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5ACUTE HEMATOGENIC OSTEOMYELITIS IN CHILDREN Assistant Shirinov Hussein Isroilovich, Clinical resident Khudoykulova Malika Bakhodirovna, Assistant Berdiyarova Shokhida Shukurullaevna Student Turaev Shahzod Botir ugli Department of Clinical and Laboratory Diagnostics with the Course of Clinical and Laboratory Diagnostics of the Faculty of Postgraduate Education Samarkand State Medical University Republic of Uzbekistan, city of Samarkand https://doi. org/10.5281/zenodo. 749 7822
Annotation. Hematogenous osteomyelitis is one of the most severe purulent-septic diseases, leading, with untimely diagnosis and inadequate treatment, to the development of severe sepsis with multiple organ failure, septic shock and death. Improving the methods of diagnosis and treatment allowed to reduce mortality in acute hematogenous osteomyelitis to 0.5-2.7% and chronicity of the process to 3.1%, but orthopedic complications are still quite common in this pathology. Diagnosis of acute hematogenous osteomyelitis in children in the early stages of the disease presents certain difficulties, therefore, along with the generally accepted diagnosis, the use of modern non-invasive diagnostic methods (ultrasound, CT) is very important.
Keywords: Acute hematogenous osteomyelitis, children, C-reactive protein
ОСТРЫЙ ГЕМАТОГЕННЫЙ ОСТЕОМИЕЛИТ У ДЕТЕЙ
Аннотация. Гематогенный остеомиелит - одно из самых тяжелых гнойно-септических заболеваний, приводящих при несвоевременной диагностике и неадекватном лечении к развитию тяжелого сепсиса с полиорганной недостаточностью, септическому шоку и летальным исходам. Совершенствование методов диагностики и лечения позволили снизить летальность при остром гематогенном остеомиелите до 0,5-2,7 % и хронизацию процесса до 3,1 % но по-прежнему при данной патологии достаточно часто встречаются ортопедические осложнения. Диагностика острого гематогенного остеомиелита у детей в ранние сроки заболевания представляет определенныетрудности, поэтому наряду с общепринятой диагностикой очень важным является использование современных неинвазивных методов диагностики (УЗИ, КТ).
Ключевые слова: Острый гематогенный остеомиелит, детей, С-реактивного
белка
INTRODUCTION
Determination of the most significant diagnostic criteria, identification of the most frequent localization of the process and features of the clinical course, evaluation of the effectiveness of the complex treatment of hematogenous osteomyelitis in children.
MATERIALS AND METHODS OF RESEARCH
The work is based on the analysis of the results of diagnostics, clinic and treatment of 83 children aged from the neonatal period to 15 years old with acute hematogenous osteomyelitis, who were treated in the pediatric purulent surgical department of the Samara State Medical University Center for Pediatric Surgery over the past 4 years. All children underwent a clinical examination, laboratory, ultrasound, X-ray methods of investigation. Comprehensive treatment included surgery and intensive care.
RESEARCH RESULTS AND DISCUSSION
From the neonatal period to 2 years, 13 patients were treated, including 5 newborns; from 3 years to 15 - 70 children.
Localization of the process in acute hematogenous osteomyelitis:
- femur - 28 children;
- tibia tibia - 21 children;
- humerus - 13 children;
- bones of the forearm - 10 children;
- foot bones - 7 children;
- ischium - 3 children;
- patella - 1 child.
In children with acute hematogenous osteomyelitis from the neonatal period to 2 years, there was a lesion of the metaepiphyseal zone of long tubular bones (femur - 6 and shoulder - 7). The clinical picture in children of this age group was dominated by anxiety, refusal to eat, a symptom of "pseudoparalysis" or "pseudoparesis" (drooping of the limb), the presence of swelling in the joint area, and expansion of the subcutaneous venous network in the area of the affected joint. In two preterm infants with intrauterine infection, of the listed symptoms, only the symptom of "pseudo-paralysis" was observed. In a laboratory study, in the general blood test in children under 2 years of age, leukocytosis was noted (up to 13x109 g / l) with a shift in the formula to the left, a moderate increase in C-reactive protein was determined in a biochemical blood test; the procalcitonin test (PCT) was greater than 2 ng/ml. Ultrasound examination of the area of the affected joints in 11 children of this age group revealed thickening of the soft tissues and effusion in the joint already in the first 3 days of the disease. In two premature babies, ultrasound examination of the pathology in the joints did not reveal. X-ray changes in the area of the metaepiphyseal zone and joints were found in all children of this group: in 11 patients on the 3rd-5th day of the disease, an expansion of the joint space was noted, in two premature babies, foci of destruction were found in the metaphyses.
Children aged 3 to 15 years complained of pain in the affected limb, dysfunction of the limb (limitation of mobility), fever to febrile values (up to 38-39 °C), weakness, and fatigue. During a clinical examination in children with lesions of long tubular bones, a forced position of the limb was noted; 21 children (extramedullary phase) showed signs of soft tissue phlegmon (swelling, hyperemia, pain on palpation, local hyperthermia, fluctuation); in 27 observations (intramedullary phase) there was a slight swelling of the soft tissues, dilatation of the saphenous veins, pain on percussion, limitation of mobility and increased pain in the limb when trying to passive movements. Laboratory data indicated pronounced signs of inflammation (leukocytosis up to 19x109 g/l, an increase in C-reactive protein up to 100 mg/l, an increase in PCT over 5 ng/ml). Changes on bone radiographs were detected only by the end of 2 weeks from the onset of the disease (periostitis, foci of destruction) and therefore could not serve as criteria for early diagnosis. Ultrasound examination performed in patients with the intramedullary phase made it possible to detect an increase in volume and a decrease in muscle echogenicity already on the 3-5th day from the onset of the disease in cases of damage to the femur and humerus. Computed tomography (CT), performed in 8 patients with acute hematogenous osteomyelitis aged 3 to 15 years, revealed 3-4 days from the onset of the disease, muscle edema in the affected area and thickening of the periosteum. Systemic inflammatory response syndrome was diagnosed in 57 children with acute hematogenous osteomyelitis, sepsis was diagnosed in 3 cases.
The treatment of children with acute hematogenous osteomyelitis was complex and included surgery, immobilization, antibiotic therapy, adequate pathogenetic treatment, and symptomatic treatment.
Surgical treatment in children aged from the neonatal period to 2 years consisted in most cases of joint puncture and immobilization (Dezo bandage, Shede traction) - 6 patients. Two children underwent arthrotomy, joint drainage, and immobilization. Three patients of this age group underwent arthrotomy, opening of paraarticular phlegmon, osteoperforation of the metaphysis and immobilization. Two premature babies with intrauterine infection received conservative treatment.
Children aged 3 to 15 years with acute hematogenous osteomyelitis of long bones in 21 cases (patients with intramedullary phase of osteomyelitis) underwent osteoperforation with the introduction of intraosseous needles into the medullary canal for subsequent administration of antibiotics. In the extramedullary phase of the process (27 children), soft tissue phlegmon was opened and drained, osteoperforated with the introduction of intraosseous needles. For other localizations of the process (ischium, patella, foot bones), the purulent focus was opened and drained. After surgery, all children underwent immobilization necessary for this type of lesion using modern fixing materials.
During the puncture of the joint, the resulting pus was necessarily taken for sowing to identify the microbial flora and determine its sensitivity to antibiotics. In children from the neonatal period, pathogenic staphylococcus aureus was sown from the pathological focus in all cases. In older children, there was a predominance of Staphylococcus aureus (35 observations), epidermal staphylococcus was isolated from the focus in 5 patients, pyogenic streptococcus in 3, gram-negative flora (Proteus, Escherichia coli, Enterobacter, Acinetobacter) in 18 cases, in 18 observations of the growth of microflora not received.
When prescribing the first course of antibiotics, an empirical principle was used, giving preference to drugs from the group of II and III generation cephalosporins and aminoglycosides. When prescribing subsequent courses of antibacterial treatment, we were guided by the results of the obtained crops and the presence of affinity for the bone tissue in the preparations.
Anticoagulants, antiplatelet agents, proteolytic enzymes, immunopreparations were included in the complex treatment of children with acute hematogenous osteomyelitis for the purpose of pathogenetic influence. Symptomatic therapy consisted in the appointment of painkillers and anti-inflammatory drugs. All patients with acute hematogenous osteomyelitis received adequate infusion therapy aimed at replenishing the volume of circulating blood and detoxification. The complex treatment included sessions of hyperbaric oxygenation (HBO-therapy). Patients with sepsis used extracorporeal detoxification (hemofiltration).
When the condition stabilized, the patients were prescribed physiotherapy: magnetic fields, electrophoresis with antibacterial drugs, calcium chloride.
All children were discharged in a satisfactory condition.
There were no lethal outcomes. In two observations, the process passed into the chronic stage. All children over 3 years of age are recommended sanatorium treatment in a local specialized sanatorium. All patients are recommended for follow-up.
CONCLUSION
1. Acute hematogenous osteomyelitis is a severe purulent-septic pathology affecting children of all age groups.
2. The long tubular bones are most often affected in children with OSO.
3. Acute hematogenous osteomyelitis in children of different age groups has certain features of the course.
4. In the early diagnosis of acute hematogenous osteomyelitis, an important role belongs to minimally invasive methods - ultrasound and CT.
5. The key to successful treatment of acute hematogenous osteomyelitis is timely diagnosis and adequate pathogenetically substantiated treatment.
6. Children who have undergone CSO must be registered with the dispensary to decide on further rehabilitation.
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