Symptoms and treatment of swelling of the femur and tibia

Trabecular edema is an acute, pathologically complex process characterized by changes in the structure of bone tissue (bone marrow trabeculae), which occurs with severe inflammation, fracture, dislocation and injury to bones of any part of the skeleton. Simply put, this is the destruction of bone tissue in the joints. This phenomenon can, for example, manifest itself in arthritis and osteoporosis of the knee, as well as dysplastic processes in the vertebral skeleton. Often, swelling is localized in the hip bone, knee joint (tibia or femur), spine (spinal cord) and other bones (skull, cervical spine). Today there is a system for treating edema of any complexity, and in order to reduce the risk of complications it is necessary to undergo examination, including MRI and MCT of bone tissue.

Pathogenesis

It is a characteristic manifestation of traumatic contusions, hidden subcortical and stress fractures. Bone marrow edema is one of the earliest nonspecific MR symptoms of a large number of diseases of the osteoarticular system. The pathomorphological basis of edema is an increase in the content of extracellular (interstitial) fluid in the bone marrow, as well as a local increase in blood flow and perfusion in it.

Epidemiology

The prevalence of bone marrow edema is directly related to etiological factors.

What does bone marrow edema mean?

Spongy substance (trabecular tissue) consists of loose plates and septa. The spaces are filled with bone marrow, which is responsible for hematopoiesis and the formation of immune chains in the human body. Swelling of the spongy tissue is accompanied by the accumulation of exudate in the trabecular plates. The fluid level may increase up to 20% (normally 10%).

Trabecular edema on MRI of the spine (affected area highlighted in red)

Based on the nature of the course, three types of bone marrow hyperhydration are distinguished:

• vasogenic - due to increased permeability or damage to the walls of the capillaries, fluid accumulates in the intercellular space;
• interstitial – under the influence of exudate, collagen fibers increase in volume;
• cytotoxic – swelling of bone marrow cells (osteocytes, osteoblasts, osteoclasts) is observed.

In the early stages, the process is asymptomatic. If left untreated, the pathology negatively affects the condition and functionality of the bone marrow. Against the background of the development of edema, the progression of autoimmune diseases (rheumatoid arthritis) is observed. Dysfunction of hematopoietic function consists in a decrease in the production of formed elements:

• red blood cells;
• monocytes;
• lymphocytes.

When the process lasts for a long time, the patient experiences:

• nosebleeds;
• the appearance of bruises and hematomas for no apparent reason;
• anemia.

The development of bone marrow edema leads to an increase in the volume of spongy substance, and the vertebral body swells. The changes are transmitted to neighboring tissues, affecting nerve fibers and the subarachnoid space.

Vertebral deformation leads to canal stenosis and compression of the spinal cord. Compression provokes pathological changes in the area of ​​nerve tissue. Spinal cord edema is accompanied by clinical manifestations, the nature of which depends on the location of the affected area. The higher the focus is located, the more serious the consequences of the pathology. Symptoms are most pronounced when the cervical spine is affected. In case of an unfavorable course of the process, death is possible.

Suspicions regarding the development of trabecular edema of the vertebrae and spinal canal arise in the presence of:

• constant aching back pain, aggravated by physical activity;
• paresthesia, paralysis of the upper and lower extremities;
• causeless disturbances in the functioning of the respiratory and cardiovascular systems;
• pain when urinating, bowel movements (if the process is localized in the coccyx area);
• complaints of frequent seizures;
• dysfunction of the genitourinary system.

A feature of the clinical picture with swelling of the spongy substance of the vertebra is the localization of the pain impulse above the point of injury. The reason is compression of the adjacent spinal roots by altered tissues.

Vertebral body fracture and signs of bone marrow edema (indicated by arrows)

Along with pain, compression of nerve trunks leads to disruption of the internal organs of the chest, abdominal cavity and small pelvis.

Radiation diagnostics

MRI semiotics

T1-weighted image: area of ​​lower MR signal intensity relative to the normal image of fatty bone marrow.

T2-WI, PD, FS, STIR: area of ​​higher MR signal intensity relative to the normal image of fatty bone marrow.

Contrast-enhanced T1-weighted image: increased signal from edema compared to native T1-weighted image.

The most informative are pulse sequences with signal suppression from adipose tissue (STIR, SPIR, FS), which improve visualization of the edema zone, which will have a hyperintense signal.

The structure of the signal from edema is heterogeneous, the contours of the zone of signal changes are unclear, the boundaries of the edema are relatively sharp, the shape of the zone of the changed signal is incorrect, the localization is at the site of the main process: inflammation, tumor, injury.

The MRI picture of edema in various diseases and skeletal trauma is nonspecific, but it is a highly sensitive symptom

Rice. 1. a – PD cor. scan of the knee joint: against the background of medium-intensity normal bone marrow, areas of edema are identified in both femoral condyles and the lateral tibial condyle (indicated by green arrows). b – T1-VI cor. scan of the knee joint: a hypointense area of ​​bone marrow edema of the medial condyle (green arrow) and an even more hypointense area of ​​fibrous bone remodeling in the area of ​​the fracture of the medial tibial condyle (red arrow).

Rice. 2. MRI of the left hip joint: a – T1-VI cor. scan, b – T2-FS cor. scan 1 – fracture line 2 – area of ​​bone marrow edema.

Treatment of ANFH

Avascular necrosis occurs due to hemodynamic disturbances. The disease is terrible, its consequences can be severe. It is very important to make a diagnosis in time, then there is a chance to save the leg and avoid surgical intervention. Comprehensive treatment of osteonecrosis depends on the stage and severity of the disease. At the onset of the disease, conservative therapy is used, later on they resort to surgery and endoprosthetics.

Goal of treatment:

• resumption of hemodynamics in the affected area;
• bone cell regeneration;
• restoration of limb functionality;
• relief from pain.

Treatment tactics by periods of illness

The approximate treatment regimen for osteonecrosis depends on the severity of the process. The patient must know its basic principles; each point of treatment is agreed upon with the patient, because only through the joint and concerted efforts of the doctor and the patient can the desired effect be achieved.

Initial stage of ANGBC

The initial stage of the disease lasts from several days to six months. This is the stage when blood vessels are injured. During this period, it is still possible to reverse the process by improving local trophism and stimulating the growth of bone tissue. Great emphasis in this period is placed on a gentle protective regime, thanks to which the head of the joint is unloaded.

Recommendations:

1. The orthopedic regimen consists of following measures aimed at reducing the load on the affected joint. How to achieve this?

• it is necessary to reduce the time spent on your feet;
• use a stick or crutches while moving;
• standing for long periods of time should be avoided;
• whenever possible you need to rest, preferably in a lying position;
• eliminate the transfer of cargo;

1. Exercise therapy:

• be careful when choosing physical exercises, avoid jumping, running, twisting in the hip area;
• be sure to do strength exercises to avoid congestion in the vessels and to activate blood flow (up to 30-40 minutes a day);
• All exercises must be coordinated with your doctor or exercise therapy instructor.

1. Medicines (only as prescribed by a doctor):

• NSAIDs;
• vasodilators;
• if necessary, blockade with anesthetic,
• vitamin and mineral supplements.

1. Massage – both general and local (the qualifications and experience of a specialist are extremely important);
2. MBST

Second stage of ANGBC

Six months after the onset of the disease, intense bone destruction begins, and the femoral head becomes deformed.

Recommendations:

1. Exercise stress:

• daily measured walking for half an hour to an hour (preferably Scandinavian) without getting tired;
• going up and down stairs;
• forward and reverse riding on an exercise bike (at a calm pace) or a calm bike ride (without going uphill);
• visiting the pool (water aerobics classes without sudden movements, swimming).

1. Strengthening therapeutic exercises.

Therapeutic exercises are necessary in any period of illness. It is important that the set of exercises is compiled by an instructor and that at first he observes their correct implementation.

1. Drug therapy:

• dilating vessels;
• promoting bone cell regeneration.

1. Massage

Massage can also be beneficial in the second stage. But hand movements should be light, after the massage the patient should feel pleasant warmth

1. Femoral head decompression - this intervention can help the patient and slow down the disintegration of the femoral head.

3rd stage

The disease enters the third stage usually after 8-9 months. The head is almost destroyed and the question of surgical intervention arises.

Recommendations:

1. Exercise therapy.
2. Massage.
3. Drug therapy.
4. Surgical intervention.

Physical therapy, drug therapy, massage and physiotherapy at this stage are auxiliary measures. The emphasis in this period is already on operations.

List of used literature and sources

1. Bryukhanov, A.V. Magnetic resonance imaging in osteology: monograph / A.V. Bryukhanov, A.Yu. Vasiliev. – M.: OJSC “Publishing House “Medicine”, 2006. – 200 p.
2. Radiation diagnostics of osteomyelitis [Electronic resource] / V.V. Kovalinin [et al.] // Russian electronic journal of radiation diagnostics: electronic journal. – 2014. – T. 4, No. 3. – P. 66-76. – URL: https://www.rejr.ru/nomer/vol-4-3-2014.html (03/29/2018).
3. X-ray diagnosis of tuberculosis of bones and joints [Electronic resource] // Second opinion: website – (2013-2017). – URL: https://secondopinions.ru/rentgenovskaya-diagnostika-tuberkuleza-kostey-i-sustavov (03.29.2018).
4. X-ray diagnosis of gonarthrosis [Electronic resource] // Second opinion: website – (2013-2017). – URL: https://secondopinions.ru/poleznye-materialy/rentgen/rentgen-sustavov/rentgenovskaya-diagnostika-gonartroza (03/29/2018).

Causes

Factors contributing to the formation of edema:

• the presence of an infectious pathogen;
• knee injuries, dislocations and subluxations with displacement;
• tendon and ligament ruptures;
• hemorrhages, impaired blood supply;
• diseases of the musculoskeletal system ─ osteomyelitis, osteoarthritis;
• oncological neoplasms.

Diagnostics

It is impossible to independently determine the presence of trabecular edema. The most effective diagnostic method is computed tomography. The technique demonstrates a three-dimensional image of the injured area, allowing you to see the areas surrounding the swelling. The presence of visible signs of pathology allows you to receive a referral for additional tests.

Methods for diagnosing trabecular edema, in addition to the main one, are:

• X-ray examination - reveals the presence of excess fluid, spinal injuries;
• MRI - allows you to see pathological processes affecting the soft tissues of the body;
• blood test for rheumatoid factor - prescribed for parallel diseases.

Neglecting to visit a doctor promptly after the onset of pain symptoms is dangerous for future life. The consequences of a late visit are fraught with irreversible consequences.

Therapy

Treatment consists of reducing pain, preventing the destruction of CM, restoring the functions of the damaged area and normalizing blood circulation.

Therapeutic measures should have an integrated approach and include medications of different effects:

• a painkiller is prescribed and, if necessary, supplemented with potent narcotic drugs;
• antibiotics, potassium iodide preparations, hormonal drugs (Prednisolone) are used to treat the inflammatory process;
• to improve blood supply, Trental and Actovegin are administered intravenously;
• severe edema requires diuretics;
• in case of destruction of cartilage tissue, chondroprotectors are prescribed;
• to restore the nervous system, intramuscular injections of B vitamins are used;
• according to indications, it is recommended to adhere to bed rest or, if possible, limit movement with the help of crutches or wearing a bandage;
• adjust their diet by consuming more foods rich in calcium and vitamin D;
• Medicinal physical procedures are used locally, and exercise therapy is performed under the supervision of a rehabilitation physician.
• surgery is indicated in extreme cases.

The rehabilitation period until complete recovery lasts several months. It is important to follow all doctor’s instructions to avoid serious complications that are irreversible.

Tibial condyle fracture

First aid involves immobilizing the limb with a splint from the foot to the upper third of the thigh and urgently transporting the victim to a medical facility. Treatment of this pathology is carried out in a trauma department. Upon admission, the traumatologist performs a puncture of the knee joint and administers novocaine to anesthetize the fracture. Further tactics are determined taking into account the characteristics of the injury.

Conservative treatment

For incomplete fractures, tibial fractures, and non-displaced marginal fractures, the treatment plan involves applying a plaster cast for 6-8 weeks. Analgesics, walking on crutches, and elevated limb position during rest periods are prescribed. The patient is referred for UHF and exercise therapy. After stopping immobilization, it is recommended to continue using crutches and not lean on the limb for 3 months from the date of injury.

For displaced fractures, depending on the type of damage to the tibia, treatment includes simultaneous manual reduction followed by traction or traction without previous reduction. The presence of slight displacement allows the use of adhesive traction. In case of a fracture of one condyle or both condyles with significant displacement, a fracture of one condyle with subluxation or dislocation of the other condyle, skeletal traction is applied.

Traction is usually maintained for 6 weeks, during which time exercise therapy is performed. Then the traction is removed, and the patient is recommended to walk on crutches without supporting his leg. A distinctive feature of intra-articular fractures of the upper tibia is delayed healing, so light weight bearing on the leg is allowed only after 2 months, and full support after 4-6 months.

Surgery

Indications for surgical treatment are an unsuccessful attempt to reduce fragments, pronounced compression of fragments, entrapment of a fragment in the articular cavity, compression of blood vessels or nerves, and a displaced fracture of the intercondylar eminence of the tibia when closed reduction is unsuccessful. Operations are performed as planned a few days after admission.

Since the use of skeletal traction in a significant number of cases does not allow for accurate comparison of fragments, the list of indications for surgery is currently expanding. Specialists in the field of traumatology and orthopedics are increasingly offering patients surgical treatment not only for the injuries listed above, but also for any condylar fractures with fairly pronounced displacement of the fragments.

• For ordinary fresh injuries, an arthrotomy is performed. Fragments lying freely in the joint cavity are removed. Large fragments are reduced and fixed with a screw, and intramedullary or extraosseous osteosynthesis is performed with a nail, knitting needles, or special L- and T-shaped support plates.
• For multi-fragmented injuries of the tibia and open fractures, external osteosynthesis is performed using the Ilizarov apparatus.
• For fresh fractures with significant compression, unresolved and old fractures, as well as secondary subsidence of the condyles due to premature load on the leg, osteoplastic surgery according to Sitenko is performed.

According to the Sitenko method, the joint is opened, an osteotomy is performed, the upper fragment of the condyle is raised so that its articular surface is located at the same level and in the same plane with the surface of the second condyle, and then a wedge made of autogenous or heterogeneous bone is inserted into the resulting gap. The fragments are fastened with tightening screws and a plate. After osteosynthesis, the wound is sutured layer by layer and drained. With stable fixation, immobilization in the postoperative period is not required.

The drainage is removed for 3-4 days, then physical therapy with passive movements is started to prevent the development of post-traumatic joint contracture. Postoperative treatment includes painkillers, antibiotics, thermal procedures (ozokerite, paraffin). After the pain has reduced, they move on to active development of the joint. Light axial load on the limb with conventional osteosynthesis is allowed after 3-3.5 months, when performing bone grafting - after 3.5-4 months. Full support on the leg is possible after 4-4.5 months.