A Systematic Approach to the Evaluation of Acute Musculoskeletal Injuries in the Emergency Department

Musculoskeletal (MSK) complaints account for a significant proportion of emergency department (ED) visits and range from minor soft tissue injuries to fractures, tendon ruptures, dislocations, septic arthritis, and compartment syndrome. Despite their frequency, these presentations can be diagnostically challenging because of variable mechanisms of injury, overlapping examination findings, and limitations of plain radiography for detecting soft tissue and occult bony injuries. Missed diagnoses, such as Achilles tendon rupture, scaphoid fracture, Lisfranc injury, and tibial plateau fracture, may result in substantial morbidity, while excessive imaging contributes to unnecessary cost and resource utilization. This review presents a practical framework for evaluating acute MSK injuries in the ED. The approach emphasizes five core components: mechanism of injury, functional assessment, focused physical examination, targeted imaging, and disposition planning. Validated clinical decision tools, including the Ottawa Ankle and Knee Rules, are reviewed, along with the evolving role of point-of-care ultrasound in emergency MSK evaluation. High-risk injuries that are commonly missed in the ED are discussed in detail, with emphasis on recognition, imaging strategy, and early management. By applying a structured diagnostic approach, emergency physicians can improve diagnostic accuracy, reduce unnecessary imaging, and better identify injuries requiring urgent intervention or specialty follow-up.