tuberculosis of the hip
Introduction
Introduction to hip tuberculosis Hip tuberculosis accounts for 7.20% of the total body and joint tuberculosis, ranking second only to spinal tuberculosis. More common in children and young adults, more men than women, 7% -10% of cases can be seen with ankle joint tuberculosis or lower waist tuberculosis. More common in preschool children. The onset is slow, the earliest symptom is the change of gait. When walking, the limbs are heavy and the limbs are light, slightly lame. After the main complaint, leg pain, often radiated to the knee joint and the anterior medial thigh. Minhangs and pains are intermittent, can disappear after a break, and gradually increase in the future. basic knowledge The proportion of illness: 0.052% Susceptible people: more common in children and young adults Mode of infection: respiratory transmission Complications: muscle atrophy
Cause
Hip tuberculosis
Infection (45%):
The disease is mainly caused by infection of Mycobacterium tuberculosis, and its pathological changes are mainly characterized by the following characteristics:
1 simple synovial tuberculosis: lesions are limited to the synovium, manifested as congestion, edema, exudation and fibrous tissue hyperplasia.
2 simple bone tuberculosis: the lesion is limited to the bone, can occur in the femoral condyle, can also occur at the edge of the metaphysis of the proximal femur.
3 total joint tuberculosis: developed from simple tuberculosis, characterized by destruction of articular cartilage, if only part of the cartilage free necrosis, that is, early total joint tuberculosis; if all articular cartilage necrosis, it is late total joint tuberculosis, At this time, there are many serious bone destruction, pathological dislocation and so on.
Chronic strain factor (25%):
A large number of clinical facts have proved that traumatic fractures, dislocations or sprains are not localized to tuberculosis, and chronic strain or cumulative injury has a certain relationship with the formation of tuberculosis.
Low body immunity (20%):
When the body's immunity is low, it can cause the disease.
Causes
1. Infection route 80% to 90% of tuberculosis patients, especially in cases of lung cavity, there are many bacteria, so spitting is still an important measure to prevent the spread of tuberculosis. When patients cough or sneeze, they can pollute the air. It can also cause respiratory infections.
Gastrointestinal infections are rare, and food and beverage are treated by low temperature (65-72 ° C) pasteurization to prevent gastrointestinal infections.
Tuberculosis can not pass through healthy skin. When there is a rupture, it can cause infection. The bones and joints directly infect tuberculosis and the incidence is extremely rare. Intrauterine infection tuberculosis (congenital tuberculosis) is also extremely rare.
2. Formation of bone and joint lesions
Primary tuberculosis is usually formed in childhood. After inhalation or ingestion of tuberculosis into the tissue, it begins to multiply under favorable conditions and causes exudative inflammation locally. At this time, some tuberculosis enters the nearby lymph nodes through the lymphatic vessels. Then through the lymph nodes into the blood, bacteria that enter the bloodstream form a large number of bacterial emboli. These emboli are distributed along the bloodstream to various tissues of the body, most of which are eliminated, but only a few under favorable conditions to form some tiny In the lesions, most of these small lesions were destroyed and repaired under the action of the body reaction. Although a small number of small lesions of tuberculosis were not completely eliminated, the lesions were surrounded by fibrous tissue, so the lesions were static and later with age. Growth, decreased immunity, or other unfavorable factors, this latent, quiescent, rapid onset can reactivate in months, years or decades after the onset of the primary lesion, lurking The tuberculosis bacteria rapidly multiply, and the surrounding fibrous tissue is broken, so that the inflammation expands or invades new areas, forming a Ministry symptoms, systemic reactions, can be used to detect lesions, which is the formation of primary lesions of bone and joint tuberculosis.
The tuberculosis of the hip joint is the same as other bone and joint tuberculosis, usually starting from the primary bone lesion near the joint. This lesion is a special lesion that occurs in the cancellous bone or periosteum of the joint of the bone through the blood flow. A lesion is the cause of joint infection and various types of lesions. It can be seen that the initial joint tuberculosis is simple bone tuberculosis or simple synovial tuberculosis. Primary simple bone tuberculosis accounts for more than 90% of all hip tuberculosis. This type is also the main cause of hip tuberculosis with a specific onset of disease.
The formation of primary bone lesions, the early stage of formation, the size of the lesions and the size of the lesions, as well as the formation of parts with the number of tuberculosis, virulence, body physique and immunity, local anatomy and physiological characteristics Have a close relationship.
Pathogenesis
Among the hip joint tuberculosis, simple synovial tuberculosis and simple bone tuberculosis are rare. Most of the patients present with total joint tuberculosis at the time of treatment. The most common site of the acetabulum is the accommodative part, the femoral neck is the second, and the femoral head is the least.
Simple synovial tuberculosis rarely has abscesses, less sinus formation, and simple bone tuberculosis forms abscesses. The pus produced by acetabular tuberculosis can penetrate the cartilage downwards and invade the hip joints, and gather back in the hips. Form a hip abscess, can also penetrate the inner wall of the pelvis, forming a pelvic abscess, the pus of femoral neck tuberculosis penetrates the periosteum and synovium of the femoral neck, enters the hip joint, or flows along the femoral neck medullary cavity to the large trochanter Or the outside of the thigh, the pus of the femoral head tuberculosis penetrates the cartilage surface early and invades the hip joint. The late hip tuberculous abscess often appears in the anterior medial aspect of the joint, because the joint capsule is weak, and often with the iliopsoas bursa In the same way, after the abscess collapses, the sinus is formed. About 20% of the patients have formed sinus at the time of treatment. Long-term mixed infection can be secondary to chronic sclerosing osteomyelitis.
In simple synovial tuberculosis or early total joint tuberculosis, the synovial membrane surrounding the round ligament is also edematous, hyperemic, hypertrophic, and the late round ligament is destroyed and destroyed. The acetabular, femoral head or joint capsule is severely damaged. The femoral head often has pathological features. Dislocation, mainly post-dislocation, muscle spasm around the late hip joint tuberculosis, because the adductor muscle and hip muscles have greater muscle strength, often suffered from flexion and adduction.
When the hip joint is severely damaged, and the lesion tends to be stationary, the joint is fibrotic or ossified. The hip joint is often fixed in flexion, adduction and external rotation, such as the femoral head, the neck is destroyed, and sometimes the upper end of the femur. False joint activity can occur between the acetabulum and the acetabulum
Children's hip tuberculosis has a certain effect on the growth of the affected limb bone. After the smoothing of the synovial membrane and acetabular tuberculosis, the femoral head can be enlarged, the femoral neck becomes longer, the neck dry angle increases, and the hip valgus deformity, the affected limb It can be 0.5~2.5cm longer than the healthy limb. This growth acceleration phenomenon is the result of inflammation stimulating the upper end of the femur. The femoral head and neck tuberculosis have two effects on the growth of the femoral neck: one is the growth stimulation, which is more common in the talus Far femoral neck basal lesions, the second is growth inhibition, more common in the head and neck lesions near the talus palpebral, because the latter lesion directly destroys the epiphyseal plate, or destroys the blood supply of the tarsal plate, so that the femoral head, The development of the neck is frustrated, so that the femoral head becomes smaller, the femoral neck becomes shorter, the hip is inverted, and the affected limb is shortened by 1-3 cm. The late total joint tuberculosis is destroyed, not only the upper end of the femur cannot grow and develop normally, but the affected limb cannot By exerting its normal function, the growth and development of other epiphyses of the lower limbs are also affected to some extent, which can cause more serious shortening, and some can be as much as 10 cm or more.
Prevention
Hip joint tuberculosis prevention
1. The disinfection and isolation of open tuberculosis patients must be done to reduce the incidence of tuberculosis in the lungs or intestines, thereby reducing the incidence of bone and joint tuberculosis.
2. Improve the level of medical technology and achieve early diagnosis and early treatment.
3. Vigorously carry out mass patriotic health campaigns, and carry out in-depth and meticulous publicity and education on the significance of spitting, disinfection and isolation, health check, early treatment and BCG vaccination, so that the masses can participate in flood prevention work and eliminate them in China. Fighting against tuberculosis.
4. Hip joint tuberculosis is mainly caused by primary disease sources such as tuberculosis infection, so prevention and thorough treatment of primary active pathogens is the key.
Complication
Hip joint tuberculosis complications Complications muscle atrophy
At the beginning of the lesion, the bone type is more common, and the synovial type is less. The bone type lesions are mostly in the acetabulum or femoral head, gradually expanding, penetrating into the joints, forming total joint tuberculosis, synovial lesions, and also spreading the joints. Cartilage, femoral head, neck and acetabulum, become total joint tuberculosis, lesions often have cheese-like and cold abscess formation, and can be worn through the groin area or large trochanter, causing sinus and co-infection, due to the femoral head, Progressive destruction and flexion of the acetabulum, adduction of sputum, can cause pathological dislocation of the joint, after the lesion is still, there is fibrous tissue hyperplasia, so that the joint forms fibrous tonic or bony rigidity, often adduction and flexion deformity, lesions from The longer the course of the disease, and the inevitable widespread destruction and deformity, must actively provide contradictory conditions, eliminate unfavorable factors, transform pathological processes, and restore the patient's health and limb function as soon as possible.
Most of the disease left the limbs unequal length, and obvious lower limb shortening, other common complications are sinus, secondary infection, pathological dislocation, etc., the occurrence of complications make the healing tend to be poor, due to the application of anticonvulsant drugs , early surgical treatment of the source of the disease and other treatments, joint function can be preserved to varying degrees.
Symptom
Hip joint tuberculosis symptoms Common symptoms Fatigue dystrophia Loss of appetite, easy to cry, children do not dare to sleep, low heat, persistent pain, weakness, weightless gluteal groove, flattening and sagging
Slow onset, low fever, fatigue, fatigue, loss of appetite, weight loss and anemia, systemic symptoms, mostly single, early symptoms are pain, the pain will not improve after the initial break, the child will be better at night Children often complain of knee pain. If you don't pay attention, it will delay the diagnosis. As the pain increases, limp will appear. In the later stage, a cold abscess will appear on the inside of the groin and hips, and become a chronic sinus after rupture. Pathological dislocation occurs when the destruction of the femoral head is obvious, usually after dislocation. After healing, various deformities will be left behind, and the hip joint will be contracted to receive internal rotation deformity. The hip joint stiffness and the lower limb unequal length are the most common.
(a) pain
The early symptoms are hip and knee pain (dissipated along the obturator nerve to the knee), and the child's complaint is often knee pain, to prevent misdiagnosis as a knee lesion. At the time of examination, the hip joint of the lesion had limited activity and pain, and the pain was aggravated with the development of the lesion, and the activity was aggravated.
(two) tendon
Muscle spasm caused by pain has a protective effect against limb activity. Children often have nightingale, long-term sputum and disuse of the results of muscle atrophy, quadriceps atrophy is particularly evident.
(three) deformity
As a result of tendon, the hip joint has flexion, adduction contracture deformity, Thomas positive, and can cause subluxation or total dislocation of the hip, and the limb is relatively short. In children with osteophyte damage affecting the length of growth, limb shortening is more obvious. Due to pain, bone destruction, deformity and limb shortening, patients have varying degrees of lameness and cannot even walk.
(four) tenderness
There is significant tenderness in the front and outside of the hip joint. Although the knee joint was painful, there was no abnormality in the knee joint examination.
(5) Sinus formation
In the late stage, sinus formation often occurs, mostly in the large trochanter or the medial side of the femoral joint.
(6) X-ray examination
Local early stage has femoral head and acetabular osteoporosis. Later, due to cartilage destruction, the joint space is narrowed, the bone may be irregularly damaged, there are dead bones or hollows, and even the femoral head and neck are completely destroyed, but few new bones are formed. There may be pathological dislocation.
Examine
Hip joint tuberculosis examination
The following various test tests are helpful for diagnosis:
1, "4" word test:
This test includes hip flexion, abduction or external rotation. The hip joint tuberculosis should be positive in this test. The method is as follows: the patient lies flat on the examination table, rubs his limb, and rests the external hemorrhoid on the healthy side of the limb. Above, the examiner presses the affected side of the knee with his hand. If the hip has pain and the knee can not touch the table, it is positive. It should be noted that the test is affected by individual factors (old or obese). For comparison on both sides, the position of the external helving must be the same when comparing, and there must be no height.
2. Hip joint overextension test:
It can be used to check early childhood tuberculosis in children. The child is in prone position. The examiner holds the pelvis in one hand and the lower limb in the other hand, until the pelvis begins to rise on the tabletop. The contralateral hip joint is also tested. It can be found that the affected hip joint has a feeling of resistance when it is extended, so the range of the extension is not as large as the normal side, and the normal side can have a 10 degree extension.
3, Thomas sign positive:
It is used to check the hip joint for flexion deformity. The method is as follows. The patient is lying on the hard table. The examiner will flex the hip joint and the knee joint completely, so that the knee sticks or is as close as possible to the front chest. The lordosis disappears completely and the back is flat on the bed. If the hip has a flexion deformity, it can be seen at a glance. According to the angle between the thigh and the table, the flexion deformity is determined.
4, imaging examination:
(1) X-ray examination is very important for the diagnosis of hip joint tuberculosis. It is necessary to compare the two hip joints at the same time. The early lesions only have localized osteoporosis, and the good quality X-ray film can show the swollen joint capsule. Progressive joint space narrowing and marginal bone destruction lesions are early X-ray signs. As the damage increases, voids and dead bones appear. In severe cases, the femoral head almost disappears, and there is pathological dislocation in the later stage. When turned to clear, the lesion tends to be stationary.
(2) Early diagnosis can be obtained by CT and MRI. It can clearly show how much fluid in the hip joint can reveal the tiny bone destruction lesions that can not be displayed by ordinary X-ray films. MRI can also show inflammatory infiltration in the bone.
5. ESR (ESR) repeated examination results, clinical signs of various stages of refractory disease and evaluation of treatment effects, cytological and bacteriological examination of joint contents obtained by diagnostic puncture, less negative results, of course, obtained If the pus is used, the diagnosis can be determined.
Diagnosis
Diagnosis of hip joint tuberculosis
diagnosis
For the diagnosis of hip joint tuberculosis, it is generally not difficult to perform according to medical history, symptoms, signs and X-rays, but it is not very easy to diagnose early cases. Therefore, early symptoms and some insignificant signs should be caused by doctors. I dont pay much attention to it. Otherwise, the consequences for patients due to misdiagnosis are not as terrible as death, but their lifelong pain is quite bad.
Only the key points in clinical examination and diagnostic analysis will be slightly repeated here.
To understand the history of the disease, first understand the time of onset, the performance of the disease, the relationship with trauma and other diseases, the history of exposure to tuberculosis, etc., and then understand the complications and past medical treatment and diagnosis and treatment results, these information will be correct for you. Diagnose lays the foundation.
Careful and comprehensive examination of the patient is a prerequisite for correct diagnosis and a prerequisite for proper treatment. Therefore, from the moment the patient sees the patient, he should pay attention to his posture, gait and general behavior, and then take the patient off the clothes. Naked examination, so, what deformity, swelling, muscle atrophy, dysfunction, and the color of the limbs, scars, etc. can be obvious, sometimes can achieve "at a glance" harvest, if conditions permit, it is best to stand and position separately an examination.
Passive examination of the range of motion of the hip joint is important because its rotational activity barrier and pain are one of the early features of hip joint disease. For accurate control, it should be a bilateral control or simultaneous examination. Muscle contracture is the beginning of hip joint tuberculosis. One of the characteristics, therefore, must pay attention to the hip joint hyperextension activity check, when the disease develops, the contracture becomes obvious, the Thomas sign is positive.
In later stage lesions, due to anatomical changes in the joints, their activities in all directions are intractable. The degree of joint limitation is best determined by measurement. The so-called "mild", "obvious" and other words The expression is really not clear enough.
X-ray examination is a necessary supplement. It cannot be understood as a means of determining the diagnostic significance and neglecting others. It is also known that the changes in X-ray signs are often later than clinical changes, so the X-ray features are not available before they can be completely Denying tuberculosis, there was a patient who had only decided to diagnose tuberculosis after seeing the complete destruction of the femoral head on the X-ray film, thus delaying treatment.
The position of the X-ray examination is more important, and there is often a positive position without lateral position. There is one side without contralateral side. The ideal one is to include a bilateral hip joint, and it is a completely symmetrical X-ray film. Sometimes in order to find small lesions, lateral or even oblique projections must be performed. The significance of tomography is still to be further explored.
In the diagnosis, for early patients, when the diagnosis is indeed difficult, the surgical exploration can be carefully selected, and the pathological examination should be performed at the same time. It is not suitable to wait for a long time.
Differential diagnosis
1. lesions near the hip joint
(1) Large TB tuberculosis: This disease has the same femoral pain as hip tuberculosis, radiation pain and lameness to the knee, and may have slight flexion of the hip, abduction and external rotation, but its pain It is limited to the large trochanter, especially when the lateral compression is more obvious, and the pain of the hip joint tuberculosis is limited to the femoral head and neck. When there is large TB tuberculosis, the hip has no activity limitation and the muscle atrophy is not significant. The difference can be clearly defined after the X-ray examination.
(2) Ankle arthritis: This disease can occur not only on the basis of tuberculosis, but also on the basis of rheumatism, brucellosis, gonorrhea and other infectious diseases. The two can be distinguished according to the following characteristics.
(3) Spinal tuberculosis: Tuberculosis in the lower part of the spine is easily misdiagnosed as hip joint tuberculosis, especially in the case of hip fossa abscess and thigh abscess, and both have limited hip extension activity, but in the spinal tuberculosis with flow injection In the case of an abscess, there is no hip flexion and rotational dysfunction, and the diagnosis of the spine and hip X-ray film can be taken in suspicious cases.
2. Intra-articular lesions
(1) Septic arthritis: acute septic arthritis is generally acute, patients with high fever, chills, increased white blood cells, white blood cells often more than 20 × 109 / L neutral multinuclei increased significantly, lower limbs often abduct, external rotation Malformation, because at this position, the largest volume of joint capsule can reduce the pressure of abscess and relieve pain. This typical case is not difficult to identify with tuberculosis, but a few hip tuberculosis may be a subacute development process, some low toxicity suppuration Sexual arthritis also has a chronic development process, when identification is more difficult, and needs to be distinguished in treatment observation or by special means.
Suppurative hip osteomyelitis secondary to suppurative hip arthritis must be differentiated from the combined infection of hip joint tuberculosis, the former often has an acute history, X-ray film upper tibia lesions are more extensive, diffuse; the latter mostly chronic disease, but There is a long history of sinus, and the X-ray film is limited to the vicinity of the joint.
(2) Rheumatoid arthritis: Hip rheumatoid arthritis is often part of central rheumatoid arthritis, some starting from one hip, and X-ray films are completely similar to hip synovial tuberculosis. There are signs of swelling of the joint capsule, small obturator and local osteoporosis. Most of the patients are young men over 15 years old. If you have a detailed history, the contralateral hip joint may also be painful. When examining the lumbar vertebrae, some may find Activity is limited.
(3) Aseptic necrosis of the juvenile femoral head: also known as Legg-Perthes' disease. According to statistics, 1/10 of the hip joint tuberculosis is misdiagnosed as the disease, and 1/5 of the disease is misdiagnosed as tuberculosis. Therefore, it should be paid more attention when identifying.
(4) Adult aseptic necrosis of the femoral head: more common after traumatic hip dislocation or femoral neck fracture, occasionally caused by a large number of applied hormones, the upper part of the femur is dense, flattened, and later broken, the clinical symptoms are better than the younger type Heavy, bone reconstruction is also more difficult, patients with erythrocyte sedimentation, history of trauma or massive use of hormones.
(5) Osteoarthritis: This disease is rare in China. Most of the patients are elderly. It can be seen on one side or both sides. It is clinically suffering from hip pain and limited activity, but the erythrocyte sedimentation rate is not fast. X-ray films can be seen in acetabular and femoral hernias. Bone hyperplasia, edge hardening, narrow joint space, cystic changes in the acetabulum or femoral head.
(6) Temporary synovitis: more common in children under 8 years old, complaining of hip pain, not walking, checking for mild mobility of the hip, the front of the hip is slightly full, and the child has no obvious systemic symptoms. Sulfonamide or oxytetracycline is cured after 3 to 4 weeks of treatment.
(7) Charcot's arthropathy: common in the shoulders, elbows, hips, knees, vertebral bodies, feet, etc., the lower extremities are often secondary to the spinal cord hernia or meningocele bulging, the affected joints are obviously swollen, There are bloody fluids in the joints. The X-ray films show that the bones are dense, fragmented and absorbed. Compared with the degree of joint swelling and bone destruction, the pain and movement limitation are not obvious. Careful examination of the affected limbs often reveals sensory disturbances and membrane reflexes. Disappear and other neurological symptoms.
(8) syphilitic osteochondritis: a congenital disorder, rarely seen in China, X-ray film can be seen soft tissue swelling and metaphyseal destruction, the main point is that the disease is more common in remote areas, often symmetry or multiple The serum Kangwa reaction is mostly negative, and the plum therapy is effective.
3. Tumor aspect
Chondrosarcoma of the hip or trochanter, the calcification zone should be distinguished from the calcification of cold abscess, myeloma, fibrosarcoma, reticulum sarcoma, giant cell tumor, metastatic carcinoma, etc. should be associated with central bone tuberculosis or cyst without dead bone. Type tuberculosis is different. The fibroids and neurofibromas behind the hip joint can cause hip flexion, internal rotation is limited, and there is fullness and tenderness behind the hip, but the X-ray film is negative, and the blood sedimentation and body temperature are normal.
4. Avascular necrosis of the femoral head
The general condition of the child is good, no symptoms such as weight loss, night sweats, fever, hips may be mild, moderate activity is limited, Thomas sign is positive, no swelling, the distance between the epiphysis and the acetabulum is widened, the epiphysis is delayed, and the deformation is small. The density is increased, the femoral head is flattened or even broken, the neck dry angle becomes smaller, and the acetabulum has no obvious damage.
5. Congenital dislocation of the hip
More common in girls, can occur unilaterally or bilaterally, the femoral condyle appears late, the acetabulum becomes shallow, the femoral neck becomes shorter, there is no obvious bone destruction or osteoporosis, and the Shenton's line is discontinuous.
