Acute hematogenous osteomyelitis

Description:

As the suffering of the person connected with damage of bones osteomyelitis is mentioned in Hippocrates's compositions, however actually the term "osteomyelitis" introduced Raynod in 1831 for the first time. Long time dominating was reasonable opinion that the process essence is captured more precisely by the term "panosteitis", considering bystry involvement in process of all departments of a bone, including a periosteum. In recent years the frequency of so-called obryvny options of this pathology, that is bystry stopping of inflammatory process increased at early (to 3 weeks of a disease) surgical sanitation of a focus of the disease. In these cases it is rather frequent (to 30% of observations), even at the most careful radiological inspection, it is not possible to reveal at least the minimum macroscopic pathological changes of a bone and a periostitis. This circumstance allowed to assume that the osteitis and a periostitis are the osteomyelitis complications (that is marrow inflammations) arising for various reasons main of which — the late beginning of complex treatment. Therefore stopping of inflammatory process in a myelitis stage (so-called phlegmons of marrow) would be reasonable to be read out from the practical point of view ideal medical and diagnostic tactics.

Thus, it is necessary to understand an acute purulent inflammation of marrow, bone as acute hematogenous osteomyelitis and subjects of soft tissues of various etiology. Acute hematogenous osteomyelitis at children proceeds with various pathoanatomical changes and in some cases can lead to orthopedic deformation of the affected bone.

Symptoms of Acute hematogenous osteomyelitis:

The clinical picture at newborns and children of the first year of life hayorakterizutsya most often by rapid development of inflammatory process, an ukhudyosheniye of the general state, emergence of purulent metastasises. However in posledyony years often the disease is shown with erased clinical priznakayom, especially against the background of an antibioticotherapia.

The beginning of a disease is characterized by uneasy behavior of the child, lack of appetite, pallor of integuments, increase in a temperatuyora to 39 °. At the same time or later a small period the lekalny symptomatology poyavlyayotsya: the child spares a sore extremity (a pseudoparalysis symptom), restriction of mobility in a joint, pain reaction on the passive movements is observed, swelled, sometimes the sosudiyosty drawing. In 2-3 days all perechisyolenny symptoms become more vyrayozhenny. Hypostasis from a joint extends to all extremity, reactive вы­пот in a joint becomes purulent, forming subperiostal abscess.

In many cases when OHO at children of a younger age group inadequate treatment on a poyovoda of other disease is not distinguished or carried out, gnoyyony metastasises appear. Especially often the zapushchennoyom to osteomyelitis is accompanied by septic pneumonia with characteristic clinical and radiological signs. In otdelyyony cases secondary BDL with unilateral is observed or bilateral porazheyoniy Purulent metastasises can be also localized in other bones, in a sredyony ear, in soft tissues, etc.

Acute hematogenous osteomyelitis.

The disease begins suddenly without harbingers with increase in a tempeyoratura till 39-40 °. At the same time there is gradually amplifying affected extremity pain (in a metaphysis of a tubular bone, in a body of a flat bone) which quickly leads to disturbance of its function. In several hours from the beginning of a disease of pain happen so strong that force the child to get sick in a bed. He refuses to load an extremity, loses a dream. At objective survey in an initial stage of a disease the contracture of muscles of the affected extremity, moderate bending in a joint turns on themselves vnimayony and sharp strengthening of pains at the passive movements in it is mute. At an easy palpayotion and effleurage it is possible to find local morbidity in the field of the metaphysis involved in inflammatory process In 2 days, and in otdelyyony cases a little earlier, hypostasis of soft tissues, svidetelstvuyuyoshchiya about spread of an infection podnadkostnichno develops and on a marrowy kayonal For 4-6 days of border of hypostasis extend to an average third of a diaphysis, skin becomes hyperemic, the venous drawing is visible. In later terms hypostasis of all extremity is observed.

At septicopyemic and toksikoseptichesky forms of a disease the general state most of all suffers because of the accruing intoxication of Nayochavsheesya excitement soon is replaced by an adynamia, stupefaction respiratory insufficiency which reason "the shokoyovy lung" is Develops. Skin has a marble, spotty appearance with hemorrhagic rash.

Sharply the ABP and a diuresis  If not to take urgent measures for treatment decreases, then such patients are waited by a failure.

It is the most difficult to reveal localization of the osteomiyelitichesky center in the bones forming a hip joint. At OHO neck of a femur, a body of ileal, pubic and sciatic bones clinical manifestations happen quite similar. The severe pain in a hip extending to a knee joint, high temperature to 39,5 ° is characteristic of all specified localizations. It is very important to note position of an extremity. At defeat of a proximal metaphysis of a hip the extremity is in the provision of moderate bending and an otyovedeniye If the osteomiyelitichesky center is localized in the bones forming an acetabular hollow early there is an expressed flexion contracture, assignment of a hip and rotation of a knaruzha. Inflammatory process quickly perekhoyodit on a hip joint. Therefore there are painful points at a palpation in an upper corner of a skarpovsky triangle, in midpoint between  an anterosuperior awn and a big spit. Hypostasis of soft tissues in a joint develops rather late (for 5-7 days) and is shown by a sglazhenyonost of inguinal and buttock folds, increase in volume of an upper third of a hip. During this period septic metastasises in lungs can appear. At a joint puncture from a front or side surface it is possible to receive pus. X-ray inspection gives the chance to find narrowing of a susyotavny crack, distenzionny dislocation or an incomplete dislocation.

Reasons of Acute hematogenous osteomyelitis:

Causative agents of acute hematogenous osteomyelitis children can have various microorganisms: aerobes (golden staphylococcus, hemolitic streptococcus, etc.), anaerobe bacterias, viruses. Results of own researches and the analysis of data of literature demonstrate that the main causative agent of this disease is golden staphylococcus. Most often (to 40% of cases) this activator is found in patients of chest age with acute hematogenous epiphyseal osteomyelitis. The important role in etiologies of the disseminated forms of acute hematogenous osteomyelitis which are followed by development of system reaction of an organism is played by gram-negative flora (a pyocyanic stick, proteas, a salmonella, etc.) which frequency of detection makes 25,9%.

Neklostridialny anaerobe bacterias can be causative agents of acute hematogenous osteomyelitis, especially in case of increase in permeability of gistogematogenny barriers at deterioration in a local blood-groove, low redox potential in fabrics, a metabolic acidosis and fabric destruction. Activation of obligate microflora at children usually arises against the background of immunodeficiency. Frequency of detection of neklostridialny anaerobe bacterias averages 40%, from them bacteroids — 72% of cases, peptokokk — 28%. In 97% of researches sporeless anaerobe bacterias come to light in association with aerobic flora (generally with pathogenic staphylococcus, Proteus, a pyocyanic stick).

Important etiological factor of acute hematogenous osteomyelitis children in 40–50% of observations can have viral infections against the background of which the disease develops. Viruses suppress protective forces of an organism and promote increase in virulence of microorganisms.

Key link of a pathogeny of acute hematogenous osteomyelitis is formation of the center of an acute inflammation in a bone which is characterized by a complex of standard vascular and fabric changes. Formation of the systematized ideas of an etiology and a pathogeny of osteomyelitis began with vascular, or embolic, the theory which was offered by E. Lexer (1884). According to the embolic theory, in emergence and development of osteomyelitis in children anatomic age features of blood supply and a structure of bones have great value. About the epiphyseal line (the most frequent localization of the center of defeat at children of younger age) vessels in the growing bone come to an end blindly, without connecting with each other. Existence of dense network promotes considerable delay of a blood flow and a mechanical delay of a bacterial embolus in one of trailer vessels. The settled embolus causes blood supply disturbance, development of an inflammation and a necrosis of a bone tissue. Further the bacteriological research of marrowy punctate allowed to make the conclusion that the microbic obsemenennost of the departments of a marrowy cavity which are not changed earlier proceeds from the main center in a metaphysis. Exactly from there is a throwing of an infekt in below - and overlying departments of a bone to which there correspond borders of hypostasis of soft tissues. At the same time features of blood supply of metaepiphyseal zones of tubular bones are leveled by 12 months of life, as distinguishes osteomyelitis at children of early age from that at seniors. The embolic theory explains a pathogeny secondary, or metastatic, osteomyelitis which is quite often observed at a septicopyemia of any nature. At the same time the source of bacteremia is easily identified. It usually is primary inflammatory center which was complicated by sepsis. Children of the first three months of life such centers can have an omphalitis, piogenic dermatitis, a coloenteritis, etc.

The embolic theory not fully explains sudden, against the background of full health, the beginning of primary acute hematogenous osteomyelitis which developed without any previous inflammatory disease. Wide recognition in the middle of the 20th century was gained by the neuroreflex theory according to which pathological irradiation from the center of inflammatory process is connected with sharp irritation of the interoretseptorny device of a bone and its reflex influence on a condition of TsNS and cardiovascular system. At the same time an effective agent of pathological osteoreception is the sharp increase in intra bone pressure caused by various reasons. This theory matters in an explanation of emergence of pathological process in a bone, in understanding of development of a number of pathological reactions from vitals. Neurogenic frustration formation of generators patholologically is the cornerstone of the strengthened excitement. Physical and chemical factors, cicatricial deformations, and also the cascade of enzymes of hydrolysis of phospholipids, excess formation of arachidonic acid and its metabolites belong to number of the influences causing formation of generators patholologically of the strengthened excitement. These processes are activated in the conditions of thrombosis, ischemia of a bone tissue in dynamics of development of acute hematogenous osteomyelitis. Besides, emergence of generators patholologically of the strengthened excitement is promoted by endogenous biologically active agents: pro-oxidizers, hydroperoxides, products of fosfolipazny hydrolysis, the strengthened peroxide oxidation of lipids, nitrogen oxide.

In the analysis of features of a pathogeny of acute hematogenous osteomyelitis a decisive circumstance which should be taken into account is the known feature of red marrow is long to hold the various microorganisms capable under the influence of various factors quickly to recover the life activity (I. S. Vengerovsky, 1952). Persistention of microorganisms in marrow can proceed for a long time (days, months, years), that is tranzitorny bacteremia from any center of an infection, including hidden, can be implemented through the term, uncertain on duration, by an acute inflammation of marrow. Time when process begins, is defined by provocative factors and a condition of a macroorganism. Necessary starting conditions for development of an acute inflammation of marrow are explained by the allergic theory of S. M. Derizhanov (1937, 1940). This researcher created experimental model of hematogenous osteomyelitis in which the area of damage of a bone was defined by localization of traumatic influence. The allergic theory proves that in an osteomyelitis pathogeny the important role belongs to a hyperreactivity and a sensitization of an organism.

Thus, the main factors in a pathogeny of acute hematogenous osteomyelitis are the previous tranzitorny bacteremia from the infection center (more often endogenous) and a sensitization of an organism of any nature against the background of which sensitivity of vascular system to external irritants sharply increases. At the same time the insignificant reason in the form of a slight injury, overcooling is capable to lead to a resistant vasospasm of marrow, its long hypoxia, destruction of macrophages, dysfunction of biological membranes, "release" of microorganisms and the beginning of inflammatory process.

At newborns and babies the most significant risk factors of development of acute hematogenous osteomyelitis are: 1) an adverse premorbidal background (inflammatory diseases of mother, the burdened pregnancy and childbirth, a pre-natal hypoxia and infection of a fruit); 2) perinatal damage of the central nervous system; 3) invasive medical manipulations in the early post-natal period.

The pre-natal infection is one of the reasons of perinatal development of acute hematogenous osteomyelitis in children up to three months, generalization of inflammatory process and lethal outcomes. For a fruit any microflora which got to a circulatory bed of a maternal organism in the endogenous or exogenous way can become pathogenic. Endogenous sources of microflora (an umbilical wound and umbilical vessels, skin, mucous membranes of respiratory tracts and a digestive tract) are one of risk factors of development of hematogenous osteomyelitis. However in most cases pathological process at the newborn develops as a result of the bacteremia caused by implementation of microorganisms through an umbilical wound or after catheterization of an umbilical vein.

At children 1 years the contributing and provocative factors of development of acute hematogenous osteomyelitis are more senior the centers of the latent or dozing infection in carious teeth, almonds, adenoides are. Action of nonspecific factors of damage on the child's organism, in particular the injury and overcooling, are followed by phase changes of nature of inflammatory reaction in a bone tissue: the aseptic form of inflammatory reaction consistently is replaced bacterial and toxic and immunoallergic.

Treatment of Acute hematogenous osteomyelitis:

The principles of complex treatment of acute hematogenous osteomyelitis at children were developed by T. P. Krasnobayev in 1925, however so far did not lose the practical value. Medical actions consist of three components: 1) topical treatment — surgical sanitation of all centers of an inflammation; 2) antibacterial therapy taking into account a type of the pathogenic activator and its sensitivity to himiopreparata; 3) impact on a macroorganism — correction of the broken homeostasis parameters.

Topical treatment provides early sanitation of the osteomiyelitichesky center. Despite the lack of unanimity of views concerning character and the volume of an operative measure, frezevy osteoperforation remains by the main surgical method of treatment. A main objective of osteoperforation — elimination of the increased intra bone pressure. At newborns and babies with metaepiphyseal osteomyelitis use a puncture method of topical treatment of purulent arthritis with evacuation of exudate and washing of a cavity of a joint antibiotic solution. At metafizarny localization of process children up to 5 years have no unambiguous opinion on need of opening of the intra bone center (osteoperforation). Nevertheless osteoperforation in early terms of a disease (up to 3 weeks) at children is more senior than year is possible and effective. Operation has to be executed in most sparing way and least destroy structure of a joint and bone.

The immobilization is an important component of complex treatment of acute hematogenous osteomyelitis, especially at children of younger age. However use of a strict immobilization at favorable disease has to be short-term (4–8 weeks) to avoid disturbance of blood circulation, an atrophy of muscles, the phenomena of osteoporosis, decrease in reparative processes.

Concerning the principles of antibacterial therapy, it should be noted that the choice of antibacterial drug is defined by sensitivity of microflora, a tropnost, compatibility with other drugs and toxicity for the child's organism. Before identification of the activator it is recommended to resort to antibiotics of a tsefalosporinovy number of the third or fourth generation in combination with Nitazolum drugs. Recently there was a set of antibiotikorezistentny forms of microorganisms that explains the fact of an atypical course of acute hematogenous osteomyelitis at children of early age. The last accepts character subacute, significantly complicating timely diagnosis in the absence of accurate clinical and radiological manifestations.

Correction of a homeostasis includes recovery of a system hemodynamics and perfusion of fabrics (inotropic and volemichesky support for increase in cordial emission and delivery of oxygen); respiratory support; nutritive support; correction of an immunological state; intensive disintoxication care.

In a complex of detoksikatsionny actions the wide range of active methods of intensive extracorporal care is applied. The preference of various methods of gravitational surgery is caused by many reasons, the main of them — availability and technical equipment of medical institution. The developed traditions at scientific medical schools matter: use exchange (a cytapheresis, a plasma exchange) or membrane technologies (a hemodialysis, ultrafiltration, hemodiafiltration, etc.), physical and chemical methods of an intrakorporalny and extracorporal destrukturization of toxic substances, beginning from photomodification of blood and biological liquids up to indirect electrochemical oxidation of blood.

The complex of medical actions can be added with physical therapy and stimulates with the differentiated immunocorrection directed to various links of system of anti-infectious resistance that reduces an exudation phase proliferation, activates T-system of lymphocytes, normalizes kallikrein-kinin system. As purposeful correction of activation of processes of free radical oxidation and antioxidant system include vitamins E in a complex of medical actions, With, Unithiolum and membranostabilizator (fatty emulsions, Essentiale, etc.).