Hematogenous osteomyelitis in children
With the advent of the child in the family come not only happiness, joy and all-consuming love, but also cares, experiences and, sadly, to realize illnesses. Lucky to those parents, in the medical card of the child who only scheduled examinations, common colds and typical childhood infections. But there are those whose children were affected by a rather serious medical verdict. One of these very dangerous medical diagnoses is osteomyelitis in children, caused by damage to bone and bone marrow tissues.Species of
osteomyelitis Provoke the appearance of a disease of the bacterium and staphylococcus. The most common type is hematogenous osteomyelitis in children , which in adults practically does not occur. The development of the disease occurs after the penetration of any infection into the baby's blood, the cause may be an open lacerated wound.
Another form - acute hematogenous osteomyelitis can affect the bones of both children and adults. The cause of its appearance can be and trauma, and the penetration of infection through the unhealed cord in newborn babies. It is worth noting that in children the disease rarely acquires a chronic character, the children quickly recover and do not have serious consequences. Diagnosis of the acute form of the disease will help x-rays, a blood test, and in rare cases, and bone puncture. Alert parents can easily notice the symptoms of osteomyelitis: redness and swelling in the affected area, increased body temperature, general weakness - and promptly consult a doctor. Treatment, appointed by him, will not do without antibiotics.
If the parents miss the time, the disease will pass to chronic osteomyelitis in children , so it is extremely important to start treatment on time with the help of a qualified specialist, because even misdiagnosed drugs can trigger a change in the form of the disease. This occurs 10-12 weeks after the onset of the disease, the periods of exacerbation are replaced by periods of rest, the duration of which is difficult to predict, all individually. A particularly terrible feature of chronic osteomyelitis is the appearance of a fistula, which can not be cured.Methods of treatment
Be careful with your children and consult a doctor as soon as possible. After all, the process of treating osteomyelitis in children takes quite a long time and takes a lot of strength. There are various methods for getting rid of this dangerous disease: surgical intervention, when an infected bone is removed - this is an extreme measure, which doctors resort to. Modern medicine, thanks to the latest technology, is able to keep the bones of your crumbs, using mechanical osteoperforation. In the focus of infection, a special drug is introduced that does not allow bacteria to spread to healthy areas of the baby's bone.As already noted, antibiotics correctly prescribed by a specialist after complete diagnosis & gt; disease can also save an operation. It should be said that in addition to bones, the disease quite often affects the liver, kidneys, thyroid and immune system. Many people also use folk remedies, but remember - it can not replace taking antibiotics, and before using it, it is better to consult a doctor.
Finally I want to say about epiphyseal osteomyelitis in newborns. The peculiarity of the structure of the circulatory system makes babies suffer from the moment they are born. The defeat of cartilaginous tissue can lead to the acquisition by the child of the status of an invalid, and in the worst case, to a fatal outcome. Therefore it is extremely important to be attentive to your baby from birth! Hematogenous osteomyelitis
Hematogenous osteomyelitis - purulent inflammation of the bone, resulting from the introduction of microbes with blood flow from the pustules on the skin, purulent wounds and inflammatory foci in various organs. Suffer mainly children. Usually long tubular bones are involved in the process, both isolated and multiple lesions are possible. The disease begins suddenly. In the first day, symptoms of general intoxication predominate: high fever, nausea, vomiting, chills, weakness and headache. At the end of 1-2 days, intense pain and swelling of the extremity occur. In the subsequent pus penetrates into soft tissues, forming phlegmon, and can break through the skin with the formation of fistulas. Diagnosis is made on the basis of symptoms and laboratory data. Radiography is informative only from the third week of the disease. Treatment - antibiotic therapy, detoxification therapy, opening and draining of abscesses.
Hematogenous osteomyelitis is a purulent process in the bone tissue caused by the introduction of infection through the blood. This type of osteomyelitis is a serious disease that affects mainly children and adolescents aged 7 to 15 years. Children of younger age group may suffer as well. Boys are three times more likely than girls. Adults get sick very rarely. It begins acutely, but later it sometimes turns into a chronic form and can last for many years - this is due to the presence of a certain number of adult patients suffering from hematogenous osteomyelitis. Purulent inflammation can develop in any bone, but more often the long tubular bones( humerus, femoral, tibial) are affected. Traumatology is used to treat hematogenous osteomyelitis.
Etiology and pathogenesis of hematogenous osteomyelitis
Staphylococcus aureus is the causative agent of the disease. Less often hematogenous osteomyelitis is caused by pneumococcus, streptococcus and Escherichia coli. The onset of the disease is preceded by bacteremia( the presence of microbes in the blood), which can occur due to the presence of large purulent processes, and because of small foci of infection( furuncles, suppurative abrasions, tonsils in tonsils with angina, pus with acute otitis).However, experts in the field of traumatology note that osteomyelitis can develop both against the background of the existing infection, and after many months or even years.
The predisposition of children to hematogenous osteomyelitis is explained by the peculiarities of bone structure in childhood. In children, the metaphysis has a very wide branched network of vessels with a slowed flow, which is caused by the need to supply a large number of nutrients to the bone growth zone. Metaphysis vessels do not communicate with the vessels of the epiphyseal cartilage, so many arterioles blindly end at the border of the metaphysis and epiphysis, which creates favorable conditions for the retention of pathogenic microorganisms. Getting into this zone, microbes create centers of dormant infection, which can become more active with weakening of the organism or minor trauma.
In about half of cases, hematogenous osteomyelitis occurs after a minor trauma( injury) in which, according to the researchers, previously introduced pyogenic microorganisms are released from the "dormant focus" and begin to multiply. As a result of their vital activity, a purulent focus in the bone forms and general intoxication develops. Factors that reduce the body's resistance and promote the activation of microbes are childhood infectious diseases, influenza and general hypothermia.
Pathological picture with hematogenous osteomyelitis
At first, a small ulcer forms in the thickness of the bone marrow of the metaphyseal zone. Since the stability of the epiphyseal cartilage to suppuration is high enough, the pus spreads toward the diaphysis, destroying the bone marrow and thereby depriving the bone of nutrition from within. Through the Havers canals pus penetrates the periosteum and exfoliates it from the bone, so the bone loses its power from the outside. The bone that is left without nutrients is destroyed, a site of osteonecrosis is formed. Toxins from the focus of infection enter the surrounding tissues and are actively absorbed into the blood, which causes the development of violent intoxication. A high pressure of pus in the cavity, bordered by the medullary canal, causes sharp, very intense pain. In the subsequent pus melts the periosteum and penetrates into soft tissues, as a result of which intermuscular phlegmon is formed. When a phlegmon breaks out, a fistula is formed on the skin.
Classification and symptoms of hematogenous osteomyelitis
There are three forms of hematogenous osteomyelitis.
Septic-piecemic. Accompanied by severe intoxication and rapid development of local changes. The disease begins with a fever of 39-40 degrees. The patient's condition is severe, with chills, repeated vomiting and headaches. Possible delirium and loss of consciousness. Sometimes there is a hemolytic jaundice. On the second day there are very intense, clearly localized pains and rapidly growing edema of soft tissues. The limb is in a forced position, movements are impossible due to pain. The skin above the affected area is tense, local hyperemia and hyperthermia are noted.
Hematogenous osteomyelitis often combines with arthritis of nearby joints. The analysis reveals metabolic acidosis, hyponatremia, hypercalcemia and hyperkalemia, as well as cyclic changes in the blood coagulation system: first, hypercoagulation develops, followed by hypocoagulation and fibrinolysis. Violated the function of the liver and kidneys. With the development of sepsis, purulent foci are formed in various organs. Multiple lesions of the bones, suppurative pericarditis, or purulent destructive pneumonia are possible.
Local. With this form of hematogenous osteomyelitis, local symptoms predominate: pain, swelling and limb hyperemia. The general condition suffers less than with other forms, it may slightly worsen, and sometimes even remain satisfactory.
Toxic( adynamic). It is observed quite rarely. Characteristic of the rapid development and very heavy current. In the first day there is an increasing toxicosis, accompanied by a sharp increase in temperature, the appearance of meningeal symptoms, a sharp decrease in blood pressure and the development of acute cardiovascular insufficiency. There are convulsions and loss of creation, followed by adynamia. Local symptoms at the initial stages are poorly expressed, which significantly complicates the diagnosis.
Diagnosis of hematogenous osteomyelitis
Diagnosis of hematogenous osteomyelitis is made on the basis of the clinical picture and laboratory data indicating an acute infectious process. If there is a suspicion of a violation of the internal organs and the spread of infection, consultations of the relevant specialists are appointed: pulmonologist, gastroenterologist, nephrologist. Depending on the location, radiography of the femur is performed, radiography of the humerus, etc.
X-ray examination is repeated in dynamics, since at the initial stages of the disease there are no changes on the radiographs. Approximately two weeks after the onset of the disease, signs of periostitis appear on the pictures, and signs of lubrication and rarefaction of the spongy bone in the metaphysis area begin to appear later. After 2-4 months after the appearance of the first symptoms on the radiographs, sequestrants are found. Fistulography, radiotherapy, MRI of the bone and ultrasound of the affected segment are performed to determine the location of sequestration, fistula and cavities.
Treatment of hematogenous osteomyelitis
Treatment of hematogenous osteomyelitis is performed in conditions of traumatology department. To combat infection, intramuscular and intravenous injections of semi-synthetic penicillins, cephalosporins or lincomycin are prescribed. In some cases, the early onset of antibiotic therapy can stop the development of the inflammatory process and eliminate the purulent focus before the destruction of bone and the formation of sequesters. Simultaneously, detoxification therapy is carried out using plasma, blood substitutes and crystalloid solutions. Prescribed drugs of symptomatic effect.
Local treatment includes immobilization of the affected limb. In the formation of an abscess in the area of the metaphysis or diaphysis, an opening is performed, creating milling holes in the bone, and flow-washing drainage is performed. Intermuscular phlegmons are widely opened and drained. Antibiotics are injected into the cavity of the abscesses located in the bone and soft tissues. In the postoperative period, antibiotic therapy and detoxification therapy are performed. Immobilization is continued until complete relief of inflammation.
Acute hematogenous osteomyelitis - Pediatric surgery
Acute hematogenous osteomyelitis is an inflammation of the bone marrow that extends to the compact and spongy substance of the claws and periosteum resulting from the penetration of infection into the bone through the bloodstream.
In 96% of cases, the disease occurs in children of primary school age. Boys are sick 3 times more often than girls. Long tubular bones are affected in 82.9%, flat bones in 17.1%.Of the tubular bones, the femur is most often affected - 34.7%, then the tibial bone - 31.6% and the humerus - 8.1%.Frequency of defeat of flat bones: pelvic bone - 3.5%;jaws - 2,5%;blade - 1,2%;the skull - 0,9%, the rib - 0,9%.
Causes of acute hematogenous osteomyelitis
Staphylococcus aureus is 75-95%, the association of staphylococcus with E. coli, proteus and Pseudomonas aeruginosa is 15-20%.As the risk factors for the development of the disease, anatomical and physiological characteristics of tubular bones in children, violations of regional blood supply( trauma, hypothermia), sensitization of the body.
Anatomico-physiological features of tubular bones in children that promote the development of acute hematogenous osteomyelitis .
Significantly developed network of blood vessels;autonomy of the blood supply of the epiphysis: prevalence of the epiphyseal system of blood supply in children under 2 years;slowing of blood flow in the basin of intraosseous vessels, in the Havers channels;terminal character of the vessels.
Due to the anatomical and physiological characteristics of the tubular bones in children, the infection has a predisposition to localization in the metaphyseal zone, where there is a slowed blood flow in the terminal sections of the arteries.
In the conditions of a sensitized organism and under the influence of penetrated infection, the function of the reticuloendothelial system in the area of bone damage is inhibited. Microbial emboli are hematogenous to the foci of traumatic hematomas or impaired blood supply.
The reticuloendothelial system( a system of macrofactors forming immunity) attempts to neutralize the pathogenic effects of microorganisms in the lesion site. When the infection is preserved locally in the metaphyseal part of the bone and has no tendency to further spread, then Brody's abscess is formed.
In cases where the virulence of microorganisms persists, the developed acute hematogenous osteomyelitis spreads transversely to the bone, through the folkmann canals under the periosteum.
Pathomorphology of acute hematogenous osteomyelitis .
Bone marrow edema with necrotic changes, increased pressure in the bone marrow canal and impaired blood supply to the bone.
Peeling of the periosteum by inflammatory exudates from the cerebral canal through the Havers and Folkmann channels.
Increased vascular permeability due to products of inflammation and enzymes of microorganisms with fibrin formation and blood clot, which contributes to deterioration of blood supply to the bone.
Necrosis of tissues becomes worse, the inflammation becomes purulent, the exudate exfoliates the periosteum more, melts it and enters soft tissue, forming muscle phlegmon.
Symptoms of acute hematogenous osteomyelitis
Clinical manifestations largely depend on the clinical form of the disease. There are the following three clinical forms of acute hematogenous osteomyelitis: toxic or adynamic;septicemic or severe;local or easy.
Toxic form is characterized by a predominance of severe clinical manifestations over the local:
is an acute onset of the disease with an increase in body temperature to 40 degrees C, chills, vomiting, impaired consciousness, seizures;
- the appearance of a septic rash on the skin - red spots of rounded shape, located on the chest, abdomen and extremities.
Prolonged course of the disease for several months with periods of exacerbation of the inflammatory process and its remission.
Local edema of soft tissues, fistulas through which pus is released, or scar changes of soft tissues in place of closed fistulas is locally determined.
Radiographically marked areas of osteoporosis and severe osteosclerosis, sequestral capsule, sequestral cavity, in which are sequestrants.
Sequential capsule is a compacted layer of bone substance that restricts healthy tissue from sequestration.
Sequential cavity is a cavity filled with granulation tissue and purulent exudate.
Presence of a soft-tissue saint, through which pus comes out, small sequesters. Sclerotherapy and thickening of the bone, sclerotherapy of soft tissues, violation of their trophism and muscle atrophy.
Treatment of acute hematogenous osteomyelitis
Treatment is surgical, which consists in trepanation of the bone, removal of sequestrum, purulent granulations, in antiseptic treatment of the bone cavity and its filling with antibiotics.Thank you for reading, you will receive a gift! ( Visited 245 times, 1 today)
Osteomyelitis in children - Diseases of pediatric surgery
• Tumor osteomyelitis.
Acute hematogenous osteomyelitis
Acute hematogenous osteomyelitis is a common Pyogenic metastasizing infection in an allergic organism with localization of the inflammatory process in the bone marrow. Prevalence In 90% of cases is observed in children, in boys 2-3 times more often than in girls.
Etiology of acute hematogenous osteomyelitis
Called gnoyutvoryuyuchimy microbes - staphylococcus in 60-80% of cases, streptococcus - 5-30%, gram-negative bacteria, anaerobes and mixed flora in 10-15%.Pathogenesis At the present stage, it is believed that the realization of bone infection in children occurs on the basis of the interaction of many factors in the conditions of morphofunctional immaturity of tissues, organs and systems. Pattern of the pathogenesis of acute hematogenous osteomyelitis:
1. Entrance gate infection. The exit of infection into the blood and dissemination in the body.
2. Seizure of an infectious agent by cells of the reticuloendothelial bone system.
3. Alteration of interosal vessels. The provoking factors are trauma, immune deficiency.
4. Fluid exudation. Increased intraosseous pressure.
5. Occlusion of the intraosseous vessels. Conversion of exudate into manure.
6. Complete violation of intraosseous circulation. Intraosseous osteonecrosis with the spread of the process.
7. Exit pus under the periosteum. Development of periostitis with a violation of the periosteum blood supply.
8. Necrosis of periosteum.
I phase. Edema of the bone marrow( 1-2 days).
Phase II.Bone marrow phlegmon( 2-4 days).
III phase. Pidokisna phlegmon( 4-5 days).
IV phase. Soft tissue phlegmon
( 6-7 days). Stages of acute hematogenous osteomyelitis:
1. Acute( 2-4 weeks).
2. Subacute( from 2-4 weeks to 2-3 months with recovery or chronic stage with the formation of sequestration)
3. Chronic( starting from 2-3 months)
Clinic of acute hematogenous osteomyelitis
Toxic( adynamic) formIt is characterized by fulminant development and extremely severe course with a predominance of general and septic phenomena. After a prodromal period( 1-4 days), sudden temperature rises to 39-40 C. Brad, convulsions, loss of consciousness Development of shock lung and shock kidney. The patients die on the third and third day. Septicopyemic( severe) form It occurs in 40% of patients. It begins with a pronounced chill with an increase in body temperature up to 39. Symptoms of severe intoxication: Acute pains in the affected limb During the 1-2 days - local changes in the form of painful puffiness of soft tissues, hyperemia, increase in skin temperature. Further - local phase changes with the development of intermuscular phlegmon. Local( light) form. The mild beginning and course of the disease with the prevalence of local inflammatory phenomena.
Diagnosis of acute hematogenous osteomyelitis
1. Puncture of bone with intraosseous thermometry and osteotonometry - exceeding of intraosseous temperature above 37.2 degrees and pressure of more than 100 mm of water. Art.- Testifies about the presence of osteomyelitis.
2. Cytological diagnostic methods - the study of bone marrow transplantation on a leukocyte composition.
3. Skin thermometry and thermal imaging - the skin temperature above the focus of inflammation above the surrounding tissues is 2-4 degrees.
4. Ultrasound - allows to reveal swelling of soft tissues.
5. Radiological diagnostics:
a) survey radiography. Informative from 2 weeks. The disappearance of the spongy substance of the bone with the development of linear periostitis;B) Electro-radiography. Indirect signs of osteomyelitis appear for 3-5 days;
c) digital subtraction angiography( CAA) helps to locate the focus of the disease. More information about this and other methods of angiography can be found in Appendix 4 at the end of the book.
Complications of acute osteomyelitis
The complication of acute osteomyelitis includes an artificial joint( formed after a pathological fracture), a segmental bone defect( formed after the removal of total sequestration), destructive dislocation and instability in the joints( due to complete or partial destruction of the epiphysis), growth disordersand deformation of bones( on the principle of complete or partial destruction of the germinal zone).All of the above complications are subject to surgical treatment( reconstructive interventions on the joints, bone plastic, distraction osteosynthesis).Inadequate in terms of time and volume of treatment of acute osteomyelitis leads to its subacute course, accompanied by subsidence of acute inflammatory phenomena, improvement in the general condition of the patient and improvement of paraclinical parameters, but from the locus morbi, moderate infiltration of soft tissues and a slight increase in local temperature are kept, although pain, as a rule, subsides. If the pathological process lasts more than 4-6 months, then in such cases it is already a transition to the chronic stage of the disease - secondary chronic osteomyelitis.
Treatment of acute osteomyelitis
1. Influence on the macroorganism. Combating intoxication, immunotherapy, desensitizing and vitamin therapy.
2. Effect on the microorganism. Rational antibiotic therapy.
3. Influence on the center of the disease. Timely and adequate local decompression, local antibiotic therapy, rational fixation. Surgical measures for acute hematogenous osteomyelitis are the decompression of the disease( I-II phase), periostotomy( III phase), drainage of soft tissue phlegmon( IV phase).
Rehabilitation of acute osteomyelitis
The main principles of rehabilitation of children with GO are stage complex treatment and medical examination. After discharge from the hospital, outpatient physical therapy, massage, balneotherapy, sanation of foci of chronic infection( purulent inflammatory diseases of the skin, tonsils, ears, teeth, etc.) are performed outpatiently.
.Therapy is carried out twice a year( in autumn and spring), using a set of measures: vitamin therapy, immunomodulators, desensitizing therapy, and locus morbi - electrophoresis with antibiotics, magneto- and laser therapy. Control clinical-roentgenological examination is carried out at month, 6 months.after discharge from the hospital, in the future - once every 12 months for three years. An important role in the full rehabilitation of children with OO is played by sanatorium-and-spa treatment, which is advisable to carry out in conjunction with. Therapy.
Acute hematogenous osteomyelitis
Acute hematogenous osteomyelitis( OGO) is a purulent inflammation of the bone, in which the bone marrow, compact matter and periosteum are affected. In some cases, osteomyelitis occurs as a result of the transition of purulent process to the bone from adjacent soft tissues or other organs( odontogenic osteomyelitis associated with tooth decay, osteomyelitis of the rib due to pleural empyema, osteomyelitis of finger phalanges, panarization, etc.).
The most frequent causative agent of osteomyelitis( 75 -95%) is considered to be Staphylococcus aureus or a combination of Staphylococcus a proteus and Pseudomonas aeruginosa. CSO is a disease of a growing organism. Most often( 96%) the disease occurs in children of primary school age. An important role in the development of osteomyelitis in children is played by the age-related anatomical features of the structure and blood supply of bones:
- a significantly developed network of blood vessels,
- autonomic blood supply of the epiphysis, metaphysis and diaphysis,
- , the presence of a large number of small branchings of the vessels radiating through the epiphyseal cartilage to the ossification core.
In children of the first 2 years of life, the epiphyseal system of blood supply predominates, while the metaphyseal system begins to develop after 2 years. Epiphyseal and metaphyseal systems are isolated, but there are anastomoses between them. A common vasculature is formed only after the ossification of the epiphyseal growth zone. For children younger than 2 - 3 years, the destruction of metaepiphyseal zones is characteristic. With age, when the system of blood supply to the metaphysis begins to develop, diaphysis most often suffers.
The pathogenesis of The CSO has not been fully studied to date. The main links of pathogenesis are:
- the presence of exo and endoinfection,
- anatomical bone characteristics,
- decrease in immunological reactivity of the organism.
An important feature of the inflammatory process is that it is closed by the rigid walls of the bone tube;this leads to squeezing the veins, and then the arteries. Indirect evidence of this interpretation of a violation of the circulation of the bone is pain, which is a consequence of hypertension in the medullary canal. The value of intraosseous pressure in CSO reaches 300-500 mm of water. Art.(at a rate of 60-100 mm H2O in healthy children).If the osteomyelitis process is not diagnosed at the stage of inflammation within the medullary canal, then from the 4th to the 5th day after the onset of the disease, the pus spreads along the bony( gavers) canals and nutritional( folkmannian) canals under the periosteum, gradually peeling it off.
In later periods( 8-10 days and later) pus and decay products continue to exfoliate the periosteum, then pus breaks into soft tissues, forming intermuscular and subcutaneous phlegmon. In these cases, we are talking about the advanced diagnosis of osteomyelitis, the treatment of which presents significant complications. Pain, as a rule, subsides at spontaneous opening of subperiosteal abscess in surrounding soft tissues, as the pressure in the medullary canal decreases.
Currently, hematogenous osteomyelitis is classified as follows:
Clinic Depending on the site of the lesion, osteophytal, metaphyseal, diaphyseal spongiform, short and flat bone osteomyelitis is distinguished. The clinical course and treatment of CSO depends on the localization of the inflammatory process and the age of the child. The defeat of metaphysis and diaphysis of long tubular bones occurs mainly in children older than 3 years. Clinical manifestations of the disease are diverse and depend on the virulence of the pathogen, the age and reactivity of the child, and also on the localization of the process.
Toxic ( adynamic, fulminant) form of acute hematogenous osteomyelitis is the most severe. In its current general phenomena of purulent intoxication prevail. The disease begins suddenly with an increase in body temperature to 40-41 ° C. The general condition is very severe, dullness of consciousness, nonsense, hallucinations are observed. Pulse is frequent, weak filling. The heart sounds are muffled. Due to the extremely difficult condition, it is almost impossible to determine the primary focus of inflammation: the child does not complain of pain, and local changes in the first 24 hours are not expressed. Diagnosis of the toxic form is extremely complicated.
Septic-pimic form of is most common in children and is accompanied by acute septic manifestations. Sometimes they are preceded by a short prodromal period, in which the child complains of general fatigue, weakness, headache. The temperature rises to 39 ° C and has a remixing character. A few hours after the onset of the disease, pain occurs in the affected limb. The pain is bursting, extremely intense, the child takes a forced position in bed, cries, can not sleep. Even touching the limb causes great suffering. The general condition of the child is severe. There are signs of toxicosis. Heart sounds are muffled, tachycardia.
Local manifestations in the septic-piemic form of osteomyelitis in the first 2 days of the disease may be indistinct. At the same time, the child does not localize the pain, reacts to the feeling of the whole limb. From 3-4 days there are more noticeable local signs of inflammation, swelling( more over the lesion), painfulness at palpation is delimited and becomes distinct. Later, if the patient is not helped, swelling and fluctuation appear over the swelling. For the septic-piemic form of osteomyelitis metastasis of purulent infection and the appearance of pyemic foci in other bones or parenchymatous organs( lungs, liver, kidneys) are characteristic.
This should be remembered for a correct assessment of the repeated worsening of the general condition. In such cases, a thorough search for a new focus of purulent lesion is carried out. For young children, since it is impossible to localize pain and other painful manifestations, the microsymptoms , which allow suspected development of a purulent-destructive process of bone tissue, are characteristic:
- sparing and / or limiting the mobility of the affected limb;
- local increase in the temperature of soft tissues;
- pastosity and slight swelling in the projection of a purulent-inflammatory process.
The disease begins sharply with an increase in temperature to 37-38 ° C and sharp pains in the affected limb. The affected limb is immobilized, is in a forced position, on a limited area is edematous, soft tissues are pasty, hot to the touch. Quite quickly there is hyperemia over swelling and fluctuation. Establishment of the fact of intraosseous hypertension, during micro-osteoperforation, allows to confirm this diagnosis even in the absence of pus under the periosteum or in the medullary canal. In doubtful cases, it is necessary to use a diagnostic bone puncture followed by a cytological examination of the punctate.
In the study of blood leukocytosis( 30 - 40 · 10 · 9 / l) with a shift of the blood formula to the left and toxic granularity of neutrophils are observed. There is a significant increase in ESR( up to 60 mm / h), which lasts a long time. There are pronounced changes in the protein spectrum of blood serum, which consist in dysproteinemia, increased globulin fractions and the occurrence of hypoalbuminemia. With prolonged and severe course of the disease, anemia develops due to bone marrow suppression with long-term exposure to toxins.
Thermography, as well as ultrasound in the vascular regime, allowing to establish characteristic changes at early stages of the disease, is an extremely effective diagnostic method. In recent years, for an earlier and more accurate determination of the localization and prevalence of the inflammatory process, the method of radionuclide scanning of bones is used, followed by computer processing of the obtained data. For this purpose, short-lived radionuclides with bone tropicity( technetium) are used. The use of nuclear magnetic resonance imaging( MRI) in the diagnosis of osteomyelitis is a promising and reliable method: already on the 4th-6th day, the changes visible on radiographs are visible on day 14-15.
First radiologic sign of CSO of long tubular bones: near the shadow of the cortical layer of the diaphysis or metaphysis, periostitis is defined as a thin linear plate along the bone.
The length of the periostitis depends on the degree of abruption of the periosteum with exudate. The severity of the periosteal reaction depends on the localization of the focus. The greatest periosteal reaction is observed with diaphyseal lesion, less pronounced - with metaphyseal and even less pronounced - with epiphyseal. Radiographic changes in the bones appear about 2-4 weeks after the onset of the disease. In the thickness of the cortical layer or the spongy substance of the metaphysis, separate light foci of destruction begin to separate, which, merging, manifest themselves radiologically with osteoporosis. The bone becomes transparent, the trabecular network is wide-padded, the cortical layer is thinned.
Along with the processes of destruction, signs of the formation of a new bone are also revealed: a thickening of the cortical layer appears due to a changed periosteum. With a long course of the disease on the roentgenogram, signs of osteosclerosis predominate. With the transition of acute osteomyelitis to chronic radiographs after 3-6 months, cavities filled with sequestrants and a significant thickening of bone tissue are revealed.
Treatment of is performed in accordance with the principles of therapy for purulent surgical infection. When a child enters the hospital, first of all, detoxification is carried out - intravenous injection of 10% glucose solutions, plasma and albumin transfusion. From the first day of the disease, the introduction of vitamins C and B is started. For desensitization of the body and normalization of the vascular-tissue permeability, calcium preparations, antihistamines are administered. To increase the level of specific immunity in the acute period of osteomyelitis passive immunization of the child's organism is carried out. For this purpose, hyperimmune staphylococcal plasma and antistaphylococcal gamma globulin are introduced, as well as nonspecific immunomodulators.
When performing intensive care, it is necessary to control electrolyte exchange, KChR and urinary system function. The course of treatment also includes stimulation of the body's defenses. In severe forms of the disease, when oppression of the adrenal cortex becomes oppressive, it is possible to use hormonal drugs( hydrocortisone, prednisolone) in a short course( 7 days).Intravenous drip infusions continue for several days until the elimination of toxicity, a decrease in the temperature response, and an improvement in the child's appetite. Effective modern detoxification methods for septic purulent infection are hemosorption and plasmapheresis.
Antibiotic therapy is one of the main methods of treating CSOs. At the first prescription of antibiotics, children should give preference to broad-spectrum drugs for intravenous administration along with intraosseous application of combined antibiotics. In the future, antibiotics are prescribed in accordance with the sensitivity of the microflora of the lesion focus. The effectiveness of antibacterial therapy is significantly increased when it is combined with proteolytic enzymes. On the subsequent course appoint antibiotics, possessing bone tropnostju( linkomycin), in an age dosage for a period of 2-3 weeks.
In the early stages of CSO development, when there are no clear indications of localization of the purulent-destructive process, the most effective diagnostic and therapeutic method is the micro-osteoperforation with the use of the original device( Puncture tool, 1980. NF Bokov et al.),
Manipulation is performed under general anesthesia, taking into account the premorbid background. A device connected to an electric drill conducts a consistent perforation of soft and bony tissues, and penetrates the bone marrow canal. The size of the needle for micro-osteoperforation depends on the localization of the process and the thickness of the soft tissues of the child. This low-traumatic surgical manual allows:
- to measure intraosseous pressure,
- visually assess the contents of the medullary canal,
- perform sampling for its morphological and cytological studies,
- provide flowing washing of the
- bone marrow canal to perform intraosseous administration of antibiotics.
After osteoperforation, the pain syndrome decreases or disappears completely. Micro-osteoperforation is the only manipulation on the bones, suitable for CSOs.
Immobilization of the limb in osteomyelitis is an indispensable and integral part of the treatment. Immobilization creates a relatively complete peace of limb, which reduces pain, prevents pathological fractures of the affected limb and the possible formation of contractures. Currently, with the defeat of the lower limbs, the Belera bus( double extensor apparatus) is used, and for the upper ones - a bandage dressing.
Complications of , arising from CSOs depend on the form of the disease, the immunobiological reactivity of the organism, and on the timing of the provision of medical qualified care. The most serious complications are metastasis of the infection and the appearance of purulent foci in other organs( abscessed pneumonia, pericarditis, pyelonephritis, etc.).A serious complication of metaphyseal and diaphyseal osteomyelitis are pathological fractures that occur spontaneously or under the influence of a minor effort.
When the process is spread from the metaphysis to the epiphysis, and then to the joint, complications typical of epiphyseal osteomyelitis( limb shortening, arthritis, pathological dislocations, persistent contractures, etc.) are possible. In a number of cases, the acute process of osteomyelitis subsides and changes into a chronic stage. This is most often developed with extensive lesions, as well as in neglected cases, when medical care is rendered late or irrationally.
Bychkov VA, Manzhos PI, Bachu M. Rafik H., Gorodova A.V.