Download CHRONIC SPECIFIC BONE INFECTION

CHRONIC SPECIFIC
BONE INFECTION
DR.MARWAN ZAMZAMI,ABOS
CHRONIC SPECIFIC
BONE INFECTION
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TUBERCULOSIS
BRUCELLOSIS
FUNGAL
SYPHILIS
TUBERCULOSIS
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THE BASIC MICROSCOPIC LESION;
THE TUBERCLE
FIRST DISCOVERED BY THE FRENCH
PHYSICIAN LAENNEC (1781-1826)
WHO DIED AT THE AGE OF 45 BY TB
TUBERCULOSIS
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ESTIMATED 30 MILLION TB PATIENTS
WORLD WIDE.
1 -3 % (300 000 – 1000 000) HAVE
SKELETAL INVOLVEMENT
TUBERCULOSIS OF
BONES AND JOINTS
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TB Bacilli lived in symbiosis with
mankind since time immemorial.
Recorded in ancient Egyptian
mummies
Still common in developing countries
REDUCED INCIDENCE
OF TB DUE TO:
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IMPROVED LIVING STANDARDS;
SANITATION, HYGIENE, NUTRITION
B.C.G. VACCINE (80% PROTECTION)
TUBERCULOSIS BACILLI
MYCOBACTERIUM TUBERCULOSIS
BOVINE
UNPASTEURISED MILK
HUMAN
MORE COMMON
OTHERS
LESS COMMON
TUBERCULOSIS
GROUPS AT RISK
NON AFFLUENT COUNTRIES
OVER GROWING MALNUTRITION, POOR
YOUNGER AGE
AFFLUENT COUNTRIES
IMMUNE DEFICIENT
STEROIDS ANTICA
OLDER AGE
TUBERCULOSIS
FACTORS FAVORING
LOCALISATION
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BLOOD SUPPLY AND STAGNATION
LOCAL TRAUMA; HAEMATOMA?
LOCAL STEROIDS ?
TB PATHOLOGY
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Secondary to other primary TB lesions (Pulm.,
GL, Renal, LN)
Route of spread:
HAEMATOGENOUS ****
DIRECT (much less)
* bone to joint
* soft tissue to bone
THE PRIMARY LESION
QUIESCENT
ACTIVE: (Apparent, Latent)
TB PATHOLOGY
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INFLAMMATION HYPEREMIA - OSTEOPENIA
TB FOLLICLES (TUBERCLE):
LYPHOCYTE – MONOCYTES
ENDOTHELIAL CELLS
LANGHANS GIANT CELLS
COALESCE
CASEATION LATER
GRANULATION TISSUE
BONE DISTRUCTION
SINUSES
TB Follicle
TB PATHOLOGY (JOINTS)
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SYNOVIAL SWELLING
GRANULATION TISSUE
PERIPHERAL ARTICULAR DESTRUCTION
NO PROTEOLYTIC ENZYMES
CENTRAL ARTICULAR WEIGHTBEARING AREA PRESERVED
RICE BODIES
FIBRIN & ARTICULAR CARTILAGE
INCREASED BLOOD SUPPLY
OSTEOPENIA
CLINICAL PICTURE
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AGE
INSIDIOUS ONSET
MONO ARTICULAR
OTHER LESIONS
FAMILY HISTORY – CONTACT
GROUPS AT RISK
SYMPTOMS & SIGNS
CONSTITUTIONAL
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LOW GRADE FEVER
ANOREXIA
WEIGHT LOSS
NIGHT SWEATING
TACHYCARDIA
ANEMIA
SYMPTOMS & SIGNS
LOCAL
Symptoms :
 PAIN
 NIGHT CRIES
 SWELLING
 STIFFNESS
 ULTERED
FUNCTION
Signs :
 WASTING
 SYNOVIAL SWELLING
 TENDERNESS
 WARM
 STIFFNESS
 LIMPING
INVESTIGATIONS
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LEUCOPENIA – LYMPHOCYTOSIS
ANEMIA
RAISED ESR
MANTOUX POSITIVE
NOT IN:
MILIARY TB / RECENTLY VACCINATED/
ON STEROIDS / REDUCED IMMUNITY / FEVER
RADIOLOGY
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CHEST X-RAY : ALL PATIENTS
JOINTS: PHEMISTER’S TRIAD:
1. PERIARTIC. OSTEOPENIA
2. REDUCED JOINT SPACE
3. PERIPH. OSSEOUS EROSIONS
BONES:
1. DESTRUCTION
2. SEQUESTRATION
3. ABSCESS FORMATION
RADIOLOGY
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BONE SCAN: MONO – ARTICULAR
CF: RHEUMATOID ARTHRITIS
CALLIUM SCAN INFECTION
CT SCAN MORPHOLOGY
MRI MORPHOLOGY
DIAGNOSTIC
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ASPIRATION:
AFB POSITIVE
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HISTOLOGICAL
CULTURE
TB SPINE
SURGICAL PATHOLOGY
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FIRST THREE DECADES
THORACO-LUMBAR
CENTRAL SPINE
SPARKS POSTERIOR ELEMENTS
SPREADEDS UP/DOWN
ANT./POST. LONG. LIGS.
LESIONS COALESCE – COLLAPSE
KYPHUS FORMATION
TB SPINE
SURGICAL PATHOLOGY
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PARA VERTEBRAL ABSCESS
CERVICAL
: RETROPHARALYGEAL
THORACIC : P.V. & ALONG RIBS
LUMBAR
: PSOAS ABSCESS
POSTERIOR:LUMBAR TRIANGLE
ANTERIOR: ILIAC FOSSA
BELOW ING. LIG.
NEUROLOGICAL COMPLICATION
MORE IN THORACIC (NARROWEST CANAL)
TB SPINE
CLINICAL FEATURES
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GENERAL:
INSIDIOUS ONSET
CONSTITUTIONAL
LOCAL: PAIN – FIRST INDICATION
LOCAL – REFERRED
STIFFNESS – SPASM
WEAKNESS – NEUROLOGICAL
SIGNS OF TB SPINE
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MUSCLE SPASM
KHPHUS – GIBBOUS
TENDERNESS
STIFFNESS
PARA VERTEBRAL ABSCESS
NEUROLOGICAL – WEAKNESS
PARAPLEGIA
TB SPINE
RADIOLOGICAL FEATURES
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DISC NOT INVOLVED PRIMARILY
NARROWING OF DISC SPACE
BONE DESTRUCTION
USUALLY TWO ADJACENT VERTEBRAE
MAY SHOW SKIP LESIONS
PARA VERTEBRAL ABSCESS
KHYPUS
CT/MYELOGRAM/MRI IN PARAPLEGIA
PARAPLEGIA IN
TB SPINE
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IN 10-30% OF TB SPINE
MORE IN THORACIC REGION
PRESSURE ON CORD ANTERO
LATERAL
MOTOR EARLIER THAN SENSORY
SIGNS: UPPER MOTOR NEURON
MAY START BY CORD SHOCK
REMARKABLE ABILITY TO RECOVER
PARAPLEGIA IN TB SPINE
CAUSED BY EXTRADURAL
PRESSURE
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GRANULATION TISSUE
PRESSURE OF ABSCESS & CASEATON
SEQUESTRUM
PATHOLOGICAL FRACTURE/DISLOC.
SEVERE KYPHUS
INFLAMMATION: TOXIC EDEMA
VASCULAR
MANAGEMENT OF TB SPINE
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USUALLY
CONSERVATIVE
GENERAL
SPECIFIC
REST
IMMOBILISE
CHEMOTHERAPY
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SURGICAL
DIAGNOSE
ASPIRATION
DRAIN ABSCESS
DEBRIDE
DECOMPRESS
ANTERIOR
ANTERO-LATERAL
STABILISE FUSION
MOST CASES OF TB SPINE RESPOND
VERY WELL TO CONSERVATIVE
TREATMENT INCLUDING THOSE
WITH PARAPLEGIA
THE NEED FOR SURGICAL
DECOMPRESSION OF THE CORD IS
LIMITED
BRUCELLOSIS
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MILK AND MILK PRODUCTS
BACK PAIN AND STIFFNESS
MUSCLE SPASM
FEVER – MILD
SACRO-ILIAC JOINT
LESS DESTRUCTIVE OF TB
BRUCELLA TITRE
ANTIBIOTICS
e.g. SEPTRIN - OXYTETRACYCLINE
SYPHILIS
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SPIROCHETE
TREPONEMA PALLIDUM
CONGENITAL SYPHILIS – COMMONEST
CHRONIC OSTEOCHONDRITIS
PERIOSTEITIS
OSTEITIS
TIBIA LESABRE TIBIA
FUNGAL INFECTION
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CHRONIC – VERY LOW GRADE
FEET – FARMERS – THORNS Madura Foot
SLOW DESTRUCTION
SINUSES – GRANULES
SECONDARY BACTERIAL INFECTION
RESISTANT TO CHEMOTHERAPY
NEEDS SURGICAL DEBRIDEMENT
IF ADVANCED MAY NEED AMPUTATION