Myositis Ossificans and Homoeopathy

Dr Beenadas

Presenting Complaints
1) Difficulty in walking due to pain in upper part of left thigh, for 4 months.
Associated with Pain, tenderness and paralytic feeling especially of lateral aspect, below left hip, and extents to toes through lateral aspect. Pain < by lying on painful side, night.< by pressure, walking and changing posture in bed.
Numbness of lateral aspect of thigh is < at night and slight > by walking.

2) Low Back Ache (4 months) . < by lying on back and sitting

3) Can’t eat anything due to want of taste in mouth.(4 months).

History Of Presenting Complaints.
Pain in hip started 4 months back after a fall from chair, due to hypoglycemia. Then he had sweating and vertigo followed by unconsciousness. Regained consciousness within 10 minutes after intake of sugar. Had injury in forehead and difficulty in walking.

L.B.A started after 5this fall and pain is < by lying on back and sitting. 

History of Previous Illness.

• Had similar falls due to hypoglycemia 3 times during 2006. by taking sugar he gets relief.
• Once had lower jaw dislocation towards inside of mouth due to fall. Consulted dentist and cured.
• HO jaundice at 36 year. Took Allopathic treatment and relived. 

Treatment History.

• Took treatment from Coperative Hospital for head injury.
• Took Ayurvedic treatment including massaging for the local pain, which continued for 16 days. But there was no relief. Pain is < by walking, pressure and lying down. Numbness of thigh started after massaging and slight > by continued walking and <at night. 

Family History : Father and mother died  at childhood. No relevant history.

Personal History.

1) Life situation:-

• Place of birth : Kuruvissery.
• Educational status : intermediate.
• Economic status : middle class.
• Occupational status : was clerk in food corporation now resigned.
• Nutritional status : poor.
• Marital status : married and has 2 children. wife died 12 years back, after removal of tumor in abdomen.

2) habits and hobbies :-

• Food : Non-veg.
• Addiction : Alcoholism for 40 years. Now stopped.
• Smoking : Habit of smoking beedi one packet per day started at the age of 20.

3) Domestic relation : Good.

Physical Features.

Generals :  1) Functionals :

• Appetite : Normal
• Thirst : reduced.
• Sleep ; reduced
• Dreams : Nil

2) Elimination :

• Stool ; Hard stool difficult to pass.
• Urine: No complaints.
• Sweat : Increased.

3) Aversion to : sugar.

4) Desires : fanning, covering.

5) Modality : Touch , pressure and changing posture in bed < pain.

6) Thermal reaction : warm.

Psychic Features.
Much worried as no one to look after him. Sad disposition.

Regionals.

• Head : Vertigo when he changes position in bed.
• Eye : Vision diminished in both eyes. Advised surgery for cataract, but not done.
• Abdomen : Distension, > by belching and flatus.
• Stools : Constipated.
• Back :Difficulty in bending or stooping due to pain.
• Extremities :Pain and numbness from hip. > by walking and pain starts if he stops walking.
• Sleep : Reduced.
• Perspiration : Increased. 

Physical Examination.

1)General :-Built :ill built.

• Complexion : black.
• Wasting : present
• Temperature : 99 degree.
• Anemic, no cyanosis, no edema, no lymphadenopathy, no jaundice, no rash.
• Gait : Painful.
• Respiratory rate : 16 | minute.
• Pulse rate :72 | minute.
• Blood pressure ;130|80 mm of Hg. 

2)Systemic:-

• Examination of spine :
• Inspection : No gibbus(angular deformity if 1|2 vertebrae alone is affected), no kyphosis, no crowding of ribs, no lumbar lordosis. No limitation of movement on flexion, extension and rotation.
• Palpation : NAD.
• Examination of leg :
• SLR  – +ive above 40 degree  on left leg.
• PSLR – -ive  on R&L leg. 

Local examination of left hip :

Inspection: No visible swelling or redness. No flexion deformity.

                   Internal and external rotation of hip is restricted.

                   An ulcer of 3c.m.length is seen at middle of left thigh,

                   lateral part.

Palpation : Palpable, hard, tender mass 4+4 c.m. over greater

                   trocander of left femur.  Local temperature present. 

Provisional Diagnosis: Fracture of upper part of left thigh.

Differential Diagnosis:
1) All complications of fractures – vascular injury. compartment syndrome or Volkmann’s ischemia, nerve injury, haemarthrosis, infection, delayed union, non-union, mal union, joint stiffness, algodystrophyor sudeck’s atrophy, avascular necrosis,OA etc.

2) Osteosarcoma.

3) Ectopic calcification and ectopic ossification

Investigations:

Urine:-   R|E on 17. 03. 2007.

• Albumin : trace.
• Pus cells : 1-2|hpf.
• Epithelial cells : 0-2|HPF.
• Granular casts : Plenty.
• Bacteria present.

Blood :- R|E on 17.03.2007.

• TC : 7900cells|mmcube.
• Dc: P 51, L 43, E 5, M 1.
• ESR : 16 mm|hr.
• Sugar : 96mg%.

X-ray :-AP view of left upper thigh and hip –

• a mass 4+5 c.m. is seen attached over the greater
•  trochanter of left femur, suspecting a calcified
• haematoma.

Blood :- on 22.03.2007.

• Blood urea :- 20mg|dl.
• S.creatinine :- 0.8mg|dl. 

Final Diagnosis: Myositis ossificans.

Diagnosis of patient:

Totality of symptoms of patient:-

1) Much worried of life.

2) Sad disposition.

3) Thermal reaction is hot.

4)  Aversion to sugar.

5) Desires fanning and covering.

6) Stool hard difficult to pass.

Totality of symptoms of disease:-

1) Paralytic feeling on lateral aspect of left hip.

2) Numbness, < night, lying, sitting and slight > by walking

3) Vertigo while changing position in bed.

Miasmatic diagnosis :

• Psora : pressure <, lying on affected side <, hypoglycemia.
• Sycosis : compels to move, movement <, calcification, wants to move.
• Syphilitic : night <
• Psedopsora  

Symptoms Evaluated:

1)Mind – anxiety.

2)Mind – sadness, mental depression.

3) Stomach – aversion – sweets.

4) Generality – air – desire for.

5)Rectum – constipation –difficult stool.

6)Extremities – numbness – lower limbs – thigh

7)generality – lying – painful side <.

8)generality – lying > on back.

9) Stomach – eructation’s >

10) generality – injuries – extravasations with.

Medicines of High Marks

• Grap – 198                       ars . alb – 146
• Sulph -198                        cal carb – 146
• Bry -178                           iodum – 146
• Lyco – 178                       nit. Acid – 146
• Puls – 178                         nat.mur – 147
• Carbo veg – 157               nux.vom – 148
• Kali carb – 157                 nat.sulph – 63
• Laches – 157 

Medicines Given

• 19.03.2007                  –  cal.flour 301d
• 22.03.2007                  –  nat.sulph 301d
• 25.03.2007                  –  nat.sulph 301d
• 16.04.2007                  –  nat.sulph 2001d
• 24.04.2007                  –  Rpt. 

Myositis Ossificans
It is heterotopic ossification in the muscle sometimes occur after an injury, particularly dislocation of the elbow or a blow to brachialis, deltoid or quadriceps. It usually develops in athletic adolescents and young adults and follows an episode of trauma in more than 50% of cases. The lesion typically arises in the musculature of the proximal extremities. It is thought to be due to muscle damage but it also occur without a local injury to unconscious or paraplegic patient.

Elbow is the most common site for acute post traumatic soft tissue ossification. The clinical finding is related to its stage of development. Persistent or recurrent pain and increasing stiffness are the danger signals. Soon after the injury the patient complains of pain, local swelling and soft tissue tenderness. X-ray may be normal and bone scan show increased activity. Within several weeks it becomes more circumscribed and firm. Next 2-3 weeks the pain generally subsides but joint movement is reduced. Eventually it evolves into a painless, well demarcated mass.

Diagnosis :-

X-ray :-initially soft tissue fullness.

             After 3 weeks periphery shows fluffy patchy calcification of the soft tissues.

              By 8 weeks the bony mass is easily palpable and is clearly defined in x-ray.

Joint should be rested in the position of function until pain subsides. Gentle active movements are then begun. Months later, when the condition has stabilized, it may be helpful to excise the bony mass.

Differential Diagnosis.
1)Osteosarcoma:-

2)Vascular injury:- here the blood vessel may be blocked and the effects vary from transient diminution of blood flow to profound ischemia, tissue death and peripheral gangrene.

3)Compartment syndrome (Volkmann’s ischemia):-bleeding or edema may increase the pressure in osteofascial compartment, there is reduced capillary flow which results in muscle  ischemia, after 12 hours leads to necrosis of nerves and muscles in that compartment. Muscles once  infracted, is replaced by inelastic fibrous tissues called Volkmann’s ischemic contracture.

4)Haemarthrosis:-fracture involving a joint may cause acute haemarthrosis. Joint is swollen and tense and patient resists any attempt of moving it. Blood should be aspirated before dealing with the fracture.

5)Infection :- in open fracture, wound becomes inflamed, starts draining seropurulent fluid.

6)delayed union :- due to severe soft tissue, inadequate blood supply, infection, insufficient splintage0.

+ and excessive traction.

7)Non-union:-due to improperly treated delayed union, too large gap, interposition of periostium, muscle or cartilage between the fragments.

8)Malunion :- due to failure to reduce a fracture adequately and failure to hold reduction while healing proceeds.

9)joint stiffness :- Due to synovial adhesions, edema& fibrosis of capsule, ligaments and muscles around the joint or adhesion of soft tissue to eachother.

10)Algodystrophy (sudeck’s atrophy):- reflex sympathetic dystrophy usually seen in foot or hand after a trivial injury. Symptoms are burning pain, local swelling, redness and warmth at first and after weeks the skin becomes pale atrophic, movements are restricted and x-ray show patchy rarefaction of bones.

11) Avascular necrosis :- it is common at head of femur after fracture of femoral neck or dislocation of hip.

12) post traumatic OA:- occur due to severe damage of articular cartilage. Even if the cartilage heals, irregularity of joint surface cause localized stress and predispose to secondary OA years later.

13)Dystrophic calcification :-due to previous damage to soft tissue.  This occurs in inherited and acquired disorders involving connective tissues – alkaptouria, pseudoxanthoma elasticum, systemic sclerosis and dermatomyositis etc.

14)Metastatic calcification :- eg :-in hyperparathyroidism.

15)Calcification and hypocalcaemia ;- occurs in post surgical hypoparathyroidism,pseudohypoparathyroidism.

16) Calcification in hyperphosphataemia:-rare, idiopathic autosomal recessive disorder with maximal tubular reabsorptions of PO4and inappropriate increase in plasma concentration.

17)Calcification in inherited hypophosphataemia:-X-linked inherited hypophosphataemia in which widespread calcifications and ossification of ligaments and tendons at their insertions into periostium – sharpey fibers –termed enthesiopathy.

18)Idiopathic soft tissue calcification :- includes calcific tendonitis and called calcinosis circumsripta.

19) Progressive Myositis Ossificans :-localized ossification in voluntary muscle may occur through repeated trauma , – exercise, occupation – seen in muscle around hip joint following spastic paralysis.

Rubric taken.

KENT

• Generality – injuries – extravasations with
• 3 – arnica, sulph.acid.
• 2 – bad.,con. Hep.suiph, lache, puls, ruta, sulph.
• 1- bry, cham, china, cic, dulc, euphra, ferr, iod, laur, nux.vom, plb, rhus.tox, sec.                               

SYNTHESIS

• Generality – indurations – muscles of
• 3 – cal, flour.
• 2 anthra, bad, bry, caust, lyco. 

MURPHY

• Disease – myositis – muscle.
• 2 – arni, rhus.tox, ruta.
• 1 – bell, bry, cal, ham, hep, kali.iod, merc, mez. 

BOERRICKE

• Generality – muscle – infection – myositis
• 2 – arn, bry, mez, rhus.tox
• 1 – bell, hep.sulph, kali.iod, merc.  

Indications of remedies.

ARNICA
Bad effects of mechanical injuries with sore, lame bruised feeling of body as if lacerated. For traumatic affection of muscle. For injury with blunt instruments. Everything on which he lies seems too hard and keeps moving from place to place in search of a soft place. For concussions and contusions without laceration of soft parts.

CAL.FLOUR
Indurations threatening suppuration is characteristic. Swelling or indurated enlargements having their seat in the fasciae and capsular ligament of joint or  in tendons. Indurations of stony hardness. Chronic lumbago < on beginning to move. For rachitic enlargement of femur in infants.

SULPH.ACID
Bad effects from mechanical injuries with bruises. Echymosis, cicatrices turn blood red or blue and are painful. Hemorrhage of black blood. Pain of gradual and slowly increasing intensity which ceases suddenly at its height and is repeated. Pain as if pressure by blunt instrument. Tendency to gangrene following mechanical injuries.

BRYONIA
Aching of muscle, characteristic pain – stitching, tearing worse by motion and better by rest Cracking and dislocation of hip joint when walking. Paralysis of legs, painful stiffness of knees. Red and shining swelling of knees with violent shootings esp. on walking. Insupportable pain on touching and moving with sweat of the body.

MEZERIUM
Long bones inflamed, swollen. Nightly pains going from above downwards, after abuse of Hg, after venereal disease. Pain in periosteum of long bones < at night in bed, least touch, damp weather.

RHUS.TOX
Pains tearing in tendons, ligaments and fascia. Limbs stiff, paralysed,.Cold fresh air is not tolerable, it makes the skin painful. Tearing pain in the thigh, paralysis trembling after exertion. Pain as if sprained, as if a muscle or tendon was torn from its attachment. Pain as if bones were scraped with a knife.< midnight, wet rainy weather.

RUTA
Bruised lame sensation after a fall or blow, worse in limbs and joints. Parts of body he lies are painful as if bruised. Restlessness – turns and changes position when lying. For bruised and other mechanical injuries  of bones and periosteum.

NAT.SULPH
For mental traumatism. Mental effects from injury to head. Pain in limbs, compels frequent change in position. Must change position frequently but it is painful and gives little relief. Feel every change from dry to wet. Pain in hip joint, worse left, stooping. Tearing and drawing in legs, esp. in tendo Achilles and calf.

BADIAGA
Several hard, small lumps along the shin bone. At night violent lancinating pains in limbs.

CONIUM
Muscular weakness esp. lower extremities. Putting feet on chair relives pain. Dragging pain in hips, < on beginning to walk after sitting, with a sensation as if tendons were too short.

HEP.SULPH
Pain as from a bruise on thighs. Painful tension in thighs which prevents sleep. Sudden lassitude of limbs when walking.

LACHESIS
Sensation of contraction of tendons of ham. Nocturnal pain in hip and thigh. Sensation of heaviness, paralysis, of numbness and trembling in thigh and knees.

PULSATILA
Pain as from bruise or ulceration. Pain in coxi-femeral articulation with painful jerks as in a wound extending as far as knees. < during repose.

SULPHER
Pain as from bruise  in hip on least movement, with shooting pains in legs esp. at night in bed. Heaviness of legs, with lesion in thigh and knees esp, at night.

MERC.SOL
Sharp lancinating pain in hip joint, thigh and knees esp. at night and during movement, with sensation of coldness in diseased parts. Tearing in hip joint and knees. < at night with pulsating pain.

BELLIS
Left sided. Joints sore, muscular soreness. Pain down anterior of thighs. Itching on back and flexor surface of thigh.

Dr.Beenadas
Lecturer, Department of MM
Govt. Homeopathic Medical College. Calicut