IV. Table of contents of teaching

Osteomyelitis is an infectious disease, characterized inflammation of bone tissue with engaging in the pathological process of marrow, compact part of bone, periosteum and quite often surrounding soft tissues.

Exciters are staphylococcus, streptococcus and other microorganisms. An infection can get to marrow of hematogenous by a way from some inflammatory hearth (hematogenous, or primary, osteomyelities) or directly from purulent wound at a injuring (traumatic, or second, osteomyelities).

Most frequent localization of hematogenous osteomyelities: tibia, lower third of thigh-bone and humeral.

An infection, getting in a marrowy channel, causes an acute bone brain fever with purulent his subsequent melting. Leave to rot from a marrowy channel through Hawers channels passes through a bone and saved under a periosteum. At the same time there is a defeat of bone matter, vessels of which trombed, that results in numbness of bone tissue. The purulent-necrotic area of bone (sequestrum) is delimited from healthy a granulation billow, what results in formation of cavity, surrounding a sequestrum (sequestral box). In the case of destruction of periosteum purulent content spreads in surrounding tissues, forming a osteomyelitic phlegmon. An abscess can be unsealed independently, purulent fistulas appear.

Clinical picture. For acute hematogenous osteomyelities a clinic is characterized those, that during 1-2 days general indisposition, dull ache in extremities, muscle pains, head pain, is marked. Then a shocking chill appears with the proof increase of temperature to 39 °C and higher, weakness, brokenness, sometimes vomiting. The general state becomes heavy, consciousness is darkened, a delirium, symptoms of irritation of brain-tunics, appear. A face becomes pale, eyes fall back, lips of cyanotic, a skin is dry, with an icteric tint, turgor it goes down. Arterial pressure is lowered. Breathing is speeded up, superficial. A liver and spleen is increased, painful. In urine is an albumen, cylinders, in blood is leucocytosis, neutrophilosis, decline of eosinophils and monocytes, anaemia grows. Great pain which is increased at motion appears in normal extremity. On 3-4th days the sickly slight swelling of soft tissues, moderate redness of skin, edema, local increase of temperature appears in the area of defeat, fluctuation appears. Roentgenologic changes are marked on the average in 10 days and characterized removing a layer by the layer of the thickened periosteum.

Chronic osteomyelities arises up as a result of acute. He shows up the periodic intensifying of inflammatory process. Intensifying is accompanied the increase of temperature, proceeding in pain in the hearth of suppuration, edema of tissues, reddening of skin, by formation of fistulas with a selection from them leaving to rot sequestra. Destruction is roentgenologic determined of bone sequestral small boxes with a presence, sequestra, a bulge and deformation of bone. Chronic osteomyelities, being investigation acute, is named second chronic osteomyelities.

Treatment.At acute osteomyelities appoint antibiotics (sometimes they are entered by endosteal in the area of the staggered bone), disintoxicational therapy. At formation of abscess he is unsealed. At presence of pus in a marrowy channel make trepanation of bone. At chronic osteomyelities treatment is operative; unseal a sequestral box, delete a sequestrum, a cavity is purged from granulations. A wound is sewn up tight with the subsequent sucking of content of sequestral cavity and introduction of antibiotics. Sometimes a cavity is filled the biological filling – muscle on a skin. After calming down of intensifying a good effect is given by sanatorium-resort treatment.

Along with acute and chronic hematogenous osteomyelities considered higher there are rare forms of hematogenous osteomyelitiшс process, which are incorporated under the name initially-chronic osteomyelities , in connection with that a disease from the beginning flows atypical (subacute or in general revealed already in the chronic stage). To these forms behave: abscess of Brodie, sclerosed osteomyelities of Garre, albuminous osteomyelities of Ollje.

Endosteal abscess of Brodie is the limited necrosis of spongy matter of bone with subsequent its melting and formation of cavity. The last is filled a festering, serous or with blood liquid, sometimes in it find tissue detritus. An exciter in most cases is staphylococcus. A process is localized more frequent in the proximal area of tibia. This type of osteomyelities а is pathogenetically related to the littlevirulent infection and lowered reactivity of organism.

Clinical displays. There is the limited sensitiveness at pressing on on a bone, however quite often hearths show up nothing and pain arises up only sometimes – at night, after physical tension, at the change of weather. The increase of temperature of body, chill and other general symptoms, is usually absent. Meet, however, and forms with the periodic intensifying, increase of body temperature, reddening of skin, sickliness at pressing on and motions. A process can last by years, the periods of intensifying are replaced temporal remission. Examination usually of little informative; in more expressed cases find a bulge in area of metaphysis, the reactive phenomena are not uncommon in a joint.

On radiographs it is possible to see in spongy part a metaphysis cavity by a diameter 2-2,5 sm, rounded or oval form. Surrounded the well expressed area of sclerosis as a narrow or wide border; on the surface of bone tender periostitis impositions are visible quite often. The basic method of treatment of abscess is surgical. Make trepanation of cavity, scrape an internal wall. A wound is taken in tight. At large cavities apply muscle the plastic arts.

Sclerosed osteomyelities of Garre begins subacute, without acute pains in extremity or expressed inflammatory phenomena. Phlegmons and purulent fistulas appear extremely rarely. The flow of inflammatory process is languid, clinically it is characterized pains in extremity, more frequent nightly, by violation of its function, moderate increase of temperature of body, blood-sedimentation and leucocytosis, the feature of this form of osteomyelities а is the acutely expressed sclerosis of the staggered bone (more frequent long tubular), determined roentgenologic. On a background a sclerosis there are small hearths of discharging of bone tissue, a костномозговой channel in course of time is narrowed and can fully sclerose; диафиз of bone is fusiform thickened at the same time.

Basic type of treatment — conservative with introduction of antibiotics (lincomycin, semisynthetic penicillins), electrophoresis of trypsin and application of physical therapy treatment (microwave therapy). Surgical treatment is directed on the delete of great number of shallow osteomyelitic hearths.

Albuminous osteomyelities of Ollje from the beginning flows without the expressed picture of infectious disease, with insignificant local changes extremity as small infiltration of soft tissues and weak hyperemia of skin. At this form of disease in place of pus serous is saved in a osteomyelitic hearth, rich in squirrel or mucin liquid, that got a reflection in the name. At sowing of liquid staphylococcus and streptococcus discover sometimes. Pathogeny of albuminous osteomyelities а is not quite clear. Apparently, because of small virulence of microflora, high level immunobiological protective forces of organism or on some to other reasons in primary hematogenous osteomyelitic focus there is not suppuration. Inflammation remains on the stage of exudation, in this connection there is a serous or mucous liquid in a osteomyelitic cavity. The languid flow of disease is sometimes complicated bone destruction with formation of sequestra or second joining of purulent infection.

Treatment of albuminous osteomyelities а is surgical, his purpose is liquidation of hearth of chronic purulent inflammation.