Osteomyelitis - Causes, symptoms and treatment. MF.

Osteomyelitis is a purulent infection that affects bone tissue( ostitis), surrounding the periosteum( periostitis) bone and bone marrow( myelitis).The first appearance of osteomyelitis is called acute. In the case of a prolonged course of the disease with periods of exacerbation and remission, they speak of the development of chronic osteomyelitis.

Causes of osteomyelitis

Osteomyelitis develops as a result of bacteria entering bone tissue, periosteum or bone marrow.

Bone infection can occur endogenously( internally) when bacteria enter bone tissue with blood flow through blood vessels. Such osteomyelitis is commonly called hematogenous( in translation from the Greek language - originated from the blood).Acute hematogenous osteomyelitis is more common in infants, children and adolescents, adults rarely suffer from it.

Purulent inflammation of the bones can occur when microorganisms from the environment penetrate - this is an exogenous osteomyelitis. An example of exogenous osteomyelitis is a bone infection that develops as a result of an open fracture, a gunshot wound or after a traumatic surgery( also called posttraumatic osteomyelitis).Another type of exogenous osteomyelitis is contact osteomyelitis, which occurs when a purulent inflammation passes to the bone from surrounding soft tissues.

The main causative agents of hematogenous osteomyelitis are staphylococci and streptococci. In the case of posttraumatic osteomyelitis, more than one microorganism is found at the same time, a Pseudomonas aeruginosa often occurs.

Acute hematogenous osteomyelitis occurs after an infection such as tonsillitis( tonsillitis), middle ear inflammation, festering, panaritium, furuncle and furunculosis, pyoderma( pustular skin diseases), omphalitis( inflammation of the umbilical ring), or after infectious diseases - measles, scarlet fever, pneumonia and others.

Post-traumatic osteomyelitis occurs after massive contaminated injuries of soft tissues, open fractures, gunshot wounds, after surgical treatment of closed fractures with metalosteosynthesis( restoration of bone integrity by metal plates, spokes, screws).

Contact osteomyelitis occurs when the infection passes to the bone from surrounding soft tissues in the presence of their purulent lesions( abscess, phlegmon).

The following conditions contribute to the development of osteomyelitis:

• alcohol abuse, smoking, intravenous drug use;
• Atherosclerosis of vessels;
• varicose veins and chronic venous insufficiency;
• diabetes mellitus;
• frequent infections( 3-4 times per year), indicating the presence of a deficiency of the immune system;
• impaired renal and hepatic function;
• malignant diseases( tumors);
• transferred splenectomy( removal of the spleen);
• elderly and senile age;
• low body weight, poor nutrition.

Symptoms of osteomyelitis

Diagnosis of acute hematogenous osteomyelitis in early stages is difficult.

General and local symptoms of the disease can be identified. The general picture of the disease due to the presence of bacteria in the blood( bacteremia) is as follows: after a short period of malaise, chills appear, the temperature rises from 37.5 ° C to 40 ° C, and the pulse rate increases( above 90 beats per minute).At this stage, osteomyelitis can be considered a normal acute respiratory infection( eg, influenza).

On the 2nd - 3rd day of the disease, local symptoms appear in the form of local pain over the affected area, restriction of mobility and swelling of the soft tissues of the limb segment, redness of the skin. The bones of the lower extremities are most often affected( femoral and tibial).Of the bones of the upper limb, the shoulder, then the ray and the ulnar are more often affected. Less often, the bones of the hand and foot are involved in the process, as well as the ribs, spine, collarbone, pelvis, and scapula.

In exogenous acute osteomyelitis, the local signs of the disease come to the fore: the presence of a purulent wound, the trauma and deformity of the limbs, the redness and increase in skin temperature, the swelling and tenderness of the soft tissues to the touch, pain while moving in the affected area of ​​the body. Common symptoms are less pronounced and usually go to the background.

With such symptoms for osteomyelitis, you can take an abscess( a limited accumulation of pus in the soft tissues), phlegmon( a common purulent infection in soft tissues), erysipelas, posttraumatic hematoma( local blood accumulation).These conditions also require urgent medical attention.

In the chronic course of the disease, the previously transferred osteomyelitis and the presence of fistulous passages are added to the above symptoms( round purulent wounds of small diameter on the skin from which the purulent discharge comes).

First aid for suspected osteomyelitis

Post-traumatic osteomyelitis develops after a time( 1 to 2 weeks) after getting injured, so it is important to properly treat the wound and contact the doctor in a timely manner. If you have received extensive trauma with a violation of the integrity of the skin, then the wound should be rinsed with a soap solution and 0.05% chlorhexidine bigluconate solution in order to mechanically remove microorganisms. The skin around the wound should be treated with a solution of brilliant green, put a sterile napkin on the wound( sold at the pharmacy).The napkin can be impregnated with a 3% hydrogen peroxide solution to stop bleeding. The limb should be immobilized. You can attach ice. Then you need to go to the emergency room, where you will be examined by a trauma doctor.

Treatment of osteomyelitis that occurs after fractures, as well as operations of metalloesteosynthesis, are performed by trauma doctors. In other cases( hematogenous osteomyelitis, contact osteomyelitis), you should seek the help of a surgeon in the on-duty surgical hospital or a surgeon in a polyclinic.

Often in the case of hematogenous osteomyelitis, patients enter non-core units, in particular, into the infectious or therapeutic department. However, after the manifestation of the symptoms of damage to the bone, they are transferred to the surgical department.

Hospital examination for suspected osteomyelitis

For the diagnosis of osteomyelitis, the following examination will be necessary. To pass the general analysis of a blood and urine, the analysis of a blood on level of a glucose( for that to reveal a diabetes).If possible, you need to donate blood to C-reactive protein, which is a sensitive indicator of inflammation.

In the presence of an open purulent wound or fistulous course, a purulent discharge is sown from them in order to determine the causative agent and its sensitivity to antibiotics.

For visual confirmation of the presence of osteomyelitis, radiograph the affected area of ​​the body. However, it should be remembered that the x-ray picture of the disease is 2 weeks behind the clinical one, therefore, in case of acute osteomyelitis, there can be no obvious changes in the onset of the disease.

The figure shows a typical radiographic picture of osteomyelitis - a cavity in the bone, a pathological fracture.

A more sensitive diagnostic method is computed tomography, which allows a more detailed examination of bone defects. The possibilities of computed tomography exceed magnetic resonance imaging. The latter allows to differentiate soft tissue diseases from the affected bone, determine the length of nonviable tissues. Therefore, when choosing between computer and magnetic resonance imaging, the latter should be preferred.

Ultrasonic examination possible. It allows to identify the accumulation of pus in soft tissues, the presence and extent of fistulous passages, changes in the periosteum, as well as assess the blood supply to the limb.

The most modern way to diagnose osteomyelitis is radionuclide diagnostics. The method is based on the use of radioactive pharmaceuticals, which specifically accumulate in the inflammatory focus, which allows early detection of the presence of bone tissue destruction. Unfortunately, this is an expensive study that requires high-tech equipment and a special room, so it is only available in large medical centers.

Treatment of osteomyelitis

Treatment of osteomyelitis is complex, it is possible only in hospital settings in traumatological or surgical departments, it includes conservative and surgical measures.

Conservative treatment methods include:

• antibiotic therapy with broad-spectrum antibiotics - usually 2 -3 drugs( ceftriaxone, lincomycin, gentamicin) are prescribed for a long time( 3 to 4 weeks), replacing them with drugs from other groups( eg, ciprofloxacin, abaktal, etc.));
• detoxification therapy( intravenous saline solutions and plasmapheresis, procedures for ultraviolet and laser irradiation of blood - purification of blood plasma from toxins);
• immunotropic therapy - the use of pharmaceuticals that increase the activity of the immune system( polyoxidonium);
• administration of probiotics - drugs that normalize the intestinal microflora. Due to massive antibacterial therapy, dysbacteriosis develops. For its correction, appoint a linex, bifiform;
• administration of drugs that improve microcirculation( pentoxifylline, trental);
• Local wound treatment - dressings with antiseptic ointments( levomecol, levosin, 5% dioxidin ointment) and proteolytic enzymes( trypsin, chymotrypsin), which help to clean and heal the wound.

Surgical treatment of osteomyelitis consists in the sanation of a purulent focus( opening and draining of purulent cavities), removal of sequestrants - areas of non-viable bone tissue and performing recovery operations. Implementation of the latter is necessary due to the formation of defects in the skin and bone tissue. Restorative operations include closure of defects by local tissues, bone filling with various preparations and osteosynthesis( for example, Ilizarov apparatus).

Osteosynthesis with the Ilizarov apparatus

There are no restrictions on the diet after the operation. A full-fledged diet rich in vitamins and proteins is needed. The amount of physical activity should be discussed with the attending physician individually. It is advisable to refrain from drinking alcohol, smoking - they slow down the healing process of the wound. In the presence of diabetes, blood sugar levels should be monitored, if it increases, a relapse of the disease is possible. In the postoperative period and after discharge from the hospital, therapeutic physical therapy and physiotherapy( electrophoresis, phonophoresis, magnetotherapy) are necessary.

Possible complications of osteomyelitis

Osteomyelitis complications can be local and general.

Local complications include:

• abscess and phlegmon of soft tissues - accumulation of pus and purulent impregnation surrounding the affected bone of soft tissues;
• purulent arthritis - purulent inflammation of the joint, located next to the osteomyelitis focus;
• spontaneous fractures - occur at the slightest load due to bone loss of strength;
• contractures - impaired mobility due to scar formation in muscles surrounding the purulent focus;
• ankylosis - loss of mobility in the joints affected by purulent arthritis;
• development of malignant tumors.

General complications include:

• sepsis - blood infection;
• secondary anemia - anemia, develops due to oppression of hemopoiesis against a background of chronic inflammation;
• Amyloidosis - an autoimmune disease that primarily affects the kidneys, is difficult to treat.

Prevention of complications of osteomyelitis

The incidence of complications and the likelihood of the transition of osteomyelitis to the chronic stage directly depends on the time to see a doctor. That is why it is so important to consult a specialist at the first signs of the disease. Do not self-medicate: in the presence of a purulent focus in the bone or soft tissues, it is necessary to give an outflow of pus( perform the operation).Until this is done, even the use of modern antibiotics will be ineffective.

As Arthur Schopenhauer said: "Health before that outweighs all other benefits of life, that a truly healthy beggar is happier than a sick king."Therefore, take care of your health. It is better to overestimate the severity of your symptoms than it is too late to seek medical help.

Surgeon-physician Tevs DS