Heinz Lippmann disease
By Harish S. Hosalkar, MD, MBMS (Orth), FCPS (Orth), DNB (Orth), Purushottam A. Gholve, MD, Neil Roach, MD, and Murray K. Dalinka, MD
The radiographs of the affected extremity (Figure 1) reveal fine
granular densities that represent ossifications in the subcutaneous
tissue, independent of the veins, and can be further confirmed on
venography. The other radiologic features are oval or cylindrical
densities that may interface and coalesce. These frequently show
thin rims and lucent centers, which may have a fine weblike
pattern. Heavy cords and sheets may retain central lucent zones and
may show a trabecular pattern (Figure 2).
Subcutaneous osseous deposits in relation to chronic venous
insufficiency were first reported by Lippman in 1960 and have
subsequently been labeled as Heinz Lippmann disease.1
Chronic venous insufficiency is defined as tissue damage caused by
abnormal changes in the venous circulation. In the lower
extremities, chronic venous insufficiency is frequently caused by
varicosities of the long saphenous system or by pathologies in the
deep venous system, including obstruction or insufficiency. Less
commonly, a short saphenous system may also be involved. Other less
frequent etiologies are arteriovenous fistulas and vascular
malformations. Dependent edema is an important contributory factor
in the pathogenesis.1,2
Clinical manifestations of chronic venous insufficiency are
chronic dermatitis and cellulitis, as well as atrophy of the skin
and subcutaneous tissue with induration and brown discoloration.
Late sequelae include recurrent ulceration and subcutaneous
Although Lippmann et al1 quoted a high incidence of
subcutaneous ossification, the incidence has declined over
subsequent years, following earlier diagnosis and adequate
treatment of varicosities and other etiologies that lead to chronic
insufficiency. Hence, in the current medical era, subcutaneous
ossification is a rare event and is primarily found in cases of
extremely long-standing venous insufficiency. Interestingly,
Lippmann et al1 noted a higher incidence of subcutaneous
ossification in females, although venous insufficiency may have
higher occupational preponderance in males.
Phleboliths can occasionally be confused with subcutaneous
ossified deposits. Phleboliths tend to be more discrete and present
a smoother outline.3 They have a denser rim and a small
central zone of lucency. Multiple phleboliths usually remain
discrete, while ossifications generally tend to
coalesce.3 Arterial calcifications are usually linear,
showing a double-tracked appearance, and are present in the deeper
soft tissues of the leg.4 Myositis ossificans is
classically located in the muscle rather than in subcutaneous
tissue and has a characteristic appearance.5 Rarely,
other calcifications (including parasitic infestations and
calcinosis) can present in a similar manner. In most cases, a
clinical history and evaluation of the radiodensities will lead to
The subcutaneous ossific deposits following chronic venous
insufficiency can be confused with various other causes of
ossification in deeper tissues or muscle. Some etiologies may
require treatment and further investigation. The evaluation of
different radiodensities in tandem with a typical clinical
presentation helps the diagnosis.
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- Lippmann HI, Goldin RR. Subcutaneous ossification of the legs
in chronic venous insufficiency. Radiology. 1960;74:279-288.
- Dalinka MK, Melchior EL. Soft tissue calcifications in systemic
disease. Bull N Y Acad Med.1980;56:539-563.
- Koval G, Vinogradov S. X-ray semeiotics of changes in the soft
tissues and bones of the lower extremities in disorders of the
venous outflow [in Russian]. Vestn Rentgenol Radiol.
- Lanzer P. Monckeberg media calcinosis [in German]. Z Kardiol.
- Zeanah WR, Hudson TM. Myositis ossificans: Radiologic
evaluation of two cases with diagnostic computed tomograms. Clin
Orthop Relat Res. 1982;168:187-191.
Heinz Lippmann disease.
July 06, 2007