Osteomyelitis in a child prognosis. Hematogenous osteomyelitis in children. Mortal danger of acute hematogenous osteomyelitis

Hematogenous osteomyelitis in children is an acute purulent inflammation of the entire bone, which affects both the bone marrow and the compact bone substance and periosteum. In children, osteomyelitis is called hematogenous because pathogenic microorganisms that cause purulent inflammation penetrate the bone through the blood. The hematogenous route is the most common route of infection. Much rarer cases occur when the infection penetrates the bone from purulent foci in the surrounding soft tissues or from direct damage to the soft tissues and bone (traumatic osteomyelitis). The latter often occurs in wartime.

Hematogenous osteomyelitis is a disease that is observed almost exclusively at a young age, during the growth of the body, at the so-called epiphyseal age. With the disappearance of the epiphyseal fugue (line) and the end of bone growth, hematogenous osteomyelitis becomes very rare. The highest frequency of patients is between 8-17 years of age. They often get sick and infants up to 2 years of age. This selective lesion of childhood is explained by the anatomical features of the blood supply to the children's skeleton. Boys get sick more often (two to three times more often than girls).

The most common causative agent of hematogenous osteomyelitis is considered Staphylococcus aureus, the second place as a pathogen is occupied by streptococcus. However, with purulent inflammation of the bones, other pathogens are also found, although much less frequently - pneumococci, gonococci, typhoid bacilli, etc.

Pathogenic microorganisms that enter the body in the form of an embolus spread towards the periphery and reach the bone, where they settle and develop a purulent inflammatory process. The retention of bacteria is favored by the narrowness of the terminal arteries and the slow flow of blood in the dilated venous capillaries. The abundant vascular network in the metaphyses and the growing children's bone explains the more frequent localization of the inflammatory process in the metaphysis of children's and adolescent bones.

The predisposing causes of the disease can be the most various irritations: irritation of the bone marrow by chemicals, vitamin deficiencies, previous infections, poor living conditions and poor nutrition, injuries.

Acute hematogenous osteomyelitis

Acute hematogenous osteomyelitis in children can affect all bones, but most often affects large tubular bones and their metaphyses. And so most often it affects the tibia, femur, humerus, fibula, etc. The epiphyses of bones, as well as small flat bones, very rarely develop purulent inflammation. They are very often affected by tuberculosis infection - unlike long bones.

Pathological anatomy

Pathoanatomically, the inflammatory process begins first in the bone marrow with hyperemia and exudation, which soon becomes purulent and can cover smaller or larger areas of the bone marrow - bone marrow phlegmon. Inflammation during a weakly virulent infection may be limited to the central bone abscess, which can exist for a long time even asymptomatically. However, more often the inflammation in the first days is transferred through the Haversian canals to the swollen, reddish periosteum, which peels off due to the inflammatory exudate accumulating under it. A subperiosteal abscess forms, occurring with symptoms of acute inflammation with extremely severe pain. The subperiosteal abscess soon opens into the surrounding muscle tissue, and phlegmons and abscesses of soft tissues arise, which, if they are not opened in a timely manner surgically, can break through the skin and form fistulas characteristic of osteomyelitis.

The epiphyseal line represents a serious obstacle to the inflammatory process and protects the adjacent joint from infection, but when the purulent process destroys the bone metaphysis, the joint is also at risk. The latter can participate in inflammation, since sympathetic (collateral) effusion accumulates in it. Inflammation of the joint, however, can also be purulent. In early childhood, when the joint capsule is partially attached to the metaphysis, as in the femoral, humeral and knee joint, secondary suppuration of the joint often develops.

As a result of acute purulent inflammation of the bone, necrosis of a smaller or larger part of the metaphysis and diaphysis of the affected bone occurs. This necrosis leads to the formation of bone sequesters. They are central, cortical and complete, when necrosis affects the entire bone. The release of dead bone occurs slowly over a period of 2-3 months. Inflammatory irritation emanating from the dying and protruding part of the bone - a factor causing powerful growth new bone from the periosteum. The new bone formed surrounds the sequestrum, and sometimes the entire bone, like a “bone sarcophagus”, which is pierced by many holes, from which purulent secretion flows out through the fistula passages. Often, small bone sequestra are also released from them along with purulent secretion. Large sequestra can maintain the secretion of these passages for many years. Chronic fistula is a source inflammatory complications– suppuration, erysipelas, eczematization of the skin, and possibly carcinoma.

Insufficient reaction of the periosteum with poor formation of new bone can cause spontaneous (pathological) fracture. Excessive formation of new bone substance thickens the bone corticalis, the medullary canal is greatly narrowed or obliterated, and the so-called bone eburnation occurs.

If the purulent process affects the epiphyseal cartilage, then disturbances in bone growth occur - stopping bone growth or uneven growth, which causes deformation of the limbs.

Clinical picture

Acute hematogenous osteomyelitis in children begins suddenly with great force and severity. The initial acute stage is characterized by purulent inflammation of the bone marrow, the formation of a subperiosteal abscess, acute purulent infiltration of the surrounding soft tissue, and, sometimes, participation in the inflammation of an adjacent joint. A breakthrough of the abscess to the outside, during which the temperature usually drops, improves the course of the disease and promotes the removal of the sequestered necrotic part of the bone.

The onset of the disease is acute, with a rise in temperature to 39-40°C, sometimes accompanied by chills. Along with an increase in temperature, severe pain appears in the affected limb. Older children accurately localize the pain and spare the affected limb. Small children become restless and cry. An observant mother reports that the baby cries especially hard when moving a certain limb. The temperature continues to remain at high levels and is constant without large fluctuations. The child looks seriously ill and complains of pain throughout the body, headaches, insomnia, and the baby loses his appetite. At severe forms consciousness may be clouded and children may become delirious.

Soon after the onset of pain, after 1-3 days, swelling of the soft tissues is established. The pain (spontaneous and with pressure) becomes especially severe when a subperiosteal abscess forms, which older children describe as “throbbing pain.” A few days after this, signs of soft tissue phlegmon appear with localized severe swelling, redness of the skin, and if the lesion is close to the joint, the appearance of so-called sympathetic effusion in the joint cavity. Usually, after 7-8 days, an abscess can be identified in the soft tissues, which, if not opened, breaks through the skin to the outside, and the general condition of the sick child improves.

In addition to this clinical picture, hematogenous osteomyelitis also has a particularly severe form with a very rapid onset, with a picture of a pyemic general infection, which literally ends in death within a few days. This fulminant osteomyelitis occurs with high fever, chills, severely affected circulation with tachycardia up to 120-140 beats per minute, dry tongue and diarrhea. The sick child is apathetic and in oblivion. Jaundice develops as a result of hemolysis. At autopsy, purulent foci in the bone marrow, pneumonia, septic endocarditis and purulent metastases to other organs are identified. With this form there is often no clear picture of local bone damage.

Complications

Among the complications that may arise in children with acute hematogenous osteomyelitis, the following should be noted:

Sympathetic articular hydrops, which must be considered as collateral inflammation from a bone purulent focus adjacent to the joint. Serous or serofibrinous effusion is resorbed after the acute phenomena subside. The effusion is usually sterile.

Suppuration of the joint (purulent arthritis) appears when the abscess breaks through the epiphysis of the bone into the joint or when periosteal suppuration spreads to the joint capsule. For example, the femoral joint always suppurates with osteomyelitis of the femoral neck. Joint suppuration in acute hematogenous osteomyelitis is a serious complication that can lead to dysfunction of the joint. They are successfully treated by timely administration of antibiotics into the joint itself.

In young children, the epiphysis of the bone is often affected, which is accompanied by impaired bone growth.

Extensive necrosis is accompanied (with insufficient formation of new bone) sometimes by spontaneous fractures.

Pathological fractures are observed later, when dead bone is released - approximately around the third month.

Diagnostics

With a clearly defined clinical picture, the diagnosis of acute hematogenous osteomyelitis is easy to make. A young patient who develops swelling of the limb at high temperatures is characteristic of osteomyelitis. Mistakes are made when osteomyelitis is mixed with acute rheumatism, however, monoarticular lesions in rheumatism are rare; on the other hand, in rheumatism, swelling usually does not extend beyond the boundaries of the joint capsule. Sometimes osteomyelitis is confused with deep-seated inflammation lymph nodes, thrombophlebitis and phlegmon of soft tissues. Careful observation of a sick child usually determines the diagnosis. X-ray examination at the beginning of acute hematogenous osteomyelitis does not show changes in the bone.

Among paraclinical studies, a blood test that establishes leukocytosis (15-20 thousand) with polynucleosis is valuable for diagnosis. In severe forms, however, leukocytosis may be absent and leukopenia may even be detected. Sometimes the causative agent of osteomyelitis can be identified in a blood culture.

Treatment

Treatment of acute hematogenous osteomyelitis in children is carried out in the following way. Firstly, it is necessary to ensure absolute rest of the affected limb, which soothes the pain to a certain extent and provides favorable conditions for proper treatment of osteomyelitis. For this purpose, as most convenient tool, use a plaster splint, which allows you to observe the source of inflammation in the bone in order to promptly discover purulent collections or the participation of neighboring joints in inflammation. Immobilization of the affected limb is very important therapeutic event and it should be applied in all cases without exception. At the same time (in case of severe pain), the child is given analgesics.

Specific treatment against the causative agent of bone inflammation is carried out with penicillin, which is very effective for staphylococcal infections. The best results are obtained when treatment begins at early stages acute hematogenous osteomyelitis, in the first days. In such cases, penicillin leads to an improvement in the general condition - the temperature drops, chills disappear, the sick child’s well-being improves, sleep and appetite return. Local inflammation also calms down. Early treatment leads to recovery without the formation of ulcers. In such cases, x-rays reveal changes in the bone - periosteal reaction, disruption of the bone structure, but without the appearance of sequestration.

Formation of local abscesses (subperiosteal abscess), which on some bones (tibia, fibula) can be established clinically, or with soft tissue phlegmon, requires additional therapeutic measures. Penicillin can be used locally after puncture of the abscess cavity and evacuation of pus. Penicillin can also be injected into the medullary canal by piercing the cortical layer of the bone with a thick needle. It is more advisable in such cases, however, to perform a surgical opening of soft tissue phlegmon or subperiosteal abscess. The bone should not be trepanned. Incisional soft tissue wounds are drained using a short time thin rubber bands and ensure constant rest of the limb. A purulent focus treated in this way can also be treated by local injection of penicillin into the surgical wound. This method of treating abscesses is accompanied by significantly less bone necrosis. Purulent inflammation of the joint adjacent to the lesion is also treated effectively with punctures, evacuation of pus and the introduction of penicillin into the cavity. The joint should not be opened and drained. Treatment of purulent arthritis, which appears as a complication of osteomyelitis, with local use of penicillin is quite satisfactory.

In addition to immobilization, penicillin therapy and treatment of a purulent focus, measures aimed at improving the general condition of the sick child are indicated, which are important for strengthening the body’s resistance. In this regard it matters proper nutrition light, nutritious food, rich in vitamins, and drinking plenty of fluids to maintain good diuresis. For this purpose, give plenty of fluids or make drip, intravenous or rectal infusions of 5% glucose solution and saline solution. Important remedy is a blood transfusion, which stimulates the body and increases the defenses of a sick child; Anemia is being combated. Small amounts of blood (50-100 ml of blood) are stimulatingly transfused by drip every 4-5 days. It may be necessary to use means to maintain blood circulation, especially in severe forms of osteomyelitis, which may be accompanied by collapse.

Forecast

The prognosis of acute hematogenous osteomyelitis in children depends on clinical form and correctly applied treatment. In severe forms, the prognosis is very serious due to the danger of a general infection.

Chronic hematogenous osteomyelitis

The chronic stage of hematogenous osteomyelitis can be characterized by two features: the formation of necrosis in the bone (sequestrum) and the presence of purulent fistulas leading to the surface of the body.

The onset of the chronic stage occurs after acute phenomena have subsided under the influence of therapy, postoperative or spontaneous opening of the abscess to the outside. The cause of the chronic stage of the disease is bone sequesters that support chronic suppuration.

Clinical picture

The limb affected by hematogenous osteomyelitis in the chronic stage has characteristic appearance. When examining a child, edema or swelling of the corresponding area of ​​the limb is detected, which is the result of thickening of the bone and swelling of the soft tissues. Surgical scars and fistula openings that secrete pus are visible on the skin. Pale, atonic granulations usually grow near their openings.

Upon examination, severe muscle atrophy is also revealed. By palpation, the roughness and thickening of the bone is determined. Examination of the course of the fistula with a metal probe leads to exposed bone.

At this stage, some complications of osteomyelitis may be observed - spontaneous fractures, pseudarthrosis, contractures and ankylosis of the joints.

Children in the chronic stage of hematogenous osteomyelitis have and general symptoms. They are emaciated, pale and anemic. The chronic stage most often occurs without fever, but children can have a long time and low-grade fever. From time to time, a sudden increase in temperature to 39-40°C may be observed, which occurs when the fistula is temporarily closed by delaying purulent secretion and the formation of new ulcers. Often such abscesses open spontaneously through the old tract, pus flows out, and the condition of the sick child improves.

A sick child can also get complications from internal organs - pneumonia, complications from the heart, pleura, pericardium, and prolonged suppuration is dangerous due to the possibility of developing amyloidosis.

Very valuable data for determining bone changes is provided by an x-ray, which establishes the size of the lesion, the presence of sequesters, their size, bone regeneration, and determines the indications for surgical treatment.

Diagnostics

Based on anamnesis data that establish the acute stage of the disease, and especially X-ray data, the diagnosis of chronic hematogenous osteomyelitis in children in most cases is not difficult.

Still, sometimes there may be doubt about tuberculous inflammation of the bone in the fistulous stage, but this disease is generally chronic, causes early muscle atrophy and, usually, fistulas are associated with the affected joint. Tuberculous changes are identified on an x-ray and are focal in nature, with sequesters usually rounded and most often there is no periosteal reaction, which is so characteristic of the chronic stage of hematogenous osteomyelitis. In addition, the shape of sequestra in osteomyelitis is oblong with pointed edges.

IN differential diagnosis must be kept in mind, especially when bone sclerosis is established. A complete examination of a sick child and carrying out serological tests for syphilis usually reveal the syphilitic nature of bone changes.

Treatment

The goal of treatment in the chronic stage of hematogenous osteomyelitis is to remove the necrotic area from the bone and eliminate the purulent focus that supports chronic fistulas. This can only be achieved by surgical intervention, the so-called sequestrectomy or necrotomy.

The most appropriate time for surgery is when the sequestration has formed and separated from the healthy bone. The process of demarcation of necrotic bone requires several months. The moment of surgical intervention is determined on the basis of a good radiograph, on which a delimited bone sequester is installed. Surgery should not be delayed for a long time, since a purulent focus can adversely affect the body and cause damage to parenchymal organs. It is advisable to prepare emaciated and anemic children with stimulating blood transfusions.

Sequestrectomy is performed in children under general anesthesia, and a soft tissue incision is made to reach the bone lesion. After deperiosteum of the bone, the medullary canal is opened using a chisel and hammer and the sequestration cavity is found. The latter is removed along with the granulation tissue and the bone is leveled with a sharp spoon, removing all small sequesters. Smooth the edges of the bone. The cavity is wiped with alcohol and filled with penicillin.

For large cavities, muscle grafting can be done by introducing part of the adjacent muscle into the cavity. It is possible to fill the bone with a bone graft - pieces of bone, bone spongiosis, which is successfully transplanted.

The soft tissue wound - periosteum, muscle and skin - is carefully sutured and the limb is immobilized plaster cast. In the period after surgery, penicillin is always used prophylactically.

At good cleansing purulent focus postoperative period proceeds smoothly and recovery occurs. However, relapses with new formation of sequestra and fistulas can also be observed.

Pseudarthrosis, which results from osteomyelitis due to the formation of an extensive total sequestration and the formation of a bone defect, is difficult to treat. In such cases, plastic surgery with bone transplantation is necessary.

Spontaneous fractures, which can occur in the chronic stage of hematogenous osteomyelitis, are treated according to general principles treatment of fractures. Prevention is more important– prolonged immobilization of the limb and its unloading so that sufficient bone regeneration occurs.

The most severe consequences for a sick child occur when the inflammatory process affects the pineal gland, resulting in various bone growth disorders that are difficult to treat.

Osteomyelitis – infection, affecting the bone, periosteum and bone marrow, accompanied by suppuration and inflammation, and with severe course necrosis.

Causes and types of pathology

The disease develops when microbes penetrate the bone through the affected area (traumatic form) or into the blood (hematogenous form).

In the vast majority of cases, the disease is caused by staphylococci, but sometimes it is pneumococci and streptococci. IN in rare cases The causative agent is microscopic fungi, Escherichia coli, Proteus and other pathogens.

Traumatic osteomyelitis, as the name suggests, occurs due to trauma, for example, after an open fracture, gunshot wound and so on. Hematogenous osteomyelitis in adults and children is the result of congenital or acquired internal infection. Most often, this form of the disease is diagnosed in newborns and older children.

It is worth noting that boys are most often affected by it. Infection in the blood is detected after an abscess, purulent sore throat, boils, tonsillitis, carious teeth and other infectious pathologies. Purulent lesion localized not only on the bones, but also in bone marrow. It leads to irreversible destructive changes.

Each type of disease has a form - it can be chronic or acute. The latter is most often observed during the development of the inflammatory process, that is, at the very beginning. In the absence of adequate treatment, it becomes chronic.

Clinical picture

Acute hematogenous osteomyelitis is observed in children for no more than 4 weeks. The difficulty of diagnosis lies in the fact that it is almost impossible to detect earlier than 14 days after its occurrence.

Symptoms of the disease include:

• Aching pain in the injured limb that occurs spontaneously. Subsequently, it becomes sharp, bursting or boring, and interferes with normal movements;
• Increased body temperature;
• General bad feeling, unclear consciousness, nausea and vomiting, loss of appetite;
• Low blood pressure, paleness and dryness skin, mucous membranes become bluish;
• There is pain on palpation of the liver and spleen. Organs are enlarged;
• The affected area swells and turns red, veins bulge, regional lymph nodes enlarge;
• The level of neutrophils, leukocytes, and ESR in the blood increases.

Symptoms of osteomyelitis develop in children very quickly, literally in 1-2 days.

If treatment is not started in a timely manner, intermuscular phlegmon will form. Purulent inflammation nearby cells are affected. At this time, the person’s condition may improve slightly, but the need for surgical intervention is still present. If treatment does not begin, then purulent arthritis and even sepsis - blood poisoning - occur in the future.

Symptoms of the traumatic form do not differ from the hematogenous form. The only caveat is the availability open injury allows you to monitor the development of pathology.

In the absence of treatment or in case of insufficient effectiveness, the acute form of the disease becomes chronic. The latter develops within 2-3 months from the moment of injury and is characterized by necrosis of the affected tissue.

Chronic osteomyelitis is characterized in children by two stages: rest and exacerbation. They alternate with each other with different intensities, which is explained by the individual characteristics of the body.

Symptoms of the chronic form of hematogenous and traumatic osteomyelitis:

• The affected area hurts, but the swelling subsides. The general well-being of a person improves. The temperature decreases;
• The site of inflammation is covered gray coating. In traumatic form, if present open wound pus comes out of it;
• Destruction of bone tissue and joint deformation occurs;
• Muscle atrophy may occur. The long course of the chronic form of the disease sometimes leads to shortening of the affected limb;
• Metabolism is disrupted, which leads to organ failure.

Diagnosis of the chronic form of the disease includes x-ray and laboratory tests. They start it when treatment of the acute course of the disease has not produced tangible results.

Osteomyelitis in children

In approximately 90% of cases, children are diagnosed with acute hematogenous osteomyelitis. The disease first affects the bone marrow and then reaches the periosteum.

The peculiarity of this pathology is that it is difficult to diagnose at an early age. How smaller child, the more difficult it is for doctors to make a diagnosis. Very often, the only symptom of pathology in children under one year of age is restlessness and immobility of the limb.

Older children show the same signs as adults.

Osteomyelitis in children, as a rule, occurs in one of 3 forms:

• Local is the easiest. Characterized by elevated temperature body, moderate intoxication, satisfactory condition of the child. The patient is recovering after opening the abscess;
• The septic-pyemic form is observed in almost 50% of cases. The body temperature rises significantly, the child feels unwell, feels sick, may vomit, and has headaches. The affected limb swells, hurts greatly, and turns red;
• Toxic is a very rare form, occurring in approximately 2% of patients. In this situation, body temperature drops along with blood pressure. Very often the disease ends in death.

Children, due to the characteristics of their bodies, have a very difficult time with this disease. When parents notice mild nausea, headache, or the child complains of painful limbs that are red and swollen, they should immediately consult a doctor. The doctor, based on the results of x-rays, laboratory tests and ultrasound, will be able to confirm or refute the alleged diagnosis.

Treatment of osteomyelitis in children with different methods

Conservative therapy is carried out in three directions at once. First, the pathogen infection is removed from the body. Antibiotics have worked well in this case. Widely used: gentamicin, fusidine, lincomycin, kefzol.

Other types of drugs in this series, including penicillin, are ineffective. In addition, doctors prescribe powerful therapy to eliminate intoxication in the body. The complex of measures includes plasma transfusion, hemosorption, hyperbaric oxygenation.

Mandatory local treatment affected body tissues. In this case, they resort to physiotherapeutic procedures, and also apply a plaster splint to the affected limb.

Osteomyelitis in children develops more often due to the fact that children have a larger number of bone zones containing bone marrow, and also due to the fact that the bones have an active blood supply for full active growth. The most susceptible to damage are the shoulder and lower leg, thigh, jaw, and vertebrae. With the development of osteomyelitis, a purulent process occurs with destruction (necrosis) of bone tissue, damage to the bone marrow and surrounding soft tissues. The causes of development are infection with microbes capable of forming pus. The process can be acute and chronic course, with the latter, severe skeletal deformations with bone growth problems can occur.

For reasons, osteomyelitis can be nonspecific - it is a lesion by microbes of the opportunistic and pathogenic group (staphylococci, streptococci, Proteus, etc.). In case of specific damage, the causes of purulent straightening of the bones will be tuberculosis and brucellosis microbes.

The infection can penetrate the bone area hematogenously, with the bloodstream the pathogens settle in bone tissue. There may also be other ways - with wounds, injuries, the transition of inflammation from the tissues surrounding the bones.

Osteomyelitis occurs more often in boys, due to their greater tendency to injury; odontogenic osteomyelitis can become a separate option - the transfer of infection to the jaw bones from the cavity of carious teeth.

Symptoms

Manifestations of osteomyelitis are quite obvious, especially in children after 1-2 years. They manifest themselves acutely, with chills and high temperature reaching critical levels, increased heart rate, severe weakness with pallor, lethargy and malaise. Arises sharp pain in the joint and limb affected by the process, older children may notice pain inside the bone, which gradually intensifies and prevents them from making habitual movements. Over the course of a couple of days, pronounced swelling and local redness occur at the site of the lesion, an abscess is formed, which can literally disappear after a few days with a decrease in pain, which leads to increased swelling of the redness. The mobility of the affected area is sharply limited, the child spares the area of ​​edema. At the site where the pus breaks out, a fistula may remain, a duct through which pus flows out or the wound closes. If the acute process is not treated, the purulent focus remains inside the bone and tissues, leading to slow destruction of the bone and deformation of the limb, tissues, pathological fractures and tissue disfigurement.

Diagnosis of osteomyelitis in a child

The basis of diagnosis is typical complaints and clinical picture, it is necessary to confirm the source of infection using tests. The blood test will reveal leukocytosis as a sign purulent infection, the biochemical blood test changes. When inoculating the discharge or blood, the pathogen that gives rise to a purulent focus will be identified. It is important to take an X-ray of the bones to identify areas of bone thinning and destruction, and thickening of the periosteum. It is often necessary to distinguish manifestations of osteomyelitis from cancerous bone lesions, the development of rheumatism, and purulent arthritis. For these purposes, CT and MRI of the affected areas and specific studies can be used.

Complications

Osteomyelitis is dangerous due to complications in the form of joint instability and bone deformations, pathological dislocations, changes in bone growth processes, and arthritis. At improper treatment or its absence, the process becomes chronic with progressive skeletal deformation. Damage to the spine can lead to profound disability with immobilization; damage to the jaws threatens changes in the face and the spread of infection to the cranial cavity. Damage to the hip leads to immobility.

Treatment

What can you do

Osteomyelitis is a dangerous purulent disease that has serious complications, self-medication is unacceptable. At the first symptoms you need immediate appeal to the doctor.

What does a doctor do

It is important to simultaneously influence both the pathogen and the child’s body in order to stimulate it to fight infection and restore bone tissue. All activities are carried out only in the hospital. Held immune treatment, stimulation of the immune system, as well as the introduction of vitamins and antibiotics to which the pathogen is sensitive. Antibiotics are injected into large doses, intravenously or into a muscle, in combination with drugs to protect the intestinal microflora. Local decompression is also indicated - pressure on the bone marrow and its vessels is removed, pathological tissue is eliminated. The affected area is fixed in a special way, special periostomy operations are performed - the periosteum is dissected and separated from the bone, the focus of suppuration is drained with the removal of dying tissue and pus. After the purulent focus is eliminated, the condition is normalized, further rehabilitation methods are necessary - physical therapy and massage, sanitation of foci of infection, exposure to climatotherapy and hydrotherapy (sanatorium). Then twice a year they are treated with immunostimulating drugs, antiallergic and anti-inflammatory, as well as physical therapy to stimulate bone growth and restore tissue integrity. This includes laser therapy, magnetotherapy, vitamins, electrophoresis with antibiotics. It is important to regularly conduct x-rays to monitor the healing for three years; rehabilitation is required within the framework of sanatoriums.

Prevention

The basis of prevention is a healthy lifestyle and treatment of foci of chronic infection, prevention of injuries, good nutrition and strengthening the immune system.

Osteomyelitis is a purulent-necrotic pathology that develops in bones, soft tissues, and bone marrow. The disease is caused by bacteria that produce pus. Osteomyelitis is most common in children. Its chronic form can cause severe bone deformation. The pathological process usually affects the thigh, lower leg, foot, and spine.

Classification

Osteomyelitis was assigned a code according to ICD 10 in children - M86. If there is a need to identify an infectious agent, then additional coding B95-B98 is used. When the pathology is caused by salmonella, it is assigned the code A01-A02.

According to etiology there are:

• Nonspecific osteomyelitis, which is caused by microbes that form pus;
• Specific, which is a consequence of tuberculosis, brucellosis, syphilis. The most severe form is recurrent multifocal osteomyelitis, leading to damage to long bones. Often in such a situation the foot and hip joint suffer.

According to the path of penetration of microorganisms, pathology is divided into:

• , in which damage occurs as a result of bacteria entering the circulatory system;
• Secondary, non-hematogenous, which can occur as a result of trauma if the surrounding tissue is damaged.

According to clinical manifestations there are:

1. Spicy;

Causes

Usually the causes of the disease are associated with the penetration of infection into the bone marrow canal. Metaepiphyseal osteomyelitis in children occurs due to infection with Staphylococcus aureus.

If the disease is characterized by multiple purulent foci, then its causative agent is an anaerobic infection. The most common causes of the disease include:

• An infectious focus present in the body, which is the source of the pathogen entering the bone marrow. This could be otitis media, caries, tonsillitis, enterocolitis;
• A congenital infectious process that is caused by intrauterine damage or penetration of the pathogen during childbirth;
• Reduced immune activity. This condition can be acquired and congenital. It is provoked by oncology, brucellosis, tuberculosis;
• Slow blood flow, which occurs as a result of hypothermia, inflammation of soft tissue;
• Injury causing, as a result of hematoma, swelling, impaired bone blood flow, infectious process.

Interesting!

Epiphyseal osteomyelitis in children occurs due to the structural features of the vessels feeding the bone.

Symptoms

Symptoms of osteomyelitis in children are directly related to the age of the child, the stage of the pathology, and the cause that caused it.

Acute form

Acute osteomyelitis in children is characterized by rapid development and is presented in several forms. Local, in which the inflammatory process affects soft tissues and bones. Usually general state the child does not suffer. The septic-pyemic form is accompanied by:

• Increased body temperature;
• Chills;
• Migraine;
• Nausea;
• Vomiting;
• Fainting;
• Impaired coordination;
• Blood clotting disorders;
• Swelling;
• Hormonal imbalance;
• Deterioration in the functioning of the liver and kidneys.

For toxic form Characterized by blood poisoning, which causes the following symptoms:

• Vomiting;
• Increased body temperature;
• Convulsions;
• Decreased blood pressure;
• Heart failure.

Interesting!

Osteomyelitis in newborns produces more pronounced symptoms than in older children, who often experience only a slight deterioration in general well-being.

Chronic form

If the disease is not diagnosed in a timely manner and treatment is not started, then chronic osteomyelitis in children. During this period, the sign of poisoning subsides, but the general well-being of young patients deteriorates sharply.

In the affected area, fistulas with accumulated pus appear. The chronic stage of the disease is characterized by subsidence of symptoms and relapses. Remission can sometimes last for years.

Relapses of the pathology are similar to the acute form, but have a less pronounced manifestation. Typically, an exacerbation occurs as a result of a closed fistula. Because of what the purulent process accumulates.

Diagnostics

Speedy is the key full recovery. After assessing the symptoms, the doctor prescribes studies to confirm or refute the diagnosis:

• X-ray of bone. This type of diagnosis is not informative at the very beginning of the development of pathology. Subsequently, as the disease progresses, the X-ray image shows the presence of a pathological compaction, the absence of boundaries in the soft tissues;
• CBC (General blood test). Indicates the presence of osteomyelitis increased content leukocytes. Markedly altered leukocyte formula shows inflammation;
• Sowing, which allows to identify the causative agent of the disease and determine the antibiotic that is sensitive to it;
• Ultrasound allows for early identify swelling, muscle changes;
• MRI accurately diagnoses chronic form diseases;
• CT visualizes the acute form more clearly.

Treatment

Treatment of osteomyelitis in a child should begin as early as possible. In this case, the development of sepsis and bone changes can be avoided. Therapy of the disease is based on the following principles:

• Pediatric surgeons perform osteoperforation, in which antiseptics and antibiotics are injected through the formed holes into the inflammatory focus. The surgery relieves the pressure inside the bone that causes pain;
• Intravenous administration of antibiotics for 5-7 days;
• Carrying out symptomatic treatment to eliminate fever, relieve pain, remove toxins from circulatory system. For this purpose, nonsteroids, analgesics, and vascular agents that improve blood microcirculation are prescribed;
• The application of splints to ensure rest in the affected limb is a feature of the treatment of children. This measure allows you to reduce swelling and relieve pain. Immobilization should not be carried out for more than a month. Otherwise, muscle atrophy may develop.

Children suffering from osteomyelitis are subject to mandatory hospitalization.

They are prescribed for a long time, the course of treatment is 3 months. An important condition for recovery is taking multivitamins and immunoglobulins.

After acute symptoms are relieved, children need rehabilitation, which lasts for six months. Children are prescribed vitamins, therapeutic massage, and gymnastics. The exercise is prescribed individually, based on the condition of the little patient. Further, to exclude relapses, it is necessary to undergo a comprehensive examination every six months.

Possible complications

If the disease is not detected in a timely manner and its prompt treatment is not started, complications may develop:

• Bone defects;
• Child growth disorder;
• Frequent leg injuries;
• Arthritis.

The acute form of bone osteomyelitis becomes chronic, in which, if it occurs, the baby loses the ability to move. It is also possible to develop oncology and pinched spinal cord.

Osteomyelitis of the leg bone in a child is a serious problem. Early diagnosis and adequate treatment are the key to complete recovery. If you do not consult a doctor in a timely manner, serious complications can develop, including death.

Osteomyelitis in children can cause permanent disability. Early diagnosis, as well as timely conservative and surgical treatment of osteomyelitis in children even before the spread of infection, allows one to avoid severe consequences. Damage to the growth plates of bones and synovial membrane joints.

Causes of osteomyelitis

Acute infectious lesion bones is most often of bacterial origin. In all age groups, including newborns, the main pathogen is Staphylococcus aureus. In newborns, group B streptococci and gram-negative intestinal flora are also often cultured. Group A streptococci are the second most common, but they account for less than 10% of cases. After 6 years of age, the causative agent of osteomyelitis in children in most cases is S. aureus, streptococci or Pseudomonas aeruginosa. Infection with Pseudomonas almost always occurs when puncture wounds foot and direct penetration of bacteria from wet shoe insoles into bone or cartilage, which leads to the development of osteochondritis.

With penetrating wounds, infection with atypical mycobacteria is also possible. Fungal infection of bones usually develops when pathogens disseminate from other sites. Bacteremia in newborns with an indwelling vascular catheter is sometimes complicated by osteomyelitis.

Microbial etiology is confirmed in approximately 3/4 of cases of osteomyelitis in children. The small number of bacteria cultured may be due to pre-ingestion and the inhibitory effect of pus on the growth of microorganisms.

Prevalence

Osteomyelitis most often develops in young children. Thus, 50% of all cases of arthritis are registered in children under 2 years of age and 3/4 of cases in children under 5 years of age. In boys, bone infections occur 2 times more often than in girls, which can be explained by their more active behavior, which predisposes them to injuries. There are no racial differences in this regard.

Most bone infections in children are hematogenous in origin. Osteomyelitis in children in approximately a third of cases is preceded by minor closed injuries. Infection can occur through penetrating wounds or procedures such as arthroscopy, joint replacement, intra-articular corticosteroids, or orthopedic surgery, although this is rare. A decrease in the body's resistance also contributes to bone infection.

Pathogenesis

The sedimentation of bacteria from the blood at the ends of long bones is due to the peculiarities of the structure and blood supply of the latter. The arteries break up under the growth plates into non-anastomosing capillaries, which form short loops before entering the venous sinuses (draining into the bone marrow). Blood flow in these areas is slow, creating an ideal environment for bacteria to colonize.

In older children, the periosteum adheres more closely to the bone, and pus seeps through it. In late adolescence (after the closure of growth plates), the process often begins in the diaphysis and can spread throughout the intramedullary canal.

Symptoms of osteomyelitis in children

Signs and symptoms of a bone infection vary by age. The earliest clinical manifestations often do not attract attention.

Newborns may experience pseudoparalysis or movement of the affected limb. In 50% of cases there is no fever, the child looks completely healthy. In later life, fever and pain are more common; Local signs also appear: redness and a local increase in temperature. Approximately 50% of children with lower limb impairment begin to limp or refuse to walk.

Redness and swelling of the skin over the site of infection in purulent arthritis occurs earlier than in osteomyelitis, since the membrane of the joint is usually located more superficially than the metaphysis. The exception is purulent arthritis of the hip joint, since this joint is located deeper. Local swelling and redness may indicate the spread of infection from the metaphysis to the subperiosteal space and reflect a secondary inflammatory reaction of the soft tissues.

Osteomyelitis in children mainly affects long bones. The femur and tibia are affected with equal frequency, and osteomyelitis in both accounts for almost 50% of all cases. Bones upper limbs are affected in approximately 2/4 of all cases of osteomyelitis.

Usually only one bone is affected. Multiple bone or joint lesions are observed in less than 10% of cases. An important exception is gonococcal infection and osteomyelitis in newborns, in which two or more bones are affected in almost 50% of cases.

Diagnosis of osteomyelitis

When the history and examination data suggest osteomyelitis in children, it is necessary to puncture the affected area, followed by Gram staining of the punctate and culture, which allows confirming the diagnosis. Joint contents or pus from bone - best material for sowing. If gonococcal infection is suspected, bacterial cultures should also be obtained from the cervix, anus, and pharynx. Any suspicion of osteomyelitis or suppurative arthritis requires a blood culture.

Specific laboratory parameters There is no osteomyelitis in children. Indicators such as total leukocyte count and leukocyte formula, ESR and C-reactive protein are very sensitive, but nonspecific and do not distinguish bone infections from others inflammatory processes. In the first few days of the disease, the white blood cell count and ESR may remain normal, but on this basis the diagnosis of a bone or joint infection cannot be excluded. At the same time, dynamic determination of ESR and C-reactive protein makes it possible to evaluate the effectiveness of therapy and helps to identify complications.

Belongs to radiation research methods vital role in the diagnosis of osteomyelitis in children. WITH diagnostic purpose They use conventional radiography, CT, MRI and radionuclide studies. Initially, it is usually carried out plain radiography, allowing to exclude injury and the presence of foreign bodies. MRI is widely used as a very sensitive and specific diagnostic method.

Survey radiography. In the first 72 hours after the onset of symptoms of osteomyelitis in children, signs of deep tissue edema can be detected on a plain radiograph of the affected limb. Osteolytic lesions are revealed on radiographs only when 30-50% of the bone matrix is ​​destroyed. In long tubular bones such foci are detected on the 7-14th day after the onset of the infectious process. In other bones they are detected later.

CT scanning for osteomyelitis in children can identify bone and soft tissue abnormalities and is ideal for detecting soft tissue gas. MRI is better than other radiation methods in identifying abscesses and allowing one to distinguish infectious processes in bones and soft tissues. Using MRI, the localization of pus in the subperiosteal space and necrotic tissue in the bone marrow and metaphysis is clarified, which is extremely important for surgical intervention. At acute osteomyelitis purulent contents and swelling appear as dark areas; The signal intensity on T1-weighted imaging is attenuated and the fat produces a bright spot. With T2-weighted imaging the picture is reversed. The signal from adipose tissue can be attenuated using appropriate techniques, resulting in a clearer image. The T2-weighted plane shows high signal intensity from cellulite and fistulas.

MRI data in acute osteomyelitis in children have no less prognostic value than the results of radionuclide scintigraphy. MRI is especially indicated for vertebral osteomyelitis and inflammation of the intervertebral discs, as it clearly delineates the vertebral bodies and cartilaginous discs.

Radionuclide studies in osteomyelitis in children. MRI data can be supplemented by the results of radionuclide scintigraphy, especially if multiple lesions are suspected. For this, it is best to use 99Tc, which accumulates in areas of increased bone tissue metabolism (three-phase scintigraphy). In the focus of osteomyelitis, blood supply and activity of osteoblasts increase, which causes increased accumulation of Tc. In the first (5-10 min) and second (2-4 h) phases, this can be observed in areas of any inflammation and increased blood flow, but with osteomyelitis, increased accumulation of 99Tc also occurs in the third phase (24 h). In hematogenous osteomyelitis, the method of three-phase scintigraphy with Tc has high sensitivity(84-100%) and specificity (70-96%), allowing detection pathological process already 24-48 hours after the first symptoms. In newborns, due to insufficient bone mineralization, the sensitivity of this method is much lower. Its advantages include the ability to do without sedatives, repeatedly obtain an image of the entire skeletal system after one injection of radionuclide and low cost of research.

Differential diagnosis

Osteomyelitis in children should be distinguished from accidental and intentional injury. Bone or joint pain is common early symptom leukemia in children. Neuroblastoma with bone damage can also be mistaken for osteomyelitis in children. With a primary bone tumor, fever and other general signs of osteomyelitis are usually absent. Chronic recurrent multifocal osteomyelitis in children and SAPHO syndrome (Synovitis - arthritis, Acne - acne, Pustulosis - pustular eruptions, Hyperostosis - hyperostosis and Osteitis - osteomyelitis) are rare and are characterized by repeated inflammation of bones and joints and various skin manifestations - pustular eruptions, psoriasis, acne, neutrophilic dermatosis (Sweet's syndrome) and pyoderma gangrenosum.

Treatment of osteomyelitis in children

Treatment of bone infection requires the joint participation of orthopedic surgeons, radiologists and exercise specialists.

Antibiotics. When prescribing antibiotics for osteomyelitis in children, they are based on ideas about the most common bacterial infections at a given age, data from Gram staining of punctures, and a number of additional factors. In newborns, antistaphylococcal penicillins (nafcillin or oxacillin IV 150-200 mg/kg per day every 6 hours) and broad-spectrum cephalosporins are used.

In children under 5 years of age, the main causative agents of osteomyelitis are S. Aureus and streptococcus, and in vaccinated children - H. influenzae. Cefuroxime acts on these bacteria. In children over 5 years of age, almost all cases of osteomyelitis are caused by gram-positive cocci. Antistaphylococcal antibiotics, for example nafcillin, cefazolin, can be administered.

Special cases of osteomyelitis in children require deviations from the above rules of thumb. Patients with sickle cell osteomyelitis typically have gram-negative intestinal flora. In addition to antistaphylococcal agents, broad-spectrum cephalosporins such as cefotaxime or ceftriaxone are used. Clindamycin can be administered intravenously. Clindamycin not only has high antistaphylococcal activity, but also acts on anaerobic flora. It is effective for infections caused by penetrating wounds or open fractures. Clindamycin and vancomycin can be used as alternatives for infections caused by methicillin-resistant S. aureus. In patients with immunodeficiency, combination therapy is usually used: vacomycin with ceftazidime or piperacillin/clavulanate with aminoglycosides.

After determining the nature of the causative agent of osteomyelitis in children, antibiotics are changed if necessary. If the pathogen remains unknown, but the patient's condition improves, treatment is continued with the same antibiotics. If the patient’s condition does not improve, a repeat puncture or biopsy is performed and the possibility of a non-infectious disease is considered.

The duration of the course of antibiotics for osteomyelitis in children depends on the nature of the pathogen and clinical course diseases. For infections caused by S. Aureus or gram-negative flora, the minimum duration of the course (if signs and symptoms disappear on the 5-7th day and the ESR returns to normal) is 21 days. However, a 4-6 week course may be required. When infected with group A streptococci, S. pneumoniae or H. influenzae, antibiotics are administered for at least 10-14 days, based on the same criteria. After intensive curettage of the affected tissue in patients with pseudomonas osteochondritis, it is enough to administer antibiotics for only 7 days. Patients with immunodeficiency, as well as those with mycobacterial or fungal infections, usually require longer treatment.

After about a week, when the patient’s condition has stabilized, you can switch to oral antibiotics. In these cases, the dose of ß-lactam antibiotics for staphylococcal or streptococcal infections should be two or three times higher than for other infections. The adequacy of the dose can be judged by the maximum bactericidal serum titer, or Schlichter titer, 45-60 minutes after taking the suspension or 60-90 minutes after taking the capsule or tablet. The required bactericidal serum titer should not be less than 1:8. Taking antibiotics by mouth reduces the risk of infection normal microflora oral cavity, which is possible with long-term intravenous therapy, is more convenient for patients and allows treatment to be continued at home. At home, for osteomyelitis in children, intravenous antibiotics can be continued (through a central venous catheter).

Randomized prospective studies of different methods of surgical treatment of osteomyelitis in children have not been conducted. If pus is detected in punctates of the subperiosteal space or metaphysis, surgical removal of the lesion is indicated. Surgical intervention is often carried out after a penetrating wound, as well as in cases of possible entry of foreign bodies.