Children dare not sleep on their backs
Introduction
Introduction Children's ability to locate pain is poor, often complaining of pain in the knee joint and less in the hip joint. Sometimes I cried at night and didn't even dare to sleep. This is a clinical symptom of 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 both ankle joint tuberculosis or lower lumbar tuberculosis. The disease is mainly caused by infection with Mycobacterium tuberculosis.
Cause
Cause
(1) Causes of the disease
1. Infection route
80% to 90% of tuberculosis patients, especially in cases of lung cavity, have a large number of bacteria. Therefore, spitting is not an important measure to prevent the spread of tuberculosis. When a patient coughs or sneezes, it can contaminate the air and can also cause respiratory infections.
Gastrointestinal infections are rare. The diet is treated by low temperature (65-72 ° C) pasteurization to prevent gastrointestinal infections.
Tuberculosis cannot pass through healthy skin, and when it is broken, it can cause infection. It is extremely rare for bones and joints to directly infect tuberculosis, and intrauterine infection of tuberculosis (congenital tuberculosis) is extremely rare.
2. Local factors affecting the onset
From the point of view of the predilection of bone and joint tuberculosis, the incidence of the following local factors is also important in addition to the pathogenic bacteria infection and body reaction.
(1) Chronic strain factors: A large number of clinical facts prove 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.
(2) Muscle fiber factors: Blood-derived muscle fiber tuberculosis is very rare, even in miliary or disseminated tuberculosis cases. Clinically, from the perspective of bone tuberculosis, long bones, vertebral arch, humeral wing, scapula, etc., which are rich in muscle adhesion, rarely form lesions, but there are no or few muscles attached to the vertebral body, calcaneus, short bones and long bones of the hands and feet. The bone ends are more likely to form lesions. This shows that the muscle fiber not only has its own resistance to tuberculosis, but also has a certain protective effect on the attached bone.
(3) Terminal vascular factors: In addition to the large nourishing arteries in the long bone backbone, there are numerous tiny blood vessels that pass through the epicardium into the cortical bone, which coincide with the small branches of the nourishing artery, so the blood vessels of the cortical bone The collateral circulation is more abundant. The nourishing artery has a large caliber, and the blood flow velocity is fast, and the bacterial plug is not easy to stay in it. Even if a small number of bacteria stay in the cortical bone, it will not cause embolism, and the thrombus will be easily eliminated without causing disease. On the contrary, the end of the bone is supplied by the terminal artery with small caliber and few anastomotic branches, and because the blood flow velocity is slowed down, the thrombus easily stays here to cause ischemia, embolism and formation of lesions.
The bones of long bones are visible, as well as the theory of reticuloendothelial and immunology.
3. Formation of bone and joint lesions
Tuberculosis of the hip joint is the same as other bone and joint tuberculosis, usually starting with a 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 by the blood flow. This 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 joint tuberculosis. This type is also the main cause of hip tuberculosis with special pathogenesis.
The formation of primary bone lesions, the early stage of formation, the size and extent of the lesions, and the formation of the parts are related to the number of TB bacteria, virulence, body physique and immunity, local anatomy and physiological characteristics Have a close relationship.
(two) pathogenesis
Among the hip joint tuberculosis, simple synovial tuberculosis and simple bone tuberculosis are rare, and most patients show total joint tuberculosis when they visit the doctor. The most common site is the acetabulum, the femoral neck is the second, and the femoral head is the least.
Examine
an examination
Related inspection
Thomas test mammography
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 the affected limb, and rests the external hemorrhoid above the iliac bone of the healthy side limb. The examiner presses the knee of the affected side with his hand, and if the hip has pain, the knee can not touch the tabletop. Positive. It should be pointed out that this test is more affected by individual factors (old age or obesity), and the two sides should be compared on both sides. For comparison, the position of the external hemorrhoids must be the same, and there should be no high or low.
2. Hip overextension test
It can be used to check early childhood tuberculosis in children. The child is in a prone position. The examiner holds the pelvis in one hand and the lower limb in the other hand until the pelvis begins to rise. Similarly, the contralateral hip joint was tested. On both sides of the hip joint, it can be found that the affected hip joint has a sense 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 fully flexes the hip and knee joints of the healthy side to make the knee stick or 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, cavities and dead bones appear. In severe cases, the femoral head almost disappears. There is a pathological dislocation in the later stage. After the treatment, the edge of the bone contour turns clear and 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 damage lesions that ordinary X-ray films can't show. MRI also shows inflammatory infiltration in the bone.
5. ESR (ESR)
Repeated examination results, clinical signs of difficult to respond to disease at various stages and evaluation of treatment effects. The cytological and bacteriological examination of the joint contents obtained by diagnostic puncture has fewer negative results. Of course, if you get pus, the diagnosis can be more certain.
Diagnosis
Differential diagnosis
According to the history, symptoms and influence performance, the diagnosis is not difficult, and it must be differentiated from the following diseases:
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, abduction and external rotation of the hip. But its pain is limited to the large trochanter, especially when it is pressed laterally. The pain of hip tuberculosis is limited to the femoral head and neck. In the case of large TB, no hip activity was restricted, and muscle atrophy was 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.
(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. However, in the case of spinal tuberculosis with an abscess, there is no hip flexion and rotational dysfunction. The diagnosis can be confirmed by taking the spine and hip radiographs simultaneously in suspicious cases.
2. Intra-articular lesions
(1) Septic arthritis: Acute septic arthritis is generally acute, and patients have high fever, chills, and increased white blood cells. Leukocytes often have a significant increase in neutral multinuclei over 20 x 109/L. The lower extremities are often abducted and externally deformed. Because of this position, the largest volume of the joint capsule can reduce the pressure of the abscess and reduce the pain. This typical case is generally not difficult to identify with tuberculosis. However, a small number of hip joint tuberculosis may be a subacute development process, and some low-toxic septic arthritis also has a chronic development process, and identification is more difficult. Need to be distinguished in treatment observations or by special means.
Suppurative hip osteomyelitis secondary to suppurative hip arthritis must be differentiated from co-infected hip joint tuberculosis. The former often has a history of acute onset. The X-ray film has a wide range of humeral lesions and is diffuse; the latter is mostly chronic, but has a long history of sinus. The X-ray upper bone lesion is confined to the vicinity of the joint.
(2) Rheumatoid arthritis: Hip rheumatoid arthritis is often part of central rheumatoid arthritis. Some start from the hip joint on one side. The X-ray film is completely similar to the synovial tuberculosis of the hip joint, that is, there are signs of swelling of the joint capsule, small obturator and local osteoporosis. Most of the patients were young men over the age of 15. Careful inquiry about the medical history, the contralateral hip joint may also be painful. When examining the lumbar spine, some may find that activity is limited.
