Myositis ossificans: Difference between revisions

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==Background==
==Background==
Myositis ossificans (MO), also known as heterotopic calcification, is a condition of benign bone deposition within soft tissues, most often skeletal muscle. The condition can arise secondary to one larger traumatic event or repeated small trauma and will be localized to a single muscle or group of muscles involved in the trauma. Alternatively, the condition can be generalized, widespread, progressive and unrelated to trauma. The latter of which is generally considered to be hereditary and has a separate pathophysiology and treatment approach than what is discussed here. <ref name=litreview> Walczak BE, et al. Myositis Ossificans. J Am Acad Orthop Surg. 2015;23(10):612-22. </ref><ref> Ropper AH, et al. Chapter 48. Diseases of Muscle. In: Ropper AH, Samuels MA, Klein JP. eds. Adams & Victor's Principles of Neurology, 10e. New York, NY: McGraw-Hill; 2014. </ref>
*Also known as heterotopic calcification
*Benign bone deposition within soft tissues, most often skeletal muscle.
*Usually arises secondary to trauma (either one larger traumatic event or repeated small traumas) and will generally be localized to a single muscle or group of muscles involved in the trauma.<ref name=litreview> Walczak BE, et al. Myositis Ossificans. J Am Acad Orthop Surg. 2015;23(10):612-22. </ref><ref> Ropper AH, et al. Chapter 48. Diseases of Muscle. In: Ropper AH, Samuels MA, Klein JP. eds. Adams & Victor's Principles of Neurology, 10e. New York, NY: McGraw-Hill; 2014. </ref>
**Alternatively, can be generalized, widespread, progressive and unrelated to trauma - this is thought to be a hereditary form with a separate pathogenesis and treatment
*Pathophysiology not completely understood - may be related to inappropriate differentiation of mesenchymal cells into chondrocytes and osteoblasts in the setting of trauma/inflammation<ref> Kan L, et al. Dysregulation of local stem/progenitor cells as a common cellular mechanism for heterotopic ossification. Stem Calls. 2009;27(1):150-156. </ref>


===Pathophysiology===
[[File:MyositisOssificans.png|thumbnail|Plain radiograph taken two months after injury demonstrates irregular calcification located along muscle on medial aspect of right thigh. Diagnosis was myositis ossificans]]
The pathophysiology of myositis ossificans is not completely understood but likely involves inappropriate differentiation of mesenchymal stem cells into chondrocytes and osteoblasts in the setting of inflammation. <ref> Kan L, et al. Dysregulation of local stem/progenitor cells as a common cellular mechanism for heterotopic ossification. Stem Calls. 2009;27(1):150-156. </ref>


==Clinical Features==
==Clinical Features==
Patients often present with reports of pain lasting longer than expected following a trauma to the hip or thigh muscles with associated decreased range of motion. Often there is a palpable painful mass within 2 weeks of the initial trauma.
*Length of pain out of proportion to trauma
Typical scenario involves blunt soft tissue injury to the thigh such as with football players who then present with protracted pain and stiffness with a palpable mass in the thigh. Alternatively, those who experience repeated minor trauma such as horseback riders or shooters (rifleman or marksman) may develop pain decreased range of motion in their thighs or deltoid respectively.<ref name=tintinalli> Tintinalli JE, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016. </ref><ref name=litreview> Walczak BE, et al. Myositis Ossificans. J Am Acad Orthop Surg. 2015;23(10):612-22. </ref>[[File:MyositisOssificans.png|thumbnail|Plain radiograph taken two months after injury demonstrates irregular calcification located along muscle on medial aspect of right thigh. Diagnosis was myositis ossificans]]
*Decreased range of motion
*Palpable, painful mass (generally forms within 2 weeks of initial trauma)


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
The diagnosis of myositis ossificans can be relatively straightforward with a good patient history of an inciting event and a plain radiograph showing peripheral calcifications consistent with the diagnosis. However, early radiographs may be non-specific showing an indeterminate lesion wherein an MRI and biopsy may be necessary. It is important to note that it can be difficult to distinguish MO from malignancy such as a soft-tissue sarcoma without a biopsy. Additional conditions to consider include soft-tissue abscess and calcifying peritendinitis or bursitis. <ref name=litreview> Walczak BE, et al. Myositis Ossificans. J Am Acad Orthop Surg. 2015;23(10):612-22. </ref><ref name=contusion> Trojian TH. Muscle contusion (thigh). Clin Sports Med. 2013 Apr;32(2):317-24. </ref>
*Plain radiograph showing peripheral soft tissue calcifications
**Early radiographs may be non-diagnostic
*Biopsy may be required if concern for malignancy, calcified peritendonitis/bursitis, etc<ref name=litreview> Walczak BE, et al. Myositis Ossificans. J Am Acad Orthop Surg. 2015;23(10):612-22.</ref><ref name=contusion> Trojian TH. Muscle contusion (thigh). Clin Sports Med. 2013 Apr;32(2):317-24. </ref>


==Management==
==Management==
===Thigh Contusion===
*Generally self-limited disease process (may take up to 1 year to resolve)<ref name=litreview> Walczak BE, et al. Myositis Ossificans. J Am Acad Orthop Surg. 2015;23(10):612-22. </ref>
As soon as possible following injury the patient should have their knee painlessly held in 120 degrees of flexion with a brace or wrap and maintain this flexion for 24 hours. This can help minimize hematoma formation and subsequent MO. Following that, active painless range of motion exercises should begin. NSAIDs can be used for the first 48 to 72 hours only; beyond this NSAIDs can negatively affect healing. <ref name=contusion> Trojian TH. Muscle contusion (thigh). Clin Sports Med. 2013 Apr;32(2):317-24. </ref>
*Supportive care, including pain control and physical therapy, is the mainstay of treatment
 
===Myositis Ossificans===
Surgical management is rarely necessary as MO is often self-limiting and self-resolving. Management is focused on minimizing symptoms and maintaining function of the involved muscle group. Range of motion and strengthening exercises can be used to improve range of motion and function. MO may take as long as 1 year to mature and resolve.<ref name=litreview> Walczak BE, et al. Myositis Ossificans. J Am Acad Orthop Surg. 2015;23(10):612-22. </ref>


==Disposition==
==Disposition==
Patients benefit from referral to sports medicine specialist or orthopedist for core treatment.<ref name=tintinalli> Tintinalli JE, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016. </ref>
*Discharge with referral to orthopedic surgery or sports medicine<ref name=tintinalli> Tintinalli JE, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016.</ref>


==See Also==
==See Also==
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==External Links==
==External Links==


==References==
==References==
<references/>
<references/>

Revision as of 02:33, 2 September 2016

Background

  • Also known as heterotopic calcification
  • Benign bone deposition within soft tissues, most often skeletal muscle.
  • Usually arises secondary to trauma (either one larger traumatic event or repeated small traumas) and will generally be localized to a single muscle or group of muscles involved in the trauma.[1][2]
    • Alternatively, can be generalized, widespread, progressive and unrelated to trauma - this is thought to be a hereditary form with a separate pathogenesis and treatment
  • Pathophysiology not completely understood - may be related to inappropriate differentiation of mesenchymal cells into chondrocytes and osteoblasts in the setting of trauma/inflammation[3]
Plain radiograph taken two months after injury demonstrates irregular calcification located along muscle on medial aspect of right thigh. Diagnosis was myositis ossificans

Clinical Features

  • Length of pain out of proportion to trauma
  • Decreased range of motion
  • Palpable, painful mass (generally forms within 2 weeks of initial trauma)

Differential Diagnosis

Extremity trauma

Evaluation

  • Plain radiograph showing peripheral soft tissue calcifications
    • Early radiographs may be non-diagnostic
  • Biopsy may be required if concern for malignancy, calcified peritendonitis/bursitis, etc[1][4]

Management

  • Generally self-limited disease process (may take up to 1 year to resolve)[1]
  • Supportive care, including pain control and physical therapy, is the mainstay of treatment

Disposition

  • Discharge with referral to orthopedic surgery or sports medicine[5]

See Also

External Links

References

  1. 1.0 1.1 1.2 Walczak BE, et al. Myositis Ossificans. J Am Acad Orthop Surg. 2015;23(10):612-22. Cite error: Invalid <ref> tag; name "litreview" defined multiple times with different content Cite error: Invalid <ref> tag; name "litreview" defined multiple times with different content
  2. Ropper AH, et al. Chapter 48. Diseases of Muscle. In: Ropper AH, Samuels MA, Klein JP. eds. Adams & Victor's Principles of Neurology, 10e. New York, NY: McGraw-Hill; 2014.
  3. Kan L, et al. Dysregulation of local stem/progenitor cells as a common cellular mechanism for heterotopic ossification. Stem Calls. 2009;27(1):150-156.
  4. Trojian TH. Muscle contusion (thigh). Clin Sports Med. 2013 Apr;32(2):317-24.
  5. Tintinalli JE, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016.