Stress Fractures of the Upper Limb

Home , Radius (bone), Second metacarpal bone, Spiral fracture

Sports Med 1998 Dec; 26 (6): 415-424 INJURY CLINIC 0112-1642/98/0012-0415/$05.00/0

Peter Brukner Olympic Park Sports Medicine Centre, Melbourne, Victoria, Australia

Contents Abstract ...... 415 1. Clavicle ...... 415 2. Scapula ...... 416 3. Humerus ...... 416 4. Olecranon ...... 418 5. Ulna ...... 419 6. Radius ...... 421 7. Metacarpal ...... 421 8. Conclusions ...... 422

Abstract Stress fractures are commonly found in the lower limb, but also occur in the upper limb, and are particularly associated with upper limb–dominated sports such as tennis and swimming and those involving throwing activities. Stress fractures of the clavicle and scapula are rare but have been reported, whereas those of the humerus are more frequent and have been described mainly in adolescent baseball pitchers. Olecranon stress fractures occur in throwers and gymnasts. Stress fractures of the ulna and radius have also been reported in a number of different upper limb–dominated sports. In all cases, these fractures heal with conservative management. The physician should consider stress fracture as a possible diagnosis in cases of upper limb pain of bony origin where the pain is associated with overuse.

Upper limb stress fractures are far less common fracture. Isotope bone scan or magnetic resonance than those of the lower limbs, but have been de- imaging (MRI) should be performed to confirm the scribed in upper limb–dominated sports such as clinical diagnosis. tennis, swimming and throwing activities. They have been cited in individual case reports but there 1. Clavicle are no large series published in the literature. Stress fractures of the clavicle have been de- The physician should always consider the diag- scribed as a late complication following radical nosis of stress fracture in any athlete involved in an neck dissection,[1,2] but only 2 cases of clavicular upper limb–dominant activity who presents with stress fracture in athletes have been reported.[3,4] bony pain of gradual onset and displays bony ten- One patient was a 25-year-old right-handed derness on physical examination. Imaging should male elite javelin thrower,[3] the other a collegiate be used to confirm the diagnosis, although plain springboard diver.[4] The 2 cases presented with radiography frequently fails to reveal a stress insidious onset of pain over the clavicle and local 416 Brukner

tenderness. The pain was maximal on abduction of and pressure applied to the tip of the acromion the shoulder above the horizontal plane. Radio- caused pain at the base of the acromial arch. Antero- graphs showed periosteal reaction in both cases posterior, lateral, West Point and modified oblique and the diagnosis was confirmed with isotope scan view radiographs demonstrated an incomplete in one case and plain tomography in the other. Both transverse radiolucent line in an area of sclerotic athletes returned to full activity after 8 weeks. In bone at the underside of the acromion near its ori- the javelin thrower, the authors of the report postu- gin from the scapula spine. The fracture was best lated that repeated stress from contraction of the seen on tomography. A technetium bone scan re- clavicular portions of the deltoid and pectoralis vealed increased activity in this region. Weightlift- major muscles contributed to the development of ing and football activities were discontinued for the fracture. In the diver it was thought that the 6 weeks. Following this, the patient gradually re- position on water entry with the fingers and wrists sumed weightlifting and contact sport activities extended, the forearms pronated and the hands and was playing competitive football within 2 overlapping, may have transmitted impact stress months without pain or tenderness. Follow-up ra- from the hands to the clavicle. diographs 2 months later showed callus in the area of the fracture. The authors felt that the intense 2. Scapula weightlifting programme had contributed to the development of the stress fracture. Stress fractures of the scapula are also rare. Stress fracture of the coracoid process has been There have been reports of scapula body stress described in association with trap shooting.[12] A fracture related to occupation: 3 stress fractures in 27-year-old female professional trapshooter regu- lorry drivers[5-7] and one in an automobile assem- larly shot trap at the rate of 200 to 1000 rounds per bly line overhead worker[8] appear in the literature. week. She complained of aching in the shoulder at Scapular stress fractures in athletes have been re- the point at which the butt of the rifle rests. On ported in a gymnast,[9] a jogger using hand-held physical examination the patient had point tender- weights,[10] at the base of the acromial process in a ness directly over the coracoid process and tender- professional American football player[11] and in the ness along the bicipital groove. Resistance against coracoid process in a trap shooter.[12] adduction and flexion of the shoulder caused in- Veluvolu et al.[10] reported the case of a 30-year- creased pain over the coracoid process. Antero- old man who had been jogging with weights in his posterior and lateral radiographs of the shoulder hands for about 8 weeks. He complained of pain in were normal; however, the axillary view demon- the right shoulder for 2 weeks. Isotope bone scan strated a fracture through the mid portion of the showed a linear band of increased uptake in the base of the coracoid process. Treatment consisted superomedial portion of the right scapula superior of rest from trap shooting until asymptomatic and to the spinous process. Later radiographs showed then gradual resumption of activity. Six weeks after a fracture through this region. The authors sug- the onset of symptoms the patient had no point ten- gested that the likely cause was overuse of muscle derness over the coracoid process and full active fibres of the supraspinatus in stabilising the hu- painless range of motion of the shoulder. Gradual meral head while jogging with weights. resumption of shooting caused no shoulder pain Ward et al.[11] described a 28-year-old male and the patient returned to her usual rate of trap offensive lineman, with no history of significant shooting. trauma, who developed pain in the shoulder during an American football game. He had not noticed 3. Humerus pain before the game but was lifting weights in a intensive prescribed programme. Physical exami- Stress fracture of the humerus has been de- nation revealed point tenderness over the acromion scribed in baseball pitchers,[13-17] a tennis player,[18]

a javelin thrower,[19] a body-builder[20] and a these fractures: (i) age over 30 years; (ii) a pro- weightlifter.[21] The majority of these fractures longed period of lay-off from pitching; (iii) lack of occurred in adolescents and were associated with a regular exercise programme; and (iv) prodromal a recent increase in activity. throwing arm pain. Sterling et al.[15] reported the case of a 14-year- Bartsokas et al.[20] reported a 20-year-old male old athlete competing in swimming and baseball as body-builder who presented with left shoulder and well as weight training. He felt and heard a ‘pop’ upper arm pain that developed insidiously over a in his right arm while throwing a baseball. Before 4-week period. The patient had been ‘bulking up’ the injury the patient had deep aching arm pain and for 3 weeks before the onset of pain by lifting heav- tenderness in the region of the mid-shaft of the ier weights than usual. Progressive worsening of humerus. Physical examination after the initial in- shoulder and upper arm pain was reported, partic- jury showed swelling, ecchymosis and extreme ularly with bench presses but also brought on by pain with active and passive motion of the arm. incline presses, biceps curls and overhead presses. x-Rays revealed a closed comminuted spiral frac- Symptoms were present only during exercise but ture of the humerus which extended proximally. flared at each weightlifting session despite 1 week The patient was placed in a cuff and collar for 1 of rest and treatment with anti-inflammatory med- week and then a humeral fracture brace was sup- ication. Examination demonstrated mild pain on plied. Three weeks after the event the patient had manual resistance testing of shoulder movements, no complaints and the alignment of the fracture especially on internal rotation and abduction. Mild was anatomical. His pain had ceased about 1 week tenderness to palpation was noted over the inser- earlier. Rehabilitation was instituted with an active tion of the anterior deltoid muscle. A radiograph range of motion, stretching and progressive resis- revealed a small lucent line in the cortex of the tance exercises. Six weeks postinjury, radiographs mid-humerus along its anterior aspect. Isotope demonstrated abundant callus formation. The bone scan showed an area of focal increased activ- brace was removed 11 weeks after the injury and ity in the mid portion of the humerus. The patient the patient was allowed to begin swimming. He was prescribed 6 weeks’ rest, followed by a gradual returned to full activity 16 weeks after the injury. resumption of training. Allen[16] described the case of a 13-year-old Lit- Rettig and Beltz[18] reported a 15-year-old elite tle League baseball pitcher who sustained a dis- tennis player who had a history of onset of pain just placed spiral fracture of the mid-humerus while in above the elbow without a history of trauma. His mid-pitch. He had had pain in the region of the symptoms worsened after he began playing more mid-humerus at rest and during pitching during the intensively, and he was unable to play for 2 months preceding week. Presumably, this was a case of a because of severe pain. On examination he had full stress fracture which had progressed to an overt range of motion of the shoulder and elbow and had fracture during the stress of a forceful side arm point tenderness over the lateral aspect of the distal curve ball pitch. third of the humerus. Initial x-rays of the humerus Branch et al.[17] reported 12 cases of spontane- were unremarkable, but a bone scan showed abnor- ous humeral shaft fractures in a men’s Over 30 mal uptake within the ventral aspect of the mid- Baseball League. Three-quarters of the pitchers shaft of the humerus. A computerised tomography had arm pain at some point before the fracture and (CT) scan showed a vertical fracture through the 11 of the 12 heard a crack at the time of the occur- ventral cortex of the humerus. The patient was rence. Nine of the fractures were spiral. There were rested for an additional 4 weeks and then com- 2 nerve injuries associated with the fracture, one menced the slow return to tennis. Approximately to the radial and one to the cutaneous nerve. The 2 weeks after his return, he developed the same authors noted 4 common factors associated with symptoms of pain. It was therefore felt that this was

a case of delayed union and external electrical stim- in throwers, and the third is a stress fracture of the ulation was begun. His symptoms and signs re- olecranon itself. solved completely over the next 2 months and, after Hulkko et al.[23] described 4 javelin throwers a gradual weight training and flexibility pro- with stress fractures of the olecranon. In one of gramme, the player was allowed to return to tennis. these patients, acute painful dislocation of the frac- He had no further problems. Interestingly, it was ture occurred during a competitive throw. Two pa- noted that the patient was undergoing a growth tients had a stress fracture of the tip of the olecra- spurt during the initial occurrence of symptoms non. One of these was treated conservatively but and had grown some 5 inches in the 5 to 6 months did not heal for 18 months; the other was treated before symptom onset. It was also noted that he by excision of the tip and was able to throw after 2 was of slight build. It is unclear whether this was a months. The other 2 patients had slightly oblique, true delayed union and therefore whether the elec- more distally located stress fractures which were trical stimulation affected the healing or not. treated with a tension band and 2 Kirschner wires. The most probable explanation for the occur- The fractures healed in 4 months. One had a refrac- rence of stress fractures in these younger athletes ture 11 months after the primary operation which is that the high level of activity among the adoles- was successfully treated with a compression screw cents placed a degree of stress upon immature and 2 bone pegs. bone, possibly aggravated by a period of rapid Maffulli et al.[24] reported 2 cases of stress frac- growth. ture through the olecranon growth plate in gym- From the few cases of stress fracture of the hu- nasts aged 18 and 19. Conservative management merus reported in the literature, the recommended was successful in one, and the other required inter- treatment involves a minimum of 4 weeks’ absence nal fixation. This paper also described 8 younger from the aggravating activity and then gradual gymnasts with traction apophysitis of the olecra- resumption of activity over another 4-week period. non, and postulated that the lesions were probably A strengthening programme may be of some ben- age-dependent. The authors suggested that when efit. the olecranon apophysis is not fully ossified, traction forces may cause disturbance of blood flow 4. Olecranon and result in localised areas of avascular necrosis with disturbed ossification and fragmentation, A small number of stress fractures of the olecra- known as traction apophysitis. When the apophysis non have been reported and this possibility should is more mature but not yet fused, the same forces be considered in the diagnosis of overuse elbow may produce a stress fracture through the growth injuries, especially among throwers and gymnasts. plate. Other authors have described similar stress The usual presentation is gradual onset of pain in fractures through the olecranon growth plate.[25-27] the elbow over a period of a few weeks. Wilkerson and Johns[28] reported a case of non- There appear to be 3 different types of stress union of a stress fracture of the olecranon epiphyseal fracture of the olecranon. One is a stress fracture of plate. The 14-year-old gymnast presented initially the growth plate reported in adolescent gymnasts. with a dull ache and local tenderness. Radiographs This fracture appears as a radiolucency extending revealed a widening of the epiphyseal plate, and a from the posterior (nonarticular) aspect of the ulna diagnosis of stress fracture was made. Three to the articular surface in a transverse fashion. months after discontinuing gymnastics the patient Sclerosis of the fracture margins with persistent was found to be asymptomatic, with a full range of radiolucency and no relief of pain are signs of a motion. Approximately 6 months later the patient delayed union or a nonunion.[22] The second type returned with a recurrence of pain, limited exten- is a stress fracture of the tip of the olecranon seen sion and radiographic evidence of nonunion. The

nonunion site was surgically excised and packed to respond best to surgical excision. The olecranon with iliac crest bone graft. The site was then fixed stress fractures, on the other hand, appear to re- using a tension band wire technique and the patient spond to conservative methods. commenced on rehabilitation with emphasis on In the stress fractures of the growth plate and strengthening the range of motion. At 12 months the olecranon itself, if the diagnosis is made rela- postsurgery the fracture site was completely healed tively early, there is a reasonable chance that con- and the range of motion was normal. servative management could be successful and the Nuber and Diment[29] described 2 cases of stress athlete will resume sport in 8 to 12 weeks. The fracture of the olecranon in throwers, successfully treatment of choice for a stress fracture of the tip treated by conservative methods. Both patients of the olecranon is surgical excision, which ap- presented with pain around the olecranon while pears to enable the athlete to return to his sport at pitching. They were initially diagnosed with tendi- approximately 8 weeks. nitis and continued to pitch until an episode of severe pain was felt during pitching. In both cases, 5. Ulna x-rays before the episode of acute pain were re- Stress fractures of the ulna have been described ported as normal, while x-rays after the episode in baseball[30,31] and softball[32] pitchers, tennis showed evidence of olecranon stress fracture. In players,[33-36] volleyball players,[32,37] weight- one case, the patient was placed in a posterior splint lifters,[38-41] bowlers[42] and a golfer.[43] Athletes for 3 weeks. After this the patient began elbow present with pain in the region of the ulna shaft range-of-motion and forearm exercises for the next during and after athletic activity. Physical examin- 6 weeks. Follow-up tomograms done at 3 months ation reveals tenderness and pain with movements. showed evidence of healing and the patient re- Radiographs show either a small crack in the cor- sumed light throwing. He was able to gradually tex of the ulna or a slight haze of new periosteal progress to his previous level of throwing without bone at the site of the stress fracture. Bone scans recurrence of his symptoms. The second patient can be used to confirm the diagnosis when radio- was prescribed complete rest until follow-up x-rays graphs fail to show any abnormality. All the re- 5 weeks later showed evidence of fracture healing. ported affected athletes have returned to activity in He continued his activity restriction for 2 more 4 to 6 weeks after a period of rest from the aggra- months and then began exercising and throwing, vating activity and gradual resumption. returning to his previous level of throwing in 6 Mutoh et al.[32] described stress fractures of the months. ulna in a softball pitcher throwing underarm and a [29] Nuber and Diment felt that the transverse volleyball player who experienced pain during stress fracture of the olecranon and the olecranon underhand manoeuvres. Both actions involved tip fractures were not the same entity, even though repetitive movements of the unilateral upper limb they were both seen in throwers. They stated that with a light load following contraction of the flexor tip fractures were more likely to be seen in patients muscles. In the volleyball player where wrist flex- who present with a painful elbow after a particu- ion was more pronounced, the stress was more larly strong throw. Patients with stress fractures, proximal; in the softball player it was more distal. however, were more likely to present with a longer Bollen et al.[33] described 2 stress fractures of history of pain that recurred when they resumed the ulna in tennis players. In the first case, a 17- throwing. Radiographically, the tip avulsion frac- year-old right-handed female professional tennis tures involve as much as one-third of the proximal player complained of gradually increasing pain in olecranon. The stress fractures occur in the middle the left forearm when using the double-handed third of the olecranon. Tip fractures are likely to go backhand stroke. The only physical findings were on to nonunion, may form loose bodies and seem tenderness over the middle third of the ulna and

pain on resisted pronation. Radiographs were un- torsional stresses to those found in the softball remarkable but an isotope bone scan showed mark- players. Young et al.[34] reported a similar case in a edly increased uptake over the site of tenderness 15-year-old female tennis player. (fig. 1). In the second case, a 21-year-old right- Bell and Hawkins[36] described the case of a 19- handed male professional tennis player also com- year-old right-handed tennis player who presented plained of pain in the left forearm. He had been with pain in his left wrist while hitting a double- undertaking intensive backhand training over the handed backhand. He described the pain as being previous few weeks and had developed increasing just proximal to the ulnar styloid, involving both pain over the anteromedial aspect of the forearm the dorsal and volar aspects of the forearm. He was on ball contact when using the double-handed tender to palpation along the ulnar aspect of the backhand stroke. He also had tenderness to palpa- distal forearm. Direct palpation of the distal third tion of the anteromedial aspect of the ulna at the of the ulna, 3 to 4cm proximal to the ulnar styloid, junction of the proximal and middle thirds. Radio- produced pain similar to that encountered during graphs were normal but bone scan confirmed the backhands. Marked dorsiflexion of the wrist and pronation/supination also elicited pain. Plain x-rays presence of a stress fracture. Both of these patients of the forearm demonstrated a discrete area of peri- were treated with standard procedures for stress osteal elevation along the dorsal aspect of the distal fractures, with rest of the affected limb and gradual ulna. A diagnosis of stress fracture was made and resumption of activities after resolution of the ten- treatment consisted of a modification of the pa- derness. tient’s swing pattern with an attempt to utilise a The authors felt the injury mechanism was sim- one-handed backhand. A dorsally applied exten- ilar to that reported in softball players by Tanabe sion block splint was applied on a temporary basis. [37] et al. (repetitive excessive pronation). In the After 4 weeks the patient returned to his full level double-handed backhand stroke of tennis players, of activity and resumed his double-handed back- pronation occurs during the phase of ball strike and hand, at that time pain-free. Repeat x-rays at that follow-through, and presumably causes similar time showed additional callus. Escher[42] described the case of a 16-year-old right-handed bowler who reported 3 weeks of increasing pain in the proximal right ulna. He bowled 3 to 8 games per day using a 16lb (7.25kg) fingertip ball. An isotope bone scan showed increased uptake in the ulna in the area of his pain. Management consisted of 5 weeks’ bowling cessation with a gradual return to activity. The author postulated that the fracture was caused by stress on the ulna at the origin of the flexor profundus muscle from re- peatedly grasping the ball with a fingertip grip. Koskinen et al.[43] reported a case of a 44-year- old golfer who presented with a 4-week history of a painful left wrist. The report does not mention whether the golfer was right- or left-handed. Radio- graphs showed a periosteal reaction on the radial side of the distal ulnar diaphysis. An MRI disclosed cortical thickening and an area of low signal den- Fig. 1. Isotope bone scan of stress fracture of the ulnar diaphysis. sity on T1-weighted images and oedema on T2-

weighted images consistent with healing stress distal radial diaphysis with periosteal new bone fracture. One week later, radiographs showed a formation. lucent fracture line with periosteal callus. The Loosli and Leslie[48] described a 25-year-old patient’s golf instructor recognised that excessive right-handed high level female tennis player who external rotation was used with the affected left developed increasing pain in her right wrist. Phys- hand. ical examination revealed diffuse tenderness of the distal radius and over the second and third meta- 6. Radius carpals dorsally. Hyperextension of the wrist caused pain at the back of the hand and extension Stress fracture of the radius was first described of the thumb to resistance caused pain to the back in the military setting. Farquharson-Roberts and of the hand and wrist as well as in the proximal Fulford[44] described a case in which a 23-year-old second and third metacarpals. x-Rays were normal; naval recruit developed bilateral radial stress frac- however, a bone scan showed markedly increased tures after training or ‘field gun running’, an activ- uptake in the distal radius. At the time of diagnosis ity which involves catching a heavy gun barrel the patient had had persistent pain for 5 months in across the forearms and manhandling a heavy gun spite of reduced activity in a splint. She was there- over simulated obstacles. Radiographs showed fore placed in a short arm cast for 3 weeks, fol- stress fractures of the radius bilaterally in the prox- lowed by a posterior splint for 3 more weeks. When imal third along the anterior cortex. Treatment con- the posterior splint was applied she began an iso- sisted of 6 weeks’ rest and a progressive return to metric strengthening programme for her wrist flex- training. No complications were reported and the ors and extensors. After her immobilisation she fractures appeared well healed on radiography 6 began a strengthening programme of resistive ex- weeks later. ercise using latex tubing. The patient began hitting Stress fractures of the radius have also been de- the tennis ball painlessly approximately 8 weeks scribed in gymnasts,[45-47] a tennis player,[48] a pool after the start of immobilisation. She gradually player[49] and a cyclist.[50] Stress injuries of the dis- progressed to tennis every other day in a painless tal radial growth plate are seen frequently in young fashion and in 2.5 months was able to hit a tennis gymnasts.[45,47] ball comfortably. She had returned to painless, full Ahluwalia et al.[46] described a 24-year-old fe- competitive level tennis at 3 months. male gymnast with a 3-month history of bilateral Orloff and Resnick[49] reported the case of a 22- forearm pain. The pain began when the gymnast year-old pool player who complained of a painful increased her training from 9 to 18 hours per week. mass on the dorsum of the distal part of the right Radiographs showed no abnormality, but an iso- forearm. The pain was accentuated by rotation tope bone scan demonstrated focally increased ac- of the forearm in a movement designed to put tivity in the radial shafts of the radius in both arms. ‘English’ (side spin) on the billiard ball. He spent Eisenberg et al.[50] reported the case of a 12- at least 4 consecutive hours playing pool 3 nights year-old boy who presented with a 3-week history per week. Radiographs demonstrated fluffy perios- of pain in the left wrist and forearm. He stated that teal reaction extending 2cm along the dorsoulnar he had been riding a bicycle very hard for several margin of the distal third of the radius. 16 weeks months and had been doing ‘wheelies’ by jerking later, the pain had subsided and radiographs re- the front wheel of the bicycle off the ground and vealed a healing stress fracture. riding on the back wheel only. The front wheel then came back down to the ground with a hard thud, 7. Metacarpal jarring his forearm. The left forearm was tender at the junction of the mid and distal thirds of the There are a total of 8 cases of metacarpal stress radius and x-rays revealed a fracture line at the fractures reported in the literature, 5 in sports

people and 3 occupationally related. The occupationally related stress fractures involved the second metacarpal and resulted from extrinsic pressure from a solid object, such as an ice-cream scoop[51] or a pen,[52] exerting a force on that bone. Details are available regarding 3 of the 5 reported stress fractures of the metacarpal in athletes. The other 2 were reported as part of a large series.[53] Two of the cases in athletes involved stress fracture of the second metacarpal bone in tennis players.[54,55] The third involved a stress fracture of the fifth metacarpal in a softball pitcher.[56] There are certain similarities between the metacarpal and metatarsal bones. The second metacarpal is the longest and has the largest base of all the metacarpals, articulating at the base with the trap- Fig. 2. Isotope bone scan of stress fracture of the fifth metacarpal ezoid, trapezium, capitate and third metacarpal. (palmar view of the right hand). Movement at the second carpometacarpal joint is limited in directions other than flexion/extension. competition and had altered the grip for her curve The fifth metacarpal articulates with other bones ball. This involved an increased degree of abduc- only on the lateral aspect of the base with the fourth tion of the fifth finger and delivery of the ball with metacarpal and hamate, while its medial surface is the fingers perpendicular to the direction of the nonarticular and presents a tubercle for the inser- pitch, thus increasing abduction forces.[56] tion of the extensor carpi ulnaris. The conformation In all the described cases of stress fracture of the of its base allows for a greater range of motion than metacarpals, relative rest and avoidance of aggra- the second, third and fourth metacarpals in direc- vating activity resulted in clinical healing within 4 tions other than flexion/extension. In the metatar- weeks. Attention must be paid to the errors in tech- sal bones, the relative frequency of stress fractures nique and training overload which first precipitate of the second metatarsal probably reflects its im- the problem. mobility at the base, while the fifth metatarsal articulates only at part of its base and has insertion 8. Conclusions from the powerful peroneus brevis tendon. As with so many stress fractures, the precipitat- Stress fractures of the upper limb are infrequent ing factors in the development of these 3 described but not rare. The case reports from the literature metacarpal stress fractures are a combination of in- summarised here probably only represent a small creased load and changes in technique. The 2 cases proportion of all upper limb stress fractures, which of stress fracture of the second metacarpal in tennis are examples of bone stress injuries due to repeti- players[54,55] described an increase in training vol- tive muscle pull. ume and intensity as well as an alteration in tech- The diagnosis of stress fracture should always nique. Intrinsic pressure from a solid object, the be considered in overuse syndromes of the upper racket, on the second metacarpal bone provides a limb. Careful anatomical examination is required. fulcrum for an external compressive load.[57] The presence of localised bony tenderness should The softballer who presented with a stress frac- make the clinician suspicious of stress fracture. A ture of fifth metacarpal (fig. 2) had recently in- plain radiograph should be performed, but if that creased training intensity in preparation for a major proves negative, the clinician should immediately

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