Differentials
Proximal humerus fracture
SIGNS / SYMPTOMS
There is usually shoulder and upper arm swelling and bruising.
Possibility of paraesthesias or weakness in the arm.
INVESTIGATIONS
Anteroposterior (AP) and lateral view x-rays in the scapular plane and an axillary view confirm the fracture.
Distal clavicle fracture
SIGNS / SYMPTOMS
Pain, particularly on upper extremity movement, and swelling.
After the swelling has subsided, the fracture can often be felt through the skin.
INVESTIGATIONS
AP x-ray shows fracture.
Acromioclavicular joint separation
SIGNS / SYMPTOMS
Pain is a common symptom of this injury and is usually severe.
Evidence of traumatic injury to the shoulder, such as swelling and bruising, is also commonly found.
INVESTIGATIONS
AP x-ray rules out dislocation.
If diagnosis is unclear, an x-ray taken while the patient is holding a weight in the hand may be helpful. The force of the weight accentuates any shoulder joint instability and shows the effects of the injury better.
Rotator cuff tear
SIGNS / SYMPTOMS
Shoulder pain is the most common presenting symptom.
Pain is typically aggravated by over-head activities.
Patients may also complain of functional weakness, loss of motion, night pain, and pain in the deltoid region.
Acute pain and weakness may be seen following traumatic rotator cuff rupture.
INVESTIGATIONS
AP x-ray or MRI scan rules out dislocation.
Soft tissue contusion of the shoulder
SIGNS / SYMPTOMS
Tenderness, swelling, and bruising of the shoulder.
INVESTIGATIONS
An x-ray or MRI scan rules out dislocation.
Scapula fracture
SIGNS / SYMPTOMS
Relatively rare.
Most patients present after high-energy trauma.
Typically, there is swelling, tenderness, crepitus, and bruising over the scapular region.
INVESTIGATIONS
AP, lateral, and axillary x-ray views of the shoulder/scapula show fracture.
Biceps tendon rupture
SIGNS / SYMPTOMS
Some patients report a sudden pain in the anterior shoulder during activity.
This acute pain, frequently described as sharp in nature, may be accompanied by an audible pop or a perceived snapping sensation.
INVESTIGATIONS
AP and axillary x-ray views are the most useful and rule out dislocation.
Distal humerus fracture
SIGNS / SYMPTOMS
Pain occurs with palpation or movement of the shoulder or elbow.
Swelling and bruising are usually present.
INVESTIGATIONS
AP and lateral views of the humerus, as well as trans-thoracic and axillary views of the shoulder, should be adequate to visualise a fracture.
Radial head fracture
SIGNS / SYMPTOMS
Usually presents with a history of a fall on the outstretched hand.
Localised swelling, tenderness, and decreased motion of radial head.
The wrist, especially the distal radioulnar joint, may be damaged simultaneously.
INVESTIGATIONS
Most radial head injuries can be adequately assessed with standard plain radiography of the elbow.
Coronoid fracture
SIGNS / SYMPTOMS
Usually occurs in combination with a radial head fracture.
Patients often present with a history of a fall on the outstretched hand and a deformity of the elbow.
The presence of an unstable reduction of the elbow is suggestive of an associated coronoid fracture.
INVESTIGATIONS
Radiographs of the elbow in the AP, lateral, and, if required, oblique views should be obtained to ascertain clearly the extent of bony injury.
Ulnar collateral ligament injury
SIGNS / SYMPTOMS
Medial elbow tenderness and swelling are the most notable findings.
Medial elbow pain is the most common symptom in athletes who throw.
INVESTIGATIONS
Plain x-ray or MRI scan rules out dislocation.
Monteggia fracture
SIGNS / SYMPTOMS
Depending on the type of fracture and severity, patients may experience elbow swelling, deformity, crepitus, and paraesthesia or numbness.
Some patients may not have severe pain at rest, but elbow flexion and forearm rotations are limited and painful.
INVESTIGATIONS
Views of the forearm in orthogonal planes (planes at 90° to each other) are needed with the wrist and elbow joints included.
Separate radiographs of the elbow should also be obtained to assess the proximal radioulnar joint, ulnohumeral articulation, and radiocapitellar joint.
Soft tissue contusion of the knee
SIGNS / SYMPTOMS
Patients usually state that something struck the affected knee.
On physical examination, there should not be any valgus laxity on abduction stress testing.
INVESTIGATIONS
Bony pathology can usually be distinguished from soft tissue injury with plain radiographs.
Chondromalacia patellae
SIGNS / SYMPTOMS
Softening and fissuring of articular hyaline cartilage.
Patients may report anterior knee pain, especially while climbing stairs.
Compression of the patella during flexion and extension of the knee elicits crepitation and discomfort.
INVESTIGATIONS
Over-exposed lateral x-ray of the knee.
Axillary x-ray views of the knee determine which facet is involved.
Patellar tendon rupture
SIGNS / SYMPTOMS
Palpable defect in patellar ligament.
With complete tears, patient is unable to extend the knee.
With partial tears, patient is able to extend the knee, but extension may not be full.
INVESTIGATIONS
Lateral radiograph of the knee may reveal small avulsion from the inferior patellar pole.
Quadriceps tendon rupture
SIGNS / SYMPTOMS
Usually occurs in patients over 40 years of age.
Patients typically present with acute knee pain, swelling, and functional loss following a stumble, fall, or giving way of the knee.
Obvious suprapatellar swelling, bruising, and tenderness are present.
INVESTIGATIONS
Standing AP x-ray or MRI scan rules out dislocation.
Medial synovial plica of the knee
SIGNS / SYMPTOMS
Symptoms may mimic those of a torn meniscus (e.g., snapping, clicking, and medial joint line tenderness).
INVESTIGATIONS
Standing AP x-ray or MRI scan rules out dislocation.
Anterior cruciate ligament injury
SIGNS / SYMPTOMS
Subluxation on twisting, turning, or pivoting. Some patients can feel it coming on; other patients are not able to feel it and may experience frequent falls due to their injury.
INVESTIGATIONS
Standing AP x-ray or MRI scan rules out dislocation.
Posterior cruciate ligament injury
SIGNS / SYMPTOMS
History of hyper-extension mechanism or a blow to anterior aspect of the knee.
Difficulty going down inclines, descending stairs, or running down hills.
INVESTIGATIONS
Standing AP x-ray or MRI scan rules out dislocation.
Medial collateral ligament injury of the knee
SIGNS / SYMPTOMS
Sensation of side-to-side toggle with activity.
Difficulty with twisting or turning.
Difficulty with running or pivoting.
INVESTIGATIONS
Standing AP x-ray or MRI scan rules out dislocation.
Posterolateral knee injury
SIGNS / SYMPTOMS
Sensation of side-to-side toggle of knee with activity.
Weakness of foot and ankle that may be secondary to a concurrent common peroneal nerve neuropraxia or complete injury.
INVESTIGATIONS
Standing AP x-ray or MRI scan rules out dislocation.
Meniscal tear
SIGNS / SYMPTOMS
Patients frequently complain of mechanical symptoms in the knees such as catching, giving way, locking, clicking, and popping.
On physical examination, meniscal injuries may present with quadriceps atrophy; they often have an associated knee effusion, and tenderness localised to the joint line may be present.
INVESTIGATIONS
Standing AP x-ray or MRI scan rules out dislocation.
Osteochondral fracture of the knee
SIGNS / SYMPTOMS
Patients have immediate pain and swelling of the knee at the time of injury.
They also have significant pain with weight-bearing.
The mechanism of injury usually involves a high-force, twisting injury of the knee.
INVESTIGATIONS
Diagnosis can be confirmed by an MRI scan.
Ligament avulsions of the finger
SIGNS / SYMPTOMS
Patients often experience diffuse pain, swelling, and tingling.
INVESTIGATIONS
AP, lateral, and oblique radiographs of the affected digit rule out dislocation.
Tendon avulsions of fingers
SIGNS / SYMPTOMS
Patients often experience diffuse pain, swelling, and tingling.
INVESTIGATIONS
AP, lateral, and oblique radiographs of the affected digit rule out dislocation.
Mallet finger
SIGNS / SYMPTOMS
Patients notice the inability to extend the distal joint, although full passive extension remains intact.
The dorsum of the joint may be slightly tender and swollen, but often the injury is painless or nearly painless.
INVESTIGATIONS
AP and lateral radiographs centred at the distal interphalangeal joint of the affected finger are required to rule out dislocation.
Gamekeeper's thumb
SIGNS / SYMPTOMS
A weakened ability to hold objects, decreased thumb stability (catching the thumb in objects, etc.), local swelling, local pain, and bruising.
INVESTIGATIONS
Plain x-ray or MRI scan rules out dislocation.
Femoral neck fracture
SIGNS / SYMPTOMS
No differentiating signs or symptoms. Pain may preclude weight-bearing.
INVESTIGATIONS
Femoral head fracture identified, but the femoral head remains reduced on all radiographs.
CT of the hip clearly shows the reduced hip joint.
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