BURSITIS (bursitis; late lat. bursa a bag) — the inflammatory disease of synovial bags which is followed by the increased formation and accumulation in their cavities of exudate. Can be B. on a clinical current acute, under acute, chronic, recurrent; on character of exudate — serous, serofibrinous, purulent, it is purulent - hemorrhagic; on character of the activator — nonspecific or specific (gonorrheal, brucellous, tubercular, syphilitic); some authors allocate aseptic and infected B.
Inflammatory process can take place both in constants, and in neogenic bags in places of continuous pressure and friction of skin, fastion, muscles, sinews about bone ledges.
Most often B. of elbow synovial bags and synovial bags of knee and humeral joints meets. Frequency of such localization is caused postoyannm by traumatizing the corresponding body parts in connection with features of certain professions (miners, engravers, floor polishers, parquet floor layers, porters, athletes, etc.). It allows to carry B. to occupational diseases. Frequency of incidence of B. depends on a type of the performed works and working conditions.
The etiology and a pathogeny
the Origin of acute B. more often happens an injury (a bruise, a graze, small wounds) and secondary infection of a synovial bag with pyogenic microbes — preferential stafilokokka and streptococci, is much more rare gonokokka, pneumococci, tubercular and intestinal sticks, brucellas, etc. Infection of synovial bags happens on limf, to ways from suppurative focuses (at an erysipelatous inflammation, furuncles, an anthrax, osteomyelitis, decubituses), also the hematogenous way of infection is not excluded. Hron. B. often is a consequence of long constant mechanical irritation.
Pathoanatomical changes at acute B. are expressed by signs of an acute inflammation of walls of a synovial bag.
Initial stages of acute B. are characterized by serous treatment of fabrics p accumulation in a cavity of a bag of serous exudate (acute serous B.). In the presence of microbic flora the serous inflammation quickly enough passes in purulent (purulent B.). Distribution of purulent process on surrounding
fabrics can proceed as a phlegmonous inflammation with a necrosis of a wall of a bag and formation of hypodermic and intermuscular phlegmons. In the started cases are formed it is long not healing fistulas. The break of pus in a cavity of a joint leads to development of purulent arthritis.
At acute traumatic B. in the stretched synovial bags and their pockets hemorrhagic liquid collects. At involution there is an organization of fibrin and an obliteration of vessels of a synovial membrane. Permanent changes in a wall of a bag develop, edges it is thickened, the surface of a synovial membrane becomes covered by the growths of connecting fabric (proliferating B.) dividing a cavity of a bag into additional pockets.
At microscopic examination of a wall of a bag in places of growth of connecting fabric its vitreous degeneration is found; around vessels proliferation of cells, places inflammatory infiltration of vascular walls is observed.
Adjournment of salts in a wall and a cavity of a bag leads to so-called limy B.' (bursitis calcarea) development, and the organized fibrin forms so-called fleecy («rice») little bodies.
During the subsiding of an acute inflammation and at a subacute current of B. in a wall and pockets of bags there are encapsulated sites of nekrotizirovanny fabrics or exudate which at a repeated injury and an infection serve as favorable circumstances for development of a recurrence of an inflammation (recurrent B.).
At tubercular B. walls of a bag are evenly thickened, find tubercular hillocks in it.
The clinical picture and diagnosis
On site an anatomic arrangement of a bag is defined a roundish limited painful swelling of a soft and elastic consistence, fluctuating. Diameter of a swelling can reach 8 — 10 cm. The patient complains of pains in the field of a swelling, an indisposition; body temperature increases; function of a joint is moderately limited.
At a phlegmonous inflammation hypostasis of the fabrics surrounding a bag is noted, the dermahemia (limfangiit), are expressed (especially at gonorrheal B.) the general symptoms of a disease: severe pains, temperature increase to 39 — 40 °. During the progressing of an inflammation and its transition to soft tissues signs are defined phlegmons (see).
At hron. Arrangements of a bag B. on site there is a roundish limited swelling of a soft consistence, skin over it is mobile, is not changed, function of an extremity is not broken. Hron, process can become aggravated; at the same time the amount of liquid in a cavity of a bag increases that sometimes leads to formation of the isolated cystous cavity filled with the liquid called hygroma (see).
In a shoulder joint the bags which are not reported with a cavity of a joint — subdeltoid, supraclavicular and subacromial most often are surprised. Complaints come down to pains at assignment and pronation of an upper extremity. Especially painfully B. of a subdeltoid bag proceeds.
At survey contours of a shoulder are maleficiated, the seeming uniform increase in the most deltoid muscle is noted; at the big sizes of a bag the swelling is visible on an outer surface of a shoulder.
Morbidity usually is defined by a palpation with a pressure upon an inner edge of a big hillock of a humeral bone.
Supraclavicular B. often should be differentiated from purulent arthritis, and also from very widespread disease of a shoulder joint — humeroscapular periarthritis (see).
Acute B. of elbow bags is result of mechanical traumatization and infection of an elbow bag at engravers, watchmakers more often, etc. The bag sharply increases in sizes and gets a hemispherical form (fig. 1, 2). Accession of an infection is followed by emergence of sharp morbidity, erubescence in the field of an elbow shoot, temperature increase.
Acute B. quite often strikes a beam - the humeral bag located between tuberosity of a beam bone and a sinew of a biceps (a bursitis of tennis players).
B. in the field of a hip joint differ in weight of a current; the inflammation quite often extends to a hip joint. More often deeply located iliopectineal bag which is between muscles and the joint capsule and also superficial and deep bags of a big spit is exposed to an inflammation.
At a purulent inflammation of these bags sharp morbidity at assignment of an extremity, extension and rotation of a hip is noted. The hip is in the provision of bending, is taken away and slightly rotirovano outside.
At a palpation the swelling is determined by the anteromedial surface of a hip under an inguinal sheaf painful, an elastic consistence.
At a purulent inflammation of bags of a big spit the swelling is located on an outer surface of a hip more often.
On weight of a clinical current and similarity of symptomatology in some cases it is difficult to distinguish these types of B. from a purulent inflammation of a hip joint. At B., unlike arthritis, are observed: 1) relative painlessness of bending and reduction of a hip; 2) lack of morbidity at load of an extremity on length; 3) existence of the swelling which is located on anteriointernal side of a hip is lower than an inguinal sheaf.
The smeshchayemost of the last at the movements of a hip of a kzada allows to distinguish defeat of a hypodermic bag of a big spit from defeat of a deep bag; at an inflammation of a hypodermic trochanterian bag of shift it is not noted.
In the field of a knee joint prepatellar bags — hypodermic, subfascial and subtendinous most often are surprised; with a knee joint they are not reported. Due to more superficial arrangement the hypodermic bag is surprised most often (fig. 1, 2). The inflammation is followed by sharp local hypostasis, fluctuation, temperature increase, increase regional limf, nodes.
The inflammation of a deep subpatellar bag arises more often for the second time as a complication of acute gahnite.
Subnodal B. is difficult diagnosed owing to a deep arrangement of a bag; at it restriction of movements and a gonalgia is observed a nek-swarm.
A frequent type of B. in the field of foot is the inflammation of the large bag located between a calcaneal hillock and heelstring — an achillobursitis. As its reason serve Traumatization of a synovial bag as footwear, hematogenous or lymphogenous infection.
A B. hypodermic calcaneal bag represents a painful swelling in the field of a calcaneal hillock. Inflammatory process can be limited to a phase of serous treatment or lead to abscessing. In some cases this type of B. should be differentiated from the inflammation caused by an injury of soft tissues calcaneal «spur».
From purulent B. of neogenic synovial bags of foot the purulent inflammation of a bag on an inner surface of a head of the I plusnevy bone meets at hallux valgus (see). At hit of an infection on site of a bag the abscess which is followed by redness, the swelling expressed by morbidity during the walking is formed.
Gonorrheal B. proceeds with sharply painful swelling of the struck bag, the expressed acute inflammatory phenomena in surrounding fabrics. More often also prepatellar bags are surprised calcaneal.
At tubercular B. deeply lying bags are surprised more often, the swelling, a zybleniye is observed. In a cavity of a bag serofibrinous exudate which can pass into tvorozhistognoyny is found. Tubercular B. quite often is complicated by outside fistulas.
the Diagnosis is simple at an inflammation of superficially located bags and is based on the typical clinical signs described above. The diagnosis is facilitated by a puncture of a cavity of the bag allowing to establish character of an inflammation on the received contents (serous, purulent, it is purulent - hemorrhagic etc.), to establish character of microbic flora and its sensitivity to antibiotics.
For performing the most effective treatment it is important to exclude specificity of the infection which caused an inflammation (gonokokk, brucellas, spirochetes, etc.) that is possible on the basis of carefully collected anamnesis, a bacteriological research of contents of bags, results of specific serological tests.
The main differential diagnostic character allowing to distinguish B. from arthritis is preservation of movements in a joint.
Radiodiagnosis superficially located (hypodermic) B. of any localization of a sravnitelnoprost. Owing to availability them for clinical recognition it usually has only the specifying character. Radiodiagnosis deep B has much bigger practical value. Among them the radiologist most often should meet B. of area of a knee joint and a big spit of a hip, an achillobursitis and an inflammation of a non-constant subcalcaneal mucous bag, and on an upper extremity — with hron, subacromial B. (fig. 2 and 3).
The main method of radiological recognition of B. is the X-ray analysis. Its diagnostic opportunities depend on localization of the struck mucous bag, character and expressiveness of changes in it, and also on existence or lack of secondary changes in nearby bones. Deep B. is easier distinguished if the anatomic area where it arises, causes well differentiated picture of soft tissues on the roentgenogram (e.g., areas of a knee joint, a calcaneus). In such cases B.'s diagnosis is based on detection of a shadow of the increased synovial bag and inflammatory infiltration (fig. 2) around it. On the contrary, at insufficiency of natural contrast in the image of soft tissues (area of a shoulder joint, a big spit of a hip) B., as a rule, comes to light or at adjournment of limy salts in a wall or a cavity of a bag, or in the presence of different changes in adjacent bones (fig. 3).
In some cases for the purpose of differential diagnosis of B. (hygroma) of area of a knee joint in addition to a usual X-ray analysis it is necessary to carry out artrografiya (see), the communication of a cavity of a joint with the defined pathological education allowing to reveal or reject. For exact recognition of B. of some localizations sometimes resort to artificial contrasting of synovial bags by their direct puncture (bursografiya). At the same time use both positive, and negative radiopaque substances.
Treatment of a bursitis shall be complex, including local and general, conservative, and also surgical actions.
At acute B. in an early stage the rest, a compressing bandage warming compresses is recommended. Purulent B.'s prevention requires early active treatment of a serous form of acute B., use of retentive bandages.
At hron. To a B. thicket resort to a puncture with removal of exudate and the subsequent washing of a cavity of a bag solutions of antiseptic agents or antibiotics.
At traumatic B. enter solution of a hydrocortisone into a cavity of a synovial bag (on 25 — 50 mg with antibiotics from 2 to 5 times after preliminary introduction of 8 — 10 ml of 2% of solution of novocaine). Careful observance of an asepsis since otherwise serious complications are possible is important.
At purulent B. apply treatment by punctures. In case of progressing of process resort to opening of a bag and removal of pus; a purulent wound treat by the general rules. A lack of this method is duration of mending of an operational wound.
From surgical methods, in addition to punctures, at hron. B. opening or partial excision of a synovial bag with after-treatment of her cavity chemical substances (5% solution carbolic to - you, spirit of iodine) and sewing up of a bag mattress seams are offered; removal of an upper wall of a bag and greasing of her cavity spirit of iodine; opening and packing of a bag — the ways directed to an obliteration of her cavity. The most radical is operation of removal of a bag without its opening: after careful allocation and removal of a synovial bag a wound sew up tightly after processing it with antibiotics, more rare leave open.
Physiotherapeutic procedures — use of dry heat, UVCh, etc., on elimination of the acute inflammatory phenomena — massage are widely applied to acceleration of a rassasyvaniye of exudate, to lay down. physical culture and so forth. At acute B. physiotherapeutic treatment is appointed for the purpose of an antiinflammatory p of resorptional action. In an initial stage UF-radiation of area of a joint — 4 — 6 biodoses every other day, microwave therapy with a thermal power of 30 — 60 W of 10 — 15 min. every other day with a repeated course in 3 — 4 weeks is recommended, to-ruyu it is possible to alternate to the UVCh-field on area of a joint cross 8 — 10 min. or only UVCh daily. From the 7th day, after subsiding of the inflammatory phenomena, the induktoterapiya by a small disk (or an electrode cable) with a current of 150 — 200 ma 20 min. daily, paraffin or ozokeritovy applications of t°48 — 55 °n area of a joint 30 min. daily is recommended.
At hron, traumatic B. the physical therapy has anesthetic, antiinflammatory and resorptional effect. It is recommended: UF-radiation of the center of a disease of 2 — 3 biodoses every other day; novocaine electrophoresis of area of a joint cross 20 — 30 min. daily or every other day; The UVCh-field on area of the center cross 10 — 15 min. daily or every other day; microwave therapy of area of the center (as at acute B.) daily or every other day with a repeated course in 1,5-2 months; ultrasound on area of a joint of 6 — 10 min. daily or every other day; paraffin or ozokeritovy applications of t ° 50 — 55 ° on area of a joint of 20 — 40 min. daily or every other day; an induktoterapiya of area of a joint (in a week after an aggravation a small disk 20 — 25 min. daily or every other day). From the general medical actions at conservative and especially operational treatment of B. introduction of antibiotics, sulfanamide and nitrofuran drugs is recommended.
At gonorrheal B. treatment of a basic disease is necessary; use of physiotherapeutic methods. At big accumulation of an exudate make a puncture of a bag for removal of exudate with washing by its antibiotics. The early active and passive movements in joints in order to avoid development of contractures are recommended.
At tubercular B. treatment of a basic disease is also necessary, the extirpation of the struck mucous bag is possible.
Radiation therapy of a bursitis is applied at subacute and hron, forms of a disease. Having antiinflammatory effect, radiation therapy promotes recovery of the broken trophicity and removal of a pain syndrome. Generally apply a roentgenotherapy: irradiate area of the struck synovial bag from two fields which sizes are defined by the volume and a configuration of a joint (6X8, 8X10, 10X15 cm are more rare), at distance a source — skin — 30 — 40 cm. The direction and a tilt angle of the central beam depend on localization of a bag and a condition of surrounding fabrics. Technical specifications on radiation: voltage is 180 — 200 kV, a layer of half easing — 1,8 — 1,2 mm of copper.
Optimum doses and a rhythm of radiation are defined by sharpness of inflammatory process. Single focal doses 20 — 60 I am glad (respectively air doses — 25 — 75 r); total focal doses — 300 — 400 I am glad. In the absence of an aggravation an interval between radiations — the 48th hour. The therapeutic effect (reduction or disappearance of pains, increase in volume of movements in a joint) comes usually in the course of treatment, however in some cases it is implemented in 2 — 3 weeks after its termination.
the Forecast at acute B. depends on extent of pathological changes in fabrics of the struck bags, their prevalence, virulence of an infection, body resistance of the patient. Failures of acute B. can take place at its complication arthritis, osteomyelitis, fistulas, sepsis. The recurrence at hron, traumatic B. is celebrated at 2 — 2,5% operated.
Prevention consists in elimination of continuous traumatizing synovial bags, in particular carrying protective bandages, replacement of manual skills with mechanisms, in careful primary surgical treatment of wounds of synovial bags, timely and rational treatment of pustulous diseases.
Bibliography: Varava L. A. About treatment of a traumatic bursitis, Vestn, hir., t. 106, No. 3, page 121, 1971; The Vinterga - S. F rubbed. ikeleras E. Yu. X-ray inspection of soft tissues of extremities (without artificial contrasting), page 106, Vilnius, 1971, bibliogr.; Kevesh JI. E. K to radiodiagnosis of an inflammation of a subcalcaneal mucous bag (bursitis subcalcaneae), Vestn, rentgenol, and radio-gramophones., No. 2, page 57, 1958; Kreshchik A. M. of M. S iterenin. Treatment of a chronic and acute bursitis, Vestn, hir., t. 106, No. 3, page 122, 1971; JI and m of m of Ya. E. Traumatic (professional) bursitis, M., 1966, bibliogr.; Lukyanova A. A. About a traumatic bursitis at miners, Vestn, hir., t. 74, JsTs 7, page 40, 1954; The Multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 2, page 283, M., 1964, bibliogr.; Reznik S. D. Chronic traumatic bursitis of knee and elbow joints, Kiev, 1962, bibliogr.; V. I pods. Purulent surgery, page 192, M., 1967; Khromov B. M. Acute purulent surgical diseases, page 157, L., 1965; Reinhardt K. Ein Beitrag zur arthrographischen Sympto-matik und zur Klinik der Popliteazysten und der popliteogenen Unterschenkelzysten (Baker-Zysten), Fortschr. Rontgenstr., Bd 115, S. 596, 1971.
V. I. Struchkov, L. S. Tapinsky; Century M. Ben-tsianova (rents.), L. E. Kevesh (I am glad.).