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Myositis ossificans traumatica (MOT) is a pathological condition characterized by extraskeletal formation of bony tissue, induced by violent or repeated trauma. Reports of this pathology occurring in the region of the head and neck are rare, and even more so in the muscles of mastication. We present the case of patient with MOT of the temporal muscle, the etiology of which seems to be related to traumatic manipulations during dental treatment. A review of the literature is presented and the surgical approach, which resolved this case is discussed.

Myositis ossificans (MO) is a disorder characterized by the intramuscular proliferation of fibroblasts and osteoblasts, with subsequent deposition of bone and cartilage. A typical clinical presentation involves traumatic injury to a young adult, usually localized to the thigh, buttock, or upper arm, with resultant MO and mildly restricted range of motion in adjacent joints. Rarely, MO is associated with peripheral neuropathies involving the radial, median, sciatic, and sural nerves. The authors present an unusual case of MO causing a brachial plexopathy. To their knowledge, this is the first description of such a presentation.

Myositis ossificans is usually the result of direct injury to a muscle and is a self-limiting disease. It may present as a soft-tissue mass with a broad differential diagnosis, including highly malignant tumours, such as soft-tissue sarcomas. Many theories can be found concerning the aetiology of myositis ossificans, but minor or major traumas are considered to be the most common cause. A unique case of myositis ossificans of the neck in a 17-year-old professional, female, ground gymnast, who presented initially with a soft-tissue tumour, was treated successfully. The main differential diagnosis is presented along with typical radiographic features on conventional radiography, computerised tomography and magnetic resonance imaging, and typical pathological appearance, such as the pathognomonic "zoning phenomenon". Myositis ossificans should be added to the differential diagnosis of every young patient who engages in sport presents with a soft-tissue mass. Careful padding of the area and teaching the rolling technique to avoid repeated injuries to the neck can prevent recurrence.

One muscle trauma is a common injury in contact sports. The most extensively damaged muscle is that segment closest to the underlying bone. By an unknown mechanism, this injured muscle can become transformed into heterotopic bone, a complication also called myositis ossificans. It is best managed conservately and rarely requires surgery.

Heterotopic ossification, or myositis ossificans, denotes true bone in an abnormal place. The pathogenic mechanism is still unclear. A total of 643 patients (mean age, 9.1 years) admitted for neuropediatric rehabilitation were analyzed retrospectively with respect to the existence of neurogenic heterotopic ossification. The purpose of this study was to obtain information about incidence, etiology, clinical aspect, and consequences for diagnosis and therapy of this condition in childhood and adolescence. Heterotopic ossification was diagnosed in 32 patients (mean age, 14.8 years) with average time of onset of 4 months after traumatic brain injury, near drowning, strangulation, cerebral hemorrhage, hydrocephalus, or spinal cord injury. The sex ratio was not significant. In contrast to what has been found in adult studies, serum alkaline phosphatase was not elevated during heterotopic ossification formation. A persistent vegetative state for longer than 30 days proved to be a significant risk factor for heterotopic ossification. The incidence of neurogenic heterotopic ossification in children seems to be lower than in adults. A genetic predisposition to heterotopic ossification is suspected but not proven. As a prophylactic regimen against heterotopic ossification we use salicylates for those patients in a coma or persistent vegetative state with warm and painful swelling of a joint and consider continuous intrathecal baclofen infusion and botulinum toxin injection for those patients with severe spasticity. We prefer to wait at least 1 year after trauma before excision of heterotopic ossification.

Fibrodysplasia ossificans progressiva is a rare disorder characterized by the progressive development of heterotopic bone in the connective tissues of skeletal muscle, ligaments and tendons. Surgical trauma is one of the most potent stimuli for ossification and surgical treatment is generally considered to be contraindicated in this condition. We report a good functional result in a patient with severe hand disability secondary to an ulna-carpal bar in fibrodysplasia ossificans progressiva., (Copyright 2000 The British Society for Surgery of the Hand.)

The article reports the occurrence of osteochondroma in a fibrodysplasia ossificans progressiva patient. A 5-year-old boy presented with limited mouth opening and firm swelling of the right zygomatic complex area. The boy had bilateral hallux valgus of the great toes and heterotopic endochondral ossification of facial and neck regions. Associated osteochondroma of the coronoid process and aggressive heterotopic ossification of masticatory and neck muscles were found in response to traumatic injuries. Natural and clinical histories of fibrodysplasia ossificans progressiva were reviewed. An early diagnosis and avoidance of factors that aggravate ossification are key factors in reducing the expected degree of physical disabilities of patients. An early recognition of congenital skeletal deformities, early detection of abnormal ossification, and awareness of the disease by the involved physicians are important factors in the early diagnosis of the disease and in reducing any unnecessary trauma. Bone scintigrams and CT scans are effective noninvasive tools for an early detection of ossification and for monitoring the progression of the disease. Further investigation of its pathogenesis at a molecular level is important to understand better the nature of the disease and to develop an effective treatment protocol.

We present a case of myositis ossificans of the hand and review the clinical, radiological, and histological presentation, as well as the appropriate therapeutic management.

Myositis ossificans is a non-neoplastic heterotopic bone formation within muscle or soft tissues. The most commonly involved muscles are the muscles of the upper arm and thigh. Occurrence in the head and neck is rarely encountered clinically. A 53-year-old Turkish man (farmer) was operated on for traumatic myositis ossificans circumscripta in his neck. During the operation the mass was found to originate from the scalenus medius muscle and was readily and completely dissected from surrounding tissues. The histologic examination of the specimen revealed focal cartilage and mature bone tissue, which was compatible with the late stage of myositis ossificans. In 5 years of follow-up, the patient has remained asymptomatic and no signs of recurrence have been noted.

A case of a nine-year-old boy with a rare connective tissue disorder is presented. Fibrodysplasia ossificans progressiva is a chronic progressive hereditary disease of unknown etiology and unfavourable prognosis. Any injury to tissue must be avoided as it induces further progression of the disease.

Objective: To discuss the clinical radiographic findings in a 70-yr-old woman suffering from chondrosarcoma., Clinical Features: The patient experienced right SI pain present initially only at night. She later developed morning numbness. An X-ray examination revealed a flocculent calcification in the right buttock region. Computed tomographic scans confirmed the diagnosis., Intervention and Outcome: Initial palliative care continued until surgery was performed to resect the area., Conclusion: Chondrosarcoma is a severe disease that must be differentiated from myositis ossificans.

The authors report the case of a 22-year-old female suffering from thigh pain for 5 months. The first diagnosis considered was circumscribed myositis ossificans but the duration of symptoms and the radiological aspect mimicking some malignant features led to consider parosteal sarcoma as a possible diagnosis. Surgical resection was therefore requested and histological analysis confirmed the diagnosis of circumscribed myositis ossificans. This case emphasizes the difficulty in differentiating circumscribed myositis ossificans from a slowly growing tumor as both can be associated with increasing pain and a malignant radiological aspect. A surgical approach is therefore frequently necessary for definitive diagnosis and treatment.

A 5-year-old boy underwent arthroscopic surgery because of a lateral discoid meniscus, which was followed by an overly strenuous rehabilitation program. At 6-week follow-up, a painful mass at the distal part of the thigh and a flexion restriction of the operated knee were detected, caused by myositis ossificans inside the vastus medialis muscle. The symptoms disappeared with an appropriate rehabilitation program and the patient recovered.

The authors report one case of a bilateral atraumatic circumscribed myositis ossificans (C.M.O.) developed from the triceps muscles with major equinism, in a 15 years old girl. One side presented a current tumor, the other was seen at the first episode. The authors obtained a good functional result after surgical treatment and advocate this treatment.

A case of a myositis ossificans occurring in the distal portion of the finger is reported. An 18-year-old female noticed a small nodule in the tip of the left thumb for 11 months. Plain radiographs showed calcified shadow and there was a radiolucent zone between the mass and the distal phalanx. The excised mass was diagnosed as myositis ossificans. To our best knowledge, there has been no report of a myositis ossificans in the tip of the finger in literature.

Myositis ossificans traumatica of the masseter muscle is uncommon. The condition is benign and results in reactive heterotopic bone formation, usually producing limitation of opening of the jaws. Radiographic and microscopic examination can confirm the diagnosis. Treatment of myositis ossificans traumatica of the masseter muscle is surgical, with other modalities used when occurring in other muscles of the body.

The pessimism associated with the treatment of pancreatic cancer may result in inappropriate management in certain patients thought to have that disease. We analyzed the recent UCLA experience with a variety of periampullary tumors in which various issues concerning management were unusual. The records of nine patients (age 15-75 years) with pancreatic or periampullary tumors were reviewed retrospectively. The tumor was evident on CT scan in all patients. The diameter of the mass was greater than 5 cm in five cases. Eight of the tumors appeared to arise from the pancreas, but at exploration, two were found to originate from other structures (duodenum and retroperitoneum). One patient with an apparent gastric lesion on CT scan was found to have a mass of pancreatic origin at operation. Operative procedures included: pancreaticoduodenectomy (four), distal pancreatectomy (three), total pancreatectomy (one), and retroperitoneal tumor resection (one). Pathological diagnoses included: solid and papillary epithelial neoplasm (two), mucinous cystic neoplasm (two), serous microcystic adenoma (two), myositis ossificans (one), degenerative neurilemoma (one), spindle cell tumor (one), and intraductal papillary carcinoma (one). We conclude that patients with large or unusual-appearing pancreatic or periampullary tumors should be managed aggressively. Major resections can be done safely with the achievement of an excellent quality of life in individuals at the extremes of age. Unlike the usual pancreatic ductal adenocarcinoma, the prognosis for many of these neoplasms is excellent.

After reviewing the literature, the authors report a case of myositis ossificans of the right pterygoid and temporalis muscles in a patient undergoing surgery to remove the left medial pterygoid muscle owing to the same pathology. The metachronous localisation in contralateral masticatory muscles compared to the primary site leads the authors to emphasize the post-traumatic and iatrogenic etiology of this rare pathology. In the light of their experience, they underline the importance of a precise diagnosis and surgical exeresis, followed by cautious rehabilitation with the least trauma, if necessary backed by appropriate medical treatment.

A case of traumatic myositis ossificans of the iliopsoas muscle in a 13 year old ballet dancer is presented. A history of multiple minor injuries to the region of the left hip in addition to the radiographic appearance of calcification were indicative of ectopic bone formation. The lesion was explored surgically because of the clinical symptoms of the coexistant femoral hernia as well as to obtain biopsy material to exclude a soft tissue tumor. Histological examination demonstrated the zoning effect of myositis ossificans with patterns varying from a cellular central zone to a peripheral one of fairly well oriented bone. The patient remains symptom-free and no radiographic evidence of recurrence was observed four years postoperatively.

Myositis ossificans is a non-neoplastic lesion characterized by heterotopic ossification of soft tissue. At varying stages of maturity, it shares similar histologic characteristics with sarcomatous lesions or maturing bone. Misdiagnosis can result in unnecessary radical treatment. This lesion has only rarely been reported in the foot. We present the case of a patient with plantar forefoot myositis ossificans.

Fibrodysplasia ossificans progressiva (FOP) is a rare, congenital disease of the striated muscular system, ligaments and fascia; it leads to complete ossification in adult life. The disease usually begins in the first decade of life and is accompanied by abnormalities of the hands and feet that have already begun to occur at birth. There is no effective therapy. Although some of these patients have to undergo an operation, there is very little information available on anaesthetic procedures. CASE REPORT. A 49-year-old-woman came to the anaesthetic ward for amputation of her left foot with the diagnosis of fibrodysplasia ossificans progressive (FOP) and an infection resistant to any antibiotic treatment. Except for her left elbow, she could not move any of her extremities. Her back and neck were stiff (Figs. 1, 2), she could not open her mouth more than 2.5 cm, and her teeth were full of cavities and loose (Fig. 3). Aspiration of gastric content some time ago was known. Lung function showed a restrictive pattern. She suffered from kyphoscoliosis and needed chronic nasal administration of O2. With this therapy the arterial blood gas analysis was normal. Right bundle-branch block on the electrocardiogram was found. She was in a wheelchair and was completely dependent on the help of others. She was taking no medicine at the time of admission. A second operation was necessary because of reactive bone proliferation with a danger of skin perforation. DISCUSSION. This rare and congenital disease was first described in 1648 by G. Patin [14] and again in 1736 by J. Freke [10]. Since then, the progressive ossification of striated muscles, ligaments and facia has been described more than 600 times. Despite this fact, descriptions of anaesthetic procedures are rare. Because of the neck stiffness, the small mouth opening, the poor teeth and the recently observed history of aspiration, fiberoptic nasal intubation when the patient is awake was found to be the best choice. The possibility of atlanto-axial subluxation in such cases [2, 4] favored this procedure. Other authors have used blind nasal intubation [11], ketamine without intubation [18], or even local anaesthesia for a cesarean section [21]. Newer publications [13, 20] promote fiberoptic intubation and general anaesthesia with or without muscle relaxation. In this case propofol/fentanyl/ N2O/O2 without muscle relaxation was used for the first operation and etomidate/fentanyl/ethran/ N2O/O2 without muscle relaxation for the second procedure. During both anaesthesias important hypotension with good response to a generous volume supply was seen. The patient recovered well. Unfortunately, she died a few weeks later from suicide. The goal of this case report is to emphasize the value of the fibrobronchoscope in patients with FOP.

Functionally disabling myositis ossificans of the posterior aspect of the elbow occurred in a 66-year-old man as a sequela of tetanus. Serial quantitative bone scans were done to determine the optimal time for excision, which produced an excellent functional result without recurrence at 4 years.

It is well known that clinical assessment of the metastatic status of the cervical lymph nodes in patients with squamous cell carcinoma of the upper aerodigestive tract is frequently inaccurate, and several causes for false-positive assessments are well described. We report a novel cause, namely, a case of myositis ossificans traumatica of the sternocleidomastoid muscle, which presented as a neck mass after a direct laryngoscopy for biopsy of a laryngeal squamous cell carcinoma. The importance of this lesion is that it should be considered in the clinical differential diagnosis of swellings in the neck.

Background: Myositis ossificans circumscripta is a benign lesion with an acute course and may simulate a malignant tumor. It usually follows trauma to soft tissue., Case Reports: Case n. 1. A 13 year-old girl was admitted because of a painful inflammatory tumour in the left thigh. Initial X-rays were normal. Ultrasound imaging showed a heterogeneous echogenic mass with several extending shadow cones in the distal part of the vastus medialis muscle resembling a calcifying hematoma. Twenty days later, X-rays showed a vague calcified peripheral rim in the medial distal part of the thigh. White blood count was normal, and blood sedimentation rate was 46 millimeters in the first hour. CT scan showed a transparent zone between the lesion and the adjacent bone and a lucent central area, surrounded by a dense outer area consistent with myositis ossificans. Histological examination of the excised mass confirmed myositis ossificans. Two years later, the patient was asymptomatic and X-rays showed no ossification. Case n. 2. A 14 year-old girl suffered from pain in the right anterior hip area since 10 days. She denied any trauma. A firm mass was palpable in the anterior superior iliac spine area and X-rays revealed a calcific density. CT scan showed a dense bony mass in the right gluteus medius muscle clearly separated from the adjacent bony pelvis by a soft tissue plane. Histological examination of the excised mass confirmed myositis ossificans. One year later, the patient was asymptomatic and X-rays of the pelvis showed no ossification., Conclusion: Myositis ossificans circumscripta is rare in children. CT scan suggests the benign nature of the lesion by demonstrating integrity of bony cortex and characteristic disposition of calcifications. The biopsy is not necessary if the diagnosis is certain. Surgery permits to reduce the evolution.

The clinical features of two children with myositis ossificans progressiva are described. Skeletal malformations can be observed in many sites: hand, femur, tibia and spine. Phalangeal abnormalities (shortened hallux, hallux valgus) are essential to the diagnosis. We recommend systematic roentgenographic examination to search for other skeletal malformations for congenital hallux valgus in young children because it can be the first sign of myositis ossificans progressiva. Progression of disability does not seem to be influenced by any form of medical treatment. Surgical removal of ectopic bone is thought to be followed inevitably by rapid recalcification at the original site.

The authors report a case of fibro-osseous pseudo-tumour affecting a long finger. This is a rare tumour difficult to diagnose. Complete excision of the tumour was delayed till two years after its appearance as it's true nature had not been recognised at the time of the initial histopathologic examination. It is a benign tumour with a good prognosis as it does not undergo malignant degeneration and does not recur locally if excision has been complete. Errors in interpretation of the histopathologic picture have, in the past, led to unwarranted amputations of the involved fingers.

A case of ischemic limb salvage associated with myositis ossificans of the left thigh in a 66-year-old man was reported. The patient had a medical history of cerebral palsy and a cervical spinal cord injury, and had an operative past history of hip arthroplasty for fracture of the left femoral neck 10 years before. He showed ischemic symptoms such as paleness, coldness, and loss of the left dorsal arterial pulsation in the left toe, and had a rapidly growing mass in the left thigh. Roentgenography and computed tomography showed a mass 10 cm by 10 cm by 8 cm in size with severe calcification in the left quariceps muscle. Occlusion of the left common femoral artery was found in the arteriogram. Surgery was carried out in order to establish an accurate diagnosis and to rescue the left lower limb. The arterial pulsation was recovered as the result of completely resecting the left quariceps muscle tumor. The pathohistological diagnosis was of myositis ossificans in the quariceps muscle of the thigh. Etidronate disodium was administered in order to prevent a recurrence postoperatively. The patient has been well for the 13 months since surgery.

Two new cases of pseudomalignant myositis ossificans of the hand are reported. This lesion may be mistaken for a malignancy. The benign diagnosis is confirmed by the histologically characteristic zone phenomenon. Local excision cured both patients, without evidence of recurrence at 18 and 24 months postoperatively.

A ten year nine month-old girl was admitted to hospital for a painful inflammatory tumour of the right popliteal area. There was a calcification on X-ray and computerised angiography showed a tumour. MRI showed a heterogenous irregular mass. This looked like a malignant tumour. At surgical biopsy: it was a circonscripta myositis ossificans. This benign tumour of soft tissues, rare in children (25 cases in the literature), had a spontaneous favourable evolution. Differential diagnosis with malignant tumour is well known, but is still difficult. Biopsy is necessary in doubtful cases. We had to remove the mass because of acute pain.

The clinical features of 9 patients with circumscribed myositis ossificans (CMO) are described and the effects of treatment with surgical removal of ectopic bone are assessed. The average age of these patients was 24.4 years, and the average follow-up period was 7.4 years. Early correct diagnosis remains unusual, mainly because myositis may be mistaken for bruising, sarcoma or mumps. Once histological diagnosis was established in biopsy, surgical resection of the mass was found in these series. Although spontaneous recurrence was found in this series. Although spontaneous regression of the clinical findings has been reported, we consider surgery to be necessary in CMO in order to establish the diagnosis; furthermore, when the clinical and radiological diagnosis is uncertain or when the lesion causes pain or mechanical blocking of a joint, the removal of the mass is mandatory.

Myositis ossificans traumatica is a benign muscular lesion that is frequently reported in the orthopedic literature, but is not commonly found in the foot. This case report discusses myositis ossificans occurring in the foot. It is most likely subsequent to a heel spur injection received by the patient.

This case reviews a myositis ossificans of traumatic origin discovered beneath the fifth metatarsal in an adult male. Details of its anatomic appearance are illustrated with the assistance of plane film roentgenography and magnetic resonance imaging. Histologic sections are included to support the diagnosis and present characteristic cellular patterns. A review of the literature including etiology, clinical classification, and diagnostic criteria are also presented.

Benign fibrous lesions of the digits can present a considerable diagnostic challenge. Some lesions may resemble sarcomas, resulting in needless amputation. One such benign entity resembles myositis ossificans histologically but presents as an aggressive hand lesions. Unfortunately, this lesion has been given multiple names. It is most appropriately termed florid reactive periostitis. This paper reports a case of florid reactive periostitis in a 12-year-old girl.

A 14-yr-old boy with fibrodysplasia ossificans progressiva (FOP) presented for surgery for bilateral division of his ossified masseter muscles. Patients with FOP may present problems to the anaesthetist, including difficulties with tracheal intubation, restrictive pulmonary disease and abnormalities of cardiac conduction. With our patient sedated the trachea was intubated using a fibrescope and anaesthesia was induced and maintained with nitrous oxide and enflurane in oxygen. Ventilation was controlled throughout surgery and recovery was uneventful.

Two patients with fibrodysplasia ossificans progressiva who presented with jaw immobilization due to formation of bone between the maxilla and mandible were treated with surgical resection of their ectopic bone in conjunction with experimental, adjunctive medical therapy using isotretinoin. Both patients had recurrence of their ectopic ossification within 2 months of surgery. Surgery to remove joint-bridging ossifications in FOP is not recommended.

Computed tomography was performed in five patients with myositis ossificans circumscripta. In three cases, and possibly four, CT scans obtained during the active stage of the pathologic process demonstrated findings that in general corresponded to the "zone phenomenon" seen on histology, although a distinct peripheral ring of ossification was not always present. In these patients, CT was useful in limiting the differential diagnosis and obviating surgery. In the fifth patient, with long-standing myositis ossificans, CT showed complete ossification indicative of the mature phase of the pathologic process and was helpful in planning surgical resection.

An eight-year-old boy presented with massive pseudomalignant heterotopic ossification around the upper femur. The mass was completely excised because of severe pain, systemic illness and a flexion contracture at the hip. Symptomatic improvement was swift, but two weeks later the mass had recurred and was even more extensive. During the subsequent 18 months of conservative management he has been free of pain and there has been progressive resorption and remodelling of the heterotopic bone. There is now no limitation of physical activity and movement at the hip is full.

Pseudomalignant osseous tumor of soft tissues is a rare tumor of the hand. Histopathologic differentiation of this benign lesion from malignant lesions is difficult because mitotic figures are common in typical cases, but bizarre pleomorphic and hyperchromatic nuclei never occur. Wide excision is adequate in most cases, but ray resection is indicated when this benign lesion recurs after wide excision, invades the vital structures, or causes severe functional impairment. Review of the literature revealed 15 cases of this lesion in the digits of the hand, including our case. Of these 15 cases, misdiagnosis of malignancy in three cases and loss of function in an additional four cases led to ray resection.

We observed 52 patients with myositis ossificans localisata partly of a traumatic, neurogenic or morbid (inflammable) origin. The fact that preferably young men are concerned in cases of traumatic and neurogenic myositis ossificans localisata is certainly not only caused by their increased exposition to trauma, but also by disposition. For indication and operative treatment it is necessary to classify as well as radiologically III different stages of development as respective groups of muscles. In posttraumatic and neurogenic cases relapses post operationem may probably be avoided in case, there is a radiological stage III (total development of muscle ossification).

A case is reported of progressive ossifying myositis (fibrodysplasia ossificans progressiva, Münchmeyer's disease) with onset at 16 years of age by a lesion of internal pterygoid with limitation of opening of mouth. Surgery to relieve ankylosis was followed by recurrence. Diagnosis was established only after the appearance of lesions in other regions (sternocleidomastoid, latissimus dorsi, lumbar muscles...). Clinical and paraclinical signs of this exceptionally rare disease are reviewed and diagnostic difficulties at onset of the disease discussed. Treatment of acute myositis episodes with diphosphonates delays passage to the ossification stage, allowing local surgery to be performed with less risk of relapse.