CT picture of the periostite of the femoral bone. X-ray symptoms

One of the main features of the periosteum - the creation of a new bone tissue. In an adult, in normal conditions, this function is almost terminated and appears only at some pathological conditions:

• in injuries;
• in infectious and inflammatory processes;
• with intoxication;
• with adaptation processes.

Normal periosteum on radiographs does not have its own shadow display. Even thickened and palpable periosteum at ordinary post-traumatic periodites is very often not determined in the pictures. Its image appears only with increasing density as a result of occurrence or osxification.

Periosteal reaction - This is a periosteum reaction to this or that irritation, both with the damage to the dice and the surrounding soft tissues and the pathological processes in the organs remote from the bone.

Periostitis - the reaction of the periosteum on inflammatory process (injury, osteomyelitis, syphilis, etc.). If the periosal reaction is due non-inflammatory process (adaptation, toxic), it should be called periostosis. However, this name did not fit among radiologists, and any periostal reaction is usually called periostitis.

The X-ray picture of the periodites is characterized by several features:

• drawing;
• form;
• contours;
• localization;
• length;
• the number of affected bones.

Drawing periosal layers Depends on the degree and character of the ossification.
Linear or detached periostitis It looks on a radiograph as a strip of dimming (osxification) along the bone separated from it with a light gap due to exudate, osteoid or tumor tissue. Such a picture is typical for the acute process (acute or exacerbation of chronic osteomyelitis, the initial phase of the formation of periosal bone corn or malignant tumor). In the future, the strip of dimming can expand, and the light gap to decrease and disappear. Periosteal layers merge with a cortical bone layer, which thickens in this place, i.e. arises hyperostosis. For malignant tumors The cortical layer is destroyed, and the drawing of the periosal reaction on radiographs changes.

Laminate or bulbous periostitis It is characterized by the presence on the radiograph of several alternating strips of dimming and enlightenment, which indicates the progressive progression of the pathological process (chronic osteomyelitis with frequent exacerbations and short remissions, Sarcoma of Yinga).

Baked periostitis The pictures are represented by a relatively wide, uneven, sometimes intermittent shadow reflecting the integrity of soft tissues at a greater distance from the bone surface during the progression of the pathological (more often inflammatory) process.

A variety of fridge periostite can be considered lace Periosteit during syphilis. It is characterized by the longitudinal wave of periosal layers, which, besides, often have an uneven wavy contour ( comb shaped periostitis ).

Needle or spiculous periostitis It has a radiant pattern due to thin strips of dimming, located perpendicularly or fan-forming to the surface of the cortical layer, the substrate of which are paravazal asset as cases surrounding vessels. This option of periostitis is usually found with malignant tumors.

Form of periosal layers maybe the most diverse ( spine-shaped, cloth, buggy , I. grebidoid etc.) depending on the localization, length and nature of the process.

Of particular importance periostitis in the form of a visor (visor Kodmana ). Such a form of periosal layers is characteristic of malignant tumors that destroy the cortical layer and peeling periosteum, which forms an integrated "canopy" over the surface of the bone.

Contours of periostal layers on radiographs are characterized by the shape of the outline ( smooth or uneven ), sharpness of the image ( clear or fuzzy ), discreteness ( continuous or intermittent ). Under the progression of the pathological process, the contours of periosal layers are non-letters, intermittent; When sinking - clear, continuous. Smooth outlines are typical for a slowly occurring process; With the wave-like course of the disease and the uneven development of the periostite, the contours of the layers become nervous, wavy, gear.

Localization of periosal layers Usually directly related to localization of the pathological process in the bone or the surrounding soft tissues. So for the tuberculous bone damage is typical, epimethafizar localization of periostitis, for non-specific osteomyelitis - metadiahizar and diaphizar, during syphilis periosal layers are often located on the front surface of the tibia. Certain patterns of localization of the lesion are found at various bone tumors. Length of periosal layers fluctuates in large limits from a few millimeters to total diaphysis damage. Distribution of periosal layers by skeleton It is usually limited to one bone, in which the pathological process is localized, which caused the reaction of the periosteum. Multiple periodites are found in rickets and syphilis in children, frostbizes, diseases of the hematopoietic system, diseases of the veins, Engelman diseases, chronic professional intoxication, with long-term chronic processes in the lungs and pleura and under congenital heart defects ( periostost Marie - Bamberger).

Assistant Department of Oncology with Course

radiation diagnosis and radiation therapy Yurkovsky A.M.

Sequestration and sequesters. This is the process of rejection of the dead section of the bone. A sequestrate is called an uncrolized bone fragment, tightened from the living maternal bone and located in a special cavity (sequestral box) containing a pump or granulation tissue. Sequestration is the subsequent phase of septic infectious osteenecosis.
X-ray assessment sequestration It consists of two signs: a free intense shade a piece of bone tissue; Enlightenment stripes (demarcation shaft) surrounding this shading from all sides.

Depending on bone structuresThe sequesters are divided into spongy and compact (cortical). Sponge sequesters are more often epiphyseal fragments of tuberculosis origin, and compact, arising from damage to diaphysis, have osteomyelitic origin.
Cortical sequesters In turn, divided into two groups - circular and segmental.

Circular sequestrel - This is a dead section of the bone in full thickness throughout the entire cylinder of a long tubular bone. Segmental sequestrate is called bone necrosis sites only for some segment, and not the entire cylinder of the bone.

Both circular and segmental sequesters There are peripheral and central. If donysome bone layers, located closer to the periphelter, are formed peripheral (external) sequesters. When the bone areas located closer to the bone marrow canal are formed, internal (central) sequesters are formed.

Depending on the location in relation by sequestral box distinguished sequesters: located inside the cavity; located outside the cavity (in soft tissues); Penetrating (penetrating), i.e. one end of the sequestration is in soft tissues, and the other part is located in the sequestral cavity.

Sexifying periostitis. The periosteum is normal and with a soft thickening (serous, purulent, albumin, fibrous periostites, etc.) during x-ray does not form shadows and is not detected. It becomes visible only in the origin of the thickened periosteum. The deadlines for the start of occurrence of periostitis in children by 7-8, in adults for 12-14 days from the beginning of the disease (first clinical manifestations).

Aiming radiograph of the right thigh in a direct projection. During this diaphysis - hyperostasis with foci of destruction; layered bulbous periostitis; On the outer surface in the proximal and distal departments, a typical symptom of periosal "visor". In the lower department, from the inside, the symptom of "visor" with needle periostitis is also detected. Yingang's tumor

Distinguish the following precipitating periostits: linear; layered or bulbous; fringe or broken; lace or grains; needle or spicho-shaped; and a special form of periostite in the form of the so-called raised (malignant) visor.
Linear periostitis. On radiographs parallel to the shade of the cortony bone layer and a slight darkening strip (linear shadow), separated from the body of the bone with a light gap.

Linear periostitis Specifies to the beginning inflammatory process, most often about hematogenous osteomyelitis or on exacerbation of chronic inflammation.
Layered, bulbous periostitis. On radiographs along the bone, several alternating light and dark strips will be revealed, outgoing as if from one point and layers located above the other. The basis of this phenomenon is the wave-like, the impetuous nature of the development of the process, which is more often observed at a ying tumor and less often with inflammatory diseases (Fig. 18).

First manifestation diseases accompanied by periostitis, then a pause comes in growth, during which the ossification of the periosteum is formed. The re-progression of the process leads to the formation of new layers of the besifying periostitis, which creates a picture of a bully multi-layer vengeance of the periosteum.

Torn, baked periostitis - the subsequent phase of linear periostitis, when accumulated under the thickened periosteum of the Pump, breaking into soft fabrics And multiple disorders of the integrity of the periosteum form a broken, fringe form.

Lace or zobneoid periostitis It is typical for tertiary. Its drawing on the radiograph is a mapping of multiple periosal and subperiodal gums located in the range of long diaphysis tubular bones (more often tibial). Gumms on radiographs are manifested in the form of multiple not very clear oblong enlightenments against the background of a pronounced sclerosis, which sprinkled with the cortical layer of periosal layers.

Needle, spiculate periostitis - Pretty demonstrative form of periosal reaction, manifested by the formation of numerous subtle processes (Spiculae), growing perpendicular to the diaphysia. These needles are an ossification of newly formed tissue along blood vessels. This form of periostitis used to be considered pathogenic for osteogenic sarcoma. Currently, it is already known that such a radiant pattern with transverse is estimated may be observed with slowly current osteomyelitis and syphilitic bones.

Sexifying periostitis in the form of a raised visor. Its essentially is that the tumor process from the middle of the bone, a well-in-law cortical layer, moves the periosteum, in which reactive changes arise in the form of a besifier periodite. Subsequently, the gap of the periosteum arises and the characteristic picture occurs in the form of a raised, peeling and proposed on the border of the tumor mass and normal unchanged bone. The presence of this symptom indicates a relatively slow tumor growth.
With quick it growing periostal reaction It happens unfriendly or absent at all and this symptom does not have time to impose.

X-ray diagnostics. Research methods: Polyprosection X-ray (Fig. 3), with one-sided development, a choice of projection under the control of translucent can help. Fabrics with a simple periostilite transparent for X-rays and therefore radiographically not detected.

The substrate of the shadow with a precipitating periostite (periosal osteophyte) is an internal, cambial layer of periosteum; It causes a linear or stripped shadow on radiographs on the surface of the bone or close to it outside the fitting of the cartilage and attaching tendons and ligaments. This shadow can be the most thick in the diaphysides of tubular bones, thinner in metaphizes and even thinner on the surface of short and flat bones, respectively, the different thickness and costeral activity of the Cambinal layer of the periosteum in these places. The shadow of the periosal osteophyte can be separated from the surface of the bone of the neo-windows, the X-ray-transparent part of the Cambinal layer of the periosteum (non-massimized periosal osteophyte) thickness from a fraction of up to several millimeters, in addition, the osteophyte shadow can be separated from the cortical layer of the extravasation (serous, purulent, blood), tumor or granulation.

The slow development of the periostite (for example, with a diffuse syphilitic ostepheryrity) or the subsoil of its cause causes an increase in the intensity (often and homogenization) of the shadow of periosal impositions on radiographs and the merger to assimilate them with the surface of the subject to dice (assimilated periosal osteophyte). With the reverse development of the periostite, the shadow of the periosal osteophyte is also thinned.

The rate of development of periosal layers, density, length, thickness, degree of assimilation with the cortical layer, outlines and structure play an important role in differential diagnosis Causes of occurrence of periostitis. For acute development the main disease, the high reactivity of the body and the small age is the first, weak shadow of the periosal osteophyte can be detected after a week from the beginning of the disease; With these prerequisites, the shadow can significantly increase the thickness and length. The shadow of the line, or stripes, periostitis can be smooth, large or fine, incorrect interrupted. The higher the activity of the main disease, the less rosary on X-ray diffuses the external outlines of periosteal impositions, which can be smooth or uneven - prototype, fringeless, in the form of flames or needles (especially with a malignant osteogenic tumor) perpendicular to the cortical layer of the dice (due to chambling ossification Cells along the walls of vessels stretching out of the cortical layer during the trapping of the periosteum).

The frequency, the repetition of the activity of the causing periostitis causes (in pus breakthrough, the relapses of infectious flares, the pushing growth of the tumor, etc.) can cause a layered pattern of the structure of the periostite on radiographs. The introduction of elements of the main disease into the fabric of the periosal osteophyte leads to unevenness, to the enlightenment in the shade of it (for example, with a "lace" periostitis) and even a complete breakthrough of the central part of the shadow (for example, with a malignant tumor, less often with osteomyelitis), due to What the edges of the breakthrough are similar to the visors.

The shadows during the periostitis should be differentiated with normal anatomical protrusions (inter-site ridges, journeys), skin folds, ligaments, tendons and muscles, laminated pattern of the cortical layer at a ying tumor

Fig. 3. X-ray diagnostics of periostite: 1 - linear clear shadows of a non-dissimilar periosal osteophyte with a relapse of chronic osteomyelitis of the shoulder bone; 2 is a linear non-intense, fuzzy shadow of a fresh unassimulated periosal osteophyte near the rear surface of the thigh diaphysis during acute osteomyelitis of three weeks ago; 3-shadow of a partially assimilated periosal osteophyte with fringeless outlines at the "tumor-shaped" hip osteomyelitis; 4 - delicate needle shadows of costhics along the vessels of the periosteum; 5 is an assimilated dense periosal osteophyte on the front surface of the tibia with the zoirs with gummimonian ostepheritto; 6 is an assimilated periosal osteophyte with a lace pattern due to hole-haired enlightenments (gumm) on the dice of the elbow bone with gummime and diffuse osteoperity; 7 is an intense, thickened shadow of an assimilated periosyl osteophyte with a chronic cortical abscess; cavity with a sequester in the thickness of osteophyte; 8 is an asymmetrically located shadow of the assimilated periosal osteophyte of the tibia in a chronic trophic tibia ulcer.

The inflammatory process usually begins in the internal or outer layer of the periosteum (see the full arch of knowledge) and then applies to the rest of its layers. Due to the close connection between the perception and the bone, the inflammatory process easily moves from one tissue to another. Solving the issue of the availability of currently periostitis or osteoperity (see the full arch of knowledge) seems difficult.

A simple periostitis is an acute aseptic inflammatory process in which hyperemia is observed, a slight thickening and serous cellular infiltration of periosteum. It develops after bruises, fractures (traumatic periostitis), as well as near inflammatory foci, localizing, for example, in bones, muscles, and so on, accompanied by pains on a limited area and swelling. Most often the perception is affected in the bones sites, weakly protected by soft tissues (for example, the front surface of the tibial bone). The inflammatory process mostly subsides quickly, but sometimes it can give fibrous growths or accompanied by the postposition of the lime and the neoplasm of bone tissue - osteophytes (see the full arch formation) - the transition to a precisfactory periostitis treatment at the beginning of the anti-inflammatory process (cold, peace and so on), in the future - Local use of thermal procedures. In severe pains and the protracted process, ionoforosis with novocaine, diathermy and other are used

Fibrous periostitis develops gradually and flows chronically; manifests itself with corn fibrous thickening of the periosteum, tightly soldered with the bone; Arises under the influence of the last years of irritation. The most significant role in the formation of fibrous connective tissue is played by the outer layer of periosta. This form of periostitis is observed, for example, on the tibia in cases of chronic shin ulcers, with bone necrosis, chronic joint inflammation and other

Significant development of fibrous tissue can lead to superficial bone destruction. In some cases, with a significant duration of the process, the neoplasm of bone tissue is noted, etc. The direct transition to the besifiant periostitis to eliminate the irritant is usually observed. reverse development process.

Purulent periostitis - a frequent form of periostitis it is usually developing as a result of an infection that penetrates the injury to the periosteum or from neighboring organs (for example, the periostitis of the jaw during the caries of the teeth, the transition of the inflammatory process from the bone to the periosteum), but may occur and hematogenic way (for example, metastatic periostitis in peymia); There are cases of purulent periostitis, in which the source of the infection cannot be detected. The causative agent is purulent, sometimes anaerobic microflora. Purulent periostitis is a mandatory component of acute purulent osteomyelitis (see the full vault of knowledge).

Purulent periostitis begins with hyperemia, serous or fibrinous exudate, then the purulent infiltration of periosteum comes. The hyperemic, juicy, thickened periosteum in such cases is easily separated from the bone. The loose inner layer of peripost is impregnated with a pus, which then climbs between periosit and bone, forming a subperiodal abscess. With a significant distribution of the process, the period is extended at a considerable distance, which can lead to disruption of dice and superficial necrosis; Significant necrosis, exciting whole areas of the bone or all the bone, occur only when the pussy, following the vessels in the gaverc canals, penetrates the bone marrow cavities. The inflammatory process may stop in its development (especially with timely removal of pus or with an independent breakthrough it outwards through the skin) or go to the surrounding soft tissues (see the full arch of the phlegmon knowledge) and on the bone substance (see the full knowledge of the knowledge of the knowledge). In the metastatic pyoderma, the periosteum of any long tubular bone is usually affected (most often hips, tibia, shoulder bone) or at the same time several bones.

The beginning of the purulent periodite is usually acute, with an increase in temperature to 38-39 °, with chills and an increase in the number of leukocytes in the blood (up to 10,000 -15,000). In the field of lesion strong painIn the affected area, swelling, painful in palpation, is trying. With continuing accumulation of pus usually, it is soon possible to note the fluctuation; The process can be involved surrounding soft fabrics and skin covers. The course of the process is in most cases acute, although there are cases of primary-protracted, chronic flow, especially in weakened patients. Sometimes it is observed clinical picture without high temperatures and severe local phenomena.

Some researchers allocate acute form Periostitis - malignant, or more acute, periostitis, with it, exudate quickly becomes rotten; Nobuchhesha, gray-green, dirty type of periosteum is easy to break on the shreds, disintegrates. In the shortest possible time, the bone is deprived of the periosteum and enveloped by a layer of pus. After a peripost breakthrough, a purulent or purulent inflammatory process passes by type of phlegmon on the surrounding soft tissues. The malignant form may be accompanied by septicopemia (see the full arch of Knowledge of sepsis). The forecast in such cases is very heavy.

IN initial stages The process is shown the use of antibiotics both locally and parenterally; In the absence of effect, the early opening of the purulent focus. Sometimes to reduce tissue tanks, it is resorted to cuts even before the detection of fluctuations.

Albumin (serous, mucous) Periostitis first described A. Ponce and Olle (L. Oilier). This inflammatory process in the periosteum with the formation of an exudate, accumulating substitute and having a kind of serous-mucous (dyed) liquid, rich albumin; It detects separate fibrin flakes, a few purulent tales and cells in the state of obesity, red blood cells, sometimes pigment and fat drops. Exudate is surrounded by a granulating cloth of brown-red. Outside, the granulation tissue along with the exudate is covered with a dense shell and resembles a cyst, sitting on the bone, with a localization on the skull can simulate a brain hernia. The amount of exudate sometimes reaches two liters. It is usually under a periosteum or in the form of a cystoid bag in the most supervisor, it can even get along its outer surface; In the latter case, there is a diffuse midfielding of surrounding soft tissues. If the exudate is under the perception, it peers, the bone is exposed and may occur to its necrosis with cavities made by granulations, sometimes with small sequesters. A part of the researchers highlights this periodite as a separate form, the majority considers it a special form of purulent periostitis caused by microorganisms with weakened virulence. In the exudate, they detect the same pathogens as with purulent periostitis; In some cases, sowing exudate remains sterile; There is an assumption that at the same time the causative agent is a tuberculosis wand. The purulent process is usually localized at the ends of the diaphysis of long tubular bones, most often femoral bone, less often - bones of the leg, shoulder bone, Ryube; The young people are usually ill.

Often the disease is developing after injury. In a certain area, painful swelling appears, the temperature is at first rises, but soon becomes normal. When localizing the process in the joint area, there may be a violation of its function. Initially, the swelling of a dense consistency, but over time it can soften and more or less clearly flushing. Subighteous or chronic flow.

The most difficult differential diagnosis of albumin periostitis and sarcoma (see the full arch of knowledge). Unlike the latter with albumin periostite, radiographic changes in the bones in a large part of cases are absent or poorly pronounced. When puncture, the periostitis punctate is usually a transparent, light yellow-yellow liquid.

The precision periostitis is a very frequent form of chronic inflammation of the periosteum, developing with long irritations of peripost and characterized by the formation of a new bone from the hyperemic and intensively proliferating inner layer of periosta. This process is independent or more often accompanying inflammation in the surrounding tissues. In the proliferating inner layer of periosta, osteoid fabric is developing; In this tissue, the lime and formation of bone substance, whose beams are mainly perpendicular to the surface of the main bone. Such costh formation in a large part of cases occurs on a limited area. Bone growths have the appearance of individual warts or needle elevations; They are called osteophytes. The diffuse development of osteophytes leads to a common thickening of the bone (see the full arch of knowledge of hyperostosis), and the surface of it takes a wide variety of outlines. Significant bone development determines the formation of an additional layer. Sometimes, as a result of hyperostic, the bone is thickened to huge sizes, "elephant-like" thickening are developing.

The precision periostitis develops in the circumference of inflammatory or necrotic processes in the bone (for example, in the area of \u200b\u200bosteomyelitis), under chronic varicose legislands, under chronically inflamed pleural, in the circumference of inflammatory-changed joints, less pronounced with tuberculous foci in the cortical bone layer, in a slightly larger degrees when damaged to tuberculosis of bone diaphysis, in significant sizes with acquired and congenital syphilis. It is known to develop a reactive besifying periostite with bone tumors, rickets, chronic jaundice. The phenomena of the besifying generalized periostitis are characteristic of the so-called Bamberger's disease - Marie (see the full arch of the knowledge of Bamberger-Mary Periostit). The phenomena of the besifier periodite can be joined to the cheefalgemate (see the full arch of knowledge).

Under the termination of irritations causing the phenomena of the besifying periostitis, further costh formation stops; In dense compact osteophytes, an internal bone restructuring (medulipation) can occur, and the fabric takes the character of spongy bone. Sometimes precipitating periostitis leads to the formation of synostoses (see the full set of knowledge of synostosis), most often between the bodies of two adjacent vertebrae, between the beam bones, less often between the wrist bones and are replous.

Treatment should be directed to the main process.

Tuberculous periostitis. Isolated primary tuberculosis periostitis occurs rarely. The tuberculosis process with the surface location of the focus in the dice can go to the periosteum. The defeat of the periosteum is possible and the hematogenic way. The granulation tissue is developing in an internal periosal layer, exposed to curly reincarnation or purulent melting and destroys the periosteum. Under the perioslet detect necrosis; It becomes uneven, rough. The tuberculous periostitis is most often localized on the rubers and the bones of the facial skull, where he is in a significant number of cases is primary. Under the defeat of the assault rib, the process usually spreads rapidly along its entire length. Granulation growths When defeating the periosteum, the phalange can cause the same bottle-like swollen of the fingers, as with a tuberculous ostepheriota phalange, - Spina Ventosa (see the full arch of knowledge). The process is often found in childhood. The flow of tuberculosis periostitis

chronic, often with the formation of fistula, is released by fuses. Treatment - according to the rules for the treatment of bone tuberculosis (see the full arch of knowledge of tuberculosis extreme, tuberculosis bones and joints).

Syphilitic periostitis. A significant majority of the lesions of the bone system during syphilis begins and localized in the periosteum. These changes are noted both in congenital and at the acquired syphilis. According to the nature of the changes, syphilitic periostitis is assifting and gummime. In newborns with congenital syphilis, there are cases of a besifying periostitis with localization of it in the field of bone diaphysis; The bone itself can remain without any changes. In the case of serious flowing syphilitic osteochondrites, the precision periostitis has both epimethafizar localization, although the periosal reaction is expressed significantly less than on the diaphys. The precision periostitis with congenital syphilis occurs in many skeleton bones, and usually changes are symmetrical. More often and sharper all these changes are detected on long tubular bones. upper limbs, on the tibial and iliac bones, to a lesser extent on the femoral and small bones. Changes in the late congenital syphilis are essentially not much different from the changes in the acquired syphilis.

Advocacy changes in the acquired syphilis can be detected already in the secondary period. They are developing either directly following the hyperming phenomena preceding the periods of rashes, or simultaneously with later refunds of syphilides (more often than bustle) recycling; These changes are in the form of transient periosal swelling that do not reach significant sizes, and are accompanied by sharp volatile pain. The greatest intensity and prevalence of changes in the periosteum are achieved in the tertiary period, and often a combination of a gummime and besifier perioditis is observed.

Assecting periostitis in the tertiary period of syphilis has a significant distribution. According to L. Ashoff, the pathoanatomic picture of the periostitis has nothing characteristic of syphilis, although with histological examination sometimes it is possible to detect a picture of miliar and submiliary gum in the preparations. The localization of the ceilization is characteristic of syphilis - most often in long tubular bones, especially in the tibial and in the bones of the skull.

In general, this process is localized by the advantage on the surface and edges of the bones, weakly covered with soft tissues.

The precision periostitis can develop primary, without gummamine changes in the bone, or be a reactive process with a gum of periosteum or bone; Often there is a gummamine on one bone, on the other - the ossifting inflammation. As a result, the periostitis develops limited hyperostic (syphilitic exostosis, or nodes), which are observed especially often on the tibia and underlie typical night pains or form diffuse spilled hyperostices. There are cases of a precision syphilitic periodite, in which multi-layer bone shells separated from the cortical layer of the bone of the porce (cerebral substance) are formed around the tubular bones.

With syphilitic periostitis, it is often strong, sharpening in the night of pain. During palpation, limited dense elastic swelling, having a spine-shaped or round shape; In other cases, swelling is more extensive and has a flat form. It is covered with unchanged skin and is associated with the subject to the dice; When feeling it, there is significant pain. The course and outcome of the process may vary. Most often, the organization and the ossification of infiltrate with bone tumors are observed. The most favorable outcome is to dissolve the infiltration, observed more often in fresh cases, and only a small thickening of the periosteum remains. In rare cases, the purulent inflammation of the periosteum develops, the process captures usually and the surrounding soft tissues, with the velocity of the skin and the output of the pus.

In Gummimon, the periostitis develops gums - flat elastic thickening, in one degree or more painful, on the context of the student consistency, having their own inner layer of the periosteum. There are both insulated gum and diffuse gummime infiltration. Gumms are most often developing in the bones of the skull arch (especially in the frontal and dark), on the chest, the tibia, the clavicle. With diffuse gummamine periostitis, for a long time may not be changes from the skin, and then in the presence of bone defects, unchanged skin is immersed in deep depressions. This is observed on the tibia, clavicle, sternum. In the future, the gum can be dissolved and rented by a scar tissue, but more often they are subjected to fat, cotton or purulent melting, and the surrounding soft tissues, as well as the skin. As a result, the skin is melted on a certain section and a breakthrough of the contents of the gum to the formation of a peptic surface, and with the subsequent healing and wrinkling of the ulcers, the rotten scars are formed, paved with the subject to bone. There are usually significant phenomena of the besifying periostitis with reactive costhics, and sometimes they perform on the fore and can hide the main pathological process - gumm.

Treatment specific (see the full set of knowledge syphilis). In the event of a gum breakthrough to the formation of ulcers, the presence of bone lesions (necrosis) may require operational intervention.

Fig. 3. Direct radiograph of the hip patient with a ying tumor: Linear layered periosal layers (indicated by arrows) of the femur diaphysis. Fig. four. Rate X-ray radiograph of a child of a child of 11 years, patient with osteomyelitis: uneven, "baked", periosal layers (1) on the front surface of the femur; Disorderly "torn" periosteal osteophytes (2) due to breaks and detachments of periosteum on the back of its surface.

Periostitis with other diseases. In the OPP, the periodite of the diaphysies of long tubular bones is described with the corresponding thickening them, and this phenomenon is usually observed during the reconvaluation period. During the Sapa, the foci of limited chronic inflammation of the periosteum is noted. When lepring, infiltrates are described in the periosteum; In addition, lept-like patients on tubular bones due to chronic periostitis may form spine-like blown. With gonorly there are inflammatory infiltrates in the periosteum, with the progression of the process - with purulent separated. The pronounced periostitis is described in blastomicosis of long tubular bones, irradiated diseases are possible after a raw tit in the form of a limited dense thickening of periosta with smooth circuits. Local periostitis occurs in varicose expansion of the deep veins of the shin, with varicose ulcers. Rheumatic granulomas of bones may be accompanied by periostitis most often the process is localized in small tubular bones - mills and tall, as well as in the main phalanges; Rheumatic periostitis is prone to relapses. Sometimes with diseases of the blood-forming organs, especially during leukemia, there are insignificant periostitis in size during Goshe disease (see the full vault of Goshe's knowledge) are described periosal thickening preferably around the distal half of the hip. With long walking and running, the tibia periostitis can occur. For this, the periostitis is characterized by cruel pain, especially in the distal parts of the leg, increasing when walking and exercises and eating alone. Locally visible limited swelling due to the ethnicity of the periosteum, very painful when palpation. The periostitis is described during the actinomyosis.

X-ray diagnostics. X-ray research reveals localization, prevalence, shape, size, nature of structure, outlines of periosal layers, their relationship with cortical bone layer and surrounding tissues. Radiographically distinguish linear, fringe, comb-shaped, lace, layered, needle and other types of periosal layers. Chronic, slowly current processes in the bone, especially inflammatory, usually cause more massive applications, usually merging with the main bone, which leads to the thickening of the cortical layer and an increase in the bone volume (Figure 1). The rapid flowing processes lead to the detachment of the periosteum by gently propagating between it and the cortical layer, inflammatory or tumor infiltrate. This can be observed with acute osteomyelitis, Yinga tumors (see the full arch of the knowledge of the Jinga Tumor), reticulosarcomer (see the full arch of knowledge). In these cases on the radiograph, a linear strip of a new bone, formed by the perception, is separated from the cortical layer of the enlightenment strip (Figure 2). With uneven development of the process of such a new bone strip, there may be several, as a result of which the picture is formed by the so-called layered ("Lukovichny") periosal survivors (Figure 3). Smooth, even periosal layers accompany the transverse pathological functional restructuring. With an acute inflammatory process, when the pus accumulates under high pressure, the periosteum may be breaking, and the bone continues to produce, giving a picture of uneven, "torn" fringe (Figure 4) on the radiograph.

With the increase in the malignant tumor in the metaphy of the long tubular bone, periosal reactive costection over the tumor is almost not pronounced, since the tumor is growing quickly and the periosteum that hesitated it does not have time to form a new reactive bone. Only in the boundary areas where the tumor growth is slower compared to the central, time to form periosal layers in the form of the so-called visor. With slow tumor growth (for example, osteoblastoclastomes) periosteum

gradually pushes it and periosteal layers have time to form; The bone is gradually thickened, as if "swells"; In this case, the intake is preserved.

In the differential diagnosis of periosal layers, normal anatomical formations should be borne in mind, for example, bones, inter-site ridges, skin projections (for example, on the upper edge of the clavicle), which are not spilled with the main bone of the apophysis (according to the upper edge of the ileal bone) and the like It should not be taken for the periostitis of the oakes of the tendons of the muscles at the places of their attachment to the bones. Differentiate individual forms of periostitis only on the X-ray picture is not possible.

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- This is an acute or chronic inflammation of the periosteum. Usually provoked by other diseases. Accompanied by pain and swelling of surrounding soft tissues. With the suppuration, symptoms of general intoxication occur. Features of the flow and severity of symptoms are largely determined by the etiology of the process. The diagnosis is exhibited on the basis of clinical signs and data of x-ray research. Treatment is usually conservative: analgesics, antibiotics, physiotherapy. With fistulous forms, excision of the affected periosteum and soft tissues are shown.

MKB-10.

M90.1. Periostitis with other infectious diseases classified in other categories

General

Periostitis (from Lat. Periosteum - periosteum) - inflammatory process in the field of periosteum. Inflammation usually occurs in one layer of periosteum (outer or internal), and then distributed to the remaining layers. The bone and periosteum are closely related, therefore, the periostitis often goes to osteoperity. Depending on the cause of the disease, the treatment of periostite can carry out traumatologists-orthopedists, oncologists, rheumatologists, phthisiators, venereologists and other specialists. Along with the measures to eliminate inflammation, the treatment of most forms of periostite includes therapy of the underlying disease.

Causes of Periosteit

According to the observations of experts in the field of traumatology and orthopedics, rheumatology, oncology and other areas of medicine, the cause of the development of this pathology can be injured, inflammatory damage to bones or soft tissues, rheumatic diseases, allergies, a number of specific infections, less often - bone tumors, as well as chronic diseases veins and internal organs.

Classification

Periostitis can be acute or chronic, aseptic or infectious. Depending on the nature of pathologist changes, simple, serous, purulent, fibrous, precision, syphilitic and tuberculous periostitis are isolated. Disease may affect any bone, however, more often is localized in the region lower jaw and the diaphysis of tubular bones.

Symptoms Periostita

Simple periostitis It is a aseptic process and arises due to injuries (fractures, bruises) or inflammatory foci, localizing near the periosteum (in the muscles, in the bone). The velocity sections are more affected, covered with a slight layer of soft tissues, for example, the elbow process or the apparent surface of the tibia. Patient with periostitis makes complaints of moderate pain. In the study of the affected area, a slight swelling of soft tissues is detected, local elevation and pain in palpation. Simple periostitis is usually good to treat. In most cases, the inflammatory process is stopped for 5-6 days. Less often, the simple form of periostitis goes into a chronic precision perioditis.

Fibrous periostitis It occurs with long-term irritation of the periosteum, for example, as a result of chronic arthritis, bone necrosis or chronic trophic shin ulcers. Characterized by the gradual beginning and chronic current. Patient complaints are usually due to the main disease. In the area of \u200b\u200bthe lesion, a slight or moderate swelling of soft tissues is detected, with palpation, a dense painless bone thickening is determined. With successful treatment of the main disease, the process regresses. With prolonged flow of periostitis, the surface destruction of bone tissue is possible, there is data on certain cases of the illicitality of the affected area.

Purulent periostitis It develops in the penetration of infection from the external environment (with injuries with damage to the periosteum), when the microbes are propagated from the neighboring purulent focus (with an purulent wound, phlegmon, abscess, inflammation, purulent arthritis, osteomyelitis) or during peymia. Typically, staphylococcis or streptococci act as the pathogen. More often the periosteum of long tubular bones - shoulder, tibial or femoral. In Fime, multiple lesions are possible.

On the initial stage The perception is inflamed, serous or fibrinous exudate appears in it, which is subsequently converted into a pus. The inner layer of peripost is soaked in gently and is separated from the bone, sometimes at a considerable distance. A subperiodal abscess is formed between the perception and bone. Subsequently, several course options are possible. In the first embodiment, the pus destroys the suspension section and breaks into soft tissues, forming paraensile phlegmon, which in the subsequent can either spread to the surrounding soft tissues, or to open out through the skin. In the second embodiment, the pus flaps a significant portion of the periosta, as a result of which the dice is deprived of nutrition, and a section of surface necrosis is formed. With the unfavorable development of events, necrosis spreads in deep layers of bone, the pus penetrates into the bone marrow cavity, osteomyelitis occurs.

For purulent periostitis is characterized by a sharp start. The patient makes complaints about intense pain. The body temperature is raised to febrile numbers, odnants, weakness, driers and headache. In the study of the affected area, swelling, hyperemia and sharp pain during palpation are detected. Subsequently, the focus of fluctuations is formed. In some cases, erased symptoms or primary chronic flow of purulent periostitis is possible. In addition, they allocate an acute or malignant periostitischaracterized by the predominance of putrefactive processes. With this form, the periosteum swells, it is easily destroyed and disintegrated, deprived of the periosta bone turns out to be a shrouded layer of pus. Pump applies to soft tissues, causing phlegmon. It is possible to develop septicopemia.

Serous albumin periostit It is usually evolving after injury, more often amazes the metadaphisis of long tubular bones (thigh, shoulder, small -board and tibia) and ribs. It is characterized by the formation of a significant amount of album-mucous liquid containing a large number of albumin. Exudate can accumulate intensively, form a cystoid bag in the thickness of the periosteum or located along the outer surface of the periosta. The zone of the exudate cluster is surrounded by a red-brown granulation tissue and covered with a dense shell. In some cases, the amount of fluid can reach 2 liters. With the substitute localization of the inflammatory focus it is possible to detach the periosteum with the formation of a bone necrosis area.

The flow of periostite is usually subacute or chronic. The patient complains of pain in the affected area. At the initial stage, a slight increase in temperature is possible. If the hearth is located near the joint, the movements may arise. In case of inspection, the swelling of soft tissues and soreness during palpation is detected. The area of \u200b\u200bthe lesion at the initial stages is sealed, subsequently the softening section is formed, the fluctuation is determined.

Sexifying periostitis - A common form of periostite, arising from prolonged irritation of the periosteum. It develops independently or is a consequence of a long-lasting inflammatory process in the surrounding tissues. It is observed in chronic osteomyelitis, chronic varicose neases, arthritis, bone-joint tuberculosis, congenital and tertiary syphilis, rickets, bone tumors and periostosity Bamberger-Marie (symptom complex, which occurs in certain diseases of the internal organs, is accompanied by the thickening of the nail phalanx in the form of drum sticks and deformation of nails in the form of watch windows). The precision periostitis is manifested by the growth of bone tissue in the inflammation zone. It ceases to progress with the successful treatment of the underlying disease. With a long existence in some cases, it may cause synostoses (bones) between the bones of the bones and wrists, the beam bones or vertebral bodies.

Tuberculous periostitisAs a rule, it is primary, more often occurs in children and is localized in the region of ribs or skulls. The course of such periostitis is chronic. Perhaps the formation of fistulas with the fissile separated.

Syphilitic periostitis It may be observed with congenital and tertiary syphilis. At the same time, the initial signs of the defeat of the periosteum in some cases are revealed already in the secondary period. At this stage, small swelling appear in the field of perillers, there are sharp volatile pain. In the tertiary period, as a rule, the bones of the skull or long tubular bones are affected (more often the tibia). There is a combination of gummime lesions and a besifier periodite, the process can be both limited and diffuse. For congenital syphilitic periostitis, a testimicing damage to the diaphysis of tubular bones is characterized.

Patients with syphilitic periostitis complain about intense pains that amplify at night. When palpation, round or spindle-like limited swelling of the density consistency is detected. The skin above it is not changed, palpation is painful. The outcome can be spontaneous absorption of infiltrate, the growing of bone tissue or the suppuration with the propagation to the nearby soft tissues and the formation of fistulas.

In addition to listed cases, periostitis may be observed in some other diseases. So, with gonor in the field of periosteum, inflammatory infiltrates are formed, which are sometimes caught up. Chronic periostitis may occur during a supa, a rapid tit (characteristic of the defeat of the ribs) and blastomycosis of long tubular bones. Local chronic periosteum lesions are found in rheumatism (the main phalanges of the fingers, hanging and metatar bones are usually affected), the varicose expansion of deep veins, Goshe disease (the distal part of the femoral bone) is affected) and diseases of the blood formation organs. Under excessive load on the lower limbs, there is sometimes observed perioditis of tibia, accompanied by severe pain syndrome, minor or moderate edema and a sharp pain of the affected area during palpation.

Diagnostics

The diagnosis of acute periostitis is exhibited on the basis of anamnesis and clinical signs, since the radiographic changes of the periosteum becomes visible not earlier than 2 weeks from the beginning of the disease. Basic instrumental method The diagnosis of chronic periostitis is a radiography that allows us to estimate the form, structure, outlines, the size and prevalence of periosal layers, as well as the condition of the subject to the bone and, in some extent surrounding tissues. Depending on the species, the causes and stages of the periostite can be revealed needle, layered, lace, grains, baked, linear and other periosal layers.

For long-term current processes, a significant thickening of the periosteum and its fusion with the bone is characterized, as a result of which the cortical layer is thickened, and the volume of the bone increases. Under purulent and serous periostites, the detachment of the periosteum with the formation of the cavity is revealed. When the periosteum breaks, due to the purulent melting on radiographs, the "ribbon fringe" is determined. With malignant neoplasms, periosal layers have the type of visors.

X-ray study allows you to make an idea of \u200b\u200bthe nature, but not about the reason for the periostitis. A preliminary diagnosis of the underlying disease is exhibited on the basis of clinical signs, for final diagnosis, a variety of studies can be used, depending on certain manifestations. So, if the varicose extension of deep veins is suggested, ultrasound duplex scanning is prescribed, with suspicion of rheumatoid diseases - the definition of the rheumatoid factor, the C-reactive protein and the level of immunoglobulins, if suspected gonor and syphilis - PCR studies, etc.

Treatment of periostita

Tactics of treatment depends on the main disease and the shape of the defeat of the periosteum. With simple periostitis, they recommend peace, painkillers and anti-inflammatory agents. In purulent processes, analgesics and antibiotics are prescribed, and the drainage and drainage of the waste. In chronic perioditis, therapy is carried out by therapy, sometimes laser therapy, ionetyl sulfoxide ionophoresis and calcium chloride are prescribed. In some cases (for example, with syphilitic or tuberculous periostitis with fistulas), operational treatment is shown.