CHAPTER XIX,
ACUTE OSTEOMYELITIS.
‘This is an acute infection of great gravity, more often due to the staphylococcus or the streptococcus; but, in rare instances, the pneumo- coccus, bacillus coli communis, or tubercle bacillus may be the ex- citing cause,
Usually the germ reaches the affected site through the blood current; at other times, leaving a primary focus which is perhaps unsuspected, it reaches its destination by way of the lymph channels or by continuity of tissue. For the germ to gain a foothold, there must be a lowered resistance or an impaired nutrition. The predisposing causes are found in certain constitutional states and in traumatism.
‘The diagnosis is not always easy in the beginning, as the constitu- tional symptoms may be marked before the local signs are quite definite.
Rheumatism does not have the symptoms of sepsis, though, indeed, the fever may be high, The pain is usually in the joint and usually in more than one joint.
Arthritis likewise involves the joint, although it is to be remembered that an arthritis may be secondary to osteomyelitis and overshadow it clinically, but the history of the case will usually decide between arthritis and osteomyelitis.
Erysipelas may be thought of when, after a little while, the skin becomes brawny and edematous, but in erysipelas the skin is so in- volved from the first.
‘The symptoms may seem to suggest typhoid fever or other infectious fevers, but these may usually be rled out by the absence of charac- teristic features,
The symptoms of meningitis are often present, but by the time they arise, the local conditions point to the nature of the trouble,
‘The general symptoms are those of sepsis; high fever beginning with a chill, rapid pulse, foul tongue, profound prostration, and tnady delirium.
ae 369
370 ACUTE OSTEOMYELITIS.
Locally, the pain over the affected area is extreme, and the least pressure tends to aggravate it. Gradually, as the inflammation spreads from the marrow through the bone to the periosteum, the skin begins to swell, redden, become edematous, and finally shows fluctua tion,
In the virulent cases not operated upon, the patient dies within the firs few days from septic infection. In the milder cases, even, large areas of the bone necrose,
‘The treatment, then, must be prompt. It isan emergency. There is only one thing of any use to be done, ‘The suppurating marrow must be evacuated and the medallary exnal freely opened and cleaned out, Local applications, poultices, or even fe cisions through the periosteum are illusory. ‘The bone must be érepheimed, its cavity opened up at its most secs ble part, and all the inflamed tissur scraped away. The whole extent of the canal may need to be opened, irrigated, drained, and treated with vigorous antisepsis,
Mosetig-Moorhof’s* iodoferm- plombe or filling is applicable te suck cases as these. It is prepared a follows:
Equal parts of spermaceti ( sesamoil are melted in an evaporating dish, then filtered inte Florentine flask and sterilized in a waterbath; forty grammes finely powdered iccdoform (not crystallized) are put into = ste #ask, and sixty grammes of the hot fat mixture are added) a
- Sargery, Gynecology anid Obstetrics, Val. WW, 80. 4
“IODOPORM PLOMBE FOR BONE ABSCESS. $72
constant agitation. This agitation must be continued without in- terruption, until the mass solidifies. The flask is closed with a sterile rubber stopper. Before using, the plombe is to be heated in water- bath toa little above 50° C,
‘The bone cavity is most carefully prepared for the reception of the filling. Everything must be removed down to sound bone. The Jaws of gravity must, of course, be observed in filling the cavity, If the cavity is large, it is advisable to fill it in several steps letting the
ete Paras Sait plombe solidify in one portion, before any is poured into another, ‘The cavity must be dry before the mixture is poured in. This may be by sponging, by the application of adrenalin to oo: points, by hot air, ete. ‘The course of healing after iodoform filling is aseptic azarule. Sometimes the temperature rises within the first two or three days—so-called aseptic fever—which yields to a cathartic, ‘The disposition of the sprouting granulations toward the solidified plombe varies between complete closure of the wound and healing by primary intention, and incomplete closure. Tn the first cases, Sosacy- tion of the plombe is effected through the steadily advancing FEA
372 ACUTE OSTEOMYELITIS. |
tions by vital phenomena; in the second, by partial displacement and expansion, OSTEOMYELITIS OF THE UPPER END OF THE TIBIA.
Here the disease occurs more frequently and here, fortunately, is most easily operated upon.
General anesthesia; special instra- ments: a mallet, a gouge, a periosteal elevator or rugine, and curette.
Begin by elevating the limb to empty the blood vessels. About the middle of the thigh apply an Esmarch tube. Do not apply an Esmarch bandage, beginning at the toe and extending upward, for that oaly spreads infection.
On the right side, dhe iucision com- mences at the level of the and extends to the middle of the leg, following the sharp crest of the tibia just to its inmer side, However en- gorged the tissues may be, this first incision reaches to the bone (Fig. 273).
Often by this first stroke, one opemk intoa pascavity. Donot be beguiled by this into thinking the operation completed. This collection is to be evacuated and drained, of course, but Pre sta —Treo! ta there is another one in the central ““’ canal. Extend the incision to the
limit of the loosened periosteum. With the rugine, expose the amterior ” surface of the bone. A fistelous opening leading to the medullary canal may possibly be found. In any event, proceed to trephine, ‘At the upper end of tbe incision make an opening with the down to the canal, ‘The pus will be almost certain to flow, but it! often difficult to distinguish from the marron .
OSTEOMYELITIS OF Tuy: THnTA. 373
At the lower end of the incision, make another opening (Fig. 278). Tf again pus appears, it is certain that the lowest limit of the suppura~ tion has not been reached and you must lengthen the incision. Con~ tinue to expose the canal uatil the full extent of inflammation has been exposed. It may require the removal of the whole anterior surface of the tibia, but you are engaged in saving life, 30 that bone is a minor consideration. Chisel away, then, all the anterior wall between the two limits of suppuration (Fig. 279). Curette vigorously the medul- lary canal down to firm and uninflamed bone, and especially cureite the upper part, for there the suppuration is greatest,
In the case of a child, the epiphyseal cartilage is quickly reached, and this one should try to avoid, since too free removal will end linear growth.
Next frrigate with normal salt solution, mop out thoroughly with sterile gauze, and pack with sterile or iodoform gauze. ‘This ix an important part of the operation and it must be carried out thoroughly and methodically,
Drainage must now be applied to the subperiosteal areas of suppura- tion, using rubber drains in the manner indicated (Fig. 280),
If the operation has been delayed, the muscles of the calf may be infiltrated with pus and will require drainage as in diffuse phlegmon.
If there is serous effusion into the joint, it will require no especial treatment, for it will gradually be absorbed as the osteomyctitis is cured.
If the joint is suppurating, it is quite different and another operation is required (see operation for Purulent Arthritis).
Over the trephined area, apply a moist dressing and change daily. As the exudate becomes less abundant, change to a dry dressing and change the packing in the canal every other day. Smaller drains may be inserted about the tenth day, and are removed entirely when the suppuration shall have ceased.
‘As Veaut says, this intervention is only the first act of a prolonged and tedious process and this the family should understand beforehand. After several months, it may be necessary to remove some weexonrs bone; and, long after the cure appears complete, the troulhe may TECO-
374 ACUTE OSTEOMYELITIS.
OSTEOMYELITIS OF THE UPPER END OF THE HUMERUS,
Begin the incision a finger’s breadth below the clavicle, following the axis of the humerus, Prolong it downward five or sixinches. The incision will traverse the deltoid near its anterior border. Separating the lips of the wound, divide the periosteum and proceed to trephine and drain as in the preceding case (Fig. 282)
Poo, afs.—Osiecenyelitie of the buenas, (Marane)
OSTEOMYELITIS OF THE LOWER END OF THE HUMERUS,
Make an incision eight to fifteen inches in length in the line of, and eating below at, the external condyle, ‘The incision will traverse the thick fibers of the triceps. Trephine and drain, fit it necessary to make an internal counter-opening for a drain, remember the situa- tion of the ulnar nerve. If the whole bone is affected, the same prin ciples are involved. ‘The prognosis is exceedingly grave.
OSTEOMYELITIS OF THE LOWER END OF THE FEMUR,
Make the incision along the antero-internal border of the thigh, traversing the fleshy vastus internus
OSTEOMYELITIS OF TIKE FEMUR. MS
‘The femoral vessels are behind this line. The bone is deeply placed and the operation difficult, but trephine thoroughly. Drain the medullary cavity and the periosteal abscess (Fig. 282).
placing drains after trephining
OSTEOMYELITIS OF THE UPPER EXTREMITY OF THE FEMUR. Make the incision along the outer surface of the thigh over the great trochanter. Divide the aponeurosis of the gluteal muscle, weysdor, and drain, ‘