骨结核英文七年制课件

TUBERCULOSISofBONES&JOINTS

LiQiang

For7-yearmedicalstudents

Septiclesion?Tumor?IntroductionTuberculosisofbonesandjointsGenerallytobeachronicinflammatoryandinfectiousdiseasecausedbyMyobacterium

tuberculosis.Extrapulmonarysecondarydiseases Approximately95%casesoftuberculosisofbonesandjointsareduetopulmonarytuberculosis,butpulmonarytuberculosisisevidentinonlyhalfthepatientswithskeletalinvolvement.EpidemiologyEpidemiologyIngeneral,mostpatientswiththisdiseaseareintheageof30orbelowatdiagnosisindevelopingcountries

Thesusceptiblepopulation

withthisdisease

isintheelderlyindevelopedcountries.Bothsexesareequallyaffected.EpidemiologyTuberculosisofspineisthemostcommonsite,thenextinorderoffrequencybeingtheknee,hip,ankle,sacroiliac,shoulder,andwristjoints.LocationIncidenceEtiologyPathogen(致病菌)

Acid-fastbacilliMycobacteriumtuberculosisHumantuberclebacilli

（人型结核杆菌）commonBovinetuberclebacilli(牛型结核杆菌)rareThefluorescentstainingofacid-fastbacilli

EtiologyOnMarch24,1882,RobertKochannouncedhisdiscoveryofthetuberclebacillus.HediscoveredastainingtechniquethatenabledhimtoseeMycobacteriumtuberculosis.（结核杆菌）

Dr.RobertKochEtiologyTransmissionRoutesHematogenousdissemination

（血液传播）tolongbonesandvertebraeDirectspreadtobonefromadjacenttuberculouslymphadenitis

（结核性淋巴腺炎）Singleormulticentric（单发或多中心），particularlyinAIDSPredilectionforsynovium

（偏好滑膜）-higheroxygenpressurePathologyBasicPathologyChanges:

Exudation渗出

Deterioration变质

Proliferation增殖SimpleSeletal

TBTBoftheCancellousBone

centrallesion

PeripherallesionTheanteriorlesion

Theparadiscallesion

TBoftheCorticalBoneTBoftheMetaphysisPathology(SimpleSekeltal

TB)TBoftheCancellousBone

Centraltypepoorbloodsupplymainpathologicalchangesincludeskeletalerosionandnecrosisformingsequestruaandcavities.calcaneusPathology(SimpleSkeletal

TB)TBoftheCorticalBone

Localizeddestroywithoutformingsequestrumonion-likeproliferation;thequantityofnewboneformationofperiosteumisdeterminedbytheage.Pathology(SimpleSkeletal

TB)TBofthemetaphysis(干骺端结核）formingsequestrua(死骨片）(cancellousbone)newboneformationofperiosteum（骨膜）(compactbone)Pathology

(TBoftheSynovialmembrane滑膜结核)Earlystage:Hyperaemia

充血Synovialhypertrophy肿胀Exudateincreasing渗出增多Pannusformation（血管翳）&Ricebodies米粒体(small,freewhitebodiescomposedofcompactmassesoffibrin,necroticsynovialvilli,orcartilagefragments)Latestage:hyperplasiaofsynovium

滑膜肥厚增生Theriskofjointsinvolveknee,hip,elbowandankle.ComplicationsofLateStageTBofBonesandJointsAbscess脓肿Pathologicalsubluxation,dislocationorfracture病理性半脱位、脱位或骨折Articulardeformityorstiffness关节畸形强直Shorteningofextremities肢体短缩(epiphyseserosion)骨骺受损Paraplegia(spinalcordcompressed)截瘫ComplicationsofLateStageTBofbonesandjointsAbscess(ColdAbscess)寒性脓肿Paraspinalabscess椎旁脓肿Gravitationabscess流注脓肿Psoasabscess腰大肌脓肿Lumbertrangleabscess腰三角脓肿OtherabscessParaspinalabscess椎旁脓肿Deepgravitationabscessofgroin腹股沟深部流注脓肿Articularstiffnessanddeformity关节强直畸形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Diagnosisand

DifferentialDiagnosisDiagnosis

MedicalhistoryInsidiousonset隐匿起病Symptoms:

pain疼痛

lowfever低热nightsweats盗汗anorexia厌食anemia贫血weightloss体重减轻localswelling局限肿胀morbidnightcryingofbabies夜啼contacthistory接触史DiagnosisClinicalexamination

Systemicandregionallymphnods:singleratherthanmultipleappearanceLocalswellingColdabscess:withoutruborandcalorLocalheatandrednessareusuallyabsent,andtendernessisminimal.

Sinustracts:multiple

appearance,periarticulartendernessandpercussingpainJointfunction:insidethejointoroutsidethejointSystemicsymptoms:mildexceptforchildDiagnosisRadiographicFindings(6-8weeksafter)SkeletalTBTBofthecancellousbone:Centrallesion:bonenecrosisPeripherallesion:bonelysisTBofthecorticalbone:layerperiosteumproliferation&shuttle-likeinflationTBofthemetaphysis:DiagnosisRadiographicFindingsTBofthesynovialmembrane:Theearliestfindingsintheradiogramsareregionalboneatrophy,soft-tissueswelling,andcapsulardistention.Thesechangesareduetosynovitisandarenonspecific.Tuberculouspanarthritis:Theabovechangesarefollowedbyperipheralerosionoftheboneanddestructionofthesubchondralbone,withthejointspacenarrowing.

Diagnosis

Labtestbloodrt.10%pt.whitecellThesedimentationrate:non-pathognomonicfortuberculosisbutaltersearlythanX-ray(male<15mm/h;femal<20mm/h)

Tuberculinskintest:immunocompetentpatients:alwayspostiveimmunocompromisedpatients:33%postiveDiagnosis

LabfindingBacteriologicexamination

(thetuberclebacillusculture)

(3~6weeks)

orhistologicalexaminationofpusorbiopsyspecimen.PositiveRateofCultureforM.tuberculosis

onsmearpus:70%granulomasorcaseation(orcheesy)necrosisarea:43%jointasperationordeadbone:35%PositiveRateofPathologicalexam:70-80%(Langerhansgiantcells)

MRIandPCRuseforearlydiagnosisMethodofJointAspirationforTBDifferentialDiagnosisRheumatoidArthritis:

20~55岁女性，多关节、小关节，对称性。RF因子（+）AnkylosingSpondylitis:

15~35岁男性，多发，（脊柱、髋、膝），对称性，无脓无死骨，HLAb27（+）

Septicarthritis:关节穿刺SepticOsteomyelitis:

全身中毒症状重。细菌学和病理检查BoneTumor: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ProphylaxisandTreatmentEffectiveTBControlTheWHO-recommendedtreatmentstrategyfordetectionandcureofTBisDOTS.TreatmentEarlydiagnosisandtheuseofantituberculousdrugshaveradicallyimprovedtheprognosisoftuberculousarthritis.Othermeasuresadoptedareresttotheaffectedjointinfunctionalposition,tractionwhenneededanddietaryimprovement.Treatmentconsistsofgeneralmedicalmeasures,chemotherapy,localconservativeorthopediccare,andsurgery.CriterionofCure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Indicationsofoperation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SpinalTuberculosisClinicalManifestationCervical:NeckPain(mildtosever)NumbnessofarmduetoneuralcompressionObstructingbreathingandswallowingwithPostpharyngealabscessTuberculosisofSpine

ClinicalManifestationThoracic:BackpainGibbousdeformityLumbar:SpecialStandingstancePick-uptest(+)GravitationabscessOsseousdestroyanddecreaseinoneormorediscspacesColdAbscess:Cervical:

Lumbar

ThoracicTuberculosisofSpine

RoentgenographicFindings

PrincipleofTreatmentCastfixationSurgicaltreatmentEvacuationorexcisionofsofttissueabscesses（切开排脓）Clearanceoffocallesion（病灶清除术）Osteotomy,Arthrodesisandarthroplasty.（矫形手术）HipTuberculosisClinicalManifestationHippainLimpAbscessofgroinPE:Figure4testHiphyperextensiontestThomastestHipTuberculosis

RoentgenographicFindingsX-rayCTMRIHipTuberculosisPrincipleofTreatmentChemotherapySkintractiontopreventionformingcontracturehip(bendingdeformity)thenfixwithhipspicafor3months.SimplesynovialTB:Intra-articularinjectionwithanti-tuberclemedicineSynovectomyorcurettageforthecaseswithintra-articulardropsytoreservefemoralhead.(arthroscopy/locallesion,open/extensivelesion)Tuberculouspanarthritis:(anti-tbdrug>1yr.ESR,CRPNormal.)Osteotomy,Arthro