No abstract

bRat bite fever is a rare infection usually caused by Streptobacillus moniliformis. A case of septic arthritis and possible osteomyelitis as sequelae of rat bite fever in a pediatric patient is described. CASE REPORTA 22-month-old male presented during the summer of 2011 to the emergency department of the Alfred I. duPont Hospital for Children with 2 days of upper respiratory tract symptoms followed by 5 days of fever, malaise, and a gradually worsening rash on his upper and lower extremities, including his palms and soles. The rash began to blister, and the toddler became irritable, prompting evaluation. Given his prodrome and rash, the patient was initially thought to have a viral syndrome, such as coxsackievirus. He was admitted for intravenous hydration and pain control. Initial vital signs included mild hypertension, tachycardia, and a fever to 38.0°C.Physical examination revealed a toddler in moderate distress with a tender, erythematous, pustular rash scattered on his feet (Fig. 1), ankles, and hands. No joint swelling or tenderness was initially noted; however, due to patient anxiety, examination was difficult. Initial laboratory results were unremarkable, including a white blood cell (WBC) count of 10,200/l, a hemoglobin concentration of 10.9 g/dl, and a platelet count of 217,000/l, with normal differential values, electrolytes, and urinalysis results. Blood and left-foot pustule fluid were sent for cultures. Over the next few days, his fevers persisted in the setting of a worsening rash and pain. The patient had reportedly been walking less prior to admission, which was attributed to the painful lesions on his feet, but on day 5, he refused to bear any weight and on exam was noted to have pain when his right-hip range of motion was examined. Repeat blood work revealed a WBC count of 18,100/l, a hemoglobin concentration of 10.0 g/dl, a platelet count of 523,000/l, and a neutrophilic predominance. Inflammatory markers revealed a C-reactive protein concentration of 5.4 mg/dl and an erythrocyte sedimentation rate of 94 mm/h. A repeat blood culture was drawn, a lumbar puncture was performed, and an infectious disease specialist was consulted for further evaluation. An ultrasound of the right hip was performed, which found a joint effusion, and the child was started on vancomycin and ceftriaxone for empirical bacterial coverage. Caretakers rereviewed the patient's initial history, and a physical and further discussion revealed that the family had two pet rats. Rat bite fever (RBF) quickly entered the differential.The patient was taken emergently to the operating room due to concern for septic joint, where right-hip joint aspiration revealed a cloudy, green fluid, which was sent for a cell count and culture. Given the clinical scenario and appearance of the fluid, formal open irrigation and debridement of the joint were performed. After 6 liters of irrigation, a sterile Jamshidi needle was used to aspirate the proximal metaphysis of the right femur, and the bone sample was sent for culture. The Gram stain of ...

The use of computed tomography (CT) to triage suspected scaphoid fractures is appealing because it is more readily available and less expensive than magnetic resonance imaging (MRI). Twenty-eight patients with suspected scaphoid fractures (defined as tenderness in the area of the scaphoid and initial scaphoid-specific radiographs interpreted as normal) were enrolled in a prospective protocol evaluating triage with CT. Twenty patients reached an endpoint consisting of either (1) identification of a fracture accounting for the patient's symptoms on CT or (2) normal radiographs 6 weeks or more from the time of injury. Only 2 of 28 patients (7%) were diagnosed with a nondisplaced fracture of the scaphoid waist. CT revealed an avulsion fracture of the distal pole of the scaphoid in two patients, nondisplaced fractures of the distal radius in six patients, and nondisplaced fractures of other carpal bones in four patients. Radiographs of the scaphoid taken 6 weeks or greater from the time of injury were interpreted as normal in the six patients with normal CT scans that completed the study. True scaphoid waist fractures are uncommon among patients with suspected scaphoid fractures. CT scans are useful for triage of suspected scaphoid waist fractures because alternative, less-troublesome fractures were identified in 43% of patients and no fractures were missed or undertreated. Immediate triage of suspected scaphoid fractures using CT in the emergency room has the potential to reduce unnecessary immobilization and diminish overall costs associated with treatment.

Level IV-prognostic case series.

This paper presents the results of two surveys conducted with users of a functional upper extremity orthosis called the Wilmington Robotic EXoskeleton (WREX). The WREX is a passive anti-gravity arm orthosis that allows people with neuromuscular disabilities to move their arms in three dimensions. An online user survey with 55 patients was conducted to determine the benefits of the WREX. The survey asked 10 questions related to upper extremity function with and without the WREX as well as subjective impressions of the device. A second survey used a phone interview based on the Canadian Occupational Performance Measure (COPM). Parents rated their child's performance and satisfaction while partaking in important activities both with and without the exoskeleton device. Scores were assessed for change between the two conditions. Twenty-five families responded to this survey. Twenty-four out of 25 subjects reported greater levels of performance and satisfaction when they were wearing the WREX. The mean change in performance score was 3.61 points, and the mean change in satisfaction score was 4.44 points. Results show a statistically significant improvement in arm function for everyday tasks with the WREX.