A patient presents with redness and swelling. There had been a wound there 2 weeks before and the patient is worried about retained foreign body. Xrays are negative for foreign body. The student tells the patient “Good news! The xrays show there is no foreign body there!”


You wince a bit. Every mature clinician must know the limitations of the tools they use. I want to take a divining rod to the beach and see if it knows which direction is the ocean. If it doesn’t, that doesn’t mean the ocean is a mirage. It means the tool doesn’t work perfectly.


You clarify the student’s comments. The xrays do not show there is no foreign body. Instead they merely are negative. You manipulate the swelling and it reproduces pain. That is the hallmark of an infected foreign body (or any sharp foreign body, infected or not). Alas, anything infected hurts when you manipulate it, so this rule is not very specific.


You tell the patient there could be a foreign body there. You ask more about the history and it turns out there could be some plastic in there. Ultrasound is suggestive enough that you choose to dissect, and indeed uncover a broken piece of plastic.



-Always acknowledge the limitations of imaging studies (or any studies)

-Foreign bodies are suggested by pain with manipulation



A patient presents with a recurrent anterior shoulder dislocation. Milch fails but Spaso works. The next month she is back and the procedure feels different, with more resistance. This time Spaso fails and Milch works. Same shoulder, so what is different? Why did the efficacy reverse?


Milch’s 1938 article started with a question: why do some reductions seem impossible and then under general anesthesia they become very easy, almost going in spontaneously? It was the muscle and tendon opposition, he concluded, so his technique focused on putting the patient in the muscle neutral position overhead (hanging from a limb position). The various shoulder muscles would share equal stress and equal angles.


Milch’s idea has probably not yet been fully fulfilled – it was the idea that shoulder reduction is not about overcoming force but about untangling the humeral head from the adjacent muscles, tendons, and soft-tissues. That was the same idea that inspired Kocher.


We have all had the tough shoulder that would not go in with technique A, but after trying technique B, a second attempt with A yielded an effortless reduction. There seems to be an unlocking of the soft structures that occurs.


Now as to the unlocking. I suspect there is advantage in the difficult shoulder to running through a variety of techniques. Ideally we would know which soft structures are causing the locking, but the literature lacks consensus and I do not know to resolve that. So I run though a variety of techniques.


This is reductionistic but you can think of all techniques as the application of external rotation in different positions.


Kocher is external rotation in the adducted humerus, as are all the derivative techniques.


Milch is external rotation in the abducted elevated humerus (technically he advocated doing the external rotation on the way up).


Spaso is external rotation in the forward flexed shoulder.


Back to the bedside. Its your next shoulder attempt. The shoulder is locked in internal rotation. Your goal is to get it into external rotation. You try Kocher but there is too much resistance to external rotation. You laterally abduct to Milch and you came close but did not fully reduce the shoulder. Finally, you perform forward flexion (Spaso) which also does not work. You then go back to Kocher, which this time was successful.


Take Home Points:

-The obstruction to shoulder reduction is not bone position but soft structures

-The obstruction can apparently be unlocked through applying external rotation in various positions through the range of motion

-If your favorite technique does not work, range the shoulder, externally rotate, and try it again.

Check out for more on Milch. If the link does not work, here is the location.



A patient presents with a laceration to the flexor side of her left forefinger. The student tells you function was normal.

“How did you determine that?” you ask.

“Range of motion.”

You ask the patient to repeat the range of motion test, but this time you apply active resistance and simultaneously check the opposite side for comparison. There is significant weakness on the left compared to the right. You just discovered a partial tendon laceration and prevented an easy misdiagnosis.

Range of motion is not sufficient to rule out a partial tendon laceration. Strength testing picks up partial lacerations because some of the muscle fibers were connected to the part of the tendon that was lacerated. You can’t always visualize the laceration so this strength testing a useful part of the examination.

There are some interesting articles about this that indicate range of motion can not even be used to rule out a complete tendon laceration. A patient had complete transection of the FDS and FDP yet intact range of motion via the vincula (connections between tendons). Resisted range of motion made the diagnosis (Sasaki J Hand Surg Br 1987)

Take Home Points:

-For suspected tendon laceration, don’t just test range of motion, test resisted range of motion


A patient presents in a coma after head and face injury. You note proptosis and the CT shows retroorbital hematoma. You wonder whether you should decompress this. Normally we based decompression on visual acuity but that is not available in the comatose patient. What can we do?


Afferent pupillary defect (swinging flashlight test) may be an important finding in these patients. A recent review of 8 cases showed that it was present in 7 of the 8, and was not able to be tested in the 8th.(Sun MT EMA 2014)


Other objective findings would include firmness to palpation, which is helpful because when you decompress the eye you want to be able to confirm your procedure was effective. If the tense eye becomes soft, that is helpful. Measure intraocular pressure for an objective measure. Do not press on the eye if open globe is on the differential.


Take Home Points:

-Look for afferent pupillary defect in patients suspected of having orbital compartment syndrome

-Palpate the eye before and after decompression


A patient presents with chest discomfort after a fall from height. You suspected fractured ribs but the chest radiograph was negative. Traditionally radiographs are considered to have poor sensitivity for rib fractures. But how helpful is physical examination?


First, localize the tenderness. One can gently palpate the individual ribs through their arc. Crepitus essentially confirms a fracture, but is not expected in most patients. If the tenderness is anterior over the costal cartilage, a fracture there is not expected to be visible, as the bone in this area is “invisible” on x-ray.


The spring test argues for a fracture.  Squeeze the chest cage perpendicularly from the area of interest. For example, if there is anterior tenderness then squeeze laterally. If there is lateral tenderness then squeeze the anterior-posterior dimensions.


Have the patient take a deep breath. Although not specific, exacerbation of pain with breathing increases the probability of a fracture.


In the past, with negative x-rays we diagnosed rib contusion in patients with negative x-rays, but then told the patient that recuperation typically is the same duration. But how many of these patients had subclinical fractures?


One study of ultrasound looked at 20 patients with a clinical diagnosis of rib fractures and negative x-rays. Ultrasound confirmed fractures in 18 of the 20.(Turk EMJ 2010)


Take Home Points

-Use the AP or lateral spring test to raise clinical suspicion of rib fracture

-Use deep inspiration to increase suspicion of a rib fracture

-Consider bedside ultrasound


A patient presents with a stab wound to the neck. You examine the wound and see a 1 cm laceration. The patient reports no other symptoms. How can we best identify injuries?


Through the neck run longitudinal blood vessels, nerves, as well as organs of the respiratory and gastrointestinal systems. The mechanism is important – what is the direction of the wound tract?


Below is a template of a thorough examination of penetrating neck trauma, with more detail on pertinent items. This is based on the 1997 article by Demetriades et al.


Airway: No subcutaneous emphysema, hoarseness, or stridor, no bubbling from wound

Esophagus: No odynophagia, no pharyngeal blood, no hematemesis

Vascular: Normal pulses, no bruit, no hematoma, no active bleeding


Motor/Sensory/Reflexes normal

Cranial nerves:

II – pupils equally reactive (no Horner’s syndrome)


V – normal facial sensation

VII – symmetrical facial movements

IX – normal soft palate

X – no hoarseness/dysphonia, normal cough

XI – symmetrical shoulder lift

XII – tongue midline

Brachial plexus:

normal radial, ulnar, median function of hand

musculocutaneous – normal forearm flexion

axillary  – normal arm abduction



In penetrating neck trauma, evaluate the airway and esophagus, in addition to the vascular and neurologic functions.


A 70 year old male presents after a fall with left hip pain.  The radiologist interprets the CT scan as revealing no fracture.  The patient is able to bear weight and is discharged home.  10 days later the patient presents with persisting pain and difficulty ambulating.  A fracture is now clearly seen in the inferior public ramus.  Looking back at the prior scan, a subtle fracture was actually visible 10 days prior.  You want to make sure this doesn’t happen to you again.  Can physical diagnosis help?

The pelvis is a complex three dimensional structure, but most parts are palpable from the outside.  In fact, physical examination for fractures performs much better than x-rays, with one study showing x-rays as 79% sensitive but physical examination rising to 96% (Duane 2008).

Press over the symphysis pubis as well as compressing the bilaterally iliac crests.  Check the acetabular integrity by compressing over the greater trochanter. Palpate the sacrum.  Grab the ischial tuberosity and try to shake it, checking for fractures of the pubic rami.  By the end of this examination, you will know exactly where the patient might have a fracture.  Such vigilence is rewarded with a 98% sensitivity and 94% specificity for fractures (McCormick 2003).

Some recommend digital rectal examination for coccygeal fractures, and this certainly is reasonable if there is coccygeal pain.  The hip is brought through a full range of motion including flexion, abduction, and internal and external rotation.

Not every trauma patient needs such a detailed pelvic bone examination, but if the patient is complaining of hip or pelvic pain then dive in, knowing that a good physical examination is MUCH better than a set of x-rays.

A few weeks later you see a patient with pelvic pain after a fall, and the tenderness is maximal when you manipulate the ischial tuberosity and symphysis pubis. You look at the CT scan focusing in on the pubic rami and indeed see what you are looking for- both rami are fractured.

Take home points:

-The pelvis is an external bone and all areas of the pelvis are accessible to palpation and compression.

-A thorough physical examination is highly sensitive for fractures (Sauerland 2004).


In 2010, the total number of motor vehicle fatalities dropped to the lowest level since 1949.  Watch crash test videos for the large number of Insurance Institute for Highway Safety “top safety pick” vehicle models and you will see no cabin intrusion. That means crush injuries are less and less common each year. The kinematics of motor vehicle trauma in the emergency department are changing.

Frontal airbags prevent most of the facial fractures we used to see, side airbags prevent the rib, kidney, and skull injuries we used to see, and head restraints prevent whiplash.  Electronic stability control prevents about 1/3 of accidents from happening at all.

From a physics standpoint, momentum might be conserved but kinetic energy is not. Collisions are considered “inelastic,” meaning that the kinetic energy of the collision is converted into the “work” of deforming materials. The more the energy is absorbed by the car, the better. Otherwise the work of deformation works on the patient, whose tissues have different densities and physical properties. Here are some of the forms this can take:

-Tensile strain essentially means things are being pulled apart, like the mesentery shearing away from its origin

-Shear strain means things are separating along a line, like the sacroiliac joints shearing in the patient who jumps from a great height

-Compressive strain is direct crush

-Overpressure strain is from compression of a gas or fluid filled cavity, for example, bladder or viscus rupture

In the future we see will fewer of all types of injuries. Clinical studies should tell us what sorts of injuries we will see in the future. For now, I have seen a dramatic decrease in crush injuries to the side (rib fractures, renal contusion, splenic/liver injuries), apparently related to improved engineering of the cage of automobiles as well as because of side airbags;

Take Home Points:

Motor vehicle collision injuries are becoming less severe as cars are engineered to absorb kinetic energy.