Mitcrodantin®
BRIEF COMMUNICATION
(Nitroturantoin Ma.rocrysuals)
Reterences 1. Roth, R.B. et al. The Ruined Kidney, Filmstrip produced with the cooperation ot the Hess Urological Foundation, Inc. Erie, Pa., U.S.A. 2. Kunin, C.M.: Detection, Prevention and management of urinary tract Infections. Philadelphia, Lea&Febiger, 1972 pg. 18811. 3. Kalowski S., Radford N., Kincaid-Smith P: New Eng. J.M 290: 386, 1974 4. Shirley SW. and Ozog L.S.: Urology Digest 9:8-10, 1970 Action: The large crystal size of Macrodantin (nitorfurantoin macrocrystals) provides the proven clinical efficacy of Furadantin (nitrofurantoin) hut with increased gastro intestinal tolerance. In a comparative clinical study the incidence of nausea and/or emesis was appreciably less with Macrodantin than with Furadanfin. Patients unable to tolerate Furadantin reported good tolerance of Macrodantin. Indications: Macrodantin is indicated for the treatment of pyelonephritis, pyelitis and cystitis caused by sensitive organisms. Contraindicatlons: Anuria, oliguria or extensive impairment of renal function. Infants under one month. Warnings: Haemolytic anaemia, which disappears on cessation of drug therapy has been reported in sensitive individuals. Usually defined as the 10% of negroes and lower percentages of people of Mediterranean and near Eastern origin who exhibit glucose -6 - phosphate dehydrogenase deficiency of the red blood cells. Safety during pregnancy and lactation has not been established. Precautions: Peripheral neuropathy has been reported with nitrofurantoin. This may become severe and irreversible and one fatality has been reported. Therapy should be discontinued if numbness and tingling occur. Macrodanfin should not be co-prescribed with drugs which impair renal function. Adverse Reactions: Nausea, emesis, and less frequently, diarrhea may occur; reduction in dosage may alleviate these symptoms. Sensitization appearing as an erythematous, maculopapular cutaneous eruption, urticaria, eczematoid eruption or pruritus has occurred. Hypersensitivity reactions resulting in nonfatal anaphylaxis, angioedema, pulmonary infiltration with pleural effusion, and eosinophilia have been reported. Other possible reactions are chills, fever, jaundice, asthmatic symptoms, and hypotension. Occasional minor reactions such as headache, dizziness, nystagmus, vertigo, drowsiness, malaise, and muscular aches have occurred. Transient alopecia has been reported. Leukopenia, including granulocytopenia has been reported rarely. Return of the blood picture to normal has followed cessation of therapy. As with other antimicrobial agents, superinfections by resistant organisms may occur. With Macrodantin, however, these are limited to the genitourinary tract because suppression of normal bacterial flora elsewhere in the body does not occur. Administration and Dosage: Dosage: Adult: 50 to 100 milligrams four times a day. Children: Should be calculated on the basis of 5 to 7 milligrams per kilogram (2.2 to 3.2 mg per Ib) of body weight per 24 hours, to be given in divided doses four times a day (contraindicated under one month of age). Administration: Macrodantin (nitrofurantoin macrocrystals) may be given with food or milk to further minimize gastric upset. Therapy should be continued for at least one week and forat least 3 days after sterility of the urine is obtained. Continued infection indicates the need for re-evaluation. If the drug is to be used for long-term suppressive therapy, a reduction of dosage should be considered. How Supplied: Macrodantin is available in opaque white imprinted capsules of 25 mg. (Eaton 007) in bottles of 30, 100 and 500 capsules; opaque yellow/white imprinted capsules of 50 mg. (Eaton 008) in bottles of 30, 100, and 500 capSules; opaque yellow, imprinted capsules of 100 mg. (Eaton 009) in bottles of 30, 100, and 500 capsules. Praduct monograph available on request. Originators and Developers of the Nitrofurans
EATON LABORATORIES .
Division of Norwich Pharmacal Company Ltd. Paris, Ontario.
Myositis ossificans due to hockey injury T. TREDGET,* MD; C.V. GODBERSON,t MD; B. BosE,t FRCS[C], FRCS (ENG), FRCS (EDIN)
Injuries are common in hockey, particularly in males aged 15 to 21 years. Studies1" have implicated the hockey stick as the most common cause of hockey injuries; lacerations have been the most frequent type of injury and contusions the second most common type, but with a longer period of disability.1 Myositis ossificans traumatica is a rare but important sequel of contusion that, to our knowledge, has not been reported following hockey injury. Two case histories illustrate this complication.
Case reports Case 1 A 15-year-old boy was hit on the left arm by a hockey stick, with resulting local bruising and pain. He did not seek medical attention and took part in practice games 2 weeks later, with minimal disability. Because pain and tenderness at the site of injury and some disability persisted after 4 weeks, he consulted his doctor, who found induration, tenderness and minimal swelling at the site of injury on the left midarm. A radiograph confirmed myositis ossificans (Fig. 1). Treatment consisted of plaster-cast immobilization for 3 weeks, followed by gradual exercise. He returned to full-time hockey after 8 weeks. Although he had no disability, radiographs at 3 and 9 months showed an increase in density, but a reduction in size of the myositis ossificans. Case 2 An 11-year-old boy sustained a contusion to his thigh from body contact during a game of hockey. Examination showed soft-tissue bruising only, with pain and From 5Royal Columbian Hospital, New Westminster, BC and tBarrhead General Hospital, Barrhead, Alta. Reprint requests to: Dr. B Bose Barrhead General Hospital, P0 Box. 880, .Barrhead, Alta. TOG OEO
FIG. 1-Myositis ossificans In midarm (case 1).
CMA JOURNAL/JANUARY 8, 1977/VOL. 116 65
Myositis ossificans from football injuries is well documented,6 and one can conclude that in hockey injuries the incidence of myositis ossificans is appreciable, though as yet undetermined. Since the limb muscles are more prone to injury these are the common sites of myositis ossificans. Traumatic myositis ossificans refers to heterotrophic calcification in an inflamed area of muscle following Discussion trauma. Causes include contusion, hematoma, fracture or, rarely, muscle The reported incidence of hockey in- strain. Repeated trauma and a past juries varies from 3 to 5% *14 One study history of myositis ossificans are preshowed that more injuries resulted from disposing factors. Often the condition hockey than from baseball, football and develops near the origin or insertion soccer combined.4 Muscle injuries are of the affected muscle. The osteoblasts not uncommon and contusions are fre- that lay down the bone arise either in quent,5 the rate in one study being. ap- situ from mesenchymal cells or from proximately one out of four injuries.1 the adjacent periosteum that is affected in the muscle injury.7 Typically myositis ossificans follows muscle contusion from an external blow. The clinical features include painful swelling in the first 24 hours, local tenderness and heat, and, rarely, a short febrile episode in the ensuing few days. Functional disability is determined by the extent and location of the injury. Early radiographs, in the absence of fracture, show only a softtissue mass, and calcification usually does not appear until the 2nd to 4th week after injury. The feathery calcification is distributed parallel to the bone shaft or along the axis of the damaged muscle.6 The lesion may be entirely unassociated with the underlying bone or connected by a wide or narrow stalk. The extent of the ossification parallels that of the contusion. The condition stabilizes in size at 3 to 6 months and the resultant painless lesion tends to reabsorb slowly, yet often incompletely, and without residual disability. Inclusion of myositis ossificans among causes of bony tumours is important. The early radiographic appearance of myositis ossificans in the young with a history of recent trauma may be confused by the unwary with that of osteogenic sarcoma or another type of ossifying bone tumour; unjusti. :.V.$.; fied biopsy and even amputation have ensued.'9 Histologically, myositis ossificans resembles normal callus, with a centrifugal pattern of maturation that evolves into a pseudosarcomatous central zone merging into oriented osteoid 4 formation and mature bone peripherally;9 thus differentiation from osteogenic sarcoma is rarely difficult. A history of 2 to 4 weeks' antecedent trauma in a young athlete, a relatively painless mass that recedes clinically and radiographically, and a normal serum FIG. 2-Typical feathery calcification in alkaline phosphatase value usually clarify the diagnosis.6'1 quadriceps (case 2).
limitation of use of the quadriceps muscle. Treatment consisted of rest and local application of heat. Two weeks later he injured the same area in a fall; a radiograph revealed typical early myositis ossificans (Fig. 2). With immobilization in a cast for 6 weeks and gradual exercise for 2 weeks he recovered completely. At 8 weeks minimal increase in density was evident but no change in the extent of the myositis ossificans.
66 CMA JOURNAL/JANUARY 8, 1977/VOL. 116
The mainstays of therapy are rest and rehabilitation well within the limits of pain. Early return to participation increases the risk of reinjury and prolongs morbidity. Passive manipulation should be avoided for up to 6 months. Heat seems to arrest osteogenesis, but other modes of therapy, such as shortwave diathermy, ultrasonic therapy, radiotherapy, hyaluronidase, corticosteroids and proteolytic enzymes, have not been shown to shorten disability. Diagnostic biopsy may increase ossification and delay recovery and should be avoided. Similarly, early surgical removal of the mass of bone simply invites recurrence and magnifies the extent of both the lesion and the disability. Late surgical intervention, after appropriate conservative treatment, has been effective in removal of the nonpainful calcific mass.6 Diphosphonate, which prevents deposition of calcium phosphate in vivo and in vitro, has been used orally with success in the treatment of myositis ossificans progressiva and Paget's disease,11'12 and there may be a place for diphosphonate therapy in selected cases of myositis ossificans traumatica. Certainly prevention of trauma by adequate protective equipment and enforcement of rules pertaining to the use of the hockey stick will prevent many such injuries. Education of players, coaches and spectators will maintain hockey as a fast-moving, specta- cular and healthy sport Canadians can identify with and enjoy. References 1. HASTINGS DE, CAMERON 3, PARKER SM, Ct al: A study of hockey injuries in Ontario. Ont Med Rev 41: 686, 1974 2. REEVES JHS: A Study of incidence, Nature, and Causes of Hockey Injuries in Greater Edmonton Metropolitan Area, thesis, University of Alberta, Edmonton, 1970 3. Toooooo T, LOVE GW: Hockey injury survey. Can Assoc Health Phys Ed Recreat 1 32: 20, 1965/66 4. PASHBY TJ, PA5HBY RC, CHIsHoLM LDJ, et al: Eye injuries in Canadian hockey. Can Med Assoc 1 113: 663, 1975 5. JANES 3M: Ice-hockey injuries. Clin Orthop
23: 67, 1962 6. O'DONOGHUE DH: Treatment of Injuries to Athletes, 49, 447
Philadelphia,
Saunders,
1970,
pp
7. Rossrns SL: Pathological Basis of Disease, Philadelphia, Saunders, 1974, p 1428 8. GREENFIELD GB: Radiology of Bone Disease, 2nd ed,' Philadelphia, 1975, p 504
Toronto,
Lippincott,
9. ACKERMAN LV: Extraosseous localised nonneoplastic bone and cartilage formation (socalled myositis ossificans). Clinical and pathological confusion with malignant neoplasm.
I Bone Joint Surg (AmJ 40: 279, 1958 10. JACKSON DW: Managing myositis ossificans. Phys Sportsmed 3: 56, 1975 11. BASSETr CAL, DONATH A, MACAGNO F, Ct al:
Diphosphonate in the treatment of myositis ossificans. Lancet 2: 845, 1969
12. FLEISCH H, BONJOUR JP: Diphosphonate treatment in bone disease. N Engl 1 Med 289: 1419, 1973
BRIEF COMMUNICATION
(Nitroturantoin Ma.rocrysuals)
Reterences 1. Roth, R.B. et al. The Ruined Kidney, Filmstrip produced with the cooperation ot the Hess Urological Foundation, Inc. Erie, Pa., U.S.A. 2. Kunin, C.M.: Detection, Prevention and management of urinary tract Infections. Philadelphia, Lea&Febiger, 1972 pg. 18811. 3. Kalowski S., Radford N., Kincaid-Smith P: New Eng. J.M 290: 386, 1974 4. Shirley SW. and Ozog L.S.: Urology Digest 9:8-10, 1970 Action: The large crystal size of Macrodantin (nitorfurantoin macrocrystals) provides the proven clinical efficacy of Furadantin (nitrofurantoin) hut with increased gastro intestinal tolerance. In a comparative clinical study the incidence of nausea and/or emesis was appreciably less with Macrodantin than with Furadanfin. Patients unable to tolerate Furadantin reported good tolerance of Macrodantin. Indications: Macrodantin is indicated for the treatment of pyelonephritis, pyelitis and cystitis caused by sensitive organisms. Contraindicatlons: Anuria, oliguria or extensive impairment of renal function. Infants under one month. Warnings: Haemolytic anaemia, which disappears on cessation of drug therapy has been reported in sensitive individuals. Usually defined as the 10% of negroes and lower percentages of people of Mediterranean and near Eastern origin who exhibit glucose -6 - phosphate dehydrogenase deficiency of the red blood cells. Safety during pregnancy and lactation has not been established. Precautions: Peripheral neuropathy has been reported with nitrofurantoin. This may become severe and irreversible and one fatality has been reported. Therapy should be discontinued if numbness and tingling occur. Macrodanfin should not be co-prescribed with drugs which impair renal function. Adverse Reactions: Nausea, emesis, and less frequently, diarrhea may occur; reduction in dosage may alleviate these symptoms. Sensitization appearing as an erythematous, maculopapular cutaneous eruption, urticaria, eczematoid eruption or pruritus has occurred. Hypersensitivity reactions resulting in nonfatal anaphylaxis, angioedema, pulmonary infiltration with pleural effusion, and eosinophilia have been reported. Other possible reactions are chills, fever, jaundice, asthmatic symptoms, and hypotension. Occasional minor reactions such as headache, dizziness, nystagmus, vertigo, drowsiness, malaise, and muscular aches have occurred. Transient alopecia has been reported. Leukopenia, including granulocytopenia has been reported rarely. Return of the blood picture to normal has followed cessation of therapy. As with other antimicrobial agents, superinfections by resistant organisms may occur. With Macrodantin, however, these are limited to the genitourinary tract because suppression of normal bacterial flora elsewhere in the body does not occur. Administration and Dosage: Dosage: Adult: 50 to 100 milligrams four times a day. Children: Should be calculated on the basis of 5 to 7 milligrams per kilogram (2.2 to 3.2 mg per Ib) of body weight per 24 hours, to be given in divided doses four times a day (contraindicated under one month of age). Administration: Macrodantin (nitrofurantoin macrocrystals) may be given with food or milk to further minimize gastric upset. Therapy should be continued for at least one week and forat least 3 days after sterility of the urine is obtained. Continued infection indicates the need for re-evaluation. If the drug is to be used for long-term suppressive therapy, a reduction of dosage should be considered. How Supplied: Macrodantin is available in opaque white imprinted capsules of 25 mg. (Eaton 007) in bottles of 30, 100 and 500 capsules; opaque yellow/white imprinted capsules of 50 mg. (Eaton 008) in bottles of 30, 100, and 500 capSules; opaque yellow, imprinted capsules of 100 mg. (Eaton 009) in bottles of 30, 100, and 500 capsules. Praduct monograph available on request. Originators and Developers of the Nitrofurans
EATON LABORATORIES .
Division of Norwich Pharmacal Company Ltd. Paris, Ontario.
Myositis ossificans due to hockey injury T. TREDGET,* MD; C.V. GODBERSON,t MD; B. BosE,t FRCS[C], FRCS (ENG), FRCS (EDIN)
Injuries are common in hockey, particularly in males aged 15 to 21 years. Studies1" have implicated the hockey stick as the most common cause of hockey injuries; lacerations have been the most frequent type of injury and contusions the second most common type, but with a longer period of disability.1 Myositis ossificans traumatica is a rare but important sequel of contusion that, to our knowledge, has not been reported following hockey injury. Two case histories illustrate this complication.
Case reports Case 1 A 15-year-old boy was hit on the left arm by a hockey stick, with resulting local bruising and pain. He did not seek medical attention and took part in practice games 2 weeks later, with minimal disability. Because pain and tenderness at the site of injury and some disability persisted after 4 weeks, he consulted his doctor, who found induration, tenderness and minimal swelling at the site of injury on the left midarm. A radiograph confirmed myositis ossificans (Fig. 1). Treatment consisted of plaster-cast immobilization for 3 weeks, followed by gradual exercise. He returned to full-time hockey after 8 weeks. Although he had no disability, radiographs at 3 and 9 months showed an increase in density, but a reduction in size of the myositis ossificans. Case 2 An 11-year-old boy sustained a contusion to his thigh from body contact during a game of hockey. Examination showed soft-tissue bruising only, with pain and From 5Royal Columbian Hospital, New Westminster, BC and tBarrhead General Hospital, Barrhead, Alta. Reprint requests to: Dr. B Bose Barrhead General Hospital, P0 Box. 880, .Barrhead, Alta. TOG OEO
FIG. 1-Myositis ossificans In midarm (case 1).
CMA JOURNAL/JANUARY 8, 1977/VOL. 116 65
Myositis ossificans from football injuries is well documented,6 and one can conclude that in hockey injuries the incidence of myositis ossificans is appreciable, though as yet undetermined. Since the limb muscles are more prone to injury these are the common sites of myositis ossificans. Traumatic myositis ossificans refers to heterotrophic calcification in an inflamed area of muscle following Discussion trauma. Causes include contusion, hematoma, fracture or, rarely, muscle The reported incidence of hockey in- strain. Repeated trauma and a past juries varies from 3 to 5% *14 One study history of myositis ossificans are preshowed that more injuries resulted from disposing factors. Often the condition hockey than from baseball, football and develops near the origin or insertion soccer combined.4 Muscle injuries are of the affected muscle. The osteoblasts not uncommon and contusions are fre- that lay down the bone arise either in quent,5 the rate in one study being. ap- situ from mesenchymal cells or from proximately one out of four injuries.1 the adjacent periosteum that is affected in the muscle injury.7 Typically myositis ossificans follows muscle contusion from an external blow. The clinical features include painful swelling in the first 24 hours, local tenderness and heat, and, rarely, a short febrile episode in the ensuing few days. Functional disability is determined by the extent and location of the injury. Early radiographs, in the absence of fracture, show only a softtissue mass, and calcification usually does not appear until the 2nd to 4th week after injury. The feathery calcification is distributed parallel to the bone shaft or along the axis of the damaged muscle.6 The lesion may be entirely unassociated with the underlying bone or connected by a wide or narrow stalk. The extent of the ossification parallels that of the contusion. The condition stabilizes in size at 3 to 6 months and the resultant painless lesion tends to reabsorb slowly, yet often incompletely, and without residual disability. Inclusion of myositis ossificans among causes of bony tumours is important. The early radiographic appearance of myositis ossificans in the young with a history of recent trauma may be confused by the unwary with that of osteogenic sarcoma or another type of ossifying bone tumour; unjusti. :.V.$.; fied biopsy and even amputation have ensued.'9 Histologically, myositis ossificans resembles normal callus, with a centrifugal pattern of maturation that evolves into a pseudosarcomatous central zone merging into oriented osteoid 4 formation and mature bone peripherally;9 thus differentiation from osteogenic sarcoma is rarely difficult. A history of 2 to 4 weeks' antecedent trauma in a young athlete, a relatively painless mass that recedes clinically and radiographically, and a normal serum FIG. 2-Typical feathery calcification in alkaline phosphatase value usually clarify the diagnosis.6'1 quadriceps (case 2).
limitation of use of the quadriceps muscle. Treatment consisted of rest and local application of heat. Two weeks later he injured the same area in a fall; a radiograph revealed typical early myositis ossificans (Fig. 2). With immobilization in a cast for 6 weeks and gradual exercise for 2 weeks he recovered completely. At 8 weeks minimal increase in density was evident but no change in the extent of the myositis ossificans.
66 CMA JOURNAL/JANUARY 8, 1977/VOL. 116
The mainstays of therapy are rest and rehabilitation well within the limits of pain. Early return to participation increases the risk of reinjury and prolongs morbidity. Passive manipulation should be avoided for up to 6 months. Heat seems to arrest osteogenesis, but other modes of therapy, such as shortwave diathermy, ultrasonic therapy, radiotherapy, hyaluronidase, corticosteroids and proteolytic enzymes, have not been shown to shorten disability. Diagnostic biopsy may increase ossification and delay recovery and should be avoided. Similarly, early surgical removal of the mass of bone simply invites recurrence and magnifies the extent of both the lesion and the disability. Late surgical intervention, after appropriate conservative treatment, has been effective in removal of the nonpainful calcific mass.6 Diphosphonate, which prevents deposition of calcium phosphate in vivo and in vitro, has been used orally with success in the treatment of myositis ossificans progressiva and Paget's disease,11'12 and there may be a place for diphosphonate therapy in selected cases of myositis ossificans traumatica. Certainly prevention of trauma by adequate protective equipment and enforcement of rules pertaining to the use of the hockey stick will prevent many such injuries. Education of players, coaches and spectators will maintain hockey as a fast-moving, specta- cular and healthy sport Canadians can identify with and enjoy. References 1. HASTINGS DE, CAMERON 3, PARKER SM, Ct al: A study of hockey injuries in Ontario. Ont Med Rev 41: 686, 1974 2. REEVES JHS: A Study of incidence, Nature, and Causes of Hockey Injuries in Greater Edmonton Metropolitan Area, thesis, University of Alberta, Edmonton, 1970 3. Toooooo T, LOVE GW: Hockey injury survey. Can Assoc Health Phys Ed Recreat 1 32: 20, 1965/66 4. PASHBY TJ, PA5HBY RC, CHIsHoLM LDJ, et al: Eye injuries in Canadian hockey. Can Med Assoc 1 113: 663, 1975 5. JANES 3M: Ice-hockey injuries. Clin Orthop
23: 67, 1962 6. O'DONOGHUE DH: Treatment of Injuries to Athletes, 49, 447
Philadelphia,
Saunders,
1970,
pp
7. Rossrns SL: Pathological Basis of Disease, Philadelphia, Saunders, 1974, p 1428 8. GREENFIELD GB: Radiology of Bone Disease, 2nd ed,' Philadelphia, 1975, p 504
Toronto,
Lippincott,
9. ACKERMAN LV: Extraosseous localised nonneoplastic bone and cartilage formation (socalled myositis ossificans). Clinical and pathological confusion with malignant neoplasm.
I Bone Joint Surg (AmJ 40: 279, 1958 10. JACKSON DW: Managing myositis ossificans. Phys Sportsmed 3: 56, 1975 11. BASSETr CAL, DONATH A, MACAGNO F, Ct al:
Diphosphonate in the treatment of myositis ossificans. Lancet 2: 845, 1969
12. FLEISCH H, BONJOUR JP: Diphosphonate treatment in bone disease. N Engl 1 Med 289: 1419, 1973
![[Myositis ossificans following head injury (author's transl)].](/assets/img/hold.png)
