OSTEOMYELITIS

From Big Medical Encyclopedia

OSTEOMYELITIS (osteomyelitis, grech, osteon a bone + myelos marrow + - itis) — the infectious inflammatory process striking all elements of a bone — marrow, a compact and spongy part of a bone and a periosteum, i.e. being actually a panosteitis. However the term «panosteitis» did not find broad application in medical literature.

Classification

On etiol, to a sign nonspecific, caused by pyogenic microbes (acute hematogenous and all types of not hematogenous), and specific, caused by specific microflora distinguish O. (tubercular, syphilitic, etc.).

Depending on ways of penetration of an infection to O.'s bone divide on hematogenous, caused by the endogenous microflora getting into a bone from the remote center on blood vessels (acute hematogenous and primary and chronic), and not a hematogenous, caused exogenous infection getting into a bone at wound, operation and other injuries (fire and traumatic O.) or by direct transition to a bone of a purulent inflammation from the next fabrics and bodies.

On a wedge, to O.'s current happens acute (acute hematogenous, acute stages of the fire, traumatic and arisen by direct transition inflammatory process to a bone from the next fabrics and bodies); chronic (secondary), developing after any form of acute nonspecific O.; primary and chronic, atypical forms O. (sclerosing osteomyelitis of Garre, albuminous osteomyelitis of Ollye, a Brodie's abscess, posttyphoid O., etc.), and also O. belong to Krom at nek-ry inf. diseases (tuberculosis, syphilis, etc.).

History

Data about it is purulent - a destructive disease of bone system are available in works of physicians of an extreme antiquity and the Middle Ages (Hindu physicians, Hippocrates, Ibn-Sina, A. Tseljs, Zh. Pti, K. Galen, etc.), to-rye connected an origin of it patol, process with injury of a bone. In the first half of 19 century instructions on inf appeared. the nature of this disease, and the attention to primary damage of marrow was paid that gave M.'s grounds of Reynaud (1838) to offer the term «osteomyelitis». In the second half of 19 century it was succeeded to find out a crucial role of pyogenic microbes in O.'s etiology and to shed light on a pathogeny hematogenous

O. Klien, the picture and O.'s diagnosis were studied at the beginning of 20 century in detail. Improvement rentgenol, methods of a research allowed to obtain rather exact data on volume and character patol, changes in bones.

Many discussions caused various aspects of treatment of the Lake. At the XVII Congress of the Russian surgeons in 1925 after the program report of T. P. Nrasnobayev the principles of complex treatment of acute hematogenous O., including early use of the sparing operational methods were accepted that promoted considerable reduction of a lethality. With approach of an era of antibiotics it was succeeded to lower even more a lethality at acute O. and to reduce percent of transition it in hron, a stage.

N. I. Pirogov repeatedly pointed to serious consequences of fire O. Studying of this form O. became more active at the end of World War I. Works of H were devoted to it. N. Petroveg, S. A. Novotelnov, Ya. M. Smirnov, etc. The largest researches were executed by the Soviet scientists in the period of the Great Patriotic War and in post-war years.

At the present stage studying of a pathogeny of O. and improvement of methods of its diagnosis and treatment continues. It is promoted by progress of the equipment and biol, sciences.

An etiology

acute nonspecific O.'s Activators in 80 — 85% of cases are pathogenic staphylococcus, streptococci and pneumococci are more rare. The role of gram-negative flora, high-resistant to antibacterial drugs, increased: a pyocyanic stick, vulgar a protea, colibacillus and a capsular stick of a klebsiyella, to-rye in 6 — 7% of cases are sowed in associations with staphylococcal flora, in 2 — 4% — in the form of a monoculture. Important etiol, acute hematogenous O.'s factor can be and viral infections, against the background of to-rykh nearly 40 — 50% of cases of the Lake proceed. Viruses lead to bystry decrease in body resistance, increase virulence of pyogenic bacteria and create favorable circumstances for their implementation. At hron. The lake with is long the existing fistulas, as a rule, gram-negative microflora is allocated.

Penetration into an organism of the bacteria causing hematogenous O. happens in various ways: through mucous membranes of a nasopharynx and a mouth, a lymphoid pharyngeal ring, the injured skin. Babies the most frequent source of an infection can have an infected umbilical wound, an intertrigo and an attrition of skin, and at newborns value of pre-natal infection of a fruit in the presence of the centers hron, inflammations at the pregnant woman increases. At the senior children the significant role is played by earlier postponed inflammatory processes with formation of the center of latent infection which is localized in reticuloendothelial system, in particular in marrow, and also not - the debrided centers in almonds, adenoides, etc. These centers autoinfections (see) under certain conditions can give the outbreak of purulent osteomyelitis.

At not hematogenous O. microflora gets into a bone from the environment through a wound at an open change, at operation of an osteosynthesis etc. or by transition from the centers located in the next fabrics and bodies.

Specific microflora — tubercular can become specific O.'s activator (see. Tuberculosis extra pulmonary, tuberculosis of bones and joints ), syphilitic (see. Syphilis ), leprose (see. Leprosy ), brucellous (see. Brucellosis ), etc.

the Pathogeny

In studying of a pathogeny of acute hematogenous O. the outstanding role belongs to A. A. Bobrov, G. To M. Derizhanov, T. P. Red bayevu, to G. I. Turner, E. Lekser, etc. It was established that blood supply of a long tubular bone of newborns and children of younger age is carried out by three systems of vessels: diaphyseal, metafizarny and epiphyseal. About the epiphyseal line (where hematogenous O.'s centers are most often localized) in the growing bone vessels of each of these systems come to an end blindly, without anastomosing among themselves. On the basis of it A. A. Bobrov (1889) and AA. A lexer (1894) offered the embolic theory of an origin of the hematogenous Lake. The bacterial embolus from primary center of an infection brought in a bone by a blood flow settles in one of trailer vessels that is promoted by abundance of narrow trailer arteries and delay of a blood-groove in them here. The settled embolus is a source of purulent process in a bone.

The embolic theory of Bobrov — the Lexer a long time was the main, explaining a pathogeny of the hematogenous Lake. The subsequent researchers, adhering to it, considered that O.'s emergence depends also on a number of accessory factors, in particular from constitutional types of a structure of vessels of a bone, from character of a corner of an otkhozhdeniye of the arteries feeding a bone etc. A. O. Vilensky (1934) attached great value to the progressing trombarteriit or thrombophlebitis. However value of these moments, as well as existence of trailer arteries in a bone of newborns and children of younger age, was disproved by N. I. Anserov's works, M. G. Privesa, etc. Besides, this theory could not explain the reasons of development of the center of the hematogenous O. localized out of the region of growth of a bone; in addition, in it also other essential gaps were revealed.

An outstanding contribution to a solution of the problem of a pathogeny of hematogenous O. were works of G. M. Derizhanov (1937) who created and experimentally proved the allergic theory of a pathogeny of hematogenous O., edge in the subsequent it was enriched with new data. Completely denying a role of an embolism, he considered that the disease can arise only in an organism, sensibilized a latent bacterial flora. Continuous and long impact of endotoxins of this flora on fabrics promotes development of the allergic reaction of the slowed-down type causing a sensitization of an organism, at a cut its protective mechanisms are distorted. Under the influence of any nonspecific irritant (allowing a factor) — injuries, coolings, diseases, etc. — the center of an aseptic inflammation as Artyus's phenomenon develops in bones (see. Artyusa phenomenon ). It creates favorable conditions for development of a latent bacterial flora, and she begins to breed quickly in the marrowy channel, gains virulence and gives to inflammatory process acute infectious and purulent character. The acquired immune insufficiency develops, the system of a hemostasis with a syndrome of the disseminated intravascular coagulation is broken. Increase in coagulating properties of blood leads to thrombosis of vessels of a bone at the level of capillaries and venules that in combination with their neuroreflex spasm leads to delay of a blood-groove, development of a hypoxia and finally — to an osteonecrosis of an affected area of a bone. Sharply increasing Intra bone pressure conducts to a prelum and destruction of intra bone vessels that promotes expansion of a zone of infection of marrow, an osteonecrosis and development of a condition of septic shock.

The allergic theory S. M. De-rizhanova considerably expanded idea of hematogenous O.'s pathogeny as process, in to - rum participates all organism, and opened ample opportunities for further studying of this problem.

In a pathogeny not gematogenno guo O. serious value get other factors. So, in development of fire and it is close to it the standing traumatic O. the leading role weight of anatomic destructions, degree and the nature of microbic pollution of a change and the nature of response of an organism to an injury play. Viable bone splinters from a compact bone, as well as a compact bone tissue, have big resistance to an infection, but at their isolation from surrounding soft tissues and a periosteum in the conditions of microbic pollution of a wound they become the peculiar foreign bodys favoring to development inf. process. In these conditions sensitivity of a bone tissue to an infection increases. Yellow marrow has high resistance to an infection, and inflammatory process in it at fire changes is early delimited in a zone of damage. Red marrow and spongy substance of a bone have much smaller ability to an otgranicheniye of inflammatory process, to-ry in these departments of a bone accepts the long progressing current, as the fire Island characterizes. Development of an infection in a bullet bone wound and the surrounding damaged soft tissues is followed by oppression and a perversion of regenerative processes that often leads to acute O.'s transition in chronic, i.e. to formation patol, the bone callosity which quite often have the purulent cavities and the fistular courses containing dead bone splinters.

Consistently suppurating centers of a necrosis in a bone tissue make one of very essential links in fire O.'s pathogeny, just as in a pathogeny of the chronic (secondary) O. which developed after any form of the acute Lake.

Primary and chronic (atypical) forms O. develop generally as a result of action of sharply weakened microflora (e.g., long reception of antibiotics concerning any inf. disease) at the remained sufficient body resistance. In these conditions in the center of defeat there is no usual suppuration and destruction of a bone tissue, and the disease proceeds atypically.

The pathological anatomy

Acute hematogenous O. begins as the diffusion inflammatory process in marrow extending then on gaversova channels and a periosteum. The inflammation has the nature of the phlegmon which is followed by a necrosis of marrow, spongy bone tissue, and is frequent also a compact plate. Purulent fusion and otgranicheniye of the centers of an inflammation leads to formation of the abscesses arising already on 3 — 4 days from the beginning of a disease. Primary formation of blood clots or an embolism of intra bone vessels as predecessors of an inflammation are not registered. In the capsule of abscesses and in adjacent fabrics quite often arises thrombophlebitis (see), extending sometimes and to vessels of gaversovy systems and a periosteum, but connect distribution of an inflammation on a periosteum and soft tissues with this process. Around the centers of an inflammation from the first days the rough rassasyvaniye of a bone tissue further extending to all injured bone begins and at a long current of O. leading to its rarefikation — to osteoporosis (see).

In favorably proceeding cases, especially at early use of antibiotics, abscessings can not come and elimination of the center of an inflammation happens even before formation of sequesters. In the course of healing leukocytes of exudate are exposed to fatty disintegration and are absorbed by macrophages, a liquid part of exudate is soaked up, and the cavity of an abscess is gradually filled with the granulations coming from not osteogene stroma of marrow. Granulations turn into fibrous connecting fabric and further rezorbirutsya with recovery of normal structure of marrow On site of the large inflammatory centers cysts with fibrous walls can be formed. If trepanation of a bone was made, then the trepanation opening is gradually filled osteogene, and later with a bone tissue. At children's age all traces of the postponed inflammation can disappear.

Fig. 1. Microdrugs of a compact plate of a bone in the course of its sequestration: and — formation of lacunas (1) in a wall of a gaversov of the channel (2) in an initial phase of demarcation of a suppurative focus; — the cicatrizing granulations containing osteoclasts (1) on places of contact with the sequester (2); in — the separated sequester (1), an atrophy of the subject granulations (2); coloring hematoxylin-eosine; x 120.
Fig. 2. Microdrug of a spongy bone with the sequester (1) on border with the region of growth of granulations (2), coloring hematoxylin-eosine; x 80.
Fig. 1. Macrodrug of a diaphysis of a femur (a longitudinal cut) at osteomyelitis after a gunshot wound: 1 — the sequestered site of a bone; 2 — growths of granulyatsionny fabric in a zone of demarcation; 1 — complexes of bone beams. Fig. 2. Macrodrug of a tibial bone at osteomyelitis after a gunshot wound: in a zone of an accrete change the abscess with small sequesters is visible (one of them is specified by an arrow). Fig. 3. Macrodrug of a metaphysis of a femur at hematogenous osteomyelitis: 1 — intra bone abscesses with sequesters of spongy substance; 2 — a subperiosteal abscess.

In other cases encapsulation of abscesses in a bone is observed. To 3 — 4th week from the beginning of a disease at rentgenol, a research against the background of a rarefikation the centers of a necrosis of a bone as the devitalized bone is not exposed to a resorption are defined and keeps former density. At a pathoanatomical research sites of a necrosis come to light even earlier. Further those from them, to-rye are in the center of suppuration, are exposed to sequestration (fig. 1). Sequestration (see. Sequester, sequestration ) consists in rejection of the devitalized sites of a bone which are in a cavity of an abscess from a surrounding bone tissue. At the same time in case of formation of the sequester in a compact plate on its surface in a zone of a prileganiye of granulations arises and gradually the sequestral furrow, and in the thickness — expansion of gaversovy channels and their merge among themselves goes deep. After all bone substance in the specified zone is dissolved, the sequester is freely lying in a cavity of an abscess (tsvetn. fig. 2 and 3). Sequesters of spongy substance of a bone separate from its other part due to dissolution of the adjacent bone beams which are in a zone of granulations (fig. 2).

Sequesters interfere with healing of the center of O. Vozmozhnost of «implantation» or a rassasyvaniye of the sequester by most of researchers is denied since in its thickness even at plentiful use of antibiotics the microorganisms suppressing activity of fabric enzymes remain. In an experiment both the rassasyvaniye, and «implantation» of sequesters are observed only in the conditions of sterile suppuration, napr, after introduction to a bone of croton oil.

Fire O. is characterized by suppuration in a zone of a fire fracture of bone, a cut is followed by formation of sequesters and an angenesis. On the basis of the analysis of kliniko-anatomic features of fire osteomyelitis P. G. Korney allocates three stages of his dynamics: 1) an acute inflammation in the regions of a wound with an otgranicheniye and partial fusion of nekrotizirovanny fabrics; 2) formation of a suppurative focus around the nekrotizirovanny and sequestered sites of a bone with formation of a pyogenic cover, and in some cases and a bone callosity; 3) education and long existence of a suppurative focus after an union of a change and recovery of function of the damaged body.

Fig. 3. The diagrammatic representation of the suppurated bullet wound of a hip: 1 — a free bone splinter; 2 — a purulent cavity; 3 — purulent flow; 4 — sequesters; 5 — the wound channel; 6 — an osteogenesis.

The inflammation begins in soft tissues of edges of a wound in the form of diffusion inflammatory infiltration, after a cut on border with a zone of necrosis the line of demarcation forms. The exudate coming to a cavity of a wound and impregnating the nekrotizirovanny fabrics which are exposed at the same time to fusion is at the same time formed, and it is frequent also to ichorization. To 4 — to the 5th day in a zone of a line of demarcation the granulations which are plentifully producing pus are formed. To this term also the purulent inflammation in fragments of a bone is shown, a cut proceeds on border with nekrotizirovan-ny fabrics, keeping character of demarcation. From the beginning of suppuration the bone splinters and soft tissues which tested a commotio connected with a periosteum — a zone of a reserve of a necrosis according to I. V. Davydovsky can undergo necrosis. The center of suppuration is gradually isolated by shaft from granulations, and in the subsequent and the connective tissue capsule. In it the free bone splinters which are not removed at surgical treatment of a wound, the splinters which kept communication with a periosteum, the ends of fragments deprived of a periosteum, foreign bodys, scraps of soft tissues, the breaking-up blood parcels (fig. 3) are located. Suppuration quite often extends in depth of soft tissues and in thickness of a bone along the cracks and channels done by the bone splinters displaced at the time of wound that gives to the center difficult outlines (tsvetn. fig. 1).

During suppuration there is a fusion of devitalized fabrics under the influence of enzymes of pus and their allocation from a wound, and also sequestration of the devitalized sites of a bone which are in the center of suppuration. Rates of sequestration decrease at extensive paraossalny suppuration, a delay of pus in a wound, heavy intoxication.

Fig. 4. A type of fragment of the femur affected with osteomyelitis: bone growths at the edges of fragment are visible (are specified by shooters).
Fig. 5. A type of a femur with the center of fire osteomyelitis: in the center of an excess bone callosity (1) as in a sekvestralnok to the capsule, there is a sequester (2).

During suppuration in the fabrics surrounding the center proliferative and dystrophic processes are developed. Proliferation of fabrics is resulted by a pyogenic cover, and then forms bone callosity (see) with the subsequent consolidation of a change or only bone growths at the edges of fragments (fig. 4) are formed. The arisen bone callosity includes abscesses with sequesters (tsvetn. fig. 2) also plays thus a role of the sequestral capsule, from a cut the fistular courses conduct on the surface of skin (fig. 5). Dystrophic changes are expressed in a diffusion rarefikation, and later in focal eburnation bones (see) in a zone of formation of a callosity. In surrounding soft tissues and in the next joints the phenomena of an atrophy develop.

The aggravation of purulent process is possible at any stage, including and many years and even decades later. In a result in of a bone and in soft tissues there can be centers phlegmons (see), so-called sympathetic arthritis, thrombophlebitis, purulent flow (see).

Distinctiveness of fire O. of spongy bones is the weak otgranicheniye of suppurative focuses, the scanty mozoleobrazovaniye is frequent with steady progressing of process, and.

In addition to a typiform of fire O., in hard cases, especially at nonperforating missile wounds of an epiphysis and spongy bones, there is phlegmonous O. (nekro-phlegmon of marrow) extending to big sites of a bone without tendency to an otgranicheniye. It is characterized by a necrosis of the struck fabrics, purulent thrombophlebitis and arteritis; develops at the end of the first — on the second decade after wound, is more rare in the late period (against the background of long suppuration of a bone wound) and quickly comes to an end with the death of the patient from sepsis. Phlegmonous O.'s emergence is connected with sharp easing of immunity. It is supposed also that it is expression of giperergichesky reaction. It is possible that in its pathogeny the extensive contusion of marrow plays a role what pointed N. I to. Pirogov.

At O. resulting from transition of a purulent inflammation to a bone from surrounding fabrics, process affects at first a periosteum, and then extends to cortical substance of a bone where sequesters are formed.

The chronic (secondary) O. arising as a further stage of the dragged-out inflammatory process in a bone is characterized by existence in it of well delimited abscesses containing sequesters. Abscesses are surrounded with sequestral capsules — the bone growths in a periosteum and marrowy spaces located knaruzh from the connective tissue capsule of abscesses. Sequestral capsules have one or several openings («foul places») which are reported with the fistular courses in surrounding soft tissues. The inner surface of connective tissue capsules of abscesses is covered with granulations, to-rye during remission cicatrize, and products of pus stop. At an ekza-tserbation there is a flash of a purulent inflammation in a bone which is followed by resuming of the closed fistulas and an otkhozhdeniye together with pus of small sequesters. At hron. Lakes often form periosteal bone growths exostoses (see) and osteophytes (see) a bizzare shape. The compact plate can be thickened that conducts to eburnation of a bone. At the same time also the rarefikation of the affected bone which is especially expressed in the region of growth of granulations proceeds. At massive dissolution of an affected area of a bone speak about a caries, inflammatory caries. Alternation of sites of eburnation, rarefika-tion, formation of exostoses creates a motley picture of damage of a bone and is followed by its deformation.

On site the cicatrized centers of suppuration in soft tissues and a periosteum dense hems, on the periphery to-rykh perhaps adjournment of limy salts and ossification as ossifying are formed miositis (see).

At children's and youthful age, especially at metafizarny localization, hron. The lake can lead to destruction of a rostkovy cartilage and shortening of a bone. At diaphyseal localization the strengthened growth and an osteocampsia are possible that it is connected with irritation of a rostkovy zone.

Atypical forms O. are characterized by inertly current inflammatory damage of bones with dominance in them sclerous processes and smaller expressiveness of exudation, necrosis and formation of sequesters. The last arise at albuminous more often and after hardly typhus O. Vopros is discussed existence of sclerosing osteomyelitis of Garre. Often this term designate a tumor (osteoid osteoma), proceeding with massive growth of a bone in a circle. The tumor which is in the thickness of a neogenic bone conglomerate (usually no more than 1 — 1V2 cm in the diameter) was often not revealed before, and its nest in a bone was regarded as the center of an inflammation.

Carry to primary chronically O. also its inertly current forms, the observed hl. obr. at children at unsystematic use of antibiotics. In the affected bone at an integrity of a cortical plate find sites of a softening of marrow with existence in them of the kroshkovaty brownish masses sometimes impregnated with pus. At microscopic examination note a necrosis of marrow with treatment serofibrinous, more rare the purulent exudate sometimes containing a large number of eosinophils; bone structures in the center and its circle — with the phenomena of the resorption leading to a ra-refikation of a bone; in spongy substance of a bone «miliary» sequesters meet. Process can extend also to a periosteum, in Krom in such cases the seroznofibrinozny inflammation, scanty proliferative reaction is noted. Otgranicheniye of the center of an inflammation in a bone indistinct in the form of accumulation of macrophages, growth of friable granulations, and later and rare network of bone beams.

The lake can develop as a complication of a row inf. diseases — sepsis, a typhoid, a brucellosis, tuberculosis, syphilis. In all these cases damage of bones has specific to each disease morfol, the lines creating an originality of inflammatory process in a bone.

Clinical forms

Acute hematogenous osteomyelitis

Acute hematogenous osteomyelitis in peace time is the most frequent form O., edges, according to T. P. Krasnobayev, in 75 — 85% of cases arises at children. Among the diseased apprx. 30% children aged up to one year make, 45 — 48% — aged from 6 up to 14 years, boys — 65 — 70%, girls — 30 — 35%. In children's surgical hospitals sick O. make 2 — 2,5% of number of the hospitalized children and 8 — 10% — from number of the hospitalized children with purulent diseases. At adults aggravations and a recurrence of this disease postponed in the childhood are usually observed.

Acute hematogenous O. strikes preferential long tubular (80 — 85%), bones are more rare flat (9 — 13%) and short (6 — 7%).

Most often bones suffer femoral (35 — 40%), tibial (30 — 32%) and humeral (7 — 10%); from short — a bone of foot; from flat — pelvic bones and an upper jaw.

At damage of long tubular bones distinguish O.: metafi-zarny, the center to-rogo usually affects the fringe region of a diaphysis or epiphysis (it is observed at 65% of patients), epiphyseal (25 — 28% of patients), the metadiaphyseal, striking metaphysis and more than a half of a diaphysis, or the total, striking diaphysis and both metaphyses (7 — 10% of patients). Multiple processes are observed at 10 — 15% of patients.

A clinical picture

According to T. P. Krasnobayev's proposal, distinguish three forms a wedge, acute hematogenous O.'s currents: local (easy), septicopyemic (heavy), toxic (adynamic). A wedge, disease at damage of various bones it is generally same.

The local (easy) form of hematogenous O. differs in lack of the septic phenomena and dominance of clinic of local changes over disturbances of the general state, a cut can be heavy, moderately severe or close to satisfactory. Intoxication is expressed moderately, temperature at the beginning of a disease and further — 38 — 39 °. Local inflammatory changes have limited character, their wedge, manifestations are expressed less brightly, than at a septicopyemic form.

If subperiostal abscess is not opened timely, it breaks in soft tissues, and then intermuscular phlegmon forms (see). Pus can spread on interfascial spaces and break outside far from the bone center. After emptying of an abscess the condition of the patient quickly improves, temperature decreases, process accepts hron, a current.

At a septicopyemic form the disease begins suddenly with rise in temperature to high figures. During the first hours and days of a disease the heavy disturbance of the general condition of patients caused by intoxication develops, repeated vomiting is observed. Local changes develop quickly enough. During the first 2 days there are localized pains; they have sharp character, the extremity adopts the forced provision (a painful contracture), the active movements in it are absent, passive — are sharply limited. Quickly hypostasis of soft tissues accrues, to-ry at localization of the center in a femur can extend to a shin, a front abdominal wall, at localization in a humeral bone — to a thorax. Skin over the center of defeat is hyperemic, strained, shines, the venous drawing is quite often expressed; increase in local temperature is noted. Emergence of hypostasis corresponds to the beginning of formation of subperiostal abscess, development of a hyperemia — to break of abscess in soft tissues and to emergence of fluctuation in the depth of them. Often at the same time sympathetic (reactive) arthritis of one or both adjacent joints, in the beginning the serous, then usually getting purulent character develops (see. Arthritises ). In the next days high temperature sticks to a disease (39 — 40 °) without noticeable daily fluctuations, changes of composition of blood, typical for an acute purulent inflammation, are noted.

At inefficiency of treatment the serious general condition of the patient worsens, accrue intoxication (see) and dehydration of an organism (see), the headache, all body pain, loss of appetite, thirst, the phenomena of an anemization are observed. Exchange processes are broken: metabolic develops acidosis (see); frustration water salt metabolism (see) lead to a resistant hyperpotassemia and a kaltsiyemiya, a hyponatremia and other disturbances. Indicators of nonspecific factors of immunity, coagulant system of blood worsen, there is an excess accumulation of chemical mediators of an inflammation (a histamine, serotonin, etc.).

In system of a hemostasis there are expressed phase changes. During the first 10 days of a disease the phenomena of hypercoagulation (the I phase) are observed that creates conditions for the disseminated intravascular blood coagulation which is sharply aggravating destruction of a bone. On 10 — the 20th days arise the phenomena of hypocoagulation (the II phase) with a tendency of transition to a phase of activation and increase patol, a fibrinolysis (the III phase). At a septicopyemic form these changes develop at 90%, at local — at 25% of patients.

Hormonal regulation of functions of an organism, metabolism of a myocardium, anti-toxic function of a liver, function of kidneys are broken, compensatory mechanisms of system of breath and blood circulation are exhausted.

All these changes develop for 5 — 10 days and create favorable conditions for generalization of a purulent infection, its hematogenous innidiation. Quite often toxic hemolitic jaundice develops.

Fig. 6. Roentgenogram of knee joints of the child sick with epiphyseal osteomyelitis: an epiphysis of femoral (1) and tibial (2) bones is destroyed; deformation of joints is visible.

Peculiar the hematogenous O. at early children's age which is usually developing in the first weeks or months of life at sepsis proceeds. As a rule, several bones as a result of hematogenous emergence of several epiphyseal bone centers are surprised at once owing to what the disease received epiphyseal O.'s (fig. 6) name. Usually a proximal epiphysis of a shoulder, hip, an epiphysis of the bones which are jointed in a knee joint are surprised. The inflammation quickly extends to a joint. This heavy osteoarthritis (see) practically never comes to an end with an anchylosis, even at extensive bone destructions, and recovery of bones happens almost full. If there is no break of an abscess through integuments, then epiphyseal O. can remain not diagnosed. Its effects quite often are found only at later age and can be interpreted not always correctly, napr as an inborn incomplete dislocation or dislocation.

The toxic (adynamic) form of hematogenous O. occurs at 1 — 3% of patients. The disease develops immediately. Within the first days the phenomena of heavy toxicosis accrue: the hypothermia, Meningeal symptoms, a loss of consciousness, spasms replaced by an adynamia; acute cardiovascular insufficiency develops, the ABP decreases. The local inflammatory phenomena do not manage to be shown: patients perish in the first days of a disease as a result of deep metabolic disturbances.

Complications

the Most characteristic and heavy complication of acute hematogenous O. is sepsis (see), to-ry especially often develops at overdue or wrong treatment of a disease. Purulent arthritis of adjacent joints in one cases arises gematogenno, along with the center of an inflammation in a bone as a result of generalization of septic process, in others — owing to spread of an infection from the bone center on limf, to ways or break of pus from a bone in a cavity of a joint. 8 — 10% of patients (at septicopyemic forms — at 30%) have metastatic suppurative focuses in internals with development of septic pneumonia, purulent pleurisy, a pericardis, myocarditis, abscess of a brain, etc. Patol, a fracture of a bone, including egshfizeoliz (see. Changes ), results from destruction of a bone, it is frequent from the outcome in nearthrosis (see). Epiphyseal and metafizarny O. owing to a close arrangement of the center to a rostkovy zone can lead to a growth disorder and considerable deformations of bones (to a curvature, shortening, is more rare to lengthening), patol, to dislocation (see), to a contracture (see) or to an anchylosis (see).

The diagnosis

the Characteristic anamnesis and typical the wedge, a picture of a local form of hematogenous O. (resistant high temperature of a body, sharp pains in the field of damage of a bone, accession of the phenomena of acute arthritis is frequent) help to make the diagnosis.

Early recognition of a septicopyemic form is connected with the known difficulties in connection with dominance of the general symptoms over a little expressed initial local, especially at small children. Quite often the injury, rheumatism, pneumonia, scarlet fever, etc. appear as primary diagnosis. The careful palpation and check of mobility of extremities allowing to reveal a painful zone, existence of hypostasis, limited mobility in a joint, a protective contracture can protect from mistakes. The main early symptom of local and septicopyemic forms of hematogenous O. is the extremity pain amplifying at the movements, loading on a longitudinal axis, a palpation and percussion. By a palpation it is possible to define the strengthened pulsation of the main artery (humeral or femoral), and during the pressing on them — the expressed morbidity. Repeated crops of blood on the maintenance of bacteria in it are obligatory.

Lack of local symptoms and a rapid current of a toxic form O. create great difficulties for timely diagnosis.

For diagnosis the research is of great value rentgenol. The earliest indirect rentgenol, acute O.'s sign is the thickening and deformation of the soft tissues surrounding a bone that can be found on 2 — the 3rd day of a disease. Initial manifestations of a periosteal osteogenesis at small children can be seen at the end of the first week in the form of a low-contrast linear shadow of periosteal stratifications near a cortical layer of a meta-diaphysis of the affected bone. Further the cortical layer begins razvoloknyatsya, instead of it at the level of defeat new linear layered periosteal beddings accrue. Only on 2 — 3rd week of a disease there are centers of destruction and acute O. can be surely diagnosed.

Such late term of diagnosis forces to look for and approve new methods of earlier recognition of the acute Lake. According to L. V. Prokopova to be hit the image of the centers of destruction in bones, and also to find the phenomena of a periostitis and strengthening of contours of soft tissues already on 3 — - the 4th day of a disease works well by means of electrox-ray analysis (see).

The method of densitometry of roentgenograms is perspective (see. Densitometry ), to-ry it is based on property of mineral substances of a bone in various degree to absorb X-ray depending on their atomic mass. The main components of mineral composition of a bone are the calcium and phosphorus having high atomic mass. At a X-ray analysis of a normal bone they absorb respectively 79,6 and 14,8% (totally — nearly 95%) beams. At acute O. in its most initial stages there is an intensive process of demineralization of a bone in connection with removal from it both specified minerals in the form of tricalcium phosphate that is fixed by a microphotometer.

Deserve use also methods of registration of the increased intensity of infrared radiation, the coming from center of an inflammation of any depth. This radiation is registered by means of mirror or optical thermographs of infrared radiation (see. Termografiya ) and radiometers. The first will transform an invisible range of beams to visually perceived image and allow to record it in the black-and-white or color photo, to-ruyu then estimate by quality or quantitative indices. Radiometers of infrared radiation, in addition to quantitative indices, register data in the form of graphic curves. To perspective for early recognition of acute hematogenous O. it is necessary to carry methods of radio isotope scanning of the marrow allowing to define in it sites of destruction; ultrasonic (pulse) scanning (see. Scanning ); medullografiya (see), edges in the most difficult diagnostic situations it can be combined with an osteopuncture and an osteotonometriya.

For early diagnosis of acute hematogenous O. the method of a puncture of the marrowy channel (osteopuncture) with simultaneous measurement of intra bone pressure (osteotonometriya) by means of Valdman's device gained distribution, a cut at an inflammation of marrow it is raised by that more, than the pain syndrome is expressed stronger. The osteopuncture is made under local anesthesia in the field of a metaphysis of the affected bone by means of Kassirsky's needle. After entry into the marrowy channel remove mandrin from a needle. Release of pus allows to make the diagnosis of the acute hematogenous Lake. In the absence of pus for 5 min. attach Valdman's device for registration of intra bone pressure to a needle. Normal at children 5 years are more senior it fluctuates within 25 — 80 mm w.g., at acute hematogenous O. — within 100 — 400 mm w.g. These indicators can be received only in the first 4 — 5 days from an onset of the illness — before break of pus in soft tissues, i.e. in the period of an intramedullary stage of process.

Differential diagnosis acute hematogenous O. carry out more often with acute rheumatism, phlegmon of soft tissues, acute deep lymphadenitis, a fracture of a bone at small children, it is more rare — with nek-ry other diseases.

At acute rheumatism (see) process it is from the very beginning localized in a joint whereas at O. in the beginning it has the non-local character, and changes in a joint if appear, then later. At rheumatism the phenomena of polyarthritis are frequent, at O. they are observed only in cases of multiple damage of bones. Besides at rheumatic polyarthritis smaller are surprised more often, than at O., joints, the exudate in them never happens purulent, on roentgenograms there are no destructive changes in bones.

Phlegmon of soft tissues (see Phlegmon), deep acute lymphadenitis (see) especially difficult happens to distinguish from O. which was complicated by intermuscular phlegmon. At primary phlegmon of soft tissues and lymphadenitis the dermahemia and fluctuation come to light usually earlier, than at O., on the roentgenogram there are no changes in bones, however quite often final diagnosis manages to be established only after a section and inspection by the probe of a periosteum.

The fracture of a bone at small children gives a similar picture with acute O.'s beginning as in the first days it is followed by disturbance of the general state, fervescence, and locally — the expressed pain, a swelling, restriction of movements in the affected extremity. Besides, as often the change is subperiostal, the shift of fragments does not occur. Establishment of the correct diagnosis is promoted by careful clarification of the anamnesis and an obsledo-bathtub of the patient. Disturbance of the general state at a change quickly takes place. If on the roentgenogram at the first research the subperiostal change does not manage to be revealed sometimes, then to 6 — to the 8th day in the field of a change the gentle callosity on the limited site of a bone is defined. At O. rentgenol, changes in these terms are absent or are shown in the form of a linear periostitis along all diaphysis. Special diagnostic difficulties arise at the unnoticed change which occurred at the time of delivery, especially to an epifizeo-liza because of similarity of the local changes arising at the same time at epiphyseal O. Opredelit on the roentgenogram the epiphysiolysis at a change at the newborn does not work well with changes due to the lack in an epiphysis (except a knee joint) kernels of ossification. To 6 — to the 8th day in both cases periosteal reaction comes to light, against the background of a cut at epiphyseal O. later there are centers of destruction. At children of advanced age it is practically not necessary to differentiate a change and O.

Great difficulties are presented by differential diagnosis of acute hematogenous (nonspecific) O. with bone and joint tuberculosis if tubercular process is localized in an epiphysis. Tuberculosis of bones occurs at babies seldom. For the correct recognition of these processes resort to a puncture of a joint and bacterial, to a research of pus.

Children of chest age have a wedge, p rentgenol, symptoms of an inborn syphilitic osteochondritis and a pseudoparalysis of Paro have strong likeness with epiphyseal O. Otlichiye is that at a pseudoparalysis of Paro on roentgenograms it is possible to find a symmetric epiphysiolysis of two or several pairs of bones of the same name as at inborn syphilis for 3 — 4 months X-ray contrast kernels of ossification of an epiphysis appear earlier. At children of advanced age acute hematogenous O. sometimes should be differentiated with gummous syphilis of bones. The basis of differential diagnosis in these cases is made rentgenol. a research, bacterial, the analysis of punctate from a joint, Wassermann reaction, existence of other displays of syphilis (see. Syphilis ).

Treatment

three principles formulated by T. P are the cornerstone of modern methods of treatment of acute hematogenous O. Red bayevym: operational treatment of the local center of an inflammation; immediate effect on a disease-producing factor; increase in the general body resistance.

Operational treatment consists in decompressive osteoperforation in 2 — 3 sites of a bone on an extent for the purpose of opening and drainage of the marrowy channel, elimination of the increased intra bone pressure, improvement of blood supply of a bone, prevention of its further necrosis, improvement of a condition of the patient and the termination of pains at it.

Osteoperforation at children is made under the general anesthesia. After an exposure of an affected area of a bone through its cortical layer get into the marrowy canal by means of the electric drill or a trihedral pricker; insert catheters for drainage into educated openings and washing of the marrowy channel. Sometimes it is more reasonable to enter at first into a bone Kassirsky's needle chreskozhno in the field of one of metaphyses with the diagnostic purpose; at allocation from a needle under pressure of blood with droplets of fat or pus that confirms O.'s diagnosis, other needle of Kassirsky punktirut the second metaphysis and through these needles carry out washing of the marrowy channel. Yu. F. Isakov suggested to enter before washing 0,25% solution of novocaine for the purpose of unblocking of osteoreceptors, prevention of neurotrophic osteoporosis, reduction of inflammatory reaction and acceleration of recovery of local exchange processes, and then through one of needles in one step to enter the syringe apprx. 1 l of isotonic solution of sodium chloride with antibiotics. In the next 5 — 7 days intra bone washings repeat 2 times a day the same amount of solution, but carry out it kapelno (90 drops in 1 min.). Proteolytic enzymes can be a part of the entered solution. To substitute decompressive osteoperforation for broad opening of the marrowy channel with removal of a longitudinal fragment of a bone (by trepanation) it is inadmissible since it conducts to a considerable aggravation of symptoms of the patient, promotes dissimination of purulent process and increases risk of a lethal outcome.

Intra bone washings promote bystry and full removal of pus and other decomposition products from a bone, preventing intoxication, provide constant high concentration of antibiotics in a bone, remove a pathological impulsation from the center of defeat and create conditions for acceleration of recovery processes.

Epiphyseal O.'s treatment is carried out by repeated punctures of a joint with suction of an exudate or pus and introduction to a cavity of a joint of antibiotics. The section of soft tissues is shown only at education the paraarticle of yarny phlegmon, edges arises at break of the joint capsule. At the phenomena of purulent arthritis and inefficiency of repeated punctures of a joint make arthrotomy (see) in a point of the greatest fluctuation. Length of a section of the joint capsule at the baby shall not exceed 1 — 2 cm.

All patient with acute hematogenous O. immobilize the affected extremity by imposing of a plaster splint, and for carrying out intra bone washings — by means of Bie's tire of a ler. At children to 2 — 3-year age for an immobilization of the lower extremity impose lipkoplastyrny extension across Sheda, an upper extremity — Dezo's bandage. The immobilization is carried out before full subsiding of the inflammatory phenomena and recovery of function of an extremity.

Immediate effect on acute hematogenous O.'s activators is carried out by means of antibiotics in combination with synthetic chemotherapeutic drugs. Due to the high stability of microbes, first of all to the antibiotics which long ago entered practice, a modern antibioticotherapia of acute hematogenous O. demands the differentiated approach. At prescription of antibiotics the age of the patient, weight of a current and duration of process, existence of the individual intolerance determined by the anamnesis and skin test, an antibacterial range of effect of drugs, sensitivity of microflora to them etc. shall be considered.

The most effective in modern conditions are antibiotics of group r-laktamidov — Penicillin (especially semi-synthetic), the cephalosporins (which are especially influencing gram-negative flora — cefalotin, Cefaloridinum, etc.) and aminoglycosides (gentamycin, Kanamycinum, etc.). High activity in relation to resistant strains of stafilokokk erythromycin, Oleandomycinum, Fusidinum and lincomycin have. The last two have property to collect in the inflamed fabrics and in bones. Due to the toxic properties use to children shall be almost completely excluded at acute purulent processes of tetracyclines, Neomycinum, Monomycinum and streptomycin.

At severe forms of acute hematogenous O., especially in the presence of microbic associations, appoint combinations from 2 — 3 antibiotics that allows to lower them to lay down. doses to prevent formation of stable bacterial forms. At the same time it is impossible to allow combinations of antibiotics of bacteriostatic and bactericidal action.

Doses, frequency and ways of introduction of antibiotics, duration of the general course of treatment are defined by age of the patient and weight of process.

Need of respect for the principle of an etiotropnost in the conditions of high polyresistance of microbes does obligatory definition of the activator and its sensitivity to antibiotics that demands certain time. For the purpose of quick start of causal treatment it is possible to use an approximate method of A. B. Chernomordik: apply on a slide plate and paint across Gram patol, material; within an hour most of patients manages to pick up for quantity, a form and the relation of bacteria to coloring correctly germicides according to the table developed for these purposes (see the tab.).

After carrying out full bacterial, researches make necessary changes to the appointed treatment. For the purpose of timely correction of antibacterial therapy every 7 days make repeated antibiotikogramma.

Increase in the general body resistance is of great importance in complex treatment of the acute hematogenous Lake. It is carried out in several directions, among to-rykh first-priority desintoxication of an organism is (see. Disintoxication therapy ). For desintoxication transfuse blood and apply intravenous infusions of various environments in age doses (solutions of native plasma, 10% solution of albumine, Haemodesum, a hydra of a lysine, Aminopeptidum, etc.), to-rye connect and neutralize toxins, improve peripheric circulation, fill the volume of the circulating blood, and their globulinovy fractions are an additional reserve of development of antibodies. Introduction of Polyglucinum, 10% of solution of glucose with insulin, cocarboxylase, ATP, 2,4% of solution of an Euphyllinum improves metabolism of a myocardium and cordial activity, exerts positive impact on a pulmonary blood stream, etc.

For prevention of thromboses at the phenomena of hypercoagulation appoint to lay down. doses of heparin (200 — 300 PIECES on 1 kg of weight a day), in the presence of acidosis of a dose of heparin increase by 1,5 — 2 times. At the phenomena of hypocoagulation appoint gepari-but-kontrikalovy a complex (a daily dose of heparin of 50 — 100 PIECES on 1 pg the weight, Contrykal — 5000 — 8000 PIECES to 1 kg), and at increase of a fibrinolysis — heparin (50 PIECES to 1 kg) from a kontrik scrap and dry plasma.

Fig. 7. Roentgenograms of a forearm of the child of 11 years, patient with acute hematogenous osteomyelitis: and — before treatment (the site of destruction in a beam bone with periosteal imposings at the level of defeat is visible — it is specified by an arrow); — after timely carried out treatment (almost complete recovery of a form and structure of a bone).

Forecast substantially depends on age of the child, terms of an initiation of treatment and its full value. Optimum results manage to be achieved at children aged 1 years when treatment is begun not later 3 — the 5th day from the moment of a disease are more senior. In these cases inflammatory process stops, the reparative reorganization of a bone leading to recovery of its form and structure (fig. 7) begins. If treatment is begun out of time, then at the end of the 3rd — the beginning of the 4th week signs of transition of acute O. in hron, a stage begin to come to light.

Prevention: early detection and treatment of the centers hron, inflammations at pregnant women; correct gigabyte. care of the newborn, prevention of infection at them an umbilical wound; prevention of emergence at children of any viral infections and inflammatory processes; early identification and timely sanitation at children hron, the pyoinflammatory centers; hardening of children; the correct diet etc.

Acute osteomyelitis after gunshot wounds

Various on character and a wedge, to manifestation the pyoinflammatory processes arising owing to fire injuries of bones designate the conditional term «fire osteomyelitis».

The originality of a course of inflammatory process in a bone wound at fire O. is caused by a complex structure of a wound, existence of functional frustration, extensive sites of the damaged soft tissues, existence of bone fragments, nekrotizirovanny sites of a bone, pollution of a wound foreign bodys and microorganisms. Fire O. arises after insufficient surgical treatment of a wound. All a wedge, a picture in the first weeks of a disease is caused by suppuration of soft tissues. Only further the wound surfaces of a bone are kontaktno involved in inflammatory process. On marrowy spaces and under a periosteum process gradually extends up to a bone.

As the bone wound is widely open in soft tissues, there is no symptom caused by sharp increase in the intra bone pressure so characteristic of the hematogenous Lake expressed about left. Process quickly accepts hron, a current. It is possible to learn about transition of an inflammation to a bone only by audit of a wound with a research of biopsy material or at rentgenol. research.

Fig. 8. The scheme of formation of a bone cavity around bone splinters and foreign bodys at fire osteomyelitis: 1 — the cavity is caused by an arrangement of splinters; 2 — the cavity was formed on site multiple splinters; 3 — the cavity was formed on site shifts of fragments; and — a change — early stages of formation of a cavity, in — late stages of chronic fire osteomyelitis (the created osteomiyelitiche-sky cavities are visible).

Distinguish early and late pyoinflammatory complications of fire fractures of bones. The early complications arising directly after wound are in most cases connected with ichorization of marrow or its purulent inflammation in the marrowy channel and are characterized rough a wedge, a current with the expressed general reactions, as well as at the hematogenous Lake. Late complications (1 — 2 month later after wound) develop usually out of the marrowy channel, hl. obr. in elements of a basic bone tissue; at the same time the expressed otgranicheniye of process and formation of a purulent cavity around dead bone splinters and foreign bodys (fig. 8) is observed. The reparative and regenerative processes bringing to patol, to changes in a look hyperostosis (see) and a sclerosis of a dense bone tissue (see. Osteosclerosis ), make essence of this look a complication and cause transition of its early forms to chronic.

In a wedge, a picture of an acute stage of fire O. the general symptoms prevail (gektichesky fever, the progressing weakness, the accruing hypochromia anemia, a leukocytosis, etc.). Local changes, in itself very essential (progressing is purulent - necrotic process in the field of a fire change, putrefactive character wound separated, dirty-gray plaques on granulations, puffiness and a hyperemia of edges of a wound, etc.), often fade into the background.

Acute fire O.'s recognition is based on set of local and general symptoms. Rentgenol, fire O.'s signs usually appear on 3 — 4th week after wound (see below «Chronic secondary osteomyelitis»). Along with rentgenol, data the great value in fire O.'s diagnosis is gained by radiometry after administration of radioactive strontium ( 85 Sr) and comparative local thermometry.

Prevention fire O. is based on the general principles of prevention of a wound fever, among to-rykh the leading value early and radical surgical treatment of a fire change has (see. Surgical treatment of wounds) with presurgical and postoperative rentgenol, control. Efficiency of surgical treatment increases at the general and topical administration of antibiotics. At insufficiency of primary surgical treatment during the Great Patriotic War secondary processing of fire changes was widely applied.

Treatment acute stage of fire O. complex. The priority in treatment belongs to a radical operative measure. During operation delete devitalized bone fragments, the necrotic center in a bone, than optimum conditions for suppression of an infection in a bone tissue are created. In early stages of O. it is reached timely sequestectomy (see), in late — also removal of edges of a bone cavity with the subsequent washing by its solutions of antiseptic agents. The second element of operation is elimination of a bone cavity by filling with its nearby krovosnabzhayemy fabrics or sealing with its blood clot.

Acute traumatic osteomyelitis

it is close to fire O. on an etiology, a pathogeny and a wedge, costs to a picture inf. the inflammatory process in a bone complicating open changes of not fire origin. Its feature is that the purulent inflammation extends to all departments of a bone without formation of the isolated primary center in marrow. Therefore process is called sometimes an acute posttraumatic osteitis (panosteitis) though use traditional less exact name «traumatic osteomyelitis» more often.

Hit in bone fragments and to development in them exogenous pyogenic flora is promoted by existence of an extensive and deep wound in a zone of injury of a bone. In development of process both other general and local factors matter: immunobiol, reactivity of an organism, virulence of microflora, extent of disturbance of blood circulation in the field of an open change, the splintered nature of a fracture, degree of shift of fragments, a condition of integuments in the field of a change etc. The typical sequence patol, changes at acute traumatic O. is as follows: an open fracture of a bone with deep, strongly contaminated wound; rough suppuration in it; transition of a purulent inflammation to a bone tissue in a zone of a change.

Suppuration of a wound is followed by fervescence and deterioration in the general condition of the patient. Emergence of an ostealgia outside a wound (sometimes on all extremity) demonstrates involvement in suppurative process of a bone tissue. Local changes, as well as at any phlegmonous inflammation, are shown by a hyperemia of an integument, puffiness of soft tissues, considerable purulent separated from depth of a wound. Degree of intoxication preferential depends on prevalence of a purulent inflammation in a bone.

Diagnosis traumatic O. put on the basis of persistent release of pus from a wound, sooogtsayushcheiyeya with bone fragments, and data rentgenol, researches.

Treatment acute stage of traumatic O., as well as fire, complex, in most cases using radical operation, at a cut delete sequesters, nekrotizirovanny bone splinters, purulent granulations, excise fistulas. At not accrete change make an economical resection of bone fragments with the subsequent their reposition. The issue of an immobilization of bone fragments is resolved strictly individually, and preference is given to an extra focal hardware osteosynthesis.

Prevention traumatic O. consists in careful primary surgical treatment of a wound at an open change and in the scrupulous accounting of indications and contraindications to a metalosteosynthesis.

The acute osteomyelitis resulting from transition to a bone of a purulent inflammation from surrounding fabrics, the nek-eye differs in an originality. It begins sometimes imperceptibly at rather long existence of purulent process, especially about the bones adjoining an integument. So O. of a tibial bone begins at a phlegmonous form of an ugly face, O. of a bone phalanx at a hypodermic felon, O. of bones of a calvaria at extensive contaminated wounds of a pilar part of the head with the progressing purulent lysis of an aponeurosis, etc. Jaws and from gene O. of a temporal bone are possible also dontogenous O.

Diagnosis of this type of O. does not cause usually big difficulties. It is necessary to think of its probability when, despite treatment, the contaminated wound adjacent to the surface of a bone, does not find a tendency to healing for a long time or in this area purulent fistulas are formed. At a X-ray analysis usually find changes in a bone, characteristic of O.

Treatment consists in operational removal of sequesters, sanitation of a suppurative focus.

Chronic (secondary) osteomyelitis

Chronic (secondary) osteomyelitis develops upon transition any wedge, acute O.'s forms (hematogenous, fire, traumatic, and also arisen upon transition of purulent process from surrounding fabrics) in hron, a stage. Available in the acute period morfol. and the wedge, distinctions between separate forms O. in hron, stages smooth out, and process proceeds generally equally for all these forms.

Hron. The lake develops in cases when in the first days of a disease narastayushchin acute purulent process manages to lead to a necrosis of the site of a bone tissue. It almost inevitably occurs at an overdue operative measure, napr, carried out after spontaneous break of pus outside. Frequency of transition of acute O. in hron, a stage, according to different researchers, fluctuates from 10 to 40%. Terms of transition depend on many reasons; the great influence on their lengthening is exerted by an antibioticotherapia. It is considered that acute O.'s transition in hron, a stage most often comes during the period from 3 weeks up to 1,5 months from the beginning of a disease.

With confidence it can be diagnosed only in the presence of a triad of signs: purulent fistula, bone sequester and recurrent current.

A clinical picture

In a wedge, chronic (secondary) O.'s current conditionally distinguish three phases: a phase of final transition of acute process in chronic, a phase of remission (zatikhaniye) and a phase of a recurrence (aggravation) of an inflammation.

Upon acute hematogenous O.'s transition to chronic the health of the patient improves, pains gradually weaken. Decrease or at all symptoms of intoxication disappear; body temperature decreases to norm or to subfebrile figures, functions of a respiratory organs and cardiovascular system are normalized; weakness decreases, appetite improves, the dream becomes rather long and deep. At a lab. a research decrease in a leukocytosis, delay of ROE, improvement of indicators of white and red blood is found; in urine the amount of protein and leukocytes decreases.

Fig. 9. The scheme of formation of purulent fistula upon transition of acute hematogenous osteomyelitis of a tibial bone to chronic: 1 — abscess of marrow; 2 — subperiostal abscess; 3 — intermuscular phlegmon; 4 and 5 — stages of independent break of pus with burrowing.

In the field of the center purulent fistulas on site of operational cuts or independently opened phlegmon (fig. 9) are finally created. Fistula proceeds from one osteomiyelitichesky center or from different, can be single or multiple, quite often several fistulas connect with each other in soft tissues, forming complex network of the infected channels. The outside opening of fistula sometimes is located on considerable removal from the osteomiyelitichesky center. The quantity of purulent separated can be a miscellaneous, but the tendency to considerable reduction of suppuration is noticeable. In soft tissues in the field of defeat the inflammatory infiltration which is gradually decreasing in process of transition to a stage of remission remains. In the affected extremity the tutopodvizhnost in the joints adjacent to the osteomiyelitichesky center usually remains, the noticeable curvature and shortening of an extremity can be established.

Fig. 10. The diagrammatic representation of different types of the sequesters (black color) observed at hematogenous osteomyelitis (a cross cut of a tubular bone): 1 — cortical; 2 — central; 3 — getting; 4 — total.
Fig. 11. Diagrammatic representation of options of an arrangement of sequesters: 1 — in a bone cavity; 2 — partially out of a cavity; 3 — out of a cavity.

Process of gradual sequestration in the next weeks, sometimes months, comes to the end with full separation of nekrotizirovanny sites (sequesters) from a healthy bone tissue and formation of a bone cavity. The size and a form of sequesters can be various. At all their variety allocate the following types of sequesters: cortical (cortical) — at a nekrotization of a thin bone plate under a periosteum; central — at necrosis of an endosteal surface of a bone; getting — at a necrosis of all thickness of a compact layer on the site of a bone limited on a circle; total — at a nekrotization of a tubular bone on all its circle, sometimes throughout all bone; circular (coronal) — at a necrosis of a diaphysis but all circle, but on the small site on length (the sequester in the form of a narrow ring); spongy — at necrosis of spongy tissue of long tubular or flat bones.

Most often the central, cortical and getting sequesters (fig. 10) meet. The sequester can entirely or partially be in a bone cavity or be located completely out of it, in soft tissues (fig. 11).

Fig. 12. The diagrammatic representation of the osteomiyelitichesky center and purulent fistula at chronic hematogenous osteomyelitis: 1 — the sequestral capsule; 2 — the sequester in a sequestral box; 3 — a foul place; 4 — the fistular course in muscles; 5 — an outside opening of fistula; 6 — a bone.

Along with sequestration around a bone cavity there is a formation of the sequestral capsule (box), inside a cut usually there are sequesters and pus; internal walls of the capsule are covered with granulations. In the sequestral capsule there are one or several openings (foul places), through to-rye pus from the osteomiyelitichesky center follows in the fistular courses (fig. 12). The sequesters which are in a sequestral box practically do not resolve or this process happens extremely slowly — decades.

Quite often, especially at untimely and insufficiently radical operational treatment hron. The lake, in the struck part of a bone is formed a large number of various size of cavities without sequesters, in to-rykh there are a pus and granulations.

These centers which are diffusion and disseminated in a bone can connect the intra bone narrow infected courses; they are sometimes surrounded with a cover from fibrous fabric. In similar cases the forecast at hron. The lake sharply worsens.

In a phase of remission hron. The lake most of patients notes disappearance of pains and improvement of the general state; body temperature is, as a rule, normalized. From fistulas a small amount of pus is allocated, sometimes they are temporarily closed. By the beginning of this phase processes of sequestration and formation of the sequestral capsule completely come to an end. Duration of remission can proceed from several weeks to many years that depends on size and the number of sequesters, virulence of microbes, a condition of protective forces of an organism and age of the patient, localization of process, etc.

A phase of a recurrence at hron. The island reminds acute O.'s beginning, however inflammatory changes and degree of intoxication are less expressed. To a recurrence hron. The lake most often precedes temporary closure of purulent fistula that leads at first to accumulation of pus in an osteomiyelitichesky cavity, and then to treatment of surrounding soft tissues by it, i.e. to development of a paraossalnoa of intermuscular phlegmon. At a recurrence strengthening of pains in the field of the osteomiyelitichesky center is noted, there is an inflammatory puffiness of fabrics, the dermahemia, a local hyperthermia are frequent, function of an extremity is even more broken. At the same time there are symptoms of purulent intoxication: appetite worsens, increases (to 38 — 39 hail.) body temperature, there are tachycardia, pouring sweat, the leukocytosis increases, ROE accelerates. If phlegmon is timely not opened, can be formed new purulent flow and to amplify the phenomena of intoxication. After opening of phlegmon or break of pus through the opened fistula the condition of the patient quickly improves, local inflammatory process abates, the phase of an aggravation gradually passes again into a phase of remission. Alternation of a recurrence and remissions without the expressed tendency to itself to treatment makes essence patol, process at hron. O.

Complications. The local complications caused are most characteristic of chronic (secondary) O. it is long existing is purulent - destructive process in a bone and surrounding fabrics: emergence of the new osteomiyelitichesky centers, patol, a fracture of a bone, patol, dislocation in the affected joint, development of purulent arthritis and an anchylosis in a joint, formation of a nearthrosis, deformation of an extremity, etc. Especially allocate arrozivny bleeding from large arteries and a possibility of a malignancy in the area it is long the existing osteomiyelitichesky center or purulent fistula. From the general complications the most serious: an amyloidosis of kidneys, dystrophic changes of other parenchymatous bodies and emergence of the septicopyemic centers in various bodies and fabrics.

Diagnosis. A wedge, given at diagnosis of chronic (secondary) O. anamnestic instructions on the postponed acute O., existence of purulent fistula and a recurrent current are main.

The major role in diagnosis hron. Lakes play rentgenol, methods of a research — X-ray analysis (see) and tomography (see), Fistulografiya (see), an arrangement of the fistular courses and their communication with the center allowing to investigate in a bone.

Fig. 13. The roentgenogram of bones of a shin of the patient with osteomyelitis upon transition of a disease to a chronic stage: massive periosteal stratifications (are specified by shooters) and an osteosclerosis in metadiafize are visible to a tibial bone.

At out of time begun or inefficient treatment at the end of the 3rd — the beginning of the 4th week after a disease of acute O. on roentgenograms around the destructive centers against the background of osteoporosis the picture of a diffusion and widespread enostalny osteosclerosis (fig. 13) is found, to-ry sharply differs, e.g., from a narrow zone of an osteosclerosis at a tubercular osteitis. The osteosclerosis extends on a longitudinal axis of a bone, its intensity increases; against the background of a sclerosis the new centers of destruction come to light. The widespread osteosclerosis at O. characterizes transition of process to chronic. Owing to a periosteal and enostalny osteogenesis thickness and density of the affected bone increases.

The formed sequesters concluded in a powerful sequestral box, as a rule, include a most or smaller part of a cortical layer together with sites of spongy substance of a bone. Detection of sequesters is promoted by correctly made contrast research of fistulas (Fistulografiya) with their obligatory hard filling. On the roentgenogram a shadow of the sequester usually more intensively than a shadow of live sites of a bone, it remains invariable at all subsequent researches.

Fig. 14. Roentgenogram of bones of a forearm of the patient with chronic osteomyelitis: the big sequester delimited from a live bone by a light strip of granulyatsionny fabric is visible (it is specified by shooters).
Fig. 15. Fistulogramma of a hip of the patient with the chronic osteomyelitis which arose after an open fracture of a bone: the contrasted fistular courses (1) in soft tissues extending from the center of defeat (2) are visible.

Rentgenol, recognition of sequesters is not always simple. Sometimes the sequester against the background of sharply sclerosed surrounding bone is not defined at all. Diagnosis becomes simpler if the sequester is separated from other bone by the granulyatsionny fabric looking on the roentgenogram as a zone of an enlightenment around it (fig. 14) or when the sequester was partially or completely torn away from a bone went beyond a bone cavity.

Sometimes the inflammation in a bone calms down or is at all liquidated, and process in soft tissues exists independently, supporting existence of fistulas and giving the general a wedge, a picture of a disease. In such cases for an exception of an intra bone inflammation of usual roentgenograms in two projections it appears insufficiently, and quite often it is necessary to resort to a fistulografiya (fig. 15).

Diagnostic difficulties are created at O.'s localization in pelvic bones and a backbone, especially in cases of the wrong antibacterial treatment, at Krom process is suppressed, but does not recover. The big arrays of soft tissues surrounding a basin and a backbone promote formation of abscesses with big purulent zateka, and then and fistulas. The sluggish current of an inflammation in these cases complicates differential diagnosis with tuberculosis and other specific defeats. At O. of a backbone if antibacterial treatment is early begun, one vertebra and an adjacent intervertebral disk suffers; if treatment is late, then the next vertebra and rentgenol is involved in process, the picture differs from a tubercular spondylitis a little (see). In this case more expressed osteosclerosis of the affected bodies of vertebrae (in 1 — 1,5 month from an onset of the illness), smaller perifocal abscess, more frequent involvement in process of arches and shoots of vertebrae testifies to O.

Fig. 16. Roentgenogram of bones of foot and lower third of a shin of the patient with chronic osteomyelitis of a calcaneus: in a calcaneus the multiple centers of destruction (are specified by shooters) with an osteosclerosis around them are visible.

At O. of spongy bones (a wrist, a tarsus) the osteosclerosis of spongy substance with rather neoolypy destructions of a bone (fig. 16) is expressed, however with it is long the existing fistulas.

Fig. 17. Roentgenogram of bones of a shin of the patient with chronic fire osteomyelitis of a tibial bone: the ends of fragments got the rounded-off form, there are massive periosteal stratifications (are specified by shooters), a diffusion osteosclerosis of fragments.

The earliest rentgenol, fire and traumatic chronic O.' signs appear in 3 — 4 weeks after an injury. Its first direct symptom — osteoporosis of viable fragments of bones, to-ry especially clearly is defined if there are devitalized fragments which lost touch with a periosteum and vessels. While the live bone is exposed to osteoporotichesky reorganization, in nekrotizirovanny sites this process does not happen, they can be in not changed look in fabrics for years, supporting an inflammation. Nekrotizirovanny sites more dense in comparison with the porous, kept viability bone look. Other rather precursory symptom of an inflammation in the field of fragments is destruction of their edges owing to what they lose the angularity, a sharp ocherchennost, their contours become indistinct. And, at last, the third precursory symptom of O. — emergence of periosteal stratifications (see. Periostitis ) along the ends of fragments. These stratifications are separated from a bone by the strip of an enlightenment caused by the granulyatsionny fabric expanding between a bone and the exfoliating periosteum. Further these trailer sites of fragments surrounded almost from all directions with inflammatory granulations or pus are most subject to sequestration. Along with sequestration all new and new centers of inflammatory destruction in live sites of a bone appear, around to-rykh against the background of the accruing regional osteoporosis develops characteristic for hron. Lake osteosclerosis (fig. 17).

The formed bone callosity also is involved in an inflammation.

Rentgenol, the research at O. shall be conducted surely before each operative measure, and in the presence of purulent zatek or fistulas to be supplemented with an abstsessografiya (see) or a fistulografiya, with the help to-rykh (on condition of hard filling) it is possible to reveal the hidden sequesters and other sources of suppuration.

Fig. 18. The roentgenogram (a) and a stsintigramma (b) of the tibial bone affected with osteomyelitis: on the roentgenogram symptoms of osteomyelitis are not visible yet; on a stsintigramma the local accumulation of a radioisotope indicating an acute inflammation of a bone is visible; in — the diagrammatic representation of localization of the osteomiyelitichesky center.

A certain role, especially in differential diagnosis hron. The lake and tumors of a bone, begins to play radio-gramophones, a method of a research. Stsintigrafiya (see) after administration of isotopes (a pyrophosphate of technetium or strontium) helps to establish initial signs of inflammatory process and its prevalence in various bones earlier, than the X-ray analysis (fig. 18), however small sequesters and the osteomiyelitichesky centers is easier to find with the help rentgenol, a method.

At a lab. a blood analysis in a phase of remission moderately expressed anemia and a leukocytosis with shift of a formula is found to the left at noticeable acceleration of ROE. The amount of crude protein of blood, as a rule, is in limits of average figures of norm, but the disproteinemia is observed: hypoalbuminemia, giperglobul inemiya (hl. obr. at the expense of a gamma globulino howl fractions) and decrease in proteinaceous coefficient. In a phase of an aggravation there are changes typical for flash of purulent process: hypochromia anemia, a leukocytosis, a neutrocytosis accrue, ROE accelerates, the disproteinemia becomes more expressed.

A research of acid-base equilibrium at hron. The lake quite often points to development in blood of the compensated metabolic acidosis.

The differential diagnosis

Chronic (secondary) O. should be differentiated with tumors of bones, a posttraumatic periostitis, it is rare with specific O. (at syphilis, tuberculosis, an actinomycosis of bones, rheumatism), is even more rare with an intradermal hemangioma, a lymphogranulomatosis, gout, etc.

Earlier differentiation of O. with an osteosarcoma is of especially great importance (see). Gradual increase of symptoms of a disease is characteristic of an osteosarcoma, in the anamnesis there are no clear instructions on the postponed earlier acute O., hurt much more intensively and have constant character, without decreasing even at an immobilization of an extremity; on the roentgenogram destruction of a cortical layer of a bone and amotio of a periosteum in the form of «visor», existence of radially directed periosteal spicules, etc. is noted. At a puncture in a zone of a new growth of a bone receive not purulent exudate, but serous and hemorrhagic liquid, in a cut it is possible to find tumor cells. If the given methods of a research do not allow to otdifferentsirovat hron. Lakes from a tumor of a bone tissue, do biopsy (see).

At posttraumatic a periostitis (see) in the anamnesis there are instructions on the former injury, but not on acute O.; there is no alternation of remissions and a recurrence; fistulas are not present and was not; on roentgenograms there are no characteristic osteomiyelitichessky cavities, sequesters, alternation of sites of an osteosclerosis and osteoporosis, etc. At a lab. blood analyses neither the leukocytosis, nor shift of a leukocytic formula, nor acceleration of ROE, as a rule, is noted.

At syphilitic O. at children 8 — 10-letiy and teenage age the roundish or oval centers of destruction most often are located in a diaphysis and a metadiaphysis of tibial, humeral, femoral bones, is more rare in other tubular bones. At diffusion syphilitic defeat in bones the set of the small centers is observed. Clinically process proceeds without the acute phenomena; fistulas open without serious consequences, being located on symmetric sites of bones. At the acquired syphilis of differentiation existence of other characteristic symptoms of this disease helps (see Syphilis).

Need to differentiate chronic (secondary) O. from tubercular can arise when acute hematogenous O. at the patient from the very beginning proceeded torpidno, without the expressed clinical manifestations and considerable destruction of a bone tissue. The coming atrophy of soft tissues of an extremity is characteristic of tubercular defeat (see Tuberculosis extra pulmonary, a tuberculosis of bones and joints) early; fistulas are surrounded with faded granulations, pus liquid with existence of caseous masses. Rentgenol, (dominance of osteoporosis over an osteosclerosis without the expressed phenomena of a periostitis), biochemical and mikrobiol, researches, specific tuberkulinovy tests help to make the correct diagnosis.

At actinomycotic damage of a bone secondary coccal flora often joins a fungal infection. Destroying actinomycotic druses, it interferes with their identification at mikrobiol, a research whereas itself easily it is found out that complicates differential diagnosis with hron, the nonspecific Lake. For actinomycosis (see) it is characteristic slow subacute a wedge, a current with quite late formation of purulent ulcers, to-rye it is possible to take for usual osteomiyelitichesky fistulas. The authentic diagnosis of an actinomycosis is established at detection in pus or scrapings from ulcers (fistulas) of actinomycotic druses, and also by means of serological tests.

To distinguish hron. The lake from rheumatism (see) rather easily. At rheumatism polyarthritis of small joints is more often observed, and at O. generally large bones are surprised; on roentgenograms at rheumatism there are no destructive changes and reorganization of a bone tissue characteristic for hron. The lake

Treatment

Treatment shall be complex and be carried out taking into account that at hron. The lake local is purulent - necrotic processes in a bone proceed against the background of profound general changes in an organism — intoxication, oppressions immunobiol, protective forces, a disproteinemia, etc. A main objective of treatment — elimination of the center it is purulent - destructive process in a bone tissue — it can be reached only at a combination of a radical operative measure to the rational, directed antimicrobic therapy, activation of immune forces of an organism and to carrying out some other to lay down. actions.

Operational treatment is the main link in appreciate to lay down. actions at hron. The lake as one antimicrobic therapy is not capable to liquidate a suppurative focus in a bone, so far in it remain the infected sequesters and cavities with a purulent detritis. At best it can lead to subsiding of a perifocal purulent inflammation, i.e. to the next unstable remission.

Indications for radical operation: existence of the sequester, osteomiye-lytic cavity, fistula, ulcer; the repeating recurrence of an inflammation with a pain syndrome and dysfunction of a musculoskeletal system; detection patol, changes from the parenchymatous bodies caused hron, intoxication; local malignancy of fabrics, etc.

Relative contraindications for radical operation — a decompensation of activity of kidneys, cardiovascular or respiratory system.

Training of patients for operation shall include to lay down. the actions directed to reduction of the inflammatory phenomena in a zone of defeat (washing of fistulas antiseptic solutions and solutions of proteolytic enzymes, physical therapy, etc.), sanitation of skin of a surgery field, activation of immune responses and desintoxication of an organism, on improvement of functions of vitals and systems.

Radical operations usually carry out under anesthetic. Operation consists in excision of all fistulas (more rare — a scraping of short fistulas), trepanations of a bone with disclosure of an osteomiyelitichesky cavity throughout, a sequestectomy, removal of a cavity of the infected granulations and pus, excision of internal walls of a cavity to not affected bone tissue, repeated washing of a cavity solutions of antiseptic agents (Furacilin, a furagin, Rivanolum, formalin, antibiotics, etc.), plastics of a cavity and mending of a wound tightly.

Fig. 19. Diagrammatic representation of a myoplasty of an osteomiyelitichesky cavity of a humeral bone: and — otseparovan the muscular rag (1) is also entered into a cavity (2); — the muscular rag is strengthened by a seam (3).

During the performance of radical operation various methods of plastics of bone cavities with use of autogenic, allogenic, xenogenic fabrics and endoprostheses are offered (see. Plastic surgeries). The myoplasty, a haemo seal, a chondroplasty and bone plastics are most widespread. Muscular rags find from adjacent muscles with the proximal or distal feeding leg (fig. 19). Use muscles of other extremity less often. Modern modification of a classical way of Shede consists in addition to the blood clot of antibiotics formed in a bone cavity and leading to it of one or several drainages (microirrigators), through to-rye it is possible to carry out irrigations of a cavity antiseptic solutions and drainage (including with use of vacuum devices). For hondro-and osteolasties of bone cavities apply, as a rule, preserved allotkan. The ways offered for plastics of bone cavities have both advantages, and negative sides therefore their choice shall be strictly individual.

At osteomyelitis of flat and small tubular bones, edges, a fibular bone make a resection of a bone within not changed fabrics.

In cases when the cortical sequester is in soft tissues, and radiological existence of destructive changes in a bone tissue is authentically not established, operation is limited to a syringectomy and removal of the sequester without trepanation of a bone.

At a posttraumatic hron. The lake complicated by a pseudoarthrosis necretomy (see) it is possible to add with a resection of a nearthrosis with the subsequent reposition of fragments and imposing of the device for an extra focal compression osteosynthesis (see. Distraktsionno-kompressionnye devices ).

At a recurrence hron. The lake and existence of instructions on development of phlegmon urgent broad opening and drainage of an osteomiyelitichesky cavity in a bone is shown.

From the complications connected with operative measures plentiful bleedings from a bone cavity, a necrosis of the muscular rag used for plastics of a bone cavity, suppuration of hematomas in the field of an operative measure, a necrosis of the skin rags found for cover of a bone tissue meet.

Antimicrobic therapy is an important component of treatment hron. The lake as as if carefully radical operation was performed, it one is not capable to provide sterility of the osteomiyelptiche-sky center. Therefore along with operational carry out intensive antimicrobic treatment, in the course to-rogo are guided by the following rules: at prescription of antibiotics surely consider sensitivity of microflora to them of the patient, give preference with other things being equal to antibiotics with the raised tropnost to a bone tissue (lincomycin, Morphocyclinum, etc.); it is impossible to break the mode of an antibioticotherapia as within a day, and in the period of all course of treatment since it promotes development of an antibiotic of resistant microflora and reduces efficiency of treatment; it is regularly necessary to conduct repeated researches wound separated on microflora and to check sensitivity it to antibiotics, introducing necessary amendments in treatment; for creation of high therapeutic concentration of antibiotics in a zone of operation use various ways of introduction of antibiotics, including intravenous, intra bone, regional intra arterial; it is recommended to apply to more effective suppression of pathogenic microflora at the same time various antibiotics and to combine with them introduction of other germicides (streptocides, nitrofurans, etc.) and immune means.

Immunotherapy hron. The island is carried out taking into account that in most cases an infestant is pathogenic staphylococcus in the form of a monoculture or in association with other pyogenic microbes. Therefore the main in an immunotherapy are specific to the antistafilokokko-Vyya immune drugs, in particular staphylococcal anatoxin, a staphylococcal bacteriophage. In before - and postoperative the periods carrying out a course of injections of staphylococcal anatoxin is shown. The staphylococcal bacteriophage lyseing pathogenic staphylococcus is applied locally and parenterally. In the preoperative period it is used at daily washing of fistulas and the osteomiyelitichesky centers, in postoperative — at irrigation of a bone cavity through microirrigators and drainages. Parenterally staphylococcal bacteriophage is applied in the form of 5 — 6 intramuscular injections on a course of treatment.

At the phenomena of sepsis means of passive specific immunization — hyperimmune antnstafilokokkovy plasma and antistafilokokko vy gamma-globulin are especially shown. At patients with polyanti-bnotikoreziyetentnoy or antibiotikozavisimy microflora at allergic intolerance of antibiotics the autovaccine can be applied. For activation of nonspecific protective forces of an organism in before - and postoperative the periods transfusions of blood, its components, injection of blood substitutes, use of drugs of pirimidinovy derivatives (methyluracil, pentoxyl), etc. are shown to patients.

From others to lay down. actions at hron. Lakes are important a careful immobilization of the operated extremity; local and general enzymotherapy; disintoxication therapy: correlation of protein, mineral, water and electrolytic metabolism; physiotherapeutic procedures; to lay down. physical culture. The great value gets treatment hron. The lake in the conditions of gnotobiologichesky isolation of a zone of defeat.

The physical therapy is applied as supportive application at different stages of treatment hron. O. It is used for stimulation of an osteanagenesis, acceleration of formation of the sequester and also as the soothing, antiinflammatory and desensibilizing factor.

In a phase of a recurrence it is necessary to avoid vigorous influences by physical factors. In this phase in the preoperative period it is reasonable to apply on area of defeat electric field of UVCh cross in an atermpchesky dosage, novoimanpielektroforez cross. On 4 — the 5th day after operation apply electric field of UVCh on the center of defeat, serially having condenser plates cross and longwise; UF-radiation of area of the center and healthy is symmetric also an extremity or segmented zones (collar, lumbar), an electrophoresis of zinc, calcium.

At a zatikhaniye of process for stimulation of regeneration mud or paraffin applications on the affected extremity are shown.

In a phase of remission on area of defeat use of ultrasound in the continuous mode a mobile technique, santimetrovovolnovy therapy, an inductothermy the inductor cable in three rounds, a dose slaboteplovy is rational.

For development of a deep active hyperemia, for prevention of flash of latent infection apply also electric field of UVCh: at first on the center of defeat in a slaboteplovy dosage, then on the symmetric site of a healthy extremity in a thermal dosage; the subsequent procedures give on the center of defeat in a slaboteplovy dosage again or replace them with pulse electric zero UVCh. Also use UF-ob-lucheny of the center of defeat, segmented zones, the general UF-radiation is shown.

Out of a stage of an aggravation also salty pine needle baths every other day, from the fortifying and tempering procedures — douches, rubdowns, air and solar bathtubs are recommended sulphidic (see. Hardening ).

To lay down. the physical culture at O. is applied for the purpose of all-tonic impact, stimulation of trophic processes, reduction of hypo-dynamics and disturbances of a homeostasis; it promotes also increase in force of muscles, recovery of functions of the struck segments of a musculoskeletal system (mobility in joints, an oporosposobnost, household and production motive acts) and the general adaptation to muscle performance.

After the acute hematogenous O. stopped by antibiotics to lay down. the physical culture is appointed at permanent normalization of temperature and involution of changes in a zone of defeat; at hron. Lakes apply it in a phase of remissions.

At the osteomyelitis which developed after opened (including fire) changes, in the course of treatment with ggrimensnny plaster bandages of a pla of komprsssionio-distraktsioiiy devices use a technique to lay down. physical cultures, recommended for treatment of the closed fractures of bones of extremities (see. Changes ).

Fig. 20. Exercise with the dosed axial loading for the right lower extremity: depending on increase in a corner between the inclined plane and a wall the size of axial loading decreases (at the size of a corner 10' loading makes 97% of body weight, 3 0" — M >of %, 5 0 ° — 05%, 70 ° — 34%, 90 ° — 0).
Fig. 21. Exercises with special devices: 1 — for an upper extremity; 2 — for the lower extremity; 3 — for top and bottom extremities at the same time.

At damage of the lower extremities appoint exercises with the dosed axial loading (fig. 20), and also to lay down. swimming and walking. At all localizations patol, process apply gymnastic, applied and household and game exercises, exercises with special devices and shells (fig. 21) in the form of individual and group (small groups) occupations to lay down. and gigabyte. gymnastics and the tasks which are independently performed by patients.

In the final period of treatment use of nek-ry sports exercises — rowing, walking on skis, driving the bicycle, etc. is possible.

Classes are given repeatedly for day. The technique to lay down. physical cultures in all cases is defined by O.'s current and the nature of the applied treatment.

Forecast for life at hron. The lake can consider favorable. The number of the dead from complications hron. Lake (hl. obr. from an amyloidosis of parenchymatous bodies and effects of a malignancy) it is small. The possibility of recovery and a complete recovery of functions of a musculoskeletal system depends on weight of defeat and efficiency of the chosen methods of treatment, in many respects — on timeliness and radicalism of an operative measure.

The good and satisfactory immediate postoperative result, according to most of researchers, is reached at 70 — 90% of patients hron. O. Kolichestvo of a recurrence in the remote terms is marked out at 15 — 30% of the operated patients.

Prevention — rational treatment of an acute stage of the Lake. Crucial importance at the same time diagnosing, hospitalization of the patient in a surgical hospital and early begun complex (first of all, operational) have early (better in the first 3 days) treatment.

Primary and chronic osteomyelitis

Atypical forms O., unlike chronic (secondary) O., from the very beginning proceed subacutely or stages are found already in hron.

Sclerosing osteomyelitis of Garre (it is described in 1893) begins subacutely and it is characterized by extremity pains, is more often night, disturbance of its function, moderate temperature increase, a leukocytosis and acceleration of ROE.

Fig. 22. The roentgenogram of a shin of the patient Garre sclerosing osteomyelitis: the tibial bone is veretenoobrazno thickened due to periosteal stratifications (it is specified by an arrow), the marrowy channel is narrowed owing to an endosteal osteosclerosis.

An average third of a diaphysis of a bone at men at the age of 20 — 30 years is surprised more often. Radiological the spindle-shaped thickening of a diaphysis throughout 8 — 12 cm due to the expressed dense homogeneous compact periosteal stratifications is found. At the level of defeat also the endosteal osteogenesis, as a rule, is found, for the account to-rogo a bone it is condensed, the marrowy channel is narrowed (fig. 22). Sometimes bone defeat is followed by a dense swelling of soft tissues, over a cut the expanded venous network can be visible what forces to suspect sarcoma. Therefore rentgenol. diagnosis is of particular importance. The found clinically myagkotkanny tumor at rentgenol. a research has no symptoms of bone sarcoma. Periosteal stratifications have equal smooth contours, density of a bone in sites of defeat evenly of a diffuzn that is not characteristic of sarcoma. Such O. sometimes call tumorous. At gistol, a research are found, generally dystrophic changes of marrow with its fibrous substitution.

Fibrous substitution of marrow in general is characteristic of all hron, inflammatory processes, especially in a phase of an outcome. Apparently, the descriptions of the so-called fibrous osteomyelitis diagnosed in this stage which are found in literature are also explained by it.

Albuminous osteomyelitis of Ollye (it is described in 1864) from the very beginning proceeds with minor local changes on an extremity in the form of small infiltration of soft tissues and a weak dermahemia. In primary osteomiyelitiche-sky focus there is no suppuration, instead of pus in the center serous liquid rich with protein or mucin (that was reflected in the name of this form O.) accumulates, from a cut sometimes it is possible to sow staphylococcus and a streptococcus. The disease sometimes is complicated by destruction of a bone with formation of sequesters or secondary accession of a purulent infection.

In practice of specialized to lay down. the institutions which are engaged in bone and joint pathology one more form hron quite often meets. The lake — a Brodie's abscess. Morphologically it represents a smooth-bore bone cavity of rounded shape, 1,5 in size — 5 cm, the putreform or serous liquid covered by the fibrous capsule, sometimes with pristenochny granulations, containing. The course of a disease sluggish, torpid, is diagnosed sometimes in many years (see. Brody abscess ).

Hron. The lake can develop in the course of prolonged treatment of the patient with antibiotics concerning any disease. In this case O. from the very beginning proceeds inertly, without the expressed pain syndrome and a hyperthermia, with a moderate leukocytosis in blood and acceleration of ROE. Paraossalny phlegmons and fistulas, as a rule, are not formed. In a bone tissue the small osteomiyelitichesky centers, alternation of sites of osteoporosis and a sclerosis are found.

Posttyphoid O. — the collective name of a special form O., to-ry begins soon after transferring various inf. diseases (is more often belly and a sapropyra, a paratyphoid, flu, scarlet fever) or at the end of their current. Is caused by usually nonspecific pyogenic microflora, it is extremely rare — the activator postponed inf. diseases. Virulence of microbes is, as a rule, reduced therefore the course of wasps-teomiyelitichesky process usually sluggish, without the expressed local changes, pains and temperature reaction. On roentgenograms the center of destruction of oblong shape is found in a bast layer, with periosteal reaction. Further it is filled with a bone tissue, suppuration and sequestration usually does not occur. At paratyphoid and smallpox O. (a smallpox osteoarthritis) the centers of destruction are localized in an epiphysis of long tubular bones and can cause (though it is rare) formation of ankiloz. Posttyphoid O. can proceed and is subacute, with considerable pains (usually night), with formation of sequesters and fistulas.

Diagnosis of atypical forms of per-vichno-chronic O. is based on the anamnesis, a wedge, a picture and rentgenol, researches, substantially characteristic of each of these diseases. Treatment is carried out by the same principles, as treatment of the chronic (secondary) Lake. In the absence of sequesters and fistulas conservative treatment is shown.

Tubercular O. is observed in spongy bones with myeloid marrow. Process arises in marrow, is more rare in a periosteum and is characterized by tuberculation and growth of granulyatsionny fabric. Sometimes there is a necrosis of a bone tissue and formation of the sequester. Caseous and fungozny forms of a disease are observed (see Tuberculosis extra pulmonary, a tuberculosis of bones and joints).

Syphilitic O. can be observed in all stages of the acquired and inborn syphilis, but most often in the III stage. As a rule, process begins in a periosteum from where passes to a bone and marrow.

Painful night ostealgias are characteristic of syphilitic damages of bones. At ekssudativ - but - an infiltrative form of syphilis on roentgenograms of bones the ossifying osteoperiostitis with a sharp thickening of a bone is usually observed (an osteosclerosis, sometimes with considerable eburnation).

At a gummous and destructive form of a gumma are more often localized in a diaphysis of a tibial bone, in bones of an upper extremity, a skull and the person. Quite often the eye-socket, etc. collapses Nov. At accession of consecutive infection extensive necroses with sequestration of a bone can be observed.

Diffusion osteoperiostites of long tubular bones at inborn syphilis at children sharply deform a bone, edges gets a form of a saber.

It is necessary to differentiate syphilitic O. with tubercular O., Garre's osteomyelitis, from fibrous osteodystrophy (see).

Treatment — specific antisyphilitic; in the presence of sequesters — operational.

Table. INDICATIVE INDICATIONS FOR PURPOSE of ANTIMICROBIC MEANS DEPENDING ON MORPHOLOGY of MIKROFLORA FOUND IN the SMEARS PAINTED ACCORDING TO GRAM FROM PATHOLOGICAL MATERIAL of PATIENTS WITH ACUTE HEMATOGENOUS OSTEOMYELITIS (according to A. B. Chernomordik)




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B. I. Struchkov, I. D. Kanorsky; N. A. Vladimirova (fizioter.), V. M. Derzhavin (it is put. hir.), V. K. Dobrovolsky (to lay down. physical.), P.JI. Zharkov (rents.), M. I. Lytkin (soldier.), A. V. Smolyannikov (stalemate. An.).

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