Presented by: Anggiat Humusor Ulina

C11107226
Advisor : dr. Hendrian Chaniago Supervisor: dr. Karya Triko, Sp. OT. (K) Spine
Orthopedic dan Traumatology Faculty of Medicine Hasanuddin University Makassar 2011

Pathologic

bone formation as a consequence of direct trauma or central nervous system injuries Bone formed in heterotopic locations such as muscle, subcutaneous tissues, or nerves Most commonly occurs at the hip, elbow, and shoulder joints

Less

common in children than in adults, and more common in males than in females. Incidence: Occurs in 10%-20% of patients with central nervous system or traumatic injuries, with an average onset of 2 months after injury.

A: Anterolateral/anteromedial location; B: Inferior and medial location; and C: Location around the femoral neck and posterior.

Central

nervous system injury Osteoarthrosis Osteophyte formation Surgical approach Previous surgical procedures Trochanteric osteotomy

Traumatic brain injury

Spinal cord injury

Trauma Associated Conditions Fibrodysplasia ossificans progressiva Primary osteoma cutis

 Signs

and Symptoms

Unexplained increase in pain, spasticity, or muscle guarding Decreased ROM Stiffness Radiographic evidence of ectopic bone

Physical

Exam

Limited ROM is the most common and earliest sign. Erythema, swelling, and signs of inflammation also may be noted.

Lab Serum alkaline phosphatase levels are elevated. Value begins to rise 2-3 weeks after injury. Imaging On plain radiographs, new bone formation may be 1st visible at 3-6 weeks; but radiographs generally are not confirmatory until 3 months. Bone scans allow for earlier detection and show intense uptake. CT may be used for preoperative planning and to show the zonal pattern: Mineralized in the periphery and lucent in the center.

Pathological
Initially,

Findings

an intense inflammatory response occurs with myofibroblasts and osteoblasts. Such a high degree of cellular activity occurs that the inflammatory response can be mistaken for a neoplasm.

Septic

joint Thrombophlebitis Neoplasm in the soft tissues

 General

Measures

Joint motion is maintained to allow normal functioning. Most patients are treated successfully with nonoperative measures, including physical therapy, analgesics, and NSAIDs. Few patients require surgical excision.
Special

Therapy

Radiotherapy
Radiation therapy is ineffective once heterotopic ossification has been documented.

When used for prophylaxis, it must be delivered within 72 hours.

Physical

Therapy

Use ROM exercises and treatment modalities that are designed to increase joint mobility.

First

Line Anti-inflammatories are used to prevent or to lessen the amount of heterotopic ossification formation after the initial insult and to prevent recurrence after surgical excision.
Indomethacin,

naproxen, or other NSAIDs for 6 weeks

Surgery is indicated to restore joint motion or to correct contractures in disabled patients, it should not be resected earlier than 6 months after injury. Excision after 2 years increases the likelihood of permanent contractures. After resection, patients are treated with low doses of irradiation (must be delivered within 72 hours). Some patients elect to take NSAIDs (e.g., indomethacin) for 6 weeks after resection.

For effective prophylaxis, the medications must be taken. Gastric intolerance prevents 1020% of patients from taking these medications.

Prognosis
Prognosis

varies, depending on the location of heterotopic ossification and its cause. Most patients with nonneurogenic heterotopic ossification maintain reasonable function and do not require surgical intervention.

Complications
Loss

of mobility Ankylosis
Patient
Serial

Monitoring

radiographs are obtained at 1-3 month intervals for 6 months.