Module 59, Pediatric 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
Treatment
at this stage is with oral doxycycline.
Question 59B
An
EKG should be obtained at this time.
Question 59C
Lyme's
disease has become wide spread over the whole world.
Question 59D
The
early stage of Lyme's disease may be confused with the flu.
Question 59E
Lyme's
disease affects only large joints and often involves several joints at
the same time.
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