Harrison Jordan, DO
Resident
East Carolina University Health
Greenville, North Carolina, United States
David Salchert, MD
Resident Physician
East Carolina University Health
Greenville, North Carolina, United States
Reid Huckabee, BS
Medical Student
Lincoln Memorial University-DeBusk College of Osteopathic Medicine
Bristol, Tennessee, United States
Robert T. Lombard, MD
Assistant Clinical Professor
ECU Health Medical Center
Greenville, North Carolina, United States
A 55-year-old male was admitted following a motor vehicle collision, resulting in multiple fractures, optic nerve injury, and traumatic brain injury. The patient underwent a left humerus open reduction internal fixation (ORIF) on admission. The patient presented to inpatient rehabilitation and after an initial pain-free interval, began to complain of an intense pain in the left shoulder and ankle as well as swelling and a locking sensation in the left hip. This pain was being managed with Lidoderm patches, topical diclofenac 2% gel, gabapentin, and methocarbamol. Repeat shoulder and ankle x-rays revealed heterotopic ossification (HO) with left hip CT revealing severe HO. Bisphosphonates were not recommended due to concern of delayed bone healing. With the combination of low-dose indomethacin and aquatic therapy to limit pain and improve range of motion, the patient was able to experience more relief and complete therapies throughout the remainder of the inpatient rehabilitation admission.
Discussions:
HO is noted to develop in 10-20% of patients after a closed head injury and is most commonly acquired after trauma to the central nervous system or skeletal muscle. HO can be difficult to differentiate from cellulitis or osteomyelitis due to its symptomology of swelling, erythema, and decreased joint mobility. Early treatment of HO consists of NSAIDs, local radiation, or bisphosphonates. While post-surgical pain and limited joint mobility are often seen in the rehabilitation setting, re-imaging the patient revealed new soft tissue bone growth, allowing for optimization of treatment to maximize therapy. Indomethacin, along with aquatic therapy, should be considered as a first-line treatment of HO in the inpatient rehabilitation setting.
Conclusions: Pain related to HO in the inpatient rehabilitation setting can be managed with indomethacin and aquatic therapy to maximize patients’ rehabilitation and improve tolerance with therapies.
