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9 Assessment and care of musculoskeletal problems
  1. C R FitzSimmons1,
  2. J Wardrope2
  1. 1Accident and Emergency Department, Sheffield Children’s Hospital, Sheffield, UK
  2. 2Accident and Emergency Department, Northern General Hospital, Sheffield, UK
  1. Correspondence to:
 Mr C R FitzSimmons
 Accident and Emergency Department, Sheffield Children’s Hospital, Western Bank, Sheffield S10 2TH, UK;

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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.

Box 1 Objectives of this article

  • The recognition of life threatening or limb threatening problems

  • The identification of those patients requiring obvious hospital transfer

  • The principles of a secondary survey relevant to musculoskeletal problems

  • Differentiation between injury and non-injury presentations

  • Differential diagnoses in non-injury musculoskeletal problems including pitfalls

  • Follow up arrangements

An overview of the following will be included

  • Functional anatomy

  • Forces causing injury and the injury spectrum

  • Indications/regulations for radiographs

Specific conditions to be covered

  • Back pain

  • Neck pain

  • Rib injury

  • Degenerative disease/osteoarthritis

  • Hot joints


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 …

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  • * Examples include shoulder pain due to irritation of the diaphragm or knee pain due to hip pathology.

  • * Fall from a height above one metre, fall from five or more stairs; axial load to the head such as diving or contact sports; RTA at high speed, roll over of vehicle, or ejection of patient; RTA involving bicycle or recreational vehicle; rear end shunt by a bus, vehicle at high speed, or where car has been shunted into oncoming traffic; in young children have a lower index of suspicion in falls.

  • Funding: none.

  • Conflicts of interest: none declared.