Heterotopic Ossification After Radius Fracture Repair

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Heterotopic Ossification After Radius Fracture Repair

Authors, Editors, Case Information Author: Ashley Best, MD Affiliation: University of Iowa Sports Medicine, Iowa City, IA Co Author(s): Ben Kopecky, DO, MS Mederic Hall, MD Senior Editor: Raul Rosario-Concepcion, MD Clinical Vignette: A 51-year-old male underwent an open reduction and internal fixation with a surgical plate of a left distal radius fracture from a fall. Recovery was complicated by delayed wound healing and continued pain over the fracture site with persistent paresthesias in the dorsal thumb and index finger, for which he presented to clinic at 5 months post-op. A CT of the wrist demonstrated nonunion of the distal radius. Exam was notable for limited ROM in active flexion of the left thumb IP and index finger DIP and PIP joints. He also had limited wrist extension due to his dorsal bridge plate. Type of Probe Used: 18-5 MHz Linear Array Transducer Unlabeled long axis view of the flexor digitorum tendons at the volar wrist Unlabeled long axis view of the flexor digitorum tendons at the volar wrist Labeled long axis view of the flexor digitorum tendons at the volar wrist Labeled long axis view of the flexor digitorum tendons at the volar wrist with a hyperechoic ossification (white arrow) within the flexor digitorum profundus, deep to the surgical incision, measuring approximately 1.26 cm x 0.54 cm. There is surrounding hypoechoic heterogeneity within the tendon which is grossly intact. Unlabeled short axis view of the flexor digitorum tendons at the volar wrist Unlabeled short axis view of the flexor digitorum tendons at the volar wrist Labeled short axis view of the flexor digitorum tendons at the volar wrist Labeled short axis view of the flexor digitorum tendons at the volar wristwith hyperechoic ossification within the flexor digitorum profundus measures 0.32 cm. There is surrounding hypoechoic heterogeneity within the tendon which is grossly intact. Unlabeled short axis view of the median nerve proximal to the lesion Unlabeled short axis view of the median nerve proximal to the lesion. Labeled short axis view of the median nerve proximal to the lesion Labeled short axis view of the median nerve proximal to the lesion, measuring approximately 0.22cm^2. Unlabeled short axis view of the median nerve distal to the lesion Unlabeled short axis view of the median nerve distal to the lesion. Labeled short axis view of the median nerve distal to the lesion Labeled short axis view of the median nerve distal to the lesion measuring approximately 0.17 cm2 #9 - Video View Video Long axis cine view of flexor pollicis longus myotendinous junction demonstrating intact tendon on active thumb interphalangeal joint flexion. #10 - Video View Video Long axis cine view of the flexor tendons in the volar wrist with dynamic DIP joint flexion demonstrating an ossification embedded within the flexor digitorum profundus tendon which is mobile with the tendon on active finger distal interphalangeal joint flexion. Interpretation Image Interpretation: The flexor pollicis longus tendon is intact and unremarkable. Long axis view of the flexor digitorum profundus (FDP) in the distal forearm shows a hyperechoic ossification within the FDP with surrounding hypoechoic heterogeneity of the tendon consistent with a heterotropic ossification. Short axis view of the carpal tunnel shows an enlarged median nerve suggestive of compressive median neuropathy at the wrist. Teaching Pearl: Heterotopic ossification (HO) is an uncommon but important complication following fractures, particularly in this case after surgical fixation. It results from abnormal bony formation within soft tissues and typically presents weeks to months after injury with progressive pain, stiffness, and loss of wrist range of motion. Diagnosis is most commonly made with radiographs once mature ectopic bone becomes visible, though CT/MRI can help better define the extent of ossification. Ultrasound can also be a useful advanced imaging modality, as it can delineate the relationship to tendons, neurovascular structures, and surrounding soft tissues with dynamic assessment during motion. This can be particularly helpful when planning operative intervention. Heterotopic ossification is usually visible earlier on ultrasound than plain radiographs. Initial management is typically conservative with activity modification, NSAIDs, and guided rehabilitation to maintain motion, while persistent functional limitation after maturation of the lesion likely warrants surgical intervention. References: Ranganathan K, Loder S, Agarwal S, et al. Heterotopic ossification: basic-science principles and clinical correlates. Journal of Bone and Joint Surgery American. 2015;97(13):1101-1111. doi:10.2106/JBJS.N.01056 Shehab D, Elgazzar AH, Collier BD. Heterotopic ossification. Journal of Nuclear Medicine. 2002;43(3):346-353.
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Authors, Editors, Case Information

Unlabeled long axis view of the flexor digitorum tendons at the volar wrist

Labeled long axis view of the flexor digitorum tendons at the volar wrist

Unlabeled short axis view of the flexor digitorum tendons at the volar wrist

Labeled short axis view of the flexor digitorum tendons at the volar wrist

Unlabeled short axis view of the median nerve proximal to the lesion

Labeled short axis view of the median nerve proximal to the lesion

Unlabeled short axis view of the median nerve distal to the lesion

Labeled short axis view of the median nerve distal to the lesion

#9 - Video

#10 - Video

Interpretation

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