Can’t Miss Diagnoses
- Inflammatory causes
- Open joint/Open Fracture
- Compartment Syndrome
Also, assess for soft tissue injury and /or infections which can also be very life-threatening (e.g. Necrotizing Fasciitis).
Make sure think about abuse, especially with inconsistent stories) – child abuse, domestic violence, or elder abuse.
Points to focus upon
Generally, the approach to MSK injuries will be ABCs, Look, Feel, Move:
- Look + feel for swelling, deformity, crepitus, pallor, faint or absent peripheral pulse
- Check neurovascular status (PMS: Pulse, Motor, Sensation)
- Assess bleeding/open fractures
- Active and passive ROM, if safe to do so AFTER all the above.
Key historical points are:
- mechanism of injury (high vs low energy, preceding incidents)
- associated neurological symptoms
- blood loss +vitals,
- attend to cues for non-accidental trauma
- associated injuries or medical conditions
Rule of Thumb (and Orthopods, Generally):
- Examine joint above and below fracture Investigations & radiographs as clinically indicated
- Use decision rules for lower extremity minor trauma (ankle/foot/knee) to guide your assessment (see Joint Pain Section for details).
- All x rays need at least 2 views (AP and Lateral), foot and ankle should have an Oblique/Mortise view.
Children don’t use the same words as adults and the exam must be adjusted. When assessing them for compartment syndrome ask for pain, sleepy fingers, does it feel the same on both sides, can they be distracted from the pain by objects or shows.
X rays in kids are challenging due to growth plates. If you are truly confused, x-ray the contralateral side. A junior resident tip is to also flip the image of the contralateral side so now it should look identical to the injured side when looking for injuries.
To note and document; Tetanus status, anticoagulation, surgical manipulation if any
Pain & Fever, suspect Septic joint in IVDU, DM, immunocompromised, elderly. Check WBC, CRP, Joint aspiration