09級(jí)大5上課件-外科學(xué)8擇譯

1、Tuberculosis of Bone and JiontMD.Chenshirong Tuberculosis(TB) is still a common infection in developing countries. After lung and lymph node, bone and joint is the next common site of tuberculosis in the body. It constitute about 14% of the total cases of TB. Children and young people (30 years old)

2、 are 80% in the peoples of TB The spine is the commonest site of bone and joint, constituting about 50% of the total number of TB cases. The next in order of frequeny are the hip, the knee and the elbow. TB osteomyelitis骨髓炎 effects the end of the long bone, unlike pyogenic osteomyelitis化膿性骨髓炎 which

3、affects the metaphysis干骺端. The joint constituted about 30% of the total number of TB cases.Pathology TB infection of the bone and synovial tissue produces similar response as it produces in the lunges ie.,chronic granulomatous inflammation慢性肉芽腫性炎 with caseation necrosis干酪樣壞死. The respones may be pro

4、liferative,exudative or both.1 、Proliferative responese增殖反應(yīng): It is characterised by chronic granulomatous inflammation with a lot of fibrosis纖維化.2、 Exudative responese滲出反應(yīng): there is extensive caseation necrosis without much cellular reaction.3、Caseation necrosis干酪樣壞死Natural history The inflammation

5、results in local trabecular骨小梁 necrosis and caseation. In the absence of adequate body resistence or chemotherapy, the cortices 皮質(zhì)of the bone get eroded侵蝕, and the infected granulation tissues and pus find their way to the subperiosteal骨膜下 and soft-tissue plane. Here they present as cold abscesses冷膿

6、腫, and may burst out to form sinuses竇道.1、Cold abscesses 2、Pathological fracture3、Pannus關(guān)節(jié)翳. Inflammatory synovium at the periphery周圍 of the cartilage. A tubercular osteomyelitis in the vicinity 鄰近of a joint may result in the involvement of the joint. Low grade synovitis with thickening of synovial m

7、embrane.Cartilage have been Slowly destruced.4、Fibrous ankylosis纖維性關(guān)節(jié)僵直 5、healingTreatment1、Control of infection: Anti-Tb drugs including Rifampicin利福平 , INH異煙肼, thambutol沙丁胺醇，Pyrazinamide吡嗪酰胺, Strptomycin鏈霉素. Rest .2、Care of the affected part: Proper position of the jiontMobilisationExerciseWeight-

8、bearing : it is started gradually as the osteoporosis骨質(zhì)疏松 secondary to the disease is reversed3、Operative interventionBiospyTreatment of the cold abscessCurettage of the leisionJiont debridementSynovectomySalvage operations pressionTB of the spineThe spine is the commonest site of bone and jiont TB;

9、 The dorso-lumbar region下背部 being the one affected most frequentlyType of vertebral tuberculosisParadiscalCentralAnteriorPosteriorPathologyThe basic pathology is the same as that in other bone and jiont TB.Cllopse of the vertebra椎骨塌陷. Gennerally wedging楔形.Cold abscessClincal featuresPain back pain i

10、s the commonest syptom.Stiffness para-vertebal muscle go into spasm to prevent movement.Cold abscessParaplegia 截癱Defomity gibbus駝背Constitutional symptom fever,weight-lossPhysical examinationGait步態(tài) short step小步 to avoid jerking the spineAttitude and diformity Patient with cervical TB has a stiff,stra

11、ight neck. In dorsal spine TB ,the spine e prominent脊柱突出.Para-vertebral swellingTendernessMovement spine movement is limited.Neurological examination level, severityGeneral examination investigationX-ray Destruction of the vertebral body, cold abscess,rarefaction低密度影（稀疏）.CT scanMRIBiopsyGeneral inve

12、stigation ESR,CRP,TBIGg,ELLSA test, chest X-raycomplication1、Cold abscess2、Neurological compression( pott paraplegia)Treatment1、stable 2、reconstractePrinciples of treatmentPrinciples of treatmentTo promote recovery of the affected neural tissue,by reversing the cause responsible for compression,eith

13、er by drug or by operation.To achive healing of the vertebral lesion, and to support the spine till the disease segment e stable. pression .To undertake rehabilitative measures to prevent contracture攣縮, and to regain strengh in the affected part.1、Conservative treatment drug 2、Operation debride pres

14、sion stable spineTuberculosis of the hipPathology The basic pathology is same. The usual intial is in the bone adjacent to鄰近 the jiont i.e., either the acetabulum髖臼 or the head of the femur. In some cases, the lesion begin in the synovinm, but the cartilage and the bones are affected. A purely synov

15、ial TB單純性滑膜結(jié)核 as seen in the knee, is mom in the hip. Natural history 1、 The synovium hypertrophy肥大 and effusion. The cartilage is destroyed and the joint e full of pus and granulation tissues. The synovium get thickened, oedematous, gray and ulcerated.2、Mulpiple cavitation 空洞 Such cavities are form

16、ed in the fomral head and the acetabulum. Eventually the head and acetabulum get obsorbed吸收. The joint dislocated and the neck of fomral get fracture. The pus may perforate the acetabulum and appear as a pelvic abscess.3、Healing may take place by fibrosis, leading to ankylisis of the hip in a deform

17、ed position.Clinical feature1、Stiffness of the hip, it produces a limp跛行. 2、Pain. It may be pain referred to the knee. The child may complain of night cry夜啼. Thomas征PE:Stiff-hip gait. Lameness跛行 is the first sign. Muscle wastingSwellingDischarging sinusesDeformityShorteningMovements active and passi

18、ve movement are limited.Stage of TB of the hipStage of synovitis There is effision into the jiont. This stage is called the stage of apparent lengthening. Stage of the arthritis This stage is called the stage of apparent shortening. Stage of erosion侵蝕 The cartilage is destroyed and the head or the acetabulum is erosion.InvestigationX-ray Haziness模糊影, Lytic lesion骨溶解, reduction of jiont space, Irregular outline, Acetabular change.Routinal investigation biospyPrinciple of TreatmentTo control the disease-a