Module 59, General Orthopaedist Level
An 8 year old boy presented with a seven month history of intermittent
right elbow pain and swelling. He stated that his discomfort first began
when his right arm was twisted by a girl who "got the best of him".
This injury was associated with pain, swelling, and loss of ROM in his
right elbow. It was initially treated with ice packs with much improvement
over the next several days. He had three subsequent episodes of pain and
swelling in his right elbow not precipitated by trauma with almost complete
resolution of pain between each occurrence. The last episode, occurring
three days ago, did not respond to ice packs and significantly limited
his elbow ROM. The patient denied history of fevers, chills, or rashes.
On physical exam, he had a marked effusion of his right elbow, and he was
holding his elbow flexed at 90 degrees. His ROM was 50-95 degrees, and
was unable to pronate or supinate his forearm. He had no local adenopathy,
and the rest of his exam was unremarkable. He did not have any other joint
swelling. Plain radiographs of his right elbow revealed a posterior fat
pad sign consistent with a joint effusion. There were no bony abnormalities
on x-ray. Lyme ELISA (on the joint fluid) result was 1:640, and the confirmatory
Western blot was positive.
Question 59A
Lyme
ELISA (on the joint fluid) result was 1:640. This is conclusive proof of
Lyme's disease.
Question 59B
This
child has no history of tick bite or rash therefore he can not have Lyme
disease.
Question 59C
If
this child has Lyme's disease he would have stage three disease which is
a common stage in which to make the diagnosis in children.
Question 59D
The
vector for Lyme's disease is the American Wood tick.
Question 59E
The
trauma in this boys history is probably completely incidental.
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