Osteomyelitis – an inflammation of marrow at which all elements of a bone usually are surprised (a periosteum, spongy and compact substance). Statistically, osteomyelitis after injuries and operations makes 6,5% of all diseases of the musculoskeletal device. Depending on an osteomyelitis etiology it is subdivided on nonspecific and specific (tubercular, syphilitic, brutsellezny, etc.); post-traumatic, hematogenic, postoperative, contact. The clinical picture depends on a type of osteomyelitis and its form (sharp or chronic). The basis of treatment of sharp osteomyelitis is made by opening and sanitation of all abscesses, at chronic osteomyelitis - removal of cavities, fistulas and sequesters.
Osteomyelitis (Latin osteon a bone + myelos marrow + itis an inflammation) – an inflammation of marrow at which all elements of a bone usually are surprised (a periosteum, spongy and compact substance). Statistically, osteomyelitis after injuries and operations makes 6,5% of all diseases of the musculoskeletal device. Affects a femoral and humeral bone, shin bones, vertebras, mandibular joints and the top jaw more often. After open changes of a diaphysis of tubular bones post-traumatic osteomyelitis arises in 16,3% of cases. Men have osteomyelitis more often than women, children and elderly – are more often than people of young and middle age.
Allocate nonspecific and specific osteomyelitis. Nonspecific osteomyelitis is caused by gnoyerodny bacteria: golden staphylococcus (90% of cases), a streptococcus, colibacillus, is more rare – fungi. Specific osteomyelitis arises at tuberculosis of bones and joints, a brucellosis, syphilis etc.
Depending on a way which microbes get into a bone distinguish endogenous (hematogenic) and exogenous osteomyelitis. At hematogenic osteomyelitis causative agents of a purulent infection are brought through blood from the remote center (a furuncle, a felon, abscess, the phlegmon infected a wound or a graze, tonsillitis, sinusitis, carious teeth and so forth). At exogenous osteomyelitis the infection gets into a bone at wound, operation or extends from surrounding bodies and soft fabrics.
In initial stages exogenous and endogenous osteomyelitis differ not only by origin, but also on manifestations. Then differences smooth out and both forms of a disease proceed equally. Allocate the following forms of exogenous osteomyelitis:
- post-traumatic (after open changes);
- fire (after fire changes);
- postoperative (after carrying out spokes or bone operations);
- contact (upon transition of an inflammation from surrounding fabrics).
As a rule, osteomyelitis proceeds sharply in the beginning. In opportunities comes to an end with recovery, in adverse – passes into chronic. At atypical forms of osteomyelitis (a Brodie's abscess, albuminozny osteomyelitis of Ollye, skleroziruyushchy osteomyelitis of Garre) and some infectious diseases (syphilis, tuberculosis, etc.) the sharp phase of an inflammation is absent, process has primary and chronic character.
Displays of sharp osteomyelitis depend on a way of penetration of an infection, the general condition of an organism, extensiveness of traumatic damage of a bone and surrounding soft fabrics. On roentgenograms of change are visible 2-3 weeks later since the beginning of a disease.
As a rule, develops at children's age, and a third of patients gets sick aged till 1 year. Rather exceptional cases of development of hematogenic osteomyelitis in adults actually are a recurrence of the disease postponed at children's age. Affects tibial and femoral bones more often. Perhaps multiple damage of bones.
From the remote center of an inflammation (abscess of soft fabrics, the phlegmon infected a wound) microbes with blood are carried on an organism. In long tubular bones, especially – in their middle part the wide network of vessels in which the speed of a blood-groove is slowed down is well developed. Causative agents of an infection settle in spongy substance of a bone. Under adverse conditions (overcooling, decrease in immunity) microbes begin to breed strenuously, hematogenic osteomyelitis develops. Allocate three forms of a disease:
Septiko-piyemichesky form. The sharp beginning and the expressed intoxication is characteristic. Body temperature rises to 39 — 40 °, is followed by a fever, a headache and repeated vomiting. Consciousness loss, nonsense, spasms, hemolytic jaundice are possible. A face of the patient pale, lips and mucous membranes are cyanotic, skin dry. The pulse which is speeded up pressure is reduced. The spleen and a liver increase, bronchial pneumonia sometimes develops.
For 1-2 days of a disease there is precisely localized, sharp, drilling, holding apart or tearing, amplifying at the slightest movements pain in the field of defeat. Soft tissues of an extremity are edematous, skin hot, red, intense. At distribution on nearby joints purulent arthritis develops.
In 1-2 weeks in the center of defeat the fluctuation center is formed (liquid in soft fabrics). Pus gets into muscles, intermuscular phlegmon is formed. If not to open phlegmon, it can independently be opened with formation of fistula or progress, leading to development of paraarticulary phlegmon, secondary purulent arthritis or sepsis.
Local form. The general state suffers less, sometimes remains satisfactory. Signs of a local inflammation of a bone and soft fabrics prevail.
Adynamic (toxic) form. Meets seldom. It is characterized by the lightning beginning. Symptoms of sharp sepsis prevail: sharp temperature increase, heavy toxicosis, spasms, consciousness loss, the expressed lowering of arterial pressure, sharp cardiovascular insufficiency. Signs bone subinflammations, appear late that complicates diagnosis and performing treatment.
Arises at open fractures of bones. Development of a disease is promoted by pollution of a wound at the time of a trauma. The risk of development of osteomyelitis increases at splintered changes, extensive damages of soft fabrics, the heavy accompanying damages, vascular insufficiency, decrease in immunity.
Post-traumatic osteomyelitis affects all departments of a bone. At linear changes the zone of an inflammation is usually limited to the place of a change, at splintered changes purulent process is inclined to distribution. Is followed by the gektichesky fever expressed by intoxication (weakness, weakness, a headache etc.), anemia, leykotsitozy, increase in SOE. Fabrics in the field of a change are edematous, hyperemic, sharply painful. From a wound a large amount of pus is allocated.
Arises at extensive damages of bones and soft fabrics more often. Development of osteomyelitis is promoted by a psychological stress, decrease in resilience of an organism and insufficient processing of a wound.
The general symptoms are similar to post-traumatic osteomyelitis. The local symptomatology at sharp fire osteomyelitis is quite often expressed poorly. Extremity hypostasis moderate, is absent plentiful purulent separated. Development of osteomyelitis is demonstrated by change of a wound surface which becomes dim and becomes covered by a gray raid. In the subsequent the inflammation extends to all layers of a bone.
Despite existence of the center of an infection, at fire osteomyelitis usually there comes the bone union (an exception – considerable dissociation of a bone, big shift of otlomk). At the same time the purulent centers appear in a bone callosity.
Is a kind of post-traumatic osteomyelitis. There are after operations on an osteosynthesis of the closed changes, orthopedic operations, carrying out spokes when imposing compression devices or imposing of skeletal extension (spoke osteomyelitis). As a rule, development of osteomyelitis is caused by non-compliance with rules of an asepsis or big injury of operation.
Arises at purulent processes of the soft fabrics surrounding a bone. Especially often the infection extends from soft fabrics to a bone at a felon, abscesses and phlegmons of a brush, extensive wounds of a hairy part of the head. Is followed by increase in hypostasis, strengthening of pains in the field of damage and formation of fistulas.
Only in a hospital in office of traumatology. Carry out an extremity immobilization. Carry out massive antibiotic treatment taking into account sensitivity of microorganisms. For reduction of intoxication, completion of volume of blood and improvement of local blood circulation pour plasma, a haemo misinformation, 10% albumine solution. At sepsis apply methods of extracorporal haemo correction: haemo sorption and limfosorbtion.
Indispensable condition of successful treatment of sharp osteomyelitis is drainage of the purulent center. At early stages in a bone do trepanatsionny openings with the subsequent washing by solutions of antibiotics and proteolytic enzymes. At purulent arthritises carry out repeated punctures of a joint for removal of pus and introduction of antibiotics, the arthrotomy is in certain cases shown. At distribution of process on soft fabrics the formed abscesses open with the subsequent open washing.
At the small centers of an inflammation, complex and timely treatment, mainly at young patients restoration of a bone tissue prevails over its destruction. The centers of a necrosis are completely replaced with again formed bone, there occurs recovery. If it did not occur (approximately in 30% of cases), sharp osteomyelitis passes into a chronic form.
Approximately by 4th week at all forms of sharp osteomyelitis there is sequestration – formation of the become lifeless site of a bone surrounded with the changed bone tissue. For 2-3 month of a disease sequesters finally separate, on the place of destruction of a bone the cavity is formed and process becomes chronic.
Upon transition of sharp osteomyelitis to chronic the condition of the patient improves. Pains decrease, become aching. The svishchevy courses which can look as difficult system of channels and on the surface of skin to leave far from the place of damage are formed. From fistulas the moderate quantity of purulent separated is distinguished.
During remission condition of the patient satisfactory. Pains disappear, separated from fistulas becomes poor. Sometimes fistulas are closed. Remission duration at osteomyelitis fluctuates from several weeks to several decades, depends on the general condition and age of the patient, localization of the center etc.
Development of a recurrence is promoted by associated diseases, the decrease in immunity and closing of fistula leading to a pus congestion in the formed bone cavity. The recurrence of a disease reminds the erased picture of sharp osteomyelitis, is followed by a hyperthermia, the general intoxication, leykotsitozy, increase in SOE. The extremity becomes painful, hot, reddens and swells. The condition of the patient improves after discovery of fistula or opening of an abscess.
Chronic osteomyelitis often is complicated by changes, formation of false joints, deformation of a bone, contractures, purulent arthritis, a malignization (malignant regeneration of fabrics). Constantly existing center of an infection influences all organism, causing kidneys and change of internals. During a recurrence and when weakening an organism sepsis is possible.
Diagnosis at chronic osteomyelitis in most cases does not cause difficulties. For confirmation carry out MPT, KT or a X-ray analysis. For identification of the svishchevy courses and their communication with the osteomiyelitichesky center carry out a fistulografiya.
Operation is shown in the presence of osteomiyelitichesky cavities and ulcers, purulent fistulas, sequesters, false joints, a frequent recurrence with intoxication expressed by pain and dysfunction of an extremity, a malignization, violation of activity of other bodies and systems owing to a chronic purulent infection.
Carry out a nekrektomiya (sekvestrektomiya) – removal of sequesters, granulations, osteomiyelitichesky cavities together with internal walls and excision of fistulas with the subsequent washing drainage. After sanitation of cavities carry out bone plasticity.