Musculoskeletal Injury Evaluation and Management
Structured assessment
Use a consistent sequence: history mechanism, observation, palpation, range of motion, strength, neurovascular status, then special tests. Mechanism narrows the differential - valgus contact suggests medial knee injury, a planted foot with rotation suggests meniscal or ligamentous damage, and a pop with immediate swelling suggests hemarthrosis. Document neurovascular status before and after any reduction or splinting.
Special tests and their limits
No special test is definitive. Lachman is the most sensitive test for ACL rupture; the anterior drawer is less sensitive acutely. McMurray and Thessaly help with meniscal pathology but have modest accuracy. Apprehension testing is more useful than sulcus sign for anterior shoulder instability. Neer and Hawkins are sensitive but nonspecific for impingement. Treat test results as probabilities that modify a pretest likelihood, not as verdicts.
Bone and growth plate issues
Know Salter-Harris types I–V and that physeal injury can occur without radiographic abnormality. Distinguish apophysitis (traction at a tendon insertion, such as Osgood-Schlatter or Sever disease) from tendinopathy. Recognize high-risk stress fractures that threaten nonunion or avascular necrosis: femoral neck, anterior tibial cortex, tarsal navicular, base of the fifth metatarsal (Jones), and medial malleolus. Low-risk sites include posteromedial tibia and second to fourth metatarsals.
Traps
Ottawa ankle rules apply to ankle and midfoot pain in defined zones with specific tenderness or inability to bear weight four steps; they do not justify skipping imaging for other complaints. Always consider compartment syndrome with disproportionate pain and pain on passive stretch.
Worked example: a footballer twists an ankle, has tenderness at the posterior edge of the lateral malleolus, and cannot take four steps. Ottawa criteria are positive, so obtain radiographs.