Hematogenous osteomyelitis is a purulent inflammation of the bone resulting from the introduction of microbes with blood flow from pustules on the skin, purulent wounds and inflammatory foci in various organs. On the first day, symptoms of general intoxication prevail: high fever, nausea, vomiting, chills, weakness and headache. Then there are intense pains and significant swelling of the limb. Subsequently, pus penetrates into soft tissues, forming a phlegmon, and can break through the skin with the formation of fistulas. The 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 drainage of ulcers.
M86.0 Acute hematogenous osteomyelitis
Hematogenous osteomyelitis (from Lat. haematogenus originating from the blood, osteon bone + myelos bone marrow + itis inflammation) is a purulent process in the bone tissue resulting from the introduction of infection through the blood. This type of osteomyelitis is a serious disease affecting mainly children and adolescents aged 7 to 15 years. Younger children may also suffer. It occurs three times more often in boys than in girls. Adults get sick very rarely. It begins acutely, but later 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 long tubular bones (humerus, femur, tibia) are more often affected. Disease is treated by orthopedic traumatologists.
Most often, Staphylococcus aureus becomes the causative agent of the disease. Less often, hematogenous osteomyelitis is caused by pneumococcus, streptococcus and E. 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 due to small foci of infection (boils, suppurated abrasions, ulcers in the tonsils with angina, pus with acute otitis). At the same time, specialists in the field of traumatology note that osteomyelitis can develop both against the background of an existing infection, and after many months or even years.
The predisposition of children to hematogenous osteomyelitis is explained by the peculiarities of the structure of bones in childhood. In children, the metaphysis has a very wide branched network of vessels with slow blood flow, which is due to the need to supply a large amount of nutrients to the bone growth zone. The vessels of the metaphysis 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 delay of pathogenic microorganisms. Getting into this zone, microbes create pockets of dormant infection, which can become active when the body weakens or a minor injury.
In about half of cases, hematogenous osteomyelitis occurs after a small injury (bruise) 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 is formed in the bone and the phenomena of general intoxication occur. Factors that reduce the body’s resistance and contribute to the activation of microbes are childhood infectious diseases, influenza and general hypothermia.
Initially, a small abscess forms in the thickness of the bone marrow of the metaphysical zone. Since the resistance of epiphyseal cartilage to suppuration is high enough, pus spreads towards the diaphysis, destroying the bone marrow and thereby depriving the bone of nutrition from the inside. Through the Haversov channels, pus penetrates under the periosteum and exfoliates it from the bone, so the bone is deprived of nutrition from the outside. The bone left without nutrients is destroyed, an osteonecrosis site is formed.
Toxins from the source of infection enter the surrounding tissues and are actively absorbed into the blood, which causes the development of rapid intoxication. And the high pressure of pus in the cavity bounded by the medullary canal causes sharp, very intense pain. Subsequently, the pus melts the periosteum and penetrates into soft tissues, resulting in the formation of intermuscular phlegmon. When the phlegmon breaks out, a fistula forms on the skin.
Septic-pyemic form of the disease is accompanied by severe intoxication and rapid development of local changes. The disease begins with an increase in temperature to 39-40 degrees. The patient’s condition is severe, characterized by chills, repeated vomiting and headaches. Delirium and loss of consciousness are possible. Sometimes hemolytic jaundice is detected. On the second day, very intense, clearly localized pain and rapidly increasing swelling of soft tissues appear. The limb is in a forced position, movements are impossible due to pain. The skin over the affected area is tense, local hyperemia and hyperthermia are noted.
Hematogenous osteomyelitis is often combined with arthritis of nearby joints. The tests reveal metabolic acidosis, hyponatremia, hypercalcemia and hyperkalemia, as well as cyclic changes in the blood coagulation system: hypercoagulation develops first, followed by hypocoagulation and fibrinolysis. Liver and kidney functions are impaired. With the development of sepsis, purulent foci form in various organs. Multiple bone lesions, purulent pericarditis or purulent destructive pneumonia are possible.
With the local form of hematogenous osteomyelitis, local symptoms prevail: pain, swelling and hyperemia of the limb. The general condition suffers less than in other forms, may slightly worsen, and sometimes even remain satisfactory.
The toxic (adynamic) form is observed quite rarely. Characterized by lightning-fast development and a very severe course. On 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. Convulsions and loss of consciousness are observed, followed by adynamia. Local symptoms in the initial stages are poorly expressed, which significantly complicates the diagnosis.
The diagnosis of hematogenous osteomyelitis is made by a specialist in the field of traumatology and orthopedics on the basis of the clinical picture and laboratory data indicating an acute infectious process. If there is a suspicion of a malfunction of internal organs and the spread of infection, consultations of appropriate specialists are appointed: a pulmonologist, a gastroenterologist, a nephrologist. Depending on the localization, femur x ray, humerus x ray, etc. is performed.
The X-ray examination is repeated in dynamics, since there are no changes in the radiographs at the initial stages of the disease. About two weeks after the onset of the disease, signs of periostitis appear on the pictures, and a little later signs of lubrication and rarefaction of the spongy bone in the metaphysis area begin to appear. 2-4 months after the appearance of the first symptoms, sequesters are detected on radiographs. To clarify the location of sequesters, fistula passages and cavities, fistulography, radiothermy, bone MRI and ultrasound of the affected segment are performed.
Treatment is carried out in the conditions of the traumatology department. To combat infection, intramuscular and intravenous injections of semi-synthetic penicillins, cephalosporins or lincomycin are prescribed. In some cases, the early start of antibiotic therapy allows you to stop the development of the inflammatory process and eliminate the purulent focus before the bone destruction and sequestration begins. At the same time, detoxification therapy is carried out using plasma, blood substitutes and crystalloid solutions. Symptomatic drugs are prescribed.
Local treatment includes immobilization of the affected limb. When an abscess forms in the area of the metaphysis or diaphysis, an autopsy is performed, creating milling holes in the bone, and flow-washing drainage is carried out. Intermuscular phlegmons are widely opened and drained. Antibiotics are injected into the cavity of ulcers located in the bone and soft tissues. In the postoperative period, antibiotic therapy and detoxification therapy are carried out. Immobilization is continued until complete relief of inflammation.