5.4. Tuberculosis of bones and joints


MBT can spread from the primary complex to any bone or joint. The risk that this will happen is greater the younger the child. Most bone or joint disease occurs within 3 years of the first infection but may be very much later. Although any bone or joint may be involved, those which are weight bearing are more likely to be affected than others.

The spine is most frequently affected by tuberculosis, then the hip, the knee and the bones of the foot, the bones of the arm or hand more rare. Tuberculosis of the spine arises from blood spread of ТВ. In about 70% of patients two vertebral bodies are affected: in 20% three or more. “Primary” osteitis – characterized by a damage of vertebra body without distribution of tubercular process from its limits. Primary osteitis accompanied by unlocalised painful sensations. On X-ray tomography the focus of destruction, in vertebra body could be revealed. Tuberculosis of the spine begins in the anterior superior (upper front) or inferior (lower) angle of the body and spreads to an adjacent (next) vertebra. The disc becomes involved and the disc space becomes narrowed. As the disease progresses an abscess forms and this may spread to sites such as the lower thoracic cage or below the inguinal (groin) ligament (psoas abscess). It may also compress the spinal cord. The commonest site is T10. Frequency decreases the further the vertebra is from T10, above or below.

Clinical signs.
Tuberculous disease of the spine is not seen in the first year of life. It begins to appear after the child has learnt to walk and jump. The first symptom is pain. To reduce the pain this child or adult holds his back stiffly. He avoids to bend to pick anything from the floor. If he needs to do so he may bend at the knees keeping his back straight. The pain gets better if he rests.

Signs of tuberculosis damage at different levels of vertebrae.

Damage of the cervical vertebrae. If the cervical vertebrae are involved. the patient may not like to turn his head, and may sit with his chin propped up by his hand. He may feel pain in his neck or his shoulders. If an abscess tracks, a soft fluctuant swelling may appear on either side of the neck behind the sternomastoid muscle or bulge into the back of the mouth (pharynx).

The damage of the thoracic vertebrae is characterized with tension in the back. In turning he moves his feet rather than swinging from the hips. When picking anything from the floor he bends his knees while his back remains stiff. Later there may be a visible lump or bend in the spine (gibbus) showing where the vertebral bodies have collapsed.

If the abscess continues to enlarge, the damage may spread to the right or the left round the chest and appear as a soft swelling on the chest wall. (A similar cold abscess can be due to tuberculosis of intercostal lymph nodes.) If it presses to the back it can compress the spinal cord and cause paralysis).

When the spine is affected lower than the chest (lumbar region) it is also below the spinal cord but the pus can spread in muscles just as it did at higher levels. If that happens it may appear as a soft swelling either above or below the ligament in the groin or lower still on the inside of the thigh (‘psoas abscess’). Rarely the pus can track through the opening in the pelvis and reach the surface behind the hip joint.

In advanced disease there may be not only a gibbus (angulations of the spine). There may also be weakness of the lower limbs and paralysis (paraplegia) due to pressure on the spinal cord or its blood vessels.

Tuberculosis of joints.

Swellings in joints come on slowly without high temperature and acute pain of a septic infection (though the joint is often a little warmer, when you lay your hand on it, than the unaffected joint in the other limb). The slow onset of a swelling either over a bone or a joint should make you think of tuberculosis.


  1. Radigraphy, anterioposterior and lateral X-rays films. The common early features are loss of anterior superior or inferior angle of the body and loss of disc space. The multiple lesions may be present in about 10 per cent of patients. A local abscess erodes the anterior surface of the several vertebral bodies. An intrathoracic abscess may give rise to an appearance resembling an aortic aneurysm on general view radigraph.
  2. Blood tests for anti-staphylococcal and anti-streptolysin haemolysis, typhoid, paratyphoid and brucellosis titres may help in difficult cases and in well-equipped centres.
  3. Needle biopsy may also be useful in difficult cases but needs experience and good histology.

In earlier stages of skeletal tuberculosis development usually is not detected in the plain radiograph. In the late stage of disease? The erosive bony lesions can be seen in the radiographs. However, CT (Computer Tomography) or MRI (Magnetic Resonance Imaging) is useful in detecting these lesions at an early stage.

Differential diagnosis.
In most cases the diagnosis is straightforward but tuberculosis may be confused with:

  • pyogenic infections (e.g. staphylococcal);
  • enteric infections (e.g. typhoid, paratyphoid);
  • tumors.

The X-ray appearances are usually characteristic for diagnosis verification.


The task of treatment of the patient with tuberculosis of bones and joints is:

  1. the increase of protective forces of the host for struggle with an infection;
  2. fastest restoration of function of the affected body organs.

For correct organization of treatment measures it is necessary to take into account reaction of organism on an infection, form and stage of process, duration of disease, age of the patient, condition of internal organs and lymphatic system, and also accompanying changes in the organism. The treatment could be valuable, only at careful performance of all elements of treatment ( chemptherapy, sanatorium-hygienic, surgery) for long time.

Chemotherapy has reduced lethality at bones and joints tuberculosis practically to zero, lowered complications, has reduced duration of an active stage and course of general process up to its subside, has raised an opportunity to return or to keep to the affected organ its normal function. At realization chemotherapy the precise technique, regular application of the proved drug’s combinations and their expedient change is necessary in connection with stages of bones and joints tubercular process.

The sanatorium-hygienic method is a main treatment complex at bones and joints tuberculosis. This method represents a combination of such elements, as day regimen, high-grade meal, climate therapy, measures influencing on the psychological condition of the patient. The best results are achieved at treatment of such patient in of a sanatorium type hospital.

The local orthopedic treatment pursues two purposes:

  1. in active stage creation of rest and unloading of the affected organ;
  2. in a stage of activity loss and subsiding – restoration of its normal function, gradual increase of walk load.

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