Osteomyelitis of long tubular bones in children

Orthopedic consequences of acute hematogenous osteomyelitis of long tubular bones - violations of anatomical relationships in the joints (de-centering, subluxation, dislocation), deformities and shortening of limb segments, violation of bone integrity (false joint and defect), and impaired joint function in the form of contractures or ankylosis.

[1], [2], [3], [4], [5], [6]

Symptoms of the osteomyelitis of long tubular bones

By localization, the defeat of the epiphyses, metaphyses and diaphyses is isolated. The boundary between the epiphysis and the metaphysis of the tubular bone in children is the metaepiphysic growth zone (physis), the reaction of which to inflammation in children of different ages has its own characteristics. So. In children of the first year of life, due to the immaturity of metaepiphyseal growth zones and the presence of transfusion blood vessels, the inflammatory process from the metaphysis extends into the epiphysis, often causing considerable damage to it. Moreover, the growth zone itself is affected.

In terms of the frequency of the lesion, the hip joint is in the first place, and the knee and shoulder joint, respectively, in the second and third places.

Hip Joint Disease

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

Knee joint injury

Variants of lesion: various deformities, limb segment shortening, contracture, ankylosis in a vicious position.

Diagnostic program: anamnesis, examination, additional methods of research (radiography, and in children under 5 years obligatory radiocontrast arthropneumography, ultrasound).

Surgical treatment is indicated with deformities of the limb greater than 10-15 ° in relation to the individual norm. In order to correct angular deformations, various types of osteotomy are used, arthroplasty with demineralized bone-cartilaginous allografts or a dura is indicated in ankylosis of the joint. When combining deformity and shortening the limb segment, it is preferable to use the techniques of transosseous compression-distraction osteosynthesis.

Defeat of the ankle

Defeat is met quite rarely - 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, as a rule, is not expressed.

Surgical treatment is aimed at correction of deformities. Compensation for shortening is carried out by orthopedic insoles or shoes. Elongation of the lower limb is indicated with a leg length difference of more than 4 cm.

[7], [8], [9], [10]

Shoulder joint damage in osteomyelitis

Variants of defeat: pathological subluxation and dislocation of the shoulder, deformities and shortening of the humerus.

The diagnostic program is similar. Surgical treatment is indicated for shoulder dislocations, restriction of movements in the shoulder joint to 45-50 °, shortening of the shoulder over 5-6 cm. Methods of transosseous distraction osteosynthesis are used.

Restorative treatment - exercise therapy, massage and physiotherapy.

Lesion of the elbow joint

Variants of defeat: ankylosis in a vicious position, dislocation of the head of the radius, various deformities.

Surgical treatment is indicated for deformities exceeding 10-15 °, ankylosis of the joint, dislocation of the head of the radius. Apply corrective osteotomy with fixation of bone fragments with spokes, arthroplasty of the elbow joint with a dura mater, methods of transosseous distraction osteosynthesis.

After the arthroplasty, an early restorative treatment is shown: mechanotherapy, massage, physiotherapy.

Lesion of the wrist joint

Variants of defeat: shortening of the ulnar or radius bone with the formation of ulnar or radial armor, shortening of the forearm. Surgical treatment is shown even with the initial signs of scoliosis in order to prevent the progression of deformation and dislocation of the head of the radial bone. Apply methods of transosseous distraction osteosynthesis.

False joints and defects of long tubular bones

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

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

The main tasks of treating patients are restoration of bone tissue integrity, stimulation of reparative bone formation and improvement of blood circulation in the affected limb. Treatment at the first stage is a restoration of the integrity of the bone, on the second - the restoration of the length of the limb. In order to restore the integrity of the bone, various variants of bone plastic are used.

Clinical follow-up of children with consequences of acute hematogenous osteomyelitis - annual examination and examination up to 18 years, and in periods of active growth with lesion of the lower limbs - 2 times a year. The annual sanatorium treatment is shown, twice a year - a complex of restorative treatment: massage, exercise therapy, physiotherapy procedures.

[11], [12], [13]

Complications and consequences

The consequences of acute hematogenous osteomyelitis of metaepiphyseal sections of tubular bones differ in variety: disruption of growth and ossification of the epiphyses, partial or complete destruction, reduction of metaphyzes as a result of total or segmental hypofunction or destruction of metaepiphyseal growth zones. The defeat of the tubular bones of metaepiphyseal localization can cause the formation of subluxation or dislocation in the joint, various deformities and shortening of the limb.

In children of younger and middle age, the metaphyseal growth zone, in connection with the absence of blood vessels in it, acquires a barrier function. The area of the inflammatory process is limited by the metaphysis and diaphysis, causing the formation of sequesters and, as a result, pathological fractures, false joints and bone defects.

Adolescents again observe the generality of metaepiphyseal circulation with the spread of the inflammatory process to the epiphysis. However, significant destruction of 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 with the use of diverting tires and immobilizing gypsum dressings. A child who has suffered acute hematogenous osteomyelitis should be examined by an orthopedist or a pediatric surgeon to assess the condition of the musculoskeletal system and develop an individual rehabilitation plan.

[14], [15], [16], [17]

Diagnostics of the osteomyelitis of long tubular bones

Diagnostic program - the collection of anamnesis, examination and additional methods of research. Typically, the indication of the transferred inflammatory process, the presence of scars on the skin of the thigh and buttocks, the hypotrophy of the soft tissues of the thigh, lameness, shortening of the lower extremity, limitation of the hip joint withdrawal, hip displacement cranial with axial load ("piston" symptom), asymmetry of the gluteal folds babies. With the growth of the child and the progression of limb shortening, secondary static deformations are added: a skew of the pelvis, a static curvature of the spine and an equinus installation of the foot.

Of the additional research methods, ultrasonography (ultrasound), radiography, and in children under 5 years - radiopaque arthropneumography, which allows visualization of the head of the femur with violation of its ossification.

[18], [19]

Treatment of the osteomyelitis of long tubular bones

In violation of ossification, conservative treatment is indicated:

• to improve microcirculation and stimulation of ossification of the epiphysis - pentoxifylline (trental) and its analogues;
• massage;
• physiotherapy:
  • electrophoresis with calcium on the region of the hip joint;
  • electrophoresis with aminophylline (euphyllinum) on the lumbosacral spine.

Conservative treatment of abnormal subluxation or hip dislocation in young children is carried out from the time they are identified. Use a wide swaddling for 1-2 weeks with the subsequent transfer to the position with the dilution of the lower extremities (the pillow of Freik, the stirrups of Pavlik, the bus of Cough). X-ray control after 1-2 months, indicating the normalization of anatomical relationships in the affected joint, allows you to transfer the child to the position of breeding and internal rotation of the hips (II Mirzoyeva's tire). Simultaneously, the child receives massage, exercise therapy, restorative treatment, physiotherapy and water procedures. The timing of fixation by the tire is determined individually by the nature and speed of the restorative processes at the proximal end of the thigh and the acetabulum and range from 3 months to 1 year. The success of conservative treatment depends on the timeliness of the diagnosis of abnormal hip dislocation and the initiation of treatment.

Indications for surgical treatment

• Violation of anatomical relationships in the joint (unrecoverable pathological dislocation, subluxation) in children older than 1 year.
• Violation of the spatial orientation of the proximal metaepiphysis of the femur (varus, valgus and torsion deformations).
• Hip joint contraction, not eliminated conservatively.
• Ankylosis of the hip joint in a vicious position.
• False joint (defect) of the femur.

The condition of the operation - after the transferred inflammatory process should expire at least 1 year. Perform an open correction of the thigh and when the hyaline cartilage of the femoral head or the acetabulum is destroyed - arthroplasty of the hip joint by demineralized osteochondral allografts. Operation on indications is supplemented with shortening osteotomy in the lower third of the femur.

When the false neck of the femoral neck is identified (X-ray functional examination and ultrasound), neck plastic is shown by a migrating musculoskeletal complex from a large trochanter (anterior portion of the median gluteus muscle) or the crest of the ilium (the sartorius muscle).

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

After the operation, an early restorative treatment is performed: exercise therapy, mechanotherapy, massage, physiotherapy. Dosage load on the operated limb is allowed after 8 months, and full - 10-12 months after the operation.

Forecast

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

[20], [21], [22]