Clinical features of metaepiphyseal osteomyelitis in young children

Classification

Osteomyelitis can be classified according to location, route of penetration, and severity of the process.

If we talk about the course of the disease, then there is an acute or chronic type.

If we are talking about how the bone tissue became infected, then it is worth noting three types of osteomyelitis - post-traumatic, hematogenous, odontogenic.

If we take into account the localization of the purulent process, then it is worth distinguishing between the disease of the lower jaw and the upper jaw.

Osteomyelitis - what is it?

Osteomyelitis is a purulent inflammatory process that often affects tubular bones as a whole. The nature of this disease is infectious. It can be caused by pathogenic staphylococci, streptococci or pneumococci. May occur as a complication of a viral infection.

Doctors divide osteomyelitis into hematogenous and post-traumatic . Hematogenous is characterized by the penetration of infection through blood vessels - for example, through an umbilical wound or carious teeth. Post-traumatic occurs due to infection in open wounds - fractures, abscesses, etc.

Most often, this disease affects children from 0 to 14 years old, less often – adults. This is due to the fact that children’s bones are not yet fully formed and are much more susceptible to infection, the process of suppuration is more active, and it is easier for bacteria to develop in tissues that have not yet become stronger.

Acute osteomyelitis in children

This form of the disease is most often observed in children. Here the clinical picture has pronounced symptoms that are characteristic of general intoxication. Inflammation and destruction also develop. This happens not only in the bone, but also in those soft tissues that are around.

Osteomyelitis in children often occurs as a result of certain characteristics of the body (functional, anatomical):

• there is hypersensitivity to infections, a high rate of reactivity;
• bone tissue is actively growing;
• when baby teeth erupt or change, the jaw structures are rebuilt;
• The Haversian canals are wider, and the bone trabeculae are quite thin;
• abundant network of blood vessels.

Localization of the disease

Most often the disease affects the femur.
The main area affected by osteomyelitis is the tibial region and the body of the femur itself. As the disease progresses, the pathological process can affect any tubular bone. The bone tissue of the elbow and shoulder is often affected. The situation is considered quite complex when the infection spreads to the area of ​​the ribs, chest and spine. In newborns, there is damage to the skull, namely the upper jaw. Less commonly, the pathology affects the phalanges of the fingers.

The most unfavorable localization is considered to be epiphyseal osteomyelitis, which in most cases leads to structural destruction of the epiphysis. More common in children under 1 year of age. The main complication is noticeable shortening of the lower limbs.

Causes

• Acute odontogenic osteomyelitis occurs from teeth that have been affected by caries or from pathogenic microorganisms that have penetrated. Typically, a similar form is diagnosed on the lower jaw. At the same time, the age period of children is 7-12 years;
• acute hematogenous osteomyelitis is the result of an infection that appeared from other foci. For example, it could be omphalitis (when the umbilical ring becomes inflamed), purulent mastitis, which the baby’s mother suffers from. If we talk about older children, they can become infected as a result of skin infections, tonsillitis, and purulent otitis media. This form occurs in the upper jaw and is accompanied by infection of the internal organs;
• Acute traumatic osteomyelitis is rarely diagnosed. It can be caused by infection of the line where the jaw fracture is noted. This occurs in case of injury, also after operations in this area. Often this disease occurs if the bone fragments are not properly treated, if bone fragments are immobilized, and also if carious teeth are caught in the fracture line and the skin and oral mucous membranes are damaged.

Republican Children's Clinical Hospital

Acute hematogenous osteomyelitis is an acute inflammation of the bone marrow (located inside the bone), in which all parts of the bone and surrounding soft tissue can be involved in the purulent process. This is a very serious disease, in which severe sepsis develops without timely treatment. In advanced cases, children continue to die from osteomyelitis even in our era of super-powerful antibiotics.

Acute hematogenous osteomyelitis is a disease predominantly of childhood. Children of all age groups are affected, but the peak incidence occurs between 10 and 14 years of age (60–80%). The male gender predominates among the patients. The predominance of males (2:1 or more) is explained by the anatomical and physiological characteristics and greater activity of boys and, consequently, their greater exposure to the external environment.

In acute hematogenous osteomyelitis, seasonality of incidence is observed. Children get sick more often in the spring and autumn (70%). This is probably due to an increase in colds and exacerbation of chronic and dormant infections, which reduce the body's resistance. It is necessary to pay special attention to the predisposing and provoking factors that can cause the disease. Important importance must be given to foci of latent or dormant infection, which is located in carious teeth, tonsils, and adenoids. This infection releases a number of toxins and breakdown products that contribute to the development of an allergic reaction and create a predisposition (readiness) of the body to the occurrence of the disease. Against this background, nonspecific irritants (trauma, hypothermia, overwork, illness, etc.) play the role of a resolving or triggering factor and can cause inflammation in the bone.

How does acute hematogenous osteomyelitis begin? As a rule, hematogenous osteomyelitis begins acutely, suddenly, often after injury (sometimes minor) or hypothermia.

The leading and most constant symptom of acute hematogenous osteomyelitis is bone pain. The pain has a bursting character, varying degrees of intensity. Children often scream and lose sleep because of it. They usually complain of pain throughout the entire limb, however, if you ask the child to point with his finger “where it hurts the most,” he will often correctly point to the source of inflammation. Pain is associated with the development of intraosseous hypertension when inflammation begins inside the bone. A characteristic feature is the fact that bone pain in acute hematogenous osteomyelitis is constant.

The second leading symptom of acute hematogenous osteomyelitis is fever. In the local form at the onset of the disease it can be from 37 to 38.0. But if a generalized (septic) form of the disease develops from the very beginning, then the temperature rises to 39 - 41 degrees and is persistent, and sometimes occurs with chills. Along with a general increase in temperature, in acute hematogenous osteomyelitis, the local temperature of the skin and underlying tissues in the projection of the affected area of ​​the bone also increases.

The third early symptom of acute hematogenous osteomyelitis is dysfunction of the affected organ (limb). At the beginning of the disease, the child begins to limp, active movements in the joints close to the primary lesion are early limited, and then quite quickly become impossible. The slightest movement intensifies the pain. This forces the patient to give the limb a forced position with muscle relaxation. So, with osteomyelitis of the thigh, the patient lies with the leg bent at the knee and hip joints, which is slightly turned outward. If you remain in this position for a long time, flexion contracture of the joint may develop, that is, the inability to perform movements in this joint.

On the 2nd - 4th day from the onset of the disease, soft tissue swelling appears at the site of the lesion, which depends on the intensity and depth of the inflammatory process. It then spreads to other parts of the limb. If the affected bone is located relatively superficially (on the forearm or lower leg), swelling above the source of inflammation occurs early; if it is surrounded by a thick muscle mass, as on the thigh, then swelling of the soft tissue appears late. Moreover, when the hip joint is affected, swelling can spread to the groin, anterior abdominal wall and scrotum, simulating other diseases. The circumference of the affected bone area increases compared to the healthy one. Soft tissues become dense and tense. Against the background of the course of acute hematogenous osteomyelitis, the general condition of the sick child begins to suffer from the first days. And the child’s condition is more severe the more extensively the bone is affected by the inflammatory process. In severe forms of osteomyelitis, other bones may be involved in the process, and the disease may be complicated by pneumonia.

Diagnosis (recognition) of acute hematogenous osteomyelitis is complex and sometimes can be extremely difficult, since osteomyelitis can appear under the guise of other diseases. Delay can lead to serious complications. Therefore, it is especially important for parents to know that if a child’s temperature rises and bone pain appears, then it is necessary to urgently contact a pediatric surgeon. The deterioration of the condition of a patient with acute hematogenous osteomyelitis can occur extremely quickly and lead to dire consequences.

Treatment of osteomyelitis occurs only in a hospital, in the surgery department. In severe, complicated cases, children are in the intensive care unit. Treatment includes surgery, several courses of antibacterial therapy, and symptomatic therapy. The child spends about one month in the hospital, followed by a course of rehabilitation and sanatorium treatment.

Thus, acute hematogenous osteomyelitis is a very dangerous disease. To prevent osteomyelitis, it is necessary to sanitize dormant foci of infection (carious teeth, etc.). When the first symptoms of the disease appear (fever, bone pain, lameness), you must immediately (at any time of the day or night) contact a pediatric surgeon. Early and complete treatment of acute hematogenous osteomyelitis allows you to save the life and health of the child.

Answer

Symptoms

Acute osteomyelitis appears very suddenly. If children are small, then they are noted to be moody and lethargic. They don’t want to eat, they don’t sleep well, and their temperature rises. If the child is older, then he may feel unwell, general weakness, and may complain of toothache.

When the disease is still in its early stages, the following manifestations may be present:

• bone pain. Initially it has a local character, and then diffused;
• the oral mucosa swells, hyperemia is noted;
• on the side that is affected, the soft tissues become swollen;
• the face becomes asymmetrical;
• chewing muscles may spasm.

If an injury occurs, signs of the disease appear after 3-5 days. The child feels much worse, the temperature rises, and pus may also be released if the mucous membrane has been damaged.

Is it possible to prevent the disease?

To protect your child from various types of illnesses, you need to carefully monitor his actions, diet and follow the drinking regime. It is important to protect your baby from falls, bruises and skin injuries. If an injury does occur, you need to carefully treat the wound and apply a sterile bandage or plaster. Strict adherence to sanitary and hygienic standards for caring for an infant plays an important role. The main thing is that if any negative manifestations concerning the baby’s health occur, immediately seek help from a pediatrician.

Diagnostics

It is based on X-ray examination. When the disease is just beginning, the images may show symptoms of osteoporosis (in the area where the inflammatory process occurs). And after a few days, radiographs already show foci of destruction. After another 2-3 weeks, bone necrosis is already visible, as well as the places where sequestra have formed.

Treatment

Here it is necessary to carry out certain measures that will help eliminate foci of inflammation and restore those functions that have been impaired.

Every case of childhood osteomyelitis must be treated urgently. To do this, you should call a doctor and admit the child to the hospital. If surgical intervention is performed on time, then we can talk about a positive prognosis and outcome.

In the case of odontogenic osteomyelitis, the tooth that provoked the inflammatory process should be quickly removed. When it comes to children, teeth can be removed, both baby and permanent teeth. After tooth extraction. the hole acts as natural drainage. However, sometimes the bone marrow spaces are opened to improve the drainage of pus.

After the tooth has been removed, the subperiosteal abscesses are opened or a periostotomy is performed.

During sanitation, they not only open, but also thoroughly clean the destruction cavity and remove necrotic masses from there. Antibiotics and antiseptics are used for washing, and drainage is also done. As for conservative therapy, special drugs from the groups of immunostimulants, anti-inflammatory and antibacterial are used.

Therapeutic measures

Part of the child's treatment may take place in the hospital.
Therapy for osteomyelitis in newborns consists of several stages, and is therefore carried out in the hospital and at home. The main thing is to promptly identify the signs of the disease, conduct a full examination and select effective treatment based on the nature of the main pathogen. Great responsibility when treating a baby falls on the parents.

Independent actions

First of all, you need to monitor the baby’s condition and note any visual or behavioral changes. If you suspect the development of the disease, you should immediately contact your pediatrician. Next, it is important that parents follow all the doctor’s recommendations and provide the child with proper care. Spa treatment is of great importance, so it is recommended to worry about organizing your trip in advance. Every six months, parents are required to provide a routine examination and, if necessary, re-treatment.

Doctor's actions

Osteomyelitis requires immediate medical intervention. Therefore, the baby is hospitalized for a number of therapeutic measures. Initially, the doctor prescribes medications aimed at activating protective functions and strengthening the immune system. A course of antibiotics is used to combat a specific type of bacteria. If the infection is caused by a violation of the integrity of the skin, then the affected area is covered with an antiseptic plaster. If complications develop in the form of an abscess with the accumulation of purulent exudate, surgery is performed under general anesthesia.

Secondary chronic

In children, rapid chronic inflammation is noted. After 3 weeks, acute symptoms disappear, but the child does not become healthier.

When it comes to chronic inflammation, there is an active process of destruction, as well as melting of the elements of bone substance. After which areas of necrosis form. In addition, thanks to the intraosseous structures and periosteum, bone tissue is actively restored. The peculiarity of this type of osteomyelitis is the presence of the rudiments of permanent teeth. If they are involved in pathology, they may then die, and their behavior will resemble sequestration.

Symptoms of chronic osteomyelitis

When the inflammatory process becomes chronic, acute symptoms decrease. 10 days after the disease began, the child feels better (appetite and sleep return to normal, fever and symptoms of intoxication disappear). But children still feel weak, they get tired quickly, they sweat profusely, and their skin is pale. Sometimes children say that their jaw hurts slightly on the side that is affected.

During the examination of such a patient, you can notice certain manifestations of the inflammatory process:

• over the place where the focus of osteomyelitis was, there are soft tissue infiltrates;
• pain is felt when the child's jaw is probed;
• There are fistulas in which pus is released. They can be multiple or single;
• lymph nodes in the neck and jaw increase in size and hurt;
• The sockets of the tooth that were removed do not heal well. It may also leak pus;
• teeth are very loose.

When the disease worsens, the symptoms resemble acute osteomyelitis.

Diagnosis of chronic osteomyelitis

An x-ray should be taken to confirm the diagnosis. It will allow you to see the foci of destruction, those rudiments of teeth that have died, sequestration. If the lesion is extensive, then jaw fractures may even be detected.

Treatment of chronic osteomyelitis

When it comes to secondary osteomyelitis of a chronic form, a conservative treatment method is used:

• antibiotic therapy. Which drugs are suitable? All this is determined after the patient undergoes a culture of the pus discharged from the fistulas. Thus, the type of microorganism that provoked the pathology and its sensitivity to different drugs will be determined;
• desensitizing therapy. This includes antihistamines, which will remove the allergic reaction and also increase the body's resistance;
• therapy that can be used to stimulate the immune system and strengthen the body as a whole;
• physiotherapy. For this purpose, UHF therapy and laser irradiation are performed.

To perform an osteotomy or sequestrectomy, you must have the following indications:

• sequesters that are large in size and do not undergo spontaneous lysis for a long time;
• there are rudiments of permanent teeth that have died. They support inflammation;
• there was a risk of amyloidosis of internal organs.

If the disease worsens, the treatment will be identical to that in the case of acute osteomyelitis. But the main method is surgical intervention, during which lesions with pus are opened and drainage is performed.

Main reasons for education

First of all, osteomyelitis is a consequence of infection with staphylococcal bacteria; in more rare cases, streptococcus and Escherichia coli become pathogens. The main route of infection of newborns is considered to be intrauterine penetration of the pathogen. In this case, the carrier of the pathogen is the mother. Once in a woman’s body, the pathogen actively multiplies and accumulates in the lymph nodes, which reduces the protective functions. This provokes the development of an allergic reaction with the release of enzymes that are unfavorable for the baby’s health. Through the bloodstream, substances that contain the bacteria enter the umbilical cord and, after cutting it, attack the child’s body. Since newborns have a very weak immune system, it is not able to prevent the further spread of infection.

There are other causes of infection. For example, the entry of pathogenic microflora during clinical procedures (blood collection, catheterization of the umbilical vein). Infection is provoked by purulent lesions of the skin due to surgical interventions or illnesses. A baby can be infected by using non-sterile medical equipment, which is considered serious negligence by medical staff.

Primary chronic

It's rare to see a form like this. Typically, this disease is caused by weakly active microorganisms. They penetrate from teeth affected by caries. They are the ones who maintain inflammation for a long time.

This form of osteomyelitis is characterized by a productive nature, since the processes of destruction observed in bone tissue are weakly expressed. However, during this process new bone is actively formed.

If we study the clinical picture of primary chronic osteomyelitis, then the acute period is omitted. The child's condition generally remains the same, only fatigue, pale skin, and weakness appear. As for local signs, the area of ​​the causative tooth hurts a little, the jaw bones and their thickness increase, and also symptoms of lymphadenitis appear in the lymph nodes. There are no fistulas on the skin or mucous membranes.

At an early stage, the productive form of the disease can be easily treated with conservative methods. If you choose the right means, you can achieve positive results quite quickly and without consequences. If the case is advanced, then surgical intervention will be required. It is used to remove too much bone tissue, as well as dead tooth germs. After that, they model the correct jaw contour.

Possible complications

In the future, the pathology can lead to arthritis.
Osteomyelitis provokes a number of negative consequences in a newborn child. As a consequence of the disease, severe pathologies of the musculoskeletal system appear. The structure of bone and cartilage often suffers, which leads to their deformation and impaired joint mobility. Prolonged inflammation provokes the development of degenerative changes in osteochondral tissue, which causes the formation of arthritis.

Purulent lesions of the bones of the head lead to the development of meningitis, which poses a danger to the health and life of the baby.

Consequences and rehabilitation

Osteomyelitis can have quite serious consequences in childhood:

• defects associated with bone tissue;
• jaw fractures that cause abnormal joints to form;
• the jaw is deformed;
• absence of permanent teeth, edentia;
• arthrosis, ankylosis, arthritis that relate to the joints of the temples and lower jaw;
• the jaw grows much more slowly, microgeny is noted;
• soft tissues are deformed and look like scars.

Due to the above complications, cosmetic defects may occur, but they do not have any effect on the masticatory apparatus or its functioning.

In order to restore the anatomy of the face and jaw to the maximum and ensure its normal functioning, it is necessary to take certain rehabilitation measures:

• sometimes plastic surgery is used. But this is done only after the facial bone stops growing;
• If adentia develops, then temporary dental prosthetics can be done. And as soon as the skeleton is finally formed, then permanent prosthetics are allowed;
• To improve the temporomandibular joint and its functioning, it is worth applying physiotherapeutic procedures.

All children who have suffered osteomyelitis that affected the jaw area are registered at the dispensary. They are required to visit the dentist at least 2 times a year.

Clinic

Hematogenous osteomyelitis. The development of the acute form begins with general symptoms: fever up to 39-40°C, weakness, vomiting, headache, impaired consciousness. Some children may exhibit hemolytic jaundice, as well as hypotension and tachycardia. Pain in the affected segments appears after 1-2 days and has a boring, tugging character, intensifying with any movement. In the affected limb, symptoms of a local inflammatory reaction are observed: edema, hyperemia, local increase in temperature. When all layers of bone and soft tissue are affected, a fistula is formed, through which the pus comes out and the patient’s condition improves.

Exogenous (post-traumatic) osteomyelitis. The clinical picture is more smoothed. The temperature reaches 38°C, the pain syndrome is less pronounced. Locally, in addition to inflammatory manifestations, pus appears in the wound. Depending on the extent of the lesion, it can be observed locally or spread to the entire segment.

Chronic osteomyelitis. Occurs when symptoms persist for more than 4-6 months. Characterized by alternating remissions and exacerbations. Exacerbations can be triggered by significant physical activity, the presence of infections in the body, or a general deterioration in the patient’s physical condition. The intensity of pain and general reactions is least pronounced. When the fistula opens, the condition returns to normal.