T HE short tubular bones of the hands and feet are uncommon loci for the manifestations of adult skeletal tuberculosis.

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1 JULY, 1971 TUBERCULOUS DACTYLITIS IN THE ADULT* By FRIEDA FELDMAN, M.D., RICHARD AUERBACH, M.D.4 nd AUSTIN JOHNSTON, M.D.t NEW YORK, NEW YORK T HE short tubulr bones of the hnds nd feet re uncommon loci for the mnifesttions of dult skeletl tuberculosis. Tuberculous dctyli tis, in prticulr, is considered hllmrk of childhood nd our roentgen concept of this lesion, s described in texts nd mjor works on tuberculosis, hs been lrgely tht of spin yentos. Scttered reports dditionlly imply its rrity in the dult. We, therefore, believe tht our experience with 23 dult, biopsy proven cses of tuberculosis distl to the trsus nd wrist merits presenttion. This report s prime purpose, however, is not to serve s review of skeletl tuberculosis, but rther to cll ttention to its occurrence in infrequently documented res, to emphsize its morphologic vribility in these loctions, nd to illustrte vriety of little emphsized roentgen mnifesttions. STATI STICS Reports of skeletl tuberculosis hve chiefly come from generl surgicl, orthopedic nd pthologic files. Among the lrger series stemming from snitri, LFond26 noted 5.2 per cent gross skeletl incidence mong 6,682 dult dmissions for ctive disese (6 cses involved the hnd, the foot), while Auerbch nd Stemmermn found 1.4 per cent incidence (119 of 1,143 utopsies) including 5 mettrsls, metcrpls nd i phlnx with ges unstted. Tuberculous dctylitis sttistics per Se, for the most prt, embrce the infncy to childhood period, rnging from o.6 to i. per cent in childhood, nd vrying with clinicp5 or surgicl 8 38 cses. In the lrger childhood series, 8 38 dctyli tis becme uncommon fter #{231} nd scrce fter 1 yers. A recent surgicl report of hnd nd wrist lii berculosis included i 7 dctyli tis cses; 9 were in children nd 8 in dults t the time of onset. A Myo Clinic musculoskelet! tuberculosis review 21 included 27 bone nd joint cses; 3 occurred solely in hnd tendon sheths nd none in the hnd or foot skeleton. Not one child ws seen in the yer period. Although other isolted reports of dult peripherl skeletl tuberculosis s herein defined (i.e., distl to trsus nd wrist) were found, 1,2,1,16,26,34 rdiologic reviews hve been rre Poppel et l.3 observed 7 cses of smll tubulr bone tuberculosis mong i 6 with skeletl involvement (the 3 illustrted were dults), Stenstrom4#{176} 3 phlngel cses in dults 29, 69, nd 76 yers old, while Nthnson nd Cohen29 in roentgen review of 2 Seview Hospitl cses, found 17 metcrpls, 8 mettrsls nd 14 phlnges involved mong ioo children (i-i6 yers) nd i metcrpl, i mettrsl nd phlnges mong ioo dults (16-7 yers). SEX AND AGE Most dult series note mle prepondernce (3:1 rtio) with no prominent sex difference when skeletl loci or extent of lesions re considered. Although most dult series give second nd third decde pek incidence of bone nd joint tuberculosis, pprent discrepncies result from compring clinicl with pthologic nd utopsy findings. In severl lrge clinicl series,4s the ge incidence of skeletl tuberculosis rnged from 69 to 85.3 per cent in the first two decdes of life, while utopsy series rnged from 49.6 per cent (2-39 yers)2 to 79 per cent over ge 2.4,8 Contrsting incidences my, in prt, be ttributed to the * From the Deprtment of Rdiology, Columbi-Presbyterin Medicl Center, New York, New York. t Associte Professor of Pthology. NIH Dignostic Trining Fellow. This investigtion ws supported in prt by NIH Trining Grnt No. 5 Toi-GMO

2 VOL. 112, No. Tuberculous Dctylitis in the Adult 461 fct tht the pthologist usully sees progressive cses, nd t much lter stge nd ge thn the clinicin. Among Nthnson nd Cohen s29 1 dults, skeletl tuberculosis ws most Irequent t those ges t which physicl ctivity is most strenuous; i.e., 77 per cent between yers, 23 per cent lter 5 yers, with pek between 2-25 yers, grdul decline till o-s yers nd n brupt drop therefter. Among the smll tubulr bone cses of Poppel et l.,3 the 3 detiled were in dult mles 28, 36 nd 62 yers of ge. MATERIAL Among 2 dult skeletl tuberculosis cses in our surgicl nd orthopedic pthology files (193 to 197) the ges rnged from 17 to 9 yers; 1 occurred in the hnd distl to the wrist, nd 13 in the foot distl to the trsus. Of the 1 hnd cses, hd soft tissues lone involved (i.e., tendon sheths),. the metcrpls nd 3 the phlnges. Of the 13 foot cses, 3 hd soft tissues solely involved, 6 the mettrsls, nd the mettrsl-phlngel joints. There were ii mles nd 12 femles (Tble I). PATHOPHYSIOLOGY Although it is generlly held tht skeletl involvement occurs chiefly vi the hemtogenous route, the origin nd onset of the bcillemi nd the mode of the orgnism s skeletl locliztion hve been controversil subjects nd severl slient concepts deserve mention. MODE OF LOCALIZATION Konig25 held tht osseous involvement ws due to obstructive emboli to nutrient vessels resulting in tuberculous infrcts. His tenets hve been used to explin the metphysel predilection of tuberculosis in children s long bones; i.e., since the metphysel rteries terminl brnches re very smll, bcilli tend to lodge here. Others,2 7 unble to find tuberculous plugs occluding fferent rteries in mn, ttributed the im- TABLE SITE AND SEX DISTRiBUTION OF 23 CASES OF PERIPHERAL SKELETAL TUBERCULOSIS (Distl to Crpus nd Trsus) I Totl Mle Femle Hnd Soft tissues 4 I 3 Metcrpls 3 2 I Phlnges 3 I 2 Foot Soft tissues Mettrsls Mettrsl-phlngel 4 3 I joints II 12 pired blood supply of involved res to n oblitertive endrteritis. They scribed the occlusion to n intiml thickening of loose non-tuberculous connective tissue resulting from toxic irrittion by the tuberculous process rther thn to tuberculous plug. Origin nd onset of the bcillemi hve been other points of contention. Auerbch2 3 reltes most skeletl involvement to hemtogenous dissemintion during the florid phse of the primry complex with the fte of seedings being determined by the primry s evolution. With heling nd/or encpsultion of the primry complex, there is tendency towrd resolution of skeletl foci, most heling without demonstrble residu. An occsionl focus, however, my persist, pursue n indolent course, nd become cliniclly or roentgenogrphiclly evident yers lter. The reson for locliztion of ctive disese to one re when multiple res hd been infected remins uncler. Some uthorities3 hve invoked the loci minoris resistentie theory; i.e., infected foci remin indefinitely dormnt, then, following decresed locl resistnce, such s my occur with trum or generlized debility, they re cpble of rectivtion. Others contend tht dult skeletl disese is due to spordic hemtogenous dissemintion t lter dte, either from quiescent primry or from n extr-osseous focus.

3 462 Feldmn,.Auerbch nd Johnston Jui., 1971 Skeletl lesions in most children, however, originte soon fter the primry infection. in n- event, bcteremi nd widespred implnttion must hve occurred in ny cse hving even solitry bone or joint lesion, nd smll bone involvement, like osseous tuberculosis elsewhere, is due to hemtogenous infection, whether occurring in childhood or dulthood, with widespred viscerl nd/or osseous disese, or s solitry skeletl lesion unccompnied by other stigmt of tuberculosis. ASSOCIATED PATHOLOGY Associted tuberculous foci re sought s ids in corroborting skeletl dignoses or s origins for bone lesions. The incidence of ssocited viscerl disese, however, (i.e., ctive or chronic pulmonry nd/or renl disese) vries with ge rnge nd mteril nlyzed (i.e., clinicl, roentgenologic, su r- gicl or utopsy). It hs been held tht osseous tuberculosis nd ctive pulmonry tuberculosis do not commonly co-exist; however, the frequency of roentgenogrphiclly dignosble ssocited disese, prticulrly of the lungs, is not esily rrived t. In Reisner s33 clinicl study, 53 per cent of i6o skeletl tuberculosis cses hd negtive lungs. Discrepncies between lower clinicl nd higher utopsy positive pulmonry sttistics my be due to the fct tht frequently terminl miliry cses were omitted from clinicl series. In ddition, picl foci were often roentgenogrphiclly unrecognized, prticulrly in the presence of perifocl emphysem. Interestingly, Reisn&3 found 2 per cent with chronic pulmonry tuberculosis, while Auerbch2 noted 19.3 per cent t utopsy. Auerbch lso found concomitnt urogenitl tuberculosis in 9 of 119 cses with skeletl disese. Among 132 other utopsies with Pott s disese,3 n ctive chronic pulmonry process ws found in 35 (26 per cent), with urogenitl lesions coexisting in 38 (29 per cent). Although deemed possible tht hemtogenous dissemintion from the lungs or urogenitl system might hve occurred, clinicl nd pthologic dt most often indicted tht the skeletl tuberculosis ws the older process. In 8o cses (66 per cent), no fresh source of hem togenon s dissemi n tion to the spine ws found; however, old pulmonry, hepne, nd splenic foci re-enforced Auerbch nd Stemmermn s3 belief tht skeletl involvement is most frequently relted to the primry complex. Among the Myo Clinic s2 27 dults with musculoskeletl tuberculosis, 3 hd clinicl evidence of cute nd io of pst pulmonry tuberculosis. Poppel et l.,3 mong I 56 skeletl cses, found 2 per cent with ctive pulmonry lesions, nd 2 per cent with coexistent genitourinry tuberculosis; 8 cses hd combined skeletl, renl nd pulmonry tuberculosis. It is not specified, however, how mny of these lesions were detected roentgenogrphiclly. Mnn27 noted history, symptoms nd bcteriologic studies to be of little ssistnce in discovering erly lung lesions mong 5 skeletl cses nd relied on roentgenogrms, 284 (#{231} per cent) of which showed ctive pulmonry infiltrtes. However, 84 per cent of positive studies were in younger ptients. He noted tht the younger the child, the more likely re primry pulmonry infiltrtes, enlrged drining medistinl lymph nodes nd bone lesions to be found simultneously. In the older child nd dult, b the time the skeletl lesion is mnifest, the pulmonry infiltrte hs heled. Therefore negtive chest roentgenogrm in the dult is of little vlue, while in the younger ge groups it csts doubt on the tuberculous nture of the skeletl lesion. Among the 3 detiled dult dctylitis cses of Poppel et l.,3 2 hd ssocited lesions; 36 yer old mle hd metcrpl nd sphenoidl wing tuberculosis, while 28 yer old mle with metcrplphlngel lesion lter mnifested lumboscrl nd pulmonry tuberculosis. A third, 62 yer old mle, hd sole metcrpl disese. Among Robins tuberculous dctylitis cses, io hd ssocited lesions, only being pulmonry. Nthnson nd

4 \OL. 112, No. 3 Tuberculous Dctvlitis in the Adult 463 Cohen29 lso commented upon infrequent ssocition of osseous nd ctive pulmonry tuberculosis, but noted the reverse to be true in their series with per cent pulmonry infiltrtion. They did not indicte, however, the number dignosed roentgenogrphiclly. Among our 23 cses, 2 of 17 ptients with roentgenogrms vilble hd evidence of ctive pulmonry disese nd i hd ctive renl nd bldder tuberculosis. MULTIPLICITY OF SKELETAL LESIONS Among the 1 dults of Nthnson nd Cohen,29 72 hd single nd 28 multiple bone involvement. Poppel et l.3 hd 12 cses with multiple osseous foci (including i with dctylitis nd sphenoid ridge involvement); io were symptomtic. Among Auerbch s2 119 cses, I prt of the skeletl system ws ffected in 86 nd 2 or more in nother 33. It hs been stted4 tht tuberculous dctylitis per se is more frequently multiple in childhood, being more often ssocited with generlized tuberculosis. Among our 23 dults, cse hd mettrsl nd i metcrpl involved (Tble ii). Of the remining 21 cses, 6 hd multiple osseous foci, none of which were peripherl, hd dctylitis s the sole lesion, while in the remining 6, this informtion ws not vilble. REPORT OF CASES CASE I. G.V., 42 yer old Puerto Ricn femle, ws seen on November 6, 1969 with the chief complint of swelling of left thumb of weeks durtion with no ntecedent trum. She hd been treted elsewhere with penicillin injections with no improvement. She hd been in prior good helth. Two siblings died of tuberculosis in childhood. Physicl exmintion reveled red, tender, fluctunt mss over the metcrpl-phlngel joint of the thumb. Aspirtion yielded 1 cc. of pus. Roen tgenogrms (Fig. i A) were interpreted s showing osteomyelitis. Intrmusculr nd orl penicillin were prescribed. Subsequent roentgenogrms (Fig. i, B nd C) showed no response to tretment. Cultures from spirtions reveled Stphylococci (cogulse positive nd negtive). Surgery on December 4, 1969, disclosed bony spicules in the soft tissues nd softened proximl phlnx. Microscopic exmintion showed grnulomtous osteitis of the tuberculous type. Stins for fungi nd cid fst bcilli (AFB) were negtive. Routine cultures grew out Stphylococci (cogulse positive), sensitive to oxicillin. The lbortory findings re given in Tble I I. An intermedite PPD ws positive. Coccidioidin nd histoplsmin skin tests were negtive. Intrvenous pyelogrphy, chest roentgen - ogrphy, nd skeletl survey were norml. Postopertively, she hd fever of 12#{176} F. which subsequently decresed to ioo#{176} F. where it remined for the durtion of her hospitl sty. She ws treted with oxicillin 6 mg. every 6 hours. On December 9, 1969 second fluctunt bscess developed over the rdil side of the bse of the left thumb which communicted with the previous ulnr-sided incision. Incision yielded 2 cc. of pus. The bscess gin extended to the bone. A guntlet cst ws pplied. Roentgenogrms (Fig. id) showed further mrked bone destruction with pthologic frctures nd sequestrtions within the proximl phlnx s well s deossifiction of the hed of the first metcrpl nd distl phlnx. Routine cultures showed no growth. Two sputum cultures, 3 urine cultures, 4 smers, nd 2 cultures from the bscess were negtive for AFB, but third bscess culture nd biopsy specimen were positive. She ws plced on triple therpy; the wound dringe grdully decresed nd she ws dischrged on Jnury 3, 197 to the Plstic Surgery Clinic. After removl of the cst on My 4, 197 there ws suggestive evidence of pseudrthrosis nd the dringe hd cesed by My ii, 197. She left the country on July 3, 197, while still on ntituberculous drug therpy, with miniml residul deformity of the thumb (Fig. if). CASE II. J.S., 21 yer old Puerto Ricn housewife, ws dmitted on Mrch 6, 1956 with the chief complint of swelling of the dorsum of the right foot for ii months. There ws no his-

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6 VOL. 112, No. 3 Tuberculous Dctylitis in the Adult 465 FIG. i. Cse I. (1) November 6, Mrked Soft tissue swelling of left thumb. r\liniml deossifiction of proximl phlnx. (B) Noember 2!, Mrked deossifiction of shft of proximl phlnx with periostel rection. (C) December?, Further progression. (D) December 15, Mrked further destruction. Note pthologic distl nd proximl frctures (rrows) nd sequestrtion. (E) Mrch 12, 1Q7. Deossifiction of ll bones, no chnge in lesion nd joint spce preservtion. tory of trum, redness or wrmth. Four months prior to dmission 2 dorsl drining sinuses developed with tenderness on weight bering. Physicl exmintion reveled circumscribed swelling, tender to pressure, over the dorsum of the right first mettrsl, with 2 sinuses of mm., drining purulent mteril. The upper sinus ws probed to depth of i inches nd the lower i inch to the bone. The lbortory dt re given in Tble I. The Mzzini test nd VDRL were negtive. Chest roentgenogrms were negtive, while those of the right foot (Fig. 2, A nd B) showed multiple lucent res within n otherwise dense first mettrsl shft. An exubernt periostel rection encircled the originl shft which ws FiG. i. (F) Residul deformity with mintennce of function. The thumb is still pposble. still distinctly evident within the involucrum. Extensive soft tissue swelling ws loclized to the first mettrsl re. There ws no evidence of deossifiction of the other bones of the foot or of the first toe. The dignosis ws chronic osteomvelitis. Cultures from the drining sinus grew out Stphylococci. Smers showed no AFB orgn isms. At surgery on Mrch 14, 1956 lrge involucrum ws found with dorsl defect involving the length of the first mettrsl. A ded core of bone surrounded by yellowish, green pus, ws lying within the involucrum. The 2 skin sinuses led directly to this window on the dorsum of the involucrum. Sequestrectomy nd excision of grnultion tissue were performed. Cultures were negtive for pyogenic orgnisms. Guine pig inocultion with mteril obtined t biopsy ws positive for AFB. Cultures nd guine pig inocultions of urine were negtive for AFB. Postopertively, she ws plced on streptomycin, PAS nd rimifon nd fitted with plster boot. A smll drining sinus closed by

7 466 Feldmn, Auerbch nd Johnston J(LY, 197! FIG. 2. Cse II. (4) Anteroposterior roentgenogrm. Generlized internl sclerosis with proximl res of rrefction nd destruction (rrow), mrked periostitis, nd extensive soft tissue swelling bout 1St mettrsl. (B) Oblique roentgenogrm. Outline of originl shft still evident within the exubernt involucrum (rrows). Note norml minerliztion of remining bones. My By August 1956 pin on weight bering still persisted. Roentgenogrms on August i6, 1956 showed some filling in of the suceriztion site of the first mettrsl with no intervl bone destruction since My I)eossitiction of ll foot nd nkle bones ws noted. Subsequent roentgenogrms showed the bony mrgins to be smoother, with no evidence of ctivity; the joint spce between the medil cuneiform nd the first mettrsl ppered prtilly obliterted lthough it ws indistinctly seen. Deossifiction persisted. She ws lst seen on July i6, CASE III. j.z., 77 yer old dibetic Hondurn mle, ws dmitted on jnury 1, 196! with the chief complint of ulcertion nd pin in n infected right foot following 3 opertions since October 196. He hd documented hypertension with 2 crdiovsculr ccidents since 1952 nd took insulin spordiclly. The lbortory dt re given in Tble ii. Urinlysis ws norml. A lrge fluctunt mss over the dorsum of the right foot dischrged wtery purulent mteril through s mm. medil sinus trct. Roentgenogrm (Fig. 3) showed multiple destructive foci t the first right mettrsl bse, old prtil hed resection for hllux vlgus nd lytic res in the clcneus, with pthologic frcture in the nterior tlus nd lternting res of rdiolucency nd incresed bone density in the other bones. An osteomyelitis ws dignosed. Prsitic or neurotrophic etiologies were considered. At surgery on Jnury 1, 1961 two bscess pockets contining thick, white pus long the medil nd lterl spects of the foot communicted with ech other nd contined necrotic bone t their depths. A cst ws pplied fter neobcin irrigtion. On Jnury 18, 1961, he hd 13#{176} F. temperture elevtion nd chills. He ws treted with erythromycin for bcteremi. Wound cultures hd reveled cogulse positive Stphylococci. Blood culture ws negtive. On Jnur 26, 196! he hd 12#{176} F. temperture.

8 OL. 112, No. 3 Tuberculous Dctvlitis in the Adult 467 A second opertion on Februry 23, 1961 drined nother fluctunt bscess below the lterl mlleolus. Rgged morphous bony frgments s well s gritty grnultion tissue were obtined. Microscopic exm in tion reveled sm ll newly formed islnds of bone s well s remnntsofnonviblebone. AFB stins showed n cid fst orgnism which ws typicl of Mycobcterium tuberculosis. Roentgenogrms of the right foot showed no chnge. Extensive destruction suggestive of osteomyelitis ws gin noted with frgmenttion in the tlus nd cuboid regions suggesting neurotrophic chnge. Dignoses of leprosy, mycetom or tuberculosis were considered; however, the microscopic exmintion nd cultures for vrious fungi were negtive. Mzzini test nd VDRL were negtive. Gstric wshings nd 3 urine cultures were negtive for tuberculosis. By Mrch 15, 1961, the bone curettings were reported s suggestive of tuberculosis nd culture ws positive for AFB. Triple drug therpy ws strted, nd by August 1961 his wounds nd sinuses hd heled. He ws dischrged on August 21, 1961 with bi-vlved cst. CASE iv. D.F., 2 yer old white femle, ws dmitted on July II, 1936 with chief complints of pin nd swelling of the right foot of months durtion. She first noted pin, swelling nd inbility to extend the left elbow with subsequent swelling of the right foot ner the first mettrsl bse. The symptoms of the left elbow disppered 3 weeks prior to dmission but those in the foot persisted, lthough pin ws noted only on pressure. There ws no history of trum, previous illness or fmilil tuberculosis. Physicl exmintion reveled rles nd slight dullness of the right pulmonry pex with tender swelling nd slight drkening of the skin over the dorsum of the right foot. The lbortory dt re given in Tble ii. Urinlysis nd Wssermnn test were negtive. Roentgenogrms of the right foot showed loclized swelling or mss, n irregulr motheten re of destruction t the medil bse of the first right mettrsl with mrked periostel rection but without joint involvement nd were interpreted s strongly suggestive of mlignncy but my be infectious (Fig. 4). 11G. 3. Cse Hi. Multiple destructive foci of 1st mettrsl bse extending medilly into mettrsl cuneiform joint (rrow). (Previous resection hed.) Mrked diphysel sclerosis of 2nd mettrsl. Fint periostel rections of 3rd nd 4th mettrsls. Mrked dorsl soft tissue Swelling, predominntly over the 1st mettrsl. Spotty deossifiction, loclized destruction nd sclerosis. Roentgenogrms of the left elbow were norml, while the lungs hd infiltrtes t both pices prticulrly on the right. She hd no cough or respirtory symptoms. Sputum nd gstric wshings were negtive for AFB. At surgery on july 22, 1936 ixi cm. defect ws found in the proximl dorsl spect of the first mettrsl through which 2X2 cm. gry, frible mss of grnultion tissue protruded. It hd heped up edges with the ppernce of n inverted mushroom. The bony cvity contined i X i cm. sequestrum nd extended proximlly nd distlly the full length of the shft but did not involve the crtilge or joint t either end. No pus ws noted. The cvity ws curetted nd filled with bone chips. Microscopic exmintion reveled tubercles, nd res of csetion surrounded by fibro-

9 468 Feldmn, Auerbch nd Johnston JULY, 197! TABLE III ADULT vs. CHILDHOOD TUBERCULOUS DACTYLITIS Chil d A dult Pthologic Frcture t I Fistul Formtion I Sequestr Formtion j Expnsion (endostel resorption) I (spin ventos) Periostel Rection I (intense) I Multiplicity dctylitis I other osseous sites I I Positive Chest Roentgenogrm I I = more frequent. I = less frequent. blstic tissue infiltrted with lymphocytes. Chest roentgenogrm on July 22, 1936 showed right picl cvittion. At no time hd cough, hemoptysis, night swets or weight loss been noted. Temperture nd blood cell count remined norml. She ws trnsferred to Seview Hospitl. ROENTGEN FINDINGS Peripherl skeletl tuberculosis my exhibit proten clinicl nd pthologic mnifesttions s well s host of roentgen mnifesttions which, in mny instnces, hve been t vrince with clssic criteri for bone nd joint tuberculosis. Roentgen findings, prticulrly in the hnds nd feet, differ somewht from those in other loci, with dditionl dult nd childhood distinctions (Tble iii). Our roentgen concept of peripherl tuberculosis, however, is lrgely bsed on its childhood mnifesttions nd, in most texts, is chiefly lluded to s spin ventos. Spin ventos, however, is merely descriptive term, spin mening spine-like process or projection, i.e., most commonly finger, nd ventos mening puffed full of ir. Although overwhelmingly ssocited with tuberculous dctylitis, this configurtion hs been described in metcrpls, mettrsls, ulne nd humeri.9 39 The term ws first used to describe swelling of bone, chiefly diphysel in children, when the mrrow becomes extensively infiltrted with proliferting tubercubus grnultion tissue, the epiphysis remining uninvolved (Fig. 7, A nd B; nd 8, A nd B). Initilly, the process is predominntly noncseting. With continued progression, the bone increses further in size with mrked spongiosl destruction (Fig. 9; 1; nd i i). With heling, the bone becomes sclerotic nd the focus of destruction develops smooth-wlled cvity. If the ltter hels, only sclerosis remins. The heling process, gin predominntly in children, my be so complete tht mere moderte increse in the bone s dimeter ttests to the prior existence of spin yentos (Fig. 12, ii nd B; nd 13, A nd B). The clssic roentgen ppernce most commonly ssocited with dult osseous tuberculosis is tht of purely destructive lesion with severe locl nd regionl bone trophy. Loss of rticulr corticl definition is chiefly due to bsorption by subchondrl grnultions with reltive lte preservtion ofjoint spce crtilge. Clssiclly, soft tissue trophy, s evidenced by decresed muscle mss nd incresed ft deposition in muscle bundle interstices nd subcutneous tissues,ws invribly sought, while n extensive destructive lesion without musculr trophy ws felt to probbly not represent tuberculosis. These hllmrks, i.e., locl osseous destruction, lte joint spce preservtion, pronounced regionl bone nd soft tissue trophy, re ll corollries of nother clssiclly chrcteristic feture, i.e., tht of slow evolution nd progression. As in other types of osteoporosis of long durtion, tht ssocited with tuberculosis ws emphsized s being homogenous in type, differing from tht seen in cute pyogenic infections which is initilly ptchy, mottled, primrily loclized to cncellous bone djcent to the growth plte nd rticulr crtilge, with subsequent more rpid joint spce involvement.39 Another frequently emphsized feture ws tht osseous tuberculosis provokes little surrounding sclerosis, which, when present, ws invribly ttributed to

10 VOL. 112, No. 3 Tuberculous Dctvlitis in the Adult 469 superimposed pyogenic infection or n infected sinus trct. Although these sttements mx be true in lrge numbers of cses, deprtures re so frequent tht they must be considered more thn exceptions to the rule. Contrry to the dictum tht osseous tuberculosis is purely or diffusely destructive, well circumscribed or punched-out pperingcvstic lesions my be encountered which vry widely in ppernce. They my occur s solitry or multiple circumscribed, rdiolu cent defects (Fig. ) confined to loclized re within, or widespred throughout the shft of single tubulr bone (Fig. 6, A nd B). Considerble bone production my develop bout these loclized rrefied res. Along with locl rective sclerosis, either fine periostel prolifertion or profuse periostel cloking bout the shft my be mnifest (Fig. 2, 4 nd B; nd ). Rective osteitis nd/or periostitis m be so profound s to simulte pyogenic osteomyelitis or mlignncy. Tu berculou s perios titis, however, s in nontuberculous infection, is nerly lwys prllel to the shft, in contrdistinction to the finer, interrupted or perpendiculr formtions more frequently seen in primry bone mlignncies. Although inflmmtory periostel rections my, t times, ssume n irregulr perpendiculr rrngement, the spicules re more frequently uninterrupted, lrger, nd corser thn those ssocited with mlignncy. Involvement of the shft second rv to neighboring joint is lso highly suggestive of tuberculosis. Joint involvement. Although roentgenogrphiclly the initil lesion m be pprecited in the bone itself, in soft tissues djcent to bone, or in joint svnovium with lter extension to bone, in the two ltter instnces the bone my originlly be imperceptibly involved. There is no unnimity of opinion s to which mode of infection predomintes, nd much futile rgument hs pssed s to the primry lesion s loction; i.e., bone vs. svnovi. In generl, the erly osseous focus nd extent of the lesion re difficult to pprecite cliniclly, roen tgeno- FIG. 4. Cse Iv. My 12, Right 1st mettrsl. Note over-ll lck of deossifiction. Loclized destruction of the proximl diphysis medilly (blck rrow). Productive chnges with profound circumferentil periostel prolifertion. Mrked loclized soft tissue swelling (white rrows). grphiclly or surgiclly, lthough this is less true in the peripherl skeleton, nd it becomes impossible, prticulrly in retrospect, to decide which cme first. Where only synovitis is pprecited roentgenogrphiclly, underlying custive bone involvement must be considered. In most cses surgicl disese is found in cncellous bone djcent to joint s well s in synovium. 6 3 The noncontcting crtilge nd bone, however, re destroyed erliest with the roentgenogrphiclly pprecited joint spce pprently preserved until lte. Sequestr, reputedly rre, my occur (Fig. i, A-E; 2, 4 nd B; nd ). When formed on ech side of joint, they stnd out s roughened, dense, cone-shped configurtions with contcting rticulr mrgins loclly preserved; i.e., kissing Sequestr. With extensive shft destruction, the entire tubulr bone my seprte s

11 47 Feldmn, Auerbch nd Johnston JULY, 1971 l ic. 5. tober 2, 193. Right,rd metcrplphlngel joint. Loclized cystic destruction of hed of 3rd metcrpl with sequestrum centrlly locted within the lytic focus (?kissing sequestrum of opposing joint surfces). Miniml soft tissue swelling. No periostitis, deossifiction or soft tissue swelling. sequestrum. This occurred in Cse ii (Fig. 2, A nd B), lthough sequestrtions re reputedlv uncommon in dults. They re, however, usully smller thn those ssocited with p ogenic infection. Often, sequestr begin to suppurte. Then new periosteum necroses (Fig. 14) nd fistule re formed, with smll bony frgments occsionllv extruding into the soft tissues.4#{176} Pthologic frctures, infrequent in childhood tu berculosis, re not u ncorn mon in dults (Fig. i, A-E). In dults, the initil periostitis my be replced by rrefied zones within the shfts with bsorption of finer cncellous structures, giving the ppernce of interrupted bone substnce, s in cses of nonunion. Further destruction nd delyed heling result in irregulr corticl erosions. It is t this stge tht pthologic frcture is most likely to occur. Since the dult lcks the regenertive power of the child s periosteum, structurl dmge leds to wekened support nd, with esy ccessibility of the prt to trum, s in the hnds nd feet, the possibility of frcture is enhnced. Another noteworthy feture in the evolution of osseous tuberculosis, contrr to clssicl thought, is the speed with which extension of the disese mx- occur. Cse i (Fig. i, A-F) illustrtes the rpidity with which roentgen chnges occur. Only occsionl references to such drmtic roentgen chnges exist. Not only disintegrtion of the involved tubulr bone, but destruction nd subluxtion of the neighboring bones nd joint my evolve with unexpected rpidity, nd m or my not be ccompnied by other roentgen stigmt of the disese; i.e., bone nd soft tissue trophy. Conversely, mrked prominence nd involvement of the soft tissues my be Fic. 6. (4) 7une 26, A 6 yer old Negro mle. Anteroposterior view. Mrked swelling of left proximl 4th finger. Centrl destruction nd subtle corticl erosions of distl metphysis nd diphysis of proximl phlnx. (B) Lterl view. Note mrked soft tissue prominence, loclized destruction nd deossifiction, bsence of periostel rection nd pprent joint spce preservtion. (Courtesy of Dr. I. Ktz, Brooklyn, N.Y.)

12 \OL. 112, No. 3 Tuberculous Dctvli tis in the Adult 471 Middle phlnx lso invblc ed. Note soft tissue swelling nd epiphysel spring. FIG. 8. (1) Child. Right hnd. Spin ventos with incresed diphysel-metphysel dimeter nd spongiosl destruction. (B) Left hnd. Note loclized diphysel periostel new bone. Old cortex clerly demrcted.

13 472 Feldmn, Auerbch nd Johnston JULY, 1971 I I(;. 9. Child. Spin ventos. Note centrl destruction nd stippling, cystic expnsion, nd epi- Ph) sel spring. noted. Fistul formtion commonly seen in the child occurred in 6 of our cses. The roentgen chnges of peripherl osseous tuberculosis, s herein defined, mx, therefore, be grouped into 4 brod ctegories : i. Soft tissue swelling. This often is mrked nd fusiform nd my be the sole mnifesttion with no pprent chnge in neighboring bones or joints nd, in children, my resolve completely. 2. Periostitis, expnsion, corticl nd cncel/ous destruction spin ventos. The erliest roentgen evidence of bone involvement in child nd dult (Fig. i, A-F), is periostitis indicted by liner deposit of new bone predominntl- involving the diphysis in the child (Fig. 8B) or ny portion of the dult smll tubulr bone. The periostitis my intensify with incresing corticl thickness nd expnsion. It my be so well defined tht the originl shft is distinctly evident within the periostel sheth of new bone (Fig. 2, A nd B; 7; nd 8B). Grdul destruction with sequestrtion of the former then occurs while the involucrum thickens (Fig. c). If much of the involucrurn s internl spects re bsorbed, cr st-like cvity remins which ppers to be bllooned out or injected with ir, the so-clled spin ventos (Fig. ; 1; nd ii). Concomitntl-, dense stippling of one or more res my be seen so tht the involved bone, in ddition to ppering twice its norml dimeter, my be of greter density, stippled nd without norml cncellous trbecule (Fig. io; II; nd i3a). The bove chnges, prticulrl in children, my resolve, the bone being so completel restored s to be indistinguish- Fic. io. Child. Spin ventos. Note bllooning of 4th metcrpl, rective osteitis, mixture of internl sclerosis nd destruction. Epiphysel spring.

14 VOL. 112, No. Tuberculous Dctylitis in the Adult 473 ble from norml (Fig. 12, A nd B; nd 13, A nd B) or much of the ffected bone my be restored leving one or two smll, firly well defined res of destruction, with or without surrounding sclerosis, which my persist chroniclly. If sequestr suppurte, the new periosteum undergoes necrosis with resultnt fistule through which smll frgments re extruded (Fig. i, A-E; nd 14). The disese my then dvnce nd destroy the neighboring joint in dults (Fig. 3), while in children growthplte nd epiphysel involvement my resuit in stunted growth s well s joint destruction. The pull on tendons exerted by contrcting grnultion tissue dds further deformity in children nd dults. 3. Diffuse uniform infiltrtions- honeycombing -(with or wi thou t)pthologicjrcture. The ffected phlnx my show miniml or moderte expnsion nd pper infiltrted throughout with n over-ll honeycombed or lce-like ppernce; i.e., the finer cncellous structures nd compct cortex re resorbed leving corser trbeculr pttern. This my be restored to norml, or frcture with resultnt deformity my occur, or lrger res of rrefction my supervene, which either remin loclized or progress to more extensive destruction with loclized sclerosis of djcent trbecule. The reminder of the shft s cncellous bone my lso become sclerotic nd the medullry cvity lmost completely obliterted. No lrge sequestrum, involucrum or fistul re noted.. Loclized destruction with rective osteitis. The end of the phlnx shows smll re of corticl or cncellous destruction often ner, nd/or involving the joint (Fig. ), but with no pprent chnge in the other prts of the bone or its neighbors. Lesions in the spongy bone re more esily seen in children thn in older osteoporotic dults whose trbecule re thinner nd frther prt. Lter, usully within month, the definition of the bone t the focus becomes very evident nd, for time, shows mrked contrst to the shft. The ltter then ppers to hve dded density. Fic. ii. Child. The proximl phlnx of the 1st toe is the site of internl destruction, expnsion nd soft tissue swelling. Further sclerosis of djcent trbecule my occur with oblitertion of the cncellous bone. Lter, osteoporosis of neighboring bones my be evident, while the lesion my hve ttrcted sufficient clcium to pper denser. The lesion my persist in chronic form with eventul generl osteoporosis of the entire digit of profound degree, so much so, in contrst to the other phlnges nd metcrpls, tht the extent of the focus in the finger my be difficult to determine. Deformity of the ffected dult finger is certin. ROENTGEN-PATHOLOGIC CORRELATION The pthologic counterprt of roentgenogrphic sclerosis erly ws ttributed

15 474 Feldmn, Auerbch nd Johnston JULY, 1971 Fic. 12. (4) Child. Involvement of the 1st metcrpl, proximl phlnx of the fourth finger nd middle phlnx of the fifth finger. (B) Four nd one-hlf months lter. Almost complete resolution nd norml ppernce t ll sites. (Courtesy of Dr. I. Ktz, Brooklyn, N.Y.) to impired blood supply due to oblitertive endrteritis) The involved ded bone roentgenogrphiclly ppers either of norml or incresed density due to lck of resorption in the former cse or subsequent rective osteitis nd reclcifiction in the ltter.3#{176} Auerbch nd Stemmermn demonstrted productive chnges in vertebrl u tops- specimens which, during life, showed extensive incresed density roentgenogrphicll nd noted 2 pthologic types of osseous tuberculosis to explin observed roentgen vritions; i.e., the productive or sclerotic form nd the destructive, cseous or exudtive form. Grossly, in the productive form, the bone is firm throughout, mintining morphologic integrity despite totl vertebrl body involvement. Microscopicll, there is no ctul destruction but rther trbeculr bsorption ;3 i.e., tu berculous grnultion tissue, which fills the mrrow spces, erodes neighboring trbecule leding to bone troph. Residul trbecule re ccentuted resulting in the over-ll corsened (T-pe 3) trbeculr pttern. Smll res r. of csetion, wlled off from the trbecule by productive elements, my or my not be present. Bone density, therefore, vries with the mount of grnultion tissue nd cseous mteril within the mrrow interstices s well s with the mount of rective osteitis present. Axil lesions of this type re extremely difficult to delinete roentgenogrphicl1\; i.e., the intermingling of destructive nd rective processes my blnce ech other so effectively s to prevent roentgen detection of extensive bone dmge. These subtleties re more redily pprecited in the peripherl skeleton, however. In the exudtive form, lrge res of csetion hve completely destroyed norml bony rchitecture. Sclerosis due to rective osteitis or periostitis s well s clcifiction is miniml or bsent. Mrked softening of bone, trbeculr resorption nd csetion leding to suppu rtion nd liquefction, through digestion by polymorphonucler proteolytic enzymes, develop. Abscesses so formed dissect towrds the skin forming fistule which extend for vn-

16 VOL. 112, No. 3 Tuberculous Dctylitis in the Adult 475 FIG. 13. (4) Child. Miniml involvement of 1st metcrpl with more obvious mnifesttion t 4th metcrpl nd proximl phlnx. (B) Four nd one-hlf months lter. Complete roentgen resolution. ble distnces with sinus rmifiction lwys greter thn cn be cliniclly pprecited from the size of sinus opening or mount of dischrge. Abscess formtion, in ddition to bony frgmenttion, my result in peniostel stripping nd periostitis t slowly progressive pce. However, with sudden stripping of periostel elements, devsculniztion nd bone deth my occur without obvious roentgen chnge; i.e., still grossl intct bone if rpidly deprived of blood supply remins inert without chnge in specific grvity upon which the roentgen ppernce is dependent.5 6 3#{176} Therefore, vried pthologic events result in vried roentgen findings, explining why, in some instnces, productive chnges predominte with little or no evidence of destruction. In some instnces, insidious onset nd bsence of pin-clssic clinicl fetures of osseous tuberculosis-were responsible for the dvnced stte of disese before dvice ws sought. Pthologiclly, this is relted to locl denervtion by perineurl fibrosis to neurl compression by cseous msses nd to ctul destruction of nerves pssing through disese res. Periostel stripping lso cuses loss of innervtion s well s blood supply. DIFFERENTIAL DIAGNOSIS Since dult tubenculous dctylitis is rrely reported, roentgen criteri re difficult to estblish nd severl simultors require differentition. Syphilitic dctyli tis is probbly the most difficult to exclude. In infnts nd children it tends to be bilterllv symmetric nd, unlike tuberculosis, usully not ssocited with soft tissue swelling or sequestrtion. The periostitis my be s, but is usully more pronounced thn, in tuberculosis. Syphilitic bone is incresed in bredth principlly by deposition of subperiostel new bone with little influence from internl expnsion. There is, therefore, greter density to syphilitic hone with less evidence of necrosis.7 37 Evidence

17 476 Feldmn, Auerbch nd Johnston JULY, ic. 14. Child. Profuse periostel rection with lterl cortex interrupted, sequestrtion nd soft tissue swelling. Note rective osteitis rther thn deminerliztion. of syphilis elsewhere, prticulrly in the long bones, rre occurrence in tuberculosis, is helpful. Smll tubulr bones re fvorite site for enchondrom s which m) produce loclized or generlized expnsion, simulting spin ventos. Fibrous dysplsi too my present s hicent re with or without trbecultion, expnsion or sclerotic demrction. In the former, islnds of clcium within the defect suggest its chondrorntous nture, there is no periostitis nd the cortex, lthough ttenuted, is uniformly thinned. In the ltter, typicl stigmt, i.e., cf#{233} u lit spots nd precocious femle pubert\ s well s involvement of other bones, my be helpful. There is soft tissue swelling ssocited with either lesion. Fibrous dvsplsi, when polvostoti C, poses no differentil problem long with other generlized skeletl diseses which m\ be mnifest in the smll tubulr bones. Thus, rickets, scurvy, hyperprth y roidism, osteopetrosis, Pget s disese, leukem i nd crcinom tosis usu lly produ ce chrcteristic roentgenogrphic ppernces simultneousl elsewhere. The mnifesttion of cute pvogenic osteom elitis m be ssocited with obvious infection or trumtic custion nd with more rpid sequestrtion, rthritis nd clinicl signs of sepsis. Pyogenic rticulr lesions secondry to osseous foci re much less common thn isolted pyogenic osseous foci, perhps due to the growth plte serving s brrier to extension. Conversely, wi th tu berculosis, concomitnt joint involvement is much more common thn purely osseous focus.39 Therefore, tu berculosis is repu tedly more commonly ccompnied by joint involvement thn is pyogenic osteomyelitis. Although bony nd fibrous nkylosis m occur in both p\ ogenic nd tuberculous rthritis, both re more common in the former, while fibrous nkylosis is more common in the ltter unless secondry pyogenic infection supervenes. Mycetom (m du rom ycosis), leprosy nd yws in nonendemic res m) be mistken for tuberculous dctylitis, but re usully polvostotic with numerous soft tissue stigmt. Mdur foot is preceded by locl injury, whereby the fungi re introduced into the skin nd subcutneous tissues. The highest incidence is found in tropicl climtes where no shoes re worn. Yws, too, hs predilection for tubulr bones of the hnds nd feet; however, infected nil beds, multiple joint deformities nd nkylosis re common. Fcil involvement in yws nd leprosy, nd peripherl nerve clcifiction in leprosy re distinguishing fetures. The infectious grnuloms, i.e., coccidioidomvcosis, blstomycosis, mvcobcterium other thn tuberculosis nd other fungl infections my involve bone nd exhibit destruction s well s new bone formtion However, lthough the solitry bone lesion is prcticlly indistinguishble from tuberculosis, when multiple, distinguishing fetures in other skeletl res my be evident. There is peculir tendenc for certin grnuloms, i.e., cocci-

18 VOL. 112, No. 3 Tuberculous Dctylitis in the Adult 477 dioidomycosis, ctinomycosis nd torulosis, to ffect bony eminences such s the olecrnon, mlleolus nd ptell.35 Coccidioidomycosis is predominntly destructive lesion with rective osteitis observed chiefly with heling or chronicity, while blstomycosis is virtully lwys iiestructive with sequestrtion common nd new bone formtion extremely rre.2#{176}a history of infection in n endemic re, positive rections to skin nd complement fixtion tests, nd tissue cultures my be helpful. Brucellosis is encountered chiefly in countries with unpsteurized milk nd is rre in this country without n occuptionl history of niml husbndry.e Osteoporosis is lso less common thn tuberculosis. Osseous torulosis nd echinococcosis re, in generl, nd in the peripherl skeleton in prticulr, rrities with the ltter exhibiting tendency towrds destructive expnsile cyst-like lesions with frequent corticl perfortion nd soft tissue msses. Usully, the mount nd chrcter of the bony rection re durtion-dependent with the erly nd rpidly spreding lesions tending towrds destruction without bone production or endostel sclerosis, while the chronic lesions re usully better circumscribed with mrginl sclerosis nd mixed sclerotic ppernce. In generl, the most common resons for not entertining the dignosis of peripherl skeletl tuberculosis include: (i) Atypicl bone lesions- clssic roentgen criteri were bsent (2) Unusul loci-the lesion ws not locted in common site, i.e., the spine, knee nd hip ccount for over 7 per cent of dult foci (,) Lck of pulmonry roentgen findings (4) Superimposed secondry pyogenic infections () Absence of drining sinus trcts commonly ssocited with tuberculosis (6) Cultures nd smers from bove (if present) most commonly yielded stphylococci or streptococci rther thn cid fst bcilli (7) Norml white blood cell nd differentil counts. In ddition, subtle evolution combined with fr-dvnced chnges when first seen in some cses cused initil dignoses to include neuropthic chnge, neoplsm or pyogenic osteomyelitis. Once the correct dignosis is considered, further dely cn occur in its confirmtion. As noted, the white blood cell nd differentil counts re usully not too helpful, lthough the erythrocyte sedimenttion rte is significntly elevted. Smers from sinus trcts my be misleding nd preopertive cultures of spirtes, which do not include tissue, re often sterile or yield secondry pyogenic invders. Biopsy is the finl dignostic procedure nd tissue should be submitted for culture s well s for histologic study. The surgicl specimen my be the only one to produce tubercle growth on culture. 9 An dditionl fctor in the filure to dignose tuberculosis is ttributble to its decresed incidence in this country. Nevertheless, the cses presented s well s review of the literture reflect the need for entertining the dignosis. Tuberculosis of bones nd joints, lthough decresing in incidence, is still the most common grnulomtous bcteril rthritis nd, t the Myo Clinic, ws seen more frequently thn brucellosis, mycobcteril infections other thn tuberculosis nd fungl infections. Other reports lso suggest tht the nture of osseous tuberculosis my be chnging, with lesions occurring in unusul loctions nd with pek incidence occurring in n older ge group thn is ordinrily ssumed. Erly dignosis, prticulrly in dults, is of tntmount importnce. If the bone or joint is not extensively dmged, surgery, including synovectomy combined with specific ntimicrobil therpy, hs n excellent

19 478 Feldmn, Auerbch nd Johnston JULY, 1971 chnce of rresting the disese nd preserving useful function, prticulrly in nonweight bering res. summary Tuberculou s dctvli tis, lthough most frequently encountered in children, lso occurs in dults in whom its roentgen mnifesttions hve not been sufficiently emphsized. The evolution of the disese is often subtle with fr dvnced chnges present in some cses when first seen. Tuberculosis of bones nd joints, lthough decresing in incidence, is still the most common grnulomtous bcteril rthritis, with pek incidence occurring in n older ge group thn is ordinrily ssumed nd with lesions occurring in unusul loctions. An nlysis of our experience with 23 cses of dult tuberculosis distl to the trsus nd wrist is presented with brief review of the literture nd n emphsis on heretofore in frequently stressed roentgen chnges. Fried Feldmn, M.D. Columbi-Presbyterin Medicl Center 622 W. i68th Street New York, New York 132 REFERENCE5 i. A-roi-ioii, G. M. Autoplstic bone grft in tretment of spin ventos. Bull. e mem. Soc. Piemon. di chir., 1935,5, 1 i8o-i AUERBACH,. Tuberculosis of skeletl system. Qurt. Bull. Seview Hosp., 194!, 6, AUERBACH,., nd STEMMERMAN, M. G. Roentgen interprettion of pthology in Pott s disese. AM. J. ROENTGENOL. & RAD. THERAPY, 1944, 52, BILLRoTH, T., nd MENZEI., A. Uber (lie H#{228}ufigkeit der Cries in (len verschiedenen Knochen. 4rch.f. KIm. c hir., 1871, 12, Boswoio i-i, D. M. Tretment of tuberculosis of bone nd joint. New York 4cd. Med. Bull., 1959,35, BOSWORTH, 1). M. Modern concepts of tretment of tuberculosis of bones nd joints. Ann. New York Acd. Sc., 1963, zo#{243}, 98-I BRAILSFORD, J. P. The Rdiology of Bones nd Joints. Fifth edition. J. & A. Churchill, Ltd., London, BRENNER, I. Uber klinisch ltent Wirbeltuberkulose. Frnkfurt. Ztschr. f. Pth., i 97, I, I. 9. CAFFEY, J. Peditric X-Ry Dignosis. Fifth edition. Yer Book Medicl Publishers, Inc., Chicgo, CARPENTIER, C., nd HAYEM, A. Tuberculous osteorthritis of index finger in dult. Prt. me d.frnc., , 1, I i6-i 167. II. CLEVELAND, M., nd BoswoRTH, D. M. Pthology of tubercuiosi of spine. 7. Bone & Tfoint Surg., 1942, 24, EDIKEN, J., DEPALMA, A. F., MosKowl-rz, H., nd SMYTHE, V. Cystic tuberculosis of bone. C/in. Orthoped., i 963, 28, i 63- I GHORMLEY, R. K. Pthologic chnges in diseses of joints. AM. J. ROENTGENOL. & RAD. THERAPY, 1933, 29, GIRDLESTONE, G. R. Tuberculosis of Bone nd Joint. Oxford University Press, New York, 194, Is. HARDY, J. G., nd HARTMANN, J. R. Tuberculosis dctylitis in childhood: prognosis. 7. Pedit., 1947,3, i6. HEATH, P. M. Cse of tuberculous dctylitis. Proc. Roy. Soc. Med., , 54, HEILE, B. Uber die tubercul#{246}sen Knocheninfrcte; Pthologischntomische Arbeiten in Orth s Festschrift. August Hirschwld, Berlin, 193, pp i8. HERZFELD, G., nd TD, M. D. Tuberculous dctylitis in infnts. Arch. Dis. Childhood, 1926, I, 295-3!. 19. HUNT, D. D. Problems in dignosing osteorticulr tuberculosis. 7.I1.M.A., 1964, 19, JACOBSON, H. Personl communiction. 2!. KELLY, P. J., nd KARLSON, A. G. Musculoskeletl tuberculosis. Myo C/in. Stff Proc., 1969, 44, KELLY, P. J., KARLSON, A. G., WEED, L. A., nd LIPSCOMB, P. R. Infection of synovil tissues by mycobcteri other thn Mycobcterium tuberculosis. 7. Bone & 7oint Surg., 1967, 494, KELLY, P. J., MARTIN, W. J., SCHIRGER, A., nd WEED, L. A. Brucellosis of bone nd joints: experience with thirty-six ptients. 7.A.M.A., 196, 574, KELLY, P. J., WEED, L. A., LIPSCOMB, P. R., nd DRUBE, C. Infection of tendon sheths, burse, joints nd soft tissues by cid fst bcilliother thn tubercle bcilli. 7. Bone & 7oint Surg., 1963, 454, K#{246}NIG, F. Die Tuberkulose der Menschlichen Gelenke Sowie der Brustwnd und des Sch#{228}dels. August Hirschwld, Berlin, LAFOND, E. M. Anlysis of dult skeletl tuberculosis. 7. Bone & 7oint Surg., 1958, 44,