Causes and symptoms of acute and chronic osteomyelitis
What is osteomyelitis?
Osteomyelitis is an infectious inflammation of all constituent parts of the bone tissue: bone, periosteum, and bone marrow. However, not only the bone suffers, but also the bone marrow, the softest component, increases and swells. The hard shell begins to press on the tissue, as a result of which the blood vessels are pinched, and there is a loss of blood flow in the damaged area. This, in turn, often causes destructive processes. And if the causative agent of the disease penetrates beyond the bone, for example, into the muscles, then an abscess may develop - filling the cavity with pus.
Content:
- Osteomyelitis symptoms
- Osteomyelitis causes
- Acute osteomyelitis
- Chronic osteomyelitis
- How serious is osteomyelitis?
- Osteomyelitis diagnostics
- How is the treatment carried out?
Osteomyelitis symptoms
The most dangerous is osteomyelitis, which is caused by an internal infection. The disease develops in only 2 days. During these days, the symptoms of the disease are hardly noticeable. Perhaps general malaise, muscle pain, discomfort in the joints, the person does not even suspect that he is developing osteomyelitis. Then the body temperature rises to forty degrees. There is severe pain in the area of the affected bone. When moving, the pain increases, movement becomes limited. The disease develops further rapidly. Very often this whole process is accompanied by a sharp deterioration, nausea and urge to vomit.
The main danger of the asymptomatic course of osteomyelitis is the lack of treatment and the possible transition of the disease from a local form to a generalized one, from an acute stage to a chronic one. Therefore, any unusual sensations, an increase in body temperature without other accompanying symptoms require diagnosis and investigation.
With osteomyelitis with a toxic form of the disease, pressure drops, pains in the heart are felt, convulsions and loss of consciousness are possible. The face becomes pale, the eyes sink, the skin turns yellow, the lips turn blue. When a traumatic form of osteomyelitis appears, it is very important to immediately consult a doctor, otherwise the person may die.
Traumatic osteomyelitis is characterized by acute symptoms. A high fever and severe pain in the area of injury are possible, after which all these symptoms are replaced by chronic ones. The person feels more or less normal, various purulent secretions are excreted through the fistulous passages that arise in the area of the wound and are the first cause of traumatic osteomyelitis. Severe osteomyelitis can result in blood poisoning.
According to clinical manifestations, osteomyelitis is divided into two types:
- local;
- generalized.
The local course of the disease is characterized by the following symptoms:
- Increase in body temperature up to 38.5 ° C.
- The formation of swelling, elevations in the damaged area.
- Accuracy, bursting pain.
- The skin on the problem area heats up and turns red.
- The appearance of abscesses.
- Discharge of pus through the skin.
- Soreness and limited movement.
The generalized form manifests itself in several other signs:
- the temperature rises to 39-40 degrees;
- the pain intensifies, becomes constant;
- general intoxication is increasing (general poor health);
- chills, sticky sweat, hoarse shortness of breath appear;
- neurological damage (convulsions, delirium, loss of consciousness);
- disturbances in kidney function (painful and frequent urination);
- pallor of the skin.
Osteomyelitis causes
The main causative agents of acute osteomyelitis are staphylococci, but other bacteria, rickettsiae and some fungi are also possible, which enter the bone tissue and provoke the onset of the disease.
The main "fault" lies with Staphylococcus aureus, but some E. coli, hemolytic streptococcus and Pseudomonas aeruginosa can also cause ailment. The disease can be caused both by a single pathogen and by a group of pathogenic microorganisms.
In order for the inflammatory process to begin, some factors are necessary: predisposing and triggering mechanisms.
Factors predisposing to osteomyelitis include:
- hidden infections;
- allergic diseases;
- weakening of the immune defense;
- physical exhaustion;
- a long period of fasting and a lack of nutrients in the body.
Disease triggering mechanisms:
- various injuries;
- burn injuries and frostbite;
- ARVI;
- excessive physical activity;
- violations of the general psychoemotional state (stress, prolonged nervous exhaustion).
There are three ways of infection:
- through the blood supply;
- direct contact with pathogens (for example, with a burn, injury);
- transfer of infection from adjacent parts of the body.
Risk factors include:
- tuberculosis;
- ulcer;
- trauma;
- any damage caused by thermal burns;
- circulatory disorders;
- infectious diseases of the sinuses, oral cavity, dental ailments;
- Diabetes;
- oncological diseases and their treatment (chemotherapy);
- surgical interventions.
Hematogenous ("blood-borne") osteomyelitis is common in infants and young children. From the focus of infection - for example, from a diseased tooth - microbes enter the medullary canal of the long tubular bone of the arm or leg. Rarely, osteomyelitis is caused by a soft tissue infection that spreads to the adjacent bone. One of the causes of osteomyelitis can be an open fracture, in which case the infection penetrates through the lacerated wound into the bone.
Why osteomyelitis occurs, experts still do not know. There are three theories regarding the mechanisms of development of the disease (vascular, neuro-reflex, allergic), but none of them has been confirmed enough to be considered true.
Acute osteomyelitis
Depending on how the causative agent of the disease penetrated into the tissues, acute osteomyelitis is divided into endogenous and exogenous forms. The endogenous (or hematogenous) type is characterized by the entry of infection through the circulatory system from other foci of the disease under the influence of triggering factors.
An exogenous species includes:
- contact;
- post-traumatic;
- firearm;
- postoperative.
Acute hematogenous osteomyelitis
The method of infection is the "classic" introduction of pathogenic bacteria into the blood vessels inside the bone, as a result of which the primary focus of the disease appears. Children aged 3 to 15 are most at risk, but it is also common in newborns, middle-aged and elderly people. Hematogenous osteomyelitis affects males more and most often from spring to autumn. The hematogenous form has special "love" for long bones: femur, tibia, humerus.
By the nature of the course of the disease, 4 forms of hematogenous osteomyelitis are distinguished:
- Breakaway, the most favorable and easy form. With such a course, the body activates all protective functions and restorative systems and eliminates the focus within 2-3 months.
- Prolonged, which lasts much longer abrupt, up to 6-8 months. But, although the healing process is long, the disease recedes over time.
- Lightning-fast, the most severe and unpredictable form of hematogenous osteomyelitis. Most often it is provoked by a staphylococcal infection and is characterized by a one-time release into the blood of decomposition products of bacteria (in this case, endogenous). The strength of the ejection effect is such that in a matter of minutes, blood pressure drops to almost zero. And without the provision of urgent, momentary assistance, a lethal outcome occurs.
- Chronic, with a long course of more than 8 months. It is characterized by relapses (outburst of the disease) and remissions (attenuation of inflammation). It is often accompanied by the formation of sequesters - special dead tissue areas that prolong inflammation. Fistulas are formed that open according to relapses and close during remissions. The chronic stage can lead to muscle atrophy and amyloidosis (a violation of the body's protein metabolism).
There is another form - primary chronic, which is increasingly common in recent years.
Experts associate an increase in the number of people with this form of osteomyelitis with the following factors:
- with the wrong diet;
- with insufficient intake of important trace elements in the human body;
- with a deteriorated environmental situation over the past decades;
- with irrational and widespread use of antibacterial agents;
- with limited physical activity.
The primary chronic form is subdivided into the following types:
- Brody's abscess;
- albuminous;
- antibiotic;
- sclerosing.
Primary chronic osteomyelitis is characterized by a rather sluggish course, which makes it difficult to make a correct diagnosis.
Acute odontogenic osteomyelitis
The odontogenic type is an infectious lesion of the jaw bones with the formation of a purulent-necrotic process. The vast majority of patients with this type of osteomyelitis are men over the age of 35. Damage to the lower jaw develops more often, up to 85%, of the upper - up to 15%, and damage to the maxillary tissues proceeds much easier.
Among the reasons for the appearance are:
- a general decrease in immunity;
- errors in dental surgery;
- dental diseases (dental cysts, periodontitis);
- diseases of the nasopharynx (frontal sinusitis, ethmoiditis, sinusitis);
- metabolic disease;
- a sharp increase in the number of opportunistic microorganisms;
- direct infection due to trauma and thermal damage.
The development of the disease is accompanied by the formation of small hemorrhages due to the occurrence of thrombosis of the blood vessels of the bone tissue. Because of this, purulent foci of various sizes begin to appear, and the death of individual tissue sections is provoked. In addition, isolated foci of necrosis often occur, in which case they speak of nosological forms of odontogenic osteomyelitis.
The disease is manifested by acute pain with intense recoil to the temples, sinuses, and forehead. The side of the jaw on which the focus of infection is located begins to hurt. The body temperature rises, there may be increased sweating, chills and general disturbance of well-being.
Chronic osteomyelitis
In the case of advanced acute osteomyelitis, an untimely response, a subacute period occurs, which turns into a chronic stage. It is characterized primarily by the duration of the disease, significantly exceeding 2–3 months to 8–12 months, sometimes several years. In the chronic form, sequesters and fistulas are formed. There is an alternating change of exacerbation and attenuation of the disease.
Chronic odontogenic osteomyelitis
Approximately a week after the acute onset of odontogenic osteomyelitis, a subacute stage develops, which becomes chronic after 3-5 days. Reasons for the transition of the disease from the acute stage to the chronic:
- a general decrease in the body's defenses;
- hypothermia;
- overwork;
- acute respiratory diseases;
- wrong actions to eliminate the acute odontogenic period.
Symptoms:
- increased subfebrile (around 37.5) temperature;
- slight malaise and weakness;
- the formation of fistulas and sequesters;
- discharge of pus and sometimes small areas of dead tissue through the fistulous holes;
- lack of sleep.
On radiographic images and the results of computed tomography, alternations of healthy tissue areas with lesions of various shapes and sizes are clearly visible.
Hematogenous chronic osteomyelitis
With the transition of the acute stage to the subacute, and then to the chronic, the temperature drops to subfebrile indicators, sometimes it normalizes. Severe pain disappears. The affected area is indurated, restricted in movement, and swollen. In the area where there was a surgical incision, a fistula is formed through which pus is secreted. Sometimes there is a spontaneous rupture of tissues with the subsequent formation of multiple fistulas. They often exist for months or even years. Single large sequesters or small group formations of dead tissue are formed.
If pus does not find an outlet and accumulates under the soft tissues, swelling occurs in this area, the skin becomes hot to the touch and turns red, pain and fever appear. When the fistula opens and the pus comes out, the symptoms disappear.
For diagnostics, radiography is used, which can detect changes as early as 12-14 days after the end of the acute stage. At this stage of the disease, the fistulography method is very informative, which is a computed tomography using a contrast agent. A clear image allows you to determine the size of sequesters, their localization, the general severity of the disease.
How serious is osteomyelitis?
After the doctor makes a diagnosis and a qualified consultation, patients mistakenly assume that osteomyelitis is a simple inflammation that has affected a small area of the bone and has absolutely no effect on other processes in the body. Therefore, a person does not understand the seriousness of the disease that has arisen in them, they do not take its treatment seriously, which leads to serious complications, and sometimes even death. For this reason, it is necessary to explain to the patient how dangerous this disease is and what consequences it can lead to.
Particular attention should be paid to the fact that during osteomyelitis, the functioning of the liver and kidneys is noticeably deteriorating, a general depletion of the body occurs, and the functioning of the immune system deteriorates. It happens that a person dies not from the osteomyelitis itself, but from the diseases that it causes, especially when those organs that were not completely healthy before this disease are affected.
Osteomyelitis diagnostics
On examination, gentle palpation (palpation with fingers) of the painful area is performed, while the condition of the skin (hot, there is redness and swelling, wave-like tissue movements are formed) and the general appearance of the damaged area (taut skin, "glossy" shine, swelling). With the help of careful percussion (tapping), the focus of infection is determined by increasing pain in a specific place of the swelling.
In addition to assessing clinical manifestations and manual examination, laboratory research methods are used:
- A general blood test with a leukocyte formula in expanded form shows a shift to the left. This means that inflammation in the body is caused by a bacterial nature. Neutrophils are responsible for its suppression, of which there are 4 forms (segmented, stab, young neutrophils and myelocytes). When the formula is shifted to the left, the growth of segmented neutrophils and the appearance of stab individuals are noted. The more acute and severe the infection, the more youthful forms of neutrophils appear in the analysis. In addition, parameters such as ESR - erythrocyte sedimentation rate, indicators of hemoglobin and platelet levels reveal the nature of the course of the disease.
- A general analysis of urine shows the presence of inflammation and renal failure (with generalized forms of the disease) by the appearance of protein, an increase in some indicators.
- A biochemical blood test shows an inflammatory process and notes renal and hepatic failure. At the same time, the parameters of bilirubin and protein change, the glucose indicator decreases, and the amount of some elements increases.
Along with laboratory methods, instrumental examination methods are used:
- Ultrasound is used to assess the size and shape of muscle lesions.
- Infrared scanning can show the presence of acute latent forms of osteomyelitis by identifying areas of increased temperature.
- X-rays are the most common way to diagnose osteomyelitis. With the help of images, you can determine the localization of necrotic processes, the volume and severity of the infectious focus. With the help of X-rays, the disease can be detected in the early stages. As the inflammation grows, the nature of the image in the images changes, so the time of the course of the disease can be indicated with high accuracy.
- Computed tomography is the most informative way to diagnose osteomyelitis in any of its manifestations. With the help of volumetric images, it is possible to obtain not only data on the localization and intensity of infection, but also to create a reconstruction of the surrounding muscle tissues and to predict the course of the disease.
For an accurate diagnosis, which is of decisive importance in the treatment of osteomyelitis, a combination of laboratory and instrumental research methods is required.
How is the treatment carried out?
Osteomyelitis treatment should be comprehensive and timely. It is necessary to constantly monitor the disease in dynamics, since the course is often accompanied by unpredictable complications and variations in lesions. For a thorough fight against any forms of osteomyelitis, simultaneous drug therapy, surgical interventions and a complex of physiotherapeutic procedures are recommended.
Principles of drug (conservative) treatment
The main point: the treatment of osteomyelitis with medication alone without the intervention of surgical practice does not lead to the desired result. On the contrary, an insufficient concentration of antibacterial drugs provokes mutations in pathogens, as a result of which they become resistant to drug therapy.
With the help of intraosseous infusion of a mixture of saline and antibacterial agents, the focus of infection is washed and a kind of barrier is created around it, which prevents the spread of the pathogen outside the affected area. Moreover, washing helps to reduce the pressure in the bone tissue, remove pus and relieve pain.
An antibacterial drug is selected to which the type of pathogenic bacteria is sensitive. The medicine is injected into the bone cavity and applied in a course of 1–2 months. In some cases, the period of antibiotic use is lengthened: up to 3-4 months. In general, the period of antibiotic therapy is determined by the severity and nature of the disease.
Important points:
- For the period of treatment, it is recommended to immobilize (restrict mobility) of the damaged area using special devices. And in general, to minimize physical activity.
- In the case of a long course of drug therapy with antibiotics, agents are used to increase the general resistance of the body. For this, infusion (intravenous) infusions of special solutions are carried out, blood preparations are used.
- In cases of severe damage, ultraviolet exposure to the blood is connected.
- When sepsis occurs, a number of measures are taken to cleanse the blood and lymphatic system from toxins.
- In the course of treatment, careful monitoring of the electrolyte balance of the body is necessary.
The complex of physiotherapy exercises can be used only after the patient is withdrawn from the acute period of the disease and the pain syndrome is relieved. With the help of physiotherapy exercises, the functions of damaged areas are restored, the activity of muscle tissue is stimulated, the affected area receives nutrients and vitamins.
Surgery
Surgical intervention is impossible in case of concomitant diseases in the decompensated stage: complications that are more serious than osteomyelitis may occur.
Indications for surgery for osteomyelitis:
- atypical shape;
- purulent processes;
- diffuse purulent inflammation (phlegmon) of the periosteum;
- formed sequesters;
- fistulas;
- repeated recurrence of the disease.
The basic rule is that it is necessary to remove a purulent focus, regardless of its size. Preoperative preparation includes detoxification, administration of drugs that support the immune system, checking metabolism and, if necessary, the use of corrective drugs.
Surgery is performed under general systemic anesthesia. Each operation includes specific stages of implementation, depending on the ultimate goal and the desired result.
But in general, the course of surgery looks like this:
- First, the visible surgical field is treated with antiseptics and the instruments are checked.
- The effect of anesthesia is assessed and the first incision is made if the condition is satisfactory.
- With the help of subsequent incisions, the surgeon gets to the site of infection, which in most cases has an intraosseous location.
- With the use of special tools, the bone area is opened directly above the lesion, commensurate with the inflammation. If there are signs of purulent inflammation of a diffuse form, then purulent formations are first eliminated.
- The next step is to drill small holes that resemble an elongated rectangle in location. Then, using an electric surgical jigsaw, the holes are connected with an incision, and the result is a bone plate, which is removed. The bottom of the medullary canal opens, where the focus of osteomyelitis is concentrated.
- The canal is rinsed with antiseptic solutions, a drainage tube with lateral armholes and a free edge is inserted into it, which is fixed outside the incision.
- The final stage is suturing the wound in layers.
After the operation, using the established drainage, the cavity is rinsed with antibacterial solutions and the contents are assessed: if the discharge indicates the cleanliness of the intraosseous cavity, then the wound is reopened and the drainage is replaced with a section of striated tissue with an attached vessel for nutrition (surgical plastic). This is necessary to prevent recurrent osteomyelitis. And the drainage is already installed in the soft tissues. In the course of healing, it is removed.
Treatment of gunshot and chronic post-traumatic osteomyelitis
At the forefront of the treatment of osteomyelitis of a firearm origin is radical surgical intervention, in the process of which foreign objects, bone fragments and dying tissues are eliminated. After that, the area around the wound is "chipped" with antibacterial drugs, and drainage is performed if necessary. At the end of the surgery, the patient receives antimicrobial therapy, a complex of vitamin infusions and measures to remove toxins from the body.
The chronic post-traumatic form of osteomyelitis is most often complicated by defects (fractures, bone shortening, pseudoarthrosis). Basically, the method of osteosynthesis is used to eliminate fistulas and dock bone fragments, which consists in clearly fixing the fractured areas in the correct anatomical position for subsequent fusion. In the case of the formation of phlegmon, the lesion is opened, the pus and necrosis are removed, and the cavity is drained.
Physiotherapy for osteomyelitis
After surgery, a course of exercise therapy for the damaged area can be carried out no earlier than 20 days after the operation. However, other parts of the body that are not involved in the operation need to be moved. Therefore, twice daily for 10-15 minutes, "charging" is carried out to prevent the formation of pressure ulcers and stimulate blood flow in the tissues.
Over time, the duration of the exercises is gradually increased, giving more and more load and smoothly moving to the affected area. At the final stage of physiotherapy exercises, the emphasis is on returning the damaged area to correct motor movements.
At the stage of recovery, physiotherapeutic procedures are also successfully used: electrophoresis, exposure to ultraviolet rays and therapy with ultra-high-frequency procedures.
Nutrition issues
Correctly selected diet for osteomyelitis plays its own, often important, role in the complex treatment of the disease. It is recommended to divide the daily meals into smaller and more frequent meals for better absorption (5-6 times a day). The diet must include dairy products, meat products, eggs, fresh vegetables and fruits. Fluids are required at least 2 and a half liters per day. Foods high in iron, calcium and protein are encouraged. If the patient has concomitant diseases that require a special diet, all questions and appointments are discussed with the attending physicians.
Disease prognosis
In the process of diagnosing acute or chronic osteomyelitis, a prognosis of the disease is made, which depends primarily on the form of the course of the disease and the patient's condition before hospitalization. The age and state of immunity also play a role, and, of course, the stage of the disease and the timeliness of its detection. The sooner complex treatment begins, the greater the chances of a complete recovery. An unfavorable prognosis is most likely in patients with chronic osteomyelitis in a neglected state and in combination with thinning of bone tissue.
The author of the article: Volkov Dmitry Sergeevich | c. m. n. surgeon, phlebologist
Education: Moscow State University of Medicine and Dentistry (1996). In 2003 he received a diploma from the Educational and Scientific Medical Center of the Presidential Administration of the Russian Federation.
