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"code": "M87",
"name": "Остеонекроз",
"icd_name": "Остеонекроз",
"gender": 0,
"age_min": 0,
"age_max": 100,
"cause": [
3,
1
],
"periodicity": 1,
"slug": "m87_osteonekroz",
"lead": "Нарушение здоровья, относящееся к группе другие остеопатии",
"description": "Остеонекроз – поражение различных отделов кости множественной этиологии, возникающее в ответ на нарушение в ней кровообращения и приводящее к гибели костного мозга и трабекулярной кости.",
"etiology": "<p>Наиболее распространенные причины остеонекроза следующие:</p>\r\n<ul>\r\n<li>Серьезная травма, которая нарушила нормальное кровоснабжение кости.</li>\r\n<li>Прием кортикостероидных препаратов (преднизолон, метилпреднизолон), особенно в больших дозах и длительными курсами, которые назначаются при хронических заболеваниях.</li>\r\n<li>Злоупотребление алкоголем и табакокурение.</li>\r\n</ul>\r\n<p>Другие, редкие причины остеонекроза:</p>\r\n<ul>\r\n<li>Системная красная волчанка (СКВ).</li>\r\n<li>Декомпрессионная болезнь (дисбарический остеонекроз).</li>\r\n<li>Заболевания крови, такие как серповидноклеточная анемия.</li>\r\n<li>Синдром приобретенного иммунодефицита (СПИД).</li>\r\n<li>Лучевая терапия при онкозаболеваниях.</li>\r\n<li>Прием бифосфонатов, которые связаны с некрозом челюсти. </li>\r\n</ul>",
"pathogenesis": "<p>Остеонекроз связан с гибелью клеток костной ткани (остеоцитов) и костного мозга.</p>\r\n<p>Развитие нетравматического остеонекроза может быть обусловлено эмболией сгустками крови или каплями жира, внутрисосудистым тромбозом и внесосудистой компрессией. После сосудистого эпизода развивается репаративный процесс, направленный на удаление некротизированной кости и костного мозга и замещение их живой тканью. Если зона инфаркта невелика и не подвергается значительной нагрузке, этот процесс может быть успешным. В 80% случаев он оказывается неэффективным и зона инфаркта подвергается компрессии. Так как остеонекроз обычно поражает дистальные участки длинных костей, суставная поверхность становится уплощенной и неровной, что сопровождается усилением болей и приводит к развитию остеоартрита.</p>",
"diagnostics": "<p>На начальном этапе проводится рентгенологическое исследование. Ранние рентгенологические признаки включают локализованные очаги склероза и просветления. Позднее может появиться субхондральный симптом полулуния. Затем развивается коллапс кости и уплощение суставной поверхности с последующим развитием дегенеративных изменений.</p>\r\n<p>МРТ – является более чувствительным и специфичным методом.</p>\r\n<p>Сцинтиграфия костей менее чувствительна и менее специфична, чем МРТ, и в настоящее время выполняется редко.</p>\r\n<p>КТ требуется редко, хотя иногда она может быть полезна для выявления сдавления сустава, который не определяется на обычной рентгенограмме, а иногда не виден даже на МРТ.</p>",
"treatment": "<p>Симптоматическая терапия включает покой, ЛФК, назначение нестероидных противовоспалительных препаратов.</p>\r\n<p>Хирургическое вмешательство направлено также на то, чтобы сохранить кость и не прибегнуть к протезированию. Существует несколько направлений:</p>\r\n<p>Декомпрессия, при которой в повреждённой кости делают отверстие, оно уменьшает давление внутри кости, не позволяет возникновению сдавления. Остеотомия – удаление участка некротизированной костной ткани. Аутотрансплантация – пересадка собственной здоровой костной ткани.</p>\r\n<p>При невозможности применения вышеуказанных методов и восстановления костной ткани прибегают к эндопротезированию суставов.</p>\r\n<p> </p>",
"prevention": "<p>Основными профилактическими мероприятиями являются:</p>\r\n<ul>\r\n<li>Отказ от вредных привычек – курения и употребления алкоголя</li>\r\n<li>Подбор минимальных эффективных доз кортикостероидов</li>\r\n<li>Соблюдение правил гигиены при уходе за ротовой полостью для предупреждения разрушения челюсти</li>\r\n<li>Прекращение приема бисфосфонатов за 2 месяца до инвазивной стоматологической манипуляции. </li>\r\n</ul>\r\n<p> </p>",
"clinical_picture": "<p>Заболевание может долгое время протекать бессимптомно. Затем постепенно развивается боль, но она может возникнуть и остро. По мере прогрессирования сдавления сустава боль нарастает, усиливается при физической нагрузке.</p>\r\n<p>В развернутой стадии отмечаются боли и ограничение подвижности, при этом пассивные движения ограничиваются в меньшей степени, чем активные. Возможен клинически выраженный синовиальный выпот, особенно в коленном суставе; жидкость при этом имеет невоспалительный характер.</p>",
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"standard_type": 3,
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"published": 2,
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"block_rubric": 144,
"standards": [
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5331
]
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{
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{
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{
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{
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{
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{
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}
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},
"code": "M86",
"name": "Остеомиелит",
"icd_name": "Остеомиелит",
"gender": 0,
"age_min": 0,
"age_max": 100,
"cause": [
1,
2,
5,
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],
"periodicity": 1,
"slug": "m86_osteomielit",
"lead": "Нарушение здоровья, относящееся к группе другие остеопатии",
"description": "Остеомиелит – воспаление костного мозга, при котором обычно поражаются все элементы кости (надкостница, губчатое и компактное вещество).\r\n\r\n",
"etiology": "<p>Возбудителем острого остеомиелита в 80-85% случаев являются патогенные стафилококки, реже стрептококки и пневмококки. Возросла роль высокорезистентной к антибактериальным препаратам грамотрицательной флоры (около 6-7%), нередко включаются со стафилококками:</p>\r\n<ul>\r\n<li>синегнойная палочка</li>\r\n<li>вульгарный протей</li>\r\n<li>кишечная палочка;</li>\r\n<li>в 2-4% случаев высеваются в виде монокультур клебсиелы (капсульная форма).</li>\r\n</ul>\r\n<p>Важным этиологическим фактором острого гематогенного остеомиелита могут быть и вирусные инфекции, на фоне которых протекает почти 40-50% случаев остеомиелита. Вирусы снижают сопротивляемость организма, повышают вирулентность гноеродных бактерий и создают благоприятную почву для их внедрения.</p>",
"pathogenesis": "<p>У детей грудного и младшего возраста часто встречается гематогенный («порожденный кровью») остеомиелит. Из очага инфекции – например, из больного зуба – микробы проникают в костномозговой канал длинной трубчатой кости руки или ноги. Редко остеомиелит вызывается инфекцией мягких тканей, которая переходит на прилегающую кость. Одной из причин остеомиелита может стать открытый перелом, в этом случае инфекция проникает через рваную рану в кость.</p>\r\n<p>Как только костная ткань поражается микроорганизмами, к очагу заражения мигрируют лейкоциты, они выделяют литические ферменты, которые разлагают кость. Распространение гноя по кровеносным сосудам приводит к секвестрации кости, таким образом формируется база для хронической инфекции. В это время организм пытается создать новую кость вокруг области некроза. Получающуюся новую кость часто называют покровом.</p>\r\n<p>У младенцев инфекция может распространиться к суставу и вызвать артрит. У детей могут сформироваться большие субпериостальные абсцессы, потому что периостальная ткань свободно присоединена к поверхности кости. Из-за особенностей кровоснабжения особенно восприимчивы к остеомиелиту голень, бедро, плечевая кость, позвонок, верхняя челюсть и нижнечелюстные суставы. Однако, травмой в зоне поражения могут быть вызваны абсцессы любой кости.</p>\r\n<p> </p>",
"diagnostics": "<p>Рентгенологическая диагностика</p>\r\n<p>Рентгенологические признаки появляются на 7-14 день после начала заболевания, у новорожденных на 4-5 день. Рентгенограммы производят в 2-х проекциях и для сравнения обязательно и здоровой конечности.</p>\r\n<p>Рентгенологические признаки острого гематогенного остеомиелита разделяют на ранние:</p>\r\n<ul>\r\n<li>участки разряжения и уплотнения кости;</li>\r\n<li>смазанность контуров костного рисунка;</li>\r\n<li>утолщение надкостницы – периостит;</li>\r\n</ul>\r\n<p>и поздние:</p>\r\n<ul>\r\n<li>на 7-12 сутки очаги деструкции костной ткани – секвестры;</li>\r\n<li>утолщение и уплотнение кости вокруг очага воспаления.</li>\r\n</ul>\r\n<p>Компьютерная томография</p>\r\n<p>Данное исследование является наиболее совершенным методом визуализации костной ткани на сегодняшний день. С его помощью можно выявить все вышеперечисленные рентгенологические признаки остеомиелита, а также воссоздать трехмерную реконструкцию пораженной области, включающую не только костный каркас, а еще и окружающие мягкие ткани. Помимо этого компьютерная томография имеет крайне большое значение в дифференциальной диагностике с другими заболеваниями костной ткани.</p>\r\n<p>Применяются УЗИ и электрорентгенодиагностика.</p>",
"treatment": "<p> </p>\r\n<p>При остеомиелите показана обязательная госпитализация.</p>\r\n<p>Общее лечение:</p>\r\n<ul>\r\n<li>массивная антибиотикотерапия (внутривенно цефалоспорин, линкомицин и др.) — начинают как можно раньше;</li>\r\n<li>мощная дезинтоксикация — с первых дней заболевания (переливание плазмы и дезинтоксикационных кровезаменителей);</li>\r\n<li>иммуностимуляторы и витаминотерапия;</li>\r\n<li>гемосорбция.</li>\r\n<li>ГБО — гипербарическая оксигенация.</li>\r\n</ul>\r\n<p>Местное лечение:</p>\r\n<ul>\r\n<li>покой, иммобилизация конечности гипсовой лангеткой;</li>\r\n<li>хирургическое лечение — на ранних стадиях, когда процесс не вышел за пределы кости, производят их трепанацию(образование отверстий в кости, через которые проводят проточный дренаж), в запущенных случаях, когда образовалась ещё и флегмона мягких тканей вокруг кости, производят, кроме того, и вскрытие гнойника, открытую промывку, вплоть до удаления очага и свищей;</li>\r\n<li>физиотерапия (УВЧ, УФО, электрофорез).</li>\r\n</ul>",
"prevention": "<p>Профилактика остеомиелита состоит в предупреждении загрязнения раневой поверхности, в их тщательной первичной хирургической обработке и предотвращении вторичного инфицирования даже небольших повреждений кожи, а также следует учитывать все показания и противопоказания к металлоостеосинтезу.</p>",
"clinical_picture": "<p>Различают три формы клинического течения острого гематогенного остеомиелита:</p>\r\n<ol>\r\n<li>септикотоксическая (септический шок, молниеносная);</li>\r\n<li>септицемическая (типичная, наиболее часто встречающаяся);</li>\r\n<li>легкая (местные симптомы воспаления).</li>\r\n</ol>\r\n<p>Клинические проявления зависят от возраста, характера и вирулентности возбудителей, локализации, защитных сил организма.</p>\r\n<p>Септикотоксическая форма характеризуется следующими симптомами:</p>\r\n<ul>\r\n<li>потрясающий озноб;</li>\r\n<li>высокая лихорадка (до 40˚С);</li>\r\n<li>нарушение сознание (бред, возбуждение);</li>\r\n<li>тошнота, рвота;</li>\r\n<li>сухость кожи, бледность;</li>\r\n<li>анемия;</li>\r\n<li>снижение мочевыделения вплоть до полного отсутствия мочи;</li>\r\n<li>увеличение печени и селезенки.</li>\r\n</ul>\r\n<p>Клинические местные проявления в кости и окружающих тканях не успевают развиться. Прогрессирование процесса быстро приводит к летальному исходу.</p>\r\n<p>Септицемическая типичная форма, клинические проявления начинаются с продромы, в начале заболевания преобладают общие симптомы:</p>\r\n<ul>\r\n<li>повышенная температура тела до 39-40˚С;</li>\r\n</ul>\r\n<p>общая слабость, сонливость;</p>\r\n<ul>\r\n<li>сознание сохранено;</li>\r\n<li>выраженная боль в пораженной конечности в первые 2 суток без четкой локализации;</li>\r\n<li>боль резко усиливается при движениях;</li>\r\n<li>у маленьких детей судороги (симптомы раздражения мозговых оболочек);</li>\r\n<li>лицо бледное, губы цианотичные;</li>\r\n<li>желтушность кожных покровов, склер, точечные кровоизлияния в кожу.</li>\r\n</ul>\r\n<p>В течение первых 2-х суток четко проявляются местные симптомы:</p>\r\n<ul>\r\n<li>боль локальная, в зоне поражения кости;</li>\r\n<li>отек, гиперемия, напряженность кожных покровов;</li>\r\n<li>увеличиваются регионарные лимфатические узлы;</li>\r\n<li>боль в пораженной конечности приводит к рефлекторному сокращению мышц;</li>\r\n<li>развивается сгибательная контрактура (нарушение пассивных движений в суставе) и нарушение функции конечности;</li>\r\n<li>через 7-10 дней определяется участок флюктуации (симптом наличия жидкости) в зоне поражения, свидетельствующий о наличии межмышечной флегмоны и подкожной;</li>\r\n<li>может развиваться реактивный артрит близлежащих суставов;</li>\r\n</ul>\r\n<p>Местная форма острого гематогенного остеомиелита характеризуется легким началом и не тяжелым дальнейшим течением заболевания. Местные воспалительные явления преобладают над общими. Воспаление в кости не всегда разрешается нагноением. У детей при легкой форме заболевание начинается с небольшого повышения температуры тела. Местные симптомы развиваются медленно, появляются к концу 2-ой недели.</p>\r\n<p>Примерно к 4 неделе при всех формах острого остеомиелита происходит секвестрация – образование омертвевшего участка кости, окруженного измененной костной тканью. На 2-3 месяц заболевания секвестры окончательно отделяются, на месте разрушения кости формируется полость и процесс становится хроническим.</p>",
"image": null,
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"standard_type": 3,
"danger": 54,
"published": 2,
"parent": null,
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