Myositis ossificans

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  • 1. Myositis Ossificans
  • 2. extra-osseous non neoplastic growth of new boneMisnomerHeterotopic ossificationnot always inflammatorywithin extra-skeletal soft tissues – mainly inconnective tissue than muscle
  • 3. Ectopic Calcification ?!!Deposition of radio denseCalcium PhosphateDifference in mineral phaseNo true bone matrix is formedEg:- Hyper/Hypoparathyroidism,Renal failure,Following TB,Calcific Supraspinatus Tendinopathy,Scleroderma,Dermatomyositis
  • 4. Diffusecutaneous,subcutaneousand muscularcalcification:Calcinosisuniversalis inDermatomyositis
  • 5. Types Myositis ossificanscircumscripta /traumatica fibrodysplasia ossificans progressiva (FOP)
  • 6. Myositis ossificanscircumscripta /traumaticaIn response to soft tissue injury:-blunt trauma,stab wound,fracture/dislocation,surgical incision (THR)Systemic Conditions:-Head injury,Spinal cord injuryTetanus,Burns
  • 7. Without known injury:-Nondocumented trauma,Repeated small mechanical injuries(blunt traumain horse riders)Nonmechanical injuries caused by ischemia orinflammation.Increased risk in patients with Diffuse IdiopathicSkeletal Hyperostosis (DISH) and Paget’sDisease
  • 8. PathophysiologyBMP stimulate primitive stem cells in soft tissuesto form osteoblastsOrganization of HaematomaFibroblastic hypoplasiaOsteoid formation
  • 9. Radiographic evidence in 6-8 weeks The lesion begins to calcify at the periphery andworks toward the center (Reverse inOsteosarcoma)
  • 10. Histopath- 4 distinct zones:the central undifferentiated zone- mitoticallyactivethe surrounding zone of immature osteoidformation – less activezone with new bone – osteoblast & fibroustissue with trabecular organizationPeripheral zone of fibrous tissueAt least 10 days are required following onsetof symptoms for these zones to becomeapparent.
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  • 14. drug abuserselbow ?!!
  • 15. Paraspinal
  • 16. most commonly in the second and third decadeAreas commonly affected - elbow, thigh, buttocks,shoulder and calf ., erector spinae, pectoralismuscles(Quadriceps and brachialis - most affected.)Majority –asymptomatic; may cause pain/ loss ofROM
  • 17. presents as a rapid enlargement and significantpain one to two weeks after injury.Swelling and warmth at the siteHypercalcemia- contributing factorIncreased ESR and serum alkaline phosphatase.
  • 18. TreatmentWatchful inactivityRest and gentle stretching.Surgery if persistent pain – excised in toto inmature casesRisk of recurrence +If left alone, the mass will shrink in size
  • 19. Treatmentshould not continue to play sports or use theaffected muscle.Avoid Heat and massage.Reinjury to the same area, returning to activity tooearly, or initial passive forceful stretching canlengthen recovery.Prophylaxis: NSAIDS(Indomethacin), low doseradiation
  • 20. Heterotopic Ossification OsteosarcomaSite: Diaphysis MetaphysisPeripheral rimming Ossification center(can mimic necrotic tr) to peripheryImprovement in pain over Pain worsens with time andrest timeBiopsy:Zone phenomenon Undiff tissue- viable musclefibres similar to central intact cortexzone
  • 21. Myositis Ossificans Progressiva /Fibrodysplasia OssificansProgressivarare autosomal dominant disorderskeletal malformation and progressive, disablingheterotopic osteogenesis.fibrosing and ossification of muscle, tendon andligaments of multiple sites often in the upperextremities and back that is disabling andultimately fatal
  • 22. Nine-year-old Mexican girl with FibrodysplasiaOssificans Progressiva (FOP).
  • 23. Chromosome 2q23-24Heterozygous mutation (617G®R206H) in theglycine-serine (GS) domain of theActivin A receptor type I (ACVR1) gene, a bonemorphogenic protein (BMP) type I receptorIncidence 1in 2 millionAge: Average 5 yrs (Fetus-25 yrs)Their offspring have a 50% probability ofinheriting the condition.
  • 24. painful lumps and stiffness in the adjoining joint. Lumps decrease in a few weeks, but jointmobility reduction persists.Exacerbating factors for ossifications at new sitesminor trauma, venipuncture,biopsy of lumps, IM injections,dental treatments, and excision of masses.
  • 25. Most common sites:- sternocleidomastoid,paraspinal muscles, the masticatory muscles,shoulder and pelvic girdle muscles.Spared are the abdominal muscles, extraocularmuscles,muscles of facial expression, diaphragm,larynx and tongue muscles.Ossification progresses from proximal to distaland cranial to caudal.
  • 26. C/FDigits: Short hallux in valgus with synostosisshort thumbs , ClinodactylyFibrous Tissues: Swelling in aponeuroses,fasciae, and tendons- ossification in musclesand fibrous tissues,most prominent in the neck dorsal trunk andproximal extremities (The sternocleidomastoidmuscle is commonly affected.)Kyphoscoliosis: Restricted shoulder andpelvic girdle movements
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  • 28. LabHemogram, ESR, S.Ca, P:- WNLECG findings may be abnormalspirometry :-restrictive pattern, reflective of chestwall involvement.
  • 29. Plain radiography of FOPShort metacarpals and metatarsalsPhalangeal synostosis (eg, monophalangeal greattoe)Vertebral fusions, vertebral anomalies (i.e., smallbodies), pedicle thickeningThick, short femoral neckVariations in bone maturation sequenceIncreased incidence of enchondromas
  • 30. TreatmentOnce diagnosis is established, usually clinically,any surgical biopsy is contraindicated in FOP.No established medical therapy exists. Pain medications supportive measures -gentle occupational and/orphysical therapy.
  • 31. Prevention is better!!avoid falling or getting bruisesavoid IM injections since these cancause bone to grow.Never stretch their joints outside oftheir normal ROM.Flare-ups can occur spontaneously,even perfect preventive care cannotguarantee the absence of bone growths.
  • 32. The mainstay of diagnosis is bilateralgreat toe anomaly present from birth,reported in 79 to 100% of patientsmicrodactyly of both halluces due to asingle phalanx in valgus positionThe finding of congenital hallux valgusmust raise the possibility of FOP so thatmanagement should be early andadequate.
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