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Ectopic bone deposits
ECTOPIC BONE DEPOSITS* A PARAPLEGIC MAURICE
B. ROCHE,
M.D.
COMPLICATION
AND
FREDERICK A.
JOSTES,
M.D
St. Louis Missouri
L
ITERATURE deaIing with injuries of the spinal cord, the subsequent paraIysis and compIications is growing rapidly. Emergency handIing and transportation, the diagnostic phase of neurologic and orthopedic appraisal, whether or not and when to operate, probIems of urinary management, occurrence and prevention of decubitus uIcers, nutritional problems, importance of skiIIed, sympathetic and continuous nursing-al1 these matters have been dweIt upon thoroughIy in other pIaces and wiI1 not be repeated here. Accent has been placed upon each in turn, and suffice it to say, each and a11 must be successfully managed. Satisfactory rehabiIitation means saIvaging as much of a toIerabIe and productive future for the patient as the severity of his affhction wiI1 aHow. It means he must have successfuIIy escaped the hazards of urinary sepsis and decubitus disease and has won out to at Ieast a wheeIchair existence. There is a parapIegic compIication mentioned intermittentry in recent Iiterature which merits much more emphasis. If at Ieast a wheeIchair existence is the goa toward which a11 the intensive and tedious medica and surgical measures are directed, this paraplegic compIication can and on occasion does obstruct that objective. In an issue of the U. S. Army BuIIetin a preliminary report’ appeared. In this report a study was made of sixty-two cases of parapIegia resuIting from disease or injury of the spinal cord or cauda equina. Twenty-three of these patients showed ectopic deposits of trabecuIated bone within the muscIes or fascia1 pIanes, principaIIy over the hip and knee joints. Those patients showing degrees of recovery in *From the Department
function seemed to escape this additional compIication for onIy three developed osseous deposits. Of thirty-five unimproved cases, twenty showed ossifications. An anaIysis of dermatome IeveIs in the patients with ossification showed no prediIection for any particuIar IeveI. Nor did there appear to be, in comparison with the undifference affected group, any “significant with regard to sites or severity of injuries, time of operative treatment, presence or absence of decubitus ulcers, urinary tract infection or associated injuries or .infections, or blood caIcium and total protein Ossifications were said to be IeveIs.” recognized as earIy as forty days foIIowing cord injury. The foIlowing cIinica1 case is cited to caI1 attention to the important fact that parapIegics are not out of the woods and into the cIearing of manageabIe convaIescence and rehabihtation if the compIication of ectopic bone deposits is not anticipated and an effort made to prevent their deveIopment. CASE
REPORT
In June,
1945, a patient was admitted to the NavaI Hospital at which one of us (M.B.R.) was stationed. He was a twenty-two year old male, navy veteran with paraIysis of both lower extremities, a decubitus uker over his sacrum and inabihty to sit normarly or comfortably for any period of time in a wheelchair. WhiIe in boot-camp training he had sustained an acute onset of iIIness on February 14, 1943, with rapidly progressing paralysis of both lower extremities. A diagnosis of extradural inffammatory process was made and a Iaminectomy of the third, fourth, fifth and sixth dorsal vertebrae was performed in hlarch, 1943, Convalescence which verified the diagnosis.
of Surgery, Washington
633
University
School of Medicine,
St. Louis, MO.
634
American Journal of Surgery
Roche,
Jostes-Bone
FIG. I. G. D. D., age twenty-two years; anteroposterior view. Massive bridges of coarsely trabeculated but otherwise normal appearing bone extend from the anterior portions of both iIia and the Iower rims of both acetabuli to the anterior portions of the head, neck and upper fourths of both femora. The structure of the hip joints and femora are readiIy seen through the abnorma1 bone masses and present a normal appearance except for advanced atrophy. The hip joint spaces are not narrowed. On the left side some of the bone mass appears fractured medial to the femoral neck.
had incIuded periods at two veteran’s hospitals until JuIy, 1944, at which time he was discharged to his home. The paraIysis of both Iower extremities, present before the operation and persisting thereafter, showed Iittle aIteration as time went on. A finding of note in his physica examination was the presence of soIid, hard masses over the anterior aspects of both hip joints. The right hip joint was soIidly ankyIosed in about 30 degrees of flexion while on the Ieft there was an additiona IO degrees due to as much range of motion. The patient dated the onset of his acute iIIness as of February 14, 1943. From a transcript of his history the statement was noted that on March IO, 1943, he noticed a swelling for the first time deveIoping over his right hip which became progressiveIy larger. This wouId date the appearance of the ectopic bone deposits as less than four weeks after the acute onset of the iIIness. During the course of his convaIescence he was fitted with double, upright braces. With these and the aid of crutches he was abIe to waIk tripod fashion across the room and for a distance aIong the corridor. Fatigue of his upper extremities, of
Deposits
APRIL, 1948
course, made this a self-limiting activity. He was able to move his bowels by means of abdomina1 pressure and to empty his bIadder by means of manual compression. Roentgenographic studies of his dorsa1 vertebrae disclosed the surgica1 absence of most of the Iaminae and spines of the third, fourth, fifth and sixth dorsal segments. There was no abnorma1 soft tissue calcification or ossiiication. The anteroposterior (stereoscopic), (Fig. I) and lateral views of the lumbar spine and peIvis showed massive bridges of coarsely trabeculated but otherwise normal appearing bone extending from the anterior portions of both ilia and the lower rims of both acetabuli to the anterior portions of the heads, necks and upper fourths of both femora. The structure of the hip joints and femora could be readiIy seen through the abnormal bone masses and presented a norma appearance, except for advanced atrophy. The hip joint spaces were not narrowed. On the Ieft side some of the bone mass appeared fractured in the region medial to the femora1 neck. The patient spent much of his time Iying in bed between his ambuIatory excursions rather than in a wheeI-chair. This preference couId not be discouraged nor, on the other hand, could he be prevaiIed upon to sit for any prolonged period in a wheel-chair. Because of the extension deformity of his hips such sitting was only possibIe by using the fuI1 fIexibiIity of his lumbar spine. He sat on his sacrum rather than on his buttocks and hence the persistentIy recurring decubitus uIcer. If the compIication of ectopic bone about the hips had not intervened, this patient would certainly have been an exampIe of satisfactory rehabiIitation. As a resuIt of such and simiIar observations, the authors thereafter and in private practise have been making speciaI efforts to foresta the deveIopment of this compIication in the management of parapIegics. It is their beIief that the setting of the ossification pattern, if it deveIops, wiI1 do so in the earIy stages of recumbency; that is, in the immediate interva1 of bed rest foIIowing the onset of parapIegia and unti1 such time as the patient is able to be sat up and Iater stood up for training in tripod waIking. As was noted, this may be within the first four to six weeks of re-
VC,L.. LXXV.
No.
J
Roche,
Jostes-Bone
Deposits
American
Journal
01 Surgery
635
FIG. 2. Narrow sIings of softIy padded moleskin flannel are made to fit about the heels and around the knees of the patient. These are attached to cords suspended from pulleys and disposed in such a manner that the patient himself by exerting traction can lift each extremity until the ankle, knee and hip joints flex to a complete 90 degrees. Soft pilIows are placed under the thighs and legs so overIapping as to allow 3 to ro degrees of flexron of the knees and hip joints. Rolled pillows are placed between the feet and the foot of the bed to maintain the former at right angle position to the legs. The pillows beneath the legs are sufficient thickness to prevent the heels from lying c!irectly upon the bed. To prevent continuous internal rotation and adduction contractures of the lower extremities, a small well padded block of proper dimensions is placed between the knees. The head of the fracture bed is raised slightly to relax the abdomina1 muscles.
cumbency. Mobilization as earIy as possible wouId seem to be the key-note. During the initiaI period of recumbency, it has been the practice to begin physica conditioning of the patient from the very beginning. Much of this effort has been directed toward the deveIopment of the upper extremity, shouIder girdIe and trunk muscles in anticipation of the eventua1 management of crutches in tripod ambuIation. Because of the possibiIity of ectopic bone deposits ankyIosing the hip joints and perhaps less frequentIy but just as definitely the knee joints, the powerless lower extremities shouId just as assiduously be carried through a complete range of motions in a passive manner. This is accomplished by a simpIe and time-honored device. Narrow slings of softly padded moIeskin flannel are made to tit about the heels and around the knees of the pa-
tient. These are attached to cords suspended from puIIeys and disposed in such manner that the patient himself by exerting traction can Iift each extremity unti1 the ankle, knee and hip joints ffex to a compIete 90 degrees. (Fig. 2.) This is his task in the program of his own rehabiIitation; he beIieves he is heIping to accompIish his own come-back; and because he enjoys doing it, it is good for his moraIe. Nor does he have to depend upon others to get this particuIar job done. ‘I he patient is pIaced on a two-segment air mattress in a fracture bed. Soft pillows are placed under the thighs and Iegs so overIapping as to aIIow some 3 to I o degrees of flexion of the knees and hip joints. RoIIed pillows are pIaced between the feet and the foot of the bed to maintain the former at right angle position to the legs. The pillows beneath the legs are of suffi-
636
American Journal of Surgery
Roche,
Jostes- - Bone Deposits
FIG. 3. J. E. S., age thirty years; anteroposterior view. There is a large amount of ectopic bone lying in the soft tissue anterior to the inferior portion of the ilium, the hip joint and atong the media1 aspect of the right femur, ending just betow the lesser trochanter; traumatic transection of the cord sustained five months previousIy.
cient thickness to prevent the heeIs from lying directIy upon the bed. To ward off continuous interna rotation and adduction contractures (both deformities being encouraged by the intermittent spastic seizures), a smal1 we11padded bIock of proper dimensions is pIaced between the knees. The head of the fracture bed is raised sIightIy to reIax the abdomina1 muscIes. For a period in the morning and again in the afternoon, the patient is transferred from the fracture bed and Iaid face downward upon a cart. The prone position on the cart with feet resting downward over the end, provides compIete extension of the knee and hip joints, aIso an ampIe period of time for skin care. The cart can then be moved to the sun porch or such other place as wiI1 provide a change of scene. As soon as is feasibIe, this routine of resting face downward on a cart is eIiminated by getting the patient up in a wheeIchair. He is then abIe to get about under his own power to visit about the ward and to go outside for varying periods when the weather aIIows. During the interva1 of are recumbency, his I ower extremities
measured for braces and, after a reasonabIe period in a wheeI-chair, he is next fitted with his braces and, first in a waIker and eventuaIIy with crutches, he is taught to ambuIate tripod fashion. WhiIe no proIonged periods of waIking are possibIe, the genera1 stimuIation of the upright position and weight-bearing both to his genera1 health and to his moraIe is extremeIy worth whiIe. It is yet another means of defeating the untoward influences of recumbency and, therefore, of the tendency for a continued decaIcification of his bones. Genera1 immobiIization for a proIonged period depIetes the caIcium store of the whoIe skeleton, as has been observed in x-rays, and by the abnormaIIy increased amounts of caIcium in the bIood stream and urine. The byproduct of this hypercaIcemia and hypercaIcinuria is the deveIopment of caIcuIi in the renaI pelvis and ureters. Whether there is a further refIection of this pathoIogic process in the formation of ectopic bone remains to be demonstrated. Some wouId add a neurogenie factor. But we have yet to encounter such a compIication as ectopic bone about the hip joints in parapIegic cases resuIting from anterior poliomyelitis. In the Iight of our present knowIedge, it is therefore reasonabIe to attack the probIem and foresta the appearance of this compIication by eIiminating the factors which tend to mobiIize skeIeta1 caIcium, enforced recumbency and generaIized immobiIization. REFERENCES I. SOULE, B., Jr. Neurogenic ossifying libromyopathies. U. S. Army M. Bull., 1945. 2. WATSON-JONESand ROBERTS. CaIcification, decakification and ossification. Brit. J. Surg., 21: 461, 1934. 2. PETROFF, LIPSHUTZ et aI. War wounds of the spinat c0rd.i. A. M. A., 152-165.1945. 4. MARTIN, JOHN. Treatment of injuries of the spinat cord. Surg., Gynec. Obst., $4: 1947.
B. ROCHE,
M.D.
COMPLICATION
AND
FREDERICK A.
JOSTES,
M.D
St. Louis Missouri
L
ITERATURE deaIing with injuries of the spinal cord, the subsequent paraIysis and compIications is growing rapidly. Emergency handIing and transportation, the diagnostic phase of neurologic and orthopedic appraisal, whether or not and when to operate, probIems of urinary management, occurrence and prevention of decubitus uIcers, nutritional problems, importance of skiIIed, sympathetic and continuous nursing-al1 these matters have been dweIt upon thoroughIy in other pIaces and wiI1 not be repeated here. Accent has been placed upon each in turn, and suffice it to say, each and a11 must be successfully managed. Satisfactory rehabiIitation means saIvaging as much of a toIerabIe and productive future for the patient as the severity of his affhction wiI1 aHow. It means he must have successfuIIy escaped the hazards of urinary sepsis and decubitus disease and has won out to at Ieast a wheeIchair existence. There is a parapIegic compIication mentioned intermittentry in recent Iiterature which merits much more emphasis. If at Ieast a wheeIchair existence is the goa toward which a11 the intensive and tedious medica and surgical measures are directed, this paraplegic compIication can and on occasion does obstruct that objective. In an issue of the U. S. Army BuIIetin a preliminary report’ appeared. In this report a study was made of sixty-two cases of parapIegia resuIting from disease or injury of the spinal cord or cauda equina. Twenty-three of these patients showed ectopic deposits of trabecuIated bone within the muscIes or fascia1 pIanes, principaIIy over the hip and knee joints. Those patients showing degrees of recovery in *From the Department
function seemed to escape this additional compIication for onIy three developed osseous deposits. Of thirty-five unimproved cases, twenty showed ossifications. An anaIysis of dermatome IeveIs in the patients with ossification showed no prediIection for any particuIar IeveI. Nor did there appear to be, in comparison with the undifference affected group, any “significant with regard to sites or severity of injuries, time of operative treatment, presence or absence of decubitus ulcers, urinary tract infection or associated injuries or .infections, or blood caIcium and total protein Ossifications were said to be IeveIs.” recognized as earIy as forty days foIIowing cord injury. The foIlowing cIinica1 case is cited to caI1 attention to the important fact that parapIegics are not out of the woods and into the cIearing of manageabIe convaIescence and rehabihtation if the compIication of ectopic bone deposits is not anticipated and an effort made to prevent their deveIopment. CASE
REPORT
In June,
1945, a patient was admitted to the NavaI Hospital at which one of us (M.B.R.) was stationed. He was a twenty-two year old male, navy veteran with paraIysis of both lower extremities, a decubitus uker over his sacrum and inabihty to sit normarly or comfortably for any period of time in a wheelchair. WhiIe in boot-camp training he had sustained an acute onset of iIIness on February 14, 1943, with rapidly progressing paralysis of both lower extremities. A diagnosis of extradural inffammatory process was made and a Iaminectomy of the third, fourth, fifth and sixth dorsal vertebrae was performed in hlarch, 1943, Convalescence which verified the diagnosis.
of Surgery, Washington
633
University
School of Medicine,
St. Louis, MO.
634
American Journal of Surgery
Roche,
Jostes-Bone
FIG. I. G. D. D., age twenty-two years; anteroposterior view. Massive bridges of coarsely trabeculated but otherwise normal appearing bone extend from the anterior portions of both iIia and the Iower rims of both acetabuli to the anterior portions of the head, neck and upper fourths of both femora. The structure of the hip joints and femora are readiIy seen through the abnorma1 bone masses and present a normal appearance except for advanced atrophy. The hip joint spaces are not narrowed. On the left side some of the bone mass appears fractured medial to the femoral neck.
had incIuded periods at two veteran’s hospitals until JuIy, 1944, at which time he was discharged to his home. The paraIysis of both Iower extremities, present before the operation and persisting thereafter, showed Iittle aIteration as time went on. A finding of note in his physica examination was the presence of soIid, hard masses over the anterior aspects of both hip joints. The right hip joint was soIidly ankyIosed in about 30 degrees of flexion while on the Ieft there was an additiona IO degrees due to as much range of motion. The patient dated the onset of his acute iIIness as of February 14, 1943. From a transcript of his history the statement was noted that on March IO, 1943, he noticed a swelling for the first time deveIoping over his right hip which became progressiveIy larger. This wouId date the appearance of the ectopic bone deposits as less than four weeks after the acute onset of the iIIness. During the course of his convaIescence he was fitted with double, upright braces. With these and the aid of crutches he was abIe to waIk tripod fashion across the room and for a distance aIong the corridor. Fatigue of his upper extremities, of
Deposits
APRIL, 1948
course, made this a self-limiting activity. He was able to move his bowels by means of abdomina1 pressure and to empty his bIadder by means of manual compression. Roentgenographic studies of his dorsa1 vertebrae disclosed the surgica1 absence of most of the Iaminae and spines of the third, fourth, fifth and sixth dorsal segments. There was no abnorma1 soft tissue calcification or ossiiication. The anteroposterior (stereoscopic), (Fig. I) and lateral views of the lumbar spine and peIvis showed massive bridges of coarsely trabeculated but otherwise normal appearing bone extending from the anterior portions of both ilia and the lower rims of both acetabuli to the anterior portions of the heads, necks and upper fourths of both femora. The structure of the hip joints and femora could be readiIy seen through the abnormal bone masses and presented a norma appearance, except for advanced atrophy. The hip joint spaces were not narrowed. On the Ieft side some of the bone mass appeared fractured in the region medial to the femora1 neck. The patient spent much of his time Iying in bed between his ambuIatory excursions rather than in a wheeI-chair. This preference couId not be discouraged nor, on the other hand, could he be prevaiIed upon to sit for any prolonged period in a wheel-chair. Because of the extension deformity of his hips such sitting was only possibIe by using the fuI1 fIexibiIity of his lumbar spine. He sat on his sacrum rather than on his buttocks and hence the persistentIy recurring decubitus uIcer. If the compIication of ectopic bone about the hips had not intervened, this patient would certainly have been an exampIe of satisfactory rehabiIitation. As a resuIt of such and simiIar observations, the authors thereafter and in private practise have been making speciaI efforts to foresta the deveIopment of this compIication in the management of parapIegics. It is their beIief that the setting of the ossification pattern, if it deveIops, wiI1 do so in the earIy stages of recumbency; that is, in the immediate interva1 of bed rest foIIowing the onset of parapIegia and unti1 such time as the patient is able to be sat up and Iater stood up for training in tripod waIking. As was noted, this may be within the first four to six weeks of re-
VC,L.. LXXV.
No.
J
Roche,
Jostes-Bone
Deposits
American
Journal
01 Surgery
635
FIG. 2. Narrow sIings of softIy padded moleskin flannel are made to fit about the heels and around the knees of the patient. These are attached to cords suspended from pulleys and disposed in such a manner that the patient himself by exerting traction can lift each extremity until the ankle, knee and hip joints flex to a complete 90 degrees. Soft pilIows are placed under the thighs and legs so overIapping as to allow 3 to ro degrees of flexron of the knees and hip joints. Rolled pillows are placed between the feet and the foot of the bed to maintain the former at right angle position to the legs. The pillows beneath the legs are sufficient thickness to prevent the heels from lying c!irectly upon the bed. To prevent continuous internal rotation and adduction contractures of the lower extremities, a small well padded block of proper dimensions is placed between the knees. The head of the fracture bed is raised slightly to relax the abdomina1 muscles.
cumbency. Mobilization as earIy as possible wouId seem to be the key-note. During the initiaI period of recumbency, it has been the practice to begin physica conditioning of the patient from the very beginning. Much of this effort has been directed toward the deveIopment of the upper extremity, shouIder girdIe and trunk muscles in anticipation of the eventua1 management of crutches in tripod ambuIation. Because of the possibiIity of ectopic bone deposits ankyIosing the hip joints and perhaps less frequentIy but just as definitely the knee joints, the powerless lower extremities shouId just as assiduously be carried through a complete range of motions in a passive manner. This is accomplished by a simpIe and time-honored device. Narrow slings of softly padded moIeskin flannel are made to tit about the heels and around the knees of the pa-
tient. These are attached to cords suspended from puIIeys and disposed in such manner that the patient himself by exerting traction can Iift each extremity unti1 the ankle, knee and hip joints ffex to a compIete 90 degrees. (Fig. 2.) This is his task in the program of his own rehabiIitation; he beIieves he is heIping to accompIish his own come-back; and because he enjoys doing it, it is good for his moraIe. Nor does he have to depend upon others to get this particuIar job done. ‘I he patient is pIaced on a two-segment air mattress in a fracture bed. Soft pillows are placed under the thighs and Iegs so overIapping as to aIIow some 3 to I o degrees of flexion of the knees and hip joints. RoIIed pillows are pIaced between the feet and the foot of the bed to maintain the former at right angle position to the legs. The pillows beneath the legs are of suffi-
636
American Journal of Surgery
Roche,
Jostes- - Bone Deposits
FIG. 3. J. E. S., age thirty years; anteroposterior view. There is a large amount of ectopic bone lying in the soft tissue anterior to the inferior portion of the ilium, the hip joint and atong the media1 aspect of the right femur, ending just betow the lesser trochanter; traumatic transection of the cord sustained five months previousIy.
cient thickness to prevent the heeIs from lying directIy upon the bed. To ward off continuous interna rotation and adduction contractures (both deformities being encouraged by the intermittent spastic seizures), a smal1 we11padded bIock of proper dimensions is pIaced between the knees. The head of the fracture bed is raised sIightIy to reIax the abdomina1 muscIes. For a period in the morning and again in the afternoon, the patient is transferred from the fracture bed and Iaid face downward upon a cart. The prone position on the cart with feet resting downward over the end, provides compIete extension of the knee and hip joints, aIso an ampIe period of time for skin care. The cart can then be moved to the sun porch or such other place as wiI1 provide a change of scene. As soon as is feasibIe, this routine of resting face downward on a cart is eIiminated by getting the patient up in a wheeIchair. He is then abIe to get about under his own power to visit about the ward and to go outside for varying periods when the weather aIIows. During the interva1 of are recumbency, his I ower extremities
measured for braces and, after a reasonabIe period in a wheeI-chair, he is next fitted with his braces and, first in a waIker and eventuaIIy with crutches, he is taught to ambuIate tripod fashion. WhiIe no proIonged periods of waIking are possibIe, the genera1 stimuIation of the upright position and weight-bearing both to his genera1 health and to his moraIe is extremeIy worth whiIe. It is yet another means of defeating the untoward influences of recumbency and, therefore, of the tendency for a continued decaIcification of his bones. Genera1 immobiIization for a proIonged period depIetes the caIcium store of the whoIe skeleton, as has been observed in x-rays, and by the abnormaIIy increased amounts of caIcium in the bIood stream and urine. The byproduct of this hypercaIcemia and hypercaIcinuria is the deveIopment of caIcuIi in the renaI pelvis and ureters. Whether there is a further refIection of this pathoIogic process in the formation of ectopic bone remains to be demonstrated. Some wouId add a neurogenie factor. But we have yet to encounter such a compIication as ectopic bone about the hip joints in parapIegic cases resuIting from anterior poliomyelitis. In the Iight of our present knowIedge, it is therefore reasonabIe to attack the probIem and foresta the appearance of this compIication by eIiminating the factors which tend to mobiIize skeIeta1 caIcium, enforced recumbency and generaIized immobiIization. REFERENCES I. SOULE, B., Jr. Neurogenic ossifying libromyopathies. U. S. Army M. Bull., 1945. 2. WATSON-JONESand ROBERTS. CaIcification, decakification and ossification. Brit. J. Surg., 21: 461, 1934. 2. PETROFF, LIPSHUTZ et aI. War wounds of the spinat c0rd.i. A. M. A., 152-165.1945. 4. MARTIN, JOHN. Treatment of injuries of the spinat cord. Surg., Gynec. Obst., $4: 1947.