Acute osteomyelitis is an acute purulent inflammation in which all elements of the bone are affected: the periosteum, the bone itself and the bone marrow. Usually the surrounding soft tissues are involved in the process. The cause of development may be the penetration of pyogenic microbes hematogenically (through blood) or contact (through a wound or through inflamed tissues). It is manifested by pain, swelling and hyperemia, as well as general signs of inflammation: weakness, bruising, fever, chills and headache. The diagnosis is made on the basis of symptoms and radiography data. Treatment is more often surgical, carried out against the background of antibiotic therapy.
Acute osteomyelitis is an acute purulent process in the bones. “Osteomyelitis” is a historically formed term that does not accurately reflect the essence of the disease. It was introduced by Raynaud in 1831 and translated means “inflammation of the bone marrow”, but in clinical practice such an isolated process is practically not found. Nowadays, in traumatology, osteomyelitis is understood as inflammation not only of the bone marrow, but also of other bone elements (periosteum and bone tissue itself).
In most cases, the causative agents of the disease are staphylococci, less often – pneumococci and streptococci. There may be microbial associations with Pseudomonas aeruginosa, E. coli or vulgar proteus. In some cases, Klebsiella are determined in the crops. The symptoms and course of acute osteomyelitis depend on many factors: the method of infection, the state of the body, the age of the patient, the presence of chronic diseases and intoxication, etc. The outcome is recovery or chronization of the process (development of chronic osteomyelitis). Treatment of acute osteomyelitis is carried out by traumatologists.
Pathogenesis and classification
Depending on the method of infection penetration, endogenous and exogenous acute osteomyelitis are isolated. In endogenous (hematogenous) osteomyelitis, the infection penetrates into the bone through the blood from the primary focus located in the area of the lymphoid pharyngeal ring, the mucous membranes of the nasopharynx and oral cavity, the focus of latent infection (panaritium, furuncle, pyoderma), skin wounds, scuffs or diaper rash (in infants). This form of the disease develops in children, which is due to the peculiarities of blood supply to bones in childhood.
Factors contributing to the development of acute hematogenous osteomyelitis are viral infections, acute and chronic inflammatory diseases, hypothermia, unbalanced nutrition, hypovitaminosis and other conditions accompanied by a decrease in the body’s resistance. Injuries with damage to the periosteum or bone tissue may play a certain role. Some researchers (for example, Derizhanov) believe that hematogenic osteomyelitis occurs against the background of a delayed allergic reaction due to the sensitization of the body by latent bacterial flora. There is also a neuro-reflex theory (Toronets and Elansky), according to which the development of osteomyelitis is largely due to a violation of the nervous regulation of the tone of intraosseous vessels and the occurrence of prolonged spasm, creating favorable conditions for the “settling” of microbes in the bone tissue.
All other forms of acute osteomyelitis (post-traumatic, gunshot, postoperative and contact) are exogenous. In these forms of the disease, the infection penetrates into the bone either directly from the external environment or from infected surrounding soft tissues. A feature of exogenous acute osteomyelitis is the spread of purulent inflammation to all elements of the bone without prior formation of a primary inflammatory focus in the bone marrow.
Acute hematogenous osteomyelitis
It develops mainly in childhood, while in 30% of cases symptoms appear in children younger than 1 year. Long tubular bones are more often affected, less often – short and flat. Simultaneous formation of several purulent foci in different bones is also possible. There are three forms of the disease: toxic (adynamic), local and septic-pyemic. The septic-pyemic form of acute osteomyelitis is characterized by an acute onset with a rise in temperature to febrile digits and severe intoxication, chills, repeated vomiting and headaches. Possible disorders of consciousness, delirium and hemolytic jaundice. The general condition is serious. Within two days from the onset of the disease, intense pain in the bone with a clear localization occurs, the affected limb occupies a forced position, active movements become impossible. In the affected area, increasing edema, hyperemia, hyperthermia and skin tension are detected. The appearance of a venous pattern is often noted. Arthritis may develop in a nearby joint.
The local form of hematogenous acute osteomyelitis proceeds relatively favorably. Symptoms of local inflammation prevail, the general condition suffers slightly. The toxic form of the disease is characterized by lightning-fast development with a predominance of general symptoms. In the first day, there is a significant increase in temperature, a decrease in blood pressure, meningeal symptoms, convulsions and loss of consciousness. Acute cardiovascular insufficiency develops rapidly. At the same time, local symptoms are absent or poorly expressed, which makes it difficult to make a timely diagnosis and prescribe adequate therapy.
Radiological signs in all forms of hematogenous acute osteomyelitis become noticeable by the end of 1-2 weeks of the disease, in infants – on 4-5 days. In the early stages, thickening of the periosteum, blurring of the contours of the bone, the presence of areas of compaction and discharge are determined. Subsequently, sequesters (foci of destruction of bone tissue) are detected, surrounded by a zone of compaction and thickening of the bone. If necessary, ultrasound, CT and MRI of the affected segment can be prescribed to clarify the diagnosis.
The treatment is complex, includes antibiotic therapy, limb immobilization, detoxification therapy, immunocorrection, desensitization, antioxidant therapy, metabolic correction, biostimulation, anabolic hormones, vitamin therapy and detoxification using laser blood irradiation, blood UV, plasmapheresis and hemosorption. Surgical treatment is performed against the background of conservative measures. In young children, the phlegmon is opened. In adolescents, the opening of a purulent focus is supplemented with multiple osteoperforation. Tubes for intraosseous administration of antiseptics and antibiotics are installed in the holes. According to the indications, sequestrectomy or subcostal resection is performed. In the postoperative period, the limb is immobilized and complex conservative therapy is continued.
Traumatic and contact acute osteomyelitis
Traumatic acute osteomyelitis is a complication of open fractures, gunshot wounds and orthopedic operations. Occurs within 2-3 weeks after injury or surgery. In the pathogenesis of posttraumatic osteomyelitis, compliance with the rules of asepsis and antiseptics during surgical intervention and subsequent treatment of a postoperative wound plays a leading role. The state of the patient’s body also has a certain significance. The probability of developing acute osteomyelitis in open fractures and gunshot wounds directly depends on factors such as the degree of tissue destruction, the intensity of microbial contamination, the virulence of infection, the severity of local circulatory disorders, as well as the characteristics of the body’s response to traumatic effects.
Posttraumatic osteomyelitis is characterized by both general and local symptoms. There is severe intoxication, pronounced weakness and weakness, chills, nausea and headache. The temperature rises to febrile digits. Local symptoms, as a rule, appear 5-7 days after the onset of general symptoms. In the area of damage, there is sharp soreness, swelling, hyperemia and local hyperthermia. A significant amount of pus is released from the wound.
Treatment of acute osteomyelitis is surgical. Surgical interventions are performed against the background of complex conservative therapy (the main methods of treatment are as in acute hematogenous osteomyelitis). To improve the outflow of purulent contents, stitches are removed from the wound, the lumps are opened. Necrotic bone fragments and purulent granulations are removed, sequestrectomy is performed. Washing and drainage are carried out. Questions about the immobilization of fragments are solved individually. Usually skeletal traction is used, if possible, the Ilizarov apparatus is applied, extra-focal osteosynthesis is performed.
Acute contact osteomyelitis develops when inflammation passes to the bone from the surrounding tissues. Occurs with long–running purulent processes: extensive wounds (especially the scalp), panaritia, etc. It is manifested by an increase in local soreness, an increase in edema and the formation of fistulas. Complex treatment – surgical interventions on the background of antibiotic therapy and other conservative measures. Purulent foci are opened and necrotic tissues are removed, followed by drainage. If all the tissues of the finger are affected, amputation may be required.
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