History

The value of history taking in the case of orthopedic injuries is often underestimated. In fact, knowing the precise mechanism of injury or listening carefully to the patient's symptoms can be the key to diagnosing fractures or dislocations. For example, a history of shoulder injury combined with the complaint of dysphagia may be the only clue to the existence of posterior sternoclavicular dislocation. This entity, which causes pressure on the mediastinal structures, can often be demonstrated only by computed tomography (CT) scan and is associated with severe complications if treatment is delayed. Another example is a history of landing flat on the feet from a significant height, which should prompt the physician to consider fracture of one or both calcanei, as well as lumbar vertebral compression fracture.

History is often the only means of correctly assessing and treating young children who "just won't use the arm." Such children, who present with a seemingly paralyzed arm ("pseudoparalysis") after being pulled or yanked, may be incorrectly diagnosed as having a brachial plexus injury, when in fact the history and presentation are classic for subluxed radial head, an entity not discernible on x-ray and easily and quickly remedied by a proper reduction maneuver.

A careful history may enable the physician to diagnose posterior dislocation of the shoulder, another entity commonly missed on routine films. If the patient has (1) experienced a direct blow to the front of the shoulder, (2) landed forward on an outstretched arm, or (3) had a seizure or undergone violent muscle contraction for any other reason (e.g., contact with high-voltage current) and now complains of excruciating shoulder pain and severely limited motion, the diagnosis of posterior dislocation should be entertained. If the implications of the history are not appreciated, then the specific x-ray views needed to demonstrate the injury may never be ordered.

Table259-1 provides further examples of mechanisms that might lead the clinician to suspect, or presumptively treat for, specific injuries. This is by no means a definitive or exhaustive list. Some of the mechanisms described may produce injuries other than those mentioned. Conversely, the injuries may be produced by mechanisms besides those listed.

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