Osteomyelitis is an inflammation of the bone marrow, in which all elements of the bone (periosteum, spongy and compact substance) are usually affected. Depending on the etiology of osteomyelitis, it is divided into nonspecific and specific (tuberculosis, syphilitic, brucellosis, etc.); post-traumatic, hematogenic, postoperative, contact. The clinical picture depends on the type of osteomyelitis and its form (acute or chronic). The basis of the treatment of acute osteomyelitis is the opening and sanitation of all ulcers, in chronic osteomyelitis – the removal of cavities, fistulas and sequesters.
ICD 10
M86 Osteomyelitis
Meaning
Osteomyelitis is an inflammation of the bone marrow, in which all elements of the bone (periosteum, spongy and compact substance) are usually affected. According to statistics, osteomyelitis after injuries and operations accounts for 6.5% of all diseases of the musculoskeletal system. Most often affects the femur and humerus, shin bones, vertebrae, mandibular joints and upper jaw. After open fractures of the diaphysis of tubular bones, posttraumatic osteomyelitis occurs in 16.3% of cases. Men suffer from osteomyelitis more often than women, children and the elderly – more often than young and middle-aged people.
Classification
There are nonspecific and specific osteomyelitis. Nonspecific osteomyelitis is caused by pyogenic bacteria: Staphylococcus aureus (90% of cases), Streptococcus, E. coli, less often fungi. Specific osteomyelitis occurs with tuberculosis of bones and joints, brucellosis, syphilis, etc.
Depending on the pathway by which microbes penetrate into the bone, endogenous (hematogenous) and exogenous osteomyelitis are distinguished. With hematogenous osteomyelitis, pathogens of purulent infection are introduced through the blood from a remote focus (boil, panaritium, abscess, phlegmon, infected wound or abrasion, tonsillitis, sinusitis, carious teeth, etc.). With exogenous osteomyelitis, infection penetrates into the bone during injury, surgery or spreads from surrounding organs and soft tissues.
In the initial stages, exogenous and endogenous osteomyelitis differ not only in origin, but also in manifestations. Then the differences are smoothed out and both forms of the disease proceed the same way. The following forms of exogenous osteomyelitis are distinguished:
- post-traumatic (after open fractures);
- gunshot (after gunshot fractures);
- postoperative (after knitting needles or operations on bones);
- contact (during the transition of inflammation from the surrounding tissues).
As a rule, osteomyelitis is acute at first. In favorable cases, it ends with recovery, in unfavorable cases it becomes chronic. With atypical forms of osteomyelitis (Brody’s abscess, Ollier’s albuminous osteomyelitis, Garre’s sclerosing osteomyelitis) and some infectious diseases (syphilis, tuberculosis, etc.), there is no acute phase of inflammation, the process is primarily chronic.
Acute osteomyelitis
The manifestations of acute osteomyelitis depend on the path of infection, the general condition of the body, the extent of traumatic damage to the bone and surrounding soft tissues. On radiographs, changes are visible 2-3 weeks after the onset of the disease.
Hematogenous osteomyelitis
As a rule, it develops in childhood, with a third of patients falling ill before the age of 1 year. Quite rare cases of hematogenous osteomyelitis in adults are actually relapses of the disease suffered in childhood. Most often affects the tibia and femur. Multiple bone lesions are possible.
From a remote focus of inflammation (soft tissue abscess, phlegmon, infected wound), microbes with blood are spread throughout the body. In long tubular bones, especially in their middle part, a wide network of vessels is well developed, in which the speed of blood flow slows down. The pathogens of infection settle in the spongy substance of the bone. Under unfavorable conditions (hypothermia, decreased immunity), microbes begin to multiply intensively, hematogenous osteomyelitis develops. There are three forms of the disease:
Septic-pyemic form. It is characterized by an acute onset and pronounced intoxication. The body temperature rises to 39-40 °, accompanied by chills, headache and repeated vomiting. Possible loss of consciousness, delirium, convulsions, hemolytic jaundice. The patient’s face is pale, the lips and mucous membranes are cyanotic, the skin is dry. The pulse is rapid, the pressure is reduced. The spleen and liver are enlarged, sometimes bronchopneumonia develops.
On 1-2 days of the disease, there is precisely localized, sharp, drilling, bursting or tearing, pain in the affected area intensifying with the slightest movements. The soft tissues of the limb are swollen, the skin is hot, red, tense. When spread to nearby joints, purulent arthritis develops.
After 1-2 weeks, a focus of fluctuation (fluid in soft tissues) forms in the center of the lesion. Pus penetrates into the muscles, intermuscular phlegmon is formed. If the phlegmon is not opened, it can open on its own with the formation of a fistula or progress, leading to the development of paraarticular phlegmon, secondary purulent arthritis or sepsis.
Local form. The general condition suffers less, sometimes it remains satisfactory. Signs of local inflammation of the bone and soft tissues prevail.
Adynamic (toxic) form. It is rare. Characterized by a lightning start. Symptoms of acute sepsis prevail: a sharp increase in temperature, severe toxicosis, convulsions, loss of consciousness, a marked decrease in blood pressure, acute cardiovascular insufficiency. Signs of bone inflammation are weak, appear late, which makes it difficult to diagnose and carry out treatment.
Post-traumatic osteomyelitis
Occurs with open bone fractures. The development of the disease is facilitated by contamination of the wound at the time of injury. The risk of osteomyelitis increases with comminuted fractures, extensive soft tissue injuries, severe concomitant injuries, vascular insufficiency, decreased immunity.
Post-traumatic osteomyelitis affects all parts of the bone. With linear fractures, the inflammation zone is usually limited to the fracture site, with comminuted fractures, the purulent process is prone to spread. It is accompanied by hectic fever, severe intoxication (weakness, bruising, headache, etc.), anemia, leukocytosis, increased ESR. The tissues in the fracture area are edematous, hyperemic, and sharply painful. A large amount of pus is released from the wound.
Gunshot osteomyelitis
It occurs more often with extensive lesions of bones and soft tissues. The development of osteomyelitis is promoted by psychological stress, a decrease in the body’s resistance and insufficient wound treatment.
The general symptoms are similar to post-traumatic osteomyelitis. Local symptoms in acute gunshot osteomyelitis are often poorly expressed. Edema of the limb is moderate, there is no abundant purulent discharge. The development of osteomyelitis is indicated by a change in the wound surface, which becomes dull and covered with a gray coating. Subsequently, the inflammation spreads to all layers of the bone.
Despite the presence of a focus of infection, with gunshot osteomyelitis, bone fusion usually occurs (the exception is significant bone fragmentation, large displacement of fragments). In this case, purulent foci turn out to be in the bone callus.
Postoperative osteomyelitis
It is a type of post-traumatic osteomyelitis. It occurs after operations for osteosynthesis of closed fractures, orthopedic operations, knitting needles when applying compression-distraction devices or applying skeletal traction (spoke osteomyelitis). As a rule, the development of osteomyelitis is caused by non-compliance with the rules of asepsis or a large traumatic operation.
Contact osteomyelitis
It occurs during purulent processes of the soft tissues surrounding the bone. Especially often the infection spreads from soft tissues to the bone with panaritia, abscesses and phlegmon of the hand, extensive wounds of the scalp. It is accompanied by an increase in edema, increased pain in the area of injury and the formation of fistulas.
Treatment
Only in the hospital in the Department of traumatology. Perform immobilization of the limb. Massive antibiotic therapy is carried out taking into account the sensitivity of microorganisms. To reduce intoxication, replenish blood volume and improve local circulation, plasma, hemodesis, 10% albumin solution are transfused. In sepsis, extracorporeal hemocorrection methods are used: hemosorption and lymphosorption.
A prerequisite for the successful treatment of acute osteomyelitis is the drainage of a purulent focus. In the early stages, trepanation holes are made in the bone, followed by washing with solutions of antibiotics and proteolytic enzymes. With purulent arthritis, repeated punctures of the joint are performed to remove pus and administer antibiotics, in some cases arthrotomy is indicated. When the process spreads to soft tissues, the formed ulcers are opened with subsequent open washing.
Chronic osteomyelitis
With small foci of inflammation, complex and timely treatment, mainly in young patients, the restoration of bone tissue prevails over its destruction. The foci of necrosis are completely replaced by the newly formed bone, recovery occurs. If this does not happen (in about 30% of cases), acute osteomyelitis turns into a chronic form.
By about 4 weeks in all forms of acute osteomyelitis, sequestration occurs – the formation of a dead bone area surrounded by altered bone tissue. For 2-3 months of the disease, the sequesters are finally separated, a cavity is formed at the site of bone destruction and the process becomes chronic.
Symptoms
With the transition of acute osteomyelitis to chronic, the patient’s condition improves. The pain decreases, becomes aching. Fistulous passages are formed, which may look like a complex system of channels and reach the surface of the skin far from the site of damage. A moderate amount of purulent discharge is released from the fistulas.
During remission, the patient’s condition is satisfactory. The pain disappears, the discharge from the fistulas becomes scarce. Sometimes the fistulas close. The duration of remission in osteomyelitis ranges from several weeks to several decades, depends on the general condition and age of the patient, the localization of the focus, etc.
The development of relapse is facilitated by concomitant diseases, decreased immunity and closure of the fistula, leading to the accumulation of pus in the resulting bone cavity. Relapse of the disease resembles an erased picture of acute osteomyelitis, accompanied by hyperthermia, general intoxication, leukocytosis, increased ESR. The limb becomes painful, hot, reddens and swells. The patient’s condition improves after opening the fistula or opening the abscess.
Complications
Chronic osteomyelitis is often complicated by fractures, the formation of false joints, bone deformation, contractures, purulent arthritis, malignancy (malignant degeneration of tissues). The constantly existing focus of infection affects the entire body, causing amyloidosis of the kidneys and changes in internal organs. During the period of relapse and with the weakening of the body, sepsis is possible.
Diagnostics
The diagnosis of chronic osteomyelitis in most cases does not cause difficulties. For confirmation, an MRI, CT scan or radiography is performed. Fistulography is performed to identify fistulous passages and their connection with an osteomyelitic focus.
Treatment
The operation is indicated in the presence of osteomyelitic cavities and ulcers, purulent fistulas, sequestration, false joints, frequent relapses with intoxication, severe pain and impaired limb function, malignancy, impaired activity of other organs and systems due to chronic purulent infection.
Necrectomy (sequestrectomy) is performed – removal of sequesters, granulations, osteomyelitic cavities together with internal walls and excision of fistulas followed by flushing drainage. After the cavities are sanitized, bone grafting is performed.