Topics in diagnostic imaging
Ultrasonography and Radiography to Identify Early Post Traumatic Myosistis Ossificans in an 18-Year-Old Male: A Case Report

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Abstract

Objective

The purpose of this case report is to describe a patient with post traumatic myositis ossificans (PTMO) of the anterior thigh following blunt trauma and discuss the incidence, clinical presentation, management, and imaging findings.

Clinical features

An 18-year-old male presented to a chiropractic clinic with a chief complaint of left knee pain and reduced range of motion after an impact injury to his left anterior thigh during hurdling 6 weeks earlier. Immediately after the injury, he presented to the emergency department where radiography of the left knee was negative and he was diagnosed with a muscle sprain. Follow-up radiography and ultrasonography of the left knee in a chiropractic radiology department revealed ossification consistent with PTMO within his vastus intermedius.

Intervention and outcome

The patient underwent a course of rehabilitation for 2 months including ice, class IV cold laser and vibration applied to his anterior thigh, and myofascial release of his quadriceps musculature with targeted and progressive rehabilitative exercises. His left knee pain resolved within 2 weeks of care. He resumed sports participation (American football) pain-free, while wearing protective padding over the affected thigh, 1 month after presentation, which was approximately 2 1/2 months following his injury.

Conclusion

This case demonstrates that ultrasonography may have the capability to detect early phases of PTMO approximately 2 weeks prior to radiographic evidence and to monitor progression throughout its course.

Introduction

Post traumatic myositis ossificans (PTMO) is a well understood, although uncommon, clinical entity.1 There are several subtypes of myositis ossificans (MO) including PTMO, nontraumatic/pseudomalignant myositis ossificans, and myositis ossificans progressive (congenital form).2 Over 90% of sports related injuries are diagnosed as muscle strains or contusions with PTMO developing in approximately 9% to 20%.1, 3, 4 PTMO develops commonly after a single direct blow to the musculature or through repetitive minor trauma.5 Patients report a history of trauma in 60% to 75% of cases.5, 6 The formation of MO without history of trauma may be related to increased levels of neuro-inflammatory Substance P.7 Although any muscle can be involved, the most common location for PTMO is the anterior thigh musculature.8 Signs and symptoms typically include pain, edema, swelling, and decreased range of motion with a palpable mass.9, 10, 11 This entity increases morbidity with its relationship to pain, loss of range of motion and function, and local tenderness lasting an average of 1.1 years.1, 10, 11 Ryan et al found that development of PTMO was associated with the following 5 risk factors: knee flexion less than 120°, injury during football, previous quadriceps injury, delay in treatment more than 3 days, and ipsilateral knee joint effusion.3

Histologically, PTMO represents degeneration and necrosis of damaged muscle tissue resulting in bone formation.5 Differential diagnosis includes hematoma, abscess, focal rhabdomyolysis, and malignant primary or secondary soft tissue tumors.12 Early and accurate diagnosis is imperative as many symptoms overlap and appropriate treatment is vital to an optimal outcome.12 Various imaging techniques are available to evaluate the presence and progression of PTMO including radiography, computed tomography, magnetic resonance imaging (MRI), skeletal scintigraphy, and diagnostic ultrasonography (US). US is a sensitive modality in the detection of PTMO and is at the forefront of investigation into musculoskeletal athletic injuries; however, only a few case reports describing the US appearance of PTMO have been reported.5, 13 The purpose of this study is to present a case of an 18-year-old male hurdler and an American football player that was diagnosed with PTMO utilizing radiography as well as US and monitored with interval follow ups.

Section snippets

Case Report

An 18-year-old male track and American football athlete presented to our clinic with a chief complaint of left knee and thigh pain. Patient consent was provided for publication of de-identified clinical information and images. Six weeks prior, while running, he impacted his left anterior thigh on a hurdle. At that time, he went to the emergency department where radiography of the femur was performed and interpreted as negative. He was diagnosed with a strain of his left quadriceps.

Discussion

This case demonstrates the use of US and radiography to identify and monitor PTMO within the vastus intermedius. PTMO is a condition characterized by heterotopic bone formation in the soft tissues including muscle, fascia, tendons, joint capsules, and ligaments following trauma.9 Incidence is higher in males and usually between 30 to 40 years old.10, 11 Symptoms include pain and local tenderness, edema, swelling, decreased range of motion, stiffness, and a palpable mass.10, 11 In a study of 26

Limitations

Case reports have limitations. Generalization of the diagnostic findings represented in this case may not necessarily apply to other patients and the patient may have improved regardless of care rendered. The patient dropped out of care and was lost to follow up so further imaging was unattainable, thus we were not able to definitely report final outcomes.

Conclusion

This case demonstrates that ultrasonography may have the capability to detect early phases of PTMO approximately 2 weeks prior to radiographic evidence and to monitor progression throughout its course. Careful clinical evaluation is required along with an understanding of the pathophysiological timing of PTMO (zone phenomenon) in order to prevent a false-positive diagnosis of an extraosseous sarcoma or conversely overlook the presence of a malignant lesion.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

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