Acute musculoskeletal injuries are commonly seen in our emergency departments, and are commonly missed. There are many reasons for more missed injures and a significant one is over-reliance on radiographs. An emergency department orthopedic assessment goes far beyond the radiographs. A focused, yet comprehensive history is vital to understand the forces and mechanism of injury. That injury must be understood in the context of the patient, because older and much younger patients have weaker bone. Finally, the physical examination is instrumental in localizing the pathology and is essential to put radiograph results in the proper clinical context.