Myositis ossificans elbow and forearm, distal humerus
Myositis ossificans, (MO), otherwise known as heterotopic ossification, is an extra-osseous non neoplastic growth of new bone. Though the condition often accompanies bone trauma or complications, such as paralysis, it has also known to rarely present without injury or as an hereditary disorder.
Myositis ossificans circumscripta occurs in patients who have experienced trauma, especially in their arms or thighs. Certain hereditary abnormalities also cause MO.
MO presents as a rapid enlargement and significant pain in a muscle, one to two weeks after injury. Symptoms include swelling and warmth at the site as well as an increased ESR and serum alkaline phosphatase.
Appearing two to four weeks after injury on film, the tumor presents with increasing calcification in the periphery towards the center, along with increased uptake.
Treatment consists of making the correct diagnosis, avoiding the potential incorrect diagnosis of cancer or infection, supportive treatment for pain, and treatment designed to minimize the calcification of the muscle. There are unsubstantiated reports that medical marijuana is helpful for this disease.
Introduction and Definition:
Myositis ossificans is an extra-osseous non neoplastic growth of new bone. A synonym for myositis ossificans is heterotopic ossification. There are several clinical subtypes of myositis ossificans. Myositis ossificans circumscripta refers to new extra-osseous bone that appears after trauma, and occasionally without injury.
Progressive myositis ossificans (also known as fibrodysplasia ossificans progressiva) is a rare, inherited disorder characterized by fibrosing and ossification of muscle, tendon and ligaments of multiple sites often in the upper extremities and back that is disabling and ultimately fatal.
Myositis ossificans is also a recognized complication of paralysis that occurs below the level of spinal cord injury.
Incidence and Demographics: Myositis ossificans occurs most commonly in the second and third decade in the arms and thighs of patients who have experienced some sort of trauma. The quadriceps and brachialis are the most affected. This disorder may occur in association with a hematoma which occurs in a muscle after injury.
Symptoms and Presentation:
Myositis ossificans presents as a rapid enlargement and significant pain one to two weeks after injury. The patient has swelling and warmth at the site as well as an increased ESR and serum alkaline phosphatase. The clinical picture differs from that of osteosarcoma (which is often on the differential as the age groups are the same) as the pain from myositis ossificans decreases as time goes on where osteosarcoma pain increases. Patients are typically not febrile, and do not have systemic symptoms. The pain is localized to the muscle involved.
X-Ray Appearance and Advanced Imaging Findings: Myositis ossificans appears on plain-film at approximately 2-4 weeks after injury. The lesion begins to calcify at the periphery and works toward the center. At less than three weeks post-trauma, bone scan demonstrates increased uptake in the area. Osteosarcoma calcifies at the center and continues to the periphery. CT scan helps delineate a central radiolucency surrounded by a dense periphery.
Laboratory Findings: elevated white cell count, elevated sedimentation rate,
Differential Diagnosis: neoplasm especially infiltrative neoplasm such as lymphoma, infection
Preferred Biopsy Technique for this Tumor: open biopsy to demonstrate zonal pattern of maturation. This cannot be demonstrated on needle biopsy.
Histopathology findings: On gross examination, myositis ossificans has a shell of bone and a soft red-brown center. The mass may be attached to the bone by a stalk or might be in continuum with the periosteum. Alternatively, the mass may be attached only to the muscle. Microscopically, myositis ossificans appears different at the periphery and the center. Acutely, there is proliferation of undifferentiated mesenchymal cells that infiltrates the muscle. At approximately 2-3 weeks, osteoid production begins at the periphery and fibrous tissue begins to form around the shell. The center of the lesion will be an irregular mass of immature fibroblasts. Moving towards the edge, there will be islands of disorganized osteoid. At the edge of the lesion, trabeculae of lamellar and woven bone are present. There may be a cartilage component as well. This process is in contrast to osteosarcoma where the ossification begins at the center of the lesion.
Treatment Options for this Tumor: Treatment for myositis ossificans is generally conservative.
Early surgery is may help.
Excision is an option after decreased activity is evident on bone scan. If left alone, the mass will shrink in size.
Outcomes of Treatment and Prognosis: minor cases may resolve without any sequelae. Major calcification of muscles can lead to loss of motion pain and weakness.
Special and Unusual Features: Of interest: There are several theories on the etiology of myositis ossificans. It has been suggested this is merely an organizing hematoma. Other authors think the periosteum has been pushed into the muscle or the osteoblasts escaped the periosteum. Metaplasia of connective tissue cells is also a possibility.
Suggested Reading and Reference:
Bullough, Peter, Orthopaedic Pathologv (third edition), Times Mirror International Publishers Limited, London, 1997.
Huvos, Andrew. Bone Tumors: Diagnosis. Treatment and Prognosis, W.B. Saunders, Co., 1991. Cushner, FD and RM Morwessel,
Myositis Ossificans Traumatica, Orthopaedic Review, p. 1319-1326, November, 1992.
Ultrasound Med Biol. 2010 Mar;36(3):397-409. doi: 10.1016/j.ultrasmedbio.2009.11.007. Epub 2010 Feb 4.
Shock waves in the treatment of post-traumatic myositis ossificans.
Buselli P1, Coco V, Notarnicola A, Messina S, Saggini R, Tafuri S, Moretti L, Moretti B.
Two months after the therapy, a normal range of motion and no signs of weakness were observed. Three months after treatment, 87.5% of patients resumed regular sports activities.