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
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.
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 malleolus, evidenced ...