Tests
1st tests to order
x-rays
Test
Should be ordered initially if the clinical suspicion for fracture is very high, to rule out bony injuries.
Can be repeated in 2 weeks if symptoms do not improve with initial treatment (e.g., in wrist injury to rule out scaphoid fracture).
Result
negative
MRI
Test
Can differentiate between complete and incomplete tear with reasonable certainty. It is considered gold standard in identifying acute ligamentous injuries of the ankle.[33]
However, bear in mind that some tendon injuries can be diagnosed clinically. For example, avoid routinely ordering MRI in patients with suspected acute Achilles tendon ruptures.[32][37]
For most musculoskeletal injuries in children, do not order MRI scans (or other advanced imaging studies) until all appropriate clinical and plain radiographic exams have been completed.[34]
Result
grade 1 muscle strain: focal hyperintensity in T2 sequence; grade 2 muscle strain: hyperintensity in T2 in acute phase with muscle fiber retraction; grade 3 muscle strain: hyperintensity in T2 with bell clappers sign due to muscle fibers floating in the hematoma; grade 1 ligament sprain: focal hyperintensity in T2 sequence; grade 2 ligament sprain: hyperintensity in T2 in acute phase; grade 3 ligament sprain: hyperintensity in T2 with loss of integrity of the ligament
ultrasound for nonligament injuries
Test
Initial investigation in groin area or if close to musculotendinous junction.
In situations of nonavailability of MRI, ultrasound can be helpful.
Confirms muscle sprain and grades it.
The diagnostic reliability of ultrasound is observer-dependent and requires a skilled practitioner.[35]
Ultrasound is not useful for ligament sprains.
Result
grade 1: generalized or focal hyperechogenicity; grade 2: interruption of fibers in the echogenic perimysial striae; grade 3: muscle stump appears rounded and hyperechogenic
Tests to consider
diagnostic arthroscopy
Test
More useful in ankle and wrist injuries. Used to differentiate between incomplete and complete ligament sprain.
Result
torn ligament invaginated into the joint
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