Tuberculosis of the elbow. A report of 10 cases

Current concepts in the diagnosis and management of tuberculosis of the elbow joint

Elbow is an uncommon joint to be affected by Mycobacterium tuberculosis infection. It is involved in approximately 1-5% of all cases with musculoskeletal tuberculosis (TB). Early diagnosis of TB of the elbow joint can be easily missed due to an indolent natural history, delay in presentation, and varied clinical features. Delay in diagnosis can lead to irreversible osteoarticular destruction and loss of joint function. Careful clinical assessment, adequate imaging, microbiological, and/or histopathological confirmation of Mycobacterium tuberculosis infection is essential for early diagnosis of TB of the elbow joint. Judicious and early administration of anti-tubercular therapy can lead to preservation of the joint and a satisfactory functional outcome. Surgical intervention may be needed in later stages of the disease to achieve control of the infection, correction of deformity, instability, and restoration of function.

Tuberculosis of the Elbow Region in Pediatric Age Group - Experiences from a Single Centre

BACKGROUND

Clinical series of tuberculosis of elbow region in children are few. The purpose of our study was to retrospectively review the presentation, healing response and functional results of 30 children.

METHODS

The pretreatment disease presentation was studied from patient's case records. Serial radiographs of the patients were studied to see remineralization and healing of radiological lesions. For elbow's functional evaluation, pain, range of motion and recurrence were observed at final follow up.

RESULTS

The mean patient age was 8.2 years. The mean duration of symptoms before presentation was 47 days. A discharging sinus was present in 6 patients. Multifocal presentation was found in 7 patients. The lesion was most commonly localized in proximal ulna or lower humerus. The classical 'ice cream scoop' appearance of proximal ulnar metaphysis was noted in 5 elbows. Most elbows were in Martini stage 2 (70%) at the time of presentation. All patients were treated non-operatively. Average follow up after completion of antitubercular therapy was 18.97 months. The resolution of regional osteopenia, sclerosis of lytic lesions, reappearance of bony trabeculae and decrease in size of cavities was the usual sequence of radiological healing. End average elbow flexion arc deteriorated with increasing Martini stage. 'Ice cream scoop lesions' resulted in a worse functional outcome with formation of an irregular proximal ulnar articular surface.

CONCLUSIONS

Restriction of elbow range of motion, early discharging sinus formation and radiological 'ice cream scoop' appearance indicated a tubercular pathology. Late presentation with advanced disease, total joint involvement, and 'ice cream scoop appearance' resulted in decreased elbow flexion arc.

Magnetic resonance imaging findings in tubercular arthritis of elbow

OBJECTIVE

To evaluate magnetic resonance imaging (MRI) features of tubercular involvement of elbow joint.

METHODS

Fourteen patients with tubercular arthritis of elbow were evaluated. The following findings were recorded on MRI (n=12): bones involved; erosions, intraosseous abscesses, synovial thickening, and effusion; hypointensity within the thickened synovium on T2-weighted images; and periarticular soft tissue changes.

RESULTS

The common abnormalities on MRI were synovial thickening and bone erosions (n=12), soft tissue (n=9)/intraosseous (n=5) abscesses, and T2 hypointensity within the thickened synovium (n=5).

CONCLUSIONS

A diagnosis of elbow tuberculosis should be considered if there is a combination of findings involving bone and soft tissue.

Tuberculosis of the elbow: A clinicoradiological analysis

BACKGROUND

The incidence of Tuberculosis (TB) of elbow is 2-5% of all skeletal locations. Most reports of TB elbow have focused attention on the diagnosis. The management options and classification has been missing. We present a retrospective clinicoradiological analysis of 38 cases (40 elbows) of TB of elbow joint.

MATERIALS AND METHODS

The patients presented with pain, swelling and loss of motion. Two cases had bilateral involvement. The average delay between onset of symptoms and presentation was 8 months. The elbows were classified according to modified Martini's radiological classification, which distinguishes between osseous lesions close to joint line (e.g. coronoid, condyles) and lesions away from the joint line (e.g. epicondyles, olecranon). We modified the classification to subdivide into para-articular bony lesions that had invaded the joint and those that were threatening to invade joint. All patients received antitubercular chemotherapy and immobilization in above-elbow plaster slab for 4-8 weeks. Twenty patients underwent surgical interventions (synovectomy, intraarticular debridement).

RESULTS

The average followup period was 5.3 years (range 1.5-14.2 years). The range of movement at final followup averaged 107° for stage 2, 90° for stage 3A, 47° for stage 3B and 32° for stage 4. Range of supination and pronation was less satisfactory as compared to flexion and extension and all elbows with bony involvement had less than 90° arc of supination and pronation.

CONCLUSION

Surgical intervention could appreciably alter the outcome especially in patients with extra-articular involvement close to the joint. We have classified this subgroup separately.

Tuberculosis of the elbow joint in children: a review of ten patients who were managed nonoperatively

BACKGROUND

There is scarce information regarding osteoarticular tuberculosis of the elbow in children, even in countries where tuberculosis is endemic. We report our experience with ten patients who were managed nonoperatively.

METHODS

We retrospectively assessed ten children with elbow tuberculosis with regard to their presentation, diagnosis, management, response to standard antitubercular drugs, and outcome at the completion of antitubercular therapy. All patients were managed nonoperatively with splinting for as long as six weeks, followed by mobilization along with multidrug antitubercular medication for twelve months.

RESULTS

Swelling of the elbow that did not respond to initial treatment was the most common cause for referral to our clinic. The proximal ulnar metaphysis was most commonly involved. The average duration of follow-up was twenty-six months. The average time for healing of draining sinuses was twelve weeks (range, four to fourteen weeks). Lytic lesions, including coke-like sequestrum, healed radiographically at an average of 7.4 months (range, six to nine months). Range of motion improved with treatment, but some motion restriction always persisted, depending on the extent of joint destruction.

CONCLUSIONS

In the Indian subcontinent, the presentation of elbow tuberculosis is usually exudative with abscess formation, and the disease is fairly advanced at the time of diagnosis. An "ice cream scoop" appearance of the proximal part of the ulna in children should raise suspicion for tuberculosis. Elbow tuberculosis in children can be treated adequately with use of nonoperative means, regardless of the extent of osseous destruction, with a good outcome.

Tuberculosis of the metacarpals and phalanges of the hand

Skeletal tuberculosis (TB) is less common than the pulmonary form. Involvements of the metacarpals and phalanges of the hand are infrequent. The authors report their experience with treatment and outcome of TB of the metacarpals and phalanges of the hand in 7 patients. There were 4 women and 3 men in the study who ranged in age from 3 to 60 years (average age, 22.7 years). The duration of complaints at presentation ranged from 4 to 17 months (average, 9 months). The most common presentation was pain and swelling. The presumptive preoperative diagnoses were bone tumor in 4 patients, spina ventosa in 2, and chronic pyogenic osteomyelitis in 1 patients. The results of the laboratory examination showed a mild increase in the erythrocyte sedimentation rate. No patient had an active tubercular lesion or history of pulmonary disease. The diagnosis was based on the clinical picture and radiographic features, and was confirmed by open biopsy. No patient had bony debridement or arthrodesis to control the infection. The treatment of all patients began with a 4-drug regimen for 2 months, followed by a 2-drug regimen for 10 months. The mean follow-up was 30.28 months (range, 16-52 months). At the time of the last follow-up, all lesions had healed with no recurrence. The functional results were satisfactory in all patients. One patient with thumb metacarpophalangeal TB had joint irregularity and thumb metacarpal shortening. Arthrodesis was not needed in any patient. TB of the metacarpals and phalanges of the hand can be difficult to diagnose during the early stages. TB should be suspected in cases of long-standing pain and swelling in the metacarpals and phalanges. It is necessary to keep TB in mind when making the differential diagnosis of several osseous pathologies.

Tuberculosis of the elbow in children

Ten children with tuberculosis of the elbow treated over a 21-year period from 1979 to 1999 were reviewed retrospectively. At presentation, they had pain and swelling of the joint mainly due to synovitis, and the median symptom duration was 10 weeks. All had a decreased range of movement. All were treated with 9 months of antituberculous chemotherapy without synovectomy. The radiologic stage at presentation, rather than duration of symptoms, predicted outcome. Of the 9 patients with stage 1 or 2 disease (synovitis), 8 had an excellent or good outcome. One stage 2 patient had a posterior dislocation of the radial head and had a fair outcome. The one stage 3 (arthritic) patient had a poor outcome.

Two cases of chronic arthritis of the forearm due to Mycobacterium tuberculosis

In the absence of coexisting active pulmonary disease, tuberculosis is frequently not considered in the differential diagnosis of chronic inflammation of the joints. The cases of two immigrant patients with tuberculous arthritis involving the forearm are reported. In both cases non-specific arthritis or trauma was suspected, resulting in a delay between the onset of symptoms and institution of specific therapy of 21 and 24 months, respectively. Diagnosis was achieved by histological and microbiological examination of synovial biopsy material. Polymerase chain reaction for Mycobacterium tuberculosis complex was positive in only one patient. Treatment consisted of antituberculosis chemotherapy, surgical synovectomy, and debridement of the affected joints. These cases serve as a reminder that, although rare, tuberculosis can cause chronic arthritis.