Myositis Ossificans

 Also known as localized myositis

ossificans, extra osseous localized non
neoplastic bone and cartilage formation,
myositis ossificans traumatica, myo-
osteosis, myositis ossificans circumscripta,
traumatic ossifying myositis and ossifying
haematoma.
 Reactive lesion occurring in soft tissues
and at times near bone and periosteum.
Myositis Ossificans
 It is characterized by fibrous, osseous and
cartilaginous proliferation and by metaplasia.
The term myo and itis is a misnomer
because skeletal muscle is often not
involved and inflammatory changes are
rarely evident. Also in early phase of
evolution, formation of bone may not be
observed, so term ossificans is not always
applicable.
Myositis Ossificans
 Most if not all, have a history of trauma, simple
severe blow or series of repeated minor traumas.
Condition may be classified according to its location
as extra osseous, periosteal or parosteal.
Haematoma seems to be necessary prerequisite.
Muscles most often involved are brachialis,
quadriceps femoris and adductor muscles of thigh. It
is significant that these muscles gain attachment to
bone over a wide surface area, suggesting that
periosteum participates to some extent in the
process.
Myositis Ossificans
 Young athletic men are predisposed.
Region of elbow is a favorite site, and when
the process appears to restrict elbow
motion progressively, ill advised forcible
manipulation will cause a widespread
involvement.
Pathogenesis
 Muscle is commonly but not invariably
involved, and fascia, tendon and
periosteum can also be the site.
 Process is peculiar alteration within the
ground substance of connective tissue,
associated with striking proliferation of
undifferentiated mesenchymal cells.
Pathogenesis
 Initially there is degeneration and necrosis, in
case of muscle, disrupted muscle fibers retract. In
3 to 4 days, fibroblasts from endomysium invade
damaged area and rapidly form broad sheets of
immature fibroblasts. At the same time, primitive
mesenchymal cells proliferate within injured
connective tissue. Intense cellular proliferation of
fibroblasts and mesenchymal cells produces a
histological picture that may be erroneously
diagnosed as fibrosarcoma or myosarcoma.
Pathogenesis
 Ground substance becomes homogeneous or
glassy or waxy, suggesting some type of edema. It
increases in in amount and encloses some of
mesenchymal cells, which then assume the
morphological characteristic of osteoblasts.
Mineralization follows and bone is formed. This
events typically takes place first within least
damaged part i.e. periphery. As the process of
osteoid formation and mineralization changing in
mature bone evolves, it progressively extends
towards the central, severely damaged area.
Pathogenesis
 Any trauma that produces haematoma beneath the
periosteum or damages it sufficiently to elevate it,
will produce highly cellular proliferation in space
between periosteum and bone; osteoid develops
and is rapidly converted to bone. When myositis is
not removed and is allowed to mature, it becomes
oriented and covered by a cartilaginous cap,
because of muscle action over the lesion. This is
called post traumatic osteochondroma and is
common in region of knee joint.
Clinical picture
 Result of single or repeated trauma. Brachialis is
a favorite site after posterior dislocation of elbow.
Elbow is quite swollen and tender and active as
well as passive motion is restricted. As pain and
swelling decreases, a circumscribed, indurated,
later hard tumor mass is palpable. Active
extension of joint is limited due to inelasticity of
muscle, and flexion is prevented by obstruction by
the mass.
Clinical picture
 Ossification in deltoid is common in foot soldiers
due to trauma caused by carrying a rifle. The
constant pressure of saddle against the adductors
in riders causes ossification in adductors. This
syndrome is known as Prussian disease.
 Myositis ossificans is self limited, undergoes
maturation and may persist as a hard ossified
mass, usually within a muscle or fixed to adjacent
long bone. In some cases it undergoes almost
complete regression.
Diagnosis
 Totally excised lesion or deep biopsy will
demonstrate zoning effect. Central area with
numerous cells of various shapes and sizes
and occasional mitotic figures. Next zone
shows osteoid formation with a fibrovascular
background. This is more advanced stage, cells
are more uniform, indicating a benign lesion. In
outer zone, trabeculae of well formed bone and
more mature fibrous stroma are observed.
Treatment
 Growth should not be removed in premature
stage as it is disastrous. The ossification
becomes exuberant, infiltrates beyond the
original site, and compresses the soft tissues
around beyond hope of repair. When after
serial x-rays the mass is dense, well
delineated, and at a stand still, it may be
safely removed. It may be possible to prevent
myositis by aspirating the original haematoma.
Myositis ossificans progressiva
 Congenital condition that starts without
antecedent trauma before or shortly after birth.
Consists of frequently repeated episodes of
sudden extension of ossification in muscles,
fascia, tendons and aponeuroses.
 Raised eosinophil count.
 Ossification usually starts with the upper back
muscles, trapezius, latissimus dorsi, and spreads
distally involving soft tissue structures throughout
the body.
Myositis ossificans progressiva
 IP joint of thumb, large toe and spine are
liable to fuse. All joint motion is finally lost
and patient dies of inter current infection.
This condition is very rare.
 There is no known effective treatment.
 Corticotrophin seems to have some
deterrent effect on heterotrophic bone
formation. Eosinophil count drops and joint
motion may even increase.
Tennis elbow
 Chronic disabling pain in elbow, around
radio humeral joint, is called tennis elbow
rather than epicondylitis or radio humeral
bursitis in view of lack of specificity
regarding its origin.
Tennis elbow-Etiology
 Common in people whose occupation
require frequent rotary motion of forearm
e.g. tennis players, pipe fitters and
carpenters.
Tennis elbow-Clinical picture
 Onset is gradual.
 Pain appears over outer aspect of elbow
and is referred to forearm. It is persistent
and intensified by grasping or twisting
motions. In short, all muscles required for
grasping and supination which originate
from lateral epicondyle, epicondylar ridge
and a few fibers from anterior capsule of
elbow joint.
Tennis elbow-Clinical picture
 Well localized point of tenderness at either
epicondylar ridge, lateral epicondyle, lower
edge of capitellum anteriorly, laterally over
radio humeral space or one area in the
circumference of radial head during rotation
of forearm.
 Range of motion is normal. There is weak
grasp and dropping of objects particularly
with forearm pronated.
Tennis elbow-Clinical picture
 Pain can be reproduced by completely extending the
elbow, pronating forearm and forcibly flexing wrist.
Active attempts of dorsiflexion of the wrist and
supinate the forearm against resistance will likewise
intensify the pain.
 The condition infrequently involves the medial
epicondyle where pain is intensified by strong
grasping, active flexion of wrist and pronation of
forearm against resistance. This is called Golfer’s
elbow or medial epicondylitis.
Tennis elbow-X-Ray
 X-rays are usually negative. Occasionally a
small flake of bone anterior to the
epicondyle suggests an avulsion or surface
of epicondyle may be roughened as an
indication of Peri Osteitis.
Tennis elbow-Pathology
 Actual pathology is unknown.
 May be caused by tearing of tendon fibers
from their attachment to epicondyle . The
constant muscle contractions prevent
healing, creating a traumatic Peri Osteitis.
 Annular ligament undergoes hyaline
degeneration and may be the source of
pain.
Tennis elbow-Treatment
 Conservative treatment is effective in most
cases but recurrence is common.
 Rest : Complete rest with posterior
moulded cast or splint, maintaining
relaxation of extensors by flexion at elbow,
supination and extension at wrist. This
should be removed daily for gentle
exercises to avoid elbow stiffness.
Tennis elbow-Treatment
 Heat : Moist compresses or SWD is used.
 LAHC : Multiple punctures are made in tender
area and either steroid alone or a combination of
steroid and local anesthetic is injected and
repeated at intervals of 1 to 2 weeks for 3 to 4
doses.
 Radiation therapy : 3 sittings of 200 rads in air to
each of three fields-anterior, posterior and lateral.
One field is treated every other day.
Tennis elbow-Treatment
 Manipulation : Principle is to convert the partial
tear of conjoined tendon into a complete tear,
thereby detaching the tendon from chronically
inflamed periosteum.
 Technique : Elbow flexed and forearm supinated,
epicondyle is massaged for 10 minutes. Then
elbow is fully extended and forearm forcibly
adducted to create varus position. This is
repeated every 2 or 3 days; about 4 treatments
are sufficient to provide relief.
Tennis elbow-Treatment
 Technique : While the fingers and wrist are
held fully flexed and forearm pronated, the
elbow is forced into full extension while firm
pressure is applied with thumb over the
tender epicondyle.
 Miscellaneous : Ultrasonic therapy gives
equivocal results. Phenylbutazone
produces excellent results but it is not
recommended due to its potential toxicity.
Tennis elbow-Treatment
 Surgical treatment usually gives immediate and
lasting relief. It is indicated when conservative
treatment fails.
 Technique : Under tourniquet, curved linear
longitudinal incision made just posterior to lateral
epicondyle. Deep Fascial covering over conjoined
tendon is divided transversely. IM septum is also
divided. Conjoined tendon is severed at the
epicondyle, epicondylar ridge and remaining
fibers detached by subperiosteal elevation.
Tennis elbow-Treatment
 Conjoined tendon and extensor muscles are
allowed to displace distally. Lateral incision into
joint anterior to collateral ligament exposes the
capitellum and radial head. A portion of annular
ligament is cut. Only skin and SC tissue are
closed and elastic compression bandage is
applied and immediate joint motion permitted.
Removal of annular ligament is optional and
does not affect stability.
Tennis elbow-Treatment
 Denervation : Under cover of brachioradialis
muscle, radial N gives off a branch that can be
traced to periosteum of lateral epicondyle. After
exposure of radial N, it is lifted gently and articular
branches are identified and excised from anterior
and lateral surface of epicondyle. Postoperatively
injection of periosteal and articular branches are
blocked with local anesthetic to test the
effectiveness of denervation.