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Calcific Myonecrosis: Keys to Recognition and Management

Helena M. O'Dwyer1, Nizar A. Al-Nakshabandi1, Khamis Al-Muzahmi1, Anthony Ryan1, John X. O'Connell2 and Peter L. Munk1

1 Department of Radiology, Vancouver General Hospital, 855 West 12th Ave., Vancouver, BC, Canada, V5Z 1M9.
2 Department of Pathology, Surrey Memorial Hospital, Surrey, BC, Canada.


Figure 1
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  		Fig. 1A —Compartment syndrome. Anteroposterior diagrammatic illustration of healthy muscle compartments of lower limb.

 

Figure 2
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  		Fig. 1B —Compartment syndrome. Three-dimensional rendering of selected cross-sectional level.

 

Figure 3
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  		Fig. 1C —Compartment syndrome Cross-sectional diagram through lower limb shows inflammatory response after injury (fibular fracture), with increased capillary permeability, leading to swelling, edema, pain, erythema, and heat. It is illustrated here as swelling of anterolateral muscle compartments of lower limb (arrowheads).

 

Figure 4
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  		Fig. 1D —Compartment syndrome Anteroposterior diagrammatic illustration of acute compartment syndrome.

 

Figure 5
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  		Fig. 1E —Compartment syndrome When acute compartment syndrome goes unrecognized or is poorly managed, increased intracompartmental pressure results in decreased tissue perfusion, indicated by darkening and volume loss of anterolateral musculature. Blood vessels collapse as interstitial pressure overcomes intravascular pressure and hypoxic injury ensues with local tissue ischemia, intracellular edema, anaerobic metabolism, and irreversible cell damage.

 

Figure 6
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  		Fig. 2A —68-year-old man with leg mass of gradual onset and history of tibial fracture and compartment syndrome 30 years previously. Anteroposterior (A) and lateral (B) radiographs show calcific myonecrosis involving lateral midcalf compartment, with large, well-defined ovoid peripherally calcified component; note old tibia fracture line (A) (arrow).

 

Figure 7
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  		Fig. 2B —68-year-old man with leg mass of gradual onset and history of tibial fracture and compartment syndrome 30 years previously. Anteroposterior (A) and lateral (B) radiographs show calcific myonecrosis involving lateral midcalf compartment, with large, well-defined ovoid peripherally calcified component; note old tibia fracture line (A) (arrow).

 

Figure 8
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  		Fig. 2C —68-year-old man with leg mass of gradual onset and history of tibial fracture and compartment syndrome 30 years previously. Axial CT image (bone window setting: width, 2000 H; level, 250 H) shows peripheral pattern of calcification clearly. Mass is abutting lateral aspect of fibula and causing thinning (C) and complete erosion (D) of adjacent cortex. Healed mid-diaphyseal tibial fracture is again noted.

 

Figure 9
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  		Fig. 2D —68-year-old man with leg mass of gradual onset and history of tibial fracture and compartment syndrome 30 years previously. Axial CT image (bone window setting: width, 2000 H; level, 250 H) shows peripheral pattern of calcification clearly. Mass is abutting lateral aspect of fibula and causing thinning (C) and complete erosion (D) of adjacent cortex. Healed mid-diaphyseal tibial fracture is again noted.

 

Figure 10
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  		Fig. 2E —68-year-old man with leg mass of gradual onset and history of tibial fracture and compartment syndrome 30 years previously. Coronal gradient MR sequences (TR/TE, 600/200 msec; gradient/20) show oval mass (D) abutting anterolateral aspect of mid-fibular diaphysis, paralleling radiograph findings. Peripheral rim of low signal intensity shows minimal blooming artifact (arrowheads, E) consistent with peripheral calcification. Mass is causing swelling of overlying skin. A coronal image more anteriorly (F) shows old tibial fracture and inferior aspect of peripherally calcified mass.

 

Figure 11
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  		Fig. 2F —68-year-old man with leg mass of gradual onset and history of tibial fracture and compartment syndrome 30 years previously. Coronal gradient MR sequences (TR/TE, 600/200 msec; gradient/20) show oval mass (D) abutting anterolateral aspect of mid-fibular diaphysis, paralleling radiograph findings. Peripheral rim of low signal intensity shows minimal blooming artifact (arrowheads, E) consistent with peripheral calcification. Mass is causing swelling of overlying skin. A coronal image more anteriorly (F) shows old tibial fracture and inferior aspect of peripherally calcified mass.

 

Figure 12
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  		Fig. 3A —49-year-old man with ankle pain. Anteroposterior (A) and lateral (B) radiographs of ankle show moderate amounts of calcification oriented in thick sheetlike or linear pattern, especially at periphery in both anterior and posterior muscular compartments.

 

Figure 13
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  		Fig. 3B —49-year-old man with ankle pain. Anteroposterior (A) and lateral (B) radiographs of ankle show moderate amounts of calcification oriented in thick sheetlike or linear pattern, especially at periphery in both anterior and posterior muscular compartments.

 

Figure 14
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  		Fig. 4A —38 year-old-cyclist who suffered vascular injuries to anterior tibial artery and subsequent compartment syndrome when hit by truck as teenager, now presenting with painless enlarging mass. Anteroposterior (A) and lateral (B) radiographs show sheetlike calcification in anterior and lateral compartments of lower limb consistent with calcific myonecrosis. C, Axial CT (width, 2000 H; level, 250 H) defines peripheral nature of lobular calcification.

 

Figure 15
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  		Fig. 4B —38 year-old-cyclist who suffered vascular injuries to anterior tibial artery and subsequent compartment syndrome when hit by truck as teenager, now presenting with painless enlarging mass. Anteroposterior (A) and lateral (B) radiographs show sheetlike calcification in anterior and lateral compartments of lower limb consistent with calcific myonecrosis. C, Axial CT (width, 2000 H; level, 250 H) defines peripheral nature of lobular calcification.

 

Figure 16
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  		Fig. 4C —38 year-old-cyclist who suffered vascular injuries to anterior tibial artery and subsequent compartment syndrome when hit by truck as teenager, now presenting with painless enlarging mass. Axial CT (width, 2000 H; level, 250 H) defines peripheral nature of lobular calcification.

 

Figure 17
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  		Fig. 5A —75-year-old man with remote history of tibia fracture in his teenage years. Patient was referred to rule out soft-tissue sarcoma. Anteroposterior view of tibia and fibula shows peripheral fusiform mass with sheetlike calcification mixed with areas of radiolucency, which is characteristic of calcific myonecrosis (biopsy-proven), causing erosion of adjacent tibia (arrow). Note old healed mid-tibia fracture (arrowhead).

 

Figure 18
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  		Fig. 5B —75-year-old man with remote history of tibia fracture in his teenage years. Patient was referred to rule out soft-tissue sarcoma. Unenhanced CT of lower limb (width, 2000 H; level, 500 H) shows cystic mass with plaquelike calcification replacing anterior muscular compartment of leg and causing pressure erosion of tibia (arrowheads) indicating chronic nature of this mass.

 

Figure 19
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  		Fig. 5C —75-year-old man with remote history of tibia fracture in his teenage years. Patient was referred to rule out soft-tissue sarcoma. Axial T1-weighted image of leg (TR/TE, 450/11) shows well-circumscribed mass of low signal intensity replacing muscle in anterior compartment between tibia and fibula. Note central low-signal-intensity dots (arrows) and peripheral low-signal-intensity rim representing calcification (arrowheads).

 

Figure 20
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  		Fig. 5D —75-year-old man with remote history of tibia fracture in his teenage years. Patient was referred to rule out soft-tissue sarcoma. Axial T2-weighted image (4,460/107) at proximal diaphyseal level shows well-circumscribed mass (arrow) of high T2 signal-intensity because of cystic necrosis centrally and liquefaction of muscle in anterior compartment.

 

Figure 21
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  		Fig. 5E —75-year-old man with remote history of tibia fracture in his teenage years. Patient was referred to rule out soft-tissue sarcoma. Axial T2-weighted fast spin-echo sequence (7,000/92) more inferiorly shows lobulated mass with number of cystic components abutting tibia and thinning cortex. Focal curvilinear areas of low-signal-intensity within mass correspond to dense fibrosis and areas of calcification (arrows).

 

Figure 22
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  		Fig. 5F —75-year-old man with remote history of tibia fracture in his teenage years. Patient was referred to rule out soft-tissue sarcoma. Coronal STIR (4,500/45) of leg shows subtle bone marrow edema in tibia (arrow), which is likely pressure effect from masslike calcific myonecrosis.

 

Figure 23
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  		Fig. 5G —75-year-old man with remote history of tibia fracture in his teenage years. Patient was referred to rule out soft-tissue sarcoma. Coronal gradient echo (415/12; gradient/20) shows blooming from susceptibility artifact and related to extensive calcification or hemosiderin in muscle (arrows).

 

Figure 24
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  		Fig. 5H —75-year-old man with remote history of tibia fracture in his teenage years. Patient was referred to rule out soft-tissue sarcoma. Diagrammatic illustration of ischemia after poorly managed compartment syndrome leads to extensive necrosis, fibrosis, and loss of function indicated by atrophy of musculature. In rare cases, dystrophic calcification (arrowhead) and liquefaction, which comprise entity called calcific myonecrosis, occur as late sequelae. Cystic lobulated component (asterisk) may cause chronic pressure erosion (arrow) of adjacent bone (tibia).

 

Figure 25
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  		Fig. 5I —75-year-old man with remote history of tibia fracture in his teenage years. Patient was referred to rule out soft-tissue sarcoma. Anteroposterior diagram shows cystic degeneration and fibrosis of muscle (arrow). Repeated intralesional hemorrhage causes mass to enlarge and become herniated through muscle fascia, often prompting patient's clinical presentation with enlarging mass.

 

Figure 26
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  		Fig. 6 —Gross appearance of resection of calcific myonecrosis exhibiting typical pale necrotic muscle that has undergone cystic change.

 

Figure 27
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  		Fig. 7 —Photomicrograph of wall of mass showing characteristic histiocytic reaction with embedded fragments of calcified material (arrow). (H and E)

 

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