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Osteomyelitis


Currently, under this name, the lesion of all parts of the bone is combined: inflammation of the bone (osteitis), bone marrow (myelitis) and periosteum (periostitis). It occurs as a result of endogenous (hematogenous) or exogenous infection of the bone.
There are hematogenous osteomyelitis, developing as a result of the introduction of microbes into the bone through the blood, and wound, or traumatic osteomyelitis, which is secondary and develops as a complication of the wound process, surgical treatment of closed fractures. In the initial stage, these two types of bone inflammation are completely different both in origin and in manifestations. However, in the later phases the differences are gradually smoothed out, so they have a common name.
Hematogenous osteomyelitis is more common in male children and adolescents. The process is usually localized in the femoral and tibial bones and less frequently in all others. From the primary focus (furuncles, carbuncles, panaritiums, cellulitis, abscesses, erysipelas, infected abrasions and wounds, carious teeth, tonsillitis, chronic inflammatory processes in the paranasal cavities of the nose and ear, etc.) microbes enter the bone marrow through blood flow and cause inflammation . The following factors distinguish the development of osteomyelitis: 1) anatomical and physiological, 2) biological and immunobiological, 3) predisposing. According to the clinical course, acute and chronic osteomyelitis is distinguished, which in the overwhelming majority of cases is an acute outcome, but it can also occur as a primary chronic condition.
Acute hematogenous osteomyelitis. Symptoms and course. In the first 1-2 days, the patient notes general malaise, aches in the limbs, muscle pain, and headache. Then there is a stunning oznoo with a persistent increase in temperature to 39 ± C, and above, weakness, weakness, headache, and sometimes vomiting. The general condition becomes severe, the consciousness becomes obscured, delirium appears, symptoms of irritation of the meninges, and sometimes convulsions. Appetite disappears, tongue is laid, dry. The face becomes pale, the eyes sink, the lips and mucous membranes are cyanotic, the skin is dry, with an icteric tinge, its turgor is reduced.
Blood pressure is low, heart sounds are deaf, pulse is frequent, weak filling and, as a rule, corresponds to temperature. The breathing is rapid, superficial. The lungs sometimes show symptoms of bronchopneumonia. The liver and spleen are enlarged, painful on palpation. Sometimes the kidney area is painful, there is little urine, protein and cylinders in the urine.
With 1-2 days of the disease appears severely localized severe pain in the affected limb, wearing a tearing, drilling, arching nature. Patients, especially children, with the slightest movements of the affected limb, bed shocks, shifting often screaming from increased pain. To reduce pain, they lie completely still. In connection with the deep location of the lesion, methodical palpation, which must be carried out carefully, becomes important in such cases. It allows you to identify the area of ​​the most painful, corresponding to the center of the process. The method of early diagnosis is tapping on the heel or elbow, which causes severe pain at the site of injury.
In the next 1-2 days, local phenomena appear more clearly. Accordingly, the affected area appears painful swelling of soft tissues, which quickly increases, moderate redness and swelling of the skin, increasing its temperature. Despite the fact that X-ray examination during this period does not give any data, the diagnosis becomes quite clear. The swelling of the extremities increases rapidly, dilated veins begin to shine, regional lymph nodes increase. At the end of 1 week, fluctuation begins to be determined in children and weeks after two in adolescents in the center of painful and dense swelling.
With the development of intermuscular phlegmon, the general condition of the patient is somewhat improved, but if it remains severe, it is necessary to look for certain complications (transition of the process to a nearby joint, multiple bone damage, formation of pyemic lesions, etc.). Without surgical treatment, intermuscular phlegmon can open up on its own, with the subsequent formation of a fistula. In more unfavorable cases, it progresses and leads to secondary purulent arthritis, paraarticular phlegmon and sepsis.
The course of acute hematogenous osteomyelitis depends on the timeliness of the initiated treatment, in particular the use of antibiotics. This is indicated by medical practice, noting the recent increase in "subacute" forms and a significant reduction in the number of acute and septic cases.
The reason for the transition of acute osteomyelitis to chronic is the continuing necrosis of the infected spongy or compact bone layer. The resulting sequestrum is one of the main pathoanatomical substrates that support reactive inflammation of the surrounding bone tissue. The weak development of regenerative processes, caused by a sharp malnutrition of the bone and periosteum, contributes to the chronic course.
Clinical symptoms in patients with chronic osteomyelitis with or without a fistula are mostly insignificant and worsen only when the inflammatory process worsens. They occur when the body's resistance to nesting infection in the bone is weakened (trauma, cooling, generalized illness, etc.).
Recognition:
X-ray examination is valuable for determining the localization and extent of the lesion, helps to establish the nature of the existing pathological changes. The first radiological symptoms begin to be detected from 10-14 days of illness.
In a number of unclear cases, it is advisable to use tomography. In chronic osteomyelitis, which occurs with the formation of fistulas, fistulography occupies an important place. It allows you to clarify the location of the sequester and to identify when ordinary images are not sufficiently clear. Contrast agents are used in fistulography (iodolipol, sergozin, diodon, etc.). Most accurately, the bone damage zone can be determined by radioactive scanning using radioactive technetium, which is extremely important for deciding the volume of the operation.
Treatment:
High efficacy of antibiotics significantly improved outcomes with conservative treatment and reduced the need for surgery. Treatment of hematogenous osteomyelitis consists of measures of general impact on the patient's body and local - on the site of infection.
Immobilization, carried out from the first days of the disease, helps to limit the process, reduces pain and improves the general well-being of the patient. The operation (it has to be rarely resorted to) is shown when processes are running with the development of cellulitis in cases where conservative treatment is not successful, and for the removal of sequesters.