Heterotopic Ossification Clinical Presentation

  • Author: Kresimir Banovac, MD, PhD; Chief Editor: Consuelo T Lorenzo, MD   more...
 
Updated: Dec 2, 2011
 

History

  • The onset of HO usually is 1-4 months after injury in SCI patients, although it may occur as early as 19 days or as late as 1 year following injury.
  • The condition may occur later with other precipitating circumstances (eg, fracture, surgery, severe systemic illness).[8, 9]
  • Not uncommonly, incidental HO that was not noted clinically may be detected much later on radiographs.
  • HO always occurs below the level of injury in SCI patients, and most authors agree that there is no relation to presence or absence of spasticity in SCI patients.
  • HO tends to occur more frequently with complete injuries.
  • In SCI patients with HO, the hips are most commonly involved.
    • At the hip, the flexors and abductors tend to be involved more frequently than are the extensors or adductors.
    • At the knee, the medial aspect is most commonly affected by HO.
    • Shoulders and elbows are the most commonly affected upper extremity joints.
    • One report in the literature notes involvement of the metacarpophalangeal joints of the hand.
    • The lumbar paravertebral region also has been mentioned as an infrequent site.
  • In patients who have sustained head injury or stroke, the story is a bit different. HO almost always occurs on the affected side, and most authors have noted that HO is more frequent in patients with spasticity than in those without it.
    • Garland and colleagues studied 496 patients with severe head injuries.[10] Clinically significant HO, causing pain and decreased ROM, was noted in 100 joints in 57 patients. Of the 100 involved joints, 89 were in spastic extremities. The frequency of involvement of different joints was slightly different than it was in patients with SCI; the hips were most commonly involved (44), followed by the shoulders (27) and elbows (26). HO was detected in only 3 knee joints.
    • Spielman also looked at the occurrence of HO in patients with head injuries. In that study, the inclusion criteria were (1) initial Glasgow Coma Scale score of 8 or less and (2) coma lasting more than 2 weeks. All patients had passive range of motion (PROM) of unknown frequency. Once again, HO was more common in the limbs of patients with severe spasticity. Prolonged coma also appeared to increase the likelihood of HO development.
  • In patients with neurologic deficits, increased limb spasticity, decreased joint ROM, and inflammatory signs near a joint strongly suggest the possibility of HO.
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Physical

  • A diagnosis of HO can be made clinically if localized inflammatory reaction, palpable mass, or limited ROM is observed.
  • Clinically, the onset of larger masses of HO is often characteristic of any inflammatory reaction.
  • Fairly suddenly, a warm and swollen extremity becomes obvious, and fever is present.
  • If sensation is intact, the area of swelling is painful.
    • The swelling usually is localized more than it is in thrombophlebitis, and within several days, a more circumscribed, firmer mass is palpable within the edematous area.
    • If the mass is adjacent to a joint, gradual loss of PROM may follow.
  • With the development of early HO at the hip or knee, effusion may be noted at the knee.
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Causes

See Pathophysiology.

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Contributor Information and Disclosures
Author

Kresimir Banovac, MD, PhD  Professor, Departments of Rehabilitation Medicine and Medicine, Associate Vice Chairman, Department of Rehabilitation Science, University of Miami Miller School of Medicine; Medical Director, Spinal Cord Injury Rehabilitation Unit, Jackson Memorial Medical Center

Kresimir Banovac, MD, PhD is a member of the following medical societies: American Spinal Injury Association

Disclosure: Nothing to disclose.

Coauthor(s)

John Speed  MBBS, Professor (Clinical), Division of Physical Medicine & Rehabilitation, Adjunct Associate Professor, Department of Physical Therapy, Adjunct Professor, Nursing Director, Traumatic Brain Injury Rehabilitation, Medical Director, Inpatient Rehabilitation Unit, University of Utah School of Medicine

John Speed is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Pain Society, Association of Academic Physiatrists, International Association for the Study of Pain, International Society of Physical and Rehabilitation Medicine, and Utah Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert L Sheridan, MD  Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Patrick M Foye, MD  Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

Kelly L Allen, MD  Medical Director, Medevals

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD  Physiatrist, Department of Physical Medicine and Rehabilitation, Alegent Health, Immanuel Rehabilitation Center

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

References

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