Osteomyelitis of long tubular bones in children

Orthopedic consequences of acute hematogenous osteomyelitis of long tubular bones are disturbances of anatomical relationships in joints (decentration, subluxation, dislocation), deformation and shortening of limb segments, disruption of bone tissue integrity (pseudoarthrosis and defect) and disruption of joint function in the form of contractures or ankylosis.

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Symptoms osteomyelitis of the long tubular bones

According to localization, lesions of the epiphyses, metaphyses and diaphyses are distinguished. The boundary between the epiphysis and metaphysis of a tubular bone in children is the metaepiphyseal growth zone (physis), the reaction of which to inflammation in children of different ages has its own characteristics. Thus. In children of the first year of life, due to the immaturity of the metaepiphyseal growth zones and the presence of transphyseal blood vessels, the inflammatory process from the metaphysis spreads to the epiphysis, often causing significant destruction. In this case, the growth zone itself is affected.

In terms of frequency of damage, the hip joint is in first place, and the knee and shoulder joints are in second and third place, respectively.

Hip joint damage

Variants of damage: pathological subluxation and pathological dislocation of the hip, pseudoarthrosis of the femoral neck, contracture or ankylosis of the hip joint.

Knee joint damage

Variants of damage: various deformations, shortening of a limb segment, contracture, ankylosis in a vicious position.

Diagnostic program: anamnesis, examination, additional research methods (radiography, and for children under 5 years of age, radiocontrast arthropneumography, ultrasound are mandatory).

Surgical treatment is indicated for limb deformations exceeding 10-15° in relation to the individual norm. Various types of osteotomy are used to correct angular deformations; in case of joint ankylosis, arthroplasty with demineralized bone-cartilage allografts or dura mater is indicated. In case of a combination of deformation and shortening of a limb segment, it is preferable to use transosseous compression-distraction osteosynthesis techniques.

Ankle joint damage

The lesion is quite rare - no more than 3.5%. Variants of lesion: various deformations in combination with subluxations in the ankle joint, contracture or ankylosis of the joint in a vicious position. Shortening of the limb is usually not expressed.

Surgical treatment is aimed at correcting deformities. Compensation for shortening is performed with orthopedic insoles or shoes. Lengthening of the lower limb is indicated when the difference in leg length is more than 4 cm.

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Shoulder joint damage in osteomyelitis

Variants of damage: pathological subluxation and dislocation of the shoulder, deformation and shortening of the humerus.

The diagnostic program is similar. Surgical treatment is indicated for shoulder dislocation, limitation of movement in the shoulder joint to 45-50°, shortening of the shoulder by more than 5-6 cm. Transosseous distraction osteosynthesis techniques are used.

Rehabilitation treatment - exercise therapy, massage and physiotherapy.

Elbow joint damage

Variants of damage: ankylosis in a vicious position, dislocation of the head of the radial bone, various deformations.

Surgical treatment is indicated for deformations exceeding 10-15°, joint ankylosis, and dislocation of the radial head. Corrective osteotomies with fixation of bone fragments with pins, arthroplasty of the elbow joint with dura mater, and transosseous distraction osteosynthesis techniques are used.

After arthroplasty, early restorative treatment is indicated: mechanotherapy, massage, physiotherapy procedures.

Wrist joint injury

Variants of damage: shortening of the ulna or radius with the formation of ulnar or radial clubhand, shortening of the forearm. Surgical treatment is indicated even at the initial signs of clubhand in order to prevent the progression of deformation and dislocation of the head of the radius. Transosseous distraction osteosynthesis techniques are used.

Pseudarthroses and defects of long tubular bones

False joints and defects of long tubular bones after acute hematogenous osteomyelitis are characterized by the loss of significant bone mass, inhibition of bone formation at the ends of bone fragments, and impaired blood circulation in the bone and soft tissues of the affected segment of the limb.

Diagnostic program: survey, examination, radiography, rheovasography, scintigraphy.

The main objectives of treating patients are to restore the integrity of bone tissue, stimulate reparative bone formation and improve blood circulation in the affected limb. Treatment at the first stage involves restoring the integrity of the bone, and at the second stage, restoring the length of the limb. Various types of bone grafting are used to restore the integrity of the bone.

Outpatient observation of children with consequences of acute hematogenous osteomyelitis - annual examination and testing up to 18 years, and during periods of active growth with damage to the lower extremities - 2 times a year. Annual spa treatment is indicated, twice a year - a complex of restorative treatment: massage, exercise therapy, physiotherapy procedures.

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Complications and consequences

The consequences of acute hematogenous osteomyelitis of the metaepiphyseal sections of tubular bones are varied: disruption of growth and ossification of the epiphyses, partial or complete destruction, reduction of the metaphyses as a result of total or segmental hypofunction or destruction of the metaepiphyseal growth zones. Damage to the tubular bones of the metaepiphyseal localization can cause the formation of a subluxation or dislocation in the joint, various deformations and shortening of the limb.

In young and middle-aged children, the metaepiphyseal growth zone acquires a barrier function due to the absence of blood vessels in it. The zone of spread of the inflammatory process is limited to the metaphysis and diaphysis, causing the formation of sequesters and, as a consequence, pathological fractures, pseudoarthrosis and bone defects.

In adolescents, the commonality of metaepiphyseal blood circulation with the spread of the inflammatory process to the epiphysis is again observed. At the same time, significant destruction of the metaepiphysis does not occur, the process is limited to arthritis and the formation of contracture or ankylosis of the affected joint in a vicious position.

In order to prevent orthopedic complications in the acute period of the disease, orthopedic prophylaxis is necessary using abduction splints and immobilizing plaster bandages. A child who has suffered acute hematogenous osteomyelitis should be examined by an orthopedist or pediatric surgeon to assess the condition of the musculoskeletal system and develop an individual rehabilitation plan.

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Diagnostics osteomyelitis of the long tubular bones

Diagnostic program - anamnesis, examination and additional research methods. Characteristic indications of a previous inflammatory process, the presence of scars on the skin of the thigh and buttock, hypotrophy of the soft tissues of the thigh, lameness, shortening of the lower limb, limitation of abduction in the hip joint, cranial displacement of the hip under load along the axis (the "piston" symptom), asymmetry of the gluteal folds in infants. As the child grows and the shortening of the limb progresses, secondary static deformations are added: pelvic tilt, static curvature of the spine and equinus position of the foot.

Additional research methods include ultrasonography (ultrasound), radiography, and, in children under 5 years of age, radiocontrast arthropneumography, which allows visualization of the femoral head in cases of impaired ossification.

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Treatment osteomyelitis of the long tubular bones

In case of ossification disorders, conservative treatment is indicated:

• to improve microcirculation and stimulate ossification of the pineal gland - pentoxifylline (Trental) and its analogues;
• massage;
• physiotherapy:
  • electrophoresis with calcium on the hip joint area;
  • electrophoresis with aminophylline (euphylline) on the lumbosacral spine.

Conservative treatment of pathological subluxation or dislocation of the hip in young children is carried out from the moment of their detection. Wide swaddling is used for 1-2 weeks, followed by transfer to a position with abduction of the lower limbs (Frejka pillow, Pavlik stirrups, Koshl splint). X-ray control after 1-2 months, indicating the normalization of the anatomical relationships in the affected joint, allows you to transfer the child to a position of abduction and internal rotation of the hips (I. I. Mirzoeva splint). At the same time, the child receives massage, exercise therapy, general strengthening treatment, physiotherapy and water procedures. The timing of splint fixation is determined individually by the nature and speed of recovery processes in the proximal end of the femur and acetabulum and ranges from 3 months to 1 year. The success of conservative treatment depends on the timeliness of diagnosis of pathological hip dislocation and the beginning of treatment.

Indications for surgical treatment

• Violation of anatomical relationships in the joint (irreducible pathological dislocation, subluxation) in children over 1 year old.
• Violation of the spatial orientation of the proximal metaepiphysis of the femur (varus, valgus and torsional deformities).
• Contracture of the hip joint that cannot be corrected conservatively.
• Ankylosis of the hip joint in a vicious position.
• False joint (defect) of the femur.

The condition for performing the operation is that at least 1 year must have passed since the inflammatory process. Open reduction of the hip is performed, and in case of destruction of the hyaline cartilage of the femoral head or acetabulum, arthroplasty of the hip joint with demineralized bone-cartilage allografts is performed. The operation, if indicated, is supplemented with shortening osteotomy in the lower third of the femur.

If a pseudoarthrosis of the femoral neck is detected (X-ray functional examination and ultrasound), plastic surgery of the neck with a migrating musculoskeletal complex from the greater trochanter (anterior portion of the gluteus medius muscle) or the iliac crest (sartorius muscle) is indicated.

Corrective osteotomy of the femur is performed as the second stage of surgical treatment after normalization of the structure of the bone tissue of the femoral neck.

After the operation, early rehabilitation treatment is carried out: exercise therapy, mechanotherapy, massage, physiotherapy. Dosed load on the operated limb is allowed after 8 months, and full - after 10-12 months after the operation.

Forecast

Orthopedic consequences occur in 22-71.2% of children with acute hematogenous osteomyelitis; they lead to early disability in 16.2-53.7% of patients. The severity of the formation of orthopedic pathology in children is determined not only by the age at which the child suffered the inflammatory process, but also by diagnostic difficulties, which lead to errors at the prehospital stage.

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