CHAPTER 121 ■ MUSCULOSKELETAL EMERGENCIES MARK D JOFFE, JOHN M LOISELLE GOALS OF EMERGENCY CARE Nonfracture-related orthopedic emergencies often pose a diagnostic dilemma for even the most experienced clinician due to indolent courses and lack of distinguishing signs and symptoms The pediatric emergency clinician is challenged to make the diagnosis and institute early therapy as outcomes often correlate with the time to institution of treatment after symptoms begin The time to antibiotic administration and time to surgery are key goals for these disorders A systematic approach utilizing appropriate laboratory testing, imaging, and orthopedic consultation will most often detect these conditions Certain conditions such as septic arthritis of the hip must be diagnosed at the time of the initial visit so that surgical intervention combined with timely antibiotic therapy can minimize the likelihood of poor outcomes such as growth retardation or irreparable joint dysfunction When unrecognized or untreated, other orthopedic conditions may lead to prolonged pain, chronic functional disorders, or a delay in the ability to return to normal activity KEY POINTS A normal plain radiograph does not rule out significant disease or pathology Referred pain or the inability of the young child to localize pain can obscure the diagnosis Trauma is too often assumed to be the cause of symptoms when skeletal infection is present Presence of fever and significant elevations in inflammatory markers are useful when considering infectious etiologies Provocative physical examination testing is helpful in distinguishing certain overuse injuries Cultures should be obtained from the blood and potentially infected areas when there is concern for musculoskeletal infection