骨结核英文七年制.ppt

TUBERCULOSIS of BONES & JOINTS,Li Qiang,For 7-year medical students,Septic lesion? Tumor ?,Introduction,Introduction Epidemiology and Etiology (流行病学及病因学) Pathology (病理) Diagnosis and Differential Diagnosis (诊断与鉴别诊断) Prophylaxis and Treatment (预防与治疗),Tuberculosis of bones and joints Generally to be a chronic inflammatory and infectious disease caused by Myobacterium tuberculosis . Extrapulmonary secondary diseases Approximately 95% cases of tuberculosis of bones and joints are due to pulmonary tuberculosis, but pulmonary tuberculosis is evident in only half the patients with skeletal involvement.,Epidemiology,Epidemiology,In general, most patients with this disease are in the age of 30 or below at diagnosis in developing countries The susceptible population with this disease is in the elderly in developed countries. Both sexes are equally affected.,Epidemiology,Tuberculosis of spine is the most common site, the next in order of frequency being the knee, hip, ankle, sacroiliac, shoulder, and wrist joints.,Location,Incidence,In Summary,Tuberculosis of bones and joints is a granulomatous inflammation caused by Myobacterium tuberculosis. About 5% of tuberculosis is musculoskeletal. 最常见的肺外继发性结核 Tuberculosis of spine is the most common site, the next in order of frequency being the knee, hip, ankle, sacroiliac, shoulder, and wrist joints. 脊柱结核最常见,Etiology,Pathogen (致病菌) Acid-fast bacilli Mycobacterium tuberculosis Human tubercle bacilli （人型结核杆菌）common Bovine tubercle bacilli (牛型结核杆菌) rare,The fluorescent staining of acid-fast bacilli,Etiology,On March 24, 1882, Robert Koch announced his discovery of the tubercle bacillus. He discovered a staining technique that enabled him to see Mycobacterium tuberculosis. （结核杆菌）,Dr. Robert Koch,Etiology,Transmission Routes Hematogenous dissemination （血液传播）to long bones and vertebrae Direct spread to bone from adjacent tuberculous lymphadenitis （结核性淋巴腺炎） Single or multi centric（单发或多中心）， particularly in AIDS Predilection for synovium （偏好滑膜）- higher oxygen pressure,Pathology (病理),Initial pathological changes are tuberculous osteomyelitis (结核性骨髓炎,单纯骨结核) and synovial tuberculosis(滑膜结核)。 The articular cartilages remain intact at this stage. The lesion will be healed through proper treatment in time, and joint function will be reserved thoroughly or partially. If the original focus remains active and untreated, the lesion will exacerbate, involved bone, cartilage and synovia, developing to tuberculous panarthritis（全关节结核）.,Pathology,Basic Pathology Changes: Exudation 渗出 Deterioration 变质 Proliferation 增殖,Simple Seletal TB,TB of the Cancellous Bone central lesion Peripheral lesion The anterior lesion The paradiscal lesion TB of the Cortical Bone TB of the Metaphysis,Pathology (Simple Sekeltal TB),TB of the Cancellous Bone Central type poor blood supply main pathological changes include skeletal erosion and necrosis forming sequestrua and cavities.,calcaneus,Pathology (Simple Skeletal TB),TB of the Cancellous Bone Peripheral type abundant blood supply local bone defect without forming sequestrum,Pathology (Simple Skeletal TB),TB of the Cortical Bone Localized destroy without forming sequestrum onion-like proliferation; the quantity of new bone formation of periosteum is determined by the age.,Pathology (Simple Skeletal TB),TB of the metaphysis (干骺端结核） forming sequestrua (死骨片） (cancellous bone) new bone formation of periosteum （骨膜） (compact bone),Pathology (TB of the Synovial membrane滑膜结核),Early stage: Hyperaemia 充血 Synovial hypertrophy 肿胀 Exudate increasing 渗出增多 Pannus formation （血管翳）& Rice bodies 米粒体(small, free white bodies composed of compact masses of fibrin, necrotic synovial villi, or cartilage fragments),Late stage: hyperplasia of synovium 滑膜肥厚增生,The risk of joints involve knee, hip, elbow and ankle.,Pathology (Tuberculous panarthritis) 全关节结核,Due to SimpleTB,Due to synovial TB,Complications of Late Stage TB of Bones and Joints,Abscess 脓肿 Pathological subluxation, dislocation or fracture 病理性半脱位、脱位或骨折 Articular deformity or stiffness 关节畸形强直 Shortening of extremities 肢体短缩 ( epiphyses erosion) 骨骺受损 Paraplegia (spinal cord compressed) 截瘫,Complications of Late Stage TB of bones and joints,Abscess (Cold Abscess)寒性脓肿 Paraspinal abscess 椎旁脓肿 Gravitation abscess 流注脓肿 Psoas abscess 腰大肌脓肿 Lumber trangle abscess 腰三角脓肿 Other abscess,Paraspinal abscess 椎旁脓肿,Calcification of the paraspinal abscess is essentially pathognomonic for tuberculosis 椎旁脓肿钙化是结核的基本特征,Normal shadow of psoas major 正常腰大肌影,Psoas abscess 腰大肌脓肿,Deep gravitation abscess of groin 腹股沟深部流注脓肿,Articular stiffness and deformity 关节强直畸形,Limb Shortening 肢体短缩,Kyphosis（脊柱后凸） Paraplegia（截瘫）,掌握要点,骨与关节结核的发展阶段和分型及其X线特点 松质骨结核：中心型 坏死型 边缘型 溶骨型 密质骨结核：层状骨膜增生，梭型膨大 干骺端结核：兼有松质骨和密质骨结核特性 滑膜结核：无特殊。仅骨质疏松 全关节结核：早期；晚期 骨与关节结核晚期并发症： 不同部位的寒性脓肿 关节畸形、强直,Diagnosis and Differential Diagnosis,Diagnosis,Medical history Insidious onset 隐匿起病 Symptoms: pain 疼痛 low fever 低热 night sweats 盗汗 anorexia 厌食 anemia 贫血 weight loss 体重减轻 local swelling 局限肿胀 morbid night crying of babies 夜啼 contact history 接触史,Diagnosis,Clinical examination Systemic and regional lymph nods: single rather than multiple appearance Local swelling Cold abscess: without rubor and calor Local heat and redness are usually absent, and tenderness is minimal. Sinus tracts: multiple appearance, periarticular tenderness and percussing pain Joint function: inside the joint or outside the joint Systemic symptoms: mild except for child,Diagnosis,Radiographic Findings (6-8 weeks after) Skeletal TB TB of the cancellous bone: Central lesion: bone necrosis Peripheral lesion: bone lysis TB of the cortical bone: layer periosteum proliferation & shuttle-like inflation TB of the metaphysis:,Diagnosis,Radiographic Findings TB of the synovial membrane : The earliest findings in the radiograms are regional bone atrophy, soft-tissue swelling, and capsular distention. These changes are due to synovitis and are nonspecific. Tuberculous panarthritis : The above changes are followed by peripheral erosion of the bone and destruction of the subchondral bone, with the joint space narrowing.,Diagnosis,Lab test blood rt. 10% pt. white cell The sedimentation rate: non-pathognomonic for tuberculosis but alters early than X-ray (male 15mm/h; femal20mm/h) Tuberculin skin test: immunocompetent patients: always postive immunocompromised patients: 33% postive,Diagnosis,Lab finding Bacteriologic examination (the tubercle bacillus culture) (36weeks) or histological examination of pus or biopsy specimen. Positive Rate of Culture for M. tuberculosis on smear pus: 70% granulomas or caseation (or cheesy) necrosis area:43% joint asperation or dead bone:35% Positive Rate of Pathological exam: 70 - 80% (Langerhans giant cells ) MRI and PCR use for early diagnosis,Method of Joint Aspiration for TB,Differential Diagnosis,Rheumatoid Arthritis: 2055岁女性，多关节、小关节，对称性。RF因子（+） Ankylosing Spondylitis: 1535岁男性，多发，（脊柱、髋、膝），对称性，无脓无死骨，HLAb27（+） Septic arthritis: 关节穿刺 Septic Osteomyelitis: 全身中毒症状重。细菌学和病理检查 Bone Tumor: 脊柱结核早期侵犯椎间盘，椎间隙狭窄消失,急性骨髓炎(以破坏和增生为主）X线见骨质广泛破坏，大量死骨及大量骨膜新骨形成,骨结核（破坏、疏松、萎缩为主）髓腔内溶骨性破坏,无死骨；骨干周围有广泛新骨形成,慢性骨髓炎 破坏与增生并存; 骨质硬化；大量死骨、包壳发生,骨结核 以破坏、疏松、萎缩为主; 很少硬化；死骨少、小(沙粒状）,掌握要点,骨与关节结核的诊断要点： 分四步骤： 病史与临床表现 结菌素皮肤实验 X线片检查（胸部和患肢）; MRI 细菌学检查（痰培养、脓肿穿刺液培养） 主要鉴别的疾病： 结缔组织病 骨关节感染性疾病 骨肿瘤,Prophylaxis and Treatment,Effective TB Control The WHO-recommended treatment strategy for detection and cure of TB is DOTS.,Treatment,Early diagnosis and the use of antituberculous drugs have radically improved the prognosis of tuberculous arthritis. Other measures adopted are rest to the affected joint in functional position, traction when needed and dietary improvement. Treatment consists of general medical measures, chemotherapy, local conservative orthopedic care, and surgery.,Criterion of Cure 治愈标准,全身情况良好，体温正常，食欲（orexia）良好 局部症状消失，无疼痛，窦道闭合 血沉3次结果正常 X线显示脓肿缩小乃至消失或钙化，无死骨，病灶边缘轮廓清晰 起床活动已达1年，仍保持上述4项指标,Indications of operation 手术适应证,骨关节结核有明显的死骨忽而大脓肿形成 窦道流脓经久不愈 脊柱结核引起脊髓受压,Spinal Tuberculosis,Clinical Manifestation Cervical: Neck Pain (mild to sever) Numbness of arm due to neural compression Obstructing breathing and swallowing with Postpharyngeal abscess,Tuberculosis of Spine Clinical Manifestation,Thoracic: Back pain Gibbous deformity Lumbar: Special Standing stance,Pick-up test (+),Gravitation abscess,Osseous destroy and decrease in one or more disc spaces Cold Abscess: Cervical:,Lumbar,Thoracic,Tuberculosis of Spine Roentgenographic Findings,Principle of Treatment,Cast fixation Surgical treatment Evacuation or excision of soft tissue abscesses （切开排脓） Clearance of focal lesion （病灶清除术） Osteotomy, Arthrodesis and arthroplasty. （矫形手术）,Hip Tuberculosis,Clinical Manifestation Hip pain Limp Abscess of groin PE: Figure 4 test Hip hyperextension test Thomas test,Hip Tuberculosis,Roentgenographic Findings X-ray CT MRI,Hip Tuberculosis,Principle of Treatment Chemotherapy Skin traction to prevention forming contracture hip (bending deformity) then fix with hip spica for 3 months. Simple synovial TB: Intra-articular injection with anti-tubercle medicine Synovectomy or curettage for the cases with intra-articular dropsy to reserve femoral head. (arthroscopy/ local lesion, open/extensive l