A history of a traumatic event with physical examination findings of a painful extremity or body part with swelling, obvious deformity, or the inability to use the extremity all suggest a significant musculoskeletal injury Less severe injuries may be more difficult to diagnose as they may present with only mild swelling or a history of not using the extremity normally For long bone injuries, the joints above and below the injured extremity must be examined for possible associated injuries Triage Considerations Children presenting with significant pain or with a grossly deformed extremity should be evaluated immediately by the emergency clinician A focused neurovascular assessment should be performed Those children with a more subacute presentation (e.g., trauma occurred the day prior), and those with minimal pain may be seen less urgently Clinical Assessment The injured extremity should be inspected for swelling and deformity, and the joints above and below the injury should be examined The skin should be examined for ecchymosis, abrasions, lacerations, soft tissue defects, or exposed bone If an open wound is present, the location, degree of contamination, and rate of active bleeding should be documented The neurovascular status should be determined by examining the motor and sensory function distal to the fracture site The pulses should be palpated and capillary refill assessed Management Imaging In addition to the physical examination, the history and knowledge of the most common injuries for a specific age group can guide the choice of radiographic studies The radiographs should generally include the joints proximal and distal to the fracture, particularly when examination may be limited by pain or immobilization At least two views taken at 90 degrees to one another (i.e., anteroposterior and lateral views) should be obtained When routine views not identify a fracture, but clinical suspicion is high, oblique or other additional views may be useful With the degree of normal variability, especially with the immature bone, comparison views of the contralateral extremity may be helpful to determine if a radiographic finding is a traumatic injury, developmentally normal, or an anatomic variant In addition to plain radiography, advanced imaging may be indicated for further evaluation of the injury For complex, intra-articular, or spine injuries,