Periostitis is an acute or chronic inflammation of the periosteum. It is usually provoked by other diseases. Accompanied by pain and swelling of the surrounding soft tissues. When suppuration occurs, symptoms of general intoxication occur. The features of the course and the severity of symptoms are largely determined by the etiology of the process. The diagnosis is made on the basis of clinical signs and X-ray examination data. Treatment is usually conservative: analgesics, antibiotics, physiotherapy. With fistulous forms, excision of the affected periosteum and soft tissues is shown.
M90.1 Periostitis in other infectious diseases classified under other headings
Periostitis is an inflammatory process in the periosteum. Inflammation usually occurs in one layer of the periosteum (external or internal), and then spreads to the other layers. The bone and the periosteum are closely related to each other, so periostitis often turns into osteoperiostitis. Depending on the cause of the disease, periostitis can be treated by orthopedic traumatologists, oncologists, rheumatologists, phthisiologists, venereologists and other specialists. Along with measures to eliminate inflammation, treatment of most forms of periostitis includes therapy of the underlying disease.
According to the observations of specialists in the field of traumatology and orthopedics, rheumatology, oncology and other fields of medicine, the cause of the development of this pathology may be trauma, inflammatory bone or soft tissue damage, rheumatic diseases, allergies, a number of specific infections, less often – bone tumors, as well as chronic diseases of veins and internal organs.
Periostitis can be acute or chronic, aseptic or infectious. Depending on the nature of pathoanatomic changes, simple, serous, purulent, fibrous, ossifying, syphilitic and tuberculous periostitis are distinguished. The disease can affect any bones, however, it is more often localized in the area of the lower jaw and the diaphysis of the tubular bones.
Simple periostitis is an aseptic process and occurs as a result of injuries (fractures, bruises) or inflammatory foci localized near the periosteum (in muscles, in bones). More often affected are areas of the periosteum covered with an insignificant layer of soft tissues, for example, the ulnar process or the anterior inner surface of the tibia. A patient with periostitis complains of moderate pain. When examining the affected area, slight swelling of soft tissues, local elevation and soreness during palpation are revealed. Simple periostitis usually responds well to treatment. In most cases, the inflammatory process is stopped within 5-6 days. Less often, a simple form of periostitis turns into chronic ossifying periostitis.
Fibrous periostitis occurs with prolonged irritation of the periosteum, for example, as a result of chronic arthritis, bone necrosis or chronic trophic ulcers of the lower leg. It is characterized by a gradual onset and a chronic course. The patient’s complaints are usually caused by the underlying disease. A slight or moderate swelling of soft tissues is detected in the affected area, and a dense painless thickening of the bone is determined by palpation. With successful treatment of the underlying disease, the process regresses. With a prolonged course of periostitis, superficial destruction of bone tissue is possible, there are data on individual cases of malignancy of the affected area.
Purulent periostitis develops with the penetration of infection from the external environment (with wounds with damage to the periosteum), with the spread of microbes from a neighboring purulent focus (with a purulent wound, phlegmon, abscess, erysipelas, purulent arthritis, osteomyelitis) or with pyemia. Usually, staphylococci or streptococci act as the causative agent. The periosteum of long tubular bones – humeral, tibial or femoral – suffers more often. With pyemia, multiple lesions are possible.
At the initial stage, the periosteum becomes inflamed, serous or fibrinous exudate appears in it, which subsequently turns into pus. The inner layer of the periosteum is soaked with pus and separated from the bone, sometimes for a considerable length. A subperiosteal abscess forms between the periosteum and the bone. In the future, several flow options are possible. In the first variant, the pus destroys the periosteum area and breaks through into soft tissues, forming a paraossal phlegmon, which can subsequently either spread to the surrounding soft tissues, or open out through the skin. In the second variant, the pus exfoliates a significant portion of the periosteum, as a result of which the bone is deprived of nutrition, and a section of superficial necrosis is formed. With an unfavorable development of events, necrosis spreads into the deep layers of the bone, pus penetrates into the bone marrow cavity, osteomyelitis occurs.
Purulent periostitis is characterized by an acute onset. The patient complains of intense pain. The body temperature is elevated to febrile figures, chills, weakness, bruising and headache are noted. When examining the affected area, edema, hyperemia and sharp soreness are detected during palpation. Subsequently, a focus of fluctuation is formed. In some cases, there may be erased symptoms or a primary chronic course of purulent periostitis. In addition, acute or malignant periostitis is isolated, characterized by a predominance of putrefactive processes. In this form, the periosteum swells, easily collapses and disintegrates, the bone devoid of periosteum is enveloped in a layer of pus. Pus spreads to soft tissues, causing phlegmon. Septicopiemia may develop.
Serous albuminous periostitis usually develops after injury, more often affects the metadiaphysis of long tubular bones (hip, shoulder, fibula and tibia) and ribs. It is characterized by the formation of a significant amount of viscous serous-mucous fluid containing a large amount of albumins. Exudate can accumulate subcostally, form a cyst-like sac in the thickness of the periosteum or be located on the outer surface of the periosteum. The exudate accumulation zone is surrounded by a red-brown granulation tissue and covered with a dense shell. In some cases, the amount of liquid can reach 2 liters. With the subcostal localization of the inflammatory focus, periosteal detachment is possible with the formation of a bone necrosis site.
The course of periostitis is usually subacute or chronic. The patient complains of pain in the affected area. At the initial stage, a slight increase in temperature is possible. If the focus is located near the joint, there may be a restriction of movement. The examination reveals swelling of soft tissues and soreness during palpation. The lesion area is compacted at the initial stages, subsequently a softening area is formed, fluctuation is determined.
Ossifying periostitis is a common form of periostitis that occurs with prolonged irritation of the periosteum. Develops independently or is a consequence of a long-term inflammatory process in the surrounding tissues. It is observed in chronic osteomyelitis, chronic varicose ulcers of the lower leg, arthritis, osteoarthritis, congenital and tertiary syphilis, rickets, bone tumors and Bamberger-Marie periostosis (a symptom complex that occurs in some diseases of the internal organs, accompanied by thickening of the nail phalanges in the form of drumsticks and deformation of nails in the form of watch glasses). Ossifying periostitis is manifested by the proliferation of bone tissue in the area of inflammation. Ceases to progress with successful treatment of the underlying disease. With prolonged existence, in some cases it can cause synostoses (bone fusion) between the bones of the tarsus and wrist, shin bones or vertebral bodies.
Tuberculous periostitis, as a rule, is primary, occurs more often in children and is localized in the ribs or skull. The course of such periostitis is chronic. The formation of fistulas with a pus-like discharge is possible.
Syphilitic periostitis can be observed in congenital and tertiary syphilis. At the same time, the initial signs of periosteal lesion in some cases are detected already in the secondary period. At this stage, small swellings appear in the periosteum area, sharp volatile pains occur. In the tertiary period, as a rule, the bones of the skull or long tubular bones (more often the tibia) are affected. There is a combination of gum lesions and ossifying periostitis, the process can be both limited and diffuse. Congenital syphilitic periostitis is characterized by an ossifying lesion of the diaphysis of tubular bones.
Patients with syphilitic periostitis complain of intense pain that increases at night. Palpation reveals a round or fusiform limited swelling of a dense elastic consistency. The skin above it is not changed, palpation is painful. The outcome may be spontaneous resorption of the infiltrate, proliferation of bone tissue or suppuration with spread to nearby soft tissues and the formation of fistulas.
In addition to these cases, periostitis can be observed in some other diseases. So, with gonorrhea, inflammatory infiltrates form in the periosteum area, which sometimes build up. Chronic periostitis can occur with sapa, typhus (characterized by damage to the ribs) and blastomycosis of long tubular bones. Local chronic lesions of the periosteum occur with rheumatism (usually the main phalanges of the fingers, metatarsal and metacarpal bones are affected), varicose veins, Gaucher disease (the distal part of the femur is affected) and diseases of the hematopoietic organs. With excessive load on the lower extremities, periostitis of the tibia is sometimes observed, accompanied by severe pain syndrome, minor or moderate edema and sharp soreness of the affected area during palpation.
The diagnosis of acute periostitis is made on the basis of anamnesis and clinical signs, since radiological changes in the periosteum become visible no earlier than 2 weeks after the onset of the disease. The main instrumental method of diagnosis of chronic periostitis is radiography, which allows to assess the shape, structure, shape, size and prevalence of periosteal layers, as well as the condition of the underlying bone and, to some extent, the surrounding tissues. Depending on the type, cause and stage of periostitis, needle-like, layered, lace, comb-like, fringed, linear and other periosteal layers can be detected.
Long-term ongoing processes are characterized by a significant thickening of the periosteum and its fusion with the bone, as a result of which the cortical layer thickens, and the volume of the bone increases. With purulent and serous periostitis, the detachment of the periosteum with the formation of a cavity is revealed. When the periosteum ruptures due to purulent melting, a “torn fringe” is determined on radiographs. In malignant neoplasms, periosteal layers have the form of visors.
X-ray examination allows you to get an idea about the nature, but not about the cause of periostitis. The preliminary diagnosis of the underlying disease is made on the basis of clinical signs, for the final diagnosis, depending on certain manifestations, a variety of studies can be used. Thus, if varicose veins are suspected, ultrasound duplex scanning is prescribed, if rheumatoid diseases are suspected, rheumatoid factor, C–reactive protein and immunoglobulin levels are determined, if gonorrhea and syphilis are suspected, PCR studies, etc.
Treatment tactics depend on the underlying disease and the form of periosteal lesion. With simple periostitis, rest, painkillers and anti-inflammatory drugs are recommended. With purulent processes, analgesics and antibiotics are prescribed, an abscess is opened and drained. In chronic periostitis, the main disease is treated, sometimes laser therapy, dimethyl sulfoxide and calcium chloride ionophoresis are prescribed. In some cases (for example, with syphilitic or tuberculous periostitis with the formation of fistulas), surgical treatment is indicated.