Flattening and sagging of the gluteal fold
Introduction
Introduction Muscle atrophy: Muscle atrophy of the affected limb is another feature of hip joint tuberculosis. Due to muscle dystrophy and disuse atrophy, the tension around the hip joint and the limb muscles is reduced, and the volume of the muscle is gradually reduced. Early measurements can be found in the later cases, the naked eye can also see the entire body weight loss, especially the quadriceps. At this time, the atrophy of the gluteal muscles is also obvious, the affected side of the buttocks is thin, and the gluteal folds are flattened and drooped.
Cause
Cause
Reasons for flattening and sagging of the gluteal groove:
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 is free of necrosis, it is early total joint tuberculosis; if all articular cartilage necrosis, it is late total joint tuberculosis, at this time there are many severe bone destruction, pathological dislocation and so on.
(1) Causes of the disease
1. Infection route 80% to 90% of tuberculosis patients, especially in cases of lung cavity, there are many 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 of the disease From the point of occurrence 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 point 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 primary lesions are generally formed during childhood. After inhalation or ingestion of tuberculosis into the tissue, it begins to multiply under favorable conditions, causing exudative inflammation locally. At this time, some of the tuberculosis enters the nearby lymph nodes through the lymphatic vessels, and then enters the bloodstream through the lymph nodes. Bacteria that enter the bloodstream form a large number of bacterial emboli that are distributed along the bloodstream to tissues throughout the body. Most of them were eliminated, but only a few were proliferating under favorable conditions to form some tiny 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 have not been completely eliminated, but the lesion is surrounded by fibrous tissue, so the lesion is static. Later, with the increase of age, the reduction of immunity or other unfavorable factors, this latent, resting state of rapid onset can be reactivated within months, years or decades after the occurrence of the primary lesion. stand up. The latent tuberculosis bacteria rapidly multiply, and the surrounding fibrous tissue is broken, so that the inflammation expands or invades new areas, forming a lesion with local symptoms and systemic reactions that can be detected. This is the primary lesion that forms the joints of the bones and joints.
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.
Simple synovial tuberculosis has few abscesses and less sinus formation. Simple bone tuberculosis forms abscesses more common. The pus produced by acetabular tuberculosis can penetrate the cartilage downwards and invade the hip joint, and gather back in the buttocks to form a hip abscess. It can also penetrate the inner wall of the pelvis inward to form 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 outside of the large trochanter or thigh. The pus of the femoral head tuberculosis penetrates the cartilage surface early and invades the hip joint. Late hip tuberculous abscess often appears in the anterior medial aspect of the joint, because the joint capsule is weaker and often communicates with the iliopsoas. After the abscess collapses, the sinus is formed, and about 20% of the patients have formed a sinus at the time of presentation. 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 disappeared. If the acetabulum, femoral head or joint capsule is severely damaged, the femoral head often has pathological dislocation, mainly post-dislocation. The muscles around the late hip joint tuberculosis occur, because the muscles of the adductor muscle and the hip flexor are large, and the flexion adduction deformity often occurs.
When the hip joint is severely damaged, and the lesion tends to be stationary, the joint is fibrotic or ossified, and the hip joint is often fixed in the flexion, adduction and external rotation. If the femoral head and neck are destroyed, sometimes the pseudo joint activity can occur between the upper end of the femur and the acetabulum.
Children's hip tuberculosis has a certain effect on the growth of bones in the affected limbs. After the simple synovial membrane and acetabular tuberculosis are cured, the femoral head can be enlarged, the femoral neck becomes longer, the neck dry angle increases, and the hip valgus deformity is formed. The affected limb can be 0.5 to 2.5 cm longer than the healthy limb. This acceleration of growth is the result of inflammation that stimulates the epiphysis of the upper femur. Femoral head and neck tuberculosis have two effects on the growth of the femoral neck: one is growth stimulation, more common in the femoral neck basement lesions farther from the talar tarsal plate; the second is growth inhibition, more common in the head and neck of the talus Part of the lesion. Because the latter lesion directly destroys the epiphyseal plate, or destroys the blood supply of the epiphyseal plate, the development of the femoral head and 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~ 3cm. Late total joint tuberculosis is destroyed, not only the upper end of the femur can not grow and develop normally, because the affected limb can not play its normal function, the growth and development of other bones of the lower limb are also affected, which can cause more serious shortening. It can be as much as 10cm or more.
Examine
an examination
Related inspection
Neurological examination muscle tone examination
Diagnostic diagnosis of sulcus flattening and sagging:
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 joint 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
Differential diagnosis of sulcus flattening and sagging:
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. The difference between the two can be based on 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. 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.
(3) Aseptic necrosis of the juvenile femoral head: also known as Legg-Perthes' disease. According to statistics, 1/10 of hip tuberculosis is misdiagnosed as this disease; 1/5 of this disease is misdiagnosed as tuberculosis. Therefore, you should pay more attention to the identification.
(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 application of hormones. The upper part of the femur is dense, flattened and then broken. Clinical symptoms are heavier than infants and bone reconstruction is more difficult. The patient has a history of erythrocyte sedimentation, a history of trauma or extensive use of hormones.
(5) Osteoarthritis: This disease is rare in China, and most of the patients are elderly, which can be seen on one side or both sides. Clinically, there is pain in the hip, activity is limited, but the blood is not fast. X-ray films showed obvious hyperplasia of the acetabulum and femoral head, hardening of the edge, narrow joint space, and cystic changes in the acetabulum or femoral head.
(6) Temporary synovitis: more common in children under 8 years old, complaining of hip pain, afraid to walk. Check for mild mobility in the affected hip and a slightly full front of the hip. There were no obvious systemic symptoms in the children. After treatment with sulfa or oxytetracycline for 3 to 4 weeks, it will heal.
(7) Charcot's joint disease: common in the shoulder, elbow, hip, knee, vertebral body, foot and so on. After the lower limbs are secondary to the spinal cord or meningocele, the affected joints are obviously swollen, and there are bloody fluids in the joints. X-ray films showed dense, fragmented, and absorbed bone, and the pain and movement limitations were not significant compared with joint swelling and bone destruction. Careful examination of the affected limb often reveals neurological symptoms such as sensory disturbance and loss of membrane reflex.
(8) syphilitic osteochondritis: a congenital disorder, rarely seen in China. X-ray films showed soft tissue swelling and dry end destruction. The main point of identification is that the disease is more common in remote areas, often symmetrical or multiple. Serum Kangwar's reaction is mostly negative, and plum therapy is effective.
3. Tumors in the hip or trochanteric chondrosarcoma, the calcification zone should be distinguished from the calcification of cold abscess. Myeloma, fibrosarcoma, reticulum sarcoma, giant cell tumor, metastatic cancer, etc. should be distinguished from central bone tuberculosis or cystic tuberculosis without dead bone. The fibroids and neurofibromas behind the hips can cause hip flexion and internal rotation limitation, and there is fullness and tenderness behind the hips, but the X-ray films are 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 have mild to moderate activity, Thomas sign positive, no swelling, wide distance between the epiphysis and the acetabulum The epiphysis is delayed, 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, no obvious bone destruction or osteoporosis, Shenton's line is discontinuous.
