外科學(xué)教學(xué)課件：骨關(guān)節(jié)結(jié)核（Eng）

1/27TuberculosisBoneAndJoint

KeyfactsTuberculosis–OldDiseaseMayhaveevolvedfromMbovis;acquiredbyhumansfromdomesticatedanimals~15,000yearsagoEndemicinhumanswhenstablenetworksof200-440peopleestablished(villages)~10,000yearsago;EpidemicinEuropeafter1600(cities)2/27KeyfactsTuberculosis(TB)isaninfectiousdiseasethatspreadsthroughtheair.OnlypeoplewhoaresickwithTBintheirlungs(pulmonaryTB)areinfectious.354-322BC-Aristotle（亞里士多德）–“Whenonecomesnearconsumptives…onedoescontracttheirdisease…Onetakesthediseasebecauseinthisairthereissomethingdiseaseproducing.”3/27KeyfactsWheninfectiouspeoplecough,sneeze,talkorspit,theypropelTBgerms(bacilli),intotheair.4/27TB:AirborneTransmissionTBInvades/InfectstheLungEffectiveimmuneresponseInfectionlimitedtosmallareaoflungImmuneresponseinsufficientAMulti-systemInfectionKeyfactsOnethirdoftheworld'spopulationiscurrentlyinfectedwiththeTBbacillus,butonly5%-10%ofpeopleinfectedwillbecomesickwiththediseaseintheirlifetime.6/27NaturalHistoryofTBInfectionExposuretoTBNoinfection(70-90%)Infection(10-30%)LatentTB(90%)ActiveTB(10%)UntreatedDiewithin2yearsSurviveTreatedDieCuredNeverdevelopActivediseaseTBInfection&Disease

Thereare2CategoriesofTB:Latent&ActiveTBinfectionofthelungscanfallinto2categoriesofdisease:LatentTBorActiveTB.LatentTBmeansapersonisinfectedbyTBbacteria,butcannotinfectothers,andisnotcoughingorappearingsick.LatentTBmeansthebody’simmunesystemhascontainedtheinfection.KeyfactsTuberculosismostlyaffectsyoungadultsintheirmostproductiveyears.發(fā)病年齡：好發(fā)于兒童和青少年，30歲以下的占80%9/27KeyfactsTheimmunesystem“wallsoff”theTBbacilliwhich,protectedbyathickwaxycoat,canliedormant（冬眠）

inthebodyforyears.Whensomeone'simmunesystemisweakened,thechancesofbecomingsickaregreater.Leftuntreated,eachpersonwithactiveTBdiseasewillinfectonaverageofbetween10and15peopleeveryyear.PeoplewithHIVaremuchmorelikelytodevelopTBafterinfectionduetotheirweakenedimmunesystems.發(fā)病誘因是機(jī)體抵抗力下降：外傷、營養(yǎng)不良、過度疲勞10/27Tuberculosis

BoneAndJointAlthoughskeletaltuberculosishasbeenreportedtooccurineverylocation,thespineismostfrequentlyaffected(50%),especiallythelumbarspine,followedbythehipsandkneesTuberculosis

ClinicalFeaturescontactwithTBpain,swelling,lossofweightjointswellingdecreaseROMankylosis（關(guān)節(jié)強(qiáng)直）deformity13/27臀部膿腫髖關(guān)節(jié)結(jié)核，男，34歲多發(fā)瘺孔（箭頭所示）·髖關(guān)節(jié)內(nèi)收·屈曲·內(nèi)旋·下肢短縮10cm。Tuberculosis

Pathologyprimarycomplex(inthelungorthegut)secondaryspreadtuberculousgranulomaTuberculosis

Spinallittlepainpresentwithabscessorkyphosis（駝背）Tuberculosis

DiagnosislonghistoryinvolvementofsinglejointmarkedthickeningofthesynoviummarkedmusclewastingMtuberculosisascausative

agentfortuberculosis1886RobertKochTuberculosis

laboratoryfindingsFBC（全血計數(shù)）

,ESR（血沉）,TestMantoux（結(jié)核菌素試驗，也稱為芒圖試驗、PPD試驗）Xray：

softtissueswelling periarticularosteoporosis（關(guān)節(jié)周圍骨質(zhì)疏松） jointappearwashedout articularspacenarrowing19/2720/2721/27第4,5腰椎結(jié)核22/27MRI顯示L4,5椎體破壞，椎間隙變窄CT顯示椎體破壞和腰大肌膿腫形成Tuberculosis

differentialdiagnosistransientsynovitis（一過性滑膜炎）monoarticularRA（單關(guān)節(jié)風(fēng)濕性關(guān)節(jié)炎）haemorhagicarthritis（血友病性關(guān)節(jié)炎）pyogenicarthritis（化膿性關(guān)節(jié)炎）24/271.SupportivetherapyRestSunshine，freshair

andnutritionTreatment:

chemotherapyrifampicin（利福平）

isoniazid（異煙肼）12weeksethambutol（乙胺丁醇）streptomycin（鏈霉素）

Pyrazinamide

（吡嗪酰胺）rifampicinandisoniazid6-12month2.Chemotherapy26/27Localtreatment：splintageoperativedrainage：rarelynecessary27/27indicationsofoperation①

alargesequestrum②

abigabscesswhichcannotbeabsor