Myositis ossificans is a benign disorder of
heterotopic bone formation (HO) occurring in response to soft tissue trauma. It
is common in patients with brain injuries or history of muscle trauma related
to surgery. It is rarely seen after blunt trauma to the extremities. Blunt
trauma most commonly causes HO in contact sport athletes or football players
during crush injuries of the thigh (Clin J Sport
Med. 2014 Sep;24(5):e56-8 Mani-Babu S1, Wolman R, Keen R.).
To our knowledge there are no published cases in the English literature of myositis ossificans to the
biceps following blunt trauma .
Case report:
A 12 year boy presented to our office 3 weeks after
a crush injury to the arm during a football game. He had elbow stiffness and
pain to the biceps area with palpation. Per the report of his parents there was
ecchymosis soon after the trauma however he did not have any skin changes at
the time of presentation to our office. He had restricted elbow extension and
no loss of motion in flexion. There were no other injuries, no comorbidities
and no history of head trauma. His radiographic evaluation demonstrated
ossifying lesion of the biceps muscle and his MRI delineated that there was
involvement of the biceps muscle alone (Figures below). His laboratory findings,
including white blood cell count, erythrocyte sedimentation rate and C-reactive
protein level, were normal.
The splint was removed at the time of
presentation and a stretching elbow range of motion program was initiated. After
4 weeks the patient regained nearly all of his elbow range of motion without
the need for surgery and was pain free.
Discussion:
Myositis ossificans (MO) is rare in young patients
and is most commonly seen after trauma. Over half of the patients diagnosed
with MO are in the third decade of life. Cases of MO that present with no
history of trauma can be diagnostic challenges as MO can mimic a sarcomatous
neoplastic process on imaging studies. In our case there was no diagnostic imaging
challenge due to the history of trauma. The treatment that is most commonly recommended
for this condition is surgical resection when the MO matures. Our approach was
different for this rare condition as we elected to proceed with removal of the
splint early (3 weeks after the trauma) and initiation of a program of physical
therapy with elbow stretching exercises. The patient regained his range of
motion and was pain free at 4 weeks after trauma. Considering the risks of
complications, loss of muscle strength and surgical trauma as well as the cost
of surgery it is recommended that a short period of physical therapy should be
initiated with stretching exercises before any surgical consideration. In cases
of diagnostic challenges due to lack of traumatic event a biopsy and resection
may be indicated. Similar cases that involve the thigh muscles are common
(references), however MO of the upper extremity is rarely seen.
We found no papers published on this condition involving the biceps. General reading for similar injuries of the thigh can be found at the end of this post.
REFERENCES
Journal of Pediatric Orthopaedics B:
Myositis ossificans of the hand in a child: case report
De Smet, Luc; Degreef, Ilse
Journal of Pediatric Orthopaedics B:
May 2015 - Volume 24 - Issue 3 - p 223–225
Myositis ossificans on the forearm in a 10-year-old girl
Say, Ferhata; Coşkun, Sinaa; Bülbül, Muratc; Alici, Ömerb
Myositis ossificans traumatica in young children: Report of three cases and review of the literature
ARTICLE in PEDIATRIC RADIOLOGY 30(7):451-9 · JULY 2000
Acta Orthop Scand. 1968;39(1):73-5.
A case of traumatic myositis ossificans in the iliopsoas muscle.
Acta Orthop Belg. 2003 Jun;69(3):285-8.
A case of myositis ossificans as a complication of tetanus treated by surgical excision.
Eur J Pediatr. 2009 May;168(5):523-9. doi: 10.1007/s00431-008-0906-8. Epub 2009 Jan 8.
Myositis ossificans circumscripta: a paediatric case and review of the literature.