PERIOSTITIS (periostitis; grech, peri around, near + osteon a bone + — itis) — an inflammation of a periosteum. The item — a widespread disease. On a wedge, to P.'s current divide on acute (subacute) and chronic; on a pathoanatomical picture, and partly and on an etiology — on idle time, or vulgar, fibrous, purulent, albuminous (mucous, serous), ossifying, tubercular, syphilitic.
Inflammatory process usually begins in internal or a periblast periosteums (see) also extends then to its other layers. Owing to close connection between a periosteum and a bone inflammatory process easily passes from one fabric to another. Solution of a question of existence at present P. or osteoperiostitis (see) it is represented difficult.
A simple periostitis — acute aseptic inflammatory process, at Krom the hyperemia, an insignificant thickening and serous and cellular infiltration of a periosteum are observed. Develops after bruises, changes (traumatic P.), and also near the inflammatory centers which are localized, e.g., in a bone, muscles etc. Is followed by pains on the limited site and a swelling. Most often the periosteum on sites of the bones which are poorly protected by soft tissues is surprised (e.g., a front surface of a tibial bone). Inflammatory process mostly quickly abates, but can sometimes give fibrous growths or be followed by adjournment of lime and a new growth of a bone tissue — osteophytes (see) — transition to the ossifying Item. Treatment at the beginning of process antiinflammatory (cold, rest and so forth), further — topical administration of thermal procedures. At severe pains and the dragged-out process apply an ionophoresis with novocaine, a diathermy and so forth.
The fibrous periostitis develops gradually and flows chronically; it is shown by the calloused fibrous thickening of a periosteum which is densely soldered to a bone; arises under the influence of the irritations lasting for years. The most essential role in formation of fibrous connecting fabric is played by a periblast of a periosteum. This form P. is observed, e.g., on a tibial bone in cases hron, ulcers of a shin, at a necrosis of a bone, hron, an inflammation of joints and so forth.
Considerable development of fibrous fabric can lead to superficial destruction of a bone. In certain cases, at the considerable duration of process, the new growth of a bone tissue and thus direct transition to the ossifying Item is noted. After elimination of an irritant involution of process is usually observed.
A purulent periostitis — a frequent form P. It develops usually as a result of the infection getting at wound of a periosteum or from the next bodies (e.g., P. of a jaw at caries of teeth, transition of inflammatory process from a bone to a periosteum), but can arise also in the hematogenous way (e.g., metastatic P. at a pyemia); purulent P.'s cases at which it is not possible to find a source of an infection are noted. The activator is purulent, sometimes anaerobic microflora. Purulent P. — an obligatory component acute purulent osteomyelitis (see).
Purulent P. begins with a hyperemia, serous or fibrinous exudate, then there comes purulent infiltration of a periosteum. The hyperemic, juicy, reinforced periosteum in such cases easily separates from a bone. The loose inner layer of a periosteum becomes impregnated with pus which then skoplyatsya between a periosteum and a bone, forming subperiosteal abscess. At considerable distribution of process the periosteum exfoliates on a considerable extent that can lead to disturbance of food of a bone and its superficial necrosis; the considerable necroses occupying the whole sites of a bone or all bone come only when pus, following on the course of vessels in gaversovy channels, gets into marrowy cavities. Inflammatory process can stop in the development (especially during timely removal of pus or at independent break it outside through skin) or to pass to surrounding soft tissues (see. Phlegmon ) and on substance of a bone (see. Osteitis ). At metastatic P. the periosteum of any long tubular bone (most often hips, a tibial bone, a humeral bone) or at the same time several bones usually is surprised.
Purulent P.'s beginning usually acute, with temperature increase to 38 — 39 °, from oznoba and increase in number of leukocytes in blood (to 10 000 — 15 000). In the field of the center of defeat severe pains, on an affected area the swelling, painful is probed at a palpation. At the continuing accumulation of pus usually soon it is possible to note fluctuation; surrounding soft tissues and integuments can be involved in process. The course of process in most cases acute, though cases primary and long, hron, currents, especially at the weakened patients are noted. The erased clinical picture without high temperature and the expressed local phenomena is sometimes observed.
Nek-ry researchers allocate an acute form P. — malignant, or the most acute, to the Item. At it exudate quickly becomes putrefactive; bulked up, gray-green color, a dirty look the periosteum is easily torn to shreds, breaks up. In the shortest possible time the bone loses a periosteum and is shrouded in a layer of pus. After break of a periosteum purulent or it is purulent - putrefactive inflammatory process passes as phlegmon to people around soft tkank. The malignant form can be followed by a septicopyemia (see. Sepsis ). The forecast in such cases very heavy.
In initial stages of process use of antibiotics both locally, and parenterally is shown; in the absence of effect — early opening of a suppurative focus. Sometimes for reduction of tension of fabrics resort to cuts even before detection of fluctuation.
Albuminous (serous, mucous) the periostitis is for the first time described by A. Ponce and L. Oilier. It is inflammatory process in a periosteum with formation of the exudate accumulating podnadkostnichno and having an appearance of the serous and mucous (viscous) liquid rich with albumine; in it separate flakes of fibrin, not numerous purulent little bodies and cells in a condition of obesity, erythrocytes, sometimes a pigment and fatty drops are found. Exudate is surrounded with granulyatsionny fabric of brown-red color. Outside granulyatsionny fabric together with exudate is covered with a dense cover and reminds the cyst sitting on a bone, at localization on a skull can simulate brain hernia. The amount of exudate sometimes reaches two liters. It usually is under a periosteum or in the form of a cystic bag in the periosteum, can even skoplyatsya on its outer surface; in the latter case diffuse edematous swelling of surrounding soft tissues is observed. If exudate is under a periosteum, it exfoliates, the bone is bared and there can sometimes come its necrosis with the cavities executed by granulations with small sequesters. A part of researchers allocates this P. as a separate form, the majority considers it the special form of purulent P. caused by microorganisms with is weakened-non by virulence. In exudate find the same activators, as at purulent P.; in some cases crops of exudate remain sterile; there is an assumption that at the same time the activator is the tubercular stick. Purulent process is localized usually in the ends of a diaphysis of long tubular bones, most often a femur, is more rare — bones of a shin, a humeral bone, edges; young men get sick usually.
Often the disease develops after an injury. On a certain site there is a painful swelling, temperature increases in the beginning, but soon becomes normal. At localization of process in a joint disturbance of its function can be observed. In the beginning the swelling of a dense consistence, but eventually it can be softened and is more or less clear flyuktuirovat. Current subacute or chronic.
The differential diagnosis of albuminous P. is most difficult and sarcomas (see). Unlike the last at albuminous P. rentgenol. changes in bones in large part of cases are absent or are poorly expressed. At a puncture of the center of P. punctate usually represents transparent viscous liquid of light yellow color.
Opening of a cavity and removal of all struck fabrics is in most cases recommended. Cystic educations delete entirely with a cover without disturbance of its integrity.
An ossifying periostitis — very frequent form hron, inflammations of a periosteum, developing at long irritations of a periosteum and characterized by formation of a new bone from hyperemic and intensively proliferating inner layer of a periosteum. This process independent or more often accompanying an inflammation in surrounding fabrics. In the proliferating inner layer of a periosteum ossiform fabric develops; in this fabric there is an adjournment of lime and formation of bone substance which balochka pass preferential normally to the surface main bone. Such osteogenesis in large part of cases happens on the limited site. Growths of a bone tissue have an appearance of separate warty or needle eminences; they are called osteophytes. Diffusion development of osteophytes conducts to the general thickening of a bone (see. Hyperostosis ), and the surface accepts it the most various outlines. Considerable development of a bone causes education at it an additional layer. Sometimes as a result of hyperostoses the bone is thickened to the enormous sizes, develop to «an elephant odobnya» of a thickening.
Ossifying P. develops in circles of inflammatory or necrotic processes in a bone (e.g., in the field of osteomyelitis), under chronic varicose ulcers of a shin, iod the chronic inflamed pleura, in a circle of the inflammatory changed joints, is less expressed at tuberculous focuses in a cortical layer of a bone, in a little bigger degree at defeat by tuberculosis of a diaphysis of bones, in considerable sizes at the acquired and inborn syphilis. Reactive ossifying P.'s development at tumors of bones, rickets, hron is known, to jaundice. Ossifying generalized P.'s phenomena are characteristic of a so-called disease of Bamberger — Mari (see. Bambergera — Mari a periostosis ). Ossifying P.'s phenomena can join to to a cephalhematoma (see).
After the termination of the irritations causing ossifying P.'s phenomena, the further osteogenesis stops; in dense compact osteophytes there can be an internal reorganization of a bone (medullization), and fabric accepts character of a spongy bone. Sometimes ossifying P. leads to formation of synostoses (see. Synostosis ), most often between bodies of two next vertebrae, between tibial bones, is more rare between bones of a wrist and a tarsus.
Treatment shall be directed to basic process.
Tubercular periostitis. The isolated primary tubercular P. meets seldom. Tubercular process at a superficial arrangement of the center into bones can pass to a periosteum. Damage of a periosteum is possible also in the hematogenous way. Granulyatsionny fabric develops in an inner periosteal layer, is exposed to curdled regeneration or purulent fusion and destroys a periosteum. Under a periosteum find a necrosis of a bone; its surface becomes uneven, rough. Tubercular P. is most often localized on edges and bones of a facial skull where it in considerable number of cases is primary. At damage of a periosteum of an edge process usually quickly extends on its all length. Granulyatsionny growths at damage of a periosteum of phalanxes can cause the same bottle-shaped swelling of fingers, as at a tubercular osteoperiostitis of phalanxes — spina ventosa (see). Process often meets at children's age. Tubercular P.'s current chronic, often with formation of fistulas, allocation of putreform masses. Treatment — - by rules of treatment of tuberculosis of bones (see. Tuberculosis extra pulmonary, tuberculosis of bones and joints ).
Syphilitic periostitis. The vast majority of defeats of bone system at syphilis begins and localized in a periosteum. These changes are noted both at inborn, and at the acquired syphilis. On the nature of changes syphilitic P. happens ossifying and gummous. At newborns with inborn syphilis ossifying P.'s cases with localization it in the field of a diaphysis of bones are noted; the bone can be left without any changes. In case of hard proceeding syphilitic osteochondrites ossifying P. has also enimetafizar-ny localization though periosteal reaction is expressed much more weakly, than on a diaphysis. Ossifying P. at inborn syphilis arises in many bones of a skeleton, and usually changes are symmetric. More often and most sharply these changes are found on long tubular bones of upper extremities, on tibial and ileal bones, to a lesser extent on femoral and fibular bones. Changes at late inborn syphilis in essence differ from the changes inherent to the acquired syphilis a little.
Changes of a periosteum at the acquired syphilis can be found already in the secondary period. They develop or directly after the phenomena of a hyperemia preceding the period of rashes or along with later returns of syphilides (is more often than pustular) the secondary period; these changes happen in the form of the passing periosteal swellings which are not reaching the considerable sizes and are followed by sharp flying pains. The greatest intensity and prevalence of change of a periosteum are reached in the tertiary period, and the combination of the gummous and ossifying Item is often observed.
Ossifying P. in the tertiary period of syphilis has considerable distribution. On L. Ashoffu, the pathoanatomical picture P. has no anything characteristic of syphilis though at gistol, a research sometimes it is possible to find in drugs of a picture of miliary and submiliary gummas. Characteristic of syphilis is P.'s localization — most often in long tubular bones, especially in tibial and in bones of a skull.
In general this process is localized mainly on a surface and edges of the bones which are poorly covered with soft tissues.
Ossifying P. can initially develop, without gummous changes in a bone, or represent reactive process at a gumma of a periosteum or bone; quite often on one bone is available gummous, on another — an ossifying inflammation. As a result of P. limited hyperostoses (syphilitic exostoses, or nodes) develop, to-rye are observed especially often on a tibial bone and are the cornerstone of typical night pains or form diffusion diffuse hyperostoses. Ossifying syphilitic P.'s cases are noted, at Krom around tubular bones the multilayer bone covers separated from a bast layer of a bone by a layer of porous (brain) substance are formed.
At syphilitic P. the severe, becoming aggravated at night pains are frequent. At a palpation find the limited dense elastic swelling having the spindle-shaped or round form; in other cases the swelling is more extensive and has a flatness. It is covered with not changed skin and connected with the subject bone; at palpation it considerable morbidity is noted. The current and the result of process can vary. The organization and ossification of infiltrate with new growths of a bone tissue is most often observed. An optimum outcome is the rassasyvaniye of infiltrate, observable more often in fresh cases, and there is only an insignificant thickening of a periosteum. In rare instances at a rapid and acute current the purulent inflammation of a periosteum develops, process takes usually and surrounding soft tissues, with a perforation of skin and an exit of pus outside.
At gummous P. gummas — flat elastic thickenings, in a varying degree painful, on a section of a jellylike consistence, the periosteums having the starting point the inner layer develop. Meet as the isolated gummas, and diffusion gummous infiltration. Gummas develop most often in bones of a calvaria (especially in frontal and parietal), on a breast, a tibial bone, a clavicle. At diffusion gummous P. long time can not be changes from skin, and then with bone defects not changed skin plunges into deep hollows. It is observed on a tibial bone, a clavicle, a breast. Further gummas can resolve and be replaced with cicatricial fabric, but they are more often in the latest stages are exposed to fatty, curdled or purulent fusion, and in process surrounding soft tissues, and also skin are involved. Fusion of skin on a certain site and break of contents of a gumma outside with formation of an ulcer surface results, and at the subsequent healing and wrinkling of an ulcer the involved hems soldered to the subject bone are formed. Around the gummous center usually considerable phenomena of ossifying P. with a reactive osteogenesis are found, and sometimes they act into the forefront and can hide the main patol, process — a gumma.
Treatment specific (see. Syphilis ). In case of break of a gumma outside with ulceration, existence of bone defeats (necrosis) an operative measure can be required.
A periostitis at other diseases. At smallpox P. of a diaphysis of long tubular bones with their corresponding thickenings is described, and this phenomenon is observed usually in the period of reconvalescence. At a sapa the centers limited hron, inflammations of a periosteum are noted. At a leprosy infiltrates in a periosteum are described; besides, at leprose patients on tubular bones owing to hron. Items can be formed spindle-shaped swellings. At gonorrhea inflammatory infiltrates in a periosteum are observed, during the progressing of process — with purulent separated. The expressed P. is described at zymonematoses of long tubular bones, diseases of edges after a sapropyra in the form of limited dense thickenings of a periosteum of smooth contours are possible, Local P. meets at a varicosity of deep veins of a shin, at varicose ulcers. Rheumatic granulomas of bones can be followed by the Item. Most often process is localized in small tubular bones — metacarpal and plusnevy, and also in the main phalanxes; rheumatic P. are inclined to a recurrence. Sometimes at a disease of the hemopoietic bodies, especially at leukemia, note insignificant by the sizes P. At a disease to Gosha (see. to Gosha disease ) periosteal thickenings preferential around a distal half of a hip are described. At long walking and run there can be P. of a tibial bone. Cruel pains, especially in distal parts of a shin, amplifying during the walking and exercises and abating at rest are characteristic of this P. The limited swelling in connection with puffiness of a periosteum, very painful is locally visible at a palpation. P. at an actinomycosis is described.
Radiodiagnosis. Rentgenol, a research reveals localization, prevalence, a form, the sizes, the nature of structure, an outline of periosteal stratifications, their relationship with a bast layer of a bone and surrounding fabrics. Radiological distinguish linear, fringed, pectineal, lacy, layered, needle and other look periosteal stratifications. Chronic, slowly current processes in a bone, especially inflammatory, usually cause more massive beddings, as a rule, merging with the main bone that conducts to a thickening of a cortical layer and increase in volume of a bone (fig. 1). Quickly proceeding processes lead to peeling of a periosteum the pus spreading between it and a cortical layer, inflammatory or tumoral infiltrate. It can be observed at acute osteomyelitis, Ewing's tumor (see. Ewing Opukhol ), to a reticulosarcoma (see). The linear strip of a new bone seen in these cases on the roentgenogram formed by a periosteum appears the strip of an enlightenment (fig. 2) separated from a cortical layer. At uneven development of process of such strips of a new bone can be a little therefore the picture of so-called layered («bulbous») periosteal beddings (fig. 3) is formed. Smooth, equal periosteal stratifications accompany cross pathological funkts, reorganization. At acute inflammatory process when under a periosteum pus under big pressure accumulates, the periosteum can be broken off, and on sites of gaps the bone continues to be produced, giving a picture of an uneven, «fragmentary» fringe (fig. 4) on the roentgenogram.
With a growth of a malignant tumor in a metaphysis of a long tubular bone the periosteal reactive osteogenesis over a tumor is almost as the tumor grows quickly not expressed and the periosteum which is pushed aside by it does not manage to form a new reactive bone. Only in regional sites where growth of a tumor more slowly in comparison with central, periosteal stratifications in the form of a so-called visor manage to be created. With a slow growth of a tumor (e.g., osteoblastoclastomas) the periosteum is gradually pushed aside by it and periosteal stratifications manage to be created; the bone is gradually thickened, as if blown up»; at the same time its integrity remains.
In differential diagnosis of periosteal stratifications it must be kept in mind normal anatomic educations, napr, tuberosity of bones, interosseous crests, projections of skin folds (e.g., on the upper edge of a clavicle) which did not merge with the main bone of an apophysis (on the upper edge of a wing of an ileal bone), etc. It is also not necessary to take for P. ossification of sinews of muscles at places of their attachment to bones. It is not possible to differentiate separate forms P. only on a X-ray pattern.
See also Bone .
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V. Ya. Shlapobersky; P. L. Zharkov (rents.).