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Shoulder Joint Tuberculosis

Introduction

Shoulder joint tuberculosis accounts for 1-2.8% of skeletal tuberculosis cases in children. It typically affects the glenohumeral joint through hematogenous spread from primary pulmonary infection.

Key Clinical Features

  • Insidious onset of dull aching pain
  • Gradual restriction of movement
  • Cold abscess formation
  • Muscle wasting around shoulder girdle
  • Limited range of motion, particularly abduction
  • Night cries in early stages
  • Constitutional symptoms (fever, weight loss, fatigue)

Pathological Stages

  1. Stage I (Early):
    • Synovitis with minimal erosion
    • Preserved joint space
    • Normal contour of articular surface
  2. Stage II (Intermediate):
    • Moderate erosion of cartilage
    • Early joint space narrowing
    • Focal bone destruction
  3. Stage III (Advanced):
    • Severe articular destruction
    • Joint space obliteration
    • Subluxation or dislocation

Diagnostic Approach

Imaging Studies

  • X-ray findings:
    • Phemister's triad: juxta-articular osteoporosis, peripheral osseous erosions, gradual joint space narrowing
    • Lytic lesions in humeral head
    • Superior migration of humeral head
    • Pathological subluxation
  • MRI findings:
    • Synovial thickening and enhancement
    • Bone marrow edema
    • Joint effusion
    • Abscess formation
    • Early cartilage destruction

Laboratory Investigations

  • Elevated ESR and CRP
  • Mantoux test (TST)
  • IGRA (Interferon-Gamma Release Assay)
  • Joint fluid analysis when available
  • PCR for MTB when available
  • Culture and sensitivity testing

Treatment Protocol

Conservative Management

  • Anti-tubercular therapy (ATT):
    • Intensive phase (2-3 months): HRZE (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol)
    • Continuation phase (7-9 months): HR (Isoniazid, Rifampicin)
    • Total duration: 9-12 months based on clinical response
  • Immobilization:
    • Shoulder immobilizer in early stages
    • Gradual mobilization as pain subsides

Surgical Intervention (When Indicated)

  • Indications:
    • Large cold abscess
    • Severe joint destruction
    • Failed conservative treatment
    • Neurological complications
  • Procedures:
    • Arthroscopic debridement
    • Open debridement
    • Arthroplasty in severe cases

Monitoring and Follow-up

  • Monthly clinical assessment
  • Serial ESR and CRP monitoring
  • Radiological evaluation every 3 months
  • Assessment of medication compliance
  • Monitoring for drug side effects
  • Physical therapy progress evaluation

Complications

  • Shoulder stiffness
  • Chronic pain
  • Reduced range of motion
  • Secondary osteoarthritis
  • Growth disturbances
  • Pathological fractures

Rehabilitation Protocol

  • Early Phase:
    • Pain management
    • Protected immobilization
    • Isometric exercises
  • Intermediate Phase:
    • Passive range of motion exercises
    • Active-assisted exercises
    • Scapular stabilization
  • Late Phase:
    • Active range of motion exercises
    • Strengthening exercises
    • Functional training


Disclaimer

The notes provided on Pediatime are generated from online resources and AI sources and have been carefully checked for accuracy. However, these notes are not intended to replace standard textbooks. They are designed to serve as a quick review and revision tool for medical students and professionals, and to aid in theory exam preparation. For comprehensive learning, please refer to recommended textbooks and guidelines.





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