Osteomyelitis. Brody's abscess. Tuberculosis of bones and joints. Brody's abscess of the tibia treatment, symptoms of a boil Brody's bone abscess as a complex type of osteomyelitis

It is rare to encounter a bone tissue pathology such as Brody's abscess. It arises in the bone and is characterized by a limited accumulation of pus against the background of previous necrosis. Most often the process is localized at the ends of the bone, but cases of its location in the middle sections have been described. The process most often affects young men aged 14 to 24 years. The disease itself lasts chronically, with or without periods of exacerbation. Cases of Brody's abscess have been described for 20 years or more, and during this entire period the microorganisms have not lost their activity.

It is no secret that the cause of any abscess is microorganisms. With Brodie's abscess, they enter the bone with the blood, and most often it is staphylococcus.

The body is so unique that when abscesses form, it builds a dense protective system against microorganisms. Studies have shown that the capsule that forms during abscesses is so dense and impenetrable that the strongest poisons introduced into its cavity did not in any way affect the condition of the animal being studied. But in such a limited state, Brodie's abscess can exist for a very long time with or without periods of exacerbation.

Clinical picture

The disease is chronic, but always has an acute onset, in which the temperature rises sharply to 39 or 40 degrees and persists for 2 to 3 days. Immediately after its reduction or a week later, a person notices local pain, which is located in the area of ​​a large joint. The pain is aching, intensifies when trying to move, and in later stages of the disease it bothers you at night, disturbing sleep.

Brodie's abscess never proceeds with the formation of fistulas

This form of abscess was first described by the English surgeon Brodie (1783 - 1862) in 1830. Moreover, the author described it as one of the forms of bone osteomyelitis in young men or adolescent males.

In the area of ​​the lesion, the soft tissues are slightly swollen, the local temperature is increased, and the vascular network is more pronounced in comparison with other areas.

During the period of exacerbation, which can occur at any time, the temperature does not rise, but the pain becomes a real nightmare.

Brodie's abscess never occurs with the formation of fistulas.

Due to the fact that the joint is located nearby, problems with it come to the fore, which complicates the diagnostic process. The course of the disease itself is benign.

Diagnostics

The most common way to put a definitive end to the issue is an x-ray examination. The image clearly shows a round or oval isolated cavity in the spongy substance near a large joint, the diameter of which usually does not exceed 2 - 3 cm. Most often, the abscess is located under the outer layer of bone.

The most common site of injury is the tibia; less commonly, the process can be found in the femur and very rarely in the humerus, radius, ulna and other tubular bones.

The maximum diameter of the abscess does not exceed the length of the bone, and there are no necrotic areas of bone (sequestra) in the cavity itself. The contours of the cavity are smooth, around it in the image there is a zone of compaction in the form of a strip, the edges gradually become normal bone tissue.

If the size of the cavity is small, then the outer shell of the bone does not react to this in any way. If there is a gradual increase in the cavity, then an inflammatory process of the bone shell develops, which is called periostitis. In the picture, such a bone is represented by a cylindrical or spindle-shaped thickening above the abscess cavity.

Differential diagnosis

It is necessary first of all to distinguish Brody's abscess from chronic osteomyelitis, bone tuberculosis, cysts, and metatyphoid abscess. In chronic osteomyelitis, there are several foci of destroyed bone tissue with the presence of sequesters and a pronounced reaction of the marginal layer. In the case of metatyphoid abscess, the focus is located in the marginal layer of the bone and contains a sequester.

With advanced syphilis, gummas appear, most often affecting the brain, but they can also form in the bones. In this case, Wasserman’s specific reaction to syphilis will be positive. On x-ray, gummas are located closer to the outer edge of the bone, causing severe inflammation.

With bone tuberculosis there is no clear focus of the lesion; as a rule, the process is blurred

With bone tuberculosis there is no clear focus of the lesion; as a rule, the process is blurred. The edges of the bone are most often affected, and even when testing the blood for tuberculosis or performing a tuberculin test, the result is positive.

In the case of an inert cyst, a cavity is visible on x-ray, which is most often represented by a cellular structure. The marginal layer of the bone becomes sharply thinner and the bone is swollen.

Treatment

In the early stages of the disease, preference is given to conservative methods. Initially, the limb is immobilized in a cast for a period of 3 to 4 weeks. Antibiotics are administered intramuscularly, selected taking into account the sensitivity of microorganisms from the abscess cavity. Physiotherapy is prescribed, in this aspect UHF is preferred.

Men are affected 5 times more often than women. In more than half of the cases, the process is localized in the tibia, followed by the lower parts of the femur and humerus.

CAUSES

In most cases the formation of bone abscesses is associated with previous hematogenous osteomyelitis. More often abscesses are single, rarely multiple.

As a result of necrosis, a spherical or oval closed cavity with smooth walls is formed in the bone.

SYMPTOMS

In the clinical picture, the leading ones are

• bone pain, spontaneous and with pressure.

X-ray changes should be expected no earlier than 3 weeks after the onset of complaints. For osteomyelitis in adults, one must look for focal infections (often in the genital area) and, first of all, latent brucellosis or typhoid infection.

TREATMENT

• During the period of exacerbation of Brody's abscess, antibiotics are prescribed.

• Radical treatment is surgical. The cavity is trephinated and the inner wall is scraped out. For large cavities, muscle plastic surgery is used.

Brody's abscess is one of the forms of hematogenous. With it, the inflammation has a localized form and is located in the epiphyseal part of a long tubular bone. Most often it develops in the tibia or radius.

It develops mainly in adolescents and adult men. There are practically no cases of development in children.

The lesions are of a single type. The size and shape depend on how long the disease lasts. At an early stage, they have an oblong teardrop shape and can reach 1.5 - 2 cm. With a long period of development, the shape becomes like a ball, and the size increases to 5 centimeters.

The peculiarity of the development of this type of disease is its long course. The process can take several decades.

Causes

The main causative agent of the disease is staphylococcal infection. The body gradually becomes weaker, immunity decreases. When it becomes very weak, the infection begins to progress.

Microbes can enter the body in different ways:

• through damage to the skin;
• with a large accumulation of blood;
• through boils, cysts, etc.;
• from purulent foci of inflammation.

It is also possible for it to enter the bloodstream through injections or intravenous drips.

Symptoms and manifestations

Symptoms of the development of the disease may vary. The first thing patients note is that when pressure is applied, the affected area loses sensitivity. With exertion and at night, pain gradually begins to appear.

The main initial symptoms are:

• hard knot;
• the skin in this place turns red;
• swelling.

After some time, a capsule begins to form, inside which pus accumulates.

Pathology can develop over many years. The disease may not manifest itself for a long time, but exacerbations occur from time to time. In this case, the person notes:

• elevated temperature;
• weakness;
• general deterioration of health;
• the skin around the affected area turns red;
• upon palpation the pain becomes stronger.

The onset may be acute or mildly primary chronic. Clinical signs are not particularly obvious. If the disease has this form, a person may only feel mild pain and swelling. If an abscess is located next to a joint, it can cause development, which makes the pathology similar to various joint inflammatory diseases (arthritis, etc.) It can also be mistaken for neuralgia.

If the onset is acute, the symptoms will be more obvious: the temperature will rise sharply to 39-40C, etc.

During exacerbation, the abscess does not cause the formation of fistulas.

Diagnostics

To diagnose this disease it is necessary to take an x-ray. In the image, the doctor sees a cavity in the spongy part of the bone with a diameter of 2 to 2.5 cm, which is surrounded on the sides by a zone of sclerosis. Inside, the cavity is filled with pus, as well as bloody or serous fluid. Also, upon detailed examination, tissue detritus is visible in it.

Differential analysis is carried out with tuberculosis, eosinophilic granuloma, etc.

Treatment

Treatment is carried out using different methods depending on the stage of Brody's bone abscess. At an early stage, conservative methods are used: the bone is immobilized with a plaster cast for a month, and antibiotics are prescribed. In case of exacerbation, anti-inflammatory radiotherapy is carried out; the lesion can be scraped out and penicillin injected into this place. The big one must undergo a series of physiotherapeutic procedures (UHF, etc.) Rest, proper nutrition and restorative treatment (vitamins, minerals, etc.) are also necessary.

If these methods do not have the desired effect, surgery is performed. In this case, the damaged part of the bone is removed and replaced with a graft.

Page 32 of 72

The group of atypical osteomyelitis also includes abscesses localized in the bone, mostly without a fistula or sequestration, which are one of the varieties of sluggish chronic osteomyelitis.
David first pointed out the presence of a bone abscess in 1764. This form was described in detail in 1832 by Brodie, who discovered a cavity in the tibia of the leg, amputated at the request of the patient due to unbearable illnesses that were not amenable to conservative treatment. Then he cited 9 such cases, isolating them from the general group of white tumors, and in the remaining 8 cases he treated patients by trephination of the bone and curettage of the cavity. Since then, these observations have become more frequently published in the literature, and this form is called Brodie's abscess. In 1901, Gross was able to collect 141 observations, Thomson in 1904 - 161, and M.F. Koretsky in 1928 - 174 observations from 56 authors.
Subsequently, the number of observations increased even more - in 1938, Wenkr and Henby found 374 cases in the literature (cited by G. A. Mezentsov). In reality, the number of these observations is much higher. Over 100 observations are described in the domestic literature (S. A. Reinberg, F. F. Berezkin, G. A. Mezentsev, I. B. Kuznetsov, F. M. Danovich, I. F. Ivanitsky, M. A. Kunin, M. D. Mikhelman and others). In addition, M. M. Diterichs (1932) mentions 54 cases of bone abscesses that he observed at the Moinaki resort.
Most often, intraosseous abscess clinically manifests itself at a more mature age; the average age of these patients is 20-30 years. This form has hardly been described in children and appears to be very rare. It must be assumed that a certain part of such cases in children is missed and detected clinically only at a more mature age.
But according to the current views, Brodie’s abscess develops as a result of blockage by a bacterial embolus of one of the terminal branches of the intraosseous arterial system, as a result of which bone necrosis develops in a limited area. According to S. M. Derizhanov, who generally denies the importance of vascular embolism in the pathogenesis of osteomyelitis, blockage of the metaphyseal arteries does not play a role in the origin of Brody's abscesses.
A number of authors attach great importance to the weak virulence of the infection, as a result of which the inflammatory process develops slowly in a small, limited area. However, the idea of ​​a bone abscess as a qualitatively less intense infection raises objections, since the bacteria obtained from the abscess are quite virulent and do not differ in their vital activity from the usual pathogens of osteomyelitis. Pus can retain its virulence for a long time; Even when closed bone cavities exist for many years, it is usually possible to isolate Staphylococcus aureus from their contents. Undoubtedly, the special reactivity of the body, its protective reaction, plays an important role, as a result of which abortive phlegmon of the bone marrow develops.
In typical cases, the causative agent is mostly staphylococcus. It is necessary, however, to point out that a significant number of Brodie's abscesses described in the literature, especially in adults, belong to typhoid osteomyelitis.
In V.D. Chaklin, out of 17 cases, paratyphoid pathogens were found in 6, typhoid fever in 2, and staphylococcus in 4.
The clinical picture of Brody's abscess is different. There is usually limited sensitivity to pressure. Often the lesions do not manifest themselves in any way and the pain occurs only occasionally, more often at night, after physical exertion or when the weather changes. Fever, chills and other symptoms of a general infection are usually absent. However, there are also forms with periodic exacerbations, with fever, redness of the skin, pain with pressure and spontaneous pain. The process can last for years, sometimes producing remissions. S. A. Reinberg observed a disease that lasted 55 years.
Inspection usually reveals little; in more pronounced cases, thickening is found in the metaphysis, and there are often reactive phenomena in the joint. On x-rays, in which in some cases this disease is first detected, one can see in the spongy part of the metaphysis a cavity with a diameter of 2-2.5 cm, round or oval, slightly elongated along the length of the bone, with sharply defined regular contours. As the bone grows in length, the cavity may move towards the diaphysis. It is surrounded by a well-defined zone of sclerosis in the form of a narrow or wider whitish border; delicate periosteal overlays are often visible on the surface of the bone. When the abscess is localized in the diaphysis, the periosteal reaction is more pronounced (Fig. 51). During the operation, a cavity is found, surrounded by sclerotic bone and lined with a membrane resembling granulation tissue or consisting of denser connective tissue. This cavity is filled with purulent, serous or bloody fluid, sometimes detritus is found in it.
Many modern authors also classify Brody's abscesses as cases in which intermuscular purulent accumulations and fistulas have formed. O. Starovoytenko, A.I. Elyashev and others describe under this name both bone cavities with sequestration and pathological fractures. All this makes many of the cases now cited significantly different from the description originally given by Brodie. Indeed, the course of this form of osteomyelitis can be varied.
F. F. Berezkin distinguishes three forms of Brody's abscess: 1) latent, or quiescent, 2) mature, sluggishly flowing, 3) stage of exacerbation with the formation of fistulas. V. D. Chaklin distinguishes: 1) a latent period of vague dull pain, 2) a period of infiltration or beginning sclerosis, 3) a period of abscess, 4) a period of fistula.

Rice. 51. Abscess in the lower metaphysis of the tibia (child Ch., 7 years old). A large rounded focus of rarefaction, surrounded by a zone of sclerosis.
The upper part of the tibia is most often affected, followed by the distal femur, shoulder, forearm, and other bones. Some authors include Brody's abscesses and bone cavities located in the epiphyses, as well as in short and flat bones (M. A. Quinn, A. I. Mariupolsky, M. M. Kazakov, S. A. Pokrovsky, etc.).
Lesions of the phalanges of the fingers, sternum, and skull bones also result.
Of the cases we observed, 9 had the typical course described by Brody with gradual swelling of the limb and intermittent pain.
X-ray photographs revealed a characteristic cavity with or without the formation of a sequester.
In addition to these typical cases, we observed 13 more patients with a process very similar to Brody's abscess, but characterized by a more acute course, with frequent exacerbations, with the formation of sequestration and fistulas. The onset of the disease resembled the usual form of osteomyelitis; the process was localized in the metaphysis or the adjacent part of the diaphysis, but with the formation of a fistula. It should be noted that in our observations, exacerbations occurred more often than described in adults. This is undoubtedly explained by the anatomical and biological characteristics of childhood. Let us give one observation.

Rice. 52. Intraosseous abscess in the distal metaphysis of the tibia (child K., 7 years old).
A - before the operation. Bone cavity with sequestration and fistula tract;
B - six months after the operation. The cavity is made as a newly formed
bone.
K., 7 years old. He was admitted on January 19, 1959 for a non-closing fistula in the lower third of the left leg. A year ago, a boy fell off his bike.
Soon the temperature increased, swelling, pain, and then a fistula appeared on the lower leg. He was treated as an outpatient. Upon admission, an x-ray image shows an elongated oval cavity in the lower metaphysis of the tibia, opening towards the epiphyseal cartilage; a sequestration is determined in it (Fig. 52, A). During the operation, a sequester measuring 2X1.5 cm was removed, the cavity was scraped out and filled with penicillin and streptomycin. The wound is stitched tightly. Lasting recovery. An x-ray after 6 months shows the filling of the bone defect with new bone (Fig. 52, B).
We observed 3 cases of fracture at the site of an inflammatory bone cyst. Cases of pathological fracture with Brodie's abscess are found in the literature in the form of individual casuistic descriptions.
Here is one observation.
S., 5 years old. Yesterday I fell on a flat floor and suffered a fracture of my left hip; Before that, I had never been sick or complained of pain. The general condition is good, the left femur is thickened in the lower third. By palpation, crepitus and pain are determined; there is also swelling and contracture in the knee joint. X-rays show an oval-shaped cavity in the distal metaphysis of the left femur, surrounded by somewhat sclerotic bone; in this place there is a displaced fracture (Fig. 53). A plaster cast with a pelvic girdle was applied. He was discharged in a plaster cast. Was examined after 2 years. Walks freely. Deformations and shortening of the limb. On the x-ray, at the site of the former cyst there is only an irregularly shaped compacted area.

Rice. 53. Fracture of the femur at the site of an intraosseous abscess (child S., 5 years old).
The diagnosis is easy if you remember about this disease and take an X-ray in a timely manner.
S. A. Reinberg cites a case where the diagnosis was made 34 years after the onset of the disease, as soon as radiography was performed. However, the differential diagnosis of Brody's abscess presents certain difficulties in some cases. First of all, it can be confused with tuberculosis, which, especially in young children, can be localized in the diaphysis of long tubular bones; It is sometimes necessary to distinguish an abscess also from a non-inflammatory cyst, and in rare cases from osteosarcoma.
If diagnosis is difficult, it is better to decide on an operation, which is indicated for intraosseous abscess and consists of opening the cavity, removing the contents, curettage, followed by treatment with antibiotics and suturing the wound tightly.
The above forms: 1) sclerosing osteomyelitis, 2) albuminous, 3) intraosseous abscess - are usually combined into the general group of primary chronic osteomyelitis.

As can be seen from the description of the clinical course of these forms, such a definition is incorrect, since the onset of these atypical forms is often acute or subacute; the acute onset can be overlooked. Some authors erroneously classify osteomyelitis of other etiologies as primary chronic forms. It is often not taken into account that in children the reactivity of the body is more lively; The disease takes an acute or subacute course from the very beginning, and exacerbations are often observed.

According to static data, a disease such as Brody's abscess is relatively rare in modern medical practice. Nevertheless, such cases are still recorded from time to time, so it is worth knowing what the disease is. So what symptoms accompany the disease and who is at risk?

What is pathology?

Brodie's abscess is a form of hematogenous osteomyelitis. This disease is characterized by the presence of a sharply limited area of ​​bone damage. Against the background of the disease, there is an accumulation of pus in the human bone tissue, which is the result of previous necrosis.

It is worth saying right away that the disease is much more often diagnosed in males aged 14 to 24 years. Brodie's abscess in children of primary or preschool age is also possible, but such cases are recorded extremely rarely.

The disease, as a rule, affects long tubular bones, namely their meta-epiphyseal section. The occurrence of an abscess in the diaphysis is rare. According to statistics, patients are most often diagnosed with Brodie's abscess of the tibia. Sometimes suppuration is observed in the distal epiphysis of the radius. But in other parts of the supporting apparatus, the inflammatory process and suppuration are observed only in isolated cases.

The main reasons for the development of an abscess

Brody's abscess is a disease of bacterial origin. In most cases, the cause of the inflammatory process is a staphylococcal infection, although the presence of other microorganisms, including E. coli, is often determined in purulent masses. In most cases, abscess formation is the result of osteomyelitis.

Pathogenic bacteria can penetrate bone tissue in different ways. For example, microorganisms often enter tissues through the bloodstream from another source of inflammation, so risk factors include the presence of purulent infectious diseases in the patient. Bacteria can also penetrate into the pineal gland from the cavity of a cyst or boil. On the other hand, pathogenic microorganisms are often introduced from the external environment when the skin is damaged or drugs are administered intravenously or subcutaneously (if hygiene standards have not been met). Sometimes an abscess develops during the postoperative period. By the way, the development of infection is almost always associated to one degree or another with a weakening of the immune defense.

Pathogenesis of the disease

Brodie's abscess has very pronounced features. Against the background of the necrotic process, a closed oval or spherical cavity is formed in the bone tissue, and its walls are quite stable and smooth. It is inside this cavity that thick purulent masses accumulate. In rare cases, a viscous clear liquid may be found inside the abscess. By the way, the diameter of the cavity is usually 2-5 cm.

If we are talking about an old formation, then the wall of the cavity is often lined with fibrous tissue. A concentric zone of bone sclerosis forms around the abscess, and periosteal growths appear in the periosteum.

Symptoms and signs of the disease: what to look for?

Brody's abscess is a chronic disease. It often develops over years or even decades without causing any serious symptoms (at least the signs are so mild that the patient simply does not pay attention to them).

The disease progresses sluggishly, and periods of relative well-being are replaced by short-term exacerbations, which are accompanied by more pronounced symptoms. For example, patients often note fever and general weakness. The tissue around the affected area of ​​the bone swells and the skin turns red. When pressed, the person feels pain and the skin feels hot to the touch.

The clinical picture during the period of “calm” is blurred. Patients report some discomfort only during increased physical activity. As the abscess grows, the capsule can be felt. There is often a decrease in limb mobility, as well as a change in tissue sensitivity.

Brodie's abscess: x-ray and other diagnostic methods

Of course, in this case, correct diagnosis is extremely important, since the treatment regimen and the success of therapy depend on it. After familiarizing yourself with the symptoms that patients complain about, as well as palpating the affected area, the doctor prescribes an additional study.

One of the most informative tests is radiography. In the image, the doctor can see the presence of a hollow formation in the tissue of the affected bone. The size of the abscess is small, and its walls are smooth.

Of course, there are other tests that help diagnose a disease such as Brody's abscess. MRI (magnetic resonance imaging), for example, provides more accurate information and also demonstrates that the tumor cavity is filled with purulent masses.

Differential diagnosis and its features

Differential diagnosis in this case is simply necessary, since the symptoms of this disease are somewhat reminiscent of the clinical picture of tuberculous osteitis. The formation in bone tissue may be eosinophilic granuloma or osteoid osteoma, so additional research is simply necessary.

For example, with tuberculosis lesions of the bones there is no clear focus of the lesion - this is a distinctive feature. Cysts, unlike an abscess, have a cellular structure. Sometimes, to make an accurate diagnosis, the Wasserman reaction to syphilis is performed, because this disease is accompanied by the formation of so-called gummas in the patient’s bones.

Brodie's abscess: treatment

Of course, the disease is much easier to cure in the initial stages - conservative therapy is usually sufficient for patients. First, you need to limit the mobility of the limb with a plaster cast - the patient should spend about 4 weeks in this condition. During this time, antibiotics are administered intramuscularly, which are selected only by the doctor, guided by the sensitivity of specific pathogenic microorganisms.

If there is an exacerbation of the inflammatory process, patients are also prescribed anti-inflammatory drugs. In more severe cases, curettage of the abscess cavity is indicated, followed by treatment with antiseptic agents and the introduction of penicillin (or another antibiotic) directly into the bone formation.

Physiotherapy is also a mandatory element - UHF treatment is considered the most effective. Naturally, a sick person needs to remain calm, limit physical activity, eat right, and do everything to activate the immune system.

Surgery is indicated in cases where treatment with medications does not produce the expected results. During the procedure, the doctor removes Brody's abscess. Sometimes it is necessary to remove part of the bone tissue - in such cases they are replaced with an implant. With the right approach, this disease can be treated without serious complications.