Calcific myonecrosis and tenosynovitis: sonographic findings with correlative imaging

Calcific myonecrosis mimicking soft tissue sarcoma: A case report

Calcific myonecrosis is a rare soft tissue condition. The first case was reported in 1960, however, the precise pathophysiology of calcific myonecrosis remains unclear. The disease was thought to arise from compartment syndrome within a confined space resulting in necrosis and fibrosis, subsequent repeated intralesional hemorrhage, mass enlargement and calcification. Several previous reports have described calcific myonecrosis, which include the formation of calcific myonecrosis after a prolonged period of post trauma. Notably, calcific myonecrosis has typically been described in the lower legs and characteristic imaging findings have been indicated. Furthermore, surgical intervention carries a high risk of complications. In the present case report 2 cases of calcific myonecrosis that occurred after a prolonged period of time following a traumatic event that impacted the lower leg were reported. CT images revealed disruption of calcified fascia and disease expansion into the outside of the fascia. Previous reports have implied that there is late focal enlargement of calcific myonecrosis following earlier enlargement, which may be caused by herniation through muscle fascia. However, no previous publications have focused on images for evidence of late local enlargement. To the best of our knowledge, this is the first report focusing on fascial herniation of calcific myonecrosis using images. Analysis of this feature using images may aid clinicians to differentiate calcific myonecrosis from malignancies.

[Imaging characteristics of malignant and benign lesions of skeletal muscle]

There are many different tumors and tumor-like lesions with variable biological behavior that may affect the skeletal musculature. The aim of this study was to review the different intramuscular lesions and to provide a classification based on their radiological patterns. Intramuscular lesions can present as solid, liquid, semiliquid or fat equivalent manifestations and also as diffuse muscle enlargement and muscle calcification. Additionally, lesions with mixed patterns of the aforementioned alterations can also occur. Benign and malignant muscle lesions can often manifest with identical radiological patterns, which is why a certain differentiation is often difficult. A systematic radiological description and when possible assignment with respect to etiology and dignity depending on the patient history is necessary in order to recommend a subsequent histological confirmation or to avoid unnecessary confirmation.

A challenging case of calcific myonecrosis of tibialis anterior and hallucis longus muscles with a chronic discharging wound

The occurrence of calcific myonecrosis of the anterior compartment of the leg is rare. Common risk factors include a history of trauma, although little is known about the exact pathophysiology, latency period or triggering factors resulting in disease progression. Macroscopically, it begins with a single muscle being replaced by a fusiform calcified mass, which progresses peripherally. We present a rare case of a 7-year history of chronic discharging sinus overlying the site with protruding calcified muscle and discuss the senior author's wound management strategy and surgical considerations. The initial approach used dressing applications to reduce wound exudate while obtaining repeated imaging for disease progression comparison. Repeated CT scans showed significant disease progression from a single solitary amorphous soft tissue calcification to disseminated scattered calcified myonecrosis. In planning such surgeries, extensive debridement and temporary wound coverage is the first stage. Subsequent definitive coverage includes skin grafting of the remaining defect.

Case report: role of bedside ultrasonography in early diagnosis of myonecrosis rapidly developed in deep soft tissue infections

BACKGROUND

Myonecrosis can rapidly develop in soft tissue necrotizing infections, often with initial sparing of the skin. Despite the improvements in management of necrotizing soft tissue infections, mortality remains high, according to the location, microbial agents and comorbidities, ranging between 17 and 46 %. A prompt diagnosis represents the greatest challenge for the emergency physician.

CASE REPORT

We describe the case of a patient with a history of hypertension and arrhythmia who developed nonclostridial necrotizing fasciitis with extensive myonecrosis, after articular infiltration procedure. A bedside focused ultrasonography (US) revealed disappearance of the regular fibrillar architecture of the long head of biceps muscle, with diffuse abnormal hyperechogenicity assembled in a "clod pattern". Computed tomography (CT) of the right arm did not depict muscle involvement, but showed a small gas collection around the shoulder, spreading to the subclavian region behind the major pectoral muscle. Necrotizing fasciitis with wide myonecrosis was confirmed by surgical debridement. Microbiological results showed a Staphylococcus aureus infection, managed by a selected antibiotic therapy. The patient was discharged after a small period of mechanical ventilation.

CONCLUSION

This is the first report of a previously healthy patient developing a nonclostridial necrotizing fasciitis with extensive myonecrosis attributable to infiltrative procedure and detected early by bedside US in emergency department. The role of bedside US in the emergency setting may save time for the prompt management of life-threatening necrotizing infections.

Malignant and benign lesions of the skeletal musculature

There are several tumors and tumorlike conditions with variable biological behavior that may involve the skeletal musculature. The aim of this work was to review different intramuscular lesions and to provide a classification of muscle lesions based on their radiological patterns as well as to provide as a pictorial essay the imaging characteristics of typical muscle lesions. Radiologically, intramuscular lesions can manifest as solid masses, liquid or semiliquid masses, fat-containing lesions, diffuse muscle enlargement, and muscle calcifications. Additionally, lesions with mixed patterns can also occur. It is noteworthy that different malignant or benign muscle lesions can manifest with identical radiological patterns.

Ultrasound of tibialis anterior muscle and tendon: anatomy, technique of examination, normal and pathologic appearance

Lesions of the tibialis anterior muscle and tendon are not frequently reported in international literature although pathology is not rare. Pathology can be spontaneous, associated with arthropathy or more generalized conditions. Clinical assessment may not be sufficient for distinguishing conditions like tendinopathy, tears, bursitis, etc. Therefore, imaging studies are necessary to plan appropriate therapy. US has a number of advantages, including widespread availability, absence of contraindications and low cost. It can also be used for dynamic studies of the muscle during contraction and relaxation. This article reviews the anatomy of the tibialis anterior, normal variants, the technique used for standard US examination of this muscle and tendon, its normal appearance on US and the sonographic characteristics of the most common lesions that affect it including tips on US-guided injections used for treatment.

Calcific myonecrosis of the upper extremity: case report

Calcific myonecrosis is an uncommon late sequela of limb trauma that results in calcification and necrosis of damaged muscle. It almost exclusively occurs in the lower extremity. We present a second case of calcific myonecrosis in the upper extremity.

Calcific myonecrosis and the role of imaging in the diagnosis: a case report

Calcific myonecrosis is a rare posttraumatic complication characterized by the replacement of muscles of one or more compartments with central liquefaction and peripheral calcification. We report magnetic resonance imaging (MRI) and CT imaging features of calcific myonecrosis arising 43 years after trauma. A 62-year-old man presented with a slowly enlarging mass in the left lower leg. Plain radiographs revealed a soft tissue mass with extensive amorphous calcification. The middle third of the tibia and fibula were eroded. MRI demonstrated peripheral ring enhancement on postcontrast fat-suppressed T1-weighted images. Volume-rendered images extracting only the images of bone and vessels also showed many branches from the tibialis posterior and peroneal arteries around the bone defect. During the operation, bleeding continued heavily from the vessels penetrating the cortical bone of the tibia, from the posterior compartment, and from the branches of tibialis posterior artery. The total blood loss was approximately 2,400 milliliters. There may be a causal relationship between massive bleeding and the hypervascularity of this tumor as evidenced by MRI and volume-rendering CT studies.