Periostitis

PERIOSTITIS (periostitis), inflammation of the periosteum, represents a fairly common phenomenon in the pathology of the skeletal system. Clinically, P. is divided into acute (subacute) and chronic; according to the pathoanatomical picture (and partly on the basis of etiology) into 1) periostitis simplex, 2) p. fibrosa, 3) p. purulenta, 4) p. albuminosa, 5) p. ossificans, 6) p. tuberculosa, 7) p. luetica. In a significant number of cases, the inflammatory process begins in the inner layer of the periosteum and from there gradually (or rapidly) spreads to its remaining layers. Due to the close connection between the periosteum and bone, inflammatory processes easily pass from one tissue to another and cause more complex phenomena (see Osteoperiostitis); | the transition of the process to bone (or, conversely, from bone to periosteum) sometimes occurs so imperceptibly that it becomes difficult to determine whether P. or osteoperiostitis is present at the moment. P. simplex (simple) represents an acute inflammatory process consisting of hyperemia, slight thickening, and serous-cellular infiltration of the periosteum; it usually develops after the most diverse injuries, bruises, fractures, etc. (traumatic P.), as well as in the vicinity of inflammatory foci located, for example, in bone, muscles, etc. Clinically, it is accompanied by pain in a limited area and sometimes slight swelling. Most often, areas of bones poorly protected by soft tissues are affected (for example, the tibia). The inflammatory process b. ch. (as a rule) quickly subsides, but sometimes it can lead to fibrous proliferations or be accompanied by lime deposits and the formation of bone tissue - osteophytes (transition to p. ossificans). A typical traumatic P. tibiae with transition to p. ossificans has been described by a number of authors in recruits of capitalist armies as a result of intensive exercises in the form of strong and frequent tension of the fascia and muscles of the lower leg. - Treatment at the beginning of the process is anti-inflammatory (cold, etc.), later the application of heat, hydrotherapeutic measures. In severe pain and a prolonged process, treatment by congestive hyperemia according to Bier is appropriate. P. fibrosa (fibrous P.) represents a callous fibrous thickening of the periosteum, usually firmly fused to the bone, developing under the influence of chronic, often lasting for years irritations. The outer layer of the periosteum plays the most significant role in the formation of this connective tissue. This form of P. occurs, for example, on the tibia in cases of chronic leg ulcers (ulcus cruris chron.), further in the vicinity of bone necroses, in the area of chronic joint inflammations, etc. Significant development of fibrous tissue can lead to superficial destruction of bone (caries superficialis). In some cases, with considerable duration of the process, the formation of bone tissue is observed and thus a direct transition to p. ossificans occurs. Treatment - elimination of the irritant; some authors (Tillmanns and others) recommend compression with rubber bandages for fibrous thickenings. P. purulenta (purulent) represents a frequent form of P.; it usually develops as a result of infection penetrating either during injury to the periosteum, or from neighboring organs (for example, the occurrence of P. of the jaw in the presence of dental caries, transition of the inflammatory process from bone to periosteum), or hematogenously from a purulent focus in the body (for example, metastatic P. in pyemia); Cases of purulent P. are noted in which it is not possible to detect a purulent focus in the body or a transition from neighboring organs. All pus-forming microbes can be the causative agents of purulent P. Purulent P. begins with hyperemia, serous or fibrinous exudate, and then cellular (purulent) infiltration of the periosteum. The hyperemic, fleshy, thickened periosteum in such cases is easily detached from the bone; the purulent infiltration increases more and more, phenomena of edematous impregnation are found in the adjacent soft tissues. The loose inner layer of the periosteum is impregnated with pus, which then accumulates between the periosteum and bone. In this way, the periosteum is detached in places and forms a subperiosteal abscess. With extensive spread of the process, the periosteum is detached diffusely in the form of a layer (p. purulenta dissecans). Such detachment of the periosteum over a considerable extent can cause disturbance of bone nutrition and superficial necrosis; significant necroses involving entire areas of bone or the whole bone occur only when, together with P., true endostitis develops, and the pus, following the course of Haversian canals, invades the bone and fills these canals and large bone marrow cavities. The inflammatory process may stop in its development (especially with timely removal of pus or with its spontaneous rupture outward through the skin) or spread to the surrounding soft tissues (according to the phlegmon type) and to the substance of the bone (see Osteomyelitis). In metastatic P., the disease most often affects the periosteum of some long tubular bone (most often the femur, tibia, humerus) or several bones simultaneously. Less frequently, involvement of flat and short bones (iliac bone, clavicle, scapula, etc.) is noted. Clinical course: onset is usually acute, accompanied by elevation of temperature and significant pain; a swelling, painful on palpation, can be felt in the affected area. With continued accumulation of pus, fluctuation is usually soon noted; depending on the depth of the process, the skin coverings may also be involved. The course of the process is acute in most cases, although cases of prolonged, chronic course are noted, especially in weakened patients. - Treatment is surgical - according to the general rules of opening a purulent focus; sometimes, to reduce tissue tension, it is necessary to resort to incisions before fluctuation is detected. - Some authors also distinguish from the group of purulent P. an acute form called p. maligna, s. acutissima (malignant or most acute). In it, the exudate quickly becomes putrefactive; the periosteum is swollen, gray-green in color, dirty-looking, easily tears, and disintegrates into shreds. In the shortest time, the bone is deprived of periosteum and enveloped in a layer of pus. After the rupture of the periosteum, this purulent or purulent-putrefactive inflammatory process spreads according to the phlegmon type to the surrounding soft tissues, especially into the intermuscular spaces, subcutaneous tissue, etc. These malignant forms in a considerable number of cases are accompanied by septicopyemia and easily lead to fatal outcomes. P. albuminosa, s. serosa, s. mucinosa (albuminous, or serous, or mucinous), first described by Poncet and Ollier, represents a subacute or chronically proceeding inflammatory process in the periosteum, leading to the formation of exudate that usually accumulates subperiosteally and has the appearance of serous-mucous (gelatin-like) fluid that stretches into threads. This fluid is rich in protein (albumins); individual shreds of fibrin, a small number of pus corpuscles and cells in a state of fatty degeneration, a small number of erythrocytes, sometimes pigment and fat droplets are found in it. Albert, in chemical analysis, found in this exudate mucin-like bodies (not mucin) and phosphates. This exudate is produced and surrounded by granulation tissue of brown-red color, consisting mainly of plasma cells, partly in a state of fatty degeneration, and of xanthomatous cells; between them are individual lymphocytes, leukocytes, and giant cells. Burckhardt noted the formation of Russell bodies in the granulations. On the outside, the granulation tissue together with the exudate is limited by a dense capsule, so that it can give the impression of a cyst sitting on the bone (hence the name ganglion periostale), and on the skull even simulating a brain hernia. The amount of exudate can reach considerable sizes (in Burckhardt's case up to 2 liters). This exudate is usually under the periosteum, but can form a cyst-like sac in the periosteum itself or even accumulate on its outer surface; in the latter case, diffuse edematous swelling of the surrounding soft tissues is observed. In cases where the exudate is under the periosteum, the bone is denuded from it and sometimes phenomena of superficial caries with cavities filled with granulations are found in the bone. Cases with small sequestra in the underlying bone have been described. On the basis of these changes in the bones, some authors call this disease ostitis (osteomyelitis) albuminosa, or p. et ostitis albuminosa. The question of the essence of the disease and its causative agents remains controversial to this day. Some authors distinguish this disease as a separate pathological form, while most consider it a special form of p. purulenta, possibly caused by microorganisms with reduced virulence. Along with this, there is a viewpoint that considers p. albuminosa as the outcome of some purulent P., in which the disintegrated pus corpuscles have turned into a dense gelatinous mass; thus, according to Volkmann, it is a mucous degeneration of pus corpuscles.

Upon bacterial examination, the same pathogens are found in the exudate as in p. purulenta; in some cases, the culture of the exudate remained sterile; there is also the hypothesis of the possible participation of tubercle bacilli as the causative agent. This process is usually localized at the ends of the diaphyses of long tubular bones, most often the femur, less frequently the bones of the lower leg, humerus, and ribs; it usually affects the adolescent age group (15-20 years) with a clear predominance of the male sex. Clinical picture: the disease often develops after trauma; a painful swelling appears at a certain site, the temperature initially rises but usually soon falls to normal; when localized in the area of a joint, disturbance of its function may be noted. Initially, the swelling is of firm consistency, but over time it may soften and more or less distinctly fluctuate. In differential diagnosis, the greatest difficulties may arise in differentiation from sarcoma. The question must be decided on the basis of the clinical picture, X-ray examination (in sarcoma there are changes in the bones, which are absent or weakly expressed in the majority of cases in p. albuminosa), as well as on the basis of puncture (in p. albuminosa the punctate is usually a transparent viscous fluid, light yellow in color).-Treatment. In some cases, it was possible to limit oneself to punctures of the exudate, with significant improvement of the process occurring. In most cases, incision of the cavity and removal of all affected tissue is recommended; sometimes it is possible to remove cyst-like formations entirely with the capsule without violating its integrity. P. ossificans (ossifying periostitis) is a very common form of chronic inflammation of the periosteum, developing with prolonged irritations of the periosteum and characterized by the formation of new bone from the hyperemic and proliferating inner layer of the periosteum. It develops either as an independent process or more often accompanies other diseases, especially inflammatory processes in the surrounding tissues. The formation of bone occurs in such a way that in the proliferating inner layer of the periosteum, osteoid tissue develops, in which lime is deposited and bone substance is formed, the trabeculae of which are located predominantly perpendicular to the surface of the main bone. The formation of new bone in the majority of cases occurs in a limited area; these areas of newly formed bone have the appearance of separate warty or spiny elevations and are called osteophytes. In their initial development, osteophytes are porous, of pumice-like appearance, with significant blood supply and due to incomplete calcification they represent rather delicate formations. Subsequently, with the continued activity of osteoblasts, there is an increase in bone substance in the area of the medullary spaces, the osteophyte transforms into bone tissue of considerable density (sometimes of the density of ivory), and it usually closely adheres and is connected with the rest of the bone. The development (diffuse) of osteophytes leads to a general thickening of the bone (hyperostosis), and its surface takes on the most diverse outlines. Significant development of bone can lead to the formation of an additional layer of bone. Sometimes as a result of hyperostoses the bone thickens to enormous dimensions, "elephant-like" thickenings develop (see Elephanthiatis). P. ossificans develops around inflammatory or necrotic processes of bone (e.g. in the area of osteomyelitis), under chronic ulcus cruris, under chronically inflamed pleura, around inflamed joints, to a slight degree in tuberculous foci in the cortical layer of the bone, to a greater degree in the case of tuberculosis of the diaphyses of bones, and to a significant extent in syphilis, both acquired and congenital (see below). The development of reactive ossifying periostitis in the presence of bone tumors, rickets, and chronic jaundice is known. The phenomena of ossifying generalized periostitis form the basis of the so-called disease of Marie-Bamberger. The phenomena of ossifying periostitis may be associated with cephalohematoma (see). Diagnosis of cases of ossifying periostitis with well-expressed osteophytes and hyperostoses is not difficult; X-ray examination plays a significant role in the diagnosis. In the initial stages of the process, the following can be found on the X-ray: on a limited area of the bone, on the outside of the cortical layer, at a distance of not more than a few millimeters from it, a narrow dark stripe is noted; between this calcified border and the compact cortical substance a light stripe remains, corresponding to the layer of proliferating osteoblasts. With the further course of the process, complete calcification occurs, the light zone disappears and the cortical layer appears widened. The contours of the periosteal deposits appear on the X-ray either smooth or slightly rough and wavy. In some cases, when the bone as a result of ossifying periostitis reaches considerable dimensions, the X-ray picture can simulate various diseases, for example syphilis, osteomyelitis, etc.; in these cases, the condition of the bone itself, in the sense of the presence of foci of one or another disease in it, plays a significant role in deciding the question.-Course of the process: With the cessation of the irritations causing the phenomena of ossifying periostitis, further formation of new bone stops; in dense compact osteophytes, internal restructuring of bone (medullarization) can occur, and the tissue takes on the character of spongy bone. Sometimes ossifying periostitis leads to the formation of synostoses, which is most often noted between the bodies of two adjacent vertebrae, then between the tibia and fibula (see figure), less often between the bones of the wrist and tarsus.-Treatment should be directed against the underlying process causing the irritation. In the case of osteophytes of significant size, causing pain sensations or disturbing normal function, it is necessary to remove them. P. tuberculosa (tuberculous periostitis). Isolated primary tuberculous periostitis is rare; usually the tuberculous process in the skeletal system begins in the bone itself (as osteomyelitis or a cortical focus) and in some cases, with a superficial location of the focus, it can spread to the periosteum. Tubercle bacilli thus enter the periosteum either by the spread of the process from surrounding tissues (from bone, tuberculous skin ulcer, etc.) or by the hematogenous route. Granulation tissue develops in the inner periosteal layer, undergoes caseous degeneration or purulent melting and destroys the periosteum. Under the periosteum in such cases, peripheral caries of the bone is found in the form of an uneven, rough surface. Tuberculous periostitis is most often localized on the ribs and bones of the face, where in a significant number of cases it is primary. When a certain area of the rib periosteum is affected, the tuberculous process usually quickly spreads along its entire length. Granular proliferations in tuberculous lesions of the periosteum of the phalanges of the fingers can cause bottle-shaped swelling of the fingers—a picture similar to spina ventosa. This process is most common in childhood. The course of tuberculous periostitis is chronic, often with the formation of fistulas, discharge of pus-like masses, etc.-Treatment—according to the usual rules for the treatment of tuberculosis of the bones. P. syphilitica (syphilitic periostitis) is a very common phenomenon in patients with syphilis. In contrast to tuberculosis, the vast majority of lesions of the skeletal system in syphilis begins and is localized in the periosteum. These changes are noted in both congenital and acquired syphilis. According to the nature of the changes, syphilitic periostitides are divided into 1) ossifying periostitides and 2) gummatous periostitides. In newborns with congenital syphilis, cases of ossifying periostitis are noted, and it is localized mainly in the area of the diaphyses of the bones. On X-ray examination, a characteristic picture of a sheath or case covering the diaphysis of the bone like a shell is obtained. The periosteal deposits rise above the surface of the bone quite uniformly, so that in most cases they are strictly parallel to the cortical layer of the bone throughout their entire length. The outer contours of the periosteal deposits in this form of periostitis are distinguished by their even and smooth appearance. The bone itself may remain without any changes. In cases of severe syphilitic osteochondritis (see Bone), the phenomena of ossifying periostitis also have an epiphyseal localization, although the periosteal reaction here is expressed much weaker than on the diaphyses. The phenomena of ossifying periostitis in congenital syphilis are noted on a significant part of the skeleton, and they usually have a symmetrical arrangement. These changes are most frequent and most pronounced on the long tubular bones of the upper extremities, on the tibia and ilium, to a lesser degree on the femur and fibula. The changes in lues congenita tarda essentially do not differ from the changes characteristic of acquired syphilis.

Changes in the periosteum in acquired syphilis can be detected already in the secondary period, but they reach their greatest intensity and extent in the tertiary period, and here a combination of both processes (gummatous and ossifying periostitis) is often observed. In the secondary period, inflammation of the periosteum develops either directly following the phenomena of hyperemia preceding the period of rashes, or simultaneously with later recurrences of secondary syphilides (more often pustular); these changes are in the form of transient periosteal swellings, not reaching significant sizes, and are accompanied by sharp fleeting pains. The ossifying P. in the tertiary period has considerable extent. According to Aschoff, the anatomical picture of it has nothing characteristic of syphilis, although upon histological examination it is sometimes possible to find in preparations pictures of miliary and submiliary gummas; what remains characteristic of syphilis is the distribution of changes in the skeleton. Most often these changes are localized on the long tubular bones, especially on the tibia, and on the bones of the skull. In general, this process is localized mainly on the surfaces and edges of bones, poorly covered by soft tissues. Ossifying P. can develop primarily without gummatous changes in the bone or represent a reactive process in the gumma of the periosteum or bone; often on one bone there is a gummatous, on another an ossifying inflammation. As a result of this process, limited hyperostoses (syphilitic exostoses-tophus or nodus syphiliticus) develop, which are noted particularly frequently on the tibia and form the basis of the well-known night pains (dolor osteocopi nocturni) or diffuse spread hyperostoses are formed. Cases of r. ossificans syphilitica are noted, in which as a result of the process around tubular bones, multilayered bone shells are formed, separated from the cortical layer of the bone by a layer of porous (medullary) substance, and such a phenomenon is designated by German authors as Sarg-bildung (coffin formation). Clinical picture. With strong, intensifying at night pains, a dense, elastic swelling forms, located on a small surface and having a spindle-shaped or round shape: in other cases, the swelling spreads over a considerable surface and has a flatter shape. It is covered by unchanged skin and is connected with the underlying bone; upon palpation, significant tenderness is noted. At the basis of this process in its initial stages lies a small-cell infiltration originating from the inner layer of the periosteum. The course and outcome of the process can vary. Most often, organization and ossification of the infiltrate with new formation of bone tissue (p. ossificans) is observed; the most favorable outcome is the resorption of the infiltrate, observed especially in fresh cases, and only a slight thickening of the periosteum remains. In rare cases, with rapid and acute course, purulent inflammation of the periosteum develops, and the process usually also involves the surrounding soft tissues with penetration of the skin and emptying of the pus outward. Upon x-ray examination of syphilitic P., the outer contours of it usually appear smooth or slightly rough and watery; there are no sharper nodular or spiculate deposits. In rare cases, these elevations are outlined not as amorphous formations, but consist of individual large or small densely arranged plates and spurs, directed perpendicularly to the bone; the outer contours are not smooth, but evenly notched. The x-ray picture resembles a comb with parallel to each other teeth gradually shortening toward the edges (comb-like P.). Sometimes to this transverse striation is added also a longitudinal layering; then there is a complex picture resembling lace - lace-like P. (lacework pattern of American radiologists). In gummatous P., there is development of gummas, flat elastic thickenings, to some degree painful, revealing on a cut surface a gelatinous consistency and having their starting point in the inner layer of the periosteum. Both isolated gummas and diffuse gummatous infiltration are encountered. A number of places are noted where gummas develop most often, namely: the cranial vault (especially the frontal and parietal bones), the sternum, the tibia, the clavicles. Diffuse gummatous P. for a long time may not give changes from the side of the skin. Then in the presence of bone defects, unchanged skin sinks into the deep openings. Such pictures are found on the tibia, clavicle, sternum. Later, gummas may undergo resorption and replacement by scar tissue, but more often in later stages they undergo fatty, caseous or purulent melting, and the surrounding soft tissues as well as the skin are drawn into the process. As a result of this, the skin melts on a certain area and the contents of the gumma break through outward with the formation of an ulcerative surface; with subsequent healing and wrinkling of the ulcer, indented scars are formed, fused with the underlying bone. Around the gummatous process, significant phenomena of ossifying P. with reactive new formation of bone are usually found, and sometimes they reach such intensity that they come to the fore and can hide the main pathological process - the gumma. On the x-ray film in case of gummatous P., thickening of the bone is found, which merges with the cortical layer of the bone (periosteal osteophyte). The gumma itself is outlined in the form of an oval light amorphous defect, located most superficially in the central part of the osteophyte. With multiple gummas, located close to each other, a variegated picture of numerous, merging with each other round and oval defects is obtained on the x-ray film. Treatment is specific; in complicated cases, treatment applied ex juvantibus provides diagnostic assistance. In case of breakthrough of the gumma outward with the formation of an ulcer and the presence of bone lesions (caries, sequestra)-surgical treatment according to general rules. P. actino-mycotica, see Bone-pathology of bone and Actinomycosis. P. are also noted in a number of other diseases. Thus, in smallpox, P. of the diaphyses of long tubular bones with corresponding thickenings of them are described, and this phenomenon is usually observed in the period of convalescence. In glanders, foci of limited chronic inflammation of the periosteum are noted. In leprosy, lepromatous infiltrates in the periosteum are described (Savchenko); moreover, in leprosy patients, spindle-shaped swellings can form on tubular bones as a result of chronic P. In gonorrhea, inflammatory processes in the periosteum are noted, and infiltrates form in it, which with progression of the process can lead to the formation of pus. Significant P. are described in blastomycoses of long tubular bones. Numerous authors describe post-syphilitic lesions of bones (especially diseases of the ribs after typhus), and in such cases, limited dense thickenings of the periosteum with smooth contours are noted. Sometimes in diseases of the hematopoietic organs, especially in leukemia, P. of small size are noted. In splenomegaly of the Gaucher type (see Gaucher disease), peculiar periosteal thickenings are described, mainly around the distal half of the thigh. Professional P., see Bone-clinical diseases of bone.