Rosen & Barkin's 5-Minute Emergency Medicine Consult (237 page)

Rifampin can be used to treat pregnant women with ehrlichiosis. When life-threatening disease is present, doxycycline may be considered.

FOLLOW-UP

• Significant comorbidities/severely affected
  
• Cannot take PO antibiotics
  
• Immunosuppressed patients
  
• E. chaffeensis
  (HME) has a case fatality rate up to 3%.
  

• Healthy appearing
  
• Symptoms typically last 1–2 wk; recovery occurring without sequelae.
  
• Long-term neurologic complications have been reported.
  

Severe disease or presence of complications

• American Academy of Pediatrics. In: PickeringLK, Baker CJ,Kimberlin DW, et al., eds.
  Red Book: 2009 Report of the Committee onInfectious Diseases
  . 28th ed. Elk Grove, IL:AAP, 2009.
  
• Bakken JS, DumlerS. Human granulocytic anaplasmosis.
  Infect Dis Clin NorthAm.
  2008;22:433–448.
  
• Edlow JA.
  Bull’s Eye: Unraveling the MedicalMystery of Lyme Disease
  . 2nd ed. New Haven, CT:Yale University Press, 2004.
  
• Olano JP, Walker DH. Human ehrlichioses.
  Med Clin North Am
  . 2002;86:375–392.
  
• Ramsey AH, Belongia EA, Gale CM, et al. Outcomes of treated human granulocytic ehrlichiosis cases.
  Emerg Infect Dis
  . 2002;8(4):398–401.
  
• Schutze GE, Buckingham SC, Marshall GS, et al. Human monocytic ehrlichiosis in children.
  Pediatr Infect Dis J
  . 2007;26:475–479.
  
• Stone JH, Dierberg K, Aram G, et al. Human monocytic ehrlichiosis.
  JAMA
  . 2004;292:2263–2270.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Lyme Disease
  
• Rocky Mountain Spotted Fever
  
• Tick-borne Diseases
  

CODES

• 082.40 Ehrlichiosis, unspecified
  
• 082.41 Ehrlichiosis chafeensis [E. chafeensis]
  
• 082.49 Other ehrlichiosis
  

BASICS

• Supracondylar fracture:
  
  • Most common in children
    
  • Peak ages 5–10 yr, rarely occurs >15 yr
    
  • Extension type (98%):
    F
    all
    o
    n
    o
    ut
    s
    tretched
    h
    and (FOOSH) with fully extended or hyperextended arm:
    
    • Type 1: Minimal or no displacement
      
    • Type 2: Slightly displaced fracture; posterior cortex intact
      
    • Type 3: Totally displaced fracture; posterior cortex broken
      
  • Flexion type: Blow directly to flexed elbow:
    
    • Type 1: Minimal or no displacement
      
    • Type 2: Slightly displaced fracture; anterior cortex intact
      
    • Type 3: Totally displaced fracture; anterior cortex broken
      
• Radial head fracture:
  
  • Usually indirect mechanism (e.g., FOOSH)
    
  • Radial head driven into capitellum
    

• Elbow dislocation:
  
  • 2nd only to shoulder as most dislocated joint
    
  • Most are posterior.
    
• Medial/lateral epicondylitis:
  
  • Overuse injuries usually related to rotary motion at elbow
    
  • Involving attachment points of hand and wrist flexor/extensor groups to elbow
    
  • Plumbers, carpenters, tennis players, golfers
    
  • Pain made worse by resisted contraction of particular muscle groups
    

• Subluxed radial head (nursemaid’s elbow)
  
• 20% of all upper extremity injuries in children
  
• Peak age 1–4 yr; occurs more frequently in females than males
  
• Sudden longitudinal pull on forearm with forearm pronated
  

• Mechanism aids in determining expected injury.
  
• Trauma predominates.
  
• Most elbow injuries caused by indirect trauma are transmitted through bones of forearm (e.g., FOOSH)
  
• Direct blows account for very few fractures or dislocations.
  

DIAGNOSIS

How patient carries arm may give clues to diagnosis.

Supracondylar fracture:

• Flexion type:
  
  • Patient supports injured forearm with other arm and elbow in 90° flexion.
    
  • Loss of olecranon prominence
    
• Extension type:
  
  • Patient holds arm at side in S-type configuration.
    

• Elbow dislocations:
  
  • Posterior: Abnormal prominence of olecranon
    
  • Anterior: Loss of olecranon prominence
    
• Radial head subluxation:
  
  • Elbow slightly flexed and forearm pronated, resists moving arm at elbow
    
• Medial/lateral epicondylitis:
  
  • Gradual onset of dull ache over inner/outer aspect of elbow referred to forearm
    
  • Pain increases with grasping and twisting motions.
    

• Radiographs
  
• Assess wrist and shoulder for associated injury.
  
• Evaluate neurovascular status of limb.
  
• Assess skin integrity.
  
• Examine for compartment syndrome, which is more common in supracondylar fractures.
  

None specific for elbow injuries

• Not usually necessary if overuse injury suspected
  
• Routine anteroposterior (AP) and lateral; add oblique for assessment of subtle injuries to radial head/distal humerus.
  
• Fat pad sign:
  
  • Seen with intra-articular injuries
    
  • Normally, anterior fat pad is a narrow radiolucent strip anterior to humerus.
    
  • Posterior fat pad is normally
    not
    visible.
    
  • Anterior fat pad sign
    indicates joint effusion/injury when raised and becomes more perpendicular to anterior humeral cortex (sail sign).
    
  • Posterior fat pad sign
    indicates effusion/injury:
    
    • In adults, posterior fat pad sign without other obvious fracture implies radial head fracture.
      
    • In children, it implies supracondylar fracture.
      

• Fractures in children often occur through unossified cartilage, making radiographic interpretation confusing.
  
• A line drawn down the anterior surface of humerus should always bisect the capitellum in lateral view.
  
• If any bony relationships appear questionable on radiographs, obtain comparison view of uninvolved elbow.
  
• Suspect nonaccidental trauma if history does not fit injury.
  
• Ossification centers: 1st appear:
  
  • Capitellum: 3–6 mo
    
  • Radial head: 3–5 yr
    
  • Medial epicondyle: 5–7 yr
    
  • Trochlea: 9–10 yr
    
  • Olecranon: 9–10 yr
    
  • Lateral epicondyle: 9–13 yr
    

• Sprain/strain
  
• Effusion
  
• Contusion
  
• Bursitis
  
• Arthritis
  

TREATMENT