Mycobacterium Tuberculosis infection of the wrist joint: A current concepts review

Abstract

Background: Osteoarticular Tuberculosis (TB) of wrist joint is a rare, often misdiagnosed form of site affected by Mycobacterium Tuberculosis infection that can lead to severe disability and morbidity. This review aims to summarize the current literature on the diagnosis and management of Mycobacterium Tuberculosis infection of the wrist joint.

Materials and methods: A comprehensive search strategy using the PEO (Population, Exposure, Outcome) framework was conducted on PubMed, Google Scholar, and Web of Science databases from 1967 to 2022, excluding single case reports and correspondence articles. The keywords used for the search included 'Mycobacterium tuberculosis' 'osteoarticular' and 'wrist'. Clinical presentation, demographic details, complementary investigations undertaken, trends, and complications of different management interventions were recorded to generate this review.

Results: Osteoarticular Tuberculosis (TB) of the wrist joint accounts for fewer than 1% of all skeletal TB cases across a spectrum of age ranges. Magnetic Resonance Imaging (MRI) represents an excellent modality to reveal the extent of the disease at an early stage of the condition. Synovial fluid analysis has been recommended for microbiological diagnosis. Treatment options include anti-tubercular therapy (ATT), incision and drainage, debridement, synovectomy, and arthrodesis.

Conclusion: Early diagnosis and treatment of wrist tuberculosis is crucial for achieving good functional outcomes in patients with this uncommon condition. Polymerase Chain Reaction (PCR) and GeneXpert technology for the detection of Mycobacterium tuberculosis (MTB) have improved diagnostic accuracy in detecting MTB DNA and rifampicin resistance. Anti-Tubercular Therapy (ATT) regime remains a foundation pillar in the overall management of these patients with focused surgical interventions leading to improved clinical outcomes.

Keywords: Diagnosis; Mycobacterium tuberculosis; Osteoarticular; Treatment; Tuberculosis; Wrist.

Fig. 1

(a, b) A globular swelling of 3 × 3 cm on the dorsum of the right wrist with no gross deformity and no sign of inflammation; (c) Plain radiograph of right wrist Antero-posterior and lateral view suggestive of phemister triad (joint space narrowing, diffuse osteopenia with irregular eroded radio-carpal surface), reduction in height of carpal bones and their subluxation; (d) T2 weighted Coronal and sagittal section; suggestive of osteomyelitis, synovial thickening, radio-carpal destruction, and fluid collection along the tendon sheet.

Fig. 2

(a): Clinical image showing swelling at left wrist with deformity; (b): Plain antero-posterior radiograph of wrist showing erosions, joint space narrowing with destruction of distal radio-ulna and carpals, also there is soft tissue swelling and osteopenia; (c): Plain lateral radiograph of wrist showing same finding with distal radio-ulnar joint subluxation (malalignment); (d): Non-enhanced coronal section of wrist (T2 weighted PD image) MRI showing osteomyelitis, destruction, and erosion of wrist joint.

Fig. 3

(a) Clinical image showing swollen wrist, deformity with multiple sinuses. (b) Soft tissue swelling, calcification and completely destroyed joint on radiograph.

Fig. 4

(a) Plain radiograph of wrist with hand antero-posterior shows juxtra articular osteopenia, with well aligned carpal bones; (b–d) shows patchy edema in carpal bone with synovial thickening, with intra-osseous cystic changes. There is intraarticular loculated collection with median nerve compression (arrow in figure c) due to synovial thickening.

Fig. 5

Various complications of Tb wrist documented in 16 clinical studies in the literature.

Fig. 6

Indications of surgical treatment in TB wrist patients.