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Infectious bone diseases

Among the infectious diseases of the bones, the main place is osteomyelitis - inflammation of the bone marrow and other elements of the bone. In 80-90% of cases, children fall ill, mainly boys. Men get sick more often than women. Osteomyelitis can develop in any bones, including in the vertebral bodies and in the bones of the facial skull, but the proximal and distal metaepiphyses of the femur and tibia, that is, those sections of the bones that provide their growth in length, are more often affected. The main cause of the disease is infection of the bone with various microorganisms, among which the leading role belongs to staphylococci. In addition, osteomyelitis is caused by hemolytic streptococci, as well as polymicrobial flora - Staphylococcus aureus, gram-negative Escherichia coli, mycobacteria, pathogenic fungi. These infectious pathogens penetrate the bone marrow through the bloodstream, that is, hematogenously. Risk factors for the occurrence of osteomyelitis are endogenous sources of microflora, acute infectious diseases, hemodialysis and intravenous administration of drugs with violations of aseptic rules, the presence of an orthopedic apparatus, etc.

The disease is acute and chronic. Several acute forms of osteomyelitis are clinically distinguished: hematogenous, post-traumatic, iatrogenic, gunshot, post-radiation, as well as one chronically current form - chronic hematogenous osteomyelitis and its atypical variants - Brody abscess and Garre sclerosing osteomyelitis.

Despite the variety of clinical forms, the pathogenesis and morphogenesis of osteomyelitis is quite stereotypical and consists of the initial appearance in the bone marrow of a focus of serous inflammation, plethora of blood vessels and slowing blood flow in them with the development of stasis in the capillaries. There is plasmorrhagia, migration from the capillaries and venules of hematogenous cellular elements. Plasmorrhagia and serous exudate cause a significant increase in pressure in the confined space of the bone marrow and Haversian canals, inflammation and thrombosis of venules and bone arterioles occur, blood flow stops and focal necrosis of bone tissue develops. Then, as the emigration of neutrophilic leukocytes increases, the exudate becomes purulent, purulent melting of the bone marrow occurs with the accumulation of microbial colonies in these areas. Microbes are also located in vascular thrombi. Purulent inflammation usually has the character of phlegmon, sometimes multiple abscesses, and is characterized by an extensive spread of purulent exudate through the bone marrow and havers canals, bone marrow necrosis, compact bone, the formation of a subperiostal abscess with subsequent formation of a fistula. The periosteum becomes edematous, infiltrated with pus, in the subperiostal abscess it is separated from the bone. The surface of the cortical plate is dull, grayish-red in color, pus stands out from the haversian canals. The bone marrow is diffusely saturated with pus. In children, this often causes separation of the pineal gland.

Acute hematogenous osteomyelitis is divided into local (focal) and generalized (septic). In children, the disease begins acutely, is characterized by the appearance in the bone of severe pain of a bursting nature and the restriction of movements of the affected limb, high fever. Adult osteomyelitis is characterized by a gradual onset with the appearance of progressive pain in the affected bone and moderate temperature. The clinical picture is more reminiscent of the chronic course of the disease. The septic forms of acute osteomyelitis can proceed with lightning speed and end fatally. Acute focal hematogenous osteomyelitis can end in recovery 2-3 months after the onset of the disease and treatment - the so-called discontinuous form of the course, or continue for 6-8 months - a protracted form.

Chronic hematogenous osteomyelitis develops as a result of acute hematogenous osteomyelitis.
It is divided into secondary chronic osteomyelitis and atypical forms - Brody abscess, sclerosing osteomyelitis Garre, etc.

Secondary chronic hematogenous osteomyelitis is characterized by the formation of foci of purulent inflammation of the bone marrow, around which granulation tissue grows. In areas of bone adjacent to abscesses, necrosis develops, resorption and sequestration of necrotic sites occur, as a result of which cavities containing bone sequestration are formed. Near the foci of suppuration, periosteal bone formation is expressed, as a result of which the bones sharply thicken, deform, fistulas form in them, through which small bone sequesters sometimes stand out. The periosteum is unevenly thickened and sclerotic. In the soft tissues surrounding the area of ​​bone damage, cicatricial changes, the skin is atrophic, hyperemic.

The cure is possible only after surgical debridement of the site of purulent inflammation of the bone marrow and bone. As complications, pathological fractures of the affected bone, the formation of false joints, bleeding from fistulas, secondary amyloidosis, sometimes sepsis and the appearance of a tumor are possible.

Brody's abscess is from the very beginning a sluggish intraosseous abscess. It develops more often in young people after ossification of the epiphyseal growth plate and is localized in the spongy substance of the upper or lower epiphysis of the tibia, in the metaphyses of the femur or humerus, less often in other long bones, sometimes in the bones of the spine, foot, etc. The size of the focus of inflammation is usually do not exceed 3-4 cm. The accumulation of pus is surrounded by a pyogenic membrane, in which, in addition to neutrophils, there are many plasma cells, eosinophils, and histiocytes. Around the abscess, the bone is sclerosed and fistulas are almost never formed, bone deformation is practically absent.

Clinically, with the formation of a Brody abscess, periodic pain appears in the affected bone, mainly at night and with percussion, which are accompanied by a low temperature. With treatment, the prognosis is favorable.

Garre sclerosing osteomyelitis is more a consequence of osteomyelitis than bone inflammation. Abscesses and generally signs of inflammation are absent, but spindle-shaped osteosclerosis of the cortical plate of the diaphysis of the femur, tibia, humerus and other bones with the presence of small sequesters is expressed. The bone marrow cavity of the affected bone is narrowed, sometimes obliterated. The disease is manifested by pain and swelling over the area of ​​bone damage, occurs with a change in remissions and exacerbations, more often develops in men aged 20-30 years. The forecast is favorable.

Chronic recurrent multifocal osteomyelitis is a childhood disease of unclear etiology, which is characterized by purulent inflammation in the metaphyses of long bones, but the clavicle, bones of the wrist and tarsus, spine, pelvis, ribs, sternum can be affected. Microorganisms are not detected. Morphologically in the intertrabular spaces there are moderately expressed lymphoplasmocytic and macrophage infiltrates with small foci of polymorphonuclear leukocytes and the growth of loose connective tissue. Along the edges of the zones of inflammation and subperiostally moderate osteosclerosis.

Clinically, the disease is manifested by pain and swelling of the tissues over the area of ​​bone damage. Periods of exacerbation are replaced by remissions, which sometimes last several years. The forecast is favorable.

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