Tendinitis ossificans traumatica

TENDINITIS

OSSIFICANS TRAUMATICA*

ABRAHAM S. ROTHBERG, M.D. NEW YORK, NEW YORK

C

ALCIFICATION in and about tendons, myositis ossificans and ossification in tendons have a11 been incIuded under the genera1 heading of “tendinitis ossificans traumatica.” However, these conditions are essentiaIIy different and shouId be discussed separateIy as iIIustrations of CaIcification or ossification. CaIcification is found in tissues whose metaboIism is normaIIy Iow. CampbeII and others state that caIcification is a process of death and requires necrotic tissue for its deposition. Even in such reIativeIy avascuIar tissue such as tendons, Iigaments, cartilages, etc., the fibrosis which foIIows trauma or infection resuIts in stiI1 further reduction in the metaboIic rate and aids in the deposition of caIcium. Ossification, on the other hand, occurs in tissue whose metaboIism is high. In consequence, it is seen CharacteristicaIIy in and about highIy vascuIar tissue such as muscIe or structures cIose to the periosteum. This process may present itseIf in severa forms such as spur formation, ossification of subperiostea1 hematoma and myositis ossificans. Some authors have incIuded in this category the formation of sesamoids. However, these are norma deveIopments, are usuaIIy symmetrica and appear earIy in Iife. These two processes are distinct and occur under different circumstances but with increased metaboIism and an excess of caIcium, areas of caIcification may ossify and form new bone. PathoIogicaI caIcareous deposits in any region of the body may therefore change into pathoIogica1 ossific deposits if the bIood suppIy shouId become adequate. In Paget’s disease, fractures occur in the earIy stage when the bone * From the Service of Dr. E. D. Oppenheimer,

shows granuIar caIcification. They do not occur in the Iater stage when increased vascuIarity plus CaIcification has progressed to re-ossification as demonstrated by the formation of new bone. The appearance of ossification in tissue attached to or cIose to periosteum is readiIy comprehensibIe as a manifestation of the osteogenic properties of periosteum. When the periosteum is eIevated, bone deveIops within the new Limits of the periosteum, and it is this process which expIains the formation of spurs and subperiostea1 hematomas due to trauma, scurvy, etc. When spurs occur at the insertion of muscIes, they are Iikewise due to the puI1 on the periosteum and the production of bone within this space. This process is not the primary concern of the present report. Myositis ossificans, as its name impIies, develops within the muscle. This may appear as the resuIt of a singIe injury but more often is caused by chronic muItipIe traumas. It may develop from a periostea1 injury or from the interstitia1 fibrous tissue in muscIe. From the roentgenoIogica1 point of view it presents the appearance of a “ typicaIIy Iaminated structure of the bone deposits and the so-caIIed ‘dotted vei1’ appearance.” Because of its Iocation it can readily be differentiated from the ossification which occurs in tendons. WhiIe myositis osificans and tendinitis ossificans may occasionaIIy present diffIcuIties from a roentgenoIogica1 point of view, the x-ray differentiation between caIcification of ossification in a tendon is aImost impossibIe. There have been a number of reports IabeIIed “Tendinitis Ossificans Trau-

Beth IsraeI Hospital New York.

285

and Dr. H. MiIch, HospitaI for Joint Diseases,

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matica ” but some of these are cases of caIcifIcation. In some, the diagnosis was made onIy on the roentgen films. However,

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CASE

CASE I.

REPORTS

J. S., twenty-four

a motorcycIe

accident March,

FIG. 2. Shows

years oId, was in 1934, at which

the exterior and interior mass shown in Figure I.

FIG. I. Case I. Shows two caIcitic masses which appeared to be in the tendo-achillis.

one cannot readiIy differentiate these two conditions on the basis of roentgenography aIone, as in both instances a shadow may be cast. In fact, the roentgenoIogists use the terms ossification and caIcification interchangeabIy. According to Dr. Jaffe, “The differentia1 diagnosis can be made onIy on tissue examination. CaIcification is distinct from ossification onIy by the pathoIogica1 process where caIcareous materia1 is so distributed as not to make bone; in ossification actuaI bone is organized.” Tendinitis ossificans traumatica is a reIativeIy rare occurrence. It is usuaIIy produced by a singIe trauma. AIthough the tendon may be somewhat compressed, there will be no evidence of necrosis. New bone with a cortex and meduIIa is formed within the tendon. This new bone formation is the resuIt of increased metaboIism pIus an excess of caIcium brought to the part by the hyperemia of the trauma. This ossification has no connection to the bone, or the periosteum, or the muscle and, therefore, is an entity by itseIf and is not to be confused with caIcification or myositis. The foIIowing two cases of proved tendinitis ossificans traumatica are herein presented :

of the

time his right heel was lacerated. The wound became infected and heaIed onIy after considerabIe trouble. When seen in August, 1935, the patient compIained of pain in the Iower part of the leg but waIked without any Iimp. There were severa scars about the heeI and the Iower third of the right tendo-achilIes; there was no Iimitation of motion at the foot or ankle. The x-ray (Fig. I) shows two caIcific masses which seem to be in the achiIIes tendon. At operation, this tendon was exposed but appeared to be normal. Upon probing with a needIe the mass was found within the substance of this tendon. This mass (Fig. 2) was removed and the wound closed. Since the operation the patient has been free of any symptoms. On section, two ossifying nucIei containing spongy bone with some fatty marrow were found. CASE II. H. H., fourteen years oId, was kicked in the right Ieg August, 1939, eight weeks prior to admission. This kick was foIIowed by pain near the site of the injury, accompanied by swelling without ecchymosis. This sweIIing remained constant in size, however, the discomfort diminished. His chief compIaint was pain in the caIf of the Ieg upon walking. The patient Iost fifteen pounds in weight during the eight weeks before admission. PhysicaI examination reveaIed the patient to be fairIy we11 nourished despite his Ioss of weight. He Iimped hoIding his right knee Aexed and the foot in marked equinus. Motion at this knee was normaI; dorsiflexion of this ankIe was possible only through a range of about IO degrees. There was a mass in the middIe third of the right Ieg; this was firm,

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slightly tender and movabIe; it was not attached to the overIying skin or to the underIying bone. Roentgenograms of this leg (Fig. 3)

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relatively soft, gelatinous gray tissue. Microscopic: At the periphery, at one end, practicaIIy norma tendinous tissue is situated. A rather

FIG. 3. Shows the mass in Case II.

were reported as showing “an irregular IobuIated caIcified mass in the soft tissues of the Iower part of the Ieg. The periosteum of the fibuIa shows exudative and productive changes. The tibia was normal.” X-rays of the other Ieg, peIvis, femora and chest were negative. Blood caIcium, phosphorous and phosphatase were a11 within the norma Iimits. The bIood count showed a miId anemia. Urine examination and blood Wassermann were negative. At operation, a hard bony mass was found attached to the anteroIatera1 aspect of the upper third of the tendo-achilIes. In this region, the tendon was thin but showed no evidence of inffammation nor connective tissue formation. The mass was readiIy removed without any bIeeding. After skin closure, a circuIar pIaster of paris bandage was appIied keeping the foot in moderate equinus. Five weeks after the operation, the patient waIked without any Iimp; there was no discomfort upon waIking and no Iimitation of dorsiffexion. The pathological report was as foIIows: Gross specimen (Fig. 4) is that of a bony mass 6.5 by 5.5 by 4 cm. The outer she11 consists of rather dense bone about I cm. in greatest thickness. The centra1 portion consists of

reguIar net work of norma appearing canceIIous bone permeates the structure, corre-

FIG. 4. Shows the exterior and interior mass shown in Figure 3.

of the

sponding to the gross aspect. OsteopIastic layers are very distinct. There is very little evidence of osteocIastic processes, with smaI1

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indistinct Iacunae and very occasional giant cells. There is no cartilage, no osteoid substance, no hemorrhage, no pigment, no necrosis, no scars and no foci of calcification. Diagnosis: Bone formation in tendon (so-caIIed tendinitis ossificans traumatica). CONCLUSION

Two matica

cases of tendinitis ossificans trauare presented with a differentia1

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diagnosis of myositis ossificans, spur formation, cakification and tendinitis ossificans traumatica. REFERENCES

W. C. Operative Orthopedics. P. 27. St. 1939. C. V. Mosby. GESCHICKTER, C. F. and COPELAND, M. M. Tumors of bone. Am. J. Cancer, p. 785, 1936. JAFFE, H. L. Persona1 communication.

CAMPBELL,

Louis,

WHEN reduction is not possibIe with open operation, the most usefu1 function of the shouIder joint is obtained by resection of the head of the humerus. From-“A ManuaI of the Treatment of Fractures” by John A. CaIdweII (CharIes C. Thomas).