Surgery, with Special Reference to Podiatry Part 13

Chronic periost.i.tis is not really a disease itself, but a manifestation of the reaction of the periosteum to some irritant.

+Treatment+ of the condition depends, first of all, upon a recognition of the cause and a removal of the cause, when possible. In many cases, especially those in which no pain is present, nothing in the way of therapeutic measures can be done.

The chronic thickening of the periosteum, seen in many definite bone diseases, will be mentioned under those diseases.

+Osteomyelitis.+ Infectious osteomyelitis is acute suppuration of the bone, always due to the infection of the bone marrow by pyogenic microorganisms. The process is essentially like the process seen in furuncle, and begins in the marrow of the alveolar s.p.a.ces, which communicate freely with each other, but are enclosed by a dense sh.e.l.l of cortical bone. Hence the process may quickly at first involve the entire marrow of an infected bone, because the products of bacterial infection are retained in this dense sh.e.l.l, while the primary focus can only be reached by extensive bone operation.

Most cases are due to the staphylococcus pyogenes aureus and a few to the streptococcus. Typhoid bacilli may cause suppuration. The infecting organism is present in pure culture but sometimes a mixed infection occurs, and such cases are said to be severe.

In cases of chronic osteomyelitis with open sinuses and exposed bone, a great variety of organisms, pathologic and saprophytic, may be present. Hence infectious osteomyelitis is not a specific disease, but is acute inflammation of bone that may be produced by any one of a variety of pathogenic organisms, or by a mixed infection.

Any pyogenic organism which can be carried in the blood may be deposited in the bone and produce suppuration. Some of these organisms may settle by preference in the bone marrow, others beneath the periosteum, or in the joint.

Certain general causes favor the occurrence of osteomyelitis. Children are chiefly affected and it occurs in boys about three times as often as in girls. Acute osteomyelitis frequently occurs after injuries of moderate severity, because such injuries may lower resistance of the bones and make them unusually susceptible to pyogenic infection. One of the commonest causes is the infection of a compound fracture, and before the days of asepsis, such cases were very frequently fatal.

Under modern methods the infection, when it does occur, is generally slight, although the destruction of bone may greatly delay healing and may lead to the formation of small sequestra and indurating sinuses.

Infection of a similar sort may occur subsequent to amputation.

Osteomyelitis nearly always begins in the diaphysis of the long bones, usually near the epiphyseal line. This is an important point, clinically, because tuberculosis practically begins in the epiphysis.

In rare cases, however, osteomyelitis begins in the epiphysis, and so may simulate tuberculosis. The femur and tibia are the bones most frequently attacked, but no bone is exempt. Usually only one bone is affected, but cases of multiple bone infections are not rare.

The primary area of infection is always in the bone marrow. The bony trabeculae and the cortex are destroyed only secondarily. The process nearly always begins in the diaphysis, but then may extend into the epiphysis and produce suppuration of the joint. Once the organisms have gained access to the marrow, they produce a toxin which causes necrosis of the adjacent marrow cells, and this necrosis may extend over a very considerable portion of the bone before marked infiltration with leucocytes occurs. The infection usually extends quite early through the dense cortex by way of the Haversian ca.n.a.ls, and produces an inflammatory exudation and suppuration between the periosteum and the outer layer of the cortex, which is designated _subperiosteal abscess_.

Such an abscess may strip the periosteum from the bone over very extensive areas. The infection may then extend to the adjacent soft parts, muscles and subcutaneous tissue, and form an abscess outside the periosteum.

If, from spontaneous opening of the abscess or from operation, a fatal result is avoided, the infective process may be limited and the process of repair may begin.

As a rule, a portion of the infected marrow and cortex become completely necrotic, and the lime-bearing portion of the bone persists as a more or less extensive sequestrum.

The periosteum in the early stages may be separated from the bone by a collection of pus, and in such cases it appears as a thin fibrous membrane beneath the muscles, separated from the bone by the abscess cavity.

Secondary changes occur in the soft tissues surrounding the seat of an acute suppuration of bone. During the acute stage there may be a definite abscess of the soft parts, with an infiltration which simulates phlegmonous inflammation, or, by rupture of the abscess, various sinuses may be formed leading down to the necrotic foreign body. In long continued cases the skin and subcutaneous tissues become thickened by the formation of scar tissue, due to the presence of the involucrum and the persistence of sinuses, and by thickening of the soft tissues, an affected limb may for years be nearly twice its normal size.

+Symptoms.+ The disease usually begins with a sharp onset, the first symptom being a sudden localized pain in the vicinity of the epiphyseal line, or in the shaft of some one of the long bones. This pain is extremely intense, and in typical cases is most excruciating.

Motion of the joints at this time is not painful, but the pain produced by percussing the bone, even lightly, may be intense. An extremely valuable diagnostic point is continued gentle pressure at some point over the shaft of the bone at a distance from the point of greatest constant pain.

Usually, at a very early period, there appears swelling of the soft parts about the bone. This swelling, at first, is neither hot nor red, but soon becomes edematous, red, and shows pitting on pressure, and at that time may simulate acute phlegmon.

In some cases the adjacent joint early becomes tender, hot and swollen, and this may occur even when there is no real extension of the infectious process to the joint itself. If extension does occur to the joint, swelling, tenderness, and pain on motion become more intense. The temperature usually is elevated to a considerable degree-103F. or 104F.-and usually the pulse is greatly accelerated.

Evidence of const.i.tutional disturbance and absorption of infectious material occur early. The tongue is dry, coated and tremulous; the face is drawn and flushed. Delirium of a mild type is a very common symptom, and in some cases this delirium may persist for a considerable length of time after the bone has been drained. Abscess of the soft parts may give deep or superficial fluctuation. Sinuses may appear. The leucocyte count is usually very high-25000 to 35000, and chiefly of a polynuclear type.

Such a clinical picture is perfectly distinct, and it is difficult to overlook typical cases, especially after the fluctuation in the soft parts has occurred. The diagnosis of early cases, however, is sometimes very difficult, and even in the hands of experienced men, who have the lesion in mind, is frequently impossible. Even in severe cases, occasionally the pain itself is not severe for several days, when there may come a sudden exacerbation of symptoms.

In the chronic stages of osteomyelitis the symptoms are usually characteristic. The limb is enlarged, the enlargement being partly due to thickening of the soft tissues, but chiefly to the formation of the involucrum. Usually running down to the sequestrum, are enormous sinuses, from which comes a foul, purulent discharge. On pa.s.sing a probe, dead bone can be felt at the bottom of the sinuses. It must be borne in mind, however, that in a great many cases, after attacks of osteomyelitis of moderate severity, small localized abscesses are formed in the shaft of the long bones, with no sinus communicating with the surface. An abscess of this description, as has already been stated, is always surrounded by a wall of dense bonelike cortical bone.

Such an abscess may persist for years with no symptoms beyond a moderate enlargement of the shaft of the bone at the point of abscess, and the enlargement may be so slight that it is not recognized by the patient. In other cases the entire shaft may be enlarged, but the bone may not be tender. In most cases, however, such a localized abscess sooner or later gives rise to recurring attacks of pain, which, as a rule, are extremely violent. The intervals between such attacks may vary from days to weeks, or to months, or even to years. The attacks of pain may come on, apparently, perfectly spontaneously. a.s.sociated with these attacks of pain, the bone over the abscess usually is exceedingly tender to touch. With the attacks of pain may come a rise of temperature, or in some cases, there may be no disturbance of the general condition. This kind of abscess may be of small size, no larger than a pea, or may involve a great portion of the shaft of the bone; in such abscesses no definite sequestrum may ever form.

The recognition of such conditions depends upon recurrent attacks of violent pain over circ.u.mscribed areas of bone, with or without const.i.tutional disturbance, and nearly always with extreme local tenderness.

+Treatment.+ In the acute stage there is suppuration of the marrow, more or less extended throughout the shaft, with often a subperiosteal abscess and perhaps abscess of the soft parts.

The indications are the same as in any other acute suppuration; the pus must be evacuated and the bone cavity drained. This demands not only an incision into the soft parts, but an opening into the shaft of the bone. If a piece of necrotic bone is present, it should be removed.

In the chronic stage there is usually an old necrotic shaft perforated by sinuses, and often freely movable, inclosed by a sh.e.l.l of dense periosteal bone. The sequestrum must be removed, but the bony defect fails to heal, and for months persists as a filthy, discharging cavity, with the constant danger of secondary infection and phlegmon, or erysipelatous inflammation. The healing of this cavity is very difficult and requires a very long time.

Many methods have been tried for the filling of these bone cavities with blood clot, iodoform and oil of sesame, but they have not been successful, because it is almost impossible to render such cavities absolutely aseptic.

+Tuberculosis of Bone.+ Tuberculosis of bone is always dependent upon infection of the marrow of bone by the tubercule bacillus. This germ obtains entrance to the bone marrow and causes the formation of miliary tubercules which arise from the proliferation of the connective tissue of the marrow around the primary tubercule. Other secondary tubercules are formed by extension of the tubercule bacillus. The centres of these tubercules become caseous, and, by fusion of adjacent caseous areas, also cause softening in the bone marrow.

The tuberculous process, as a rule, begins in the epiphysis in the long bones, and may affect any of the bones.

+Symptoms.+ In cases of tuberculous disease confined to the bones alone, the first symptom usually is pain, which ordinarily is not severe and has a gradual onset. Oftentimes, at first on palpation, no difference in the shape of the bone can be detected.

Toes affected by a tuberculous process, slowly enlarge at first without heat or pain; ultimately the skin becomes thickened, and reddened, and the digit is painful to pressure or motion. Oftentimes the skin is perforated at one or more points by sinuses lined with tuberculous granulations, through which caseous pus is discharged.

The diagnosis in these cases always lies between tuberculosis, actinomycosis, syphilis, and osteomyelitis, and exact determination of the origin of the cause oftentimes can be made only by inoculating animals with a discharge from the sinus, or by detection of pyogenic organisms, or of the miliary tubercule, the histologic unit of tuberculosis, or by detecting the peculiar yellow bodies seen in actinomycosis.

+Treatment.+ From a clinical point of view tuberculosis of bone should be considered in the same category as malignant disease, and the indications for treatment in all cases of tuberculous bone disease are the same as in malignant disease; which is, complete removal of the infected area, whenever it is possible.

In some cases the mere opening and curetting of tuberculous areas in bone is oftentimes enough to set up sufficient reaction in the bone and in the surrounding tissues, to put an end to the tuberculous process. Complete resection of bones may at times be avoided by this treatment.

In addition to the local treatment of opening, curetting and drainage, or the complete excision of the bone, the greatest care should be employed in the management of the general hygiene of the patient, including feeding and fresh air. Often removal to a climate which is unfavorable to the development of tuberculosis in general, is also extremely desirable.

+Syphilis of Bone.+ The lesions produced in bones by syphilitic infection may be congenital or acquired, and, as in other syphilitic lesions, the manifestations may be protean.

Most children with congenital syphilis, show an irregularity of the epiphyseal line, which results in the latter becoming markedly toothed, instead of const.i.tuting a straight line across the bone, at right angles to the long axis of the shaft.

Besides the irregularity of the epiphyseal line, three other changes are seen in the bones of syphilitic infection. The most common lesion is one which affects the periosteum and leads to the formation of periosteal bone. This periosteal formation may occur either in congenital or in acquired syphilis, and it may affect one or many bones. In some cases there is an enormous thickening of the epiphysis of the bones, and as a result of the epiphyseal thickening, secondary changes in the joints occur, so that the thickening of bones and the changes in the facets of the joints, suggest fracture or dislocation.

In other cases, the thickening affects only the shafts of the long bones, generally of the leg or arm, although no bones are exempt. In some cases, both in the congenital and acquired forms, there may be marked proliferation of the endosteum of the bone, with or without thickening of the periosteum, although thickening of the periosteum usually is present. This process, as a rule, affects one bone in its entirety, and most commonly affects the bones of the lower leg, notably the tibia. As a result of these changes the bones are enlarged and thickened, and in some cases, from endosteal thickening, the marrow ca.n.a.l is very largely or entirely obliterated. In some cases true gummata of the bone are formed. These gummata may appear in the spongy portion of the bone, sometimes in the shaft, or in the epiphysis. They also appear to be formed in the lower layers of the periosteum and lead to circ.u.mscribed nodular thickenings on the surface of the bone.

+Symptoms.+ These vary with the different pathologic conditions present.

The periosteal thickening may occur at any time of life over any bone of the body.

The presence of circ.u.mscribed periosteal thickening of bone in itself should always lead to the suspicion of the presence of syphilis.

Pain, as a rule, is only very slight, and the diagnosis depends upon the history and the detection of other syphilitic lesions.

The cases in which there is both endosteal and periosteal thickening, occur chiefly in children and are of a congenital nature.

The physical symptoms are very characteristic. The bone usually affected is the tibia, which is enlarged to a most marked degree, and often shows a p.r.o.nounced bowing forward, similar to the bowing and thickening of the tibia seen in osteitis deformans. The bone is extremely dense and obviously heavier than normal. The bones are moderately tender to pressure, but have nothing like the extreme tenderness noted on pressure in osteomyelitic bones.

In cases of gummata of bones the symptoms vary. In some cases the gummata are on the surface of the bone, especially the sternum, and at times on the long bones. In such cases there appear a softening and reddening of the skin about the affected area, which remains indolent for a long time.

If such an area opens spontaneously, or is opened by incision, the contents are seen to be composed of a yellow, rather gelatinous material, quite like the caseous material from a tuberculous abscess.

+Treatment.+ In most cases the regular anti-syphilitic treatment is indicated. In cases of periosteal thickening, the results vary with the time at which the treatment is begun. In the early cases, a thorough anti-syphilitic treatment may lead, after a varying length of time, to complete disappearance of the newly formed periosteal bone.

On the other hand, if the periosteal process has lasted for a long time and the bone has become densely cortical, although anti-syphilitic treatment may lead to a diminution of the localized pain, the dense bone does not disappear. In cases of combined endosteal and periosteal thickening, the pain usually disappears under anti-syphilitic treatment but the changes in the bone persist.

+Osteomalacia+ is an acquired disease which causes marked softening and changes in the bones. The disease begins irregularly and often progresses with or without remissions. The progress is more marked during pregnancy. The first sign is pain in the bones, which is increased by pressure, and this is especially true of pressure over the ribs. There are also muscular cramps and contractures.