Shoulder tuberculosis
Introduction
Introduction to shoulder joint tuberculosis Shoulder joint tuberculosis is relatively rare, accounting for only 1.06% of total body and joint tuberculosis. Adults are more common than children (Turek, 1977), with 21 to 30 years old. Most of the young and middle-aged patients have active tuberculosis at the same time, gender, male is slightly higher than female. The left side is slightly more than the right side. Have a history of tuberculosis or a history of exposure to tuberculosis patients. The muscles around the shoulder joint are rich, the local blood supply is good, and the abscess is easily absorbed. Therefore, the shoulder joint tuberculosis has been called dry bone ulcer, but it is rare. basic knowledge The proportion of illness: 0.001% Susceptible people: no specific population Mode of infection: non-infectious Complications: tuberculosis
Cause
Shoulder joint tuberculosis
Bacterial infections
Originally in the metaphysis of the epiphysis, bacteria and bacteria infiltrate, diffuse, osteolysate and necrosis, form a cheese-like substance, accompanied by tuberculous granulation tissue, dissolve the cheese-like substance into tuberculous pus, and appear bone-destroying cavities (containing pus and dead bone), then the pus enters the joint cavity, synovial changes occur, and total joint tuberculosis occurs.
Joint synovial abnormalities
Slow development, bone destruction can occur in a few months or years, at the onset of the disease, synovial tuberculosis inflammation, congestion, hyperplasia, hypertrophy, tuberculous granulation nodules, serous exudation, joint effusion, cellulose deposition becomes fiber Plain mass, tuberculous pus formation, invasion of joint edge bone (subchondral sneak damage, cartilage necrosis), bone destruction, leading to total joint tuberculosis.
Joint empyema can break through the joints, forming tuberculosis sinus or fistula, and then secondary infection.
Anatomical factors
The sacral anatomical neck, the scapula sacral joint is often the affected part, the joint is filled with tuberculous granulation tissue, and the child's lesion may involve the metaphysis of the entire humerus. The humeral head is composed of many small scattered lesions into a huge fibrous cheese cavity. The humeral head is deformed, the joint capsule is contracted, and the joint is fibrous and straight, and joint movement is often limited.
After the onset of the shoulder joint, the muscles around the joint capsule such as the deltoid muscle and the superior and inferior muscles can rapidly undergo a disabling atrophy. In a few cases, due to the prolonged limb ptosis, the humeral head subluxation occurs, such as the lesion destroying the upper humerus epiphysis of the child. Short limb deformities can occur in the future.
Sometimes the spread of tuberculosis in adjacent areas (such as the shoulder or shoulder sac) can also invade the shoulder joint, the supraclavicular fossa, the axillary or anterior tibial lymph node tuberculosis, and occasionally shoulder tuberculosis.
Prevention
Shoulder joint tuberculosis prevention
The focus of prevention of this disease is to control and prevent tuberculosis infection.
1. Early diagnosis and treatment: If you have tuberculosis, you should treat it early to avoid the deterioration of the disease and prevent the spread of germs. Tuberculosis patients can go to any chest and lung clinic for treatment.
2. For those who have had close contact with TB patients: this is mainly for the family members of the patients, including tuberculin test needles and/or lungs for young children, and lung examination for older children and adults.
3. Healthy living: Tuberculosis is caused by the invasion of the body when the body's resistance is reduced. Therefore, it is necessary to maintain a healthy life to reduce the chance of disease.
4. BCG vaccination: The Department of Health's chest and lung department provides BCG vaccination services to all newborn babies in Hong Kong. Children under 15 living in Hong Kong are advised to receive this vaccine if they have never been injected with BCG.
Complication
Shoulder joint tuberculosis complications Complications, tuberculosis
The incidence of shoulder joint tuberculosis is very low, but the onset is concealed, early diagnosis is difficult, and treatment is not timely, often causing serious sequelae to the patient, even amputation, death, and late stage sinus formation, often in the weakest part of the joint capsule. That is easy to pierce near the front of the armpit or deltoid muscle.
The disease is also often associated with active tuberculosis, and can be complicated with fibrous tonic in the advanced stage.
Symptom
Symptoms of shoulder joint tuberculosis Common symptoms Osteoporosis Soft tissue swelling Secondary infection Dead bone Osteoporosis Radioactive pain Nodule abscess Osteoclast
Early local pain, relieved at rest, increased when tired, generally no radioactive pain, from simple bone tuberculosis to total joint tuberculosis, pain increased, early joint tuberculosis, due to increased inflammatory exudate, increased pressure in the joint cavity The pain is more serious. Later, the pus penetrates the joint capsule and flows into the surrounding soft tissue space. The pressure in the joint decreases and the pain is relieved. When a mixed infection occurs, the local swelling is caused, and the pain is aggravated. The joints are fibrous and straight, and the pain disappears.
Simple bone tuberculosis rarely causes bone and joint dyskinesia or only mild restriction, while total joint tuberculosis has obvious dyskinesia, the arm cannot be lifted, the rotation is restricted, and the abduction, flexion and extension are limited. It is difficult to dress and undress.
The affected deltoid muscle and the superior and inferior muscles are obviously atrophied, and even the "square shoulder" deformity is called "dry tuberculosis".
Most cases have developed into severely damaged total joint tuberculosis. Some patients have abscesses or sinus. The diagnosis is not difficult, but simple synovial tuberculosis, simple bone tuberculosis and early total joint tuberculosis are not easy to achieve early diagnosis. Careful examination of medical history combined with signs and X-ray findings, attention to other areas of the lung, pleura, lymph nodes and other tuberculosis lesions, joint puncture fluid, pus culture or guinea pig vaccination can confirm joint tuberculosis, tuberculin test is helpful for diagnosis, but It is not specific, because the test positive only indicates that the patient has been exposed to tuberculosis, and the sensitivity to tuberculosis is increased. It is not certain that the tuberculosis has been infected. However, if the test is negative, the diagnosis of tuberculosis can be ruled out. When the clinical laboratory method is still not diagnosed, Feasible tissue biopsy can help diagnose (especially when X-ray examination shows a widening of the joint space due to exudation, decalcification of the joint bone end, and erosion of the articular surface).
Examine
Shoulder joint tuberculosis examination
1. White blood cell count, erythrocyte sedimentation rate: blood white blood cell count decreased, lymphocyte ratio increased, erythrocyte sedimentation rate accelerated during disease active period, up to 100mm / h or more (Wei's method), usually ESR changes earlier than X-ray, but Other inflammation, malignant tumor erythrocyte sedimentation rate is also accelerated, not a specific examination.
2. Tuberculin test:
1 test negative, indicating that tuberculosis has not been infected.
2 If positive, it indicates that it has been infected with tuberculosis.
3 If the negative is positive, it indicates that the tuberculosis infection occurred soon. Most of the children over 5 years old in China have been positive. Children under 5 years old who have not been vaccinated with BCG can try it out.
3. Guinea pig vaccination test: The positive rate is high, but the procedure is complicated, the cost is high, and the time is required (6-7 weeks), and conditions can be used.
4. Tuberculosis culture: the time is long, it takes 3 to 6 weeks, the pus positive rate is up to 74.1%, granulation, cheese, followed by joint fluid, dead bone positive rate, the positive rate is 68.80%, positive rate and disease The location has nothing to do with the course of the disease.
5. Surgical exploration and biopsy: Surgery found that cold pus or cheese substance can often be diagnosed, there is still doubt can be determined by pathology, the positive rate is between 70% and 80%.
6. X-ray performance: In early cases, only osteoporosis and soft tissue swelling, when X-ray signs appear, most have evolved into total joint tuberculosis, with bone destruction as the main performance, bone destruction can occur in the shoulder, humeral head, shoulder blade And at the junction, there is dead bone formation; more manifested as the narrowing of the joint space and the bone destruction of the joint edge, the bone destruction in the advanced case is severe, the humeral head partially disappears, and even the semi-dislocation, due to the destruction of the upper end of the humerus It affects the development of the humeral head, which is manifested as the reduction or even disappearance of the humeral head. In patients with secondary infection, there is osteopetrosis.
7. CT examination: There is fluid in the joint cavity, and bone destruction of the joint edge can be found early; in the later cases, obvious bone destruction and dead bone are displayed, and the size and flow of cold abscess in the extra-articular soft tissue space can also be shown. The direction.
8. MRI examination: It is possible to find an abnormal signal of intra-articular fluid and intra-inflammatory inflammatory infiltration earlier.
Diagnosis
Diagnosis of shoulder joint tuberculosis
diagnosis
It can be diagnosed based on medical history, clinical symptoms and laboratory tests.
Differential diagnosis
1. Shoulder joint tuberculosis needs to be differentiated from periarthritis of shoulder
The shoulder joint tuberculosis is divided into synovial type and bone type tuberculosis. Simple synovial type tuberculosis is very rare. The right shoulder joint tuberculosis is more common than the left side. The bone type joint tuberculosis can be divided into two types: bacterial type and dry type. Different types, different symptoms, the progress of the disease is slower, symptoms gradually appear, often with pain, dysfunction as the initial symptoms, pain often appears below the deltoid muscle, when abduction and external rotation, even deltoid muscle The swelling is most obvious, and the sinus is formed in the late stage. It is often worn in the weakest part of the joint capsule, that is, it is easy to be worn near the front of the axillary or deltoid muscle. The bone atrophy is the X-ray sign of the initial shoulder tuberculosis, especially the synovial type. Bone atrophy of tuberculosis can last for a long time, shoulder joint tuberculosis is most common with total joint tuberculosis, and simple bone tuberculosis rarely causes bone joint movement disorder or only mild restriction.
Periarthritis of the shoulder is also known as inflammation around the shoulder joint. It occurs mostly after the age of 50. The main clinical features are shoulder-arm pain and limited mobility. It is a chronic aseptic inflammation of soft tissues such as muscles, tendons, ligaments and bursae around the shoulder joint. X-ray findings are mainly: osteoporosis of the shoulder joint, large nodules or parts opposite the acromion end with cystic changes, hyperplastic sclerosis, and surrounding soft tissue calcification.
Early shoulder tuberculosis and frozen shoulder are characterized by clinical manifestations and X-ray findings, which are easily confused.
2. The disease should be associated with syphilitic osteochondritis
Acute septic arthritis, rheumatoid arthritis, Charcots joint, frozen shoulder, calcified rotator cuff inflammation.
