Myositis ossificans (Sterner's Tumor) Plain radiography of nonhereditary myositis ossificans
Comprises two syndromes characterized by heterotopic circumscripta
ossification (calcification) of muscle. -Early examination may be unremarkable.
a) In the first, and by far most common type, nonhereditary -Floccular calcified density is observable in soft tissues at 2-6
myositis ossificans (commonly referred to simply as "myositis weeks from onset.
ossificans", calcifications occur at the site of injured muscle, -By 6-8 weeks, calcification becomes sharply circumscribed.
most commonly in the arms or in the quadriceps of the thighs. -Ossifications tend to adhere to the periosteum.
b) The second condition, myositis ossificans progressiva (also -Obtain serial radiographs to distinguish between myositis
referred to as fibrodysplasia ossificans progressiva) is an ossificans and osteogenic sarcoma. In osteogenic sarcoma,
inherited affliction, autosomal dominant pattern, in which the calcification extends centrifugally to periphery. In myositis
calcification occurs without injury, and in a predictable ossificans, calcification first occurs in the periphery of the soft
pattern. tissue mass (centripetally). Myositis ossificans' calcification
Myositis ossificans usually presents with pain, tenderness, occurs in association with the bone's diaphysis, unlike
focal swelling, and joint muscle reduction, in the aftermath of osteogenic sarcoma, where calcification is associated with the
a painful muscle contusion which resolved more slowly than metaphysis
expected, if at all. Myositis ossificans occurs most commonly in the second and
The condition rarely is asymptomatic, and may sometimes be third decade in the arms and thighs of patients who have
diagnosed from radiographs obtained for unrelated problems. experienced some sort of trauma. The quadriceps and
Most (ie, 80%) ossifications arise in the thigh or arm, and are brachialis are the most affected. Myositis ossificans
predisposed to by a too-early return to activity after an injury. presents as a rapid enlargement and significant pain one to two
Other sites include intercostal spaces, erector spinae, weeks after injury. The patient has swelling and warmth at the
pectoralis muscles, glutei, and the chest. site as well as an increased ESR and serum alkaline
phosphatase. The clinical picture differs from that of
When a severe injury with hematoma is recognized, it is osteosarcoma (which is often on the differential as the age
important to splint the extremity and avoid activity. If further groups are the same) as the pain from myositis ossificans
trauma causes recurrent injury, ossification may reach decreases as time goes on where osteosarcoma pain increases.
spectacular proportions and resemble an osteosarcoma. Myositis ossificans appears on plain-film at approximately
Hazy densities are sometimes noted ca. one month after 2-4 weeks after injury. The lesion begins to calcify at the
injury, while the denser opacities eventually seen may not be periphery and works toward the center. At less than three
apparent until two months have passed weeks post-trauma, bone scan demonstrates increased uptake
Treatment is initially conservative, as some patients' in the area. Osteosarcoma calcifies at the center and continues
calcifications will spontaneously be reabsorbed, and others to the periphery. CT scan helps delineate a central
will have minimal symptoms. radiolucency surrounded by a dense periphery.
Disability is great, with local swelling and heat and extreme On gross examination, myositis ossificans has a shell of
pain upon the slightest motion of the adjacent joint. The limb bone and a soft red-brown center. The mass may be attached
should be rested, with the knee in extension or the elbow in 90 to the bone by a stalk or might be in continuum with the
degrees of flexion, until the local reaction has subsided. periosteum. Alternatively, the mass may be attached only to
After local heat and tenderness have decreased, gentle active the muscle.
exercises may be initiated. Passive stretching exercises are not Microscopically, myositis ossificans appears different at
indicated, because they may stimulate the ossification the periphery and the center. Acutely, there is proliferation of
reaction. undifferentiated mesenchymal cells that infiltrates the muscle.
Use of indomethacin to reduce pain and inflammatory At approximately 2-3 weeks, osteoid
reaction. production begins at the periphery and fibrous tissue begins to
It is occasionally necessary to excise excessive bony tissue if form around the shell. The center of the lesion will be an
it interferes with muscle function once the reaction is mature. irregular mass of immature fibroblasts. Moving towards the
Surgery should not be attempted before 9 months to 1 year edge, there will be islands of disorganized osteoid. At the edge
after injury, because it may restart the process and lead to an of the lesion, trabeculae of lamellar and woven bone are
even more severe reaction. present. There may be a cartilage component as well. This
process is in contrast to osteosarcoma where the ossification
begins at the center of the lesion.
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