11

Musculoskeletal SystemMusculoskeletal SystemMusculoskeletal SystemMusculoskeletal System McGill School of Nursing : Nurse Practitioner Course,compiled by: Ann Rothman, MD, CFPC (spring 2010)

McGill School of Nursing : Nurse Practitioner Course,compiled by: Ann Rothman, MD, CFPC (spring 2010)

22

MSK-OVERVIEWMSK-OVERVIEW

33

MSK CASESMSK CASES

o History

o Exam

o Imaging & Tests

o Differential Diagnosis

o Plan , Counseling, Followup

o History

o Exam

o Imaging & Tests

o Differential Diagnosis

o Plan , Counseling, Followup

44

MSK : DAY 1 - AM - ULMSK : DAY 1 - AM - UL

AM: Anatomy, Examination, Clinical Cases of Upper Limb

Shoulder

Elbow

Wrist

Hand

AM: Anatomy, Examination, Clinical Cases of Upper Limb

Shoulder

Elbow

Wrist

Hand

55

MSK : DAY 1 - PM - LLMSK : DAY 1 - PM - LL

PM: Anatomy,Examination, Clinical Cases of Lower Limb

Hip

Knees

Ankle

Foot

PM: Anatomy,Examination, Clinical Cases of Lower Limb

Hip

Knees

Ankle

Foot

66

MSK: DAY 2 - AM - SPINEMSK: DAY 2 - AM - SPINE

AM: Anatomy, Examination, Clinical Cases of Spine

C-Spine

T-Spine

L-S Spine

AM: Anatomy, Examination, Clinical Cases of Spine

C-Spine

T-Spine

L-S Spine

77

MSK : DAY 2 - PM - AGEMSK : DAY 2 - PM - AGE

PM:

Children and Adolescents

Elderly

PM:

Children and Adolescents

Elderly

88

MSK : DAY 3 - AM - WORKERS, PAINMSK : DAY 3 - AM - WORKERS, PAIN

AM :

Workers

Chronic Pain

AM :

Workers

Chronic Pain

99

MSK : Day 3-PM - COMPLEX CASESMSK : Day 3-PM - COMPLEX CASES

PM : Complex CasesPM : Complex Cases

1010

DAY 1 - AMDAY 1 - AM

1111

MSK : DAY 1 - AM - ULMSK : DAY 1 - AM - UL

AM: Anatomy, Examination, Clinical Cases of Upper Limb

Shoulder

Elbow

Wrist

Hand

AM: Anatomy, Examination, Clinical Cases of Upper Limb

Shoulder

Elbow

Wrist

Hand

1212

MSK - UL – CASES (1)MSK - UL – CASES (1)

• 1) 22 year old varsity team volleyball player has injured her long and ring finger of her right hand in returning a shot. The fingers hit the ball hard, at right angle to the surface of the ball. She can't flex the DIP or PIP joints of these fingers, and there is much swelling. Her team has a good chance for the finals, and she wants to play.

• 2) A 35 year old man slammed his hand in a car door today. He has it wrapped in a bandage with an ice pack. There are subungual hematomas of the long, index, and ring fingers, and the skin proximal to these is open. He can't flex the DIP joints.

• 1) 22 year old varsity team volleyball player has injured her long and ring finger of her right hand in returning a shot. The fingers hit the ball hard, at right angle to the surface of the ball. She can't flex the DIP or PIP joints of these fingers, and there is much swelling. Her team has a good chance for the finals, and she wants to play.

• 2) A 35 year old man slammed his hand in a car door today. He has it wrapped in a bandage with an ice pack. There are subungual hematomas of the long, index, and ring fingers, and the skin proximal to these is open. He can't flex the DIP joints.

1313

MSK – UL – CASES (2)MSK – UL – CASES (2)

• 3) A 72 year old lady slipped on the ice today, and stopped her fall by reaching behind her, and falling on her hand. Her left wrist is now swollen, deformed, and bruised. Her left shoulder hurts, as well.

• 4) For the past 6 months, this 48 year old woman has noted pain in her wrists, Right worse than left, on and off. She is right handed, and works as a secretary. She also has had bilateral shoulder and neck pain.

• 3) A 72 year old lady slipped on the ice today, and stopped her fall by reaching behind her, and falling on her hand. Her left wrist is now swollen, deformed, and bruised. Her left shoulder hurts, as well.

• 4) For the past 6 months, this 48 year old woman has noted pain in her wrists, Right worse than left, on and off. She is right handed, and works as a secretary. She also has had bilateral shoulder and neck pain.

1414

MSK - UL – CASES (3)MSK - UL – CASES (3)

• 5) While playing football, a 17 year old boy received a body check on his left shoulder, and now has, what he calls, a " burner" injury

• 6) A 56 year old man has recently taken up swimming as a regular activity to get back into shape. After 3 weeks of swimming 4-5 times per week, he has left shoulder pain.

• 5) While playing football, a 17 year old boy received a body check on his left shoulder, and now has, what he calls, a " burner" injury

• 6) A 56 year old man has recently taken up swimming as a regular activity to get back into shape. After 3 weeks of swimming 4-5 times per week, he has left shoulder pain.

1515

SHOULDER (1)SHOULDER (1)

Shoulder Exam Overview -- http://www.youtube.com/watch?v=RsTObF8W9Ds

Approach to Shoulder Pain -- http://www.youtube.com/watch?v=HULJU_ROdCI

Shoulder Abduction Test -- http://www.youtube.com/watch?v=vN_IxhLaHYIhttp://www.youtube.com/watch?v=mf8xI9GApMw

AC Joint Compression Test -- http://www.youtube.com/watch?v=mf8xI9GApMw

Shoulder Exam Overview -- http://www.youtube.com/watch?v=RsTObF8W9Ds

Approach to Shoulder Pain -- http://www.youtube.com/watch?v=HULJU_ROdCI

Shoulder Abduction Test -- http://www.youtube.com/watch?v=vN_IxhLaHYIhttp://www.youtube.com/watch?v=mf8xI9GApMw

AC Joint Compression Test -- http://www.youtube.com/watch?v=mf8xI9GApMw

1616

SHOULDER (2)SHOULDER (2)

Cervical/Foraminal Distraction Test -- http://www.youtube.com/watch?v=AIZ310fYIY8

Clunk Test -- http://www.youtube.com/watch?v=qy19mEJ89Sc

O’Brien’s Test -- http://www.youtube.com/watch?v=gaDhqFP4lCE

Neer’s Test -- http://www.youtube.com/watch?v=nq6x7f31tZ0

Cervical/Foraminal Distraction Test -- http://www.youtube.com/watch?v=AIZ310fYIY8

Clunk Test -- http://www.youtube.com/watch?v=qy19mEJ89Sc

O’Brien’s Test -- http://www.youtube.com/watch?v=gaDhqFP4lCE

Neer’s Test -- http://www.youtube.com/watch?v=nq6x7f31tZ0

1717

SHOULDER (3)SHOULDER (3)

Apprehension Test -- http://www.youtube.com/watch?v=gLBX8vUnCo0

Hawkin’s Test -- http://www.youtube.com/watch?v=q9P8zDYsERs

Apprehension Test -- http://www.youtube.com/watch?v=gLBX8vUnCo0

Hawkin’s Test -- http://www.youtube.com/watch?v=q9P8zDYsERs

1818

ELBOWELBOW

Elbow Exam Overview : Med, Lat, Ant, & Post Compartments : Look, Move, Palpate: http://www.youtube.com/watch?v=M-1V7_eKkRQ

Tinel’s Sign of Elbow -- http://www.youtube.com/watch?v=96H7Ip_Y3hQ

Elbow Exam Overview : Med, Lat, Ant, & Post Compartments : Look, Move, Palpate: http://www.youtube.com/watch?v=M-1V7_eKkRQ

Tinel’s Sign of Elbow -- http://www.youtube.com/watch?v=96H7Ip_Y3hQ

1919

WRIST & HANDWRIST & HAND

Hand & Wrist Exam Overview 1 -- http://www.youtube.com/watch?v=65mjCLGrGTE

Hand & Wrist Exam Overview 2 --http://www.youtube.com/watch?v=_SqpPvJLNYE

Tinel’s Sign -- http://www.youtube.com/watch?v=XcDhqKRT2aU

Phalen’s Test -- http://www.youtube.com/watch?v=RpGHYujo37o

Hand & Wrist Exam Overview 1 -- http://www.youtube.com/watch?v=65mjCLGrGTE

Hand & Wrist Exam Overview 2 --http://www.youtube.com/watch?v=_SqpPvJLNYE

Tinel’s Sign -- http://www.youtube.com/watch?v=XcDhqKRT2aU

Phalen’s Test -- http://www.youtube.com/watch?v=RpGHYujo37o

2020

DAY 1 - PMDAY 1 - PM

2121

MSK : DAY 1 - PM - LLMSK : DAY 1 - PM - LL

PM: Anatomy,Examination, Clinical Cases of Lower Limb

Hip

Knees

Ankle

Foot

PM: Anatomy,Examination, Clinical Cases of Lower Limb

Hip

Knees

Ankle

Foot

2222

MSK – LL – CASES (1)MSK – LL – CASES (1)

• 1) A 42 year old man has had knee pain on and off, now worse than ever after each time he plays soccer or squash. Bicycling is fine, however. Both knees hurt, but the right is worse and it is a little swollen. He has always done lots of sports, but no acute traumatic events.

• 2) A 30 yr old woman has been training for a half-marathon, and is up to 17 km on her long Sunday runs. She has started to have a pain in her left heel, and in her left ankle. At age 16, she badly sprained that ankle, but recovered fully.

• 1) A 42 year old man has had knee pain on and off, now worse than ever after each time he plays soccer or squash. Bicycling is fine, however. Both knees hurt, but the right is worse and it is a little swollen. He has always done lots of sports, but no acute traumatic events.

• 2) A 30 yr old woman has been training for a half-marathon, and is up to 17 km on her long Sunday runs. She has started to have a pain in her left heel, and in her left ankle. At age 16, she badly sprained that ankle, but recovered fully.

2323

MSK – LL – CASES (2)MSK – LL – CASES (2)

• 3) A professional dancer presents w left hip pain, radiating to the groin. Xrays are normal.

• 4) A 10 year old girl has had persistent foot pain, despite normal Xrays. No known trauma.

• 3) A professional dancer presents w left hip pain, radiating to the groin. Xrays are normal.

• 4) A 10 year old girl has had persistent foot pain, despite normal Xrays. No known trauma.

2424

MSK – LL – CASES (3)MSK – LL – CASES (3)

• 5) A 25 year old man has severe ankle pain after an eversion injury.

• 6) A 70 year old woman has had increasing pain in both knees, which doctors have told her was due to her weight. Now she has lost 20 lbs, but they still hurt. they swell on and off, especially after she walks a lot.

• 5) A 25 year old man has severe ankle pain after an eversion injury.

• 6) A 70 year old woman has had increasing pain in both knees, which doctors have told her was due to her weight. Now she has lost 20 lbs, but they still hurt. they swell on and off, especially after she walks a lot.

2525

HIPHIP

Hip Exam --http://www.youtube.com/watch?v=5LNYdJIrWYo

Hip Exam --http://www.youtube.com/watch?v=5LNYdJIrWYo

2626

KNEE ( 1 )KNEE ( 1 )

Knee Muscles/Ligaments -- http://www.youtube.com/watch?v=_StElDL5A64

Knee Ligaments --http://www.youtube.com/watch?v=RTV5Yo3E7VQ

Knee Muscles/Ligaments -- http://www.youtube.com/watch?v=_StElDL5A64

Knee Ligaments --http://www.youtube.com/watch?v=RTV5Yo3E7VQ

2727

KNEE (2)KNEE (2)

Knee Tests Overview -- http://www.youtube.com/watch?v=M4dyJpnqoYo

Look,Feel,Move -- http://www.youtube.com/watch?v=fNUGyNYVhqE

Apley’s Compression test -- http://www.youtube.com/watch?v=At0FdkHaCGo

McMurray”s test -- http://www.youtube.com/watch?v=Irg3Cb4JaE8

Knee Tests Overview -- http://www.youtube.com/watch?v=M4dyJpnqoYo

Look,Feel,Move -- http://www.youtube.com/watch?v=fNUGyNYVhqE

Apley’s Compression test -- http://www.youtube.com/watch?v=At0FdkHaCGo

McMurray”s test -- http://www.youtube.com/watch?v=Irg3Cb4JaE8

2828

KNEE (3)KNEE (3)

Anterior Drawer -- http://www.youtube.com/watch?v=yQdBrr3Mmj0

Posterior Drawer -- http://www.youtube.com/watch?v=KAUDTMu8fS0

Patellar Apprehension -- http://www.youtube.com/watch?v=xXmjYVDkmVg

Patellar Tracking -- http://www.youtube.com/watch?v=NiyhDvwhhiw

Anterior Drawer -- http://www.youtube.com/watch?v=yQdBrr3Mmj0

Posterior Drawer -- http://www.youtube.com/watch?v=KAUDTMu8fS0

Patellar Apprehension -- http://www.youtube.com/watch?v=xXmjYVDkmVg

Patellar Tracking -- http://www.youtube.com/watch?v=NiyhDvwhhiw

2929

KNEE (4)KNEE (4)

• Lachman’s test -- http://www.youtube.com/watch?v=bHytLhg-1vM

• Lachman’s test -- http://www.youtube.com/watch?v=bHytLhg-1vM

36

3030

ANKLE & FOOTANKLE & FOOT

Ankle Exam --http://www.youtube.com/watch?v=Jpsg2LCS8us

Lower Leg, Ankle and Foot Tests : Ant and Post Drawer of Ankle, Med & Lat Collat Lig, Tinel’s Foot Sign, Thompson Test, Homan”s Sign, Rigid or Flat Foot Test --http://www.youtube.com/watch?v=yoMK6M-6Ko4

Ankle Exam --http://www.youtube.com/watch?v=Jpsg2LCS8us

Lower Leg, Ankle and Foot Tests : Ant and Post Drawer of Ankle, Med & Lat Collat Lig, Tinel’s Foot Sign, Thompson Test, Homan”s Sign, Rigid or Flat Foot Test --http://www.youtube.com/watch?v=yoMK6M-6Ko4

3131

DAY 2 - AMDAY 2 - AM

3232

MSK : DAY 2 - SPINEMSK : DAY 2 - SPINE

• Day 2 – AM – Anatomy, Examination, Clinical Cases

• C Spine

• T Spine

• L-S Spine

• Day 2 – AM – Anatomy, Examination, Clinical Cases

• C Spine

• T Spine

• L-S Spine

3333

MSK - SPINE - CASES (1)MSK - SPINE - CASES (1)

• 1) A 30 year old woman has pain over her medial left clavicle and the left side of her neck. She is the mother of 5 young children, and is full time looking after them and the house.

• 2) A 22 year old student has acute pain over the right thoracic area of her back. She is under a lot of stress, for termpaper deadlines.

• 1) A 30 year old woman has pain over her medial left clavicle and the left side of her neck. She is the mother of 5 young children, and is full time looking after them and the house.

• 2) A 22 year old student has acute pain over the right thoracic area of her back. She is under a lot of stress, for termpaper deadlines.

3434

MSK - SPINE - CASES (2)MSK - SPINE - CASES (2)

• 3) A 26 year old man , training for a marathon, develops increasing lumbosacral pain. He has been doing a lot of hilly terrain.

• 4) A 36 year 0ld nurse with known lumbar disc disease, presents with sudden low back pain, radiating to her right knee, with right leg numbness and tingling sensation.

• 3) A 26 year old man , training for a marathon, develops increasing lumbosacral pain. He has been doing a lot of hilly terrain.

• 4) A 36 year 0ld nurse with known lumbar disc disease, presents with sudden low back pain, radiating to her right knee, with right leg numbness and tingling sensation.

3535

MSK - SPINE - CASES (3)MSK - SPINE - CASES (3)

• 5) A severe chronic asthmatic presents with increasing thoracic back pain after an especially long bout of coughing during an episode of bronchitis. His pain had begun after he slipped on ice and fell, two weeks earlier.

• 6) A 55 year old woman tells you she has new numbness in her thumb and index fingers of her left hand when she wakes up, most mornings over the past three months.

• 5) A severe chronic asthmatic presents with increasing thoracic back pain after an especially long bout of coughing during an episode of bronchitis. His pain had begun after he slipped on ice and fell, two weeks earlier.

• 6) A 55 year old woman tells you she has new numbness in her thumb and index fingers of her left hand when she wakes up, most mornings over the past three months.

3636

SPINESPINE

Spinal Exam Overview :http://www.youtube.com/watch?v=d9DeoAXyIXY, http://www.youtube.com/watch?v=HuBQRz1dg5o

Scoliosis Test : http://www.youtube.com/watch?v=37m5wwlVNr8

Cervical Distraction Test : http://www.youtube.com/watch?v=AIZ310fYIY8

Foraminal Compression Test: http://www.youtube.com/watch?v=Fhr1yWkwwDU

Spinal Exam Overview :http://www.youtube.com/watch?v=d9DeoAXyIXY, http://www.youtube.com/watch?v=HuBQRz1dg5o

Scoliosis Test : http://www.youtube.com/watch?v=37m5wwlVNr8

Cervical Distraction Test : http://www.youtube.com/watch?v=AIZ310fYIY8

Foraminal Compression Test: http://www.youtube.com/watch?v=Fhr1yWkwwDU

3737

SPINESPINE

3838

DAY 2 - PMDAY 2 - PM

3939

MSK : DAY 2 - PM - AGEMSK : DAY 2 - PM - AGE

PM:

Children

Elderly

PM:

Children

Elderly

4040

MSK – AGE – CASES (1)MSK – AGE – CASES (1)

• 1) A 27 month old little girl presents with a one week history of increasing pain in her right leg, now so bad she will not even put her right foot on the ground. there is no redness or swelling.

• 2) A 4 year old boy has been having low grade fevers on and off for months. His family MD has diagnosed this as sinusitis. For the past two days he has had redness and swelling in the left inguinal and greater trochanter areas, and is reluctant to bear weight on his left leg.

• 1) A 27 month old little girl presents with a one week history of increasing pain in her right leg, now so bad she will not even put her right foot on the ground. there is no redness or swelling.

• 2) A 4 year old boy has been having low grade fevers on and off for months. His family MD has diagnosed this as sinusitis. For the past two days he has had redness and swelling in the left inguinal and greater trochanter areas, and is reluctant to bear weight on his left leg.

4141

MSK – AGE – CASES (2)MSK – AGE – CASES (2)

• 3) An 83 year old woman has new severe thoracic pain, over her thoracic spine, radiating to the left and right. She has been shoveling heavy snow.

• 4) A 75 year old man gets bilateral leg pain when he walks for more than 10 minutes, worse on the right.

• 3) An 83 year old woman has new severe thoracic pain, over her thoracic spine, radiating to the left and right. She has been shoveling heavy snow.

• 4) A 75 year old man gets bilateral leg pain when he walks for more than 10 minutes, worse on the right.

4242

MSK – AGE – CASES (3)MSK – AGE – CASES (3)

• 5) A 12 year old girl’s mother tells you her back has been hurting more and more. She is a competitive swimmer, and her annual exam by you 8 months ago was unremarkable.

• 6) A 9 year old boy comes with numbness of his left foot, present for two months. He has been fatigued lately, his father says.

• 5) A 12 year old girl’s mother tells you her back has been hurting more and more. She is a competitive swimmer, and her annual exam by you 8 months ago was unremarkable.

• 6) A 9 year old boy comes with numbness of his left foot, present for two months. He has been fatigued lately, his father says.

4343

CHILDREN & TEENSCHILDREN & TEENS

Newborn Orthopedic Exam : http://www.youtube.com/watch?v=hj1OnzNptGI

Hip Dysplasia : http://www.youtube.com/watch?v=KCIybc3WyNc , http://www.youtube.com/watch?v=gc2Hs-XlHCw

Newborn Orthopedic Exam : http://www.youtube.com/watch?v=hj1OnzNptGI

Hip Dysplasia : http://www.youtube.com/watch?v=KCIybc3WyNc , http://www.youtube.com/watch?v=gc2Hs-XlHCw

4444

ELDERLYELDERLY

4545

DAY 3 - AMDAY 3 - AM

4646

MSK – ACCIDENTS (1)MSK – ACCIDENTS (1)

• 1) A 42 year old Turkish immigrant, working at a new job in the garment industry, develops new pain in her left hip area. The CSST agent, after the file is opened, asks for and gets photos of the work post from the employer.

• 2) A 34 year old Afghani refugee is in the car with her husband when they get hit from behind by another vehicle. She develops an acute headache, but also pain in her neck, radiating down her right arm to her hand.

• 1) A 42 year old Turkish immigrant, working at a new job in the garment industry, develops new pain in her left hip area. The CSST agent, after the file is opened, asks for and gets photos of the work post from the employer.

• 2) A 34 year old Afghani refugee is in the car with her husband when they get hit from behind by another vehicle. She develops an acute headache, but also pain in her neck, radiating down her right arm to her hand.

4747

MSK – ACCIDENTS (2)MSK – ACCIDENTS (2)

• 3) A 38 year old nurse, while twisting the top of a bottle of IV solution to insert the tubing, gets an acute pain in her right wrist. this pain has persisted for th past 2 weks, and is getting worse. Advil does little.

• 4) A 44 year old man, stopped at a red light, is hit from behind on his motorbike. He flies into the air, and lands on his left hand, left elbow, and coccyx. But the pain that is worst for him, is his L-S spine pain.

• 3) A 38 year old nurse, while twisting the top of a bottle of IV solution to insert the tubing, gets an acute pain in her right wrist. this pain has persisted for th past 2 weks, and is getting worse. Advil does little.

• 4) A 44 year old man, stopped at a red light, is hit from behind on his motorbike. He flies into the air, and lands on his left hand, left elbow, and coccyx. But the pain that is worst for him, is his L-S spine pain.

4848

MSK – ACCIDENTS (3)MSK – ACCIDENTS (3)

• 5) A classical guitarist , working for the MSO, develops tendinitis in his left hand. They are about to go on tour, and he needs to play.

• 6) A woman, standing on a street corner, is hit from behind, as a car runs over the backs of her ankles and heels. There are deep lacerations

• 5) A classical guitarist , working for the MSO, develops tendinitis in his left hand. They are about to go on tour, and he needs to play.

• 6) A woman, standing on a street corner, is hit from behind, as a car runs over the backs of her ankles and heels. There are deep lacerations

4949

WORKERS - CSSTWORKERS - CSST

5050

MV ACCIDENTS - SAAQMV ACCIDENTS - SAAQ

5151

CHRONIC PAINCHRONIC PAIN

5252

DAY 3 - PMDAY 3 - PM

5353

MSK - COMPLEX CASES (1)MSK - COMPLEX CASES (1)• 1) A 28 year old postgrad student in history,

working all year on her doctorate thesis , has developed very sore wrists and can hardly move her fingers. She has been extremely fatigued, and notes her hands seem puffy at times. The pain radiates to her forearms and elbows, at times.

• 2) The husband of a patient followed by you for prenatal care presents with a six month history of low back pain and stiffness. He had this a few years ago , but milder and it resolved. This has been getting worse.

• 1) A 28 year old postgrad student in history, working all year on her doctorate thesis , has developed very sore wrists and can hardly move her fingers. She has been extremely fatigued, and notes her hands seem puffy at times. The pain radiates to her forearms and elbows, at times.

• 2) The husband of a patient followed by you for prenatal care presents with a six month history of low back pain and stiffness. He had this a few years ago , but milder and it resolved. This has been getting worse.

5454

MSK - COMPLEX CASES (2)MSK - COMPLEX CASES (2)

• 3) A dancer , seen in walk-in, is terrified that she will have to end her career. Her joints--fingers, wrists, knees, ankles--have become slightly swollen, slightly pink, and very sore, all for 3 days now.

• 4) An elderly woman presents with 3 reddened, warm, tender and very painful toes. She has not had any trauma, and she is type 2 diabetic.

• 3) A dancer , seen in walk-in, is terrified that she will have to end her career. Her joints--fingers, wrists, knees, ankles--have become slightly swollen, slightly pink, and very sore, all for 3 days now.

• 4) An elderly woman presents with 3 reddened, warm, tender and very painful toes. She has not had any trauma, and she is type 2 diabetic.

5555

MSK - COMPLEX CASES (3)MSK - COMPLEX CASES (3)

• 5) A 50 yr old woman comes in with an egg-sized swelling over her elbow, olecranon area. It has been gradually increasing in size and pain, over 2 weeks.

• 6) A 36 year old woman fell off her bike, with feet in the toeclips, and hit the ac joint of her shoulder. This is very sore now. The pain radiates to the lateral clavicular area, and there is much swelling.

• 5) A 50 yr old woman comes in with an egg-sized swelling over her elbow, olecranon area. It has been gradually increasing in size and pain, over 2 weeks.

• 6) A 36 year old woman fell off her bike, with feet in the toeclips, and hit the ac joint of her shoulder. This is very sore now. The pain radiates to the lateral clavicular area, and there is much swelling.

5656

COMPLEX CASESCOMPLEX CASES

37