Rosen & Barkin's 5-Minute Emergency Medicine Consult (540 page)

• Patients with a stable injury, in an appropriate splint, may be discharged for orthopedic follow-up and possible repeat imaging in 1 wk time.
  

• Rotational deformity may not be apparent if finger is straight, exam under flexion is required.
  
• Jersey finger (FDP tendon rupture) is often misdiagnosed as a “jammed” or sprained finger, but requires more urgent management than these minor injuries.
  
• Always check for stability postreduction by having patient perform active range of motion and checking a postreduction x-ray.
  

• Oetgen ME, Dodds SD. Non-operative treatment of common finger injuries.
  Curr Rev Musculoskelet Med.
  2008;1:97–102.
  
• Okike K, Bhattacharyya T. Trends in the management of open fractures. A critical analysis.
  J Bone Joint Surg Am.
  2006;88:2739–2748.
  
• Pang HN, Teoh LC, Yam AK, et al. Factors affecting the prognosis of pyogenic flexor tenosynovitis.
  J Bone Joint Surg Am.
  2007;89:1742–1748.
  
• Tuttle HG, Olvey SP, Stern PJ. Tendon avulsion injuries of the distal phalanx.
  Clin Orthop Relat Res.
  2006;445:157–168.
  

CODES

• 816.00 Closed fracture of phalanx or phalanges of hand, unspecified
  
• 834.00 Closed dislocation of finger, unspecified part
  
• 959.5 Finger injury
  

BASICS

• Inflammation/infection of the pharynx
  
• 3rd most common complaint for physician visits
  
• 30 million cases diagnosed annually
  
• Group A β-hemolytic streptococcus (GAS):
  
  • Streptococcus pyogenes
    
  • Unusual in children <3 yr old
    
  • Cause of 20–30% of childhood pharyngitis
    
  • Bimodal incidence, highest in ages 5–7 and 12–13 yr
    
  • Cause of 5–15% of adult pharyngitis
    
  • Peak months: January–May; also at the start of the school year
    

• Viral (most common infectious cause):
  
  • Rhinovirus (20%)
    
  • Coronavirus (>5%)
    
  • Adenovirus (5%)
    
  • Herpes simplex virus (4%)
    
  • Parainfluenza virus (2%)
    
  • Influenza virus (2%)
    
  • Coxsackievirus (<1%)
    
  • Epstein–Barr virus (<1%)
    
  • Acute human immunodeficiency virus (HIV)
    
• Bacterial:
  
  • GAS (
    S. pyogenes
    [15–30%])
    
  • Fusobacterium necrophorum
    (10%)
    
  • Group C & G β-hemolytic streptococcus (5%)
    
  • Neisseria gonorrhea
    (<1%)
    
  • Corynebacterium diphtheriae
    (<1%)
    
  • Arcanobacterium haemolyticum
    (<1%)
    
  • Chlamydia pneumoniae
    
  • Mycoplasma pneumoniae
    (<1%)
    
  • Syphilis
    
  • Tuberculosis
    
• Fungal:
  
  • Candida
    (thrush)
    
• Chemical burns
  
• Foreign bodies
  
• Inhalants
  
• Postnasal drip
  
• Malignancy
  
• GERD
  

DIAGNOSIS

• Viral:
  
  • Cough
    
  • Rhinorrhea
    
  • Sore throat usually follows
    
  • Have a high suspicion for acute HIV in at-risk patients presenting with persistent pharyngitis despite treatment
    
• Bacterial:
  
  • Sudden-onset sore throat that usually precedes other symptoms
    
  • Odynophagia
    
  • Fever
    
  • Headache
    
  • Abdominal pain
    
  • Nausea and vomiting
    
  • Uncharacteristic symptoms:
    
    • Coryza
      
    • Hoarseness
      
    • Diarrhea
      

• High-risk features for a serious complication of pharyngitis:
  
  • Stridor, respiratory distress
    
  • Drooling
    
  • Dysphonia
    
  • Marked neck swelling
    
  • Neurologic dysfunction
    
• Viral:
  
  • Cough
    
  • Coryza
    
  • Rhinorrhea
    
  • Pharyngeal erythema
    
  • Gingivostomatitis
    
• GAS:
  
  • Tonsillopharyngeal erythema/exudates
    
  • Soft palatal petechiae
    
  • Beefy red, swollen uvula
    
  • Anterior cervical lymphadenopathy
    
  • Scarlatiniform rash
    
  • Uncharacteristic signs:
    
    • Conjunctivitis
      
    • Anterior stomatitis
      
    • Discrete ulcerative lesions
      
• Mononucleosis:
  
  • Mistaken for GAS due to similar presentation:
    
    • Exudative pharyngitis
      
    • Tender cervical lymphadenopathy
      
    • Fever
      
    • Rash
      
  • Other possible exam findings:
    
    • Hepatosplenomegaly
      
    • Jaundice
      
• Diphtheria:
  
  • Consider in nonimmunized patients
    
  • Airway-threatening gray pharyngeal membrane
    
  • Myocarditis (2/3 of patients); clinically evident cardiac dysfunction (10–25%)
    
  • Cranial and peripheral neuropathies (5%)
    
• Gonococcal pharyngitis:
  
  • Can be asymptomatic
    
  • Always evaluate children for sexual abuse
    
  • Recurrent episodes of pharyngitis
    

Modified Center criteria for the diagnosis of GAS pharyngitis (most widely used decision rule):

• Criteria (points):
  
  • Absence of cough (+1)
    
  • Tonsillar exudates or swelling (+1)
    
  • Swollen and tender anterior cervical nodes (+1)
    
  • Temperature >38ºC (+1)
    
  • Age in years:
    
    • 3–14 (+1)
      
    • 15–44 (0)
      
    • >45 (–1)
      
• Scoring:
  
  • <1 should not be tested or treated
    
  • 3 is associated with a risk of 28–35%
    
  • >4 is associated with a risk of 51–53%
    
• Patients with 3 criteria should receive a rapid antigen detection test (RADT)
  
• Presumptive treatment without testing has led to inappropriate use of antibiotics in about 50% of cases
  
• Some suggest that patients with a score >4 should be treated empirically without a RADT
  

• Throat culture:
  
  • Gold standard
    
  • 24–48 hr for results, will delay treatment
    
  • Necessitates contacting patient/family
    
  • Obtain when
    Gonococcus
    is suspected
    
• GAS RADT:
  
  • Results are available within 30 min
    
  • Treat all patients with (+) RADT results
    
  • Technique: Performed by swabbing the tonsils or posterior pharynx:
    
    • Avoid contact with the tongue, buccal mucosa, and lips
      
  • Sensitivity 85–95%
    
  • Specificity 96–99%:
    
    • Confirm with conventional throat culture in children/adolescents with negative RADT
      
    • Optical immunoassay is extremely accurate; negative results do not require confirmatory culture
      
• Monospot:
  
  • Detects heterophil antibody:
    
    • Sensitivity:
      
      • <2 yr old: <30%
        
      • 2–4 yr old: 75%
        
      • >5 yr old: 90%
        
  • CBC with peripheral smear: 50% lymphocytes, 10% atypical lymphocytes
    
  • Obtain rapid viral loads if HIV is suspected
    

• Lateral neck radiograph for suspected epiglottitis, retropharyngeal abscess, or foreign body
  
• Contrast-enhanced CT of the neck is useful to identify complications such as peritonsilar abscess and retropharyngeal abscess
  

• Epiglottitis
  
• Peritonsillar/retropharyngeal abscess
  
• Diphtheria
  
• Mononucleosis
  
• Lemierre disease
  
• Ludwig angina
  
• Candida
  infection
  
• Gonorrhea
  
• Acute HIV infection
  
• Acute leukemia/lymphoma
  
• Oropharyngeal cancer
  
• Foreign body
  
• Inhalants and chemical burns
  
• Postnasal drip
  
• GERD
  

TREATMENT