PowerPoint Presentation
Tuberculosis Of Appendicular Skeleton
Dr. Apoorv JainDOrtho, DNB
[email protected]+91-9845669975
INTRODUCTION Tuberculosis is a chronic granulomatous infectious
disease caused by Mycobacterium Tuberculosis (a gram positive acid
fast bacilli).
Transmitted through the air borne spread of droplet nuclei
produced by patients with infectious pulmonary tuberculosis.
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Problem StatementIndia: highest TB burden in world (accounts for
1/5 (20%) of global burden) Every year 1.8 millions develops
TBEvery day about 5000 people develop disease. 2 persons die of TB
every 3 min. More than 1000 people die every day.
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Increased incidence has been noted with prevalence of AIDS.In
India EPTB (extra pulmonary tuberculosis) form 10-15% of all types
of TB. Amongst EPTB, Lymph node TB is the commonest. TB of bone and
joints constitutes 1-3% of Extra-pulmonary TB of which the most
commonly involved is the Spine constituting 50% of all Skeletal
Tuberculosis.
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Skeletal tuberculosis (TB) refers to TB involvement of the bones
and/or joints. It is an ancient disease; features of spinal TB have
been identified in Egyptian mummies dating back to 9000 BC
TB Of Appendicular SkeletonTubercular affection of joints:Hip
JointKnee joint and Triple deformityShoulder joint and Caries
SiccaElbow joint, Wrist and Carpus, Sacroiliac jointsTubercular
Osteomyelitis (Long and Flat Bones)Tubercular dactylitis (Spina
Ventosa)Tuberculosis of tendon sheath and bursae
Insidious onset (c/w pyogenic infections)Low grade feverWeight
loss Night sweatMovement restriction, muscle wasting, regional
lymph node involvement and neurologic symptomsWeight bearing joints
like hip, knee and ankle are commonly involved, though any part of
the skeleton can get involved
Clinical features in General
Tuberculosis Of Hip Joint
Relevant Surgical Anatomy Of Hip Ball and socket type of
synovial joint. Fibrocartilaginous labrum attached to acetabulum,
makes the socket deeper. Considerable part of articular surface of
spherical femoral head remains uncovered. Opening of acetabulum
directed laterally, downwards (300) and forward (300).Femoral neck
directed medially, upward and anteriorly. Angle of anteversion in
adult 10-300, neck shaft angle around 1250.
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Ligaments around hip joint
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Tuberculosis Of Hip Joint2nd most common osteoarticular TB (next
only to spinal TB) Commoner in malesINTRODUCTION:
PATHOGENESIS:Invariably secondary to primary site elsewhere (lungs,
LNs of mediastinum,mesentry or cervical,kidney etc) The tubercle is
the microscopic pathological lesion with central necrosis
surrounded by epitheloid cells, giant cells and mononuclear
cell.
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Two types of lesions Caseating exudative type: when caseating
necrosis and cold abscess formation predominates Proliferating
type: where cellular proliferation predominates with minimal
caseation, tuberculosis granuloma is the extreme form of this type
(Former is common in children & latter in adults)
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Location of osseous origin of tuberculosis of left hip joint;
(1) acetabulum (2) femoral head/epiphysis (3) femoral
neck/metaphysic (4) greater trochanter
Babcock's triangle :A relatively radiolucent seen on an
anteroposterior radiograph of the hip in the subcapital region of
the fermoral head. It is an area of loosely arranged trabeculae
noted between the more radiodense lines of the normal bony
trabeculae groups. Tuberculosis of hip joint The disease may start
in epiphysis, Babcocks Triangle, acetabular roof or in
synovium.
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Lesions of upper end femur
Involves joint rapidly
Destruction of articular surface of head & acetabulum
Lesions of acetabululum(roof)
Jnt involvement is late & by the time patient presents
Extensive bone destruction already present
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Tracking Of Cold abscess (within the joint)
Inferior part of Capsule(weak)
Femoral triangle, medial ,lateral & posterior aspect of
thigh Pelvis
Above levator ani
Inguinal regionBelow levator ani
Ischiorectal fossa
Tracking of abcess away from the joint is usually along the
Neuro-vascular bundle
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Stages Of TB Hip
Stage I: Stage Of Synovitis
Stage II: Stage Of Early Arthritis
Plain X-ray showing "stage of arthritis;" pathology involving
articular surface. Irregular and hazy joint margins with diminished
joint space on left side
Stage III: Stage Of Advanced Arthritis
Stage IV: Advanced Arthritis with Hip Subluxation /
Dislocation
As the disease progress,Head of femur partly absorbed & gets
dislocated from acetabulum onto iliumWANDERING ACETABULUM
If left untreated,Healing by absorption & connective tissue
encapsulation occurs. Leading to distortion, deformity and fibrous
ankylosis of joint
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Clinical featuresSymptoms: (when disease is
active)Constitutional symptoms
Pain (absent in early stage, night cries/starting pain)
Limp (earliest, commonest, antalgic gait, asso. stiffness)
Deformity of limb (stage of involvement)
Fullness around hip (site of cold abcess)
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Physical signsGeneral: pallor, emaciation, LNs, signs of pulm
TBGait: antalgic, trendelenburgInspection: deformity of limb,
wasting of thigh & gluteal muscles, swelling around
hipPalpation: confirmation of above findings, muscle spasm of lower
abdomen & adductors of thigh, joint line tenderness, shift of
GTMovements: fixed deformities, painful ROMMeasurements: Apparent
lengthening/shortening, true shortening (Due to fixed deformities
secondary changes in spine (lordosis, scoliosis etc))
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Functional Assesment Group 1 Painless ROM in all directions
Group 2 Painless range of flexion 35-900 Group 3 Flexion
