Myositis ossificans refers to the abnormal ossification of the collagenous supporting tissues of tendons, ligaments and skeletal muscles. It is a complication of traumatic bone injury, also known as traumatic ossifying myositis. It belongs to the category of “fracture” in Chinese medicine.
Disease Overview
Myositisossificans is a progressive deposition of bone structures in muscle and connective tissue. The disease is caused by muscle sclerosis, toe and bunion deformities. The etiology is unclear. It is partly inherited in an autosomal dominant pattern. It is common in children or young adults. It presents with a deformed congenital oblique neck, torsion and swelling and stiffening of the neck muscles, but most are not painful. The whole body muscles can be involved. In most patients, the hematoma is absorbed, but it can be followed by muscle stiffness and ossification, eventually leading to joint stiffness and disability of the affected muscle. It should be distinguished from limited ossifying myositis due to occupational disease and traumatic ossifying myositis.
Disease etiology
Myositis ossificans is a condition in which calcification occurs in tissues that are not normally calcified, also known as ectopic ossification. The basic pathological changes are active proliferation of primitive cells in fibrous connective tissue with abundant capillary network and deposition of calcium salts to form bone. Mature heterotopic ossification has the structure of bone, with an outer layer wrapped in fibrous connective tissue and an inner
ossifying myositis
osteoblasts with trabecular junctions and osteoid tissue, with active primitive cells in the center. In principle, early heat therapy, ultrasound, and massage of the involved area should be avoided. Slow. Gentle exercises can prevent contractures. Progressive motor exercises should be used. Inappropriate treatment can worsen ossification, and resection of ossification that prevents movement must wait until 9-12 months or until the ossification is mature and the ossification is quiescent. Most of the time, ossifying myositis has a clear history of trauma, occurs within the muscle, and the main pathological change is the mechanization or calcification of the hematoma. It is a disease of muscle sclerosis, toe and bunion deformities caused by the deposition of progressive bony structures within the muscles and connective tissues. The etiology is unclear. It is partly inherited in an autosomal dominant fashion. Four factors have been reported to produce ossification.
1, irritation factors: often contusions accounted for 60% to 70%, can lead to hematoma. This injury can be very mild, only a small amount of skeletal muscle or myogenic fibers are damaged.
2, injury signal: injury tissue or cells secrete a signal protein.
3, the presence of mesenchymal cells with defective gene expression, these cells can generate bone-like or cartilage-like cells after receiving the appropriate signal.
4, the existence of continuous occurrence of ossified tissue environment, of which the signaling gene is the most critical, Urist named the gene BMP.
Pathogenesis
Osteomyositis is caused by poor fixation, repetitive rough rectification techniques, passive activities after fracture or dislocation in or near the joint, or premature passive and forceful activities soon after dislocation and before the periosteum is reconnected to the bone, resulting in proliferation of fibrous tissue and bone or osteogenesis. According to traditional Chinese medicine, it is caused by traumatic stagnation, loss of harmony between qi and blood, intertwining of stagnant blood and fascia, formation of masses and hard knots over time, and causing hematoma ossification. It mostly occurs at the muscles of joints, quadriceps, adductors, upper arm muscles, small, hip, knee, shoulder and elbow.
The diseased tissue is mostly muscle, but can also be fascia, tendon, and periosteum. Fibroblasts and mesenchymal cells proliferate after muscle injury and cool silk fibrosarcoma or muscular sarcoma. The cellular zoning is characteristic, with a central zone of highly aggregated cells, a second zone of fibroblasts at its periphery, and then a third zone of mature new bone capable of localization. When there is a pool of blood in the central zone due to hemorrhage, the tissue resembles a giant cell tumor and should be differentiated. In the case of fascial tumors, the presentation is similar to the above, but does not contain muscle fibers. Those with tendon stops may form an exophytic bone wart. In the case of periosteum, it may eventually lead to osteochondroma.
Clinical presentation
A history of previous trauma without any post-treatment, especially soft tissue injuries near the joint. If the injury often occurs in the anterior humerus muscle or the anterior horn of the spinal cord, it presents with swelling and pressure pain in the elbow joint area and limited passive and active movement of the elbow joint. Subsequently, the pain and swelling subside and a mass can be felt in the anterior aspect of the elbow joint, and the function of the elbow joint is affected by the presence of the mass. It can also be seen in the deltoid and adductor muscles.
1. There is often a history of elbow injury, mostly in adolescents.
2. Early on, the pain is mainly when the elbow joint moves, and the movement of the elbow joint is limited.
3. Abnormal bone masses can be felt around the elbow joint, which can gradually increase in size and then slowly retract until the bone masses mature.
Types of disease
There are two types of disease, traumatic ossifying myositis and progressive ossifying myositis. The most common type is traumatic ossifying myositis.
1. Traumatic ossifying myositis
Traumatic ossifying myositis, also known as limited ossifying myositis, shows only a single lesion. Most often seen before the age of 30. It often occurs after trauma, but there are a few cases that are complicated with other diseases, such as those occurring in hemiplegia, anterior spinal cord gray leukomalacia, anterior spinal cord gray leukomalacia, burn or tetanus patients. After trauma, intra-soft tissue bleeding may be the cause of ossification. Calcification and ossification in the soft tissues often appear 2-3 weeks after trauma. Lesions are often found in areas susceptible to trauma, such as the elbow, femur, and hip. The lesion is laminar in the direction of the backbone of the adjacent long bones and may be associated with adjacent bones in one or more places. The lesion rarely extends to the ends of the bones and joints. Osteosynthesis occurs in the anterior humerus muscle and is characterized by swelling and pain in the elbow joint area and limited passive and active movement of the elbow joint. After the pain and swelling have subsided, a hard, well-defined mass can be felt in the front of the elbow joint. The elbow joint extension and flexion are limited because of the inelasticity of the muscle; flexion is also significantly limited because of the blockage of the mass.
2.Progressive ossifying myositis
Progressive ossifying myositis is a congenital hereditary disease, sometimes manifested as a familial disorder. It is more common in males and often develops in infants or children. The disease is often detected in the first few years of life. Early symptoms include pain, heat, and swelling in the affected area, followed by a hard mass in the subcutaneous tissue of the back, neck, and shoulders, with severe pain or pressure. At this time, fever may be combined. As the lesion becomes gelatinized, the mass in the subcutaneous tissue gradually shrinks to a hard and fixed mass. At this point, the symptoms of the acute phase disappear temporarily, and x-ray examination can already show that there are calcium salt deposits in the lesion. New lesions may then appear. As a result, a group of muscles, tendons and ligaments may be involved one after another. Minor trauma can aggravate the disease, so biopsies should be avoided. The disease stops progressing after about 30 years of age. The disease has a poor prognosis and is most often seen in chronic starvation due to respiratory impairment or chewing starvation ossification. The disease is treated by using Chinese herbal medicine and evidence-based treatment, using methods of moving Qi and blood, resolving blood stasis and clearing ligaments, eliminating swelling and dispersing nodules, and bringing the body’s yin and yang qi and blood into balance and order through overall regulation. The earlier the disease is treated, the better the effect. The combination of external application of Chinese medicine and oral Chinese medicine punch is highly effective and fast recovery in treating this disease, which can make the calcified muscles absorb and recover their functions to achieve the purpose of recovery.
Auxiliary examination
The auxiliary examination method of this disease is mainly X-ray examination: X-ray examination is characterized by limited swelling soon after the injury. At 3-4 weeks after the injury, the swelling will show hairy dense images and the adjacent bone will show periosteal reaction. At 6-8 weeks post-injury, the margins of the lesion are clearly surrounded by dense bone and have the appearance of new bone. The core of the soft tissue mass is sometimes cystic and gradually enlarges its internal cavity to show an eggshell-like cyst in advanced stages. The mass shrinks 5-6 months after injury, resulting in a translucent x-ray zone between the mass and the adjacent cortical and periosteal reaction.
Complications
The disease can cause muscle rupture, hemorrhage and hematoma formation due to strenuous exercise or trauma; in most patients, the hematoma resolves, but it can also be followed by muscle stiffness and ossification, eventually leading to stiffness and disability of the corresponding joint of the affected muscle. The disease can also be malignant, and its aggressive features include invasion of the muscle envelope, bone, neurovascular bundles, and peripheral or distant metastases.
Disease Treatment
The staged treatment method of ossifying myositis by combining Chinese and Western medicine
1. Early stage (reactive stage).
Local soft tissue masses, sometimes fever, pain, and limited joint movement. x-ray radiographs show irregular cotton wool fuzziness in the soft tissue or cloudy calcification shadows around the joint. in the case of ossifying myositis of the elbow joint, gentle and moderate stroking, touching, kneading, pushing, flicking, and plucking techniques are used on the forearm extensor and flexor muscles, biceps and triceps near the elbow joint. The operator then holds the wrist of the affected limb in one hand and the middle of the upper elbow joint in the other hand, and then applies light continuous traction. The operator then holds the wrist of the affected limb and then gently performs painless inversion, abduction, anterior and posterior flexion and extension shaking and circular rotation of the elbow joint, avoiding violent manipulation and massage stimulation of the local mass and joint capsule. Do not use force to pull and stretch the elbow joint, and do not use hard inversion, abduction, anterior and posterior flexion and extension. During the manual treatment period, we also cooperate with local fumigation and instruct the patient to perform active functional exercises of the elbow joint without pain or with slight pain.
2.Middle stage (active stage).
Fever, high local skin temperature, pressure pain, hard mass. X-rays show a large amount of lace-like new bone around the swelling with clear boundaries, and after a period of time, the swelling stops developing and shrinks to form a denser ossified mass. the middle of the forearm of the affected limb. Gentle and slightly forceful gradual passive flexion and extension of the elbow joint, often can be heard ossifying myositis fracture sound, and adhesion tearing sound at this time the passive activities of the elbow joint can reach the basic normal range. If bony obstruction is encountered, do not force passive flexion and extension to avoid reoccurrence of fracture, and wait until the ossified tissue is gradually mature and limited. Surgical treatment should be performed. After the manual treatment, local fumigation treatment should be performed and the patient should be instructed to perform functional exercises with active movement of the elbow joint as the main activity and passive movement as a supplement when the pain is tolerable.
3. Late stage (ossification stage).
No local pain, severe muscle stiffness and atrophy, joint straightening in a certain position or only a slight degree of mobility, radiographs show shell-like bony cartilage ossification, the scope of limited ossification is obviously dense, surgical excision of ossified tissue and joint release, using the lateral elbow incision in the humeral epicondyle crest, respectively, to the front and back of the elbow, reveal the ossified tissue and then remove it and completely release the adhesions, before closing the incision should be loose Before closing the incision, a tourniquet should be loosened, and negative pressure drainage should be placed carefully to stop the bleeding.
Chinese medicine fumigation
According to the treatment principle of relaxing tendons and activating blood circulation, dispersing blood stasis and relieving pain, warming the meridians and channels, and softening and dispersing knots, the following formula is used for fumigation twice a day for 30 min each time, and each dose is fumigated for 3 days, and 10 days is a course of treatment. Prescription: 30g of hen’s blood vine, 30g of raw nanxing, 30g of safflower, 20g of wood turtle seed, 15g of raw erwu, 25g of papaya, 25g of trigon, 25g of curcuma longa, 30g of haitongpi, 30g of lutong, 30g of mulberry branch, 30g of cinnamon branch, 15g of shanjia. Wrap the upper medicine with cloth, soak it in cold water for 20-30min, then heat and boil it, and pour it into a basin after 30min to first smoke and then wash the affected area.
Manual treatment
1, the patient takes a sitting position, the operator stands on the affected side of the operator to hold the palm of the affected limb, the other hand thumb, index finger from the shoulder using the “wisp method” slowly down wisp smooth, wisp, every other section wisp pinch 1 time, in order to achieve the purpose of tendon division.
2.The operator’s right thumb uses the Shun method to knead from the shoulder, arm to the Quchi, Hand San Li, Hegu and other points to achieve the effect of pain relief.
3.The operator uses the “rubbing method” to rub the palms of both hands from the armpit to the elbow and down to the forearm, first lightly and then heavily, from heavy to lightly, in order to achieve the effect of relaxing the tendons and loosening the tendons.
4.The operator holds the distal end of the affected limb with one or both hands, and uses the “transport and pull” method to tug homeopathically, with no rough pulling force, so that the function of the affected limb is gradually restored.
5.The operator fixes the upper arm of the affected limb with the left hand, holds the wrist with the right hand, and uses the “flexion method” to bend the palm of the affected limb toward the shoulder. At this point, the operator should apply even force and not be in a hurry. To avoid aggravating the soft tissue injury of the elbow. The above techniques are performed after the first fumigation and repeatedly applied 3 times. The duration should be 15 minutes, once a day.
Radiation therapy
Radiation therapy effectively prevents the formation of limited ossifying myositis by altering the DNA and affecting the rapidly dividing cells, preventing the differentiation of mesenchymal stem cells into osteoblastic stem cells. Radiation therapy can be used in cases of limited ossifying myositis due to repeated revision after fracture, especially after removal of the ossified mass in order to prevent recurrence.
Rehabilitative interventions
Reducing local pressure and moving the affected limb is the basic method of preventing the disease. As soon as ossifying myositis is suspected, passive activities should be stopped and active activities should be limited to the pain-free range. Osteomyositis can cause localized pain, sometimes severe, and is effectively treated with local injections of lysine aspirin.
Massage method
As early as in the Yellow Emperor’s Classic of Internal Medicine “Su Wen? The pain is relieved when the blood is dispersed, and the pain is relieved when the blood is pressed”, and also said: “The pain is relieved when the heat is pressed, and the heat is relieved.” Su Wen? Blood gas shape Zhi chapter, “the shape of the number of panic, the meridians do not work, the disease is born in the unkind, treated with massage and mash medicine” records. It can be seen that its long history. Through massage can play a relaxation of tendons and channels, remove blood stasis and new, loosening tissue adhesions. Functional exercise can accelerate blood circulation, improve local metabolism and massage complement each other, together with warming the meridians, blood circulation, blood circulation, eliminate wind and dampness, moving qi to relieve pain, softening and dispersing the knots of Chinese herbal fumigation, in order to achieve the purpose of healing.
Rehabilitation Training
Shoulder joint
1.Hands-on training
(1) Crossing the waist and backhand: mainly training internal rotation.
(2) Head touching: one or both hands touching the head, mainly training external rotation.
(3) prostration: lying on the ground with upper limbs extended, hands on the ground, using the hips to move in and out before lifting the shoulder.
(4) sitting at the table: the affected hand on the table, using their own weight in all directions of activity.
2.Apparatus training
(1) Gymnastic stick training; use the healthy hand to carry the affected hand for shoulder joint activities.
(2) Pulley training; through the pulley above the head, use the healthy hand to drive the affected hand to abduct and lift up, but this method is easy to cause shoulder pain.
(3) Swing training; bend down on a high platform and hold the appropriate weight for shoulder movement in various directions.
(4) Scapular ladder; using fingers to climb up the wall with small steps of ribbed wood.
(5) Scapular wheel; train shoulder abduction and rotation at the same time.
3.Passive training
(1) Full range of motion; performed by the therapist according to anatomy and physiology, it is the most effective method with the least side effects.
(2) Proprioceptive neuromuscular easing method.
(3) Loosening technique.
Disease prevention
This disease is a complication of severe trauma, and its occurrence and development can be stopped by efforts. All patients with joint dislocation and severe trauma. Should promptly consult an orthopedic surgeon, do not blindly pushing, massage cause secondary injury, joint dislocation. If there is a large hematoma, it should be promptly punctured and extracted with pressure bandage, and early braking is appropriate for joint trauma. If there is swelling, it is advisable to combine Chinese and Western medicine to make the swelling subside rapidly. For patients with paraplegia caused by spinal cord injury, if a large hematoma of unknown origin is found in the lower extremity, it should be punctured and extracted in time and wrapped with pressure, which are effective methods to prevent secondary ossifying myositis after severe trauma.