation should be resolving
As Myositis ossificans advances, the acute symptoms described may subside, but motion continues to decrease, even with intervention such as dynamic and/or static progressive splinting
Over the next 3 to 6 months, the ossificans matures and the person develops a rigid or abrupt end feel with pain at the end range of motion. Delayed nerve palsy is common when the elbow is affected.
Areas of calcification and bone spurs may progress to ankylosis.
Sites affected most often include the hip, elbow, knee, shoulder, and temporomandibular joints.
Prevention is recommended for people at high risk of ectopic ossifications, including those with neurologic injury, burns, past history of heterotopic ossificans, and/or previous history of other conditions previously mentioned.
Diphosphonates help prevent heterotopic ossificans but the effect lasts only as long as drug is taken. Gastrointestinal disturbance and osteomalacia are adverse side effects of this treatment making it less then optimal.
NSAIDs are effective in reducing the frequency and magnitude of ectopic bone formation in some areas. You would use this during the first 3 weeks post-operatively
Low-dose external beam radiation is another effective preventive measure. It is effective in preventing heterotopic ossificans from developing when delivered within 72 hours after surgery.
The best prevention is to avoid soft tissue trauma, especially among high risk people undergoing surgery of any kind. Complete wound lavage and the removal of all bone debris and reaming may help prevent it, also.
The preferred method of initial assessment is Radiography. Radiographic evidence with mineralization may be observed 4 to 6 weeks after trauma and sometimes as early as 2 weeks after the incident event. The X-rays show both the location, extent, and maturity of pathologic bone.
Bone scanning is the method of choice for the earliest detection, and once the diagnosis is established, its used for assessing the maturity for a known lesion.
Ultrasounography may also be used for a screening tool in the hip and elbow region
CT Scan may be best to show the exact location and involvement of the articular surfaces.
Bottom Left is a picture of a Right Thigh, front and lateral view. The arrows are pointing to the site of ossificans.
Top Right is a picture of the pelivis. The white arrows in the picture is again, pointing to the site of ossificans.
The bottom right is a picture of a persons anterior hip. The arrow is pointing to the evidence of mineralization.
Treatment
During the acute phase, first 1 to 2 weeks, proper measures are taken to reduce swelling and provide pain management to allow for maximum participation in the program. Cold packs or ice massage is used during this phase along with bandages to help relieve pain and swelling. Range of motion exercises passive or active can begin but must take into account the type and extent of injury present.
During inflammatory phase, 2 to 6 weeks unorganized scar tissues form during this phase but remains soft and deformable so the ROM gains can be made. The soft tissues still respond to various modalities, such as US and E-stim, and self-passive stretching with weighted stretches and/or dynamic or static progressive splinting is most likely to recapture lost motion.
The therapist should continue to encourage functional use of affected areas, including strengthening when appropriate, and emphasize motion throughout all motions.
During the Fibrotic phase, 6 to 12 weeks, bone fracutres are typically healed, allowing for more aggressive splinting. Scar tissue is fully formed but still malleable. Splinting and resistive exercises can continue to maximize gains in motion.
During the last phase of healing, Recovery phase, 3 to 6 months, scar tissue is organized and fibrotic. The person may continue to make small gains, but often motion has reached a plateau and splints are discontinued gradually. The individual should be encouraged to continue a home strengthening program for at least another 6 months.
Injury prevention
Inform patient on the prevention of Myostitis Ossificans and ways to conserve the patients energy during the recovery phase such as taking a basket to put in items rather than making multiple trips.
Rarely surgical excision of the myositis ossificans warranted. If the myositis ossificans is removed before it is "mature," it will likely return. Therefore, most surgeons wait between 6 and 12 months before even considering removal. Furthermore, there is a chance of return even when removed very late. Generally, myositis ossificans is only removed surgically if it interferes with joint motion, if it is irritating a nerve, if symptoms (pain) persists, or if the bone is unusually large.
Crutches for hip/thigh contusions may be recommended.
A neoprene (wetsuit material) or other bandage may help reduce some of the symptoms.
Nonsteroidal anti-inflammatory medications may also reduce the formation of bone of the hematoma (clot).
