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Injury Evaluation

The assessment of a patient for an injury either during a game or practice or in regard to checking the status of an old injury begins with a focused sports-oriented history and physical exam. The basic features of sports examination involve joint range of motion, muscle strength screening, palpation for discomfort, and comparison to the contralateral side. Cervical spine motion can be evaluated by asking the patient to face the examiner and look at ceiling, floor, and over shoulders, and touch ears to shoulders. Shoulder screening involves trapezius muscle strength screening by shrugging shoulders against resistance, and deltoid testing by resisted abduction of shoulders at 90°. Standing and supine shoulder external rotation at 90° of abduction can screen for motion asymmetry, or patient apprehension that may indicate shoulder instability. Evaluate elbows for tenderness or motion asymmetry with flexion and extension, and forearm rotation (symmetric palm up and palm down) with the elbows held against the torso in 90° of flexion. Resisted thumbs-up, finger spreading, and clinched fist testing can be used for peripheral nerve function screening and finger motion deficits or deformity. Lower extremity screening for gross strength and motion deficits may be accomplished by “duck walking” 4 steps away from examiner, standing from squatting position, and rising up first on heels and then toes. The examiner evaluates for symmetry in motion and muscle bulk. In a supine position, the hips are flexed and rotated to evaluate for symmetry. The quadriceps are compared in contraction, and the knees are examined for symmetric flexion and extension, ligamentous laxity (anterior/posterior drawer testing and varus/valgus testing), and the presence of an effusion (as evidenced by a mobile fluid wave at the medial and lateral patellar margins). The ankles are evaluated for symmetric flexion and extension, pain or laxity with rotation and inversion, and the presence of an effusion (as evidenced by mobile fluid at the anterior ankle joint crease).

Screening for symmetry with this basic exam allows the identification of injuries and descriptive features of findings for use in diagnosis or referral.

Many orthopedic injuries present with obvious pain and swelling. At times, decreased use of an extremity or a limp may be presenting signs. Despite communication challenges in younger children, methodical and directed palpation using this examination technique will often localize the injury. When no reasonable history of injury is present, musculoskeletal infection should also be considered with these presenting signs of pain and swelling.

Occult Fractures

Radiographs should be obtained in most cases with significant signs of injury or duration of symptoms. When bony abnormalities are not readily apparent, a close examination of radiographic soft tissue swelling may help to localize injury and redirect examination.1 In older children and adolescents, RICE (rest, ice, compression, and elevation) is appropriate for most nonbony injuries. In younger children, occult fractures are common. Common occult fracture locations are the lateral ...

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