Myositis ossificans as a complication of tetanus.

A forty-three-year-old Indian stepped on a sharp piece of wood and suffered a small puncture wound on the sole of the right foot. A doctor gave him daily injections of penicillin for three days, but no antitetanus serum. Ten days after the injury he was admitted to hospital complaining of pains in his legs, and trismus was observed. He was immediately given an intravenous injection of 100,000 units of antitetanus serum and 600,000 units of procaine penicillin. Later the same day he complained of pain in his back, and this was shortly followed by tetanic spasms in his back and legs. Tetanus was diagnosed. The penicillin was repeated daily for ten days, but no additional serum was given. An intravenous glucose saline drip was started in the right cephalic vein, and paraldehyde was given intramuscularly as required, on an average 8 cubic centimetres five times daily. On the third day the spasms became more frequent and severe, and half a gramme of thiopentone was added to each bottle of saline. After another four days the patient had recovered sufficiently to allow the thiopentone to be discontinued, and the frequency of the paraldehyde injections was reduced. From now onwards the patient made a steady recovery. On the tenth day after the onset of the spasms the patient complained that both knees and the right elbow were stiff. The stiffness of the right elbow was attributed to a rather painful arm after the intravenous drip, which had been continued for seven days. No thrombosis was noticed. The patient was encouraged to move the affected joints as much as possible, but the stiffness increased, and four days later he was referred to the physiotherapy department for active and passive movements of the knees and right elbow. Examination revealed considerable thickening about the left knee, which felt bony hard, and there was rather less about the right knee. Neither active nor passive movement of the knees was possible. There was marked limitation of movement in both hips, and in the right elbow. Radiographs taken three weeks after the onset of the spasms revealed extensive soft flocculent calcareous infiltration in the soft tissues behind the lower end of the left femur, extending downwards some two inches below the knee joint; and similar, but less extensive, changes behind the right knee. The calcareous infiltration seemed to be mainly in the hamstring muscles or gastrocnemii, and in the medial and lateral ligaments of the knees, though there were similar changes in the medial vasti and adductors on both sides. There was faint flocculent calcareous infiltration in the periarticular tissues of both hips-again a little more pronounced on the left side-and in front of the right elbow in the situation of the lower part of the brachialis. In view of these surprising findings, characteristic of myositis ossificans, the serum levels of calcium and phosphorus were checked and found to be 11 milligrams per cent and 3 l milligrams per cent respectively. The alkaline phosphatase was 7 units (King-Armstrong), and the Kahn test was negative. Progress-Complete rest in bed was ordered, with posterior plaster splints to both knees. This treatment was abandoned after two months because no improvement had been achieved, and physiotherapy was instituted. This was discontinued after two months. A year after the onset of tetanus the patient was well, apart from complete immobility of the right elbow, left knee and left hip. There was a limited degree of movement in the right knee (180-165