myositis ossificans

i have a pt with head injury with (R)feur fracture fixated with internal fixation and (L) ischial fracture fixated with k wire and (L)elbow lower end humerus with olecranon frature with radial head fracture all fixtaed with k wire with radial nerve palsy
2 months old pt on partial weight bearing
but developed myositis ossificans of elbow
advise me on this
how shd i go about it
range is 80-100 degrees

[sharmaphysio]

i want info on this too

[MrPhysio+]

Hi
It is my understanding that their is a difference between myositis ossificans and heterotopic bone formation, as seen in head injuries.
There appears to be an increased amount of abnormal bone growth at injury sites after a head injury - cause unknown but possibly related to altered bone growth factor control following brain damage. It is critical that joint mobilisation does not aggravate the joint, as this is likely to accelerate the abnormal bone deposition.
Ongoing scanning is required to ascertain whether the heterotopic bone is affecting the joint line. If not, muscle stretching and gentle joint mobilisation is required to avoid contractures.
If vthe bone is affecting the joint line, an orthopaedic or neuro specialist needs to judge the risks of removing the bone. This is a difficult decision, as further surgery can also accelerate the abnormal bone growth, and you may be worse off. In a paediatric patient, growth plates are also a priority.
Hope this helps.

[neurospast]

Maybe I am stupid, but myositis means to my knowledge inflamation of muscle. Am I wrong in this? If not how is it possible to have myositis of the elbow?
In general passive mobilisation should be avoided as long as there is evidence of an uncontrolled bone growth since this might disturb healing process.
The radial nerve palsy has this come on gradually due to this uncontrolled bone growth or as a result of the fracture. this would be my major concern since it could develop into a permanent loss of lower arm function and in that case the mobility of the elbow is of little importance. So my choice would be to try to stimulate the healing process of the nerve by e.g. active arm movements, in which muscles innervated by the radial nerve are involved (e.g. PNF-patterns).

[arkesh_physio]

hi
myositis is inflammn of muscle itself which later leads to haematoma formation & ossification.
treatment could be hold relax at end of range without any passive stretching.

[sdkashif]

Every type of exercise should be stopped in case of myositis ossifican and joint should be rested until the bone formed is absorbed.

[arunja]

Myositis ossificans is due to the rupture of the capillaries in muscle which later develop in the form of calcium deposition over the muscle. Its common especially after an elbow # . X ray reveals a cotton wool like appeareace. The most common muscle to get affected is the Quadriceps. Never do any massage or tissue mobilisation in elbow. My suggestion is that, make the patient to do more active movmnts within the availiable ROM.

[mageshanand]

Hi guys

I absolutely agree with arunja, you should not do any movements at all until the inflammation subsides, but arunja literature says that for the MO to re absorb, it takes around an year,

and i have come across a study in which Iontophoresis with 2 percent acetic acid was tried, it was a case description and that guy has had a good relief with excellent reabsorption !, but what you have to consider is that, he had this lesion following a sports injury but yours is head injury the etiology is quite different, so you might want to consider IO only if you feel that your patient will be a suitable candidate for it.

cheers

[physiobob]

Posttraumatic Heterotopic Ossification

To give more of an overview of this issue it is important to show that there are at least 3 forms of myositis ossificans although commonly as physio's we only discuss the traumatic, sports injury type. Below is a more thorough outline of the various forms of heterotrophic ossification

Background: In 1918, Dejerine and Ceillier first described heterotopic ossification (HO) in paraplegic patients injured in World War I, referring to the process as paraosteoarthropathy. HO has been defined as the formation of mature lamellar bone in soft tissues. The process involves true osteoblastic activity and bone formation. HO has been reported in cases of brain injury, spinal cord injury, stroke, poliomyelitis, myelodysplasia, tabes dorsalis, carbon monoxide poisoning, spinal cord tumors, syringomyelia, tetanus, and multiple sclerosis. This condition also has been reported after burns and total hip replacement.

Several terms have been used to describe the condition, including heterotopic ossification, ectopic ossification, and myositis ossificans. HO usually involves the large joints of the body (eg, hips, elbows, shoulders, knees). Excessive bone formation may result in significant disability by severely limiting the range of motion (ROM) of these joints (see Image 1).

The following 3 categories of HO have been described:

* Myositis ossificans progressiva is a rare metabolic bone disease in children with progressive metamorphosis of skeletal muscle to bone and is characterized by an autosomal dominant pattern of genetic transmission.

* Myositis ossificans circumscripta without trauma is a localized soft tissue ossification after neurologic injury or burns. This process also is referred to as neurogenic HO.

In relation to your original question some USA stastics showed:

An association has been cited between spasticity and HO. The incidence is higher in a spastic extremity; 84% of patients with HO had spasticity, and 54% of patients with HO had no spasticity. HO is seen in the elbow in 4% of patients with traumatic brain injury (TBI); however, if fracture or dislocation is associated with brain injury, the incidence of HO rises to 89%.

Patients with brain injuries are at greater risk for developing HO if they have significant spasticity or increased muscle tone in the involved extremity, duration of unconsciousness longer than 2 weeks, long-bone or associated fractures, and decreased ROM. Therefore, the risk of development of HO in a patient with brain injury increases as the severity of injury, length of immobilization, and duration of coma increase.

* Traumatic myositis ossificans occurs from direct injury to the muscles. Fibrous, cartilaginous, and osseous tissues near bone are affected. The muscle may not be involved.

Pathophysiology: The specific cause and pathophysiology of HO remain unclear. HO may be due to an interaction between local factors (eg, the pool of available calcium in adjacent skeleton, soft tissue edema, vascular stasis tissue hypoxia, mesenchymal cells with osteoblastic activity) and an unknown systemic factor or factors. The basic defect in HO is the inappropriate differentiation of fibroblasts to bone-forming cells. Early edema of connective tissue proceeds to tissue with foci of calcification and then to maturation of calcification and ossification.


The typical Sport (post trauma) myositis ossificans is summarised below

Definition: Myositis ossificans is an unusual condition that often occurs in athletes who sustain a blunt injury that causes deep tissue bleeding. A typical story is a soccer player who is kicked forcefully in the mid-thigh, and develops pain and significant bruising.

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. No one knows exactly why this occurs in some people.

The common concern when abnormal bone is seen on a x-ray is that there is a tumor within the soft-tissues. Fortunately, myositis ossificans has some typical clues that usually make it easily differentiated from a tumor. If there is any question about the diagnosis, repeat x-rays will be obtained several weeks later to ensure the bone mass is a typical myositis ossificans.

Treatment of myositis ossificans consists of:

* Rest

* Immobilization

* Anti-Inflammatory Medication

Rarely is 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 or if it is irritating a nerve

Hope this information helps our understanding and therefore treatment choices

[litzphysio]

hi i could like to known more about myositis ossificans

[junior_physiotherapist]

hello all colleagues

just tell the agr of yours pt , i'd like to tell u that this ossification tissue u have to give it 3 to 4 month to resolve spontanuously during this u have to give him gentel hold -relax teqniches with gentl mobilizing exs. and more activation to active &gradual weight bearing exs .

remember u if s/he childe don't weight alotof u have to be in contact with the physician

Realy i have a current experience wirh child and so i a chieved with her great results estimated by her orthopedic physician.

All bes t

[emad]

Hi all :

Seems a complex orthopedic patient following accident , you have much work with this patient because of the femur and that radial nerve injury ! why not addressing all that and gives the elbow some time to resolve that myositis Ossification .

I think just gentle active motion is good for that elbow .

Cheers
Emad

[stalinphysio]

nothing 2 worry it , if u have any bandage r pop pls remove it as quick as possible and continue u r activ ex and if u have any pain , go 4 wax and apply mets and joint mobilzation ex and conti 4 week we con ge improvement . from this we can avoid the ossi replay after the week