Baby walking

Introduction Children with early tuberculosis of the tuberculosis have a foot on their feet and often stumble. After the fatigue, it begins to walk, especially in the evening. It can disappear after a short break or after the morning of the next morning.

Cause

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, 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 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.

an examination

Related inspection

Bone and joint MRI

First, the symptoms:

1. Symptoms and signs

(1) Age characteristics: The age characteristics of hip joint tuberculosis are more obvious than other joint tuberculosis (such as knee joint tuberculosis). The disease is more common in children and adolescents, and 60% of patients are under 10 years of age. Adult patients, mostly in childhood, suffered from illnesses due to decreased immunity or other unfavorable factors.

(2) symptoms of systemic poisoning: patients often have loss of appetite, weight loss, general weakness, temper deterioration and low fever, night sweats and other symptoms. Children often have some kind of excitement, easy to cry, poor sleep, and even the behavior becomes less lively and easy to fatigue. At this time, attention should be paid to the occurrence of lymphadenitis, and the inguinal lymphadenopathy has a certain significance. This symptom may occur very early, but it may not be possible when the symptoms of hip tuberculosis are very obvious.

(3) Pain and tenderness: The general incidence is faint. The earliest hip pain is mild, the activity is aggravated, and the rest is relieved, often accompanied by weakness or heavy feeling of the affected lower limb. Occasionally, a small number of patients have a rapid onset, and hip pain is more severe. 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. An experienced doctor, at this time pressing the femoral head and the femoral neck, may be accompanied by localized localized pain. In the future, this kind of activity is heavy, and the painful characteristics of rest can be repeated, but the intermittent period is gradually shortened and developed into persistent pain. Due to the destruction of the cartilage in the joint, the pus of the lesion directly enters the joint cavity, causing excessive pain and causing severe pain. It is often relieved by using pethidine (dolamine). At this time, the pain was fixed in the hip, and the patient did not dare to turn over or refuse to move. The sensitivity of the entire joint to both touch and compression is significantly increased. When the lesion is delayed, the period of improvement, or the intra-articular pressure is reduced after the abscess is broken, the pain gradually reduces or even disappears completely.

(4) Minhang: Slightly squatting occurs more often with pain, or it is discovered by parents carefully. Early sick children have to walk around and often stumble. After the fatigue, it begins to walk, especially in the evening. It can disappear after a short break or after the morning of the next morning. At this time, it is often mistaken for "sprain" and not much attention. In adults, the earliest symptoms are mostly feeling weak in the lower limbs. When pain occurs, the patient refuses to use the weight of the affected limb to aggravate the limp. Later, with the development of the disease, the limp gradually increased, and even lost the ability to walk completely. Patients with simple bone tuberculosis were lighter, and those with simple synovial tuberculosis were slightly heavier.

(5) 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. The symptoms of thickening of the subcutaneous tissue of the affected limb and thickening of the skin wrinkles also have certain significance. In the late stage of hip tuberculosis, significant muscle atrophy and nutritional disorders occurred in the thighs, calves and tendons of the lower extremities.

(6) Swelling, abscess or sinus formation: early patients have swelling of the joints, but it is not easy to be detected due to hip muscle hypertrophy. If there is more obvious swelling in the hip, it is proved that the change of tuberculous inflammation is significantly increased. This swelling is not so much due to exudation, but rather due to thickening of the joint capsule and soft tissue edema around the joint. Therefore, at this time, when the joint capsule is puncture and suction, there may be nothing. Of course, under certain circumstances (such as mixed infections, etc.) may also be caused by abscesses. The early feature of this swelling is that the groin folds gradually disappear, and the upper thighs are spindle-shaped and attracting attention, especially if compared with the severely atrophied lower thigh. When the joints are significantly swollen, the skin color also changes, or pale, or bruising with superficial varices. Sometimes the skin color is red and tense, the local temperature is increased and the tenderness is increased. This phenomenon usually indicates a spread of inflammation or abscess formation. According to statistics, the formation of abscesses in hip joint tuberculosis is 1 to 2 times more than that in the knee joint. A hip abscess has an irregular bulge or a diffuse mass that is fluctuating. The most common site of abscess is the front of the big trochanter, the anterior lateral part of the thigh. It occurs in the buttocks, as well as in the anterior and inferior groin areas of the groin. In some cases, the abscess can be found in the depth of the ipsilateral armpit.

The sinus is formed by an abscess, which can be at different locations, sometimes far from the joint. If the lesion is in progress, the sinus ostium may not close for a long time, or may occur after closure. Some of the sinus roads are in a single tube shape, while others are in the form of "series holes". They are branched and have traffic, but the openings are mostly one. The long-term patients are scarred and pigmented.

The characteristic of pus discharged from the abscess through the sinus is the so-called "smoked rice bran", thin and gray, often mixed with cheese-like material or dead bone. When there is a mixed infection, the thicker pus can be discharged, and if it is infected by spoilage bacteria, the smell is very large.

(7) Limited hip activity: The earliest manifestation of a certain activity is slightly limited, so it should be compared with the healthy side during the examination. It is common to have limited abduction and overextension activities, which are only found during clinical examinations.

In the future development process, on the one hand, due to the protective effect of the diseased joint itself; on the other hand, due to the reflex collapse of the muscle attached to the joint, in addition to the further limitation of abduction and over-extension, various activities will occur. Restricted, and often leads to a position of forcing in an almost inactive state. Joints in advanced cases are often incomplete, so patients often have to use crutches.

(8) Malformation: There is no malformation in the early stage of the disease. The child often sees a slight increase in the affected limb. This is because the inflammatory changes (increased blood supply) stimulate the bone growth. After the further development of hip tuberculosis, the gradual muscle contracture can cause the deformed position of the affected limb - the slight flexion, abduction and external rotation of the thigh. Of course, this position is also rare: after the thigh is further flexed, and more It becomes an adductive internal rotation and a shortened deformity. Stubborn flexion and adduction muscle contracture is a typical feature of hip joint tuberculosis. At this time, the pelvis is tilted, and lumbar lordosis or scoliosis can occur. At this time, the Thomas score was found to be positive. Painful muscle contractures and limb deformities add great pain to the patient. Of course, if combined with pathological joint dislocation, in addition to flexion and adduction of the affected limb, large trochanter elevation and limb shortening and other deformities can be seen.

2. X-ray performance

X-ray examination is very important for hip joint tuberculosis, especially early diagnosis. Some children get positive results when their parents say that they have "lime" or "love down". However, it is necessary to compare the hip joints on both sides and carefully read the film to find a slight pathological change.

(1) Simple synovial tuberculosis:

1 The affected side has more pelvis forward, so the affected side is smaller.

2 The affected acetabulum and femoral skull are loose, the trabecular bone becomes thinner, and the cortical bone becomes thinner. Children's osteoporosis is more uniform, and adults have inconsistent shadows. Sometimes, children can find a slight shape change in the femoral head on the affected side.

3 joint gap changes: At first, there is often a widening, probably due to synovial edema and joint effusion. Later, the joint space is narrowed, mainly in the upper and outer parts, and is mostly uneven.

4 swelling of the joint capsule of the affected side: the translucent image of the outer fat layer of the joint capsule can be clearly seen enlarged, and the lateral bulging is away from the joint, giving a full feeling.

(2) Simple bone tuberculosis: Because the position of the hip joint is relatively deep, its local anatomical relationship is also complicated, so its earlier bone changes are not easy to be found, especially those with smaller lesions. Observed on the radiographs is often an old lesion with more significant damage and containing dead bones, especially when the lesion is at the edge. The actual process is, first, a localized osteoporosis area, which gradually thickens and hardens and then appears dead bones. It has been reported that the acetabular lesions are mainly in the hip bone, and most of them are still in the middle, and the lateral and medial side are relatively rare. The lesions at the central, medial, and lateral sites constitute a group of so-called upper acetabular lesions. These lesions are the most common and most likely to break into the joints. Femoral neck lesions accounted for about 30% of all lesions; femoral neck and acetabulum accounted for 5% to 10% of lesions. Sometimes without obvious clinical symptoms. X-ray examinations often also unexpectedly find the lesion area. Therefore, the true incidence rate may be higher than the clinical statistics.

(3) Early total joint tuberculosis: The X-ray features of early total joint tuberculosis from synovial tuberculosis or from bone tuberculosis are: extensive range of osteoporosis, and even the upper part of the femoral shaft is affected. Localized bone destruction of the femoral head or acetabular rim is more pronounced and progressive destruction. Although this damage has reached the joint, most of the subchondral bone plate is still intact. Periosteal changes usually do not occur. Of course, significant joint space stenosis can also be observed. At the same time, there are also joint capsules and closed pores.

(4) Late total joint tuberculosis: the destruction of this period is aggravated, the cartilage surface is free, and the cartilage board is completely invaded. Therefore, the outline of the joint on the X-ray film is blurred or even completely disappeared. At this time, it is only possible to distinguish the source from the extent of the damage. When the lesion continues to develop, when the joint damage is very serious, the source cannot be distinguished.

At this time, pathological dislocation or deformity is often combined, and some even the femoral head and neck disappear, some form bony or fibrous rigidity, and some have signs of sclerosing osteomyelitis due to mixed infection. In the late stationary phase, the edges of the bone destruction show a clear outline, especially in the acetabular area. Gradually, osteoporosis is alleviated, bone edge hardening is aggravated, but the residual bone destruction zone is more pronounced.

X-ray examination can sometimes find residual abscesses and calcification shadows in soft tissue, which has important significance in differential diagnosis.

Second, the diagnosis:

For the diagnosis of hip joint tuberculosis, it is generally not difficult to rely on the history, symptoms, signs and X-ray findings. But early diagnosis of early cases is not very easy. Therefore, the early symptoms of the patient and some insignificant signs should be of great concern to doctors. Otherwise, the consequences for misdiagnosis to patients 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. Learn more about your medical history. First, understand the time of onset, the performance of the disease, the relationship with trauma and other diseases, and the history of exposure to tuberculosis. Then understand the complications and past medical treatment and diagnosis of treatment results. This information will lay the foundation for your correct diagnosis.

Careful and comprehensive examination of the patient is a prerequisite for a correct diagnosis and a prerequisite for proper treatment. So from the moment you see the patient, you should pay attention to his posture, gait and general behavior. The patient is then taken off the clothes for a naked examination. In this way, what deformity, swelling, muscle atrophy, dysfunction, and the color and scar of the limbs can be obvious, and sometimes the "at a glance" harvest can be achieved. It is best to perform standing and lying position checks separately if conditions permit.

It is important to passively check the range of motion of the hip joint. Because of its rotational activity barriers and pain is one of the early features of hip joint disease. In order to be accurate, it should be a double-sided control or a simultaneous examination. Muscle contracture is a feature of the early development of hip joint tuberculosis, so attention must be paid to the examination of hip overextension. When the disease progresses and the contracture becomes apparent, the Thomas sign is positive.

In later stages of the disease, due to anatomical changes in the joints, their activities in all directions are intractable. The extent of joint limitation is best determined by measurement. The expressions of the words mild and obvious are not precise enough.

X-ray examination is a necessary supplement and cannot be understood as a means of determining diagnostic significance and ignoring others. It is also necessary to know that changes in X-ray signs tend to be later than clinical changes, so tuberculosis cannot be completely denied before X-ray features are available. In one patient, the doctor only decided to diagnose tuberculosis after seeing the complete destruction of the femoral head on the X-ray film, thus delaying treatment.

At the X-ray examination, the position of the projection is more important, and there is often a positive position without a lateral position, and one side has no contralateral side. Ideally, it should include a bilateral hip joint and be a fully symmetrical X-ray film. Sometimes in order to find small lesions, lateral or even oblique projections must be performed. The significance of tomography needs 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

To distinguish from congenital clubfoot. Congenital clubfoot is a common congenital deformity of the foot, the incidence rate is about 0.1%, more men than women, male: female is 2:1, unilateral onset is slightly higher than bilateral. It is characterized by severe plantar flexion, forefoot adduction and plantar inward. From the therapeutic effect, the congenital clubfoot can be divided into a soft type and a stiff type. The soft deformity is lighter and the manipulation is easier. The stiff deformity is heavier and the technique is difficult to correct. The untreated child's deformity will gradually increase, the gait is abnormal when walking, and the lateral edge of the foot appears paralyzed. The ipsilateral calf muscles were significantly atrophied on the healthy side. In addition, other soft tissues associated with foot deformities such as ligaments, muscles, fascia, tendons, and neurovascular dysplasia. When the deformity is severe, the lesions are extensive, not only backward development, shrinkage, but also atrophy of the calf muscles and internal rotation of the humerus.

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