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TB shoulder,elbow,wrist,short tubular bones(fingers,toes)
This document provides an overview of tuberculosis of the shoulder and other bones. It discusses the pathology, clinical presentation, relevant anatomy, radiological features, and management of tuberculosis in the shoulder, elbow, wrist, and fingers. Tuberculosis can affect various bones and joints, most commonly presenting as pain, swelling, and limited range of motion. Diagnosis is made based on clinical features and radiological findings like bone erosion. Management involves antitubercular drugs, rest, splinting, and in some cases surgery. The document serves as a reference for musculoskeletal tuberculosis.
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TB shoulder,elbow,wrist,short tubular bones(fingers,toes)
- 1. TUBERCULOSIS OF SHOULDER ANDOTHER BONES. Dr.Punit Gaurav 1st year Postgraduate Department of Orthopaedics
- 2. INTRODUCTION: Tuberculosis isa chronic granulomatous infectious disease caused by Mycobacterium Tuberculosis (a gram positive acid fast bacilli). M.Tb and homosapiens have lived in symbiosis since the ascent of man on earth. Transmitted through the air borne spread of droplet nuclei produced by patients with infectious pulmonary tuberculosis.
- 3. In IndiaEPTB (extra pulmonary tuberculosis) form 10-15% of all types of TB. Skeletal tuberculosis (TB) refers to TB involvement of the bones and/or joints. TB of bone and joints constitutes 1-3% of Extra-pulmonary
- 4. Tuberculous diseaseof the shoulder is rare constituting nearly 1-2% of skeletal tuberculosis. More frequent in adults. Incidence of concomitant pulmonary tuberculosis is high.
- 5. RELEVANT SURGICAL ANATOMYOF THE SHOULDER JOINT: Shoulder joint is a synovial joint of the ball and socket variety 4:1 disproportion between the large spherical humeral head and the shallow glenoid fossa. Ring of fibrocartilage, the glenoid labrum attached to the margin of glenoid fossa deepens its depression.
- 6. Capsule ofthe joint is attached to the scapula beyond the supraglenoid tubercle and the margins of the labrum. Gap in the anterior part of the capsule allows communication between the synovial membrane and the subscapularis bursa. Any disease involving the synovium would easily extend to the communicating synovial
- 7. PATHOLOGY: The classicalsites of origination of disease are: 1. Head of humerus, 2. Glenoid, 3. Spine of the scapula, 4. Acromio-clavicular joint, 5. Coracoid process and rarely Synovial lesion.
- 8. Iatrogenic dueto steroid injection given for a stiff shoulder with the mistaken diagnosis of frozen shoulder, particularly in diabetics. Initial tubercular destruction is typically widespread (because of the small surface contact area of articular cartilage).
- 9. Extremely uncommonfor the disease to present at the stage of synovitis. Painful limitations of abduction and external rotation occur early and there is marked wasting of the deltoid, supraspinatus and other muscles.
- 11. As thedisease progresses there is marked destruction and atrophy of upper end of the humerus and glenoid (Fig.) and the shoulder undergoes fibrous ankylosis.
- 13. RADIOLOGICALLY: Osteoporosis Erosionof articular margins (fuzzy) Osteolytic lesion involving head of humerus,glenoid or both The lesion may mimic giant cell tumor.
- 14. The jointspace involvement and capsular contracture are seen early in the disease. Sinus formation Inferior subluxation of the humeral head Fibrous ankylosis
- 16. TYPES: THREE TYPESOF SHOULDER TB: 1. Type I: “Caries Sicca”- Marked wasting of shoulder. Painful restriction of all movements. 2. Type II: “Caries Exudata”- Swelling of the joint,cold abscess. Sometimes a sinus. (Fulminating type). 3. Type III: “Caries Mobile”- Restriction of active movements of the shoulder.Nearly full passive abduction.
- 17. CARIES SICCA: 1. Dryatrophic type of tuberculosis of the shoulder 2. Benign course 3. Without pus formation 4. Small pitted erosions on the humeral head
- 18. Classical drytype is more common in adults Fulminating variety with cold abscess or sinus formation presenting in the deltoid region, along the biceps tendon, in the axilla or in the supraspinous fossa is more common in children
- 19. PRESENTATION: • Usuallypresent with painful restriction of abduction and external rotation. • Marked wasting of muscles around the shoulder joint. • With the advance disease, there occur marked destruction and atrophy of the proximal humerus and glenoid cavity and finally the shoulder undergoes fibrous ankylosis.
- 20. RADIOLOGICALLY: • Generalizedrarefaction of bones. • Varying degree of erosion of articular margin. • Destruction of proximal humerus and glenoid cavity. • Some periosteal reactions.
- 21. MANAGEMENT: In additionto the general treatment for skeletal tuberculosis, the shoulder is immobilized by the plaster shoulder spica in 70 to 90 degrees of abduction, 30 degrees forward flexion and about 30 degrees of internal rotation (saluting position) to encourage ankylosis of glenohumeral articulation in functioning position.
- 22. After initial3 months, the plaster spica may be replaced by an abduction frame in the same position. Once the patient is being nursed on an abduction frame repetitive active assisted movements of the shoulder are encouraged. As a rule sufficient compensatory movements develop at the scapulothoracic articulation to permit all routine activities. Some patients with active life-style may develop symptomatic secondary osteo-arthrosis during their middle-age.
- 23. Generally, asound fibrous ankylosis of the shoulder is obtained with a fair range of painless motion retained. Being a nonweight bearing joint a sound fibrous ankylosis is acceptable. If the ankylosis is painful or the disease is uncontrolled or in case of recurrence, an operative arthrodesis of the shoulder in optimum position is carried out. Mobilization procedure on the principles of excision arthroplasty may be considered under exceptional circumstances.
- 24. ARTHRODESIS OF SHOULDER: Arthrodesis of shoulder is now indicated extremely rarely only as a salvage procedure for disease that may leave an unstable and painful joint. Extra-articular Arthrodesis : • Before the availability of effective antitubercular drugs bony fusion of the joint was obtained by an extra-articular operation carried out by inserting an autologous tibial strut graft (12 to 15 cm) between the scapula and humerus through a posterior approach.
- 25. Intra-articular Arthrodesis: •At present with the availability of effective antitubercular drugs extra articular arthrodesis should be replaced by intra-articular procedures which permit synovectomy, joint debridement, removal of loose sequestra and destroyed tissues, freshening of the joint surfaces, confirmation of pathological diagnosis, and insertion of bone grafts at the site of desired fusion.
- 27. INTRODUCTION: Tuberculous diseaseof the elbow constitutes nearly 2 to 5 percent of all cases of skeletal tuberculosis. Disease commonly starts from the olecranon or the lower end of humerus, sometimes the onset is synovial or from the upper end of radius.
- 28. CLINICAL FEATURES: Onsetis generally insidious. Accompanied by pain, swelling and limitation of movements of the joint. Active stage- joint is held in flexion, looks swollen, is warm and tender.
- 29. Swelling ismaximally appreciated at the back of the elbow on both sides of olecranon and the triceps insertion. Movements are accompanied by pain and muscle spasm. Marked wasting of arm and forearm muscles is obvious. Supratrochlear and/or axillary lymph nodes are enlarged in nearly one-third of the patients.
- 30. Sinuses connectedwith the joint may form rarely. Nearly 5 percent of cases may present at a stage when the disease is synovial. Because of gravity the involved elbow joint may sometimes be held in extension.
- 32. RADIOLOGICALLY: Areas ofdestruction can be seen commonly in the olecranon and/or lower end of humerus. During active stage bones of the joint show generalized demineralization and fuzziness of joint margins.
- 33. MANAGEMENT: In additionto general treatment and systemic antitubercular drugs the elbow is given rest in the best functional position. In a unilateral case 90 degrees of flexion and midprone position of the forearm is advisable. In the initial stages one may use a strong removable plaster gutter which may be later replaced by removable polythene or metallic splint.
- 34. As soonas the pain in elbow permits, active assisted repetitive flexion-extension and pronation-supination exercises are started. A splint (with the elbow held in 90 degrees and forearm in midprone position) is worn for 6 to 9 months in between the exercises and at bed time. After the removal of splint one should avoid overuse of the joint for another 9 to 12 months.
- 35. ROLE OF OPERATIVETREATMENT: Excision arthroplasty is justified after the completion of growth potential when the disease has healed with the elbow in unacceptable position. At the stage of synovitis or early arthritis, in a nonresponsive case or whenever diagnosis is uncertain arthrotomy is indicated to perform synovectomy with or without joint clearance
- 36. EXCISIONAL ARTHROPLASTY: Removean inverted V-shaped segment of the lower end of humerus with apex of V reaching the olecranon fossa on the humerus, and preserving the supracondylar ridges, epicondyles, and collateral ligaments on medial and lateral sides
- 38. INTRODUCTION: Tuberculosis ofthe wrist is a rare localization, it is more frequent in adults. Disease may start in the synovium but very soon gets disseminated in the whole carpus.
- 39. Common sitesfor the primary osseous focus are the os capitatum or the distal end of radius.
- 40. In additionto generalized carpal dissemination, the disease may spread to the neighboring flexor tendon sheaths or in extensor tendon sheaths. Concomitant involvement of the flexor or extensor tendon sheaths is secondary to the tuberculous disease of the wrist. Abscess, sinus formation, and regional lymph node enlargement are common.
- 41. CLINICAL FEATURES: Pain, Limitation of movements, Swelling, Tenderness, Usually a palmar flexion deformity. With the extension of disease into the distal radioulnar joint, pronation and supination is also limited.
- 42. RADIOLOGICALLY: Further destructionof bones and ligaments leads to an anterior subluxation/dislocation at the radiocarpal articulation.
- 43. MANAGEMENT: The treatmentis essentially chemotherapy, correction of deformity and splintage of the wrist in 10 to 15 degrees of dorsiflexion and forearm in midprone position. Immobilization in the initial active stages of disease may be by a plaster-of-Paris cast which may be replaced by a leather/ plastic/metallic corset.
- 44. In thetuberculous disease without subluxation/ dislocation intermittent active exercises for the wrist, hand, and forearm should be encouraged out of the splint as soon as the pain permits. The splintage is continued in between the exercises and at bed time for 12 to 18 months to minimize collapse of bones and avoid deformity.
- 45. OPERATIVE TREATMENT: Synovectomyof the joint (and tendon sheaths if involved) and curettage of the destroyed areas may be indicated in nonresponsive cases or whenever there is doubt in diagnosis.
- 46. In advanceddisease having ankylosis in an awkward position, or when the ankylosis is painful, or if there is a history of recrudescence of infection, arthrodesis of the wrist in the optimum functioning position (10 to 15 degrees of dorsiflexion, 5 degrees of radial deviation and midprone position of forearm) is the treatment of choice.
- 48. INTRODUCTION: Tuberculosis ofthe metacarpals, metatarsals, and phalanges is uncommon after the age of 5 years. In children the disease may occur in more than one short tubular bone at a time. Also known as Tuberculous dactylitis. Hand is more frequently involved than the foot
- 49. PATHOLOGY: During childhoodthese short tubular bones have a lavish blood supply through a large nutrient artery entering almost in the middle of the bone. The first inoculum of the infection is lodged in the center of the marrow cavity and the interior of the short tubular bone is converted virtually into a tuberculous granuloma. This leads to a spindle-shaped expansion of the bone (spina ventosa).
- 50. With occlusionof the nutrient artery of the involved bone and the destruction of internal lamellae (or formation of sequestra) there is endosteal destruction and concomitant subperiosteal new bone formation; successive layers of subperiosteal new bone formation are deposited over the involved bone.
- 52. CLINICAL FEATURES: Abscessand sinus formation is quite common leading to secondary infection and further thickening of bone. In the natural course, the disease heals with shortening of the involved bone and deformity of the neighboring joint.
- 53. RADIOLOGICALLY: Affected boneappears expanded with a lytic lesion in the middle and subperiosteal new bone deposited along the involved bone. Cavity may contain soft coke- like sequestra.
- 54. SPINA VENTOSA: Latinword Spina- short bone, Ventosa- inflated with air. Tubercular involvement of Proximal phalanx. Presenting as- • 'Spindle' shaped deformity of the finger • Tenderness • Swelling • Shortening of finger • Cold abscess or multiple discharging sinuses may present.
- 55. SPINA VENTOSA: InSpina ventosa the bone may take the • Shape of honey combing, • Diffuse uniform infilteration or of a cystic lesion, or • rarely the involved bone may show Atrophy.
- 56. TUBERCULOSIS OF THEJOINTS OF FINGERS AND TOES: Lesion may develop either in the juxta-articular bone or in the synovium. Primary lesion in the bone seems more frequent. Involvement of the finger joints is more common than that of toe joints, and in general metacarpophalangeal/metatarsophalangeal joints are involved more frequently than the distal joints.
- 57. CLINICAL FEATURES: Clinicaldevelopment of the disease is slow and insidious. Patient presents with a spindle-shaped swelling of the joint and flexion deformity. Swelling is boggy, warm and tender. Movements of the joint are restricted. Enlarged regional lymph nodes, cold abscess and sinuses (usually on dorsal aspect) may be present.
- 58. RADIOLOGICALLY: Articular endsmay show osteoporosis, Erosion of joint margins, Destruction of bones Subluxation.
- 59. MANAGEMENT: Essentially byantitubercular drugs, rest to the part in functioning position and early active exercises of the involved parts or joints. In patients with unfavorable response or with recurrence of infection surgical debridement is justified. If a metacarpophalangeal,metatarsophalangeal or interphalangeal joint is ankylosed in an awkward position excision arthroplasty or corrective osteotomy is indicated.
- 60. REFERENCE: TUBERCULOSIS OF THESKELETAL SYSTEM (SIXTH EDITION) BY DR.SM TULI.