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Causes and symptoms of acute and chronic osteomyelitis

What is osteomyelitis?

Osteomyelitis is an infectious inflammation of all components of bone tissue: bones, periosteum and bone marrow. However, it suffers not only bone but also marrow, the soft component increases and swells. Hard shell begins to put pressure on tissue, resulting in compressed blood vessels, and there is a loss of blood flow to the damaged area. This, in turn, often causes destructive processes. But if the pathogen penetrates beyond the bone, for example, in muscles, it may develop an abscess – cavity filled with pus.

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Symptoms of osteomyelitis

The most dangerous osteomyelitis, the cause of which is internal infection. The disease develops only 2 days. During those days the symptoms are hardly noticeable. Possibly a General malaise, muscle pain, discomfort in joints, the person does not even suspect that he develops osteomyelitis. Then body temperature rises up to forty degrees. There is a strong pain in the affected bone. When the pain increases, movement becomes limited. The disease develops quickly. Very often, this whole process is accompanied by a sharp deterioration, nausea and urge to vomit.

The main danger of occurrence of asymptomatic osteomyelitis – the lack of treatment and the possible transition of the disease from the local in generalized form, the acute stage to the chronic. Therefore, any unusual sensations, fever without other accompanying symptoms require diagnosis and investigation.

Osteomyelitis toxic form of the disease is falling the pressurefelt heart pain, possible convulsions and loss of consciousness. The face becomes pale, the eyes sink, the skin turns yellow, the lips are cyanotic. The appearance of the traumatic form of osteomyelitis is very important to consult a doctor, otherwise the person may die.

For traumatic osteomyelitis characterized by acute symptoms. Possible high fever, and severe pain inthe region of injury, after which all these symptoms, replaced chronic. The person feels more or less normal, different pus are derived through the fistulous passages, which occur in the area of the wound and are the primary cause of traumatic osteomyelitis. A severe form of osteomyelitis can result in the contamination of the blood.

Clinical manifestations of osteomyelitis are divided into two types:

  • local;
  • generalized.

For local the disease is characterized by the following symptoms:

  • The increase in body temperature to 38.5 degrees.
  • The formation of lumps, elevations of the damaged area.
  • Aches, pain, wearing a bursting character.
  • The skin on the problem area heats up and turns red.
  • The appearance of abscesses.
  • Pus through the skin.
  • Pain and limited movement.

Generalized form shows a few other signs:

  • the temperature rises to 39-40 degrees;
  • the pain intensifies, acquires the character of a constant;
  • increases the overall toxicity (General bad feeling);
  • there is a fever, clammy sweat, hoarse shortness of breath;

  • neurological damage (convulsions, delirium, loss of consciousness);

  • disorders in the kidneys (painful and frequent urination);

  • pale skin.

Causes of osteomyelitis

The main pathogens of acute osteomyelitis is Staphylococcus, but other bacteria, Rickettsia and some mushrooms that fall into the bone tissue and trigger onset of the disease.

The main "fault" lies on Golden staph, but also disease can cause some Escherichia coli, hemolytic Streptococcus and Pseudomonas aeruginosa. The disease may be called as a single pathogen, pathogenic microorganisms.

In order to start the inflammatory process is necessary some factors: predisposing and triggering mechanisms.

The factors that predispose to osteomyelitis include:

  • hidden infections;

  • allergic diseases;

  • the weakening of the immuneprotection;
  • physical exhaustion;
  • a long period of starvation and lack of nutrients in the body.

The mechanisms that "trigger" the disease:

  • various injuries;

  • burn injury and frostbite;

  • SARS;
  • excessive exercise;

  • violations of the General emotional state (stress, prolonged burnout).

There are three ways of infection:

  • through the blood supply;
  • direct contact with pathogens (e.g., burns, trauma);
  • the transition of infection from adjacent parts of the body.

Risk factors include:

  • tuberculosis;

  • ulcer;
  • injury;
  • any damage caused by thermal burns;
  • circulatory disorders;
  • infectious diseases of the sinuses, oral cavity, dental diseases;

  • Diabetes;

  • oncological diseases and their treatment (chemotherapy);

  • surgery.

In infants and younger children often occurs hematogenous ("born of blood") osteomyelitis. Of the source of infection – for example, from the patient's tooth – germs get into the bone marrow canal of the long bones of the arms or legs. Rarely osteomyelitis caused by infection of the soft tissues, which passes into the surrounding bone. One of the causes of osteomyelitis may be an open fracture, in this case the infection penetrates through the ragged wound in the bone.

What causes osteomyelitis, experts do not know till now. There are three theories concerning the mechanisms of development of disease (vascular, neuro-reflex, allergic), but none of them confirmed enough to be true.


Acute osteomyelitis

Depending on which way penetrated the pathogen in the tissue, acute osteomyelitis is divided into endogenous and exogenous form. Endogenous (hematogenous or) type is characterized by any infection through the bloodstream from other foci of the disease under the influence of the starting factors.

Exogenous to mind are:

  • pin;
  • post traumatic;
  • firearms;
  • the postoperative.

Acute hematogenous osteomyelitis

Method of infection – the "classic"skid pathogenic bacteria in the blood vessels inside the bone, resulting in and there is a primary lesion of the disease. Most at risk are children aged 3 to 15 years, but also often occurs in infants, middle-aged and elderly. Hematogenous osteomyelitis is more striking in males and most often in the period from spring to autumn. Special"love" hematogenous form has for long bones: femur, tibia, humerus.

The nature of the disease distinguish 4 forms of hematogenous osteomyelitis:

  1. Breakage, the best and easiest form. In this period the organism activates all protective functions and recovery system and removes the lesion for 2-3 months.

  2. Lingering, which lasts much longer break off, up to 6-8 months. But, though the healing process is long, the disease eventually retreats.

  3. Lightning, the most severe and unpredictable form of occurrence of hematogenous osteomyelitis. This files most often triggered by a staphylococcal infection and is characterized by a one-time release into the blood of the decay products of bacteria (in this case, endogenous). The strength of the influence of the emissions is such that in a matter of minutes the blood pressure is reduced almost to zero. And without providing urgent, immediate care comes death.

  4. Chronic, prolonged course more than 8 months. Characterized by relapses (spike disease) and remissions (the attenuation of inflammation). Often accompanied by the formation of a sequestrum is a special necrotic tissue, which prolong the inflammation. Formed fistulas, which open according to the recurrences and closed during remission. Chronic stage can lead to muscle atrophy and amyloidosis (disruption in the body's protein metabolism).

There is another form of primary chronic, which is increasingly common in recent years.

Experts attribute the increase in the number of cases of people with this form of osteomyelitis with the following factors:

  • with the wrong food;
  • with insufficient intake of important micronutrients in the human body;
  • with poorer over the last decades, the environmental situation;
  • with the irrational and widespread use of antibacterialmeans;
  • with limitations in motor activity.

The primary chronic form is divided into the following types:

  • Brodie abscess;
  • albuminuria;
  • antibiotic;
  • sclerosing.

Primary chronic osteomyelitis is characterized with sluggish flow, which complicates the formulation of the correct diagnosis.

Acute odontogenic osteomyelitis

Odontogenic type, represents infection of the jaw bones with the formation of purulent-necrotic process. The vast majority of patients with this form of osteomyelitis is men aged over 35 years. More likely to develop lesions of the lower jaw, up to 85 %, upper 15%, with damage of the maxillary tissues is much easier.

Among the causes are:

  • the General decrease in immunity;
  • errors during surgical dental intervention;
  • diseases of a dental nature (cyst of teeth, periodontitis);

  • nasal disease (sinusitis, etmoidit, sinusitis);

  • the metabolic disorders;
  • a sharp increase in the number of conditionally pathogenic microorganisms;
  • direct infection due to injury and thermal damage.

The disease is accompanied by the formation of small hemorrhages due to thrombosis of blood vessels of bone tissue. Because of this begin to appear purulent lesions of various sizes, and is triggered by the death of individual tissues. In addition, there are often isolated foci of necrosis, in this case we talk about diseases of odontogenic osteomyelitis.

The disease is manifested by acute pain with intense dedication in the temples, sinus, forehead. Starts to hurt that side of the jaw, which is the source of infection. The body temperature rises, there could be excessive sweating, chills and a General disturbance of health.

Chronic osteomyelitis

In the case of a running acute osteomyelitis, delayed response occurs subacute period, which is converted into the chronic stage. It is characterized primarily by termdiseases, significantly exceeding 2-3 months to 8-12 months, sometimes several years. In the chronic form there is the formation of sequesters and fistulas. Observed sequential change of exacerbations and attenuation of the disease.

Chronic odontogenic osteomyelitis

Roughly a week after the beginning of acute odontogenic osteomyelitis develops subacute phase, which after 3-5 days becomes a chronic condition. The reasons for the transition of the disease from acute stage to chronic:

  • the total decrease in the protective forces of the organism;
  • hypothermia;
  • fatigue;
  • acute respiratory disease;
  • incorrect actions in the elimination of acute odontogenic period.

Symptoms:

  • increased low-grade (around 37.5 C) temperature;
  • slight malaise and weakness;
  • fistulas and sequestrations;
  • pus and sometimes small sections of dead tissue through the fistulous opening;
  • the lack of sleep.

On radiographic images and the CT scan clearly shows the alternation of the healthy tissue areas with foci of damage of various shapes and sizes.

Hematogenous chronic osteomyelitis

When moving the acute stage to subacute and then chronic, the temperature drops to subfebrile figures, sometimes normal. Disappears severe pain. The affected area is sealed, restricted movement and swelling. In the area where there was a surgical incision, formed a fistula through which pus. Sometimes there is a spontaneous rupture of the tissues with subsequent formation of multiple fistulas. Often they exist for months and even years. Formed single large sequesters or small group education dead tissue.

If the pus does not find out and accumulates under the soft tissue in the area occurs swelling, the skin becomes hot to the touch and is red, there is pain and fever. When the fistula opens and pus comes out, the symptoms disappear.

To diagnose used x-ray that can detect changes already at 12-14 days after the end of the acute phase. At this stage of disease is very informative method of fistulography, which is a CT scan using contrast substance. The clear image allows to determine the size of the sequestrum, their localization, the overall severity of the disease.


How serious is osteomyelitis?

After the doctor make a diagnosis, carried out qualifiedconsultation, patients wrongly assume that osteomyelitis is a simple inflammation which has affected a small area of bone and absolutely does not affect other processes in the body. Therefore, the person does not understand the seriousness of the arising of the disease, not serious about treatment, which leads to serious complications and sometimes even death. For this reason, it is necessary to explain to the patient how the disease is dangerous and what consequences it may lead.

Special attention should be paid to the fact that during osteomyelitis significantly worsens the liver and kidney, there is a General depletion of the body, worsening the work of the immune system. It happens that a person dies is not from the osteomyelitis, and from diseases that they caused, especially when it affects those organs, and that to this disease was not very well.


Diagnosis of osteomyelitis

During the inspection carried out careful palpation (feeling with the fingers) of the affected area, showing the condition of the skin (hot, there is redness and swelling, the formation of wavelike motion of tissue) and the General appearance of the damaged area (stretched skin, glossy Shine, and swelling). With careful percussion (tapping) determine the source of infection for the increased pain in a particular place swelling.

In addition to the evaluation of clinical manifestations and manual inspection apply laboratory methods:

  • Common blood test with leukocyte formula in expanded form shows the shift to the left. This means that inflammation in the body caused by a bacterial nature. For its suppression the responsibility of the neutrophils, of which there are 4 forms (segmented, band, young neutrophils and myelocytes). When the sliding formula to the left marked increase of segmented neutrophils and the appearance of band of individuals. The sharper and heavier the infection, the more young forms of neutrophils appear in the analysis. In addition, parameters such as ESR – erythrocyte sedimentation rate, levels of haemoglobin and platelets reveal the nature of the disease.

  • Urinalysis shows the presence of inflammation and renal failure (in case of generalized forms of the disease) by the appearance of protein to the increase of some indicators.

  • Biochemical andnaliz blood showsthe inflammatory process and said kidney and liver failure. This changes the parameters of bilirubinand protein, reduces the rate of glucose, and the amount of some items is increasing.

Along with the laboratory methods used instrumental methods of examination:

  • Ultrasound is used to assess the size and shape of muscle destruction.
  • Infrared scanning can show the presence of sharp hidden forms of osteomyelitis, defining areas with elevated temperatures.
  • Radiography is the most common diagnosis of osteomyelitis. The snapshot feature can determine the localization of the necrotic processes, the volume and severity of infectious focus. With the help of x-rays can detect disease in its early stages. The growth of inflammation is changing the nature of the images in the pictures, so the time of the disease can be described with high accuracy.
  • Computed tomography is the most informative method of diagnosis of osteomyelitis in any of its manifestations. With the help of three-dimensional images can be obtained not only data on the localization and intensity of infection, but also to create a reconstruction of the surrounding muscle tissue and to predict the course of the disease.

For accurate diagnosis, which is crucial in the treatment of osteomyelitis, a combination of laboratory and instrumental methods of research.


How is the treatment?

Events for the treatment of osteomyelitis should be comprehensive and conducted in a timely manner. Requires constant monitoring of the disease dynamics, as the flow often accompanied by unpredictable complications and variations of the lesions. For a thorough rejection of all forms of osteomyelitis recommended simultaneous drug therapy, surgical intervention and complex physiotherapy.

The principles of medical (conservative) treatment

Highlights: treatment of osteomyelitis only medicines without the intervention of surgical practice does not lead to the expected result. On the contrary, lack of concentration of antibacterial drugs provokes mutations of pathogens, whereupon they become resistant to drug therapy.

With intraosseous infusion of a mixture of saline and antibiotics with an infection and is washed around it creates a barrier that prevents the spread of the pathogen outside of the affected area. Andlavage helps to reduce pressure in the bone tissue, remove pus and relieve pain.

The antibacterial drug is selected which kind of bacteria is pathogen sensitive. The medicine is inserted inside the bone cavity and used the course in 1-2 months. In some cases, the duration of antibiotic use is extended: up to 3-4 months. In General, the period of antibiotic therapy is determined by the severity and nature of the disease.

Important points:

  • During treatment, it is recommended to immobilization (limitation) of the damaged area using special tools. And in General, minimize physical activity.
  • In the case of a long course of drug therapy antibiotics used means to increase the overall resistance of the organism. To do this, hold infusion (intravenous) infusion of special solutions, the use of blood products.
  • In cases of severe lesions connected UV exposure to blood.
  • In the event of sepsis a number of measures to cleanse the blood and lymphatic system from toxins.
  • In the process of treatment careful monitoring of electrolyte balance in the body.

The complex treatment and physical exercise may be applied only after the withdrawal of the patient from the acute period of disease and pain. With the help of physiotherapy is the restoration of function of damaged areas, the activity is stimulated by muscle tissue, the affected area gets the nutrients and vitamins.

Surgical treatment

Surgery is impossible for concomitant diseases in decompensirovanny stage: possible complications more serious than osteomyelitis.

Indications for surgery for osteomyelitis:

  • atypical form;
  • purulent processes;
  • diffuse purulent inflammation (cellulitis) of the periosteum;
  • formed sequesters;
  • fistula;
  • the repeated recurrence of the disease.

The basic rule – you must remove the purulent focus, regardless of its size. Preoperative preparation includes detoxification, the introduction of drugs that support the immune system, examination of metabolism and, if necessary, application of corrective agents.

Surgical intervention is performed under the system-wideanesthesia. Each operation involves specific stages depending on the end goal and desired result.

But overall, the surgery looks like this:

  1. First, by means of antiseptics is processed by the visible operating field and validate the tools.

  2. To assess the effect of anesthesia and in a satisfactory condition performed the first incision.

  3. By successive incisions, the surgeon reaches the site of infection, which in most cases has an intraosseous location.

  4. Using special tools open bone area directly above the fireplace that is commensurate with the inflammation. If there are signs of purulent inflammation diffuse form, first eliminated pus formation.

  5. The next stage is the drilling of small holes, reminiscent of the location rectangle elongated shape. Then use the electric surgical jig holes are connected by a slit, and the result is a bone plate, which is removed. Open the bottom of the bone-marrow channel, where he focused the focus of osteomyelitis.

  6. The channel is washed through antiseptic solutions, it is inserted into the drainage tube with side arm openings and the free edge, which is fixed outside of the cut.

  7. The final phase – the wound closure in layers.

After the operation using the installed drainage perform lavage of the cavity with antibacterial solutions and evaluate the content: if the discharge indicate the purity of the intraosseous cavity, a second opening of the wound and replacement of the drainage area striated fabric with attached container for supplies (surgical plastic). This is to prevent recurrent osteomyelitis. And drainage installed already in the soft tissues. In the course of healing it is removed.

Treatment of gunshot and chronic posttraumatic osteomyelitis

At the forefront in the treatment of gunshot osteomyelitis of origin is prompt radical intervention, which eliminated foreign objects, bone fragments and dying tissue. Then the area around the wound is exposed to the "having" antibacterial drugs, and is performed as required drainage. At the end of the operational actions the patient receives therapy with antimicrobial agents, complex vitamin injections and measures to remove toxins from the body.

Chronic post-traumaticform of osteomyelitis is often complicated by defects (fractures, shortening of bones, false joints). Mainly for the elimination of fistula and the joining of bone fragments used in the method of osteosynthesis, which consists in accurate fixing broken plots in the correct anatomical position for subsequent adhesions. In the case of the formation of cellulitis performed the autopsy of the lesion, removal of pus and necrosis, the necessary drainage of the cavity.

Physical therapy for osteomyelitis

After surgery a course of physical therapy to the affected area may be conducted not earlier than 20 days after the operation. However, other parts of the body not involved in the operation, need a movement. Therefore, twice daily for 10-15 minutes is "charging" to prevent the formation of pressure ulcers and stimulate blood flow in the tissues.

Over time, the duration of exercise is gradually increased, giving an ever-increasing workload and smoothly moving to the affected area. In the final stage of physiotherapy focuses on return of damaged area the correct motor movements.

At the stage of recovery successfully applied physiotherapeutic procedures: electrophoresis, UV rays and ultrahigh-frequency therapy procedures.

Nutrition

Correctly selected diet osteomyelitis plays often an important role in the treatment of disease. It is recommended to divide your daily meals into smaller and more frequent meals for better absorption (5-6 times a day). The diet required the presence of dairy products, meat products, eggs, fresh vegetables and fruits. Liquid requires at least 2 quarts a day. Welcome food with a high content of iron, calcium and protein. If the patient has comorbidities that require special diets, all questions and assignments are discussed with attending physicians.

The prognosis of the disease

In the process of diagnosis of acute or chronic osteomyelitis is the prognosis, which depends primarily on the form of the disease and condition of the patient before admission. Also plays the role of age and immune status, and, of course, stage of disease and timeliness of detection. The sooner you begin comprehensive treatment, the greater the chances for a full recovery. Poor prognosis more often possible in patients with chronic osteomyelitis in a state of neglect and in combination with thinning of the bonetissue.


andidate of medical Sciences Dmitry Volkov S., surgeon