
Elbow Pain
Rapid Review
- Differentials
- Anterior
- Anterior capsule strain
- Biceps tendinopathy
- Gout
- Intra-articular loose body
- Osteoarthritis
- Pronator syndrome
- Rheumatoid arthritis
- Lateral
- Lateral epicondylitis
- Osteochondral defect
- Plica
- Posterolateral rotatory instability
- Radial Tunnel Syndrome
- Medial
- Medial epicondylitis
- Ulnar collateral ligament injury
- Cubital tunnel syndrome
- Posterior
- Olecranon bursitis
- Olecranon stress fracture
- Osteoarthritis
- Triceps tendinopathy
- Posterior impingement
- Anterior
- History
- Exact location of most pain
- Narrow differentials based on location
- Recent trauma
- Consider fracture, dislocation, etc.
- Play sports (tennis, golf, etc.)
- Consider lateral/medial epicondylitis
- Prolonged resting on the elbow
- Consider olecranon bursitis
- Fever/Chills
- Consider septic arthritis
- Exact location of most pain
- Physical Exam
- (+) Elbow abduction stress test or Milking maneuver
- Suggests ulnar collateral ligament injury
- (+) Hook test
- Suggests distal biceps tendon rupture
- (+) Middle finger test
- Suggests posterior interosseous nerve compression syndrome
- (+) Tinel test
- Suggests cubital tunnel syndrome
- (+) Elbow abduction stress test or Milking maneuver
- Work-Up
- Labs
- CBC, BMP, ESR, CRP
- Procedures
- Arthrocentesis (cell count, culture, gram stain, crystals, protein, glucose, lactate)
- Imaging
- Elbow X-ray series
- Labs
Pearls
- Beware the “fat pad” or “sail” sign on X-ray, suggesting an occult condylar fracture or radial head fracture that is otherwise not visible.
- Fractures in pediatric patients often occur through unossified cartilage. This makes X-rays difficult to interpret.

Knee Pain
Rapid Review
- Differentials
- Orthopedic/Trauma
- Bursitis
- Osteoarthritis
- Hemarthrosis
- Ligament tear (ACL, PCL, MCL, LCL)
- Meniscus injury
- Fracture
- Dislocation
- Infectious
- Septic joint
- Reactive arthritis
- Osteomyelitis
- Septic bursitis
- Crystalline
- Gout
- Pseudogout
- Other
- Tumor
- Deep Venous Thrombosis
- Baker’s Cyst
- Orthopedic/Trauma
- History
- Recent injury
- Consider traumatic process
- Hear a pop or snap
- Consider fractures or ligament/meniscal injury
- Fever/Chills
- Consider infectious process
- History of smoking, OCP’s, prolonged immobility
- Consider DVT
- Recent injury
- Physical Exam
- Recent injury
- Likely traumatic process
- Warm, swollen, erythematous
- Gout vs septic joint
- Recurrent knee effusion
- Suggests meniscus injury
- (+) Anterior drawer or (+) Lachman
- Suggests ACL injury
- (+) Posterior sag sign
- Suggests PCL injury
- Pain w/ Varus stress
- Suggests LCL injury
- Pain w/ Valgus stress
- Suggests MCL injury
- Recent injury
- Work-Up
- Labs
- CBC, BMP, ESR, CRP
- Procedures
- Arthrocentesis (cell count, culture, gram stain, crystals, protein, glucose, lactate)
- Imaging
- Knee X-rays (2-3 view)
- Labs
Pearls
- Knee pain can often be referred pain from the hip. Be sure to do a thorough exam across the entire extremity.
- Maintain a high index of suspicion for popliteral artery injuries following knee dislocations. Consider Ankle-Brachial Index (ABI) measurements and/or CT angiography.

Leg Pain
Rapid Review
- Differentials
- Vascular
- Deep vein thrombosis
- Peripheral artery disease
- Arterial occlusion
- Thrombophlebitis
- Infectious
- Necrotizing fasciitis
- Septic joint
- Osteomyelitis
- Musculoskeletal
- Compartment syndrome
- Fracture/sprain
- Spinal stenosis (pseudoclaudication)
- Cardiac
- Congestive heart failure (venous stasis, edema)
- Vascular
- History
- Pain w/ exertion
- Suggest PAD
- Sudden onset pain
- Suggests arterial occlusion
- History of trauma
- Consider fracture or compartment syndrome
- Fever/chills
- Consider necrotizing fasciitis, osteomyelitis, septic joint
- Shortness of breath
- Consider pulmonary embolism secondary to DVT
- Pain w/ exertion
- Physical Exam
- Homan Sign
- Suggests DVT
- Absent pulses
- Consider arterial occlusion
- Overlying warmth, erythema
- Consider cellulitis/necrotizing fasciitis
- Non-healing ulcers
- Suggests peripheral vascular disease
- Swelling/deformity
- Consider fracture/compartment syndrome
- Homan Sign
- Work-up
- Labs
- CBC, BMP, CPK, lactate
- Procedures
- ABI measurement
- If suspect vascular etiology
- Compartment pressure measurement
- If suspect compartment syndrome
- ABI measurement
- Imaging
- Ultrasound (DVT)
- Labs
Pearls
- Tibial plateau fractures on commonly missed on plain film. Perform a CT scan if you have high clinical suspicion for this injury.
- Remember the 6 P’s for acuter limb ischemia (pain, pallor, paresthesias, poikilothermia, pulselessness, and paralysis).
Deep Dive

Shoulder Pain
Rapid Review
- Differentials
- Non-traumatic/chronic
- Subacromial bursitis
- Biceps tendinitis
- Adhesive capsulitis
- Impingement syndrome
- Calcific tendinitis
- Traumatic/acute
- Shoulder dislocation
- Clavicle fracture
- Humerus fracture
- Scapula fracture
- Acromioclavicular joint injury
- Rotator cuff tear
- Biceps/triceps tendon rupture
- Septic Joint
- Referred Pain/Non-orthopedic
- Brachial plexus injury
- Thoracic outlet syndrome
- Myocardial infarction
- Pulmonary embolism
- Axillary artery thrombosis
- Subclavian Steal Syndrome
- Non-traumatic/chronic
- History
- Recent injury
- Likely acute process
- Hear a pop/snap
- Consider fracture
- Recent seizure
- Consider dislocation
- Pain radiate to the elbow
- Consider cervical disc disease
- Clunking sound w/ overhead motion
- Labral disorder
- Recent injury
- Physical Exam
- Deformity
- Suggests dislocation/fracture
- Apley scratch test
- Suggests rotator cuff problem
- Neer’s Sign
- Suggests subacromial impingement
- Hawkin’s test
- Suggests supraspinatus tendon impingement
- Drop arm test
- Suggests rotator cuff injury
- Deformity
- Work-Up
- Labs
- CBC, BMP, ESR, CRP
- Procedures
- Arthrocentesis (cell count culture, crystals, gram stain)
- Imaging
- Shoulder X-rays (2-3 view)
- Labs
Pearls
- Consider acute coronary syndrome as a source of shoulder pain if the patient does not have a clear history of overuse or injury.
- A CT scan is usually not needed unless there is a suspicion for intrathoracic injuries as well.
Deep Dive

Wrist Pain
Rapid Review
- Differentials
- Traumatic
- Scaphoid fracture
- Hook of hamate fracture
- Distal radius fracture
- Scapholunate ligament tear
- Perilunate dislocation
- Non-traumatic
- Carpal tunnel syndrome
- De Quervain tenosynovitis
- Ulnar neuropathy
- Radial neuropathy
- Traumatic
- History
- Fall forward on hands
- Consider distal radius or scaphoid fracture
- Fall backward on hands
- Consider injury to distal ulna, ulnar stylus, triquetrum, or lunate
- Occupational activity
- Computer based activities suggestive of carpal tunnel
- Child-care activities may cause De Quervain tenosynovitis (from lifting children repeatedly)
- Fall forward on hands
- Physical Exam
- Snuffbox tenderness
- Scaphoid fracture until proven otherwise
- Neurosensory deficit
- Warrants orthopedic consultation
- Tinnel or Phalen sign
- Suggests carpal tunnel syndrome
- Finklestein test
- Suggests De Quervain tenosynovitis
- Snuffbox tenderness
- Work-up
- Labs
- None usually needed
- Imaging
- Wrist X-ray
- Labs
Pearls
- Plain films miss approximately 40% of all scaphoid fractures. If you suspect this injury, the patient must be splinted (thumb spica) and referred to orthopedics.
- Scapholunate dissocations are the most commonly missed ligament injury of the wrist. The “Watson test” on physical exam and “clenched fist” views on X-ray can help make the diagnosis.
Deep Dive