Musculoskeletal problems account for an estimated 3.5 million emergency department (ED) attendances each year. More patients will consult their general practitioner (GP) or treat the problem themselves. Most of these conditions (sprains, bruises, and aches) will be self limiting, requiring clinical diagnosis, and straightforward treatment and advice. However, there are diagnostic dilemmas facing the practitioner on the “front line”. Even simple injuries often need hospital assessment, usually for radiographs. Some problems are rare but important to diagnose if life threatening or limb threatening problems are to be avoided. The skill is to recognise those conditions where urgent referral and treatment are required. The aim of this series is to arm the practitioner with these skills (see box 1). Major trauma is not covered in this article.

PRIMARY SURVEY

Primary survey positive patients

Musculoskeletal injuries will rarely lead to a primary survey positive patient, except in major trauma. There are however immediately life threatening problems that might mimic a musculoskeletal condition. These pose a trap for the unwary and are listed below.

• Leaking abdominal aortic aneurysm (AAA) presenting as back pain

• Aortic dissection presenting as inter-scapular pain

• Perforation/peritonitis presenting as shoulder tip pain

• Acute myocardial infarction (MI) presenting as shoulder or arm pain

A high index of suspicion and assessment of the ABCs can help identify these important conditions. A careful …