Musculoskeletal Injury Evaluation and Management
A structured exam drives musculoskeletal questions: inspection, palpation, range of motion, strength, neurovascular status, and special tests interpreted in context rather than in isolation. Know the Ottawa Ankle and Knee Rules as validated decision tools to avoid unnecessary imaging - ankle rules require pain in the malleolar zone plus bone tenderness at the posterior edge of either malleolus or inability to bear weight four steps. Knee rules hinge on age ≥55, isolated patellar tenderness, fibular head tenderness, inability to flex to 90°, or inability to bear weight.
Traps: a normal X-ray does not exclude ligamentous or meniscal injury; and a "negative" special test does not rule out pathology because sensitivity is often modest. Distinguish lateral ankle sprain (inversion, ATFL first) from syndesmotic injury (external rotation, squeeze test, higher morbidity). Recognize Achilles rupture with a positive Thompson test and a palpable gap. Shoulder: anterior dislocation presents with arm abducted and externally rotated; posterior dislocation with a locked, internally rotated arm - often missed on AP view, so get an axillary or scapular Y view.
Rule of thumb: "Treat the patient, image by rule, test to confirm." Worked example: a basketball player inverts the ankle, has lateral swelling, tenderness over the ATFL but no malleolar bone tenderness, and can bear weight - Ottawa rules negative, so no X-ray; manage with early protected weight-bearing and functional rehabilitation rather than strict immobilization.